HIV/ AIDS and Health Determinants: Lessons for Coordinating Policy and Action

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A Discussion Paper for the Ministerial Council on AIDS

1. Introduction

HIV/ AIDS is the most devastating infectious disease since the Black Death killed one-third of Europe s population in the 14 th century. Globally, 36 million people are today living with HIV/ AIDS while 22 million have already died as a result of the epidemic. HIV/ AIDS has orphaned over 13 million children under the age of 15 years, a number that is expected to double in the next decade. 1 The epidemic has certainly not spared Canada where 50,000 people are now living with HIV/ AIDS. It is the leading cause of premature death among men in Montreal and Toronto, while in Vancouver, it has reduced average life expectancy by up to twenty years among young gay and bisexual men. 2

The medical world and scientific community have responded vigorously to HIV/ AIDS. People today are living longer and better with HIV/ AIDS and AZT, for example, can practically eliminate mother-to-infant transmission. In spite of this progress, HIV remains a deadly infection for which there is no vaccine, no cure, and for which there is an expanding, but still limited, inventory of available treatments. 3 Significantly, in both Canada and around the world, HIV/ AIDS has settled resolutely in the most vulnerable of communities. It has become woven, like some kind of invisible thread, into the lives of those infected, altering their existence in ways mostly quiet and unseen. 4

The inability to control the epidemic has made clear how illusory is the belief once confidently held that advanced industrial societies are somehow immune to infectious disease and that medical science and medical care can address every biological threat. Medical means for preventing HIV infection and for curing HIV/ AIDS remain a hope for the future.

Societies, therefore, need to pursue other strategies if they are to prevent HIV/ AIDS and manage its impact. The population health concept offers one such strategy. It builds on a holistic view of health that recognizes the many environmental factors i. e. , the social determinants that contribute to good health. Population health is defined as an approach that aims to improve the health of the entire population and to reduce health inequities among population groups. In order to reach these objectives, it looks at and acts upon the broad range of factors and conditions that have a strong influence on our health. 5 It envisions initiatives in the full range of public policy areas.

1. See UNAIDS, An overview of the AIDS epidemic and Orphans and children in a world of AIDS, 2001. ( http://www.unaids.org/en/)
2. Strathdee, 2000.
3. United States, 1997.
4. New York Times, 3 June 2001, The AIDS War New Weapons and New Victims.
5. See Canada, Health Canada, 1998, Taking Action on Population Health. See also Anderson and Garmaise, 2001: 21; Hayes and Glouberman, 1999. 11.

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Population Health in Practice

The Boston Medical Centre -a hospital thattreats more poor people than any other in Massachusetts - has hired a team of lawyers to fight the legal and administrative battles that the doctors deem necessary to improve children's health in ways that pills and surgery cannot. The hospital's Chief of Pediatrics says they are trying to think "outside the box since you cannot separate out a child's organ functions from the rest of his body and the context of his environment." These lawyers, therefore, pressure landlords, help families apply for food stamps and persuade insurance companies to pay for baby formula.

"Traditional medicine can treat the effects of poverty. This program hopes to intervene so that poverty won't have the effects it has on children's health."

Goldberg, 2001

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1.1 Purpose and Objectives

Literature reviews identify and weave together the themes presented in the research findings of different people in different countries. The purpose of this literature review is:

• to consider HIV/ AIDS in a population health context;
• to identify and consider those social determinants that are most closely associated with HIV/ AIDS in Canada; and
• to identify policy directions that will strengthen the Canadian response to the HIV/ AIDS epidemic through a population health approach.

1.2 Methodology

The research took place between August and November 2001. A Steering Committee with representatives from Health Canada, the Federal/ Provincial/ Territorial Advisory Committee on HIV/ AIDS, and the Ministerial Council on HIV/ AIDS provided valuable guidance and advice, and commented on the draft report.

The project illustrated the power and utility of the Internet. A letter posted on a number of HIV/ AIDS-related list servers generated responses from around the world. The Internet also gave the project immediate access to materials that had just recently been published and to research appearing in a variety of journals. It also provided access, in a way unthinkable even ten years ago, to a broad range of resources. A simple mouse click opened the door to UNAIDS in New York, the World Health Organization in Geneva, the Centre for Health Promotion in Toronto, the National Centre in HIV Social Research in Australia, the Terrance Higgins Trust in the United Kingdom and the AIDS Housing Project in New York City. Appendix A identifies the Internet sites consulted.

The methodology included developing a comprehensive bibliography of materials from Canadian and international sources on the relationship between the social determinants of health and HIV/ AIDS. Importantly, the focus was on HIV/ AIDS itself rather than on the full range of health outcomes influenced by the social determinants of health.

InfoAction at the Vancouver Public Library used a variety of delimiters to explore search engines such as the European Database on AIDS and HIV, the OCLC ( including PAIS, Social Sciences Abstracts, SIRS, ECO, Proceedings and WilsonSelectPlus) , Microlog, the Canadian Research Index, Ebsco ( Health Source Academic, Academic Source Elite and Masterfile databases) and Medline for North America, Europe and Australia. Appendix A presents these search engines. The project team also hand searched the bibliographies of most of the reports, papers and monographs consulted. The References section lists all the sources and identifies certain of these as being particularly useful.

The project team analyzed the literature from the perspective of the project s objectives and research issues. The discussion presented in this report, however, was limited by certain factors.

• First, this literature review like most was often unable to fully assess the methodological rigour that underlay many of the publications.
  
• Second, the literature does not provide research-based evidence associating certain of the epidemic s aspects with certain of the social determinants, for example quality of life and disease progression.
  
• Third, most of those undertaking HIV/ AIDS-related research were not working from a population health perspective. Their approach was more narrowly focused and rarely considered the broad range of factors that individually and together influence HIV/ AIDS.

The report, therefore, focuses on only certain of the social determinants. Furthermore, it relies upon only those sources which appear to have employed rigorous research methodologies and which have been published in reputable journals or by reputable sources.

1.3 Report Organization

Following this Introduction, Section 2 briefly provides some background on the evolution of the population health concept. Section 3 begins by reflecting on the literature and then presents findings from that literature. It also identifies the policy and program implications that flow from these findings. Section 4 analyzes the association between HIV/ AIDS and population health and offers both conclusions and policy directions.

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