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

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A Discussion Paper for the Ministerial Council on AIDS

3. The Social Determinants and HIV/ AIDS

Section 3 begins by offering reflections on the research literature and identifies the methodological challenges inherent in conducting that research. The Section then explores in more detail the relationship between HIV/ AIDS and those social determinants for which there is adequate research, and presents findings related to each of these determinants. The criteria for selecting these findings included the author s reputation and professional associations, and the project s funding source and the report s publisher. Only those findings supported by compelling research-based evidence and having a sound methodological base are presented in the following.

Although this review presents findings on each determinant separately, the population health model affirms their inter-dependence. Poverty, early childhood experience, discrimination and the other determinants are inextricably linked and together contribute to the epidemic s spread and impact. Section 3 also offers some consideration of the policy implications that flow from the findings associated with each determinant. The more specific initiatives required to address these policy implications are presented within a broader context in Section 4, as part of the report s conclusions.

3.1 Reflections on the Literature

There is a strong body of literature that considers the population health concept and provides evidence of the social determinants impact on the health and well being of individuals and communities. There is very little literature, however, that places HIV/ AIDS in this broad population health context. Instead the literature most often explores the association between a particular social determinant and the behaviour that places a person at risk of HIV infection.

This pattern may be due to the researchers most often epidemiologists or health professionals working from a health promotion perspective that aims to influence individual and group behaviour. Given the importance of their work and the immediacy of the HIV/ AIDS threat, these researchers may be more interested in their work having an impact in the short term than in societal shifts that require a longer period of time and sustained effort across sectors.

The researchers have to confront a number of very fundamental methodological challenges. One is the need to accommodate the complex, ever-changing nature of HIV/ AIDS, the characteristics of the different at-risk groups, and the epidemic s entrenchment in the most marginalized of communities. Accessing these communities for research purposes can itself be a formidable challenge.

Another challenge is to distinguish between cause and effect. Researchers have to determine whether poverty, for example:

is responsible for HIV/ AIDS by placing people in situations where they are at higher risk of contracting the virus; or
a consequence of having HIV/ AIDS by obliging them to leave the paid labour force in order to live with the condition.

Similarly the literature must ask whether the depressive symptoms often exhibited by those living with HIV/ AIDS contribute to the disease s progression or are an early manifestation of the disease s progression. In these and other examples, cause and effect are not always clear and distinguishable.

Another challenge is to distinguish between the impact of the different determinants. If a particular community is vulnerable to HIV infection, for example, is it because of their poverty, their social circumstances, their housing, their working conditions, their ethnicity or their gender? While the population health model acknowledges the relationship among these, the ability to influence public policy requires some distinguishing among them. Furthermore in exploring relationships, the research has to take three steps rather than one:

first from social determinant to risk behaviour;
then from risk behaviour to HIV infection; and
finally, from HIV infection to AIDS.

Another challenge is to identify associations and causal or predictive relationships between health outcomes today and life situations from perhaps five, ten or twenty years ago. In this regard, researchers invariably struggle with the need not to equate the absence of evidence with evidence of absence.

Identifying these associations in a scientifically rigorous manner depends upon conducting the research through an extended period of time and having an appropriate control or comparison group. Neither the urgency of the epidemic itself nor the traditional perspective of funders allows for such a long-term approach. Adequate funding is rarely available and, indeed, the financial commitment to HIV/ AIDS-related research in Canada lags behind that of other developed countries such as Australia, Switzerland and the United States. The Canadian Strategy s funding commitment to research, for example, declined by 26% between 1994 and the present. 24

Furthermore, drawing conclusions from the literature is compromised by social and epidemiological researchers most often focusing on behavioural issues. Researchers have associated HIV/ AIDS with intravenous drug use. Only rarely, however, have the researchers taken the next step backward and associated it with the emotional pain and poverty that often contributed to this drug use. The researchers orientation is likely a consequence of their effort to identify practical prevention strategies for the short term.

Addictions always originate in unhappiness, even if hidden. They are emotional anesthetics; they numb pain. The first question - always - is not 'Why the addiction? ' but 'Why the pain? ' The methadone I prescribe for their opiate dependence does little for the emotional anguish compressed in every heartbeat of these driven souls. Mate, 2001: A9

Additionally, the literature and the researchers invariably begin with an adult population that is currently living with HIV/ AIDS and are obliged to use a retrospective approach when exploring the root causes of their current situation. As such, the researchers cannot speak to the very many people who, for example, have not contracted HIV/ AIDS in spite of their poverty or their early childhood experiences. The validity of their conclusions, in terms of association or causality, again very much depends on the appropriateness of their control groups, an appropriateness that is exceedingly difficult to achieve when addressing socio-economic conditions.

All in all, the literature relating HIV/ AIDS to population health and to the social determinants that underlie that concept was surprisingly sparse. It is narrowly focused on behaviour and on specific at-risk groups rather than more broadly on the social and economic roots of the epidemic. Nevertheless there are patterns evident in the research findings and these are compelling even if one can quibble about the methodology behind them. These findings lend support to the intuitive logic of the population health approach. It simply makes sense that a healthy social and economic environment leads to better health outcomes. It simply makes sense that a person who grew up in an abusive environment is more likely than one who did not to engage in behaviours that place them at risk of HIV infection.

The basic human need for shelter makes the relation between poor housing and poor health seem self evident. Despite, or perhaps because of, this intuitive relation, good research evidence is lacking on the health gains that result from investment in housing. Thomson, 2001: 189 21

3.2 Wealth and Health: Income, Equity and Social Status

The literature provides compelling evidence, unrelated to HIV/ AIDS, associating wealth with health. This pattern is evident throughout the income distribution ladder 25 and implies that a nation s economic structure and commitment to income equity may be the most important determinant of health. 26

That wealthy people live longer and have lower morbidity, on average, than do poor people has been well documented across countries, within countries at a point in time, and over time with economic growth. Case, 2001: 1

Consequently the United States, in spite of its wealth, scores lower in terms of health outcomes than do many other, seemingly less wealthy countries. 27 According to a study undertaken for the Rockefeller Foundation and the Swedish International Cooperation Agency, even within the United States, people living in the most affluent counties can expect to live 16 years longer than those in the poorest counties. Similarly Hogg et al. have calculated that after adjusting for age, lower income men experienced a mortality risk about 60% higher than that of higher income men. 28

In other words, regardless of overall wealth, those countries with smaller gaps between rich and poor are healthier than those in which the gap is larger. 29

Importantly, income inequities serve as proxy measures for other socio-economic inequities. In general, those with lower incomes are also those with lower educational attainment levels, higher rates of unemployment and fewer social supports. In the United Kingdom, the Terrance Higgins Trust the country s largest HIV/ AIDS-related organization emphasizes the impact of social exclusion on health and well-being, with social exclusion [ being ] a shorthand term for what can happen when people suffer from a combination of linked problems, such as unemployment, poor skills, low incomes, poor housing, high crime environments, bad health and family breakdown. 30

The concept of social exclusion provides an entrée into the discussion of health, wealth and HIV/ AIDS. Numerous research projects, dating back to the early 1980s, have identified an association among poverty, disadvantage, social exclusion, drug use and other factors that place people at higher risk of HIV infection. 31 Using monitoring data from community-based agencies in London, for example, O Brian and Tierney conclude that those living with HIV/ AIDS as a result of injection drug use are most commonly poor, early school leavers, unemployed and powerless.32 Their vulnerability to HIV infection is
determined by "the degree of control [they] ... have over life circumstances and, hence, their capacity to take action."33

AIDS is a disease of low socio-economic status ...a disease of poverty. Toronto Star, 1991: A13

Research Findings

The literature suggests that people with low incomes are more likely than those with higher incomes to be at risk of HIV infection, to have HIV/ AIDS, to progress from HIV to AIDS and to succumb to AIDS more quickly. The following are drawn from research undertaken by respected researchers, for example Martin Schechter and Steffanie Strathdee in Vancouver, and/ or published by credible sources such as the Centers for Disease Control and Prevention in the United States or Health Canada. The examples generally reflect the larger body of research.

Women from five low-income neighbourhoods in California had an HIV prevalence rate that was more than four times that of all women in the state. The California study was a one-stage, cluster-sample, population-based, door-to-door, cross-sectional survey of the prevalence of HIV infection, sexually transmitted diseases, hepatitis A, B and C, and related risk behavior. 34 The research team contacted almost 20,000 dwellings and interviewed over 2,500 participants. Similar outcomes were evident in a Quebec study indicating that HIV-infected mothers were more likely to reside in regions with incomes below the provincial median.
An Australian study published in AIDS Care found that 32% of people living with HIV/ AIDS had incomes that left them below the poverty line. It also noted some association between poverty and progression from HIV to AIDS. The author linked poverty and unemployment, and noted that two-thirds of people living with HIV/ AIDS reported they had left work for reasons related to their condition, and only one-third subsequently returned to work. 35
A Vancouver study published by the BC Centre for Excellence in HIV/ AIDS part of a decade-long examination of people living with HIV/ AIDS also found socio-economic status prior to infection to be associated with both disease progression and the chances of survival even after adjusting for CD4 count, age at infection, year of infection and use of HIV therapies and prophylaxis. 36 An article published in the Journal of Acquired Immune Deficiency Syndromes associated the nutritional deficiencies resulting from poverty with disease progression and survival among HIV-infected women. 37
A further study from the BC Centre for Excellence in HIV/ AIDS also associated poverty and HIV/ AIDS. It indicated that HIV-positive gay men with annual incomes less than $ 10,000 experience illness-related weight loss at a significantly faster rate than do those with higher incomes. 38 Meanwhile an American study indicated that gay men generally have lower mean personal incomes, lower mean household incomes and experience greater poverty than do heterosexual men. 39 A Health Canada-funded study of some 2000 people identifies the impact of this economic disadvantage: gay men with incomes less than the poverty line were twice as likely as more affluent gay men to die within ten years of contracting HIV. 40 Other BC Centre for Excellence studies indicate that those engaging in high-risk behaviours had lower incomes and were younger than non-risk takers. 41 Young gay men with less than a high school education were nearly twice as likely to be risk takers. 42

Conclusions and Policy Implications

The research findings suggest an important association between poverty, behaviours that place people at risk of HIV infection and both disease progression and life expectancy once infected. The reason very likely is that poverty, and the educational and other consequences of poverty, limit the choices available to people and compromise their ability to avoid high-risk situations. Some low-income people, for example, cannot afford even condoms while others may have to engage in commercial sex as a survival strategy. Furthermore: the links between poverty and HIV/ AIDS are bi-directional. On the one hand, poverty contributes to vulnerability to HIV and exacerbates the impact of HIV/ AIDS. On the other hand, the experience of HIV/ AIDS by individuals, households and communities that are poor readily leads to an intensification of poverty. Thus, HIV/ AIDS frequently impoverishes people in such a way as to intensify the epidemic itself. 43

HIV disease is a disease of the vulnerable, especially in the presence of marginalization and poverty. To be vulnerable in the context of HIV and AIDS means to have little or no control over one's risk of infection or acquiring HIV, or, for those infected or affected by HIV, having little or no access to appropriate treatment, care and support. Canada, House of Commons, 1996: 1/ 32

Very simply, HIV/ AIDS is both the result and a cause of poverty in Canada. 44

Poverty creates an environment that assists the spread of HIV, while the increase in illness and death associated with AIDS increases levels of poverty. European Commission, 1999: 1

This pattern does not bode well for future efforts to prevent the spread of HIV/ AIDS given that Canadians became poorer in the 1990s as average and real incomes declined and as income disparities between rich and poor widened. 45 Compounding the situation are the cutbacks in the social safety net [ that ] have pushed more people to the margins of society.
In general there are fewer social buffers and the bridges to a better life are lacking for many. 46

The policy directions required to address this situation are simple to conceive but difficult to achieve. The effort to prevent HIV/ AIDS and to ameliorate the consequences of living with HIV/ AIDS requires policies that will:

reduce both absolute and relative poverty, and ensure a more equitable distribution of Canada s wealth;
promote community development efforts that prevent children, youth and adults from being relegated to the social and economic margins of society;
enable those already marginalized by poverty to return to the mainstream; 47 and
acknowledge and offset the economic burdens associated with HIV/ AIDS and other disabilities.

3.3 Early Childhood Experience

Poverty clearly has an impact on the life-long health and well being of children. Children who grow up in poverty have a powerful strike against them when it comes time to live in an adult world. Children from low-income families are more likely than others to be living in inadequate housing and less likely to complete their high school education. They are less likely to obtain the post-secondary education and training that increasingly is the key to a stable future, and more likely as adults to be unemployed and receiving social assistance. They are less likely to enjoy good health both as children and as adults. Indeed the literature presents evidence that a family s long-term average income is a powerful determinant of children s health status The health of children from families with lower incomes erodes faster with age, and these children enter adulthood with both lower socioeconomic status and poorer health. 48

Conversely the literature indicates that a safe, secure and nurturing environment can compensate for family poverty and that broadly based developmental efforts can prevent many of the social and economic outcomes associated with poverty. Most commonly cited in this literature is the precursor of the Head Start program in the United States, the High/ Scope Perry Pre-school Program in Ypsilanti, Michigan. Established in 1962, the program has become the cornerstone of a body of longitudinal research that permits definitive statements about the value of early childhood education for children from low-income families. 49

Intuitively it makes sense that children who are well nourished both physically and emotionally will grow into healthier adults. Conversely, children who are in emotional turmoil, neglected, rejected and poorly supervised are easily manipulated and abused. 50 Ultimately these children are at higher risk of living in poverty and on the street, and of engaging in the drug and sexual behaviours that place them at higher risk of contracting HIV.

Findings

The HIV/ AIDS-related literature devotes some attention to the early childhood experiences of those who are at higher risk of contracting HIV or who are living with HIV/ AIDS. It devotes particular attention to sexual abuse and its clear association with risk-taking behaviours. The literature s methodology, however, often relies upon participant surveys and often is not supported by entirely appropriate control or comparison groups.

A number of studies associate a history of physical abuse, sexual abuse or rape with engaging in a variety of HIV risk behaviours and to a continuation or increase in the total number of these behaviours between adolescence and young adulthood. One study undertaken at the George Warren Brown School of Social Work at Washington University involved a random sample of 602 youths drawn from a group of almost 2,800 patients seen at public health clinics in ten cities. It included structured in-person interviews conducted through a period of ten years. 51
Of the 327 homosexual and bisexual men participating in an ongoing study pertaining to risk factors for HIV infection, 35.5% reported being sexually abused as children. Those with a legacy of abuse reported having more lifetime male partners and a greater incidence of having engaged in unprotected, receptive anal intercourse. 52 These findings are consistent with an older study in which over 1000 homosexual or bisexual men were interviewed. That study also found a significant association between sexual abuse and HIV risk behaviour including unprotected intercourse and injection drug use. 53 Peer-reviewed articles in the American Journal of Orthopsychiatry and the American Journal of Preventive Medicine serve to affirm these findings. They associated early sexual abuse with a higher incidence of sexual and physical assault as an adult, with high-risk behaviours such as alcohol and cocaine abuse, anal intercourse, prostitution and with not using condoms. 54
Reinforcing the importance of early childhood experiences is a host of studies conducted by leading researchers with the BC Centre for Excellence and presented to a variety of local, national and international audiences or published in major journals. In some of these studies, sexual abuse was independently associated with a two-fold increase in sexual risk-taking among young men who have sex with men. It was also one of the strongest predictors of needle sharing among injection drug users in Vancouver. 55 Indeed drug addicts with a history of abuse were three times more likely to share needles than were those who had not been abused. 56 Young gay men with a history of sexual abuse were twice as likely to be risk takers while both male and female injection drug users with a history of sexual abuse were three times more likely to share needles than were those without such a history. 57 Of particular importance was the finding that sexual abuse was an independent predictor of [ needle ] borrowing among both male and female IDUs. 58

Those sharing needles reported their abuse having occurred at all ages and for 53% of the respondents, this experience preceded their first experience with drugs.

...the lingering effects of sexual abuse, incest and rape are helping to drive the spread of HIV among both drug addicts and young homosexual men. Vancouver Sun, 1996

Conclusions and Policy Implications

According to Steffanie Strathdee, one of the most active and prolific researchers exploring the early experiences of those people engaging in high-risk behaviours, a history of sexual abuse is one of the many missing pieces of the puzzle that may help to account for the inability to adopt or negotiate safer sex practices. 59 An earlier study published in the Australian AIDS Care journal complemented this conclusion by suggesting that among youth, sex on any terms was motivated by their search for the love, caring, affection and protection denied them during their earlier years. 60

These findings serve to highlight the policy directions required as part of the effort to address the HIV/ AIDS epidemic in Canada. None of these directions, however, are new to the policy table.

Ensure the physical and emotional security of children and youth during their formative years. Health Canada has noted, for example, that many behaviour patterns are established that will affect a young person s risk of HIV infection, both within this time span and throughout his/ her adult years. Early intervention is an important step in helping youth to adopt and to maintain protective behaviours. 61
Provide sexual abuse counselling as an integral part of HIV prevention and treatment efforts, and HIV/ AIDS risk-reduction counselling as an integral part of efforts directed at sexual abuse.
Develop a partnership between the National Children s Strategy and the Canadian Strategy on HIV/ AIDS, in recognition of the former s ability to contribute to the latter. Early childhood development efforts will reduce the number of people contracting the HIV virus in the future.
Consider the health outcomes and costs associated with HIV/ AIDS treatment and care when determining the cost/ benefit associated the National Child Benefit and its impact on family poverty.

3.4 Social Support, Social Cohesion and Discrimination

The literature suggests an important association between social support, social inclusion and social cohesion on the one hand and positive health outcomes on the other. Social supports enable people to negotiate life s crises. Social cohesion helps to stabilize health-threatening situations by including and accepting people, and by enabling them to participate fully within our families, our communities and our society. 62

In the nineteenth century, school promoters often argued that schools were cheaper than jails. In the twenty-first century, we might develop a similar argument, that social and economic inclusion is cheaper than hospitals. Guildford, 2000: 16

As such, these are particularly important to those marginalized groups who are at highest risk of contracting HIV and to those who are living with HIV/ AIDS. Like other vulnerable populations, the well being of people living with HIV/ AIDS depends upon the presence of a network of formal and informal supports and services. For many, a supportive environment can enhance their quality of life and extend their very survival. Yet for people forced to the margin of society because of their sexual orientation, ethnicity, culture or addictions, these supports are often inadequate or inaccessible. 63

HIV/ AIDS is a behaviour-based disease. However it is not spread only by the behaviour of those engaging in high-risk activities. It is spread also by the discriminatory behaviour of people and governments. In the United States for example, gay and lesbian lovemaking is a criminal act in twenty-three states. Openly gay and lesbian people are considered unfit for military service and their issues are considered inappropriate for discussion in the public school system. In both Canada and the United States, we condemn gay promiscuity, but then tell gay and lesbian couples who desire to make their commitment to each other that they are somehow a threat to the family. 64

Prejudice, discrimination and stigma have played a central and defining role in the history of HIV/ AIDS in Canada and [ h ] istorically, where discrimination exists, the virus is more likely to proliferate. 65 Discrimination occurs when particular aspects of some people with HIV/ AIDS, such as sexual orientation or drug use, are magnified to the exclusion of the individual humanity of each person with HIV/ AIDS and the diversity of all people with HIV/ AIDS. 66 Discrimination and stigma are reinforced when even professionals describe injection drug users or sex workers not as people but rather as vectors of disease. 67 And discrimination and stigma can manifest themselves as violence. Studies undertaken in both the United Kingdom and Vancouver document the high level of violence directed toward gay men. 68

Discrimination is a health care concern.... Canada, House of Commons, 1996: 4/ 32

The stigma and discrimination are reinforced by the too-common perception of those groups most at risk gay men, commercial sex workers, Aboriginal people and injection drug users and continue in spite of two decades of public education. As late as 1997, 17% of the American public endorsed the idea of quarantining people with HIV/ AIDS while 19% thought the names of those who are infected should be publicized. Twenty-nine percent agreed that people who acquired AIDS through sex or drug use got what they deserved. 69

The initial identification of HIV among these marginalized groups has had a lasting impact on the way in which the disease is perceived .... Ruiz, 2000: 77

Findings

The literature provides evidence associating HIV/ AIDS and the absence of those social supports that enable people to negotiate life s crises.

A study conducted by the University of Pennsylvania concluded that interventions with parents that improve social cohesion in the family constitute effective strategies for discouraging adolescents from engaging in high-risk behaviours. The conclusions were based upon surveys of a stratified cross-section of over 350 African-American children living in public housing. 70
Other Health Canada funded research indicated that HIV-positive gay men with strong family support were less likely to engage in high-risk behaviours. 71 Based upon a literature review and endeavouring to place gay men s health into a population health context, the report concluded that a person s ability to incorporate safer sex practices is closely associated with high self-esteem, solid social supports, positive sexual identity and belonging to a peer group. Young gay men, it suggests, are often lacking all of these. 72 Similarly an Australian study published in AIDS Care associated social support with a reduction in high-risk behaviours among those using injection drugs. 73 That particular study investigated the structural and functional nature of the social support networks available to 100 injection drug users in Sydney, 60% of whom were male and 40% female.

A study published in the International Journal of STD & AIDS indicated that those people living with HIV who had adequate social support adapted more fully to the illness crisis, demonstrated less anxiety and depression and had fewer somatic complaints than those without such support. This longitudinal study tracked almost 140 patients associated with the University of Nebraska Medical Center and with Veterans Affairs medical centers in California and Pennsylvania. It endeavoured to associate perceived Quality of Life ( QOL) with satisfaction with social supports, employment, education, marital status, race and a variety of other potential factors. 74

A similar longitudinal study, tracking 82 HIV-infected gay men through a period of almost six years, associated more rapid disease progression with heightened stress and fewer social supports. At 66 months, those above the median in terms of social support had a 40% higher probability of being free of AIDS compared with those below the median. 75

Work undertaken by the BC Centre for Excellence and both published in The Clarion and presented to the XIth International Conference on AIDS, indicated that female injection drug users with greater symptoms of depression were more likely to share needles. Psychological distress, rather than access to clean needles, was strongly associated with needle sharing. 76
Studies undertaken in 1991 for the United Nations HIV and Development Programme and in 1998 at Macquarie University in Australia provide further insights into the importance of social support. Both indicate that sexually confident, well-educated gay men who are socially engaged with the gay community are more likely to have changed their sexual behaviour than gay men who are not attached to the gay community. They have the informed social support necessary to modify their behaviour while men who are isolated from others like themselves are least likely to change. 77 The importance of gay community attachment was affirmed in a later Australian study. 78

Conclusions and Policy Implications

Discrimination and stigma compromise efforts to prevent HIV/ AIDS, to control its spread and to provide treatment and care. They severely compromise the ability of people to manage their condition by creating stress, increasing social isolation and discouraging efforts to access health care services. The National Academy of Sciences in the United States further notes that: fear of discrimination is a major constraint to the wide acceptance of many potentially effective public health measures. Public health measures will be most effective if they are accompanied by clear, strict sanctions to prevent unwarranted discrimination against those who are HIV-infected or at risk for infection. 79

The protection of the human rights of vulnerable groups is a key aspect of reducing transmission, as social exclusion can increase transmission and impact of HIV/ AIDS All Party Parliamentary Group, 2001: 1

This implies a need for policy efforts, at both the national and the community level, designed to enhance social cohesion and social inclusion. In this AIDS crisis, the number one factor in helping any person young or old, gay, lesbian, bisexual or heterosexual take the necessary steps to avoid HIV is to give that person a sense that they have the potential for a bright and productive future. If they are not told that, how can they be persuaded to put on a condom, stop drinking or stop abusing substances. 80

Significantly, the success of various HIV/ AIDS interventions has been shown to be directly proportional to the degree to which human rights are promoted and protected .... These realities, demonstrated time and again over the course of the HIV/ AIDS epidemic, make clear that the protection and promotion of human rights must be an integral component of all responses to the epidemic. All Party Parliamentary Group, 2001

Further policy directions will require effort from a spectrum of people in the country.

Health professionals bear a significant responsibility for efforts to reduce discrimination and promote social cohesion. They must understand that promoting and protecting human rights are essential for promoting and protecting health since discrimination ( and other human rights issues) were found not only to be tragic results of the pandemic but to be root societal causes of vulnerability to HIV. 81

Many of the addicts [in Vancouver's downtown east side] simply don't seem to care that they are spreading AIDS Cernetig, 1997: A2 77 Carr, 1991: 3/ 13.

Improve the social supports available to and the coping skills of men and women who inject drugs in the expectation that such could reduce their needle-sharing behaviours. 82 Address addictions, in the community and in correctional institutions, as a health and social problem rather than as a criminal justice issue.
HIV treatment must address not only the physical needs of patients but their emotional and social needs as well since progression to AIDS is delayed among those who have an adequate social support system in place.

Leaders at all levels, from politicians to religious leaders to local heroes, need to challenge HIV-discrimination, spearhead public campaigns, and speak out against the multiple discriminations that poor people, women, ethnic minorities and gay men face in relation to HIV/ AIDS. Peter Piot, 2001

3.5 Race and Gender

Increasingly the HIV/ AIDS epidemic is turning toward minority populations. In the United States in 1995 for example, African Americans represented approximately 12% of the population and 40% of newly reported HIV infections while Hispanics represented 9% of the population and 19% of new cases. 83 In Brazil, HIV/ AIDS now rages in the favelas of Rio de Janeiro and Sao Paulo while in Ethiopia, it is devastatingly embedded among the poor and dispossessed. In Canada, meanwhile, the epidemic increasingly is striking at Aboriginal people and their communities. The pattern is clear:

[ In every society ] those people who were marginalized, stigmatized and discriminated against before HIV/ AIDS arrived have become over time those at highest risk of HIV infection. Regardless of where and among whom it may start within a community or country, the brunt of the epidemic gradually and inexorably turns towards those who bear this societal burden. 84

While less than 3% of the Canadian population is Aboriginal, the proportion of AIDS cases attributed to this community increased from 1% before 1990 to 15% in 1999. In 1999, Aboriginal people were five times more likely to have AIDS than other Canadians. 85

Health equity is best thought of not as a social goal in and of itself, but as inherently embedded in the pursuit of social justice. Evans, 2001

Meanwhile in British Columbia, Aboriginal people make up about 5% of the population but 19% of those newly testing positive for HIV 86 and in Saskatchewan, they comprise 15% of the population but almost 48% of new cases ( 1997) . 87

Although the literature often implies Aboriginal ethnicity as a risk factor and routinely reports numbers specific to this population it is difficult to conceive of their vulnerability being associated with race. Indeed to imply such is offensive in the extreme since [ r ] ace and ethnicity are risk markers that correlate with other more fundamental determinants of health status such as poverty . 88 The population health literature suggests their vulnerability is associated with the many difficult social, economic and behavioural factors too often evident in their communities.

Findings

The extent of the epidemic s incursion into Aboriginal society and communities speaks to the social and human rights problems evident in this country. The incarceration, suicide, drug and alcohol use and poverty rates are all very significantly higher among Aboriginal people in Canada than among the non-Aboriginal population. 89

One could add to this potent prescription for infection, the lower levels of education, the greater social stress and the greater emotional distress evident in Aboriginal communities. One could add also the living and housing conditions, both on and off reserve, that exacerbate the problems confronting Aboriginal people living with HIV/ AIDS. People without sufficient income and living in substandard housing cannot maintain and often do not care about maintaining the level of good physical health that is required to manage the infection.

Aboriginal people with HIV/ AIDS live with many layers of stigma and discrimination. de Bruyn, 1998: 58

In other words, Aboriginal people are at increased risk of HIV infection not because they are Aboriginal but because of the social determinants associated with risk of infection. 90 Furthermore, the conditions associated with race influence the health outcomes following infection. In the United States, for example, the literature speaks of African American cynicism with the medical system. Authors suggest the Tuskegee Syphilis Study has been a powerful symbol of racism in medicine, misconduct in human research, the arrogance of physicians and government abuse of black people. 91 The consequence of this cynicism and symbol is that African Americans are more reluctant to participate in clinical trials and to benefit from such efforts. 92

At times, different vulnerabilities combine with consequences that are even more devastating. In North America this is glaringly evident when race and gender intersect. Although African American and Hispanic women comprise less that 25% of all women in the United States, they account for more than 75% of AIDS cases among women. 93

The literature presents a parallel between gender and race in terms of HIV/ AIDS vulnerability. There are gender-based differences certainly. Women are more vulnerable than men to HIV infection for biological reasons and studies suggest that male-to-female transmission of HIV is twenty-four times as efficient as female-to-male transmission. 94 However, women s biological susceptibility to HIV/ AIDS is certainly exacerbated by their social and economic circumstances. For example the literature speaks:

about how a lack of economic resources can force women into survival sex where condom use is difficult to negotiate. 95 A good deal of the literature suggests that many women have to depend on sexual relationships for economic survival, again reducing their bargaining power. Over Mead gives voice to a common theme when she suggests that both poverty and income inequality facilitate and speed the spread of HIV/ AIDS. 96
of the association between abuse, violence and HIV vulnerability. Elizabeth Whynot, writing in the Canadian Medical Association Journal states that [ f ] or women, previous sexual or physical victimization may be a predisposing factor in

[ the ] drug abuse that places them at higher risk of HIV infection. 97 Meanwhile findings from a survey of 110 HIV-infected women, also presented in the Canadian Medical Association Journal indicated that 53% had been sexually assaulted as an adult, 43% had been sexually abused as a child and 27% had been sexually abused or assaulted as both a child and an adult. Women who were so abused were almost seven times more likely than those who were not to have injection drug use as a risk factor. Fifty-four percent of those with a history of sexual abuse during childhood had injection drug use as a risk factor compared to 8% of those without such abuse. 98

The bleak reality is that the sexual and economic subordination of women fuels the HIV/ AIDS epidemic. UNAIDS, Agenda for Action, n. d.

91 Gamble, 2000.
92 Auerbach, 2001: v.
93 CDC, 1997.
94 UNAIDS, Agenda for , n. d. : 6/ 13.
95 arkin, 2000: 4/ 10.
96 Mead, 2001: 47-49.
97 Whynot, 1998. 35

The literature is overwhelming in this regard. Using data gathered from 1100 women at risk of HIV infection, Health Canada indicates that over 67% reported sexual or physical violence by a current or past partner, while 33% had been victims of childhood sexual abuse and 15% of childhood physical violence. 99 Similarly a presentation to the XIth International Conference on AIDS documented the high prevalence of domestic violence and childhood abuse among women with HIV and among women at high risk of infection. 100 Other research indicated that abused women were four times more likely than others to engage in high-risk sex. 101

Women in Canada are at increasing risk for HIV infection and illness progression for the same reason as women and other marginalized groups around the world are: we share a position on the bottom rung of the social ladder in inegalitarian societies. Kellington, 2000

All their life experiences teach them that they have very little control over < their futures. Sack, 2001

Conclusions and Policy Implications

Peter Piot, Executive Director of UNAIDS, leaves little doubt about the source of women s vulnerability to HIV/ AIDS. It derives from contexts in which they have little control over sex, whether as a consequence of the predominating power relations between men and women or as a function of the economic and life choices available to them. In turn the impact of the epidemic further increases their vulnerability as women and girls from families whose economic well being has been weakened by AIDS may have to resort to the sex trade for their livelihoods. In this context planning for the future becomes a more distant goal in the face of current devastation. 102

It is the grotesque, world-wide inequality, powerlessness, poverty and violation of women and girls that is fuelling the rapid-fire spread of the AIDS epidemic. Landsberg, 2001: A2

HIV/ AIDS, in other words, is caused in part by the poverty and powerlessness of women, and in turn at the same time increases their poverty and powerlessness by imposing either health or caregiving obligations. The social framework of gender encircles and affects women s capacity and health. 103

The policy implications of these findings are clear.

It is important not to confuse race with racism or attribute HIV vulnerability to race and gender rather than to the discrimination so often associated with these characteristics.
Ensure that women, Aboriginal people and other stigmatized and marginalized groups are free of discrimination and can share equitably in the opportunities available in this country.
Develop innovative activities targeting boys and girls that will promote more equitable and mutually respectful attitudes and behaviour. Develop coherent national policies, strategies and plans directed to this purpose.
Incorporate efforts to address domestic violence in HIV/ AIDS risk reduction and care strategies.

There is a direct correlation between women's low status, the violation of their human rights and HIV transmission. This is not simply a matter of social justice. Gender inequality is fatal. Noeleen Heyzer, Executive Director, UNIFEM (Gender-AIDS, 21/ 1/ 001)

3.6 Housing and Homelessness

Inadequate housing has long been used both as an indicator of poverty and as an intervention designed to improve public health. As early as 1944, the London Association for Education in Citizenship identified the three evils associated with inadequate housing:

There is diminished personal cleanliness and physique leading to debility, fatigue, unfitness and reduced powers of resistance. A second result of bad housing is that the sickness rates are relatively high, particularly for infectious, contagious and respiratory diseases. Thirdly, the general death rates are higher and the expectation of life is lower. The evidence is overwhelming and it comes from all parts of the world the worse people are housed, the higher will be the death rate. 104

The basic human need for shelter makes the relationship between poor housing and poor health appear self-evident. Thomson and Petticrew, writing in the British Medical Journal suggest that despite this intuitive relationship or perhaps because of it good research evidence is lacking on the positive health outcomes that may result from an investment in housing. They attribute this to the methodological obstacles inherent in exploring that relationship with the most formidable of these being that poor housing invariably exists alongside of other key health determinants. Similarly, housing improvements usually occur in tandem with other efforts to address social and economic needs. 105

Generally, however, the literature acknowledges the relationship between poor housing and poor health. Stephen Hwang, for example, notes in the Canadian Medical Association Journal that Homeless people are at increased risk of dying prematurely and suffer from a wide range of health problems. Homeless people also face significant barriers that impair their access to health care. 106

Meanwhile homelessness is increasingly problematic in Canada. The number of homeless people in Canada doubled between 1992 and 1998 and now, each night, perhaps 8000 people in the country s nine largest cities are sleeping in shelters. As many as 40,000 people families, single men, single women and youth use these shelters at least once through the course of a year. Aboriginal people are especially prominent in the shelters, accounting for 35% of the homeless population in Edmonton and 11% in Vancouver. 107 Until the very recent ( 2001) federal/ provincial/ territorial agreement, only the Government of Quebec appeared committed to enhancing its stock of social housing.

Findings

The HIV/ AIDS-related literature focuses largely on the issue of homelessness. It emphasizes that people living with HIV/ AIDS require housing that is adequate, accessible and affordable, particularly in the inner cities where most people with HIV/ AIDS live in order to access services. 108

The crises of homelessness and HIV are two of our country's greatest challenges. Rather than existing independent of each other, they are inextricably interwoven Adams, n. d.

Over a decade ago, the Australian National HIV/ AIDS Strategy ( 1989) identified the homeless as a group at particular risk of contracting HIV. A series of studies confirmed the alarm. A 1990 study of 40 homeless youth in Brisbane, published in the Medical Journal of Australia, indicated that the homeless had significantly less knowledge than a control group about HIV transmission and prevention. The homeless group were also more often involved with prostitutes, used condoms only infrequently and shared needles. 109 Interviews conducted in 1989 with 200 homeless young people in Melbourne found that 75% of the females and 62% of the males described themselves as drug or alcohol dependent. In Sydney, a survey of 92 young homeless people found that 36% of females and 64% of males reported sharing needles at least occasionally. 110

A comparative study of Anglo-Australian and Greek-Australian youth, published in AIDS Care suggested that the homeless were at considerably higher risk of HIV infection than were their home-based peers as a result of both their sexual and drug activities. Homeless adolescents not only engaged more frequently in risky sexual practices but did so with a comparatively large number of partners. This study s design included qualitative interviews and questionnaires with a total of 163 young people divided into participant and comparison groups. 111

Australia has also been particularly sensitive to the risk of HIV infection among homeless people with mental health problems. Interviewer-administered questionnaires completed by 145 patients with chronic mental illnesses in Australia showed alarming patterns. Sixteen percent of respondents reported injection drug use, a figure approximately 10 times that found in the general population. Almost 13% of male respondents reported sex with another male, including 9% who engaged in anal sex, while 19% of females reported sex with a bisexual male. Nearly half of the males reported sex with a prostitute, 2.5 times the rate evident in a comparison group. Meanwhile only 16% of this population reported ever receiving information on HIV even though one-third reported having been tested for the virus. 112

One can speculate that Australia s early awareness of the risks associated with homelessness has contributed to it now having one of the lowest infection rates in the developed world.
In the United States, a comprehensive study prepared for the federal Department of Health and Human Services has estimated that between one-third and one-half of all people with AIDS are either homeless or at imminent risk of homelessness. Conversely, 15% of homeless Americans are infected with HIV. The study also found that homeless psychiatric patients at a New York shelter for men had an HIV prevalence rate double that of similarly aged men in the same inner-city community. 113

Also in the United States, the American Civil Liberties AIDS Project tracked the spread of HIV in sixteen American cities during the 1980s and early 1990s. It identified a median HIV seroprevalence of 3.4% for homeless adults compared to less than 1% among the general population. More recent studies have found HIV infection rates of 8. 5% among homeless adults in San Francisco and 19.4% among homeless, mentally ill men in New York City. A survey of homeless adults found that 69% were at risk of HIV infection because of their sexual or drug use practices, with 45% reporting at least two risk factors combined and 26% reporting three or more risk factors. 114

Similarly the Journal of Epidemiology and Community Health reporting on the situation in Philadelphia, found that people in public shelters had a three-year rate of subsequent AIDS diagnosis that was nine times that among the general population. A history of substance abuse, male gender and a history of serious mental disorder were significantly associated with the risk for AIDS diagnosis. The authors, associated with the University of Pennsylvania and the City of Philadelphia Health Department, used multiple decrement life tables analyses and logistic regression analyses to identify risk factors associated with AIDS among the homeless. 115
The Canadian literature is much more sparse with regard to homelessness although it has indicated that gay adolescents and youth are disproportionately represented among the homeless in Canada. 116 Researchers with the BC Centre for Excellence found that injection drug users with unstable housing were twice as likely to become infected with HIV 117 and significantly more likely to report emergency department and hospital use, likely a reflection of their disorganized lifestyle or poorer health status. 118

Conclusions and Policy Implications

HIV/ AIDS and homelessness each represent a social crisis. Combining the two creates a level of social marginalization that has profound implications for both public health and the HIV/ AIDS epidemic.

Access to safe, affordable housing helps people living with HIV/ AIDS and marginalized people to follow medical and drug treatments. Housing is essential to their long-term stability. BC, Minister's HIV/ AIDS Advisory Committee, 2000: 6

Homelessness and by implication poor housing clearly place people at higher risk of contracting HIV. Homelessness obliges people to engage in hasty sexual encounters in which condoms are rarely considered let alone used. It compromises their ability to insist upon safe sexual practices particularly if they must trade sex for shelter and penetration for protection. Homelessness leaves young people already hurting even more vulnerable to exploitation and abuse. It may oblige them to share needles since they do not have a private and safe place to keep their own injection equipment. The country s criminal code response to drug use only exacerbates this situation.

Homelessness and inadequate housing also make it more difficult for people to manage and live with their HIV/ AIDS. Without secure housing, people do not have the stability required to maintain their treatments or their pharmacological regimens. Indeed their housing situation will make long-term health issues pale in comparison to their immediate distress and may well compromise even their interest in changing behaviours and pursuing, receiving and sustaining treatment. Furthermore, homelessness compromises community efforts to provide information and to prevent infection.

The literature carries important implications for policy and programming. - Stabilize people s lives through safe and secure shelter and in that way prevent harm and reduce the likelihood of HIV infection. These efforts must enable the homeless including those with mental illnesses to escape the street and to address the issues that relegated them to the street in the first place.

Target people at risk of HIV infection in efforts to prevent homelessness and to provide social housing. Conversely HIV prevention programmes should target homeless people and particularly those with mental illness issues. These are often one and the same populations. 119
Ensure that staff in shelters for the homeless are better informed on HIV/ AIDS issues and are prepared both to identify the signs of HIV/ AIDS-related illness and to encourage safer sexual and drug practices. Staff must be prepared for the significant challenge of forming trusting relationships and making consistent contact over time to help improve clients situations and promote behaviour change. 120

3.7 Health Services

Most consider the health care system as being one of the important contributors to population health although Hobbs and Jamrozik, in the Oxford Textbook of Public Health suggest there are few studies demonstrating the impact of medical services on the health of populations as opposed to that of individuals. 121 Indeed one study presented in the Journal of the American Medical Association argues that the acute health care system itself inflicts significant harm. 122 Other studies describe health care services as the ambulance waiting at the bottom of the cliff to rescue those cast off by society s social structures. 123

Medicine usually fails marginalized people. Smith, 1999: 1/ 5

Nevertheless it can be assumed that most people have considerable faith in the health care system and seek its services. 124 That assumption may not hold, however, for many of those at risk of HIV infection or living with HIV/ AIDS. Indeed the health system itself is in part responsible for the poor health outcomes evident in these populations. For many women and others in marginalized groups, there are significant barriers blocking their access to treatment. A Health Canada and UNAIDS study suggests that the lack of provider-client trust and of women-centred research, and general mistrust of confidentiality laws continue to exacerbate the fatalism of women, people of colour and marginalized groups regarding
the manageability of living with HIV or AIDS. 125

Very simply, access to care and appropriate treatment are not available to many in those very populations that require the best of medical care.

Findings

A study undertaken by the Centers for Disease Control and Prevention in the United States indicated that the majority of those with HIV/ AIDS as a result of injecting drugs are not receiving optimal drug therapy. Similarly a Baltimore study employing cross-sectional survey techniques and reported upon in the Journal of the American Medical Association concluded that only one in seven HIV-infected IDU patients received the most currently recommended therapy. In fact, only half of HIV-infected injection drug users being treated at Johns Hopkins and the University of Maryland cutting edge AIDS care providers received anti-retroviral treatments.

The Baltimore study also indicated that even those who no longer used drugs were denied optimum treatment, often because of their physicians concern that they would not, or could not, comply with the treatment regimen. The Director of the Brown University AIDS program offered another reason, namely that doctors discriminate against HIV-infected IDUs and often believe that once a user, always a user. 126
This pattern appears in Canada also even though access to health care and treatment is largely guaranteed and free. AIDS Alert reported on a Steffanie Strathdee study indicating that only 40% of 177 patients received any antiretroviral therapy. 127 Similarly an article published in the Canadian Medical Association Journal indicated that 17% of HIV-positive women reported having had doctors refuse to see them because of their status. 128 The results were drawn from a 75-item questionnaire distributed through community AIDS organizations and physicians offices. A total of 110 HIV-positive women responded to this survey.

This pattern is evident also in the results from a survey of dentists practising in Canada. The survey was mailed to a random sample of all licensed dentists in Canada ( n= 6444) and enjoyed a response rate of 66% . The data were weighted to allow for probability of selection and non-response and analyzed using various econometric techniques.

The data revealed that 16% of dentists would refuse to treat HIV-infected patients. Eighteen percent were unwilling to treat homosexual and bisexual persons or patients with a history of sexually transmitted diseases while 10% were unwilling to treat recipients of blood and blood products. At the same time, 87% said they were perfectly capable of safely treating a person with HIV. 129
A Health Canada and UNAIDS study suggested that those using injection drugs and sharing needles have the least access to care for two reasons. Socially isolated and often living with a mental health problem, they seldom seek any kind of health care. Additionally Canada and many other countries has a drug policy that is more likely to imprison drug users than provide health care or the range of other social supports that could allow them to address their drug and other problems. 130

Conclusions and Policy Implications

It is more than a quarter century since Julian Hart published his famous paper on the inverse care law which suggests that those who most need medical care are the least likely to receive it. 131 The application of this law is most obvious on a global level where the highest rates of sickness and premature death are in the developing world while high quality medical care is concentrated in the developed world.

John Mann has used this law to argue that when HIV is introduced into a society it will eventually be concentrated among those whose rights are most neglected the babies of women too poor to have their HIV infection diagnosed or treated, prostitutes whose clients refuse to wear condoms, and addicted prisoners who are denied access to clean needles and pure drugs.

Most doctors will encounter patients struggling with their addictions and some will be reluctant to accept them into their practice. The perception is that this group is likely to create more difficulties and to have more demanding medical needs than other patients. In essence, because the health care system is designed for compliant groups, HIV infected injection drug users are discriminated against when attempting to access this care. 132 The literature suggests this applies as well to other groups on the margin, including homeless people, those who are mentally ill, refugees and many youth.

With all marginalized groups the poorer standard of care seems to stem from a combination of ignorance, fear and prejudice plus a feeling that they should adapt to the services rather than the other way around Smith, 1999

The policy directions to be pursued, therefore, are numerous. - Ensure quality treatment is accessible to people living on the margins of mainstream society, and that the medical care system can reach out to these groups. The health care system needs to find innovative ways to build trust and to provide service that is flexible and appropriate to a wide range of clients including those who cannot readily comply with standard regimens. 133

Access to timely and adequate health care for persons with HIV must be considered as an ethical issue given the success of newer HIV treatments, especially when health care and HIV medications are generally available and free. 134
The health care system must be prepared to treat the whole person, both their immediate HIV/ AIDS-related problems and their underlying mental health and socio-economic issues.
Educate both the public and governments so they recognize that injection drug users have a personal health problem with major public health implications. Incarceration is not an answer and apathy is not a solution.

24 Spigelman, Taking Stock, 2001a: 25-27. 20
25 Case, 2001: 1; see also Evans, 2001: 3.
26 Bezruchka, 2001: 1701
27 OECD, 2001.
28 Hogg, 1994.
29 Case, 2001: 1. See also Bezruchka, 2001: 1701-03; OECD, 2001: 81-83.
30 Terrance Higgins Trust, 2001: 1.
31 See O Brian, 1998. 22school leavers, unemployed and powerless.
32 Their vulnerability to HIV infection is determined by the degree of control [ they ] have over life circumstances and, hence, their capacity to take action. 33
32 Ibid.
33 Ryan, 2000: 48.
34 Ruiz, 2000: 368-371.
35 Ezzy, 1999.
36 Schechter, 1994; Hogg, 1994. 23
37 Baum, 1997: 272. See also Canadian AIDS Society, 1996: 4.
38 Voight, 1994.
39 Canada, National Reference Group, 2001: 27; See also Ryan, 2000.
40 Strathdee, 1997.
41 Hogg, 1994.
42 Strathdee, 1997. 24
43 UNAIDS and World Health Organization, 2001: 7.
44 European Commission, 1999; See also Canadian AIDS society, 1996.
45 See Centre for Social Justice, 2001. See also Guildford, 2000: 5. During the 1980s the real income ( i. e. ,
income adjusted to reflect inflation) of most Canadians decreased. By 1996, the poverty rate in Canada
had risen to 18% and the child poverty rate reached a 17-year peak of 21% .
46 Albert and Williams, 1998: 97.
47 Terrance Higgins Trust, 2001: 1. 25
48 Case, 2001: 29.
49 Berrueta-Clement, 1984: 2. See also Sweinhart, 1993; Healthy People 2010, 2000: 8/ 16; Spigelman,
1996: 20.
50 Canada, House of Commons Standing Committee on Health, 1996: 2/ 32. 26
51 Cunningham, 1994.
52 Lenderking, 1997.
53 Bartholow, 1994.
54 Goodman, 1998; see also Wingood, 1997.
55 Strathdee, Presentation to XI International Conference, 1996; see also Strathdee, Social Determinants
predict , 1996.
56 Vancouver Sun, 1996.
57 Strathdee, 1997.
58 Strathdee, Social Determinants predict , 1996: 3/ 5. 27
59 Strathdee, 1997: 3.
60 Rosenthal, 1994.
61 Canada, Health Canada, HIV and AIDS among youth, 2001. 28
62 Guildford, 2000.
63 Chernesky, 2000.
64 Canada, House of Commons Standing Committee on Health, 1996: 5/ 32
65 Canada, Health Canada, Legacy Discussion Paper , 2000: 1. 29
66 de Bruyn, 1998: 11.
67 Ibid. , 41.
68 See Trussler, 2000: 7; Terrance Higgins Trust, 2001: 6.
69 Ruiz, 2000: 78.
70 Romer, 1999.
71 Ryan, 2000: 64.
72 Ibid. , 66. 30
73 Stowe, 1993: 2/ 15.
74 Swindells, 1999: 384.
75 Lesserman, 1999: 397, 401.
76 Strathdee, Social determinants predict , 1996; see also Strathdee, Social Determinants related , 1997. 31
78 Chapple, 1998.
79 de Bruyn, 1998: 3.
80 Canada, House of Commons Standing Committee on Health, 1996: 6/ 32
81 Mann, 1996: 924. 32
82 Strathdee, Social determinants predict , 1996.
83 United States, 1997: n. p.
84 de Bruyn, 1998: 18; see also the presentation by Jonathan Mann to the ( U. K. ) All-Parliamentary Group,
2001: 11. 33
85 AIDS Weekly Plus, HIV/ AIDS an epidemic , 2000; see also Canada, Health Canada, HIV and AIDS among , 2000.
86 Canada, Health Canada, HIV and AIDS among , 2000: 2-3.
87 Entwisle, n. d.
88 CDC, 1997.
89 AIDS Weekly Plus, HIV/ AIDS an epidemic , 2000.
90 Heath, 1999. 34
98 Kirkham, 1998.
99 Deamant, 1996.
100 Deamant, 1996.
101 El-Bassel, 1998. 36
102 Piot, 2001: 2/ 5.
103 Nagy-Agren, n. d. 37
104 Starfield, 2001. Quoting J. N. Morris, Health Handbooks for Discussion Groups, Number 6. London: Association for Education in Citizenship, 1944.
105 Thomson, 2001: 187.
106 Hwang, 2001.
107 Ibid. 38
108 de Bruyn, 1998: 28.
109 Matthews, 1990.
110 Rogers, 1992: 1/ 8.
111 Rosenthal, 1994: 1/ 17. 39
112 Thompson, 1997.
113 Goldfinger, n. d. : 2.
114 Adams, n. d.
115 Culhane, 2001: 515.
116 Ryan, 2000: 52.
117 Strathdee, Social determinants related , 1997.
118 Palepu, 1999.
119 Culhane, 2001: 515.
120 Center for AIDS Prevention Studies, n. d.
121 Hobbs, 1997: 232.
122 Starfield, 2000: 483.
123 Gilligan, 1996.
124 Armstrong, 2001. See also Bezruchka, 2001.
125 Anderson, 1999: 13 42
126 AIDS Alert. 1998.
127 Ibid.
128 Kirkham, 1998: 7/ 13.
129 McCarthy, 1999: 541. 43
130 Canada, 2000: 9.
131 See J. T. Hart, The inverse care law. In Lancet, 1971, i: 405-12.
132 Canadian Centre on Substance Abuse, 1994: 33.
133 Anderson, 1999: 13; see also Canadian Centre on Substance Abuse, 1994: 33. 44
134 Schilder, 2001: 1643. 45

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