1
HIV and AIDS
23
Revision of a Professional Policy Statement 4
5
SECOND ROUND POLICY PANEL REVISION 6
7 8
BACKGROUND 9
HIV and AIDS are serious global public health concerns with biological social and 10
economic ramifications. Throughout the world HIV and AIDS disproportionately 11
impacts marginalized and disempowered populations throughout the world. Today one in 12
three people infected with HIV do not know they are living with HIV or AIDS (AAWH 13
2001b). The key areas of concern are prevention, testing, treatment, and the impact of 14
HIV on individuals, families and communities 15
16
In the United States HIV and AIDS prevention and treatment services available 17
today are the result of significant biomedical and social advocacy efforts by many groups 18
over a long period of time (Wheeler 2007). However, effectiveness of some prevention 19
programs has been hindered by racism, sexism, heterosexism, and homophobia (Ferrales 20
2003). 21
22
Limited government response resulted in the establishment of many community-23
based AIDS service organizations (ASO), and many are still in existence today. The 24
design of AIDS prevention strategies largely occurred on a small scale due to limited 25
funding options. Not only has there been a failure to develop effective programs, there 26
has been a governmental and societal hindrance to the development of effective 27
programs, such as needle exchange programs or sex education for young adults. 28
29
Testing 30
Testing is an important component of HIV prevention. Research has shown that people 31
who are aware of being HIV-infected may be more likely to take steps to prevent 32
transmitting the virus to others. In addition when a positive test result is obtained, 33
appropriate medical treatment can be initiated to slow the disease process (Zúñiga, M.A., 34
et al, 2007). The availability of testing on an anonymous or confidential basis is thought 35
to maximize the number of people who choose to get tested. To protect confidentiality of 36
HIV status, all states apply confidentiality laws to HIV test results. Throughout the 37
pandemic, there have been many struggles over federal and state policies on imposing 38
mandatory testing or mandatory reporting of test results for certain populations, including 39
prisoners, pregnant women, and child care workers. In addition, a number of states have 40
criminalized the potential transmission of HIV through sex, needle sharing, breast-41
feeding, or organ donation by a person who is HIV-positive or diagnosed with AIDS 42
(American Civil Liberties Union, 2000). Unlike HIV serostatus, all diagnoses of AIDS 43
must be reported to state public health departments. 44
45
The Center for Disease Control (CDC) Revised Recommendations for HIV 46
Testing in Health Care Settings recommends that HIV testing be voluntary and 47
recommended for patients in all health care settings after the patient is notified that 48
testing will be performed unless the patient declines (or “opts-out” of screening) (CDC 49
2006). This recommendation replaces the practice of “informed, written consent.” These 50
recommendations notwithstanding, many people obtain HIV tests without pre- or post- 51
test counseling, especially when they test in a physician’s office or at the client’s home. 52
Treatment 53
The emergence of antiretroviral therapies (ART), and increased access through 54
private insurance, Medicare, and AIDS Drug Assistance Programs (ADAPs), has resulted 55
in a positive, dramatic change for many people living with HIV/AIDS (PLWH/As). For 56
many, living with HIV or AIDS has transitioned to living with a lifelong, chronic illness, 57
often with a renewed sense of hope and challenges (Tomaszewski, 2001). For others, 58
however, the complexities of a strict medication regimen cannot be sustained over 59
extended periods of time, because adherence is not as simple as taking medications. An 60
increasing number of people living with AIDS are unable to tolerate the toxicity and 61
severe side effects that are common with the medications (ART and prophylaxis 62
treatments); others experience unexpected and unexplained health deterioration, or the 63
drugs simply “fail the patient.” 64
Economic issues continue to affect access to care. Few people can afford the 65
drugs unless they are enrolled in a private health insurance plan with prescription drug 66
benefits or state-administered Medicaid or ADAPs for those who are underinsured and 67
uninsured. Although ADAP funding is available nationwide, some state ADAP programs 68
limit coverage of certain medications, resulting in access and adherence problems, or 69
have waitlisted or capped enrollment (NASTAD, 2007). 70
71
Impact of HIV/AIDS on Individuals, Families and Communities 72
HIV/AIDS can have devastating consequences on affected individuals and 73
members of their families and support systems. HIV and AIDS are highly stigmatized 74
conditions (Fullilove & Fullilove, 1999), and people living with HIV/AIDS are likely to 75
experience stigmatization and discrimination related to it (Diaz & Ayala, 2001) in areas 76
such as education, employment, housing, insurance, and health care. Although the federal 77
Americans with Disabilities Act of 1990 (P.L. 101-336) has provided legal protection for 78
such people, its scope has been reduced by subsequent court rulings. In addition, state 79
laws regarding HIV/AIDS discrimination vary considerably, with some states allowing 80
certain forms of discrimination (Gostin, Feldblum, & Webber, 1999). In too many cases 81
PLWH/As continue to be denied basic civil and human rights. They may face 82
discrimination in employment, military service, housing, child care, access to health care 83
services, and social and community support programs. 84
85
ISSUE STATEMENT 86
Social workers increasingly encounter HIV/AIDS, either directly or indirectly, regardless 87
of their area of practice, geographic location, or practice setting. Because of its ecological 88
perspective and commitment to social justice, social work is particularly well suited for 89
addressing the complex problems associated with the epidemic, including those 90
experienced by PLWH/As, their friends, and their families. Globally, HIV/AIDS 91
continues to have catastrophic impact on communities, particularly resource poor 92
countries where people cannot afford medications or access treatments. 93
Heterosexism and homophobia contribute to the spread of HIV in other 95
populations as well. For example, HIV prevention and care programs for gay men that 96
include explicit sexual information or language continue to be threatened periodically 97
with loss of federal funding (Erickson, 2001). Also, the increase in HIV infection 98
among African American men who have sex with men (MSM) may be due in part to 99
these attitudes among African American communities and the continuing belief that 100
AIDS is a “gay disease” (Fullilove & Fullilove, 1999). In addition, women may often 101
contract HIV because their male sexual partners cannot admit that they also engage in 102
high-risk sex with other men. 103
104
Racism contributes to the spread of HIV. For example, MSM of color might not 105
benefit from prevention resources distributed within predominantly white gay and lesbian 106
communities because of actual and perceived racism within them (Diaz & Ayala, 2001). 107
Also, many of the strategies that have effectively prevented spread in the white gay 108
community are not effective among men of color because these programs lack in cultural 109
context. In addition, racism is an important link to disempowerment and the lack of 110
financial and other resources among communities of color, which prevents such 111
communities from responding to the epidemic as effectively as the predominantly white 112
gay community. Sexism contributes to the spread of HIV. For many years, virtually no 113
attention was given to women’s risks or needs with respect to prevention or treatment of 114
HIV/AIDS. Consequently, knowledge about the specific ways in which HIV affected 115
women, and the best ways to treat it, lagged far behind such knowledge in relation to 116
men. Women may not feel empowered in relationships to insist that their sexual partners 117
use condoms, or may use sexual practices (such as anal sex) in efforts to prevent 118
pregnancy but are considered high-risk for HIV transmission. Also, women who are 119
impoverished are more likely to prioritize daily survival issues over safer sex (Kline, 120
Kline, & Oken, 1992). Educational, occupational, and economic discrimination may lead 121
some women into high-risk sex work and IV drug use. Finally, the lack of funding for 122
female-specific microbicides is rooted in the historical lack of recognition for women’s 123
sexuality, reproductive health of women and girls, and the right to control one’s body. 124
Discrimination against transgender people may lead to at-risk behaviors that increase risk 125
for HIV and other STDs. Factors such as mental health concerns, physical abuse, social 126
isolation, economic marginalization, and unmet transgender-specific healthcare needs can 127
potentially lead to increased HIV risk . (Herbst, J., Jacobs, E., et.al 2008). In addition, 128
the inability to obtain or pay for hormone therapy drives some transgender people to seek 129
hormones illegally and to inject them with shared needles (Clements-Nolle, Marx, 130
Guzman, & Katz, 2001). 131
132
Discrimination towards people who use street drugs also contributes to the spread 133
of HIV. Federal policy continues to oppose clean needle exchanges (National Minority 134
AIDS Council, 2002). Although research shows that needle exchange programs can 135
reduce the transmission of HIV, federal policies and laws in many states and localities 136
prevent the access of IV drug users to sterile syringes (Vertefeuille et al., 2000). 137
138
Prevention efforts continue to be under funded and excessively influenced by 139
moralistic politics instead of empirical research. Limitations created by federal and state 140
policies, and funding levels and regulations, hamper the efforts of community-based 141
organizations to reduce HIV/AIDS incidence in populations at high risk. 142
143
The CDC Revised Recommendations for HIV Testing in Health Care Settings 144
(CDC 2006) recommends that HIV testing be voluntary and recommended for patients in 145
all health care settings after the patient is notified that testing will be performed unless 146
the patient declines (opt-out screening). These recommendations remove the requirement 147
for pretest and posttest counseling, a critical step in helping individuals prepare for a 148
positive test result and providing the context for exploring behavioral risk regardless of 149
test results. HIV antibody testing also provides an important opportunity for health 150
professionals to elicit important information about partners of the person testing. Such 151
information can be used to help patients communicate to partners their risk for HIV 152
infection. Partner notification laws, however, limit the confidentiality of testing results 153
in some states. 154
155
HIV testing and counseling are important components of a comprehensive public 156
health approach to reducing the devastation of HIV and AIDS, however, services for 157
infected persons, and treatments for co morbidities (e.g., other sexually transmitted 158
diseases, and substance abuse) must be available to persons after they receive their HIV 159
testing results. 160
161
The advent of HAART has greatly changed the quality of life for many people 162
living with HIV/AIDS. Yet there is evidence that the effectiveness of HIV medications 163
may cause some people to believe that HIV is no longer a threat, leading to an increase in 164
risky sexual or drug-taking behaviors (Halkitis & Wilton, 1999). In addition to the high 165
cost of medications, other medical care for people living with HIV/AIDS is exorbitant 166
and unevenly available. Coverage for emergency room visits, hospital stays, diagnostic 167
tests, physicians’ fees, and nursing care may be inadequate for many people. Those 168
enrolled in public health plans are unlikely to be able to obtain the same quality of care 169
available to those with private insurance. The quality of HIV/AIDS-related medical care 170
may depend on where people are living, given that specialized HIV/AIDS services are 171
not universally available, especially in rural areas. 172
173
POLICY STATEMENT 174
Across fields of practice, social workers provide services to HIV-positive clients, their 175
families, and clients who are at risk of becoming infected with HIV. Given the high 176
incidence of HIV/AIDS, and the rapid spread of the pandemic over the last two decades, 177
the social work profession should take an active stand to mitigate the overwhelming 178
psychological and social effects, including the inequality of access to health and mental 179
health care and the lack of education and prevention in the United States and 180 internationally. 181 182 NASW supports: 183
Prevention and Education 184
Professional cooperation with existing HIV and AIDS educational, treatment, and 185
research organizations to develop and implement programs that include 186
educational and prevention strategies that meet the needs of all segments of our 187
society. 188
Prevention programs designed and implemented to ensure they are tailored to the 189
specific needs and risks of diverse populations. Programs must be culturally 190
appropriate, taking into account the language, culture, ethnicity, sexual 191
orientation, gender and gender identity, religion, and age of the target population 192
The implementation of prevention strategies that focuses on harm reduction. 193
Evidence-based prevention efforts that target children and adolescents in both 194
public and private school systems and comprehensive sexuality education 195
programs for youths and adults. 196
The establishment of both publicly and privately funded needle exchange 197
programs and efforts to increase the quantity and quality of drug abuse treatment, 198
in order to reduce HIV incidence among IV drug users 199
SW Education 200
The education of all social workers so they are knowledgeable about behavioral 201
strategies to prevent the transmission of HIV, including safer sex and harm 202
reduction. Use of assessment tools that assess all clients for HIV risk,, and they 203
should educate clients about ways to reduce their risk. 204
Social workers take responsibility to continuously update their knowledge about 205
all aspects of HIV disease, including new prevention strategies, treatment models, 206
medication regimens, and policies. 207
Social work education programs should include curricula that examine the 208
ramifications of HIV/AIDS from the perspective of the profession’s core values. 209
Content should cover the range of health and mental health issues of PLWH/As 210
and their families, support systems, and communities and interventions at all 211 levels of practice. 212 213 Testing 214 NASW supports: 215
The education of all practitioners about both the availability and the accessibility 216
aspects of HIV antibody testing and referrals related to living with HIV and 217
AIDS. 218
Voluntary and confidential testing which is available on an anonymous basis, and 219
includes prior informed consent, 220
Pre- and post-test counseling programs, provided by trained caregivers, 221
Rapid testing conducted only by people trained and certified to do so, and 222
implemented only when consent is granted by the client or patient. 223
Access to competent professional counseling by phone for people using home-224
testing kits at no additional charge, and referral to a formal HIV testing site. 225
Informed consent of pregnant and birthing mothers prior to mandatory HIV 226
testing of themselves and their newborn child or children. 227
Prior consent for release of clients’ test results Social workers with HIV-positive 228
clients who have not informed sexual or needle-sharing partners about their sero 229
status should use their clinical skills to encourage them to do so. 230
231
Service Delivery, Care and Treatment 232
NASW supports: 233
1 The right of people living with HIV/AIDS to the highest quality care including 234
those confined in correctional institutions. 235
2. A comprehensive services delivery system based on a quality case management 236
model that includes access to suitable and affordable housing, mental and health 237
care services, adult and child foster care, home health care, nursing home care, 238
legal services, and transportation. 239
3. Comprehensive bio-psychosocial spiritual support for people with HIV/AIDS and 240
those affected should be readily available.. Service programs that are culturally 241
competent, linguistically appropriate, and client and patient centered. 242
4. Elimination of the inequities or obstacles in access to medication, clinical 243
trials, and HIV care specialists; or services that ensure psychological, social, 244
cultural, and economic wellbeing. 245
5. Policies that facilitate access to affordable pharmaceuticals worldwide. Clients 246
should have sufficient supports to help them maintain difficult medication 247
regimens. 248
6. The right to confidentiality relating to HIV/AIDS status. Clients should be 249
informed of the limits of confidentiality, including the existence of partner 250
notification and record keeping. Social workers should be familiar with applicable 251
state laws, regulations, and federal guidelines 252
Political Action and Advocacy 253
NASW supports: 254
Continued public and private funding and advocacy for health and mental 255
health care provider programs that address HIV/AIDS and related health and 256
mental health issues, including as well as state, local, national, and 257
international HIV/AIDS prevention and treatment programs. 258
Domestic and international initiatives that address structural factors such as 259
poverty, community disinvestment, and interpersonal violence to curtail the 260
HIV/AIDS epidemic. 261
Leadership in advocacy efforts at the local, state, and federal levels to improve 262
the quality of life of all PLWH/As and to protect their civil liberties, including 263
maximum access to confidential testing, diagnosis, and treatment. 264
Advocacy for adequate funding of research on all aspects of HIV/AIDS, 265
including prevention, clinical interventions, and vaccine development. 266 267 Research 268 269 NASW supports: 270
Research, including epidemiological, clinical, and comprehensive, 271
biopsychosocial-spiritual studies, funded at appropriate levels by the federal 272
government. 273
Research protocols that address the unique biomedical needs of women, children 274
and adolescents, and the psycho-social-spiritual needs of all people affected by 275
HIV/AIDS. 276
Funding for research in order to accurately assess the effectiveness of primary and 277
secondary prevention and educational strategies, service delivery models, and the 278
spiritual issues of people living with and affected by HIV/AIDS, and the unique 280
needs of women, children and adolescents, and the needs of all people affected by 281 HIV/AIDS. 282 283 284 REFERENCES 285
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288
American Civil Liberties Union. (2000). State criminal statutes on HIV transmission. 289
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291
Americans with Disabilities Act of 1990, P.L. 101-336, 104 Stat. 327. 292
293
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298
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337
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340
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348
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