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1

HIV and AIDS

2

3

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

(2)

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

(3)

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

(4)

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

(5)

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

(6)

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

(7)

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

(8)

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

(9)

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

(10)

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

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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

(12)

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

(13)

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

American Association for World Health (AAWH). (2001b). World AIDS Day Resource 286

Booklet. Factsheet on treatment information. Author: Washington, DC 287

288

American Civil Liberties Union. (2000). State criminal statutes on HIV transmission. 289

Washington, DC: author. 290

291

Americans with Disabilities Act of 1990, P.L. 101-336, 104 Stat. 327. 292

293

Centers for Disease Control and Prevention. (2006). Revised Recommendations for HIV 294

Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Morbidity 295

and Mortality Weekly, 55 (RR14), 1-17. 296

Retrieved November 13, 2007 from http://www.cdc.gov/hiv/topics/testing/guideline.htm 297

298

Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk 299

behaviors, health care use, and mental health status of transgender persons: Implications 300

for public health intervention. American Journal of Public Health, 91, 915–921. 301

(14)

Diaz, R. M., & Ayala, G. (2001). Social discrimination and health: The case of Latino 303

gay men and HIV risk. New York: Policy Institute of the National Gay and Lesbian Task 304

Force. 305

306

Erickson, E. (2001, November 30). Audit calls into question funding for sexually explicit 307

AIDS prevention programs for gays. New York Blade News, p. 7. 308

309

Ferrales, D (2003) The Development of HIV/AIDS Policy: An International Policy 310

Analysis. University of Texas at Austin School of Social Work. 311

312

Fullilove, M. T., & Fullilove, R. E. (1999). Stigma as an obstacle to AIDS action: The 313

case of the African American community. American Behavioral Scientist, 42, 1117– 314

1129. 315

316

Gostin, L. O., Feldblum, C., & Webber, D. W. (1999). Disability discrimination in 317

America: HIV/AIDS and other health conditions. JAMA, 281, 745–752. 318

319

Halkitis, P. N., & Wilton, L. (1999). Beyond complacency: The effects of treatment on 320

HIV transmission. Focus: A Guide to AIDS Research and Counseling, 14(5), 1–4. 321

322

Herbst, J; Jacobs, E; Finlayson, T; McKleroy. V; Neumann, M. ; Crepaz, N(2008) 323

Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United 324

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States: A Systematic Review. Retrieved on June 30, 2008 from 325

http://www.medscape.com/viewarticle/571708 326

327

Kline, A., Kline, E., & Oken, E. (1992). Minority women and sexual choice in the age of 328

AIDS. Social Science and Medicine, 31, 447–457. 329

330

National Alliance of State and Territorial AIDS Directors (NASTAD) (2007). June 331

2007ADAP Watch. Retrieved November 7, 2007 from 332

http://www.nastad.org/Publications/adapwatch.aspx?Area=Publications

333 334

National Minority AIDS Council. (2002). Bush administration HIV/AIDS report card. 335

Washington, DC: Author 336

337

Tomaszewski, E. (Ed.). (2001). Mental health and HIV/AIDS: Social work practice issues 338

(Trainer Manual). Washington, DC: National Association of Social Workers. 339

340

Vertefeuille, J., Marx, M. A., Tun, W., Huettner, S., Strathdee, S. A., & Vlahov, D. 341

(2000). Decline in self-reported high-risk injection related behaviors among HIV-342

seropositive participants in the Baltimore needle exchange program. AIDS and Behavior, 343

4, 381–388. 344

345

Wheeler, D.P. (2007). HIV and AIDS Today: Where is social work going? Health and 346

Social Work,22,155-157. 347

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348

Zúñiga, M.A., Baldwin, H., Uhler, D., Brennan, J., Olshefsky, A.M., Oliver, E., et al. 349

(2007). Supporting Positive Living and Sexual Health (SPLASH): A clinician and 350

behavioral counselor risk-reduction intervention in a university-based HIV clinic. AIDS 351

Behavior,11,S58—S71. 352

353 354

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