HIV/AIDS and Socioeconomic Status

Socioeconomic status (SES) encompasses not just income but also educational attainment, financial security, and subjective perceptions of social status and social class. Socioeconomic status can encompass quality of life attributes as well as the opportunities and privileges afforded to people within society. Poverty, specifically, is not a single factor but rather is characterized by multiple physical and psychosocial stressors. Further, SES is a consistent and reliable predictor of a vast array of outcomes across the life span, including physical and psychological health. Thus, SES is relevant to all realms of behavioral and social science, including research, practice, education and advocacy.

SES Affects our Society

SES affects overall human functioning, including our physical and mental health. Low SES and its correlates, such as lower educational achievement, poverty and poor health, ultimately affect our society. Inequities in health distribution, resource distribution, and quality of life are increasing in the United States and globally. Society benefits from an increased focus on the foundations of socioeconomic inequities and efforts to reduce the deep gaps in socioeconomic status in the United States and abroad.

SES Impacts the Lives of People with HIV/AIDS

Both domestically and internationally, HIV is a disease that is embedded in social and economic inequity (Pellowski, Kalichman, Matthews, & Adler, 2013), as it affects those of lower socioeconomic status and impoverished neighborhoods at a disproportionately high rate. Research on SES and HIV/AIDS suggests that a person’s socioeconomic standing may affect his or her likelihood of contracting HIV and developing AIDS. Furthermore, SES is a key factor in determining the quality of life for individuals after they are affected by the virus.

SES Affects HIV Infection

A lack of socioeconomic resources is linked to the practice of riskier health behaviors, which can lead to the contraction of HIV. These behaviors include substance use, which reduces the likelihood of using condoms (Pellowski et al., 2013).

• Limited economic opportunities and periods of homelessness have been associated with risky sexual practices, such as exchanging sex for money, drugs, housing, food and safety. Ultimately, these practices can place individuals at risk for HIV (Riley, Gandhi, Hare, Cohen, & Hwang, 2007).
• Living in poverty can also result in food insufficiency, which can contribute to HIV/AIDS infection. Lacking food can result in transactional sex and power differences in sexual relationships, which can place an individual at risk of infection. Further, individuals may continue to face hunger after contracting HIV (Kalichman et al., 2011).
• Impoverished urban areas have been found to have HIV prevalence rates equivalent to many low-income countries with generalized epidemics (Buot et al., 2014). Studies of urban health have found that factors such as level of poverty and unemployment, vacant buildings and high crime rates are all associated with increased risk of HIV infection. These factors are all highly correlated, however, making it difficult to isolate the mechanisms that promote HIV infection (Latkin, German, Vlahov, & Galea, 2013).
• Even though HIV is predominately located in major urban areas, trends over the years suggest an increasing impact of the disease on women, minorities, older adults, rural residents and those living in the South (National Rural Health Association, 2014). Rural residents face unique challenges such as distance to care, lack of health care facilities and health care providers with HIV/AIDS expertise, limited availability of supportive or ancillary services, stigma and discrimination, and limited educational and economic infrastructure (Schur et al., 2002).
• SES indicators may differentially affect HIV risk for men and women. Income inequality has been found to be related to increased HIV risk for males, whereas poverty, health and housing circumstances increased risk for females (Buot et al., 2014). However, for both men and women, increased poverty and unemployment levels and decreased median household income are related to a lower probability of survival after an HIV diagnosis (Harrison, Ling, Song, & Hall , 2008). Other SES indicators, including poverty, homelessness, hunger and lower education, have also been associated with higher mortality (McMahon, Wanke, Terrin, Skinner, & Knox, 2011).

HIV Status Affects SES

HIV status often has a negative impact on socioeconomic status by constraining an individual’s ability to work and earn income.

• The effects of HIV on physical and mental functioning can make maintaining regular employment difficult. Patients with HIV infection may also find that their work responsibilities conflict with their health care needs. Disease severity and self-reported HIV-related work discrimination place HIV-positive women and individuals with low education at risk for employment loss (Dray-Spira, Lert, Marimoutou, Bouhnik, & Obadia, 2008).
• Research indicates that unemployment rates among people living with HIV/AIDS can range from 45 percent to 65 percent (Dray-Spira, Gueguen, & Lert, 2008).
• People with advanced HIV infection and AIDS may qualify for disability benefits that limit their ability to earn additional income (Pellowski et al., 2013).
• In one study, employers who believed that job applicants with HIV/AIDS were incompetent and could not perform the functions of the job stated that they would be less likely to interview hypothetical applicants (Liu, Canada, Shi, & Corrigan, 2012). This could have implications for hiring practices and economic opportunities for people living with HIV/AIDS.

SES Affects HIV Treatment

• SES status often determines access to HIV treatment. Individuals of low SES have delayed treatment initiation relative to more affluent patients, reducing their chances of survival (Joy et al., 2008).
• Structural factors including poverty, lack of employment opportunities, limited health care access and limited transportation infrastructure have been highlighted as both independent and interactive contributors to health care engagement in HIV-positive women (Walcott et al., 2016).
• Patients of lower SES have increased HIV/AIDS mortality rates. Research suggests that an increase in SES is associated with a reduction in HIV/AIDS deaths, and HIV/AIDS death rates in a high-SES county were nearly three times greater than those in a low-SES county (Rubin, Colen, & Link, 2010).
• Women living in poorer households may experience difficulties before, during and after childbirth that can place them at risk for HIV infection and complications. Women in low-income households may be less likely to access prenatal care that could allow them to be tested for HIV. Experiencing food insecurity can also affect maternal and child health, including adherence to antiretroviral therapy (ART) and breastfeeding (Young, Wheeler, McCoy, & Weiser, 2014).
• Homeless and marginalized housed individuals who are considered food insecure are more likely to have lower CD4 (T-cell) counts, poorer medication adherence, and incomplete suppression of HIV replication (Weisner et al., 2009). Food insecurity and residential instability are associated not only with poorer medication adherence but also with inconsistent health care and poorer access to health care, as well as less favorable attitudes toward health care providers (Surratt et al., 2014).
• Barriers and facilitators to adhering to ART differ in resource-poor and resource-rich countries. In resource-poor countries, poverty may prevent access to health care and subsequent treatment, while in resource-rich countries, factors related to poverty such as addiction or depression may prevent people living with HIV from adhering to medications (Young et al., 2014).

Get Involved

• Consider SES in your education, practice and research efforts.
• Stay up to date on legislation and policies that explore and work to eliminate socioeconomic disparities . Visit the Office on Government Relations for more details.
• Visit APA’s Office on Socioeconomic Status (OSES) website.
• Visit APA’s HIV/AIDS.

References

Buot, M. L. G., Docena, J. P., Ratemo, B. K., Bittner, M. J., Burlew, J. T., Nuritdinov, A. R., & Robbins, J. R. (2014). Beyond race and place: Distal sociological determinants of HIV disparities. PLoS ONE, 9(4), e91711. https://doi.org/10.1371/journal.pone.0091711

Dray-Spira, R., Gueguen, A., & Lert, F. (2008). Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: Differences according to gender and education. Occupational and Environmental Medicine, 65, 112-119. doi:10.1136/oem.2007.034363

Dray-Spira, R., Lert, F., Marimoutou, C., Bouhnik, A. D., & Obadia, Y. (2003). Socio-economic conditions, health status and employment among persons living with HIV/AIDS in France in 2001.   AIDS Care, 15, 739-748. doi:10.1080/09540120310001618595

Harrison, K. M., Ling, Q., Song, R., & Hall, H. I. (2008). County-level socioeconomic status and survival after HIV diagnosis. Annals of Epidemiology, 18, 919-927. doi:10.1016/j.annepidem.2008.09.003

Joy, R., Druyts, E. F., Brandson, E. K., Lima, V. D., Rustad, C. A., McPhil, R., & Hogg, R. S. (2008). Impact of neighborhood-level socioeconomic status on HIV disease progression in a universal health care setting.   Journal of Acquired Immune Deficiency Syndromes, 47, 500-505. doi:10.1097/QAI.0b013e3181648dfd

Kalichman, S. C., Pellowski, J., Kalichman, M. O., Cherry, C., Detorio, M., Caliendo, A. M., & Schinazi, R. F. (2011). Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings. Prevention Science, 12, 324-332. doi:10.1007/s11121-011-0222-9

Latkin, C. A., German, D., Vlahov, D., & Galea, S. (2013). Neighborhoods and HIV: A social ecological approach to prevention and care. American Psychologist, 68, 210-224. doi:10.1037/a0032704

Liu, Y., Canada, K., Shi, K., & Corrigan, P. (2012). HIV-related stigma acting as predictors of unemployment of people living with HIV/AIDS. AIDS Care, 24(1), 129-135. https://dx.doi.org/10.1080/09540121.2011.596512

McMahon, J., Wanke, C., Terrin, N., Skinner, S., & Knox, T. (2011). Poverty, hunger, education, and residential status impact survival in HIV. AIDS and Behavior, 15, 1503-1511. doi:10.1007/s10461-010-9759-z

National Rural Health Association. (2014). HIV/AIDS in rural America: Disproportionate impact on minority and multicultural populations. Retrieved from https://www.ruralhealthweb.org/advocate/policy-documents

Pellowski, J. A., Kalichman, S.C., Matthews, K. A., & Adler, N. (2013). A pandemic of the poor: Social disadvantage and the U.S. HIV epidemic. American Psychologist, 68, 197-209. doi:10.1037/a0032694

Riley, E. D., Gandhi, M., Hare, C. B., Cohen, J., & Hwang, S. W. (2007). Poverty, unstable housing, and HIV infection among women living in the United States. Current HIV/AIDS Reports, 4, 181-186. doi:10.1007/s11904-007-0026-5

Rubin, M. S., Colen, C. G., & Link, B. G. (2010). Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective. American Journal of Public Health, 100, 1053-1059. doi:10.2105/AJPH.2009.170241

Schechter, M. T., Hogg, R. S., Aylward, B., Craib, K. J., Le, T. N., & Montaner, J. S. (1994). Higher socio- economic status is associated with slower progression of HIV infection independent of access to health care.   Journal of Clinical Epidemiology, 47, 59–67. doi:10.1016/0895-4356(94)90034-5

Schur, C. L., Berk, M. L., Dunbar, J. R., Shapiro, M. E., Cohn, S. E., & Bozzette, S. A. (2002). Where to seek care: An examination of people in rural areas with HIV/AIDS. The Journal of Rural Health, 18, 337-347. doi:10.1111/j.1748-0361.2002.tb00895.x

Young, S., Wheeler, A. C., McCoy, S. I., & Weiser, S. D. (2014). A review of the role of food insecurity in adherence to care and treatment among adult and pediatric populations living with HIV and AIDS. AIDS and Behavior, 18, S505-S515. doi:10.1007/s10461-013-0547-4