Prof_Marcos A.

Human immunodeficiency virus (HIV) was discovered in 1981 and is most often associated with high-risk groups, such as intravenous (IV) drug users, gays, bisexuals, and minority racial and ethnic groups (Bertrand et al., 2016). If HIV is left untreated it will lead to acquired immunodeficiency syndrome (AIDS) and eventually death (Bertrand et al., 2016). HIV has destroyed many lives since its discovery in 1981 it continues to majorly impact morbidity and mortality all over the world (Bertrand et al., 2016). HIV has seeped into all populations and anyone affected has experienced societal marginalization, discrimination, and isolation, all which have contributed to the inequality of HIV (Bertrand et al., 2016). As mentioned above, HIV was originally believed to affect men from high-risk populations; however, HIV does not discriminate and has shown to affect women equally. The purpose of this paper is to identify the background of marginalized women with HIV including the current incidence/prevalence of statistics at the national, local and state levels. The following sections will discuss the socioeconomic aspects this group faces, social justice and its relationship to health care and disparities, the ethical issues of this group, and a brief plan of how this marginalized group will be addressed at a local practice with three action plans to measure the outcomes of actions.

Background of the Marginalized Women with HIV

Over the years, women’s risk of becoming HIV positive has increased rapidly yet for some reason there is little research on the effects of HIV on women. The reason for this rapid increase is believed to be from a number of reasons, mostly similar to the reasons stated in the introduction. However, there are a couple reasons that are specific to women, they include biologic vulnerabilities and male sexual dominance (Paudel & Baral, 2015). Biologically speaking, women are more susceptible to infection than men because their exposed mucosal area is larger, leaving more surface area to be infected (Paudel & Baral, 2015). In addition, a man’s semen holds a higher concentration and volume of the virus versus cervical secretions, making it easier for a male to pass it to a female (Paudel & Baral, 2015). With sexual dominance, some women, even to this day, have little to no control over their sexual relationship and are left vulnerable to unsafe sex practices, therefore increasing their chances of becoming infected (Darlington & Hutson, 2015; Paudel & Baral, 2015). Additionally, women are typically at an increased risk for rape and molestation, again, leaving them more vulnerable to infection (Darlington & Hutson, 2015; Paudel & Baral, 2015).

Since the discovery of HIV, there has been a stigma associated with the disease (Darlington & Hutson, 2017). Society associates HIV with sexual promiscuity, drug use, and prostitution (Darlington & Hutson, 2017; Paudel & Baral, 2015). Women seem to be even more susceptible to the HIV stigma and are known to be referred to as diseased or vectors (Paudel & Baral, 2015). This stigma has led some women to shy away from obtaining the care they desperately need because they do not want to admit to others they are positive for the disease (Paudel & Baral, 2015). Per Paudel and Baral (2015), one study that focused on the effects of the stigma on women found that HIV positive women live in a state of panic and anxiety over the fear of or actual occurrence of social rejection from family, friends, and society; some even experience violent reactions from the community and their family.

There are an estimated 1.1 million people in the United States living with HIV (HIV.gov, 2017). In 2016, 39,782 people in the United States were diagnosed with HIV (HIV.gov, 2017). Of those diagnosed in 2016, 7,529 of them were women (HIV.gov, 2017). In 2014, the number of people in Florida living with diagnosed HIV was 103,696 and the number of newly diagnosed people was 4,849 (AIDSVu, 2018). According to AIDSVu (2018), which is affiliated with Emory University’s School of Public Health and Gilead Sciences, Inc., 29 percent of the people newly diagnosed in 2014 were women. In 2016, the number of reported HIV cases in Pasco County was 44 of which 38 were male and 6 were female (Florida Department of Health, 2018).

Socioeconomic Aspects of Women with HIV

A study done by Rueda et al (2016), found that HIV-related stigma has a severe impact on multiple health-related outcomes in HIV positive people, especially HIV positive women. The stigma associated with HIV is described as condescending, defamatory, and discriminating against people with HIV (Rueda et al., 2016). Furthermore, high levels of stigma are associated with decreased social support and decreased physical and mental health outcomes (Rueda et al., 2016). According to Rueda et al (2016), due to the stigma and discrimination, these patients lack adherence to antiretroviral medications, social support, and access to health and social service. In the U.S., individual achievements and climbing the social ladder are highly valued; people with permanent disabilities, such as HIV, do not have a chance to succeed; they become isolated in a weak and dependent position where they are negatively viewed (Kontomanolis et al., 2017). In the current society, physical appearance and strength are glorified, thus, having a chronic and highly stigmatized illness can be debilitating and extremely degrading to the dignity of people living with HIV; this is especially true for women (Kontomanolis et al., 2017). HIV can be credited to reversal of good fortune, additionally, the social consequences related to being stigmatized reduces a persons opportunity to succeed, which will ultimately lead to discrimination and rejection, even from those that are close to the person (Kontomanolis et al., 2017).

Social Justice

People with HIV are less likely to have health insurance let alone readily available access to healthcare, including a primary care physician (Philpott, 2013). Public health interventions, like programs aimed at preventing HIV, have been created to help marginalized groups gain access to care and to address the disparities they face in regards to their health outcomes (Philpott, 2013). However, the current health coverage system in the U.S., such as Medicare and Medicaid fail to address the gaps in access to healthcare and to healthcare outcomes (Philpott, 2013). An effective HIV prevention program is known as Pre-Exposure Prophylaxis or PrEP (Philpott, 2013). PrEP is a medication that when taken daily can prevent the infection of HIV by up to 92% (Philpott, 2013). If the patient is a candidate for PrEP, some insurances and even some Medicaid products are supposed to be able to pay for PrEP (Philpott, 2013). PrEP was originally designed for high-risk groups, such as men who have sex with men (MSM), which raises concern because the MSM group is not the only high-risk group in the U.S. that could benefit from this medication (Philpott, 2013). The problem is that the prevalence of HIV has become a high risk for other racial and ethnic minorities and non-minorities, as well as women (Philpott, 2013). The main goal of public health programs, such as PrEP, are to better the health of the community while addressing the needs of the community’s disadvantaged and vulnerable groups (Philpott, 2013). The truth is that the PrEP program fails to recognize the specific needs of all those affected by HIV and some patients cannot access the program because they lack insurance or a primary care physician (Philpott, 2013). Social justice encompasses 2 major aspects of care, they are population-level health improvements and fair treatment of the disadvantaged; these two points do not seem to have been fully considered when they developed the PrEP program (Philpott, 2013).

Ethical Issues

There are many ethical issues surrounding HIV. These issues can range from HIV testing to providing care for those infected with HIV to experimental medications. One of the most important issues is the patient’s access to quality, judgment-free care. All patients, including HIV patients, deserve comprehensive care that is given with respect and courtesy (Ion & Elston, 2015). In Canada, a provincial legislation was passed that places human rights principles into patient care and gives priority to the interactions between the healthcare provider and the patient (Ion & Elston, 2015). In America, those diagnosed with HIV can be placed on Medicaid. This is the government’s way of helping this marginalized group, however, this system is very flawed. A large number of providers will not see these patients because Medicaid pays the provider very little. On top of this, the providers that do see these patients have to constantly fight with Medicaid to get the system to pay for the treatments the provider orders. It is a draining process for the patients and the providers. Furthermore, there is a stigma associated with having Medicaid, which is this group is poor, uneducated, and are non-compliant. So this marginalized group of women is up against the stigma related to having HIV as well as the stigma related to being a Medicaid patient. It is the provider’s ethical and moral duty to care for all patients equally and to contribute to breaking down the barriers these patients have to accessible healthcare.

Action Plan

As a provider, it only takes one to make a difference and to begin setting an example. The following are measurable action plans that providers can take to address this marginalized group.

1. Increase access to care and decrease disparities related to HIV (German, Linton, Cassidy-Stewart, & Flynn, 2014). Providers and staff need to be educated on HIV awareness and sensitivity along with the patients right to equality of care. Conversations between the woman and the provider need to be clear and nonjudgmental (HRSA, 2013). The provider should also recognize that the newly diagnosed patient probably will not change overnight and adhere to all regimens, it may take a little while for the diagnosis and the acceptance of their new life to set in, therefore, the patient should know it is okay to be honest about failure with these things (HRSA, 2013). In doing so, an open and honest line of communication is built, allowing the provider to better care for their patient. If a provider is genuinely sensitive to the woman’s situation, the woman will feel more at ease confiding in them. Providers must never forget that an HIV diagnosis carries with it an enormous loss of control and an extreme amount of vulnerability (HRSA, 2013). A measurable outcome would be seeing more patients with limited access to care actually receiving care, regardless of the type of insurance they have.

2. Reducing the number of newly infected HIV patients by making HIV screening a routine part of the patient’s healthcare (German, Linton, Cassidy-Stewart, & Flynn, 2014). Providers and society seem to grossly underestimate the risks of HIV infection (HRSA, 2013). The provider should recognize that a lot of women are unaware their sexual partner has HIV or is at risk of contracting it and therefore will end up becoming infected themselves (HRSA, 2013). Furthermore, a lot of women will present with little to no risk factors or symptoms, making it so the disease is not caught until later stages (HRSA, 2013). This is why risk-based screening is not the best option to properly identifying women with HIV (HRSA, 2013). By making HIV screening a routine part of healthcare, early detection can occur, which means decreasing the chances of transmission to others as well as the opportunity to begin the woman on antiretroviral therapy in the early stages of the disease (HRSA, 2013). A measurable outcome would be a decreased amount of new HIV infections as evidenced by statistical data from the specific county the medical office is in.

3. Improve the health outcomes of this marginalized group living with HIV (German, Linton, Cassidy-Stewart, & Flynn, 2014). Providers cannot overlook the woman’s need for psychosocial care. The perception of the role of HIV will vary from woman to woman. In order to be effective, providers must establish a trusting relationship with their patient (HRSA, 2013). Only then will the woman open up to the provider about their psychosocial needs (HRSA, 2013). If the woman does not confide in the provider, do not assume she does not need psychosocial care. The provider should always broach the subject and offer help when necessary. A measurable outcome would be better mental health of patients and less judgment/stigma associated with the disease.

Conclusion

In conclusion, HIV is a devastating disease that can affect all walks of life. Women with HIV face more scrutiny and fear of social rejection and isolation than their counterparts, yet they are the group that is overlooked the most. They face judgment and discrimination at every corner, including from some health care providers. Programs such as PrEP and Medicaid were designed to help marginalized groups but they fall short and too many people are still without care. Action plans were devised to address access to care while decreasing disparities, reducing the number of newly infected HIV cases by routinely incorporating HIV screening into healthcare, and to improve the health and wellness outcomes of this marginalized group. Integrating these action plans into practice will potentially improve the equality and quality of care for all people living with HIV/AIDS but especially for this marginalized group of individuals.

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