which these conditions and attitudes have resulted in public policies that run counter to scientific knowledge about effective HIV prevention.

SOCIAL BARRIERS

Poverty, Racism, and Gender Inequality

There is considerable evidence that social inequalities defined by income, race, ethnicity, and gender are key elements in the social contexts and environments that contribute to HIV infection risk. These contextual forces can act at the individual level, when life circumstances such as homelessness or drug use increase the likelihood of high-risk behaviors. The forces also can act at the societal level (Henderson, 1988). For example, economic inequalities between women and men can affect women’s perceptions of their ability to negotiate safe sex practices in a social relationship. Similarly, racism—both historically and in its contemporary forms—has resulted in assaults on the economic opportunities and the self-identity of racial and ethnic minorities, and has implications for Americans’ receptivity to HIV prevention efforts. Moreover, social inequalities create conditions that make it difficult for individuals and communities to even focus on the problem of HIV, since other problems may seem more immediate (e.g., housing, employment). Better understanding these societal forces is critical to achieving the objective of preventing as many new infections as possible.

Increasingly, the metropolitan areas that are most severely affected by HIV/AIDS are also areas of social and political neglect. Individuals living in these disenfranchised environments have increased exposure to a variety of social and psychosocial factors (e.g., poverty, stress, disrupted family structures, insufficient social supports, and toxic environmental exposures) that have demonstrated associations with morbidity and mortality (Geronimus, 2000). Further, inadequate access to health care and lack of supportive, culturally appropriate social services allow co-occurring conditions—such as substance abuse, mental illness, tuberculosis, sexually transmitted diseases (STDs), and violence—to flourish, thus forming epidemiological clusters for a wide variety of concurrent health and social problems (NRC, 1993). Moreover, the higher prevalence of drug trade in impoverished neighborhoods increases the likelihood of exposure to and use of drugs, such as heroin, crack, and cocaine, that are linked to HIV risk (Zierler and Krieger, 1997). These findings are consistent with studies documenting the correlation between economic deprivation and overall AIDS incidence at the state level (Zierler et al., 2000) and in major metropolitan areas (Fordyce et al., 1998; Simon et al., 1995; Hu et al., 1994; Fife and Mode, 1992).



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