35 years ago, on June 5th 1981, the AIDS epidemic officially began. Reports from LA emerged of unusual clusters of a form of pneumonia caused by the Pneumocystis jirovecii fungus in five gay men. In the following months the same was discovered among more and more men across the US, and a year later it was suggested that it was the result of sexually transmitted infections, and at this point the term GRID, or gay-related immune deficiency, emerged. From the very beginning gay men were targeted and stigmatized. It was referred to as ‘gay cancer’, and even in 2015 during the Marriage Referendum in Ireland I was told by one No campaigner that ‘HIV is a gay disease’.
There is much debate about how the virus developed and came into being, and particularly about how it spread from non-human primates to humans, but why it spread like wildfire when and where it did is undeniably clear; inequality. It is no coincidence that Sub-Saharan Africa accounted for 69% of all people living with HIV and 70% of all AIDS-related deaths in 2011 despite only accounting for 15.2% of the world’s population, while also being the poorest region on earth. In Global Finance Magazine’s list of the ten poorest countries in the world, not a single one was from outside of Sub-Saharan Africa. It’s also no coincidence that women infected with HIV in this region outnumber men with the virus 13 to 10, or that this gender gap is growing.
Goran Holmqvist, Associate Director at UNICEF’s Office of Research, released a paper in 2009 while at the Institute for Future Studies in Uppsala, Sweden, which essentially made the case that HIV/AIDS is less so a ‘disease of poverty’ and more so a disease of inequality. Sub-Saharan Africa isn’t just the poorest region on earth, it’s also one of the most unequal, and the most at-risk groups when it comes to HIV are among the most discriminated against and most disadvantaged.
So why is it that inequality caused this epidemic? There are three primary forms of inequality that have caused HIV to become so widespread, each of which are interconnected; sexual inequality, gender inequality and income inequality.
If we look back to the beginning of the epidemic, or at least when it officially became an epidemic, it occurred in the context of an incredibly hostile world for LGBT people. Homosexuality had only been declassified as an illness in the US in 1973, and by 1981 same-sex activity was still illegal in a number of states (it wasn’t decriminalized in Texas until 2003). In 1981 homosexuality was illegal in 16 European countries and had only recently been decriminalized in many more. Even since 1991 twelve European countries have explicitly banned same-sex marriage. Like with anything that faces bans and suppression, whether it be alcohol, drugs, prostitution or same-sex relations, it continues to exist underground, and it almost always does so in a more dangerous form for those involved, both directly and indirectly. Forcing homosexuality underground and into the shadows with threat of criminal prosecution, social stigma, and vigilante violence deprived gay men, primarily, of much needed health services and education. The general conservatism of Western society throughout much of the 20th century meant education about known risks of STIs (before HIV was known of) was either not provided at all, or was provided only in a limited way. Even sex education in schools now provides a poor understanding of risks associated with sex and how STIs develop, but in the 1970s and 1980s gay sex, for all intents and purposes, simply did not exist in an open way. Instead of accepting that it was a reality, it was brushed under the carpet. When the epidemic came to the public’s attention in the 1980s the immediate reaction was one of increased stigma and homophobia, only serving to make matters worse. Many people at risk were unaware of the symptoms, and those who began to show them shied away from seeking help because of the discrimination and stigma they faced.
“The AIDS epidemic originally started from stigma. If you prevent people from getting the medicine they need, the disease is going to explode, as it did.”
– Elton John
Similarly, forcing prostitution underground makes it difficult for sex workers to seek the healthcare they need because of the taboo that is their existence, particularly in the case of trans sex workers, which brings us to gender inequality.
Trans women face arguably the most vicious discrimination in the world, and black trans women bear the brunt of this. In total transgender people are estimated to account for less than 1% of the world population, although this is likely to be higher, and world prevalence of HIV is approximately 0.8%, and even lower in high-income countries. In the hardest hit country, Botswana, about a quarter of the population is estimated to be HIV-positive. However, a number of American studies (see: Baral et al., 2013; Herbst et al., 2008) put HIV prevalence among transgender women between 22% and 28%, significantly higher than among the general population. Prevalence is even higher among African American transgender women, with over 50% estimated to be HIV-positive compared to 17% of white or 16% of Hispanic or Latina transgender women. The Centre for Disease Control & Prevention (CDC) identifies a number of reasons for this high prevalence among transgender women in the US including the violence, stigma and discrimination they face, homelessness and a higher than usual reliance on sex work due to experience of poverty. The CDC also states that once transgender women have the virus, they are also less likely to be treated effectively due to limited access to healthcare and also due to the lack of adequate training of healthcare professionals when it comes to dealing with transgender health issues.
“Gender inequality actually fuels the epidemic. It makes it much worse for rural women or women within marriages to access any kind of help, treatment or care because they have so many barriers to achieving treatment, to achieving any kind of services unless they’re pregnant.”
– Meena Seshu, Secretary General of SANGRAM
UN Women identifies gender inequality as a contributing factor to the spread of HIV because women have less information about the virus and fewer resources to prevent contracting it or spreading it, because they face barriers to negotiating safe sex due to unequal power dynamics with men, and because of experience of sexual violence, particularly in developing nations, to the extent that UN Women have identified marriage as a major risk factor for young women and girls. Many women in the developing world are forced to turn to sex work in order to provide for their families, while many others find themselves involved in high-risk activities at the whim of men who view them as a source of income or as a form of property. Female Genital Mutilation also puts women at increased risk, both during the process and afterwards, as circumcision makes exchange of blood during intercourse easier. The failure in both the developing world and the West to produce legislation that improves equality and protects vulnerable groups, instead doing the exact opposite, has kept women, cis and trans, in extremely dangerous situations. HIV/AIDS is only one of many of these dangers.
According to Sirpa Pietikäinen MEP of Finland’s centre-right National Coalition Party and a member of the European Parliament’s working group on reproductive health, HIV/AIDS and development, even when women do have knowledge of how to prevent infection it is of little use as they are not in a position of power that allows them to turn down sex or ask to use a condom, especially in the case of married women. She also states that ‘in countries where gay communities have no choice but to operate largely underground, there is a higher risk of contagion’, which is perhaps why HIV prevalence is 1.1% in Russia when it is half that or even lower in many neighbouring European countries, or why we have no data in this regard on many countries in the Middle East and North Africa.
At the heart of all this is income and wealth. Women earn less on average than men, and this gap is even more pronounced in many African and Asian countries. Transgender people are not recognized in many countries, they are not protected by anti-discrimination laws, and many will be denied employment or promotion on the basis of this. There is an inextricable link between social exclusion, drug use and sex work. It is by no means the case all the time for everyone, but it is a very clear link that exists in somewhat of a triangle. In both the developing world and the West women, trans people and gay men are disadvantaged to the point where many turn to sex work as a means of survival and many become reliant on substances, both alcohol and drugs, to cope with their lot in life. As well as the reasons given earlier, the CDC identifies the relationship between sex work and drugs, and also the selling of sex for drugs, as one of the causes of higher prevalence of HIV among trans women. Even among drug users who aren’t LGBT, HIV/AIDS is a significant risk; they’re one of the most at-risk groups in this regard. The role of drug use in the original AIDS epidemic in the 1980s is a well known fact. Just like pushing homosexuality underground increases the risks faced by gay people, brushing drugs under the carpet only makes it more dangerous for those involved, and there is largely a consensus that decriminalization of drugs, which mostly affects people from lower-socioeconomic backgrounds, particularly African American men in the US, the regulation of hard drugs like heroin, and the introduction of injection centres and methadone clinics greatly reduces the risk of transmission of HIV/AIDS and other things like Hepatitis C.
It is fair to say that correlation does not equal causation, but when the correlation is repeated time and time again in different places, different societies, with different people and in different situations, there is indeed a causal relationship. Where there is inequality in power dynamics, discrimination, criminalization or denial of opportunities, there is a greatly increased risk of HIV/AIDS and the only way to eradicate the virus is to eradicate inequality.