Discrimination against people with HIV/AIDS

The only way that HIV can be transmitted from one individual to the next is by sharing of certain bodily fluids such as semen, blood, and vaginal discharge which the virus uses as a medium to enter the bloodstream of the recipient; HIV is not transmissible via fluids such as saliva, sweat, tears, or urine as it is not in high enough concentrations to spread in these matters.[15] In order for HIV to enter another person, either the semen, blood, or vaginal discharge must find an entry point by way of injection, unprotected sex, or during pregnancy as the mother can pass it along; one would only contract the virus when coming in direct contact with these fluids, for example, with an open cut on the skin that exposes blood.[15]

PLHIV do not always pass on the virus to someone else when engaging in sexual activities or sharing bodily fluids; PLHIV can have no transmission risk by taking medication which lowers the amount of HIV present in the bloodstream, rendering the individual as having an undetectable viral load.[16][17] PrEP (pre-exposure prophylaxis), on the other hand, is a drug that is used as a preventative measure against HIV for those who are at a higher risk of contracting the virus but does not cure someone who has HIV; furthermore, the medication should be taken regularly in order to have a higher protective chance against HIV and is not a one-time medication nor does it treat PLHIV.[18]

People cannot contract AIDS, rather they are infected with HIV which progresses into AIDS over time when left unchecked; if someone has HIV, it does not guarantee that they will develop AIDS. By frequently taking medication such as antiretroviral therapy (ART), the abundance of HIV in the bloodstream is reduced and prevents it from developing into AIDS.[19]

Tim McCaskell explains that AIDS wasn't seen as a health crisis until public health officials realized that marginalized people could infect other, non-marginalized people. This was the first time that he realized that medicine and health were viewed as political topics. Suddenly, access to proper health care became a political problem. AIDS Action Now explored the fact that medical professionals were treating people in the hospital as lesser humans. He also found out that there was no money for research or education. Doctors were ignoring their roles as fiduciaries for medically fragile people while the public believed that the doctor-patient relationship meant remaining as neutral as possible.[20]

Many people incorrectly believe that HIV is exclusive to gay men who have sex, but, although the risks are higher for gay and bisexual males, anyone is susceptible to contracting the virus regardless of their sexual orientation, race, age, and so forth.[21] Some forms of violence such as childhood trauma, rape, and sexual assault can lead people to engage in unsafe sexual practices which would increase their chances of contracting HIV.[22] In some cases, young girls and women who experience these traumatic events become sex workers or engage in prostitution which further increases these risks as well as contributes to the development of AIDS with lack of treatment.[22]

These discriminatory views of HIV-positive patients also persist within the medical field. A 2006 study of health professionals in Los Angeles County found that 56 percent of nursing facilities, 47 percent of obstetricians, and 26 percent of plastic surgeons had unlawfully refused to treat an HIV-positive patient, citing concerns of HIV transmission.[23] Overall, this societal stigma and discrimination has exacerbated distrust towards healthcare workers within the HIV-positive population.[23] The health care community therefore has an ethical duty to dispel stereotypes and misconceptions about HIV.[24]

Between 1970 and 1980, more than 20,000 HIV infections were attributed to contaminated blood transfusions.[29] The lack of sensitive blood screening methods for HIV detection prompted the enactment of lifetime bans on blood donations from men who have sex with men (MSM), sex workers, and intravenous drug users, as these population groups were viewed to be at high risk of contracting HIV.[29] At the time, this policy was viewed by health professionals as an emergency measure to prevent the contamination of the general blood supply. Multilateral institutions such as the World Health Organization actively promoted the enactment of lifetime bans in efforts to mitigate transfusion-related HIV infections.[29] This ban was adopted by the United States, as well as several European countries in the 1980s.[29]

The blood donation ban on MSM and transgender women, in particular, has provoked substantial criticism. Members of the LGBTQ+ community view these laws as discriminatory and homophobic.[30] A significant criticism of the blood donation restrictions is that healthcare workers treat the LGBTQ+ community as a homogenous population that engages in similar sexual practices and behaviors.[30] However, like any other population, MSM vary greatly in the number of sexual partners they have and in their engagement in high-risk sexual behaviors.[30] Overall, the donation ban on MSM and transgender women has further exacerbated growing distrust of the medical system within the LGBTQ+ community, especially given the history of homophobia within the medical profession.[29] As a result of these policies, LGBTQ+ individuals have felt substantial pressure to conceal their sexual orientation from medical providers and healthcare personnel.[29]

Blood banks today utilize advanced serological testing technologies with close to 100% sensitivity and specificity.[29] Currently, the risk of HIV-contaminated blood infection is 1 per 8-to-12 million donations, thus demonstrating the effectiveness of modern HIV screening technologies.[29] Despite these significant laboratory advances, the lifetime blood donation ban on MSM remains in several Western countries.[29] Today, medical organizations such as the American Red Cross and World Health Organization are highly critical of these lifetime bans on men who have sex with men, as the epidemiology of HIV has changed drastically in the last 40 years.[31] In 2015, a mere 27% of novel HIV infections originated from the MSM population.[29] In response to this epidemiological data, public health experts, medical personnel, and blood-banking organizations have called upon country governments to reform these outdated MSM blood donation policies.[31]

Mounting public pressure has prompted countries such as the United States and United Kingdom to reform their MSM blood donation restrictions.[31] In 2015, the United States substituted its lifetime ban for a 12-month deferral since last MSM sexual contact, although indefinite lifetime bans remain in place for sex workers and IV drug users.[32] Despite these small steps in the right direction, the American Red Cross has recommended that the Food and Drug Administration (FDA) further revise its policy by adopting a 3-month deferral period for MSM, as this is the current standard in countries such as Canada and the United Kingdom.[33] Overall, it is estimated that completely lifting the MSM blood donation ban could increase the total blood supply in the United States by 2-4%, which could help save millions of lives.[34] Given the blood supply shortage during the COVID-19 pandemic, blood donation restrictions have recently become the subject of further criticism.[35]

On April 2, 2020, the Food and Drug Administration provided updated guidance regarding blood donation in response to the blood shortage caused by the COVID-19 pandemic. This change came following pressure from Democratic Senators and LGBTQ+ rights organizations such as the Human Rights Campaign and GLAAD to reduce the twelve-month deferral period for MSM and women who have sex with men who have sex with men.[36] The updated guidance released by the FDA reduced the deferral period to three months, but did not meet activists' demands to base blood donation eligibility on individualized situations rather than "inaccurate stereotypes."[36][37] On June 8, 2020, the American Red Cross implemented these changes made by the FDA and reaffirmed in their announcement of these changes their belief that sexual orientation should not affect blood donation eligibility.[38] These changes catalyzed increased advocacy to end the ban against blood donations from MSM and transgender women entirely. The National LGBT Bar Association launched a "End the Gay Blood Ban" Campaign which called on the FDA to replace the current policy that singles-out MSM and transgender women with an individualized risk-based assessment, a policy currently used in countries such as Italy and Argentina. This policy would assess a potential donor's personal risk factors rather than their sexual orientation.[39] On April 16, 2020, GLAAD issued an open-letter to the FDA from over 500 infectious disease and HIV specialists, public health professionals, clinicians, healthcare administrators, trainees and researchers calling for a reevaluation of the updated guidance and the elimination of the blood ban in its entirety.[40]

Marginalized groups also face barriers to accessing HIV/AIDS preventative care such as Pre-Exposure Prophylaxis (PrEP). Studies have shown that concerns about paying for PrEP and talking to healthcare providers about sexual behaviors have contributed to low PrEP use among young sexual minority men.[53] Other structural barriers to PrEP use include limited knowledge of its availability, stigma surrounding HIV, and distrust of the medical establishment among minority groups due to years of discrimination within the medical field against marginalized groups.[54] A poll conducted on the gay dating-app Grindr found a high prevalence of poor access to health insurance and lack of education about PrEP among respondents.[55] Studies have found that cost concerns, mental health, substance use issues, concerns about hormone interaction, uncomfortable side effects, difficulty taking pills, stigma, exclusion of transgender women in advertising, and lack of research on transgender women and PrEP are all barriers to PrEP use among transgender women. Structural barriers to PrEP use among transgender women include employment, transportation, and housing insecurity/homelessness.[56][57] A study of Black MSM in London found that instances of racism in spaces dedicated to gay men led to an avoidance of these spaces among the study participants, leading Black MSM to miss out on PrEP awareness that was disseminated via gay channels.[58]

As of the end of 2018, the black imprisonment rate was about twice that of Hispanics and more than five times the imprisonment rate amongst whites in the United States.[59] Moreover, black males are more likely to be imprisoned with 2,272 inmates per 100,000 black men, in comparison to 1,018 inmates per 100,000 Hispanic men and 392 inmates per 100,000 white men.[59] Incarcerated individuals have a much higher risk of having HIV than non-incarcerated individuals. The estimated global HIV prevalence for prisoners is 3%, whereas the estimated global HIV prevalence for adults in general is 0.7%.[60][61] Additionally, women in prison have a higher HIV prevalence than men.[60] Incarcerated individuals also have a high risk of transmission as well due to high-risk activity (i.e. unsafe and unsterile tattooing, needle sharing, and unprotected sexual activity). Needle sharing is much more prevalent in prisons because possession of needles in prison is oftentimes a criminal offense, causing clean needles to be scarce.[62] Only about 30% of countries worldwide offer condoms for incarcerated individuals, but for the countries that do offer condoms, coverage and access is not reported.[63] Moreover, these individuals have a harder time accessing critical HIV resources such as ART.[64] Even if ART is offered, those with HIV may still lack the ability to get specialized care and specific ART regimens.[65]

Inequities resulting from discrimination and stigma towards PLHIV can impact susceptibility to other public health threats. Discrimination in the housing, medical, and employment sectors towards PLHIV has helped to drive the COVID-19 public health threat in marginalized populations.[66] Many of the groups most vulnerable to HIV infection, such as communities of color or individuals living in poverty, are also at increased risk of contracting COVID-19. PLHIV also appear to be more likely to live in the areas hit hardest by COVID-19. The Kaiser Family Foundation found that 15 of the 20 counties with the highest HIV prevalence in the United States were also ranked in the top 20 counties with the highest COVID-19 morbidity and mortality rates.[67]

The effects of COVID-19 on people with HIV is still being studied. It is thought individuals of older age or with serious underlying medical conditions may be at greater risk for severe illness from COVID-19. This includes people with HIV who have comorbidities, a low CD4 cell count, or are not currently on effective HIV treatment.[68] The Coronavirus Under Research Exclusion (CURE HIV-COVID) database collects information on outcome of COVID-19 in people living with HIV.[69] According to the WHO, 23.1% of PLHIV hospitalized for COVID-19 died from the disease, making HIV a risk-factor for severe illness or death due to the virus.[70] The CDC, WHO, and other health organizations have recommended that PLHIV are given priority for COVID-19 vaccination, and the CDC has recommended additional vaccine doses for PLHIV with advanced disease or who are not taking medication to treat their HIV.[70][71] Some states have explicitly prioritized vaccination for people living with HIV, while others used the broader criteria of individual who are in an "immunocompromised state", which can include PLHIV. [67]

At various points in the pandemic, hospitals were overwhelmed by the number of COVID-19 patients, some of whom required intensive treatments like invasive ventilation and extracorporeal membrane oxygenation (ECMO).[72][73] As a result, there were serious concerns about the need to institute care rationing systems which would provide criteria for the prioritization of patients to receive medical attention and treatment. As there was little coordination between hospitals or guidance from local and state governments, many immunocompromised individuals, including PLHIV, were uncertain of the implications of these policies on their access to care. In March 2020, the Office for Civil Rights in the Department of Health and Human Services filed a complaint against Washington and Alabama for their care rationing policies, citing them as discriminatory against individuals with disabilities.[74]