Demographic risk factors for HIV

A person's biological sex classification (eg, male, female), as well as the social roles associated with each biological sex category (gender), influence other risk factors for HIV/AIDS. For example, men are less likely to acquire HIV from heterosexual sex than women are because of the anatomy of the penis. However, cultural norms in many parts of the world encourage men to demonstrate their masculinity by having multiple sex partners and coercing women into having sex, which increase HIV risk. Men are also much more likely than women to abuse alcohol and drugs, which increases the likelihood that they will engage in unprotected sex. Men are also more likely than women to inject drugs, exposing them to the risk of HIV from infected needles and syringes (Denny, 1995; UNAIDS, 2000).

Women, in contrast, are at greater risk of HIV infection from heterosexual sex than men are because of the anatomy of the vagina. In addition, although cultural norms in many parts of the world dictate that women should remain virgins until married (a factor that can reduce HIV risk), the denial of access to HIV education and the belief that women should be sexually passive decrease the likelihood that women will take steps to protect themselves from HIV in sexual relationships. Limited access to education, jobs, and bank credit makes women dependent on male partners, or forces them to exchange sex for food or money, thus limiting the control they have over the timing and circumstances of sex. Women are also far more likely than men to experience gender-based violence, including physical and sexual abuse, in which they do not have control over the safety of sexual intercourse (Clements-Nolle, Marx, Guzman, & Katz, 2001; Türmen, 2003; UNAIDS, 1999, 2005).

Transgender

Transgender persons constitute a third (and often ignored) gender group that is at risk for HIV infection. Transgender individuals have a persistent and distressing discomfort with their birth sex, and so may assume the roles of the other sex through such behaviors as dress, occupation, or even sex-reassignment surgery (Denny, 1995). Although there is limited information about rates of HIV among transgender people, rates are expected to be higher because transgender people have more behavioral risks factors, such as substance abuse and use of shared needles (for injection of hormones as well as for illicit drugs), irregular condom use, and multiple sex partners (Department of Health and Human Services, n.d.; Quinn, 1993).

In the United States, the group with the highest rate of HIV infection is men who have sex with men (CDC, 2005). This group has the highest rates of unprotected anal sex, which is a behavioral risk factor for HIV transmission. In most regions of the world, however, the group with the highest rates of HIV is people who have heterosexual intercourse.

In the United States, racial and ethnic minorities represent the majority of new AIDS cases, the majority of Americans living with AIDS, and the majority of deaths among persons with AIDS. Most of the excess risk of HIV/AIDS among African Americans and Latinos reflects discrimination in employment, housing, earning power, and educational opportunity (UNAIDS, 2002). This discrimination relegates minorities to lower levels of socioeconomic status (SES) and to the risks associated with lower SES, such as limited access to healthcare. Studies have shown that HIV-infected African Americans and Latinos are more likely than HIV-infected Whites to be uninsured, to have not received antiretroviral drugs, and to lack transportation for visiting doctors ("Multiple Barriers," 2003).

Socioeconomic status indicates people's standing in society and is usually measured by their income, occupation, or educational attainment. Socioeconomic status is one of the most powerful predictors of sickness and health. People with lower SES are more likely to contract and transmit HIV/AIDS, perhaps because they have less knowledge about HIV/AIDS, are surrounded by people who are more likely to have HIV/AIDS, and are more likely to use drugs and practice unsafe sex to escape from stress (Feldman, 1990; United Nations Population Fund [UNFPA], 2003). HIV-positive people with lower SES also die sooner than HIV-positive people with higher SES because of their lack of access to medical care, the high cost of antiretroviral drugs, and their lowered immunity from other illnesses.

About half of all new HIV infections worldwide, or approximately 6,000 per day, occur among young people aged 15–24, the majority of them young women (UNFPA, 2003). In the United States, for men who have sex with men, younger age is strongly correlated with increased high-risk sexual behaviors (eg, unprotected anal sex) (Kalichman, 1998). Despite high levels of sexual activity, young people often do not know the basic HIV/AIDS statistics and facts, which put them at risk (Feinstein & Prentice, 2001).

HIV disease morbidity and mortality vary greatly within and between nations. In the United States, for example, the annual number of deaths by HIV is highest in the South. US regional differences continue to increase over time (CDC, n.d.). Limited access to healthcare, poverty, and discrimination all contribute to these regional disparities. Persons who live in geographic areas in which HIV is more prevalent and who engage in risky sex or drug use behaviors are more likely to do so with persons who have HIV.