HIV 101: Who Is At Higher Risk of HIV Infection?

HIV/AIDS and Socioeconomic Status

HIV 101: Who Is At Higher Risk of HIV Infection?

Socioeconomic status (SES) encompasses not just income but also educational attainment, financial security, and subjective perceptions of social status and social class. Socioeconomic status can encompass quality of life attributes as well as the opportunities and privileges afforded to people within society.

Poverty, specifically, is not a single factor but rather is characterized by multiple physical and psychosocial stressors. Further, SES is a consistent and reliable predictor of a vast array of outcomes across the life span, including physical and psychological health.

Thus, SES is relevant to all realms of behavioral and social science, including research, practice, education and advocacy.

SES Affects our Society

SES affects overall human functioning, including our physical and mental health. Low SES and its correlates, such as lower educational achievement, poverty and poor health, ultimately affect our society.

Inequities in health distribution, resource distribution, and quality of life are increasing in the United States and globally.

Society benefits from an increased focus on the foundations of socioeconomic inequities and efforts to reduce the deep gaps in socioeconomic status in the United States and abroad.

SES Impacts the Lives of People with HIV/AIDS

Both domestically and internationally, HIV is a disease that is embedded in social and economic inequity (Pellowski, Kalichman, Matthews, & Adler, 2013), as it affects those of lower socioeconomic status and impoverished neighborhoods at a disproportionately high rate. Research on SES and HIV/AIDS suggests that a person’s socioeconomic standing may affect his or her lihood of contracting HIV and developing AIDS. Furthermore, SES is a key factor in determining the quality of life for individuals after they are affected by the virus.

SES Affects HIV Infection

A lack of socioeconomic resources is linked to the practice of riskier health behaviors, which can lead to the contraction of HIV. These behaviors include substance use, which reduces the lihood of using condoms (Pellowski et al., 2013).

  • Limited economic opportunities and periods of homelessness have been associated with risky sexual practices, such as exchanging sex for money, drugs, housing, food and safety. Ultimately, these practices can place individuals at risk for HIV (Riley, Gandhi, Hare, Cohen, & Hwang, 2007).
  • Living in poverty can also result in food insufficiency, which can contribute to HIV/AIDS infection. Lacking food can result in transactional sex and power differences in sexual relationships, which can place an individual at risk of infection. Further, individuals may continue to face hunger after contracting HIV (Kalichman et al., 2011).
  • Impoverished urban areas have been found to have HIV prevalence rates equivalent to many low-income countries with generalized epidemics (Buot et al., 2014). Studies of urban health have found that factors such as level of poverty and unemployment, vacant buildings and high crime rates are all associated with increased risk of HIV infection. These factors are all highly correlated, however, making it difficult to isolate the mechanisms that promote HIV infection (Latkin, German, Vlahov, & Galea, 2013).
  • Even though HIV is predominately located in major urban areas, trends over the years suggest an increasing impact of the disease on women, minorities, older adults, rural residents and those living in the South (National Rural Health Association, 2014). Rural residents face unique challenges such as distance to care, lack of health care facilities and health care providers with HIV/AIDS expertise, limited availability of supportive or ancillary services, stigma and discrimination, and limited educational and economic infrastructure (Schur et al., 2002).
  • SES indicators may differentially affect HIV risk for men and women. Income inequality has been found to be related to increased HIV risk for males, whereas poverty, health and housing circumstances increased risk for females (Buot et al., 2014). However, for both men and women, increased poverty and unemployment levels and decreased median household income are related to a lower probability of survival after an HIV diagnosis (Harrison, Ling, Song, & Hall , 2008). Other SES indicators, including poverty, homelessness, hunger and lower education, have also been associated with higher mortality (McMahon, Wanke, Terrin, Skinner, & Knox, 2011).

HIV Status Affects SES

HIV status often has a negative impact on socioeconomic status by constraining an individual’s ability to work and earn income.

  • The effects of HIV on physical and mental functioning can make maintaining regular employment difficult. Patients with HIV infection may also find that their work responsibilities conflict with their health care needs. Disease severity and self-reported HIV-related work discrimination place HIV-positive women and individuals with low education at risk for employment loss (Dray-Spira, Lert, Marimoutou, Bouhnik, & Obadia, 2008).
  • Research indicates that unemployment rates among people living with HIV/AIDS can range from 45 percent to 65 percent (Dray-Spira, Gueguen, & Lert, 2008).
  • People with advanced HIV infection and AIDS may qualify for disability benefits that limit their ability to earn additional income (Pellowski et al., 2013).
  • In one study, employers who believed that job applicants with HIV/AIDS were incompetent and could not perform the functions of the job stated that they would be less ly to interview hypothetical applicants (Liu, Canada, Shi, & Corrigan, 2012). This could have implications for hiring practices and economic opportunities for people living with HIV/AIDS.

SES Affects HIV Treatment

  • SES status often determines access to HIV treatment. Individuals of low SES have delayed treatment initiation relative to more affluent patients, reducing their chances of survival (Joy et al., 2008).
  • Structural factors including poverty, lack of employment opportunities, limited health care access and limited transportation infrastructure have been highlighted as both independent and interactive contributors to health care engagement in HIV-positive women (Walcott et al., 2016).
  • Patients of lower SES have increased HIV/AIDS mortality rates. Research suggests that an increase in SES is associated with a reduction in HIV/AIDS deaths, and HIV/AIDS death rates in a high-SES county were nearly three times greater than those in a low-SES county (Rubin, Colen, & Link, 2010).
  • Women living in poorer households may experience difficulties before, during and after childbirth that can place them at risk for HIV infection and complications. Women in low-income households may be less ly to access prenatal care that could allow them to be tested for HIV. Experiencing food insecurity can also affect maternal and child health, including adherence to antiretroviral therapy (ART) and breastfeeding (Young, Wheeler, McCoy, & Weiser, 2014).
  • Homeless and marginalized housed individuals who are considered food insecure are more ly to have lower CD4 (T-cell) counts, poorer medication adherence, and incomplete suppression of HIV replication (Weisner et al., 2009). Food insecurity and residential instability are associated not only with poorer medication adherence but also with inconsistent health care and poorer access to health care, as well as less favorable attitudes toward health care providers (Surratt et al., 2014).
  • Barriers and facilitators to adhering to ART differ in resource-poor and resource-rich countries. In resource-poor countries, poverty may prevent access to health care and subsequent treatment, while in resource-rich countries, factors related to poverty such as addiction or depression may prevent people living with HIV from adhering to medications (Young et al., 2014).


Buot, M. L. G., Docena, J. P., Ratemo, B. K., Bittner, M. J., Burlew, J. T., Nuritdinov, A. R., & Robbins, J. R. (2014). Beyond race and place: Distal sociological determinants of HIV disparities. PLoS ONE, 9(4), e91711.

Dray-Spira, R., Gueguen, A., & Lert, F. (2008). Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: Differences according to gender and education. Occupational and Environmental Medicine, 65, 112-119. doi:10.1136/oem.2007.034363

Dray-Spira, R., Lert, F., Marimoutou, C., Bouhnik, A. D., & Obadia, Y. (2003). Socio-economic conditions, health status and employment among persons living with HIV/AIDS in France in 2001.   AIDS Care, 15, 739-748. doi:10.1080/09540120310001618595

Harrison, K. M., Ling, Q., Song, R., & Hall, H. I. (2008). County-level socioeconomic status and survival after HIV diagnosis. Annals of Epidemiology, 18, 919-927. doi:10.1016/j.annepidem.2008.09.003

Joy, R., Druyts, E. F., Brandson, E. K., Lima, V. D., Rustad, C. A., McPhil, R., & Hogg, R. S. (2008). Impact of neighborhood-level socioeconomic status on HIV disease progression in a universal health care setting.   Journal of Acquired Immune Deficiency Syndromes, 47, 500-505. doi:10.1097/QAI.0b013e3181648dfd

Kalichman, S. C., Pellowski, J., Kalichman, M. O., Cherry, C., Detorio, M., Caliendo, A. M., & Schinazi, R. F. (2011). Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings. Prevention Science, 12, 324-332. doi:10.1007/s11121-011-0222-9

Latkin, C. A., German, D., Vlahov, D., & Galea, S. (2013). Neighborhoods and HIV: A social ecological approach to prevention and care. American Psychologist, 68, 210-224. doi:10.1037/a0032704

Liu, Y., Canada, K., Shi, K., & Corrigan, P. (2012). HIV-related stigma acting as predictors of unemployment of people living with HIV/AIDS. AIDS Care, 24(1), 129-135.

McMahon, J., Wanke, C., Terrin, N., Skinner, S., & Knox, T. (2011). Poverty, hunger, education, and residential status impact survival in HIV. AIDS and Behavior, 15, 1503-1511. doi:10.1007/s10461-010-9759-z

National Rural Health Association. (2014). HIV/AIDS in rural America: Disproportionate impact on minority and multicultural populations. Retrieved from

Pellowski, J. A., Kalichman, S.C., Matthews, K. A., & Adler, N. (2013). A pandemic of the poor: Social disadvantage and the U.S. HIV epidemic. American Psychologist, 68, 197-209. doi:10.1037/a0032694

Riley, E. D., Gandhi, M., Hare, C. B., Cohen, J., & Hwang, S. W. (2007). Poverty, unstable housing, and HIV infection among women living in the United States. Current HIV/AIDS Reports, 4, 181-186. doi:10.1007/s11904-007-0026-5

Rubin, M. S., Colen, C. G., & Link, B. G. (2010). Examination of inequalities in HIV/AIDS mortality in the United States from a fundamental cause perspective. American Journal of Public Health, 100, 1053-1059. doi:10.2105/AJPH.2009.170241

Schechter, M. T., Hogg, R. S., Aylward, B., Craib, K. J., Le, T. N., & Montaner, J. S. (1994). Higher socio- economic status is associated with slower progression of HIV infection independent of access to health care.   Journal of Clinical Epidemiology, 47, 59–67. doi:10.1016/0895-4356(94)90034-5

Schur, C. L., Berk, M. L., Dunbar, J. R., Shapiro, M. E., Cohn, S. E., & Bozzette, S. A. (2002). Where to seek care: An examination of people in rural areas with HIV/AIDS. The Journal of Rural Health, 18, 337-347. doi:10.1111/j.1748-0361.2002.tb00895.x

Young, S., Wheeler, A. C., McCoy, S. I., & Weiser, S. D. (2014). A review of the role of food insecurity in adherence to care and treatment among adult and pediatric populations living with HIV and AIDS. AIDS and Behavior, 18, S505-S515. doi:10.1007/s10461-013-0547-4

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Risk of exposure to HIV/AIDS

HIV 101: Who Is At Higher Risk of HIV Infection?

This information was provided by CATIE (the Canadian AIDS Treatment Information Exchange). For more information, contact CATIE at 1-800-263-1638.

 James Wilton

Service providers working in HIV prevention are often asked by their patients and clients about the risk of HIV transmission from an exposure to HIV through sex. What do the latest studies tell us about this risk? And how should we interpret and communicate the results?

Challenges in calculating a number

It isn't easy for researchers to calculate the risk of transmission from an exposure to HIV through sex. To do this effectively, a group of HIV-negative individuals need to be followed over time and their exposures to HIV—both the number of times they are exposed and the types of exposure—need to be tracked.

As you can imagine, accurately tracking the number of times a person is exposed to HIV is very difficult.

Researchers ask HIV-negative individuals enrolled in these studies to report how many times they have had sex in a given period of time, what type of sex they had, how often they used condoms and the HIV status of their partner(s).

Because a person may have trouble remembering their sexual behaviour or may not want to tell the whole truth, this reporting is often inaccurate.

Furthermore, a person does not always know the HIV status of their partner(s). For this reason, researchers usually enroll HIV-negative individuals who are in stable relationships with an HIV-positive partner (also known as serodiscordant couples). Researchers can then conclude that any unprotected sex reported by a study participant counts as an exposure to HIV.

Several studies have aimed to estimate the average risk of HIV transmission from a specific type of unprotected sex (for example, vaginal/anal/oral; insertive/receptive).

Due to the difficulties of calculating this risk, these studies have produced a wide range of numbers.

To come up with a more accurate estimate for each type of unprotected sex, some researchers have combined the results of individual studies into what is known as a meta-analysis.

All exposures are not equal

The results of several meta-analyses suggest that some types of sex carry on average a higher risk of HIV transmission than others. Below are estimates from meta-analyses that have combined the results of studies conducted in high-income countries. For types of sex where meta-analysis estimates do not exist, numbers from individual studies are provided.

Anal sex

A meta-analysis exploring the risk of HIV transmission through unprotected anal sex was published in 2010.

1 The analysis, the results of four studies, estimated the risk through receptive anal sex (receiving the penis into the anus, also known as bottoming) to be 1.4%.

(This means that an average of one transmission occurred for every 71 exposures.) This risk was similar regardless of whether the receptive partner was a man or woman.

No meta-analysis estimates currently exist for insertive anal sex (inserting the penis into the anus, also known as topping) but two individual studies were conducted to calculate this risk. The first, published in 1999, calculated the risk to be 0.06% (equivalent to one transmission per 1,667 exposures).

2 However, due to the design of the study, this number ly underestimated the risk of HIV transmission. The second study, published in 2010, was better designed and estimated the risk to be 0.11% (or 1 transmission per 909 exposures) for circumcised men and 0.62% (1 transmission per 161 exposures) for uncircumcised men.


Vaginal sex

A meta-analysis of 10 studies exploring the risk of transmission through vaginal sex was published in 2009.4 It is estimated the risk of HIV transmission through receptive vaginal sex (receiving the penis in the vagina) to be 0.08% (equivalent to 1 transmission per 1,250 exposures).

A meta-analysis of three studies exploring the risk from insertive vaginal sex (inserting the penis into the vagina) was estimated to be 0.04% (equivalent to 1 transmission per 2,500 exposures).4

Oral sex

No meta-analysis estimates exist for oral sex (vaginal or penile) because too few good-quality studies have been completed.

This is because it is difficult to find people whose only risk of HIV transmission is unprotected oral sex.

A review of the studies that are available was published in 2008 and concluded that vaginal and penile oral sex pose a «low but non-zero transmission probability.»5

In the three studies aimed at calculating the risk of HIV transmission from one act of oral sex, no transmissions were observed among three different populations—lesbian serodiscordant couples, heterosexual serodiscordant couples and single gay men—who reported unprotected oral sex as their only risk for HIV transmission. However, these studies enrolled only a small number of people and followed them for only a short period of time, which may explain the lack of HIV transmissions and makes it impossible to conclude that the risk from oral sex is zero.


Who Is at Risk for HIV Infection and Which Populations Are Most Affected? | National Institute on Drug Abuse

HIV 101: Who Is At Higher Risk of HIV Infection?

Anyone can contract HIV, and while IDUs are at great risk because of practices related to their drug use, anyone who engages in unsafe sex (e.g., unprotected sex with an infected partner) could be exposed to HIV infection. However, while all groups are affected by HIV, some are more vulnerable than others, as summarized below.

Men Who Have Sex with Men

Gay or bisexual MSM are the most severely affected population. MSM account for just a small fraction (2 percent) of the total U.S. population, yet nearly two-thirds of all new infections occurred within this group in 2009, and one-half of all people living with HIV in 2008 were MSM. MSM within ethnic minority populations are at greatest risk (see “Ethnic Minorities,” below).

Diagnosis of HIV Infection among Adults and Adolescents, by Transmission Category (2010)*

*These transmission categories do not distinguish infections resulting from non-injection drug use (e.g., sexual behavior resulting from drug or alcohol intoxication).  See text description

Injection Drug Users

Injection drug use has long been associated directly or indirectly with approximately one-third of AIDS cases in the United States.

The fact that IDUs made up only 8 percent of new HIV infections in 2010 versus 23 percent in 1994–2000 demonstrates the progress made in HIV prevention and treatment within this population.

Still, much work remains; while there may be fewer new infections among IDUs, in 2009, nearly one-half of those who were HIV+ were unaware they were infected.18

Hepatitis C virus (HCV), a leading cause of liver disease, is highly prevalent among injection drug users and often co-occurs with HIV. In the United States, an estimated 3.2 million people are chronically infected with HCV,22 with injection drug use being the main driver.

Nearly one-quarter of HIV patients and over one-half (50–80 percent) of IDUs are infected with both viruses.

Chronic HCV and HIV co-infection results in an accelerated progression to end-stage liver disease, with HCV infection being a leading cause of non–AIDS-related deaths among HIV+ individuals.

Injection drug use, HIV, and HCV create a complicated tapestry of ailments that present a variety of challenges to healthcare providers. Although HAART medications can effectively treat people infected with HIV, HAART provides only modest benefit for co-occurring HCV. HCV infection, HIV infection, can be successfully managed if detected early.

The newer HCV medications boceprevir and telaprevir — approved by the U.S. Food and Drug Administration (FDA) in 2011 — increase cure rates and decrease treatment length when combined with standard HCV drug regimens,23 but they must be carefully coordinated with HAART for those co-infected.

The added burden of drug addiction further complicates treatment regimens.


Heterosexual contact with an HIV+ partner accounted for over one-quarter of all new infections in 2010 and is the main way that women contract the virus (see figure), especially within ethnic minority communities. Regional variations of HIV incidence in women have changed over time.

In the early years of the epidemic, incidence in women predominated in the Northeast, but infection rates and mortality have been steadily increasing in the southern United States.19 Although injection drug use has declined as a means of HIV transmission over recent years, it is still responsible for 14 percent of HIV diagnoses in women.

A recent study conducted by the Massachusetts Department of Public Health reported 40 percent of White women contracted HIV through injection drug use.20 Another factor contributing to HIV disease in women is trauma.

Trauma resulting from sexual or physical abuse experienced during childhood or adulthood is increasingly associated with rising prevalence of HIV infection and poor health outcomes in HIV+ women.21 Comprehensive HIV treatment regimens that include mental health services are critical for this population.

Ethnic Minorities

HIV surveillance data show that the rates of new HIV infection are disproportionately highest within ethnic minority populations. African- Americans account for a higher proportion of HIV infections than any other population at all stages of the disease from initial infection to death (see text box). Moreover, specific minority subgroups are at particular risk.

Nearly two-thirds (64 percent) of new HIV infections among MSM occurred in minority men (Black/African-American, Hispanic/Latino, Asian/Pacific Islanders, and Native American/ Hawaiian).

In addition, young minority men (13–24 years old) had the greatest increase (53 percent) of HIV infections of all groups studied between the years 2006 and 2009, occurring predominantly in the South.

The Hispanic population accounted for 1 in 5 new HIV infections in the United States in 2009 — a rate 3 times that of the White community. A number of factors contribute to the high levels of HIV infection within this community, including the country of birth.

For example, there is a substantially larger proportion of HIV infections attributed to injection drug use for Hispanic men born in Puerto Rico than anywhere else.

Such differences underscore the need for interventions that are socially and culturally tailored for specific populations.


Young people are also at risk for HIV infection. Approximately 9,800 people aged 13–24 were diagnosed with HIV in 2010, representing 20 percent of newly diagnosed cases, with the highest rate occurring among those aged 20–24.

Particular HIV risk behaviors within this age group include sexual experimentation and drug abuse, which are often influenced by strong peer group relationships.

Compounding this vulnerability is “generational forgetting”: Studies show that today’s youth may be less ly to perceive the dangers associated with HIV than are older Americans, who witnessed a higher AIDS mortality rate associated with the rapid progression from HIV to AIDS in the early years of the epidemic.

Older People

Sixteen (16) percent of new diagnoses of HIV infection in the United States in 2010 occurred among individuals over the age of 50, and this number has been increasing for the past 11 years.

26 Some older persons do not believe they are at risk and thus engage in unsafe sexual practices.

The problem is further exacerbated by healthcare professionals who underestimate the vulnerability of this population.

The growing number of people contracting HIV later in life, combined with the prolonged survival made possible by HAART, has contributed to an increasing number of people over the age of 50 living with HIV. This trend will continue, and by 2015, the over-50 population is predicted to represent one-half of all HIV/AIDS cases.

27 The aging population presents a variety of treatment challenges. Older adults progress more rapidly to AIDS, have a greater number of age-related comorbidities (e.g., cardiovascular disease, limited mobility), and report smaller support networks than their younger counterparts.

Young people are also at risk for HIV infection.

Criminal Justice System

The criminal justice system is burdened with a significant population of HIV-infected individuals that can be 2 to 5 times larger than that in the surrounding community.29 An estimated 1 in 7 HIV+ individuals living in the United States passes through this system each year.

30 The criminal justice system is also burdened with significant substance abuse, with about one-half of Federal and State prisoners meeting the criteria for drug dependence or abuse.31 Yet, few offenders are screened for HIV,32 or receive treatment for substance abuse and other mental illness while incarcerated.

This situation is further exacerbated upon reentry when released offenders often lack health insurance and fail to be linked to continuing treatment programs within the community.

NIDA is helping to address these challenges by researching the best ways to identify and help prisoners get treatment for both drug addiction and HIV while incarcerated and in the community after release.

While African-Americans make up 12 percent of the U.S. population, they accounted for 46 percent of new HIV infections in 2010, substantially higher than the rate for Whites or Hispanics.

The majority of these were men (70 percent); however, African-American women also have a high rate of HIV diagnosis — nearly 20 times that of White women (see figure).

More disheartening is that 1 in 16 African-American men and 1 in 32 African-American women will eventually be diagnosed with HIV.

The causes of this HIV health disparity are complex.

HIV infection prevalence is higher and more broadly represented in the African- American community compared to the White population; thus African-Americans are at increased risk of infection simply by choosing intimate partners within their own ethnic communities.

24 Additionally, African-American communities experience high rates of other sexually transmitted infections, and some of these infections can significantly increase the risk of contracting HIV.

African-Americans also tend to be diagnosed at later stages in the disease and therefore begin therapy later, increasing the length of time of their infectivity. Once engaged in HAART, African-Americans are more ly to discontinue therapy prematurely,25 risking resurgence of HIV infectivity and further health complications.

To address these disparities, NIDA is encouraging research that expands and coordinates prevention and treatment strategies across Federal agencies and within communities to more effectively identify persons at risk and link them to the help they need. Additional efforts are being made to promote healthy lifestyle choices, safe sexual practices, and HIV and substance abuse treatment adherence in a way that is culturally relevant for the African-American community.

Text Description: Diagnosis of HIV Infection Among Adults and Adolescents, by Transmission Category (2010) Graph

Male-to-male sexual contact: 61% Injection drug use: 8% Male-to-male sexual contact and injection drug use: 3% Heterosexual contact: 28%



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