HIV and AIDS today: where is social work going?

In 2006 a bittersweet historical landmark was reached--25 years of the HIV and AIDS pandemic. Many in the field took this opportunity to reflect on the advances, progress, and stalemates (Centers for Disease Control and Prevention [CDC], 2006; Gallo, 2006; Traynor, 2006). In this column I also reflect on the 25 years of HIV and AIDS with a focus on social works' roles, past and future. In the United States, the ravages of the epidemic's early days have changed dramatically. We have gone from an epidemic disproportionately represented by white gay men to an epidemic disproportionately represented by men and women who are not white, and more specifically black and Latino men and women (Arias, 2006; Prejean, Satcher, Durant, Hu, & Lee, 2006). The devastation of the disease has also changed over the years. Now rather than seeing hospital units filled with dying men in isolation, we see a plethora of HIV rapid-testing stations and prevention and intervention programs dispersed across the country. Hopes for a medical cure have eluded scientists, and even today a cure seems outside our realm of "near-future" advents. The face of the epidemic has changed dramatically. Unfortunately, the effect of HIV and AIDS on the most marginalized groups continues to defy our best scientific efforts. Although the deaths associated with AIDS have decreased, annually an estimated 40,000 new individuals become infected with HIV in the United States (CDC, 2006).These statistics tell part of a saga that was foretold more than 20 years ago--HIV and AIDS are diseases of social systems as much as they are diseases of the immune system. The social conditions in which HIV and AIDS thrive are also the conditions in which our most marginalized members exist. Poor educational systems, racialized health and human services systems, economic deprivation, poor housing, and high rates of engagement with the criminal justice system are but a few of the co-occurring conditions that mirror the progression and entrenchment of the HIV/AIDS epidemic (Arias, 2007; Clarke-Tasker, Wutoh, & Mohammed, 2005; Dalton, 1989; Dicks, 1994; Moseby, 2005). This symbiosis of social inequality and immunological disease challenges the most aggressive HIV/AIDS science-based prevention and intervention efforts. In recent years HIV prevention and AIDS interventions have increasingly relied on evidence-based practice models, early detection, and behavior risk reduction, particularly with HIV-positive people. The problem with many of these models is that the "evidence" is not necessarily grounded in the experiences or immediate needs of the most vulnerable populations (Amaro, Raj, Vega, Mangione, & Perez, 2001; Lester, 1993; Traynor, 2006; Wingood & DiClemente, 2006; Wolitski et al., 2006). SOCIAL WORKERS AT GROUND ZERO Social workers have a long history of working in the trenches of this pandemic, from the streets of New York, Los Angeles, and San Francisco in the early 1980s to small villages and towns across the globe today (Dicks, 1994). In this work, professional social workers have had to develop skills that bring the best of what is known scientifically to bear on the "real-world" circumstances of the populations with whom they work. The work of social workers with and on the behalf of marginalized groups has never been "clean" work. The efforts of professionals in the early years of the epidemic were about "meeting clients where they were." In the early years of this epidemic, that meant dealing with fear and outrage, frustration, grief, and stigmatization. As scientific understanding of the modes of this disease transmission advanced and possibilities for preventing infections emerged, our efforts shifted from merely responding to a perceived inevitable fate to aggressively altering the environments (social and political) that produced the circumstances in which the disease flourished (Avery & Bashir, 2003; Dalton, 1989). …