A Multidimensional Conceptual Framework for Understanding HIV/AIDS as a Chronic Long-Term Illness

Cassandra is a 29-year-old single woman of Asian descent with a history of substance abuse and depression. Five years ago, while hospitalized with pneumonia, she learned that she was HIV positive and that her immune system was already significantly compromised. Initially devastated by this news and in denial, she began antiretroviral medication three months after her doctor recommended it. Although she has some unpleasant side effects from these medications, she is generally responding quite well. She has had no HIV-related illnesses since that initial episode of pneumonia, and she is now in recovery from her drug use. Last year Cassandra started dating and wanted to pursue a more intimate relationship with her partner, a man for whom she had very strong feelings. However, fearing the risk of transmitting HIV to him, she ended the relationship. She now seeks the help of a social worker because she is feeling depressed and anxious about her future. As this case study illustrates, HIV can affect clients, families, and communities in numerous and complex ways. Although most social workers may have some knowledge about HIV, many lack adequate understanding of the contexts and processes of HIV, particularly in light of treatment advances (Gillman, 1991; Wolf, 2000; Zibalese-Crawford, Brennan, & Stein, 1995). Unfortunately, this misunderstanding can result in inappropriate care and increased distress for the person with HIV and his or her support system. In response to breakthroughs in HIV treatment that greatly enhance the quality of life for people with HIV, this article provides multiple contexts for understanding HIV: the historical context; a consideration of the human behavior contexts of the person who is infected with HIV; the biomedical context; and the social environment. These contexts and the related social work principles are derived from existing approaches that are re-examined and reapplied to address anew the needs of people with HIV who may now live longer, healthier lives. HIV/AIDS: A Brief Historical Overview Despite widespread efforts to teach about HIV and prevent its transmission, the Centers for Disease Control and Prevention (CDC) (1999a) estimates that between 800,000 and 900,000 individuals in the United States are HIV positive and new infections occur at the alarming rate of approximately 40,000 per year. In addition, the CDC reports that more than 420,000 people in the United States have died from AIDS. Although black and Hispanic men, substance users, and men who have sex with men have disproportionately represented those who have been infected, these demographics are changing. For instance, according to CDC data, black and Hispanic heterosexual women represent one of the fastest growing HIV-positive subpopulations, and the number of new infections among men who have sex with men is declining. Increasingly, HIV affects the vulnerable populations traditionally served by social work, particularly people in poverty, people who are homeless, substance users, people with a serious mental illness, racial and ethnic minority individuals, and people suffering from societal discrimination (CDC, 1999a). After years of limited success in treating HIV/AIDS, new medications emerged in 1995 with promising results (Hecht, Colfax, Swanson, & Chesney, 1998; Palella et al., 1998; Weller, 1999). These potent combinations of drugs, commonly known as highly active antiretroviral therapies (HAART), are complex to manage, have toxic side effects, and must be taken with an unprecedented standard of adherence to the drug regimen to prevent drug resistance and subsequent treatment failure (Averitt, 2000; Perrin & Telenti, 1998; Williams, 1997). The sophisticated antiretroviral medications often are taken in addition to a substantial regimen of prophylactic drugs used to prevent the occurrence of opportunistic infections secondary to HIV. The emergence of such promising treatment approaches signaled a fundamental change in the HIV clinical care paradigm. …