Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) first came under scrutiny in the United States during the HIV/AIDS outbreak of the 1980’s, catalyzing an epidemic characterized by reproach. HIV is an incurable virus that leaves the body susceptible to infection and progresses in stages, with AIDS being the most severe phase of HIV indicated by a severely weakened immune system. When the disease first incited public attention, many falsely believed that the disease could be spread by air, mosquitos, or even by simply shaking hands, as stated by HIV.gov (2018). The transmission and proliferation of HIV/AIDS is principally due to dangerous behavioral components such as unprotected sex and the sharing of used needles amongst intravenous drug users. Sex and drugs are subjects of anathema, resulting in testing not being as widespread as it needs to be due to this taboo. The trifecta of shame, failure to get tested, and unprotected sex occur concurrently and permit the disease to spread, often without the knowledge of those infected until it is too late. According to the Kaiser Family Foundation, 14% of those infected with HIV never get tested, and thus do not even know that they are infected continuing to spread the disease (2018). While research, public education, and mortality rates for HIV/AIDS have indeed improved, the disease still remains one of the most stigmatized and feared infectious diseases.
This paper will focus on HIV/AIDS outcomes within the Navajo Nation. The Navajo Nation is a sovereign nation located in the Four Corners region of the American southwest, including Colorado, Utah, Arizona, and New Mexico. During the onset of the HIV/AIDS epidemic of the 1980’s, conditions were so bad that Navajo men were reported to walk into clinics with a mere cough and then die within days; nearly a third of those treated died (Frosch, 2013). There are factors amongst the Navajo that increase the propensity to partake in the hazardous behavior that may lead to HIV/AIDS. Although culturally and historically rich, the legacy of colonialism has condemned Native Americans to preservation life that is rampant with alcohol and drug abuse, poor education, and higher rates of incarceration. These factors combined with deeply embedded cultural stigma against both diseases in general and homosexuality create an environment where HIV/AIDS can only burgeon. Evidently, efforts to destigmative the disease are crucial to the production of better health outcomes for HIV/AIDS. To offer an intervention proposal, the HIV/AIDS epidemic in the Navajo Nation will be examined via the constructs of the Social Cognitive Theory (SCT).
While there are many social and cultural factors at work in the HIV/AIDS epidemic, the most threatening health behavior to the spread of HIV/AIDS in the Navajo Nation is refrainment from STD testing by infected individuals. Within the Navajo, the disease is most prevalent amongst homosexual males, constituting 75% of the Navajo AIDS Network (Frosch, 2013). These males partake in unprotected sexual activities, contract HIV, and because they are never get tested they unknowingly bringing the disease back to the reservation. Even when they do happen to know of their diagnosis, immense shame keeps them from disclosing this information, and the disease continues to spread.
The cause of this public health behavior is stigma that comes from multiple fronts. In the United States in general, there stigma remains against HIV/AIDS and homosexuality. Specific to the Navajo, there is additional culturally-driven stigma towards these two factors. Additionally, as in most close-nit communities, shame culture is exacerbated. In an evidence-based report by Lambda Legal, it was found that in a 2009 survey by the Kaiser Family Foundation, 34% of respondents still believed that HIV could be spread via sharing a drinking glass, using the same toilet seat, and/or swimming in the same pool (2010). One Navajo man reported how his own mother would not hug him and only served him food on disposable plastic plates that would not be used by anyone else (Frosch, 2013). Even with more education, viewpoints have not improved since the 1980’s. The percentage of people who believe HIV can be transmitted just by sharing a drinking glass is even higher today than in 1987 (Lambda Legal, 2010). Unsurprisingly, this type of social reaction and lack of community tolerance defers STD testing. HIV/AIDS stigma is a problem not only because it makes people fear testing, but because it also reduces quality of life. Internalized HIV stigma is correlated with stress, loneliness, isolation, anxiety, and hopelessness –all factors that are known to expedite the course and severity of disease (Lambda Legal, 2010). Additionally, bigotry still exists in the United States towards the LGBTQ community. Although strides towards equality in the US have undoubtedly been made since the first HIV/AIDS outbreak, most notably in the legalization of gay marriage, the same cannot be said for the Navajo Nation. Gay marriage remains an illegality within the Navajo Nation; the Diné Marriage Act, which outlaws same-sex marriage has not yet been abolished despite repeal efforts (Turkewitz, 2015). While gay marriage remains a crime, it is unsurprising that Navajo men choose to suffer in silence in fear of community backlash rather than get tested and treated.
This behavior has created a public health problem for the Navajo that has not dissipated with time. The increased risk for HIV/AIDS in the Navajo nation compared to other populations cannot be understated. Like all infectious diseases, HIV/AIDS attacks indiscriminately, and yet there remains a disparity among ethnic groups. The proliferation of knowledge concerning the transmission and progression of HIV/AIDS has resulted in better health outcomes overall, with HIV incidences decreasing in general across the United States. Yet this positive trend does not apply to the Navajo demographic, with these numbering having quadrupled in the Navajo Nation, as reported by Iralu et.al (2010). Infected persons can still live with HIV, but early diagnosis, access to facilities, and affordable health care are necessary to extend survival time –many of which is not readily available to Navajo people. Poverty among the Navajo is a major contributor to the HIV/AIDS epidemic. 24% of American Indians and Alaskan Natives live in poverty, twice the national average (12%), according to Iralu et. al (2010). Poverty creates a barrier to resource access, prohibiting the Navajo from being able to access HIV care. While HIV/AIDS infection rates are not much higher among Navajo as they are for whites and are even lower than those of Hispanics and blacks, Navajo are less likely to survive than any other racial/ethnic group (Froscher, 2013). The aforementioned discussions on stigma operate synchronously with poverty factors, and are likely the cause of this unfortunate health predicament.
The Social Cognitive Theory posits that the interplay between human behavior, personal factors, and environmental factors is a synergetic process; change within one sphere illicits a reciprocal change in all other spheres (Edberg, 2015). This phenomenon is known as reciprocal determinism: people input behavioral changes based on personal factors and social cues and make adjustments based on the feedback they receive in what is a continuously interactive cycle between person and environment. These behavioral inputs made by the individual require self-efficacy –people must believe in their own ability to change, overcome, and accomplish. The environment includes both the physical environment as well as the social one created by others. SCT has a plethora of constructs that aim to explain behavior: self-efficacy, self-control, expectations, expectancies, emotional arousal, behavioral capability, situation, observational modeling, and reinforcement (Edberg, 2015).
Concerning self-efficacy, Navajo men must have the confidence to get tested for HIV and then share this information with those who would be affected by this information. Safe sex is just as much about physical protection such as condoms as it is the sharing of sensitive sexual information like STD possession with potential sexual partners. The decision to disclose this information, or to even just open oneself to the possibility that they may have HIV, is an act of courage that requires self-efficacy that life will still be okay after testing amidst the pressures of HIV/AIDS and homosexual insensitivity. At present, the levels the self-efficacy amongst HIV-positive Navajo individual seems to be low. Self-control seems to be related to self-efficacy, but is different it that is deals with the extent to which people believe what happens to them is due to an internal or external locus of control. HIV-infected Navajo men seem to have an internal locus of control, acknowledging that the disease is a product of their own decision-making, but then an external locus of control when it comes to their own survival when they resign to not pursue diagnosis or treatment.
The next construct is expectations, the anticipated outcomes of what will happen if a Navajo man chooses to get tested based on their own past experiences, the experiences of others, and the potential emotional and physical consequences. The overwhelming expectation of HIV-positive Navajo men seems to be that their families will shun them. This seems to be supported by the previously mentioned scenario where a Navajo man experienced cold behavior from his own mother when he disclosed his disease to her. Hearing about situations like this one, which are common, are discouraging to others who may be uncertain if they want to disclose their disease or even find out if they have it. The same man reports that his entire family does not even know and that he would never tell his brothers out of fear of being cut out from their life; a fear that is likely shaped by his experience with his mother (Frosch, 2013). Expectancies are different from expectations in that they concern the value a person places on the outcome. The Navajo Nation values family and community, so it makes sense that a Navajo man would fear social rejection more negatively then say, someone who lives in the city and lives a more independent lifestyle.
Emotional arousal as a construct deals with the possible emotional reactions to behavioral outcomes and the individual’s ability to cope with these emotions. Fear of rejection from the community seems to be a driving factor in the avoidance of HIV testing, supporting this negative health behavior. Concerning behavioral capability, this construct does not seem to be as prominent as the others in explaining the proliferation of HIV/AIDS epidemic amongst the Navajo. The Navajo are informed enough to know how to go about seeking testing and treatments. Albeit there are significant barriers to care such as poverty and the limited number HIV specialists in the Four Corners region, shame seems to be a stronger contributing factor as to why Navajo are not getting tested (Iralu et al, 2010).
Situation has played a large role in shaping the HIV/AIDS epidemic as well. As stated before, the Navajo Nation is not an environment that is entirely tolerant of homosexuality, in fact it is still illegal. HIV/AIDS is not discussed freely and misconceptions still persist.
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