AIDS at 30: Implications for Social Work Education

This article reviews themes and changes in the teaching of HIV/AIDS content in social work programs over the first three decades of the epidemic. Social work education in the first decade of the epidemic was largely focused on helping clients in the death and dying process, while medical and pharmaceutical advancements in the mid-1990s drastically altered the roles of social work. As social work education prepares students to face the fourth decade of the AIDS epidemic, three areas of cross-curricular intersection are highlighted: HIV/AIDS as an issue of social, racial, and economic justice; the global AIDS epidemic in the context of international social work; and the social work response to HIV/AIDS in older adults.


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of effectively teaching about HIV/AIDs to broad groups of social work students: HIV/AIDS as an issue of social, racial, and economic justice; the international social work response to the global AIDS epidemic; and social work's role in addressing HIV/AIDS in older adults. At this point in the epidemic, as the effect of HIV/AIDS has reached diverse populations of all ages across the globe, the imperative for social work education to prepare students to respond to HIV/AIDS as policy makers and practitioners continues to ring true.

ADVOCACY AND IGNORANCE: SOCIAL WORK EDUCATION IN THE FIRST DECADE OF THE AIDS EPIDEMIC
There are numerous examples of the social work profession's innovative, often courageous early responses to the AIDS epidemic. As early as 1981, social workers in hospitals and medical settings began offering specialized group and individual therapy to help AIDS patients deal with their illness and grief (Collins, 1983). The social work response went well beyond grief counseling, however. In New York City, social workers advocated for housing and support for homeless people with AIDS (Kolata, 1988). Pioneering social workers such as Michael Shernoff and Luis Palacios-Jimenez, who developed educational materials that eroticized safer sex for gay and bisexual men, were also active in early prevention efforts with marginalized groups (Shernoff, 1990). However, in the first decade of the epidemic, the profession fell short in preparing most social workers to address the crisis. A 1988 survey of practicing social workers uncovered significant gaps in their knowledge of HIV/AIDS and revealed that nearly three quarters of the respondents felt they had no professional reasons or motivations for being knowledgeable about HIV/AIDS (Peterson, 1991). Recognizing that the spread of the epidemic meant that social workers in diverse settings would encounter individuals affected by HIV/AIDS, Peterson implored schools of social work to provide all students with information about AIDS and how it may affect different client populations. Weiner (1990) offered concrete ideas for integrating HIV/AIDS education into the bachelor's of social work (BSW) curriculum, advocating for content to be spread throughout the curriculum rather than concentrated into a single AIDS course. An alternative approach was offered by Miller and Dane (1990), who issued a framework for a specialized course on AIDS, focusing on how social workers could help AIDS patients and their families cope with death and dying, as well as issues such as AIDS-related stigma and prevention with vulnerable populations. The National Association of Social Workers (NASW) also called on social workers to educate themselves about AIDS, promoting the theme "AIDS: We Need to Know. We Need to Care." for its annual Social Work Month public service campaign in 1988 (NASW, 2012). Though this analysis focuses on bachelors-and master's-level education in the university context, it is important to acknowledge that the NASW has also played a critical role in training social workers about HIV/AIDS-related practice, such as by providing continuing education workshops and Web-based resources on the intersection between HIV/AIDS, mental health concerns, and substance abuse in clinical practice (Tomaszewski, 2006).
Although researchers and other professionals advocated for increased attention to HIV/AIDS in social work education, surveys of social work programs from the same period show limited coverage of AIDS content, even in some of the urban areas most affected by the crisis. In one of the first such studies, Wexler (1989) surveyed second-year master's students in a San Francisco 267 area social work program in 1987 about their knowledge and attitudes about AIDS. The survey revealed gaps in students' knowledge, particularly about diagnostic procedures and the effect of AIDS on minority groups, and also indicated that only 16% of respondents had received any AIDS information in their social work classes, though 95% thought the issue should receive more coverage. Wexler concluded that "in light of assumptions about 'AIDS awareness' in the San Francisco Bay Area, the gaps in factual knowledge expressed by these students is particularly unsettling" (p. 146). Diaz and Kelly's (1991) survey of 70 master's of social work (MSW) programs, completed in 1989 with a response rate of 71%, indicated a burgeoning interest within social work education to prepare students for practice in the field of HIV/AIDS. They reported that slightly more than one third of programs integrated HIV/AIDS content into some of their established courses, whereas 10 programs offered courses specifically focused on AIDS care and prevention. However, less than half of the responding programs offered full courses on human sexuality, an important topic pertaining not only to HIV prevention education but also to human development and diversity. An encouraging finding was that 35% of programs reported having a student or students working with HIV-affected clients through their field placements. Silberman's (1991) survey of MSW students in six northeastern schools of social work, conducted in 1988, explored the role of field experiences in educating students about HIV/AIDS in greater detail. Although results must be interpreted in light of possible selection bias because of the low 16% response rate, a sizable minority (23%) of the 240 respondents reported working with HIV-positive clients or clients' loved ones in their first-or second-year placements. Many of the respondents working with this population expressed concern about the adequacy of their skills and AIDS-related knowledge but reported that field supervisors and other professionals at their placements were good sources of information and support as they coped with these challenges. Respondents had several suggestions for better preparing students for HIV/AIDS-related practice, including greater classroom coverage of HIV/AIDS transmission issues, diagnosis, and at-risk groups such as sexual minorities and injection drug users. These findings convey the importance of field placement experiences as well as classroom instruction in social work education about HIV/AIDS. In the following decades, social work education expanded and changed significantly in its attention to HIV/AIDS in the classroom and the field.

FROM DYING WITH AIDS TO LIVING WITH AIDS: SOCIAL WORK EDUCATION IN THE SECOND AND THIRD DECADES
The second and third decades of the epidemic were marked by significant medical advances that changed the course of the disease and consequently altered the role of social work in responding to HIV/AIDS. In 1995, the emergence of powerful new antiretroviral medications had a striking effect on the health of HIV-positive people, changing the prognosis of HIV/AIDS from a terminal illness to a chronic health condition (Mitchell & Linsk, 2004;Palella et al., 1998;Strug, Grube, & Beckerman, 2002). Social work with HIV-positive people and their families was no longer centered on death and dying, although that continued to be an aspect of clinical work in some settings. Instead, social workers began to focus on assisting HIV-positive people with the complex psychosocial challenges they faced, such as negotiating intimate relationships and partner notification, deciding to have children and following protocols to avoid maternal HIV transmission, and dealing with medical confidentiality in the workplace and personal settings BOWEN (Strug et al., 2002). Prevention also remained a challenge throughout the second and third decades. Though the number of new HIV infections in the United States declined drastically after peaking at an estimated 130,000 in 1985, by 2006 it still hovered around 56,000, a number deemed unacceptably high by the public and health professionals alike (CDC, 2010). Steiner (1995), noting the growth of the epidemic and the disproportionately high incidence of HIV in subpopulations traditionally served by social work such as the urban poor, drug users, and racial and ethnic minorities, called for better integration of HIV/AIDS content into foundational BSW and MSW courses. However, Kadushin and Egan's (1997) survey indicated that in the mid-1990s, many programs were not heeding the call from Steiner (1995), Weiner (1990), and others. Of 53 outlines for graduate-level health care practice courses Kadushin and Egan reviewed, only 35% included units on working with people with HIV/AIDS.
Toward the end of the second decade, studies focusing on other indicators of HIV/AIDS content uncovered some signs of progress, particularly in the areas of specialized course work and field education. In a 1999 survey of 108 MSW programs (response rate 83.7%), Koob and Harvan (2003) found that 43% of responding programs offered HIV-specific elective courses, a substantial increase from Diaz and Kelly's (1991) findings a decade earlier. Koob and Harvan also reported that 88% of responding programs offered field placements in HIV/AIDS-focused settings, providing many students with the opportunity to learn about HIV/AIDS through direct experience. A survey of practicing social workers in Illinois, also conducted in 1999, indicated that prior HIV/AIDS training and education significantly increased participants' selfreported HIV knowledge and the likelihood of incorporating prevention services into their work, underscoring the importance of social work education (Wolf & Mitchell, 2002). Rowan and Shears' (2011) survey of 153 BSW and MSW programs conducted in 2009 shows some changing trends in HIV education toward the close of the third decade of the epidemic. The findings suggest that programs are moving toward integrating HIV/AIDS content across the curriculum. For example, 61% of responding MSW programs reported including HIV/AIDS content in practice courses. One third of MSW programs reported offering an HIV/AIDS elective, and 75% provided at least one field placement in HIV/AIDS-related practice settings. Though a direct comparison should not be inferred between different samples, the proportion of MSW programs offering HIV-specific electives and placements suggests a slight decline from Koob and Harvan's (2003) survey the previous decade. Rowan and Shears (2011) postulated that some programs had dropped their HIV/AIDS electives in recent years, preferring a cross-curricular approach. However, they note that the lack of HIV content in many commonly used textbooks on practice, social policy, and human behavior and the social environment presents a challenge to this approach. Although social work education has clearly grown in its capacity to prepare students for practice in the field of HIV/AIDS, at the close of the third decade many questions remained on how to best impart critical skills and knowledge in the face of a persistent epidemic.

SOCIAL WORK EDUCATION AND AIDS ON THE CUSP OF THE FOURTH DECADE
The year 2011 marked the beginning of the fourth decade of the AIDS epidemic. Because social workers in myriad practice settings, from schools to homeless shelters to hospitals, continue to play a role in the complex lives of people with HIV/AIDS, and because prevention remains an imperative, the issue of how social work education should prepare students for these challenges continues to be critical. Programs appear to be moving toward a model of integrating HIV/AIDS content into a variety of courses (Rowan & Shears, 2011), which may be a more meaningful approach than covering content only as an elective, given the current context of the disease. In view of the approximately 50,000 new HIV infections occurring each year and the fact that people with HIV are living longer, more people are now living with HIV/AIDS in the United States than ever before (CDC, 2012). Though valuable for students who seek to develop specialized skills and expertise, simply giving students the opportunity to self-select into an HIV course or field placement will not create an adequately broad knowledge base within the field. Furthermore, limiting HIV/AIDS content to a single course mirrors the stigma and isolation many people living with HIV/AIDS continue to face.
Integrating content across the curriculum is a more empowering approach that also provides better opportunities for learning. Given current priorities in social work education as well as trends in the epidemic, three areas of cross-curricular intersection are highlighted as areas for effectively integrating HIV/AIDS content: HIV/AIDS in the context of social, racial, and economic justice; the role of international social work in the global AIDS epidemic; and social work responses to HIV/AIDS in the elderly. The Council on Social Work Education's (CSWE; 2008) Educational Policy and Accreditation Standards, created to articulate a threshold of competence for BSW and MSW programs, contain 10 core competencies guiding the knowledge, skills, values, and demonstrable practice behaviors that students should gain through social work education. Table 1 lists the relevant core competencies pertaining to each HIV/AIDS intersectional topic area and related practice behaviors that social work students should develop.

HIV/AIDS: AN ISSUE OF SOCIAL, RACIAL, AND ECONOMIC JUSTICE
Increasingly, social work educational programs are promoting the advancement of social, racial, and economic justice as an important professional competency and key goal of social work education (Brown, 2004;CSWE, 2008;Davis & Bangs, 2007). HIV/AIDS can be regarded as a case study demonstrating the ways that forms of oppression related to race, class, gender, and sexual orientation have converged, producing devastating consequences for certain communities. To start, the disproportionate prevalence of HIV/AIDS in communities of color has been so well documented that it is now difficult to consider AIDS in the United States apart from this racial and economic context. According to 2009-2010 data from the CDC, African Americans, representing approximately 14% of the general population, account for 44% of people living with HIV in the United States, and the rate of new HIV infections is 2.9 times greater for Latino men than White men and 4.2 times greater for Latinas than White women (CDC, 2012).
The disproportionate racial effect of HIV is closely tied to poverty, with HIV prevalence rates being highest in urban areas of concentrated poverty, which are often predominantly African American or Latino. The 2.1% HIV prevalence rate in low-income urban areas in the United States is on par with HIV prevalence in developing countries such as Ethiopia, Angola, and Haiti (Denning & DiNenno, 2010). HIV is also disproportionately prevalent in other subgroups whose members frequently live in areas of urban poverty, including homeless and previously incarcerated populations, with men and women of color being markedly overrepresented in the latter (CDC, 2005;Robertson et al., 2004). Sexual orientation and gender are also key concepts in understanding the HIV/AIDS epidemic and its effects. Men having sex with men is the most common route of HIV transmission in the United States (CDC, 2012). Sexual identity is an important factor, as men who have sex with men but do not identify as gay may be at greater risk for HIV, because they are less likely to access HIV-related support and information (Goldbaum, Perdue, & Higgins, 1996). Considerable research and media attention has been paid to the issue of African American men who do not identify as gay but have sex with men, often referred to as living on the down low. Research on the effect of "down-low identity" on HIV risk behaviors has been mixed (Bond et al., 2009), suggesting that the complex issue of sexual identity, particularly in minority communities, and its effect on HIV risk is an important area for further social work research.

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Furthermore, the construct of gender is of critical importance. Though men continue to constitute the majority of HIV/AIDS cases in the United States, the proportion of AIDS cases diagnosed in American women tripled between 1985 and 2003, and is especially high in African American women and Latinas, who represented 83% of female AIDS cases in 2003 (CDC, 2005). A sometimes overlooked aspect of the AIDS epidemic is its effect on male-to-female transgendered women, whose U.S. HIV prevalence is estimated to be an alarming 28% (Herbst et al., 2008).
The intersection of race, class, sexual orientation, gender, and AIDS provides social work educators with multiple opportunities to address HIV/AIDS from a social justice standpoint. For example, there are numerous ways to include HIV/AIDS in human diversity courses or other courses that discuss systems of power and oppression. Looking at women's roles, socioeconomic status, and the effect of various forms of sexism and racism is a useful lens for explaining and finding solutions to the growth of the HIV/AIDS epidemic in women (Amaro, 1995;Wingood & DiClemente, 2000). The racial and socioeconomic breakdown of the AIDS epidemic can be analyzed in course work as a striking example of health disparities. Demographic trends in the American AIDS epidemic are also relevant to clinical courses that instruct students in social work practice methods with different populations. Courses on social work with criminal justice populations, for example, could discuss the political issues and controversies surrounding HIV prevention efforts in prisons and the effect HIV transmission in populations involved in the criminal justice system has had on communities of color (Lichtenstein, 2009).
Additionally, the HIV/AIDS epidemic provides a context for social work students to explore and confront heterosexist biases and homophobic attitudes. A survey of BSW students found considerable indications of homophobia and heterosexism in the sample; for example, more than a third of the respondents considered homosexual behavior to be unnatural and sinful (Swank & Raiz, 2010). Although it is difficult to change students' deeply held beliefs about sexuality, the authors suggest that educators help students distinguish between professional and religious views on sexual identity and behavior. Educators can help students confront homophobia in the context of the HIV/AIDS epidemic by focusing on social workers' ethical duty to respond to HIV/AIDS and to not discriminate against clients on the basis of sexual orientation, and by helping students identify the ways pervasive homophobia has contributed to the spread of the epidemic. Discussing the complex sexual, gendered, racial, and economic aspects of the epidemic dismantles the enduring myth that AIDS is primarily a gay White male disease (Moutsiakis & Chin, 2007) as well as provides educators with the opportunity to promote social justice in the profession in a concrete way.

INTERNATIONAL SOCIAL WORK EDUCATION AND THE GLOBAL AIDS EPIDEMIC
Recognizing that social problems are rarely purely national or regional phenomena, and seeking to situate the social work profession in a global context, interest in international social work education is growing at many institutions (Borrmann, Klassen, & Spatscheck, 2007). In its core competencies informing BSW and MSW curriculum design, CSWE (2008) affirms the global reach of social work by embracing a framework of social justice and human rights: "Social workers recognize the global interconnections of oppression and are knowledgeable about theories of justice and strategies to promote human and civil rights" (CSWE, 2008, p. 5). Many social work programs are exploring ways of internationalizing their curricula and broadening students' practice experiences, such as through collaborations with universities in other countries and providing field practicum opportunities abroad (Gilin & Young, 2009). In addition to these strategies, which typically involve a relatively small number of students, Caragata and Sanchez (2002) suggest that North American social work schools incorporate content on global social problems and internationally derived theories and practice approaches across their curricula.
HIV/AIDS is one such social problem with obvious global scope and effect. The Joint United Nations Programme on HIV/AIDS (2008) reported that in 2007 approximately 33 million people were living with HIV worldwide, with 67% of HIV-positive people living in sub-Saharan Africa. Although specific patterns of transmission and prevalence vary by country and region, the global AIDS epidemic encompasses many vulnerable and stigmatized populations, including men who have sex with men, injection drug users, and commercial sex workers (Natale, Biswas, Urada, & Scheyett, 2010). Given social work's international history of advocating on behalf of vulnerable groups, Natale et al. argue that it is necessary and appropriate for social workers to use their skills and resources to respond to the global AIDS epidemic.
Social work educational programs can help their students carry out this imperative in several ways. Natale and colleagues (2010) provide content and discussion questions on the effect of the global AIDS epidemic on specific vulnerable populations that can be readily integrated into a range of policy and practice courses. Social workers in the United States would benefit not only from learning about how global vulnerable populations have been affected by AIDS but also about other countries' innovative approaches to the epidemic, such as the government of Thailand's successful campaign to increase male clients' condom use with commercial sex workers (Hollander, 1996). As described in Table 1, related practice behaviors instructors should help their students develop include analyzing the applicability of internationally developed interventions to the United States and comparing the roles of social workers in the United States and abroad in responding to the HIV/AIDS epidemic. Also useful is Poindexter's (2009) human rights framework, which can be applied to understand and find solutions to the problem of HIV/AIDS in the United States and globally. As schools look for ways of helping students master CSWE's core competency of advancing human rights and social justice, human rights perspectives such as Poindexter (2009) offer an approach that educators can use to incorporate HIV/AIDS content toward this end, not only in HIV-specific electives but throughout the curriculum.

A NEW CHALLENGE FOR SOCIAL WORK: HIV/AIDS AND OLDER ADULTS
Given the well-documented graying of the American population and the consequent demand for social workers in geriatric settings, many schools are providing courses or specialized tracks on social work and aging. Considering that an estimated 27% of people living with HIV/AIDS in the United States are more than 50 years old (Gorman, 2006), AIDS is an appropriate topic to address in aging course work. As antiretroviral drugs have allowed HIV-positive people to live longer and healthier lives, people with HIV/AIDS are now facing the challenges of aging in numbers not imagined at the beginning of the epidemic when AIDS was an imminently terminal illness. People are also contracting HIV later in life, with unprotected sexual intercourse being a common risk behavior; research has indicated that older adults are somewhat less likely than younger adults to use condoms (Kohli et al., 2006).
Schools have numerous ways to prepare social workers to respond to the growing number of Americans facing the twin challenges of aging and HIV/AIDS. As Table 1 summarizes, several HIV-related practice behaviors are important for social workers in the geriatric field. For example, one of the facets of CSWE Educational Policy 2.1.10-which pertains to social workers' capacity to carry out effective engagement, assessment, intervention, and evaluation activities with clients and client systems-is to "implement prevention interventions that enhance client capacities" (CSWE, 2008, p. 7). Because many existing HIV prevention materials target youth and young adults, a key practice behavior is for social workers to develop age-appropriate prevention messages and materials to target older adults at risk of contracting HIV/AIDS. As a course assignment, an instructor might ask students to discuss HIV risks and prevention with older adults in a field placement agency or other community setting and then review the experience as a class to identify the unique challenges of conducting HIV education with this population.
Another practice behavior related to this competency is for social workers to help older HIVpositive adults cope with complex psychosocial challenges. Long-term survivors of HIV/AIDS may feel guilt and grief for the losses they have experienced while living longer than expected with the disease (Robinson, Petty, Patton, & Kang, 2008). Adults who acquire HIV/AIDS at an older age often feel increased stigma and shame, including a sense that they "should have known better" (Foster & Gaskins, 2009;Robinson et al., 2008). Gay, lesbian, bisexual, and transgender older adults who are HIV positive may face societal stigma and marginalization, and often rely more on friends and partners rather than family members for social support (Masini & Barrett, 2008). Social work education should instruct students in applying a strengths perspective to help older adults tap into their support networks to seek meaningful connections and support while dealing with HIV/AIDS and aging.
Aging policy courses should address the implications of the growing prevalence of HIV/AIDS in the elderly for the health care system. Linsk, Fowler, and Klein (2003) describes the numerous funding mechanisms for services for older adults and for HIV/AIDS treatment and care, leading to an often disjointed system in which older adults do not know where to seek the best care for HIV/AIDS and other related and unrelated health problems. Furthermore, HIV-specific community health programs typically have not focused on the needs of older adults. Social workers interested in aging policy should consider how to effect change in funding and service provision for HIV/AIDS, older adult care, and general health care to better meet these challenges.

CONCLUSION
At the start of the fourth decade of the epidemic, HIV/AIDS remains an issue of paramount importance for social workers. The fact that roughly 50,000 new HIV infections occur in the United States each year, despite the development of innovative programs and the investment of vast resources, suggests that prevention efforts cannot be confined to practitioners who identify as HIV specialists or work in HIV-specific settings. Effective prevention requires a broader social work response, particularly from those who work with the marginalized groups most affected by the HIV/AIDS epidemic. Although medical advancements in the treatment of HIV/AIDS in BOWEN the past two decades have been remarkable, those in the social work profession need to provide an equally progressive response to the psychosocial needs of people living with HIV/AIDS. Medication management, sexual decision making, legal and human rights, and life course issues are all aspects of HIV/AIDS that social workers should be prepared to address in the populations they serve (Mitchell & Linsk, 2004).
The importance of social work education in facilitating this response cannot be minimized. Consistent with research findings on other social work subfields, such as substance abuse (Bina et al., 2008), Wolf and Mitchell's (2002) survey established that previous training or education about HIV/AIDS was a significant predictor of social workers' knowledge and incorporation of HIV-related practice behaviors into their work. Although social work education has undoubtedly expanded its capacity to prepare students for HIV/AIDS-related social work practice, surveys such as Rowan and Shears (2011) suggest there is still room for growth, particularly as educators strive to uncover the most effective approaches for teaching about HIV/AIDS and the diverse populations it affects throughout the curriculum.
The start of the fourth decade of the HIV/AIDS epidemic coincides with a period of innovation and progress in social work education. Between 2004, CSWE (2009 established the Center for Diversity and Social and Economic Justice, the Katherine A. Kendall Institute for International Social Work Education, and the National Center for Gerontological Social Work Education. The establishment of these centers and their subsequent programming and scholarship represent three new priorities for social work education: promotion of social justice, acknowledgment of the global reach of the social work profession, and a call to respond to the changing demographics of an aging society. These same priorities echo themes in the evolution of the HIV/AIDS epidemic. By preparing students to meet the challenges presented by HIV/AIDS in the United States and globally, social work educators will not only be speaking truth to a 30-yearold epidemic and its victims and survivors, they will also be advancing the very goals of social work education.