AIDS in Central and Eastern Europe

Social Science & Medicine 56 (2003) 1373–1384

Social representations of HIV/AIDS in Central and Eastern Europe Robin Goodwina,*, Alexandra Kozlovab, Anna Kwiatkowskac, Lan Anh Nguyen Luud, George Nizharadzee, Anu Realof, f Ahto Kulvet . , Andu R.ammerf a

Department of Human Sciences, Brunel University, Uxbridge, UB8 3PH, London, UK b Department of Psychology, St. Petersburg State University, St Petersburg, Russia c The Warsaw School of Advanced Social Psychology, ul. Podlesna 61, Warsaw, Poland d Social and Educational Psychology Department, Eotvos Lorand University, H-1064 Budapest, Izabella u.46, Hungary e D. Udnadze Institute of Psychology, Georgian Academy of Sciences, 22 Paulo Iashvili Street, Tblisi, GA 380007, USA f University of Tartu, Estonia

Abstract Although a relatively recent epidemic, HIV is now increasing in Eastern Europe faster than anywhere else in the world. In the study reported in this paper, we interviewed 511 business people and health professionals in five Central and Eastern European nations: Estonia, Georgia, Hungary, Poland and Russia, deriving our questions primarily from a Social Representations perspective. Respondents also freely completed their associations with the stimulus word ‘AIDS’. Our findings indicate that, although there is considerable agreement about the threat posed by the epidemic, there are also notable cultural differences in attributions about the origin and spread of the virus and the nature of those groups at risk of infection. These findings are interpreted in the light of the historical legacies of the Communist era, as well as the real economic and social challenges faced by the population of this region. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: HIV/AIDS; Social representations; Central and Eastern Europe

Introduction The HIV/AIDS epidemic is a relatively recent phenomenon in Eastern Europe, not beginning until the early 1990s. Although obtaining exact prevalence figures in this region is problematic, WHO AIDS surveillance figures indicate a recent rapid growth in both HIV and AIDS in Eastern Europe (Atlanti, Carael, Brunet, Frasca, & Chaika, 2000), with Central and Eastern Europe now showing the world’s steepest increase in HIV infection (European Centre for Epide*Corresponding author. Tel.: +44-1895-816200; fax: +441895-203018. E-mail address: [email protected] (R. Goodwin).

miological Monitoring of AIDS in Europe, 1999). In the towns and cities surrounding Moscow, HIV infection increased five-fold in the first 9 months of 1999 (UNAIDS, 2000), and there have also been recent rapid increases in infection in Estonia (Estonian Health Protection Inspectorate, 2001). In addition, the geographical location of other, currently less infected nations on drug routes, and high rates of migration, raise the prospect of rapid increases in infection across the whole region (Dehne, Khodakevich, Hamers, & Schwartlander, 1999; de Jong, Tsagarelli, & Schouten, 1999). Rhodes and his colleagues (Rhodes et al., 1999a, b) have identified a number of features of the ‘macro risk environment’ that act as major factors in sustaining epidemic growth and mediate the efficacy of prevention responses. These include the growth of both prostitution

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and temporary sexual partnerships as a means of economic survival (see also Borisenko, Tichonova, & Renton, 1999; Kalichman, 1998), the deterioration of the health-care system (Atlanti et al., 2000); an increased mixing of populations (Borisenko et al., 1999; Parker, Easton, & Klein, 2000; Rhodes et al., 1999a), community values that stress greater sexual freedom (Rhodes et al., 1999a) and a widespread sense of hopelessness and fatalism that has helped promote risk-taking behaviours (Kalichman et al., 2000). However, while a number of researchers have emphasised the need for a systematic analysis of the social and cultural forces that underlie the epidemic in this part of the world (Atlanti et al., 2000; Barnett, Whiteside, Khodakevich, Kruglov, & Steshenko, 2000; Rhodes et al., 1999b; Rivkin-Fish, 1999), most of the existent research on AIDS has focused on cognitive-level explanations which attempt to link individual knowledge, attitudes and beliefs to sexual practices (Abrahams, Sheeran, & Orbell, 1998; Campbell, 2001; Sheeran, Abraham, & Orbell, 1999). Although this work has been valuable in providing important insights into individual-level factors underlying safer sexual behaviours (see for example the metaanalyses by Albarrac!ın, Johnson, Fishbein, & Muellerleile, 2001; Sheeran & Orbell, 1999), and frequently includes some assessment of a subjective, normative component of sexual behaviour (Fishbein, 2000), even those working within this paradigm have called for a wider understanding of the social relations and social environment in which sexual activity takes place (FifeSchaw, 1997; Sheeran et al., 1999). An understanding of these societal perceptions may be particularly significant if we wish to comprehend the spread of the epidemic following the rapid social transitions in Central and Eastern Europe over the past decade (Atlanti et al., 2000; Moatti & Souteyrand, 2000).

The theory of social representations One useful theoretical perspective that may aid us to understand the social and cultural factors that underpin the rising HIV/AIDS epidemic in Central and Eastern Europe is the Theory of Social Representations (Moscovici, 1984), and in the interviewers reported in this paper we use questions devised primarily by researchers working from within this theoretical paradigm. Social representations have been defined as ‘‘structured mentalycontent about socially relevant phenomena, which take the form of images or metaphorsycreated in everyday discourse between social groups’’ (Wagner, Elejabarrieta, & Lahnsteiner, 1995, p. 673). Representations can be seen as a collection of different folk theories, common sense and everyday knowledge (Wagner, 1995), and they serve important social functions in guiding and justifying actions, maintaining

social identity and allowing for the communication between group members (P!aez et al., 1991). The study of HIV/AIDS from a social representations perspective approach complements a more ‘individuallevel’ approach in a number of ways. First, analyses of HIV from a social representations perspective have been particularly concerned with the way in which different groups protect their different identities by way of group specific representations (Moscovici & Perez, 1997; P!aez et al., 1991). By examining representations of risk and risk groups we can gain a greater understanding of the ‘moral panic’ often associated with the epidemic, a panic which may allow individuals to psychologically distance themselves from particular groups, in some cases exposing themselves to further risk (Lear, 1995). This ‘out-grouping’ often extends to governmental bodies (Rosenbrock et al., 2000) and has been evident in some Central and East Europe countries in governmental discrimination against those infected (e.g. Poland; Danziger, 1994) and political obstacles to programmes aimed at HIV prevention and care (Atlanti et al., 2000). An important issue facing most individual-level models of sexual behaviour is the need for a greater understanding of the link between intended and actual behaviour. Here a social representations perspective is valuable in helping illustrate the normative factors that influence socially complex behaviours, such as the carrying and use of condoms, and in doing so can help illuminate the situational barriers that might prevent an intention from turning into actual action (Fife-Schaw, 1997; Sheeran et al., 1999). Finally, a social representations perspective can alert us to the importance of the communication processes in the transmission of information about HIV and AIDS, helping us to comprehend how an unfamiliar and complex medical phenomenon (such as the HIV virus) becomes ‘familiar’ (Farr, 1984; Moscovici, 1984, Wagner et al., 1995). In doing so, we can begin to see how the HIV/AIDS epidemic can be viewed as part of wider concerns over the costs of ‘Western’ sexual practices in post-Communist Europe (Headley, 1998; Rivkin-Fish, 1999), concerns which are themselves part of a broader debate on liberalisation and social modernisation across Europe (Rosenbrock et al., 2000).

The current study Social representations are learned and negotiated through interactions with group members, and as such they are likely to vary both between and within societies (Bergmann, 1999; Farr, 1990; Moscovici & Perez, 1997). In this project we examine variations in social representations of HIV/AIDS across occupational and cultural groups. Data for this project were collected from five nations—Estonia, Georgia, Hungary, Poland,

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and Russia. Although not being representative of the complete region of Central and Eastern Europe (we did not for example include any Islamic countries in our sample) these countries vary significantly not only in the spread of the epidemic in each nation but in political structure, the influence and nature of the religion(s) practised and levels of economic investment and growth—all factors likely to have important implications for the spread of sexual infection (Borisenko et al., 1999; Marquet, Zantedeschi, & Huynen, 1998). Estonia and Georgia were both parts of the Former Soviet Union with very low rates of HIV infection at the time of our study. In Hungary and Poland infection rates were also relatively low and stable, and there is little evidence of a recent marked increase in the prevalence of HIV/AIDS. In contrast, the Russian Federation has seen a marked escalation in the HIV epidemic, with HIV infection now increasing in this country at one of the fastest rates in the world (Kalichman et al., 2000; Joint United Nations Programme on HIV/AIDS, 2000). Infection in this Federation has also been accompanied by a dramatic increase in a range of other sexual diseases (Joint United Nations Programme on HIV and AIDS, 1998; Kalichman et al., 2000).1 Our respondents in this study were from two different participant groups: health care professionals and business people. These groups live in quite different social and economic conditions, and face a range of varying adaptational demands resulting from the economic and social changes of the past decade. Business people are a highly mobile group whose lifestyle and relatively high income permits them to engage in particular, higher risk activities (Barnett et al., 2000). Such a group are particularly likely to visit sex workers (Wellings, Fields, Johnson, & Wadsworth, 1994), an important risk group in this region for HIV infection (Towianska, Rozlucka, & Dabrowski, 1992). Given the inconsistent levels of screening and poor hospital conditions in some of these nations (Renton, Borisenko, Tichnova, & Akovian, 1999), health care professionals were also viewed as a relatively high-risk group. As social stereotypes influence health care professionals’ commitment to treatment and prevention of infection (Echebebarria & P!aez, 1989; Morin, Souville, & Obadia, 1996) the representations of medical staff are likely to be highly influential in these transient societies (Nascimento-Schulze, Fontes Garcia, & Arruda, 1995; Rivkin-Fish, 1999). 1 Actual figures must be treated with extreme care here, but less than 50 cases of AIDS had been reported in both Estonia and Georgia at the beginning of our study, i.e., at the start of 1999. 312 confirmed AIDS cases had been reported in Hungary, 726 in Poland (UNAIDS, June 2000). In contrast, 40,000 people in the Russian Federation were estimated to be living with HIV/AIDS by the end of 1997 (Joint United Nations Programme on HIV/AIDS, June 1998).

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In this study we employed two of the most frequently used methods for investigating social representations— interviews and free association tasks. Semi-structured interviews allow for the analysis of ‘naive theories’ of respondents and the exploration of the deeper levels of consensus (and conflict) that might underpin representations (Gaskell, 1994; Sotirakopoulou & Breakwell, 1992). By allowing respondents to identify their own significant categories (Doise, 1993; Clemence & LorenziCioldi; Verges, 1987; Zani, 1993), free associations allowed us to further tap the important implicit, semiconscious or unconscious meanings associated with HIV (Markova, 1992), helping us to identify shared conceptions of HIV/AIDS as well as inter-group variations in these representations.

Materials and methods Research participants Five hundred and eleven participants (104 from Estonia, 104 from Georgia, 103 from Russia, 100 from Poland and 100 from Hungary) were recruited in each of the five countries in this study. Table 1 provides details of participants by culture. Health care professionals and business people were recruited by the lead researcher in each country, with respondents coming from a wide range of institutions in the capital cities of Hungary, Russia and Georgia (Budapest, Hungary; Tblisi, Georgia; Moscow, Russia), the relatively high infection areas of Eastern Poland (Bialystok: Chodynicka, Serwin, Janczylo-Jankowska, & Waugh, 1999) and St. Petersburg, Russia (Kalichman et al., 2000), and in the towns of Kutaisi and Batumi in Georgia. Data from Estonia was primarily collected in Tartu, the site of the only medical school in the country, and in Tallinn, the capital city. Eighty-six percent of those approached agreed to participate in this study. All respondents were aged between 25 and 57 (mean age 33.2, SD 7.1), the age group at which—at the time of study—there was the greatest proportion of reported AIDS cases in the five countries studied (Joint United Nations Programme on HIV/AIDS, 1998). Forty-seven percent of the 256 business people questioned were male (M age=32.42 SD 7.20); our health care professionals were either doctors (60%, M age=34.75 SD 6.26, 61% male) or nurses (40%, M age=33.19 SD 7.28, 7% male). Respondents were generally well educated, with 62% having completed university, although only 38% of nurses had continued beyond the ‘special secondary’ level of education. Nearly all of the Polish respondents (93%) were Catholic and 53% of the Hungarian respondents were also Catholics, whilst the Orthodox Church was strongly represented in our Georgian data (96% of respondents were Georgian Orthodox) and

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Table 1 Participants

Business people Health care professionals Totals

Estonia

Georgia

Hungary

Poland

Russia

54 50 104 (45 Male)

52 52 104 (62 Male)

50 50 100 (48 Male)

50 50 100 (60 Male)

50 53 103 (49 Male)

amongst our Russian participants (75% of participants were Russian Orthodox). In contrast, 71% of the Estonian respondents claimed not to be religious. All data was collected during the first 6 months of 1999.

examined a full and translated list of these associations and worked independently to aggregate semantically similar words (Di Giacomo, 1980) identifying the most frequently listed words from across the sample to use for our analyses (Kappa for inter-rater agreement=0.90).

Procedures Results Respondents completed two procedures: interviews and free associations, responding individually to a samesex interviewer either at their place of work or at another location convenient for confidential interview. To deal with possible cultural biases in question design and implementation procedures (Goodwin, 1995), items were discussed in a series of group meetings involving the whole research team and reworded to maximise cultural sensitivity (Werner & Campbell, 1970). Questions and procedures were then translated by bilingual translators into the appropriate local languages, and revised versions checked for accuracy. Finally, items and procedures were piloted on sub-samples of 10 medical workers and 10 health care professionals prior to data collection. For our interview analysis, respondents first completed a short demographic questionnaire ascertaining age, sex, level of education and religion. They were then asked a total of 15 questions taken primarily from Joffe’s work on social representations of HIV (Joffe, 1996) but also representative of questions frequently asked in the social study of representations of HIV/ AIDS (e.g. P!aez et al., 1991) and in other broader social psychological investigations (see Appendix A). Questions were grouped into three clusters, four concerning the origin and spread of HIV/AIDS, six the nature of high risk groups and five the government’s role in caring for those infected by HIV. All interviews were audiotaped and transcribed by researchers in each country. A panel of researchers from each of the countries represented then identified key categories of responses for further analyses. For the free association task, respondents were instructed to write ‘‘everything that comes into your mind when I say the word AIDS’’ (after Doise, Clemence, & Lorenzi-Cioldi, 1993). Respondents were asked to write as many responses as possible and to be ‘unrestricted’ in their responses. Our 511 respondents produced a total of 1480 responses. Two judges

Interview analysis The origin and spread of HIV Table 2 provides a synthesised analysis of our interview respondents by country. Our respondents were generally very concerned about the spread of HIV/ AIDS, with the great majority (73%) of our interviewees viewing the epidemic as a ‘‘serious, global problem’’. Russian respondents were those least likely to directly state that HIV/AIDS was a ‘serious problem’, and it was only in this country that a sizeable proportion of respondents claimed that the epidemic had ‘little to do with me’ (26% of Russian business people and 22% of the health care professionals made this claim)—although in Hungary, Russia and Poland more than 20% of respondents thought the magnitude of the problem had been ‘exaggerated’. Considerably more Russian respondents (30% in total compared to 4% in Georgia and none elsewhere) saw the epidemic as a ‘solvable problem’. Respondents learnt about HIV/AIDS primarily through the media (72% of respondents), although more than a third of the Hungarian, Estonian and Polish respondents mentioned their workplace as the place in which they first heard of the epidemic. Few respondents (4%) reported that they first learned of the epidemic through their colleagues or friends. Africa was viewed as the origin of HIV/AIDS by the majority (68%) of our respondents. However, some 20% of our medical respondents in Russia saw the virus as emanating from ‘The West’. In addition, in response to Question 3, more than 10% of respondents in Georgia, Estonia and Russia were willing to cite ‘conspiracy theories’ to explain the origin of the virus (e.g. HIV was developed for the purpose of biological warfare). The HIV/AIDS virus was seen as spreading primarily through sex (mentioned by 91% of respondents) and

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Table 2 Synthesised analysis of interview responses

Q1. AIDS is a serious global problem Q2. I first heard about HIV/AIDS through ‘the media’ Q3. Aids originated in Africa Q4. Sex is the main method of HIV transmission Q5. Contracting HIV/AIDS is the individual’s ‘own fault’ depending on the means of contraction Q6. My nation is not particularly safe from HIV infection Q7. I do not know anyone with HIV/AIDS Q8. Homosexuals are a high risk group Q9. I would not have sex with strangers’ or those not otherwise known Q10. It is the cautious and caring that carry condoms Q11. It is the government’s role to do something about AIDS Q12. Taxpayers should pay for AIDS treatments Q13. Significantly overestimate HIV infection ratesa Q14.I am sure I am not infected because I have been tested. Q15. I know where to be tested for HIV

Estonia

Georgia

Hungary

Poland

Russia

Total

88 61

94 91

61 59

70 65

54 82

73 72

68 94

50 99

86 85

77 82

59 95

68 91

84

60

60

60

15

56

63

63

59

68

81

67

94 52 69

98 38 76

86 48 17

77 35 68

89 30 32

89 41 52

46 98

41 92

48 76

0 83

43 85

36 87

90 27 34

58 54 15

96 46 40

83 47 20

74 43 94

80 43 41

90

78

83

78

96

85

Note: Figures indicate the most frequent positive responses to interview questions, and the percentage of respondents making this response. a ‘Overestimate’ indicates that respondents at least doubled the most recent available UNAIDS statistics. Figures include only those who specified that they ‘knew’ infection rates.

blood (noted by 80% respondents) The risk of infection through syringes was mentioned by more than half the Polish respondents (53%) and 40% of the Russian respondents but by only 19% of our other respondents. There was little mention of mother–child transmission outside of the Hungarian medical sample (where 26% of the Hungarian respondents mentioned this transmission route). ‘High risk’ groups. Our data provided only partial evidence of ‘out-grouping’ in response to the HIV epidemic. The majority of our sample were unwilling to place blame on the individual for contracting AIDS (only 98 of 511 respondents directly respond ‘yes’ to the question asking ‘‘is contracting AIDS the person’s own fault?) although a majority were prepared to place conditional blame dependent on the circumstances of the infection. Most respondents did not feel particularly ‘safe’ because of the high level of morality in their own country—this was particularly notable in Russia, where 42 business people and 39 health professionals categorically denied this to be the case. Most respondents (89%) stated that they did not know anyone with the HIV virus, although unsurprisingly more health care professionals (20%) than business people (3%) knew an infected person.

Homosexuals were the group most likely to be cited as a high risk group (mentioned by 41% of respondents), followed by drug addicts (40% of respondents). Prostitutes were most likely to be mentioned as a high risk group in Estonia (by 25% of respondents) and Georgia (by 21% of participants). ‘Young people’ were more likely to be identified as a high-risk group in Poland (where 26% of interviewees claimed this). In Poland and Georgia an additional high-risk group—the ‘socially maladjusted’—was identified by 19 Georgian and 17 Polish participants. This translation of a broad Slavic term (paradashni) included the unemployed, homeless and alcoholics, all seen by this group of respondents as a group worthy of moral approbrium. There were notable country differences in response to the question ‘‘what type of person would you not have sex with?’’ Hungarians were most likely to respond ‘‘those with no emotional link’’ (60% of participants stated this), whereas Poles were most likely to say ‘‘anyone but my spouse’’ (68 respondents). In response to the question ‘what kind of person carries a condom?’ the ‘cautious’ (36%) or ‘educated’ (21%) were identified by the majority in each country, although in Poland 10% of respondents identified ‘modern young women’, a group of individuals identified as having multiple partners and being at relatively high risk from infection.

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The role of wider society The vast majority of respondents in each sample envisaged the government as having a prominent role in dealing with the HIV epidemic. Fifteen Russian respondents, however, claimed that this was not the government’s responsibility, and 12 Hungarians, and 8 Georgians, were keen to see a shared responsibility between the government, the individual and other agencies. Most respondents saw the taxpayer as having prime responsibility for paying for this treatment although 13 Russian, 9 Hungarian and 6 Estonians saw AIDS patients as having some responsibility to pay for their own treatments, and a further seven respondents in Poland gave the ‘qualified’ answer that payment should depend on the circumstances in which the disease was contracted. Where estimates were made of the number of those infected, Hungarian respondents were the most likely to over-estimate the numbers of those infected, with 24 of the business people and 18 of the health care professionals giving figures for Hungary that exceeded 10,000 persons infected and with 20% of the business respondents, and 14% of the health professionals giving infection figures of over 100,000 for their country. Finally, uncertainty about HIV status was lowest in Russia, reflecting the high levels of testing evident in this country. In Georgia and Poland, uncertainty about where to obtain an HIV test was most evident in the business community, with 40% of those questioned from each community not knowing where they might be tested. Free associations Table 3 presents the relative frequency of the most frequent 13 free-associations with the word ‘AIDS’. Within countries, there was a relatively high degree of concordance between the free associations produced by the two occupational sectors in each country, with a mean rank coefficient of 0.85 between the health care professionals and business people across the sample (ranging from 0.73 in Georgia to 0.96 in Russia), suggesting a sharing of representations within societies. However, across societies there was far greater variance in the relative frequency of these words (Kendall’s taub=0.30). The most frequently cited words across countries were disease and death, reflecting the generally pessimistic view of HIV and its outcomes already observed in our interview data. This was accompanied by an association with ‘hopelessness’ made by 17% of the Russian respondents and 5% of the Estonians (all Estonian business people). Drugs and blood were also frequently associated with the epidemic by our respondents: drugs and blood were most frequently cited by our Estonian

Table 3 Free associations with the word ‘AIDS’ Association

Disease Death Drugs Blood Homosexual Condoms Sexual activity Fear Africa Prostitution Casual sex Misfortune and intolerance Hopelessness Total number of associations made

Raw total of responses

270 172 160 160 148 120 117 106 66 66 41 33 21

Percent of respondents making this association 54 34 32 32 30 24 24 21 13 13 8 7 4

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participants (64% of respondents in this country mentioned drugs, 61% blood). Africa was most frequently associated with AIDS in Poland (associated by 36% of respondents). Homosexuality was most frequently mentioned by our Estonian and Hungarian respondents (46% and 41% of respondents, respectively). Sexual activity in general as an association with ‘AIDS’ was cited most often by the Poles and Estonians (38% of the Poles and 42% of the Estonians mentioned this). Prostitution was mentioned by 35% of the Poles but only 31 other respondents (i.e. 6%); similarly, casual sex was mentioned by 25% of the Poles but only 16 (3%) other respondents. Finally, in Georgia and Poland, we had evidence of the most compassionate associations with the AIDS epidemic, with 32% of the Georgian business people and 14% health care professionals, and 10% of the Polish business people and 12% of the health care professionals, associating AIDS with misfortune and intolerance from the wider society.

Discussion The past decade has seen substantial changes in the economic and political structure of Central and Eastern Europe. The present study attempts to examine some of the central social representations of HIV/AIDS in postCommunist Central and Eastern Europe, answering a call from many working in this field for a broader debate on the structural and cultural forces that have helped

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shape the development of this epidemic. Our results demonstrated both similarities and differences in representations of HIV/AIDS across the five cultures studied. Thus while both our interviews and free associations demonstrated an unsurprisingly negative set of associations around the AIDS epidemic, reflecting the results of other studies across the world (Sheeran et al., 1999), it was also clear that beliefs about the origins and spread of HIV, prevailing conceptualisations of moral responsibility and blame, and attitudes towards the role of the government were unevenly represented across the sample. These variations at least partly reflect differences in testing regimes across these nations, disparities in media portrayals of HIV/AIDS across the cultures and the varying influence of religious beliefs on the growth of the epidemic in different cultures. Origin and spread of AIDS First, consider our findings concerning the origin and spread of HIV/AIDS. Consistent with previous studies, Africa was seen as the original location of HIV/AIDS by the majority of respondents from all the countries surveyed (Ocholla-Ayayo, 1997), although a fifth of our Russian health care professionals claimed that the epidemic originated in ‘The West’. Conspiracy theories (e.g. AIDS was developed as a weapon of warfare) were a prominent feature of the early Soviet reporting of HIV/AIDS (Headley, 1998; Sontag, 1989). It was perhaps unsurprising therefore to see such theories still playing a role in the representations of HIV of many of our respondents in the three former Soviet nations in our sample (Georgia, Russia and Estonia). This latter finding may tap into continuing representations that see HIV/AIDS as a metaphor for a general loss of ‘moral standards’ (Rosenbrock et al., 2000). Indeed, a widespread belief that HIV is an ‘outsiders’ problem associated with the ‘decadent West’ contributed to a controversial AIDS regulation requiring the compulsory testing of foreigners visiting Russia for more than 3 months, reflecting calls for isolation common to epidemics across the ages (Sontag, 1989). One intriguing group of respondents was the relatively high number of Russians (some 30%) who believed that the ‘problem of HIV’ was exaggerated or could be readily solved. At the same time, a similar proportion of Russian respondents emphasised the ‘hopelessness’ of the situation in their free responses, reflecting an apocalyptic sense of doom frequently evoked in the early days of the Western epidemic and anchored in a wider range of fears about the future (Buckley, 1993; Sontag, 1989). This bipolarity in perspectives—between relatively extreme poles of optimism and fatalistic ‘AIDS-phobia’ (spidofobiia)—was evident amongst both the medical and business sub-samples in this country. High levels of both unrealistic optimism (Weinstein,

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1987) and fatalism (Adams, 1995; Kalichman et al., 2000) are important contributors to risky behaviour, and our findings here may provide insight into the comparatively high rates of high-risk sexual behaviour in this country (Kalichman et al., 2000). Media representations may be important in promoting this apparent bipolarity in representations. In a parallel newspaper study across these five nations, conducted at the time of our interviews (Goodwin, 2000), Russian newspapers provided both the largest number of ‘alarmist’ stories (with headlines such as ‘‘We Have No Hope’’, Kommersant, 27.10.99 p. 9) and the greatest coverage of ‘miracle cures’, with one, youth-orientated newspaper (Komsomolskaya Pravda) actively sponsoring an eventually unsuccessful AIDS ‘cure’ (Armenicum). Whilst the relationship between media representations and individual-level behaviours is a complex one (Svenkerud, Rao, & Rogers, 1999; Wagner, 1995), such active newspaper ‘propagation’ (Moscovici, 1961) might have rather deleterious implications for the perceptions of HIV/AIDS and risky sexual behaviours amongst this newspaper’s young, and increasingly ‘at-risk’, readership (Kitzinger, 1995; Triechler, 1999). ‘High risk’ groups and relations with wider society Our data provided only partial evidence of an ‘outgrouping’ in response to the HIV epidemic, and there was relatively little evidence of the social recriminations described by Rosenbrock et al. (2000) as evident in the early days of the epidemic in Western Europe. According to early media reports in the West, HIV was overwhelmingly an ‘out-groups’ disease associated with gay people’s ‘promiscuous’ behaviours (Joffe, 1996). In our study more than a third of our interviewees saw homosexuals as a high risk group, with a similar number free associating ‘AIDS’ with homosexuality. Drug addicts were seen as a high risk group by a similar proportion of respondents. Consistent with previous examinations of sexual behaviour (Sheeran et al., 1999) a large proportion of respondents from all the countries in this study also stated that they were unwilling to have sexual relations with those with high levels of promiscuity or working as prostitutes. Given that reported seropositive rates were highest amongst homosexuals, drug-takers and prostitutes at the time of our study (Joint United Nations Programme on HIV/AIDS, 1998) these results were perhaps not unexpected. Particularly encouraging, given the high levels of impoverishment in many of these societies, the vast majority of our respondents viewed the taxpayer as responsible for paying for the care and treatment of those infected with the HIV virus. At the same time, particular groups were more likely to be identified as being particularly ‘risky’ in each country. In Estonia, drug addicts were the most

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frequently cited as a high-risk group, and drugs were most frequently associated with AIDS in this country. In our parallel newspaper analysis across these five countries we also found that drugs featured more frequently in articles about HIV/AIDS in Estonia than in any other nation. Respondents in Russia were particularly concerned about levels of morality and social breakdown in their country and its implications for sexual behaviour. This finding is consistent with other studies into disclosure and support in this region, where a highly competitive (and often dangerous) business environment has served to increase the sense of psychological distance and distrust in this country (Goodwin, Nizharazde, Nguyen Luu, Kosa, & Emelyanova, 1999; Goodwin et al., 2002). Our interview and free associations findings suggest relatively conservative representations in Poland, and, to a lesser extent, Georgia, where images of the ‘promiscuous’ young condom carrier were accompanied by the strongest free associations between casual sexual activity and HIV/AIDS. Stigma and discrimination can act as important structural barriers to HIV prevention (Parker et al., 2000) and these cultural differences in associations with risk groups may reflect national differences in implicit theories concerning those most at risk (Williams et al., 1992). The Polish and Georgian samples were the most likely to declare their religious affiliation, and our findings here are in line with other results amongst religious communities which have also reported relatively conservative representations of sexual behaviour and HIV/AIDS, particularly in relation to condom use (Markova & Wilkie, 1987; Marquet et al., 1998; P!aez et al., 1991; Sontag, 1989). At the same time, research in southern Europe has suggested that religious cultures might also be associated with the greater compassion towards those infected, particularly those felt to be at no personal fault for contracting the virus (P!aez et al., 1991). Our findings seem to support this hypothesis: it was in our ‘religious’ nations—Poland and Georgia— that there was the greatest number of free associations between HIV/AIDS and misfortune and intolerance, indicators of a more compassionate attitude towards those infected. One finding with considerable practical implications is the extent to which individuals in the different societies had been tested for HIV/AIDS, or were aware of where such testing could be conducted. More than 90% of Russian respondents had been tested for HIV/AIDS, a notable contrast to Georgia and Poland, where only 15% and 20% of respondents had been tested and where nearly 40% of the business respondents in each country did not know where they might be tested. These results illustrate the very different approaches to compulsory testing across these countries (Renton et al., 1999; Rhodes et al., 1999b). Of course the availability of these testing facilities is in itself a matter for further

investigation. As elsewhere, economic restructuring, resulting partly from International Monetary Fund economic ‘reforms’ of the medical and welfare systems, have had a complex, and not always benign, impact on HIV prevention (Parker et al., 2000). Serious resource limitations question the availability of efficient testing facilities in the countries of the Former Soviet Union (Headley, 1998) and the risks of contracting HIV in medical settings (such as hospitals) was frequently noted by the Russian health care professionals in their interviews. Unfortunately, issues of trust in HIV testing procedures have yet to be extensively explored in these ex-Communist societies. Implications and further studies What are the wider implications of our findings for social scientists studying HIV in this region? HIV is a virus with a very long epidemic curve, and as a result it may have long-term, often hidden impacts on the historical and development trajectories of a society (Barnett, 2001). Economic decline can have a dynamic, long-term impact on HIV incidence (Parker et al., 2000), influencing national governmental resources, local governmental and non-governmental facilities and services and the individual psychological resilience required to cope with the epidemic. In addition, high rates of morbidity and mortality in these poor and very unequal societies are likely to have profound impacts on a range of facets of social and economic life, with increased pressures on already stressed health services and increases in dependency ratios in households and numbers of orphans (Barnett et al., 2000). Although we saw only limited evidence of explicit discrimination in this study, social representations are dynamic and fast-changing, and conflict and discrimination against particular groups can easily escalate into a vicious cycle in which inter-ethnic conflict triggers further representational discrimination and behavioural discriminations (Echebebarria, Guede, & Gonzalez Castro, 1994; Parker et al., 2000). Given the persistence of internal and crossnational conflicts in the south of this region we are fully aware of the potential for further HIV-related discrimination in these countries (Axmann, 1998). Perhaps the country of greatest concern in the present investigation was the country where the epidemic is now most wide-spread (Russia). This was the country where respondents were most willing to see the epidemic as having ‘nothing to do with them’. Russia might be characterised as slipping into a ‘‘risk society’’ (Barnett et al., 2000), where the environment conspires to make activities risky and where sexual inhibitions, relaxed following the social transitions in this society, have accompanied the increasingly large number of Russians who have turned to sex for financial reasons (Headley, 1998). Risks are particularly likely to be pronounced

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when a relatively dispersed group of individuals practice multiple partnerships (Ghani, 2001). In a related questionnaire study conducted in the same five countries (Goodwin et al., 2002), we found high rates of sexual partnerships amongst our Russian business respondents, with more than 20% of these participants reporting more than one sexual partner per week. These entrepreneurs are likely to be important in the development of new post-Communist society, and high levels of infection may be expected to have significant economic implications (Barnett et al., 2000). A further implication concerns the promotion of safer sexual practices in the two most religious cultures in our study—Poland and Georgia, the countries with the most conservative representations of risk groups and the carrying of condoms. Given that carrying a condom is an important preparatory behaviour for safer sex (Sheeran et al., 1999), the barriers imposed by social norms and roles must be a matter of some concern and may be important inhibitors to condom use (Godin et al., 1996; Triandis, 1980). In addition, it was in these countries that respondents reported the least knowledge about testing facilities. Kachkachishivili (1999) in Georgia found that older respondents in Georgia felt that public debate on sexual issues was unacceptable and immoral, whilst in Poland the influence of the Catholic Church on the media has been seen as pivotal in the restriction of safer-sex messages (Danziger, 1994). Given these restraints, our findings emphasise the need for a community focused approach that helps address prevailing representations (Delor & Hubert, 2000), as well as a broader media campaign that provides basic information about testing facilities. The present research offers a number of directions for further investigations. The current work was conducted with a relatively small sample from just two occupational groups—health care professionals and business people. Ours was a comparatively well-educated sample potentially unrepresentative in their susceptibility to health promotion messages (Campbell, 2001) and we questioned respondents only in selected cities in five countries in this region. Further research should aim to incorporate a wider range of geographical locations, both urban and rural, and should include other countries at risk from the spread of the epidemic, particularly those from the Former Soviet Union. This work should also address the spread of infection in the Islamic states of the Central Asia in particular, a region in which we currently have very little data. There is an urgent need for studies of young adolescent drug users, the group in this region in which the epidemic is now most prevalent. Such drug users are highly sexually active but report low levels of protected sex (Atlanti et al., 2000; Barnett et al., 2000; Rhodes et al., 1999b). The inclusion of this younger age group is likely to produce further evidence of representations of HIV/

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AIDS that do not match ‘official’ prevention messages (Marquet et al., 1998). Temporal and financial restrictions limited the range of questions we could ask as well as the types of methods employed. One area that requires further investigation is the representation of gender and sexual negotiation. Gender relations, at least nominally ‘egalitarian’ during the Communist era, have become particularly problematic in these ex-Communist societies (Goodwin & Emelyanova, 1995), as traditional gender stereotypes and the growing fear of male unemployment have contributed to a call for women to return to the ‘womanly mission’ of family responsibility (Gorbachev, 1987). These gender inequalities, which can act as a significant factor in reducing women’s power of sexual negotiation (Bajos & Marquet, 2000; Parker et al., 2000), should be further investigated along with additional ecological concerns, such as the need to maintain sexual relationships in order to meet basic economic needs (Barnett et al., 2000; Hobfoll, 1998). This is likely to mean an extended analysis of relational factors and their adaptational role in safer sexual behaviour (Buunk & Bakker, 1997). Such a broader range of analyses is likely to provide us with vital clues to the jigsaw of social influences that help drive this epidemic in this region of the world.

Concluding remarks Eastern Europe is perhaps the last world region to be confronted with rapidly spreading HIV epidemics. Governments and the international community should not allow another disaster to happen (Dehne et al., 1999, p. 748). The number of HIV/AIDS cases in Central and Eastern Europe is still not large compared, for example, to Sub-Saharan Africa. As a consequence it should still be possible to limit the size of the epidemic in this region (Kalichman et al., 2000). However, as Markova (1992) notes, health campaigns rarely integrate scientific knowledge with an understanding of prevalent social representations, and in the region under investigation in this study there are few of the organised groups available elsewhere to help counteract misleading representations of the epidemic (Rosenbrock et al., 2000). The findings from our research suggest new promotional campaigns that embody existing religious and social values (P!aez et al., 1991), as well as recognise the wider socioeconomic demands and ideological freedoms operating in post-Communist Europe. The consideration of such societal factors alongside other individual predictors of sexual behaviour represents, we believe, an important set in addressing the growing epidemic in this region.

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Acknowledgements The authors are indebted to the acting editor (Professor Blaxter) and three anonymous reviewers for their helpful feedback on an earlier version of this paper. This project was conducted as part of a group project grant sponsored by the Soros Foundation and led by the first author.

Appendix A. Interview Questions Group a: origin and spread of HIV 1. 2. 3. 4.

What do you think of the AIDS problem generally? How did you first hear about AIDS? Where do you think AIDS originated? How does AIDS spread amongst people?

Group b. ‘Risk’ groups 1. Is contacting AIDS the person’s own fault? 2. Do you think your nation is safer from AIDS because of high sexual morality? 3. Do you know anyone personally who has AIDS or is infected by the HIV virus? 4. What type of person gets AIDS? 5. What types of person would you not have sex with? 6. What kind of person carries a condom? Group c. Society and government 1. Do you think it is the government’s role to do something about AIDS? 2. Should the money for AIDS treatment come from taxpayers money? If not, from where? 3. How many people are infected with the AIDS virus in your country? 4. How do you know you are not infected with HIV? 5. Do you know where to get an HIV test?

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