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Preventing HIV/AIDS in Recent Latino Immigrants
There is an increasing sense of urgency to reduce, prevent, and eliminate Latino HIV and substance abuse health disparities in the U.S. Latinos are the largest and the fastest growing racial/ethnic minority group in the United States (De La Rosa, Dillon, Schwartz, Rojas, & Duan, 2009; NCMHD, 2008). According to the U.S. Census Bureau's American Community Survey (2009), Latinos comprise 50.5 million or 16.1% of the total U.S. population, discounting Puerto Rico (U.S. Census, 2010). This is a 43% increase from the 2000 U.S. Census figures which reported that Latinos comprised 35.3 million or 12.5% of the total U.S. population (U.S. Census Bureau, 2009). In addition, a 2008 Census projection report foresees the Latino population rising to approximately 30% of the total U.S. population by 2050 (U.S. Census Bureau, 2008b). The impact of the growth in the U.S. Latino population is magnified by the fact that both the non-Latino White and African American populations are stable and aging (Pew Hispanic Center, 2009). With the dramatic increase of the Latino population comes challenges in terms of access to health care (particularly among immigrant Latinos) that make it imperative to develop a clear understanding of the factors and issues that affect Latino health disparities.
Challenges faced by Latinos include the disproportionate number of HIV/AIDS infections in this population. The rate of HIV/AIDS among Latinos is almost three times that of non-Latino Whites (CDC, 2010). The disparity is even more remarkable among Latina women who have nearly four times the HIV rate of their non-Latina White counterparts (CDC, 2010). In addition to escalated rates of HIV/AIDS, Latinos face disparities in terms of consequences related to substance abuse. These consequences include: other health related costs of drug use (e.g., Latino and African American injection drug users have greater infection risk for Hepatitis B and C; NIDA, 2010); incarceration (Iguchi, Bell, Ramchand, & Fain, 2005; Iguchi, London, Forge, Hickman, & Riehman, 2002); higher rates of alcohol-related problems including driving under the influence (Caetano & Clark, 2000); intimate partner violence; and cirrhosis mortality (Caetano, 2003; Montoya, 2001).
As research on Latino health disparities indicates, there is an increasing need for research that investigates patterns of substance use and their implications on the transmission and acquisition of HIV, either directly or as mediators of sexual behavior in Latinos and other racial/ethnic minority populations (De La Rosa et al., 2010a). De la Rosa et al. (2010b) also calls for additional research that focuses on the role that social and cultural factors have on the substance abuse and HIV risk behaviors of Latinos. In the above context, the long term goal of C-SALUD is to address Latino health disparities in HIV/AIDS and substance use in the United States, and in particular Miami-Dade County, Florida.
The HIV/AIDS epidemic is a serious threat to the Latino community as rates of HIV infection among Latinos are almost three times that of non-Latino Whites (CDC, 2010). The disparity is even greater among Latina women who have almost four times the HIV rate of their non-Latina White counterparts (CDC, 2010). The increasing rate of AIDS related deaths among Latinos is also particularly troubling given the disease currently ranks as the fifth leading cause of death for Latinos ages 35â€“44; the sixth leading cause of death for Latinos ages 25â€“34; and the fourth leading cause of death among Latina women ages 35â€“44 (CDC, 2010). The escalating rates of HIV/AIDS among Latinos are distinctly evident in Florida where HIV cases among Latinos increased by 76% between the years 1999 and 2008 (Florida Department of Health, 2009). Furthermore, Miami-Dade County, where C-SALUD focuses its activities, currently ranks number one in number of new AIDS cases per capita in the United States. More specifically, Latinos account for 34% of AIDS cases and 39% of HIV cases in Miami-Dade County (Florida Department of Health, 2009).
Substance use plays an important role in the spread of the HIV epidemic. Both casual and chronic substance users are more likely to engage in high-risk behaviors (i.e., unprotected sex, inconsistent condom use, and having multiple sex partners) when they are under the influence of alcohol and/or drugs (Dillon, 2010; De La Rosa et al., 2010; Palepu et al., 2005; Raj, Silverman, & Amaro, 2004; SAMHSA, 2009; Kaminer & Bukstein, 2008). Research sponsored by the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has shown that illicit drug and alcohol use can interfere with judgment in regard to sexual (and other) behavior, thereby increasing the likelihood of engaging in unplanned and unprotected sex. Moreover, women who use crack cocaine or other non-injection drugs frequently trade sex for drugs, placing them at high risk of sexual transmission of HIV (Tross et al., 2009). Among the various methods of substance abuse, injection drug use (IDU) continues to be a significant risk factor for HIV/AIDS in Latino populations. This issue is particularly salient among Latina women whose most common methods of transmission of HIV infections are through high-risk heterosexual contact and injection drug use (CDC, 2009).
As such, Latina women have higher rates of IDU-associated HIV/AIDS (28%) in comparison to both Latino males (23%) and non-Latino White males (21.4%) (CDC, 2009). Further exacerbating the situation, Latinos in the U.S. (especially recent immigrants) reuse needles and syringes for vitamin and medication injections and may share their equipment with neighbors and friends (Denner, Organist, Dupree, & Thrush, 2005). Considerable disparities also exist in the rates of Latino substance abuse treatment enrollments. Latinos represent the ethnic group with the least amount of people receiving services (14%), in comparison to non-Latino Whites (59%) and African Americans (22%) (NIDA, 2008). Currently, 8.3% (2.6 million) of Latinos ages 12 or older are in need of alcohol use treatment, and 3.4% (1.1 million) are in need of illicit drug use treatment. Of the 2.6 million Latinos in need of alcohol use treatment, only 7.7% received treatment in specialty facilities. Fifteen percent of the 1.1 million Latinos in need of illicit drug use treatment received treatment in specialty facilities (SAHMSA, 2009). Existing evidence not only reveals disparities in access to health care services, but also in quality of care and outcomes for Latinos in treatment.
Latinos have been found to: a) exhibit the greatest need coming into treatment, indicated by ranking highest in drug use severity among other racial/ethnic groups; b) have a higher probability of being treated in organizations with the least number of on-site services and most limited schedule of substance abuse treatment counseling; and c) report the shortest duration in treatment compared to African Americans and non-Latino Whites (Marsh, Dingcai, Guerrero, & Shin, 2009).
Although Latina women are also less prone to heavy drinking and illicit drug use (Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005; Hines & Caetano, 1998), studies have found that Latinas with substance abuse problems enter treatment with problems that are at least as or possibly more serious than those of Latino males (Alvarez et al., 2007). Aggregate data from the U.S. National Alcohol Surveys (1995- 2005) reveal Latinas with a history of alcohol dependence to be more likely than their male counterparts to express avoidance in accessing treatment because they did not believe they had a substance abuse problem. These findings may imply an objective gender difference in problems that Latinas bring into treatment (Zemore, Mulia, Ye, Borges, & Greenfield, 2009).
Studies have also found Latinas to be particularly susceptible to refusing treatment due to concerns related to stigmatization and strict cultural norms (Alvarez et al., 2007). As noted in Healthy People 2020 (U.S.DHHS, 2009) the elimination of disparities in the rate of HIV infection among racial/ethnic minorities (African Americans and Latinos/as in particular) remains a challenge. Given the disparities existing in HIV/AIDS and substance use among Latinas, it is evident that prevention, intervention, and treatment strategies tailored for this population are in great demand.
Research has specifically linked migration/mobility to increased HIV incidence and vulnerability in a variety of contexts and places. These vulnerabilities are detailed in a monograph (Shtarkshall & Soskolne, 2000; Soskolne & Shtarkshall, 2002) and summarized here. First, migrant workers (MWs) are a large and growing population with an estimated 125 million people living and often working outside of their country of citizenship, while between two and four million migrate permanently each year. Second, migrant populations have a greater risk for poor health in general and HIV infection in particular due to circumstances, including their economic transitions, decreased accessibility of health services, and the complications of host country health systems, which impede the ability of migrants to meet their needs. Third, the uniqueness of migrants often fosters a kind of ethnic/racial intolerance and hostility by the host community which is likely to be more severe with HIV-positive migrants, particularly in regard to stigmatization and discrimination. Thus, migrants may be further motivated to hide their HIV status for as long as possible, making support services unavailable to them. Fourth, even if health providers were prepared to assist migrant populations, they would likely encounter great difficulties in reaching out to them. Many migrants live in constant fear of deportation, having no work permit or authorization to stay in the host country. Therefore, any contact with official government agencies increases that fear and is often accompanied by suspicion. Fifth, compared to migrant-worker populations in other areas of the United States, workers in the southeastern United States are more likely to live away from their families while doing farm and nursery work (Fernandez et al., 2004; Gadon, Chierici, & Rios, 2001; Larson, 2000; Roka & Cook, 1998).
The risk factors that appear most important among LMWs are: 1) inadequate or incorrect HIV transmission knowledge (Ford, King, Nerenberg, & Rojo, 2001; Fernandez et al., 2004; Organista, Organista, & Soloff, 1998; Organista, Organista, Bola, Garcia de Alba, & Castillo Moran, 2000; Sanchez et al., 2004); 2) multiple partners and long absences from families (Aranda-Naranjo & Gaskins, 1998; Fernandez et al., 2004; Hernandez et al., 2004; Organista et al., 1998; Sanchez et al., 2004); 3) cultural influences of machismo and familismo among single and gay men which may prevent use of safe sex practices; 4) immediate survival problems (e.g., housing, child care, transportation, exposure to pesticides, employment, medical care, violence) related to indigence and associated disempowerment that take precedence over the possibility of developing a fatal disease in the distant future (Aranda-Naranjo & Gaskins, 1998; Fernandez et al., 2004; Hernandez et al., 2004; Organista et al., 1998; Sanchez et al., 2004); 5) limited access to HIV risk reduction information, techniques, and support (Castaneda & Collins, 1997); 6) cultural and gender roles and values related to trust and integrity in intimate relationships that may deter women from securing safer sex with their steady partners (Fernandez et al., 2004; Marin & Gomez, 1999; MirandÃ©, 1997; Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987; Weatherby et al., 1997); 7) being less likely than non-minorities to discuss HIV/AIDS with others or to receive HIV/AIDS-related support (Gloria & Peregoy, 1996); and 8) alcohol and other drug use (Fernandez et al., 2004; Ford et al., 2001; Sanchez et al., 2004).
There are very few migrant worker HIV prevention studies conducted in Florida (Bowen, Williams, McCoy, & McCoy, 2001a; 2001b; McCoy, McCoy, & Lai, 1997; McCoy, McCoy, Lai, Weatherby, & Messiah, 1999; McCoy, Hlaing, Ergon-Rowe, & Malow, 2009; Watters & Biernacki, 1989; Weatherby et al., 1995;). Based on the findings reported by these studies, a few key issues can be raised. First, existing studies have been based on relatively "generic" cognitive-behavioral models, enhanced by few contextual and social determinant variables. Second, gender differences in risk among Latino migrant workers need attention. Women encounter different HIV risk issues and these differences are particularly significant among Latina migrant workers (e.g., partners who resist condom use, gender roles and cultural stereotypes discouraging women's securing safer sex, economic dependence and other relationship power imbalances, the male-controlled nature of barrier protections). Nevertheless, there is no well-articulated conceptualization of how HIV prevention for Latina migrant workers needs to differ from interventions for men. Third, given the limitations of "single shot" interventions to adequately help high risk Latino migrant workers to adopt and maintain risk reduction behaviors, it appears critical to provide the migrant worker community with the capacity and infrastructure to prolong community-based HIV prevention activities over time. Latino migrant workers are most likely to benefit from HIV prevention efforts when these efforts are sustained over time and other needs in the community are also addressed.
From the beginning of the HIV/AIDS epidemic (1981) through 2006, women accounted for 189,566 diagnoses in the United States, representing 19% of the 982,498 AIDS diagnoses in the 50 states and the District of Columbia during this period (National Latino AIDS Awareness Day, 2008). The rate of women diagnosed with HIV/AIDS has risen drastically since the beginning of the epidemic; in 2008, women accounted for more than one quarter of all new HIV/AIDS diagnoses (CDC, 2008) Latinas are disproportionately affected by HIV/AIDS in the U.S. Although Latinas represented 13% of the female population aged 13 and over in 2006, they accounted for 16% of estimated AIDS cases in that same year (Kaiser Family Foundation, 2009). In that same year, the AIDS case rate per 100,000 Latinas (9.5) was 5 times higher than the case rate for White non- Latino women (1.9) in the U.S. (Kaiser Family Foundation, 2009), a rate higher than what was reported by CDC in 2008. Latinas represented a much greater share (22%) of AIDS diagnoses among all Latino males and females living in the U.S. compared to White women's (15%) share of AIDS cases diagnosed among all non-Latino White males and females (Kaiser Family Foundation, 2009).
Latinas also face barriers to health care and HIV testing, preventing them from knowing their status (Pan American Health Organization [PAHO], 2008). Due to infrequent HIV testing, Latinas are often diagnosed during a very late stage of HIV infection and therefore develop AIDS sooner after an HIV diagnosis than White women. Consequently, AIDS has become a major cause of death for Latinas. HIV/AIDS is the 3rd leading cause of death among Latina women in Florida age 25 - 44 years (Florida Department of Health, 2009).
For Latina women living with HIV/AIDS, the most common methods of HIV transmission are: 1) high-risk heterosexual contact and 2) injection drug use (IDU; CDC, 2010). In 2005, the majority (70%) of Latinas living with HIV/AIDS were infected through heterosexual contact. Latinas are more likely to have been infected through heterosexual transmission than non-Latino White women (Kaiser Family Foundation, 2009).
The HIV/AIDS epidemic represents a growing and persistent health threat to racial/ethnic minority women in the United States. While Latina women represented a quarter (24%) of new infections among Latinos in 2006, their rate of HIV infection was nearly four times that of White women (CDC, 2010). Available research has specifically linked migration to increased HIV incidence and vulnerability in a variety of contexts and places (National Center for Farmworkers Health [NCFH], 2008). The first estimates of HIV prevalence rate among Latino migrant workers date back to 1992, when the CDC conducted the first study on this population. At the time, 5% of Latino migrant workers, nearly 10 times the 1992 national rate of 0.6%, tested positive for HIV. Since then, a few other small studies have reported rates ranging from 0.47% to 13% (NCFH, 2008). However, a large majority of participants in these studies were males. Controlled studies among Latina migrant workers aimed at preventing HIV related risk behaviors are nonexistent. Despite their high risk for HIV infection, very limited information is available on HIV infection rates and related risk behaviors among Latina migrant workers (LMWs).
Recent surveillance data (CDC, 2008, 2010; Kaiser Family Foundation, 2009) indicate that AIDS is spreading at much higher rates among Blacks and Latinos than among Whites; Latinos, who comprise the majority of migrant workers, are disproportionately affected by HIV/AIDS as they represent 15% of the population and 17% of new HIV infection cases, a rate 2.5 times that of Whites. Latina women represented a quarter (24%) of new infections among Latinos in 2006â€”compared to 13% in the early 1990sâ€”and their rate of HIV infection was nearly four times that of White women (14.4/100,000 vs. 3.8/100,000; CDC, 2010). Women are most likely to be infected through heterosexual sex. This pattern is consistent across racial and ethnic groups, although heterosexual transmission accounts for a greater share of new HIV infections among Latinas (83%) compared to White women (70%; Kaiser Family Foundation, 2011).
The HIV/AIDS epidemic among Latina women is likely to escalate dramatically by 2050 when nearly 1 out of 3 Americans will be of Latino descent (Bernstein & Edwards, 2008). Socioeconomic factors such as poverty, migration patterns, social structures, and language barriers are among the factors that contribute to Latino HIV infection rates. Socioeconomic problems include unstable employment or unemployment, transience, lack of formal education, documentation status, inadequate health insurance, and limited access to quality health care (CDC, 2010). Despite the fact that HIV/AIDS disproportionately impacts racial/ethnic minority women and migrant communities, limited research has been conducted among LMWs and little is known about HIV prevalence and associated risk factors in this community. If successful, the proposed study will delineate important HIV intervention strategies that can be practically implemented to improve the adoption and maintenance of HIV risk reduction behaviors among high risk Latina Migrant Workers.
Research on the underlying risk factors responsible for the spread of HIV/AIDS among recent Latina immigrants in the U.S is in need of further exploration. Past investigations have predominantly recruited Latina immigrant samples that have lived in the U.S. for extended periods of time and had higher acculturation levels than recent immigrants (Hines & Caetano, 1998). These studies attribute increased rates of HIV/AIDS in this population to sexual and substance use practices, often mediated by level of acculturation to the U.S. and gender role differences between Latino men and women (Nyamathi, Bennet, Leake, Lewis, & Flaskerud, 1993; Levy et al., 2005). Although a number of epidemiological studies have investigated the influence of different levels of acculturation on substance use and risky sexual behaviors of Latino immigrants (Levy et al., 2005; Uribe et al., 2009), fewer studies focus on recent immigrants and women in particular. Some of these studies suggest that young recent Latina immigrants turn to substance abuse and other risk behaviors to cope with problems caused by gaps in acculturation levels between themselves and their parents; such gaps are posited to occur because young recent immigrants acculturate at a relatively faster rate when compared to their parents (Szapocznick & Kurtines, 1980; Vega & Gil, 1998).
Miami Dade County is a community in which 61.4% of the population is Latino (U.S. Census Bureau, 2011). Miami-Dade County is a gateway for immigrants from Latin America. Approximately half (51%) of its residents are immigrants and 93% of those immigrants are from Latin America or the Caribbean (U.S. Census Bureau, 2010; Miami-Dade County Department of Planning and Zoning, 2009). The length of time since immigrating to the U.S. is an important factor for HIV related acquisition behaviors as less time in the U.S. has been associated with lower HIV screening rate, resulting in late detection and inability to receive early treatment among Latina women (Peragrallo, Fox, & Alba, 1998). Miami Dade County also has the 3rd highest rate of HIV infection in the continental U.S. (Florida Department of Health, 2009). In this community, the most important factors that place recent Latina immigrants at risk for HIV are: a) low socioeconomic status, b) lack of awareness of their partner's sexual risk behavior, and c) inability to assess their male counterparts risk for HIV (CDC, 2010b). The majority of recent Latina immigrants are undocumented, uninsured, and lack access to health care including HIV prevention services. In states like Florida where there is a large influx of recent immigrants (defined as people who have spent less than 25% of their lifetime in the U.S.), individual's attitudes and behaviors tend to reflect that of their countries of origin. The influence of immigrants' countries of origin is evidenced by the dominant language of preference remaining Spanish. Furthermore this population tends to be economically disadvantaged. For instance, in a large community sample of Latina women (predominantly immigrants) living in Miami Dade County, De La Rosa and colleagues (2010), found that the mean household income for Latina women was $10,000 or less. At MUJER, one of C-SALUD's partnering agencies, 66% of the clients in 2010 reported a yearly income of less than $3,000. Furthermore, at MUJER, most clients were foreign born (64%) and have been living in the U.S. for less than ten years.
Investigations have found low acculturated recent Latina immigrants to be less likely to engage in illegal and intravenous (IV) drug use, less alcohol use, or be less likely to have sex with multiple partners than their non-Latina White counterparts (CDC, 2010b). Nonetheless, their lower perceived risk of HIV/AIDS for themselves and their partners place them at an elevated risk of HIV infection due to a lack of safe sex practices (Nyamathi et al., 1993). Studies have also suggested that less acculturated Latina immigrants engage in more risky sexual behaviors (e.g., no condom use and anal sex) than their highly acculturated counterparts (Hines & Caetano, 1998). Other investigations have attributed higher HIV risk behaviors among less acculturated Latinas to low levels of knowledge regarding HIV risk behavior, less condom use, and the submissive gender role of women in Latina culture (Rojas-Guyler, Ellis, & Sanders, 2005).
Research has specifically linked migration/mobility to increased HIV incidence and vulnerability in a variety of contexts. These vulnerabilities are detailed in the literature (Shtarkshall & Soskolne, 2000; Soskolne & Shtarkshall, 2002) and summarized below. First, migrant workers (MWs) are a large and growing population with an estimated 125 million people living and often working outside of their country of citizenship. Between two and four million migrate each year. Second, migrant populations have a greater risk of poor health in general and HIV infection in particular due to circumstances, including their economic transitions, decreased accessibility of health services, and the complications of the host country health systems, which can impede migrants' ability to meet their needs. Third, the uniqueness of migrants often fosters a kind of ethnic/racial intolerance and hostility by the host community, which is likely to be more severe with HIV-positive migrants, particularly in regard to stigmatization and discrimination. Thus, migrants may hide their HIV status for as long as possible, making support services unavailable to them. Fourth, even if health providers were prepared to assist migrant populations, they would likely encounter great difficulties to reach out to them. Many migrants live in constant fear of deportation, having no work permit or authorization to stay in the host country. Therefore, any contact with official government agencies exacerbates their fears and is often accompanied by suspicion. Fifth, compared to migrant-worker populations in other areas of the United States, workers in the southeastern United States are more likely to live away from their families while doing farm and nursery work (64%) and travel in small groups of men (Roka & Cook, 1998; Larson, 2000; Gadon, Chierici, & Rios, 2001).
The risk factors that appear most important among Latino migrants (LMs) are: 1) inadequate or incorrect HIV transmission knowledge (McCoy, Hlaing, Ergon-Rowe, Samuels, & Malow, 2009); 2) multiple partners and long absences from families (Kissinger, Liddon, Schmist, Curtin, Salinas, & Narvaez, 2008); 3) cultural influences of machismo and familismo among single and gay men which may prevent use of safe sex practices (McCoy et al., 2009); 4) immediate survival problems (e.g., housing, child care, transportation, exposure to pesticides, employment, medical care, violence), related to indigence and associated disempowerment, that take precedence over the possibility of developing a fatal disease in the distant future (Aranda-Naranjo & Gaskins, 1998; Organista et al., 1998;); 5) limited access to HIV risk reduction information, techniques, and support (Castaneda & Collins, 1997); 6) cultural/gender roles and values related to trust and integrity in intimate relationships may deter women from securing safer sex with their steady partners (Fernandez et al., 2004; Marin & Gomez, 1999; MirandÃ©, 1997; Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stabl,1987; Weatherby et al., 1997); 7) being less likely than the non-minority population to discuss HIV/AIDS with others or to receive HIV/AIDS-related support (Gloria & Peregoy, 1996); and 8) alcohol and other drug use (AOD) (Ford, King, Nerenberg, & Rojo, 2001). Heterosexual contact facilitated by AOD (particularly alcohol) is the primary mode of HIV transmission in this population, with little risk-exposure attributable to injecting drug use and needle sharing (Amaro, 1995; Fernandez et al., 2004). However, these studies have generally been conducted among both men and women; thus, there is very limited information on those HIV risk behaviors that are specifically salient to Latina migrant workers. One particular study conducted by Fernandez and colleagues (2004) on migrant workers in Miami-Dade County did find Latinas to be almost five times more likely to be at risk of acquiring HIV as a result of sexual relations than men.