Latinos Hispanics and HIVAIDS Octavio J Vallejo MD

Latinos (Hispanics) and HIV/AIDS Octavio J. Vallejo, MD, MPH AIDS Project Los Angeles Date: May 24 th 2013

My name in traditional chinese

Objectives � Describe the demographic characteristics and epidemiologic trends of HIV infection and AIDS in the Latino community � Identify critical cultural issues and other particular considerations related to Latino/as and HIV infection � Addressing the needs of Latinos/as within the new scope of work of HIV/AIDS

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

Why is the Latino Community a Major Concern? � � � The Latino community is the fastest growing population in the U. S. and the group with the second-highest risk for HIV/AIDS 1 50. 5 million is the number of the Hispanic population of the United States as of April 1, 2010, making people of Hispanic origin the nation's largest ethnic or race minority. Hispanics constituted 16. 3 percent of the nation's total population. In addition, there are 3. 7 million residents of Puerto Rico, a U. S. territory. 2 1. 2. The Henry J. Kaiser Family Foundation HIV/AIDS Policy Fact Sheet. Latinos and HIV March 2013 Source: American Fact. Finder: United States DP-1 <http: //factfinder 2. census. gov> and <http: //www. census. gov/prod/cen 2010/briefs/c 2010 br-04. pdf>

� More than half of the growth in the total population of the United States between 2000 and 2010 was due to the increase in the Hispanic population. � 132. 8 million is the projected Hispanic population of the United States on July 1, 2050. According to this projection, Hispanics will constitute 30 percent of the nation's population by that date. Source: Population projections <http: //www. census. gov/newsroom/releases/archives/population/cb 08 -123. html>

Hispanic Population in the United States: 1970 to 2050 Population in millions Census Projections *Projected Population as of July 1 8 Source: U. S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050

Percent Hispanic of the Total Population in the United States: 1970 to 2050 Census Projections *Projected Population as of July 1 9 Source: U. S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050

Who Composes the Latino Community? Latinos are a diverse group consisting of a mix of ethnic groups and cultures regardless of race The largest Latino groups are Mexicans, followed by Puerto Ricans, Central and South Americans, Cubans and other Latinos from the Caribbean Cover courtesy of IMPACTO LATINO. AIDS Project Los Angeles.

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

HIV and Latinos � � The HIV epidemic is a serious threat to the Hispanic/Latino community. Latinos are disproportionately affected by HIV. In 2010, while representing approximately 16% of the total US population, Latinos accounted for 21% of new HIV infections in the United States. Latinos also accounted for 21% of new AIDS diagnosis in 2011. Latino MSM are particularly affected by HIV. CDC MMWR Vol. 61/No 40

Population Estimated HIV/AIDS Cases 9, 848, 011 61, 700 Overall, Race/Ethnicity 13. 3% 0. 5% 8. 8% 30. 1% 47. 3% HIV/AIDS Cases 3. 0% 1. 0% 21. 0% Black Latino White 35. 0% 40. 0% Asian/PI NA/AI Data Source: U. S. Department of Commerce, 2010; Los Angeles County Department of Public Health, HIV Surveillance, 2011

LATINOS AND HIV Current trends 1. 2. 3. The number of new AIDS cases among Latinos has increased in the last 20 years 1 Latinos receive an AIDS diagnosis within 12 months of learning their HIV status 2 HIV transmission occurs more frequently among Latino males because of male-to-male sexual contact and among Latino women through heterosexual contact 3 Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, June 2002 Centers for Disease Control and Prevention: Late versus early testing of HIV – 16 sites, United States. 2000 -2003. MMWR 2003, 52: 581 -586 Levy V. et al. : HIV-related risk behavior among Hispanics immigrant men in a population-based household survey in low-income neighborhoods of Northern California. Sex Transm. Dis 2005; 32: 487 -490

LATINOS AND HIV Health disparities and barriers to HIV prevention and care Risk factors vary by country of origin and ancestry Substance abuse and alcohol abuse Language barriers High levels of poverty Educational level below the US national average Migration patterns Limited access to health care High rates of STDs

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

Cultural Characteristics that Increase Vulnerability and Delay of HIV Testing and Care � Gender inequity � Machismo � Homophobia � Drug or alcohol abuse � Stigma associated to the disease

Latina Women at Risk Traditional gender roles • Predetermined roles and family 1 pressures • Infidelity as part of the male social role and passive acceptance by female partners 2 • Stigma 3 • Gender Inequity 4 • Domestic Violence 1 • Machismo/homophobia 1 1. Galanti. J Transcult Nurs. 2003; 14: 180 -185. 3. Marin BV. J Transcult Nurs. 2003; 14: 186 -192. 2. Hirsch JS. Am J Public Health. 2002; 92: 1227 -1237. 4. Murphy DA, et al. AIDS Care. 2003; 15: 217 -230. Poster: YWCA/WINGS Shelter services for victims of domestic violence

65% of women living with AIDS reported having one sexual partner in their entire life 1 1. CDC. Supplement to HIV/AIDS Surveillance Report. 2002. 14: 1 -48. Art work: Prof. Antonio Salazar, National School of Fine Arts UNAM Mexico 1990

Consequences of Homophobia and Latino MSMs 1 HOMOPHOBIA Low self-esteem Depression Use of drugs Denial HIGH RISK OF HIV INFECTION For many the process of acceptance of being homosexual is more difficult than being HIV 1. Diaz R. et al. The Impact of Homophobia, Poverty, and Racism on the Mental positive. Health of Gay and Bisexual Latino Men: findings from 3 U. S. Cities. Am J Public Health. 2001; 91: 927 -932 Picture: Courtesy IMPACTO LATINO/AIDS Project Los Angeles 2005

Evolving high-risk groups Men on the Down Low (“DL”) Heterosexually identified men who have sex with men but do not tell their female partners 1 ◦ Don’t “subscribe” to gay subculture ◦ Usually unaware or non-disclosing of their HIV status ◦ Prevalent behavior among minorities of color 1. Millett G. 11 th CROI, San Francisco 2004, #83 Poster: Public domain. Mexican National Campaign against machismo and homophobia. 2004

Stigma and HIV • Definition: “an attribute that is deeply discrediting within a particular social interaction” Refers to unfavorable attitudes, beliefs and policies directed toward people perceived to have HIV/AIDS, as well as their loved ones, associates, social groups and communities 1 1. HIV AIDS Stigma. HRSA CAREACTION. August 2003

HIV & Stigma • PERSON AFFECTED IS SEEN AS RESPONSIBLE FOR HAVING THE ILLNESS • DISEASE PROGRESIVE AND & INCURABLE • DISEASE NOT WELL UNDERSTOOD • SYMPTOMS CAN NOT BEEN CONCEALED A person who is stigmatized “is reduced in our minds from a whole and usual person to a tainted, discounted one. ” 1 1. Erving Goofman/ Stigma: Notes on the Management of Spoiled Identity (1963) Photography courtesy of IMPACTO LATINO. AIDS Project Los Angeles.

Nuestras Voces National Latino Gay Men’s Study • 912 men recruited in 35 Latino gay bars New York: n = 309 Miami: n = 302 Los Angeles: n = 301 • 50% under age 30 • 27% unemployed • 82% self-identified as gay or homosexual • 73% immigrant (including from Puerto Rico) • 55% some college or more • 41% mostly Spanishspeaking (with friends) • 19% HIV-positive 1. Diaz R. et al. The Impact of Homophobia, Poverty, and Racism on the Mental Health of Gay and Bisexual Latino Men: findings from 3 U. S. Cities. Am J Public Health. 2001; 91: 927 -932

Experiences of Homophobia 1 Ever experienced % (95% confidence interval) Made fun of 64% (60 -68) as a child As a child heard gays not normal Violence as a child 18% (15 -21) As a child felt their 70% (66 -75) gayness hurt family Made fun of 50% (45 -54) as an adult Have had to pretend 64% (59 -69) to be straight Violence as an adult Job discrimination 15% (12 -18) Had to move away from family 29% (25 -33) Police harassment 20% (17 -24) 10% (7 -12) As a child heard gays grow old 71% (67 -75) alone 91% (89 -94) 1. Diaz R. et al. The Impact of Homophobia, Poverty, and Racism on the Mental Health of Gay and Bisexual Latino Men: findings from 3 U. S. Cities. Am J Public Health. 2001; 91: 927 -932

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

Disparities in Access to Care Reflect Disparities in Income and Insurance Coverage � � Blacks and Hispanics are approximately 3 times more likely to live in poverty than whites 1 Blacks and Hispanics less likely to have health insurance, compared with whites 2 Insurance Coverage of Nonelderly, by Race/Ethnicity, 2008 2 1. 2. De. Navas-Walt. US Census Bureau. Income, Poverty, and Health Insurance. 2008. Thomas M et al. Health Coverage for Communities of Color, Kaiser Foundation, 2009.

Latinos and HIV Access to health care services • In 2010, one in four Latinos living with HIV/AIDS are uninsured (24%)1 • Latinos with HIV/AIDS were more likely to be publicly insured, half of them relying on Medicaid • The impact of HIV/AIDS on Latinos is part of the broader disparities in access to health care services 1. US Census Bureau. Health Insurance Coverage: 2000. Issued 9/2002. 2. Morales LS et al. Sociodemographic differences in access to care among Hispanic patients who are HIV infected in the United States. Am J Public Health. 2004; 91(7)

Advanced Disease at Diagnosis � Delayed presentation, which is common among Latino patients 1, results in • Disproportionately high number with AIDS 2 • High baseline viral load • Impaired immune status 3 • Increased morbidity, hospitalization for OIs • Increased mortality 1. Suplemental HIV Surveillance Study Project. Los Angeles County, Department of Heatlh Services, January 2000 2. Turner et al, Delayed Medical Care After Diagnosis of Persons Infected with HIV. Arch of Int Med 16, 2000 3. Swindells S. AIDS. 2002; 16: 1832 -1834.

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos

Latino Immigration and HIV 1. 2. 3. There an estimated 3 to 6 million Mexican undocumented in the U. S. 1 One-fourth of the AIDS cases in Mexico are among persons who have spent prolonged periods in the U. S. 2 AIDS statistics in Mexico report a slight trend toward “ruralization” of AIDS that might be linked to male migration to U. S. 3 Lowell, BL How many undocumented: the numbers behind the US-Mexico migration talks. Report by the Pew Hispanic Center March 2002 Rangel et al Factores de riesgo de infeccion por VIH en migrantes mexicanos: el caso de los migrantes que llegan a la casa del Migrante”Centro Escalabrinii y ejercito de Salvaci EL Colegio de la Frontera Norte ISESALUD/COMUSIDA Magis R. et al La situacion del SIDA en Mexico a finales de 1998. ENfermedades Infecciosas y Microbiologicas 1998; 6: 236 -244 Pictures: Letra S. SIDA y Sociedad/ Mexican AIDS Newspaper. 1994

Migration-related Risk Factors for HIV Infection 1 � � � Constant mobility Cultural Linguistic Geographic barriers to health care services Change in sexual practices Limited education Psychosocial factors Isolation Discrimination Poverty Chronic underemployment Substandard housing 1. Organista, KC et al. Migrant laborers and AIDS in the United States: A Review of the literature. AIDS Educ. Prev. 1997; 9: 83 -93

Examples of HIV Risk Behaviors and Practices 1 � � � Adoption of new sexual practices ◦ Seeking companionship to compensate for the alienating aspects of migration experience ◦ Fewer constraints or social control on behaviors ◦ Exposure to previously unknown or unacceptable sexual behaviors and practices ◦ Exchange sexual services for money, food or lodging Low levels of knowledge relating to the mechanisms of HIV infection and prevention Multiple partners Low condom use Increased alcohol and drug use Limited access to medical care and HIV testing 1. HIV Risk Ten Times Higher for Migrant Farm-workers. Public Health Rep. 1994; 109: 459

Outline � Why is the Latino community a major concern? � Epidemiologic trends of HIV disease in the Latino community � Cultural characteristics that increase HIV vulnerability among Latinos � Issues related to access to HIV care � Immigration and HIV � Health care reform and Latinos….

Stage of Engagement in HIV Care 2011

Health Care Reform and a Changing HIV/AIDS Care Landscape

Immigrants � Serious failing of health care reform � No formal increased access to undocumented individuals ◦ Not allowed to participate in the exchange ◦ Not allowed to receive Medicaid service � Recent immigrants will still have a five year wait for Medicaid ◦ Exceptions: refugees, people granted asylum ◦ Can purchase in the Exchange ◦ Are eligible for subsidies; as of yet no subsidy structure below 133% FPL

Summary Latinos and HIV/AIDS • • • Increase in number of new infections Increase in number of Latinos newly diagnosed with AIDS Late detection of HIV status and advanced disease Lack of access to health care Fear of stigmatization Cultural beliefs associated to HIV/AIDS Barriers to receive competent HIV care Immigration status Health care reform and Latinos