A NATIONAL PERSPECTIVE OF THE HIV/AIDS EPIDEMIC ON HISPANICS/LATINOS IN THE U.S.

 

In the United States, the HIV/AIDS epidemic has adversely affected Latino/Hispanic communities and its impact on Hispanics/Latinos continues to grow at disproportionate rates. As the youngest and fastest growing minority group in the U.S., the Hispanic/Latino population is witnessing the devastating effects of the HIV/AIDS epidemic. [1] Several factors act as obstacles to prevention efforts and thus contribute to the high level of HIV infection. Latinos living in the U.S. experience cultural factors and familial norms that act as barriers to HIV prevention. They are exposed to cultural stressors—discrimination, language barriers, and acculturation—that make them more vulnerable to maladaptive behaviors, which increase their likelihood of becoming infected with HIV. [2]

 

Background: Hispanic/Latino population in the U.S.

Hispanics are the largest minority group in the nation and in 2006 Hispanics accounted for 44.3 million or 14.8% of the U.S. population. [3] With the highest growth rate of any other minority group in the U.S., the Hispanic population grew by 24.3% or by 2.9 per 100,000 in the years 2005-2006, which is approximately half of the national population growth rate of 3.1%. [4] [5] The highest concentration of the Hispanic population remains in five states - California, Texas, Florida, New York and Illinois – and in 2006, California had the highest Hispanic population at 13.1 million, followed by Texas at 8.4 million, Florida at 3.6 million, New York at 3.1 million and Illinois at 1.8 million. [6] Among states with the highest Hispanic population growth rates in 2006, Arkansas had the highest in the nation at 60.9 per 100,000, Georgia had the second highest at 59.4, South Carolina at 57.4, Tennessee at 55.5 and North Carolina at 54.9. [7]

The new wave of Hispanic migration to the southern part of the U.S. is significant for various reasons, one of them being that the current public health infrastructure is unable to address the rapid population growth, including culturally and linguistically appropriate prevention and health services related to HIV. Local service providers in both the government and nonprofit sectors are struggling to build the infrastructure and capacity to respond to the needs of these newcomers, many of whom are vulnerable to health challenges due to the difficult living and working conditions they experience.

In addition to the high population growth, Hispanics are relatively young. In 2006, one-third of the Hispanics population was under eighteen, compared with one-fourth of the total U.S. population.[8] In 2006, the median age for the U.S. population as a whole was 36.4, compared to 27.4 among Hispanics for that same year, and 30.1 among blacks.[9] The same year, the largest Hispanic subgroup in the U.S. was Mexican, comprising 64% of the Hispanic population, followed by Puerto Rican at 9% Cuban 3.4%, Dominican, 2.8%, Central American 7.6%, and South American, 5.5%.[10] Among Hispanics living in the U.S. in 2006, 60% were born in the U.S., and 40% were foreign born.[11] This is significant because most migrants that come to U.S. do so in search of work, most often in agricultural industries, where they are exposed to a new culture, language, and, social customs and norms. This can lead to loneliness, isolation, and financial instability, making migrants more vulnerable to being at high risk for HIV infection.[12]

 

Hispanics/Latinos in the U.S. and HIV/AIDS    

As the largest minority group in the U.S., Hispanics are disproportionately affected by HIV/AIDS. In 2006, Hispanics comprised 15% of the U.S. population or 44.3 million people,[13] yet represented 18% of the HIV/AIDS cases that same year, among 33 states with a name-based reporting, excluding Puerto Rico.[14] At the end of 2006, there was an estimated 80,815 Hispanics/Latinos living with AIDS, representing 18% of those living with AIDS.[15] Hispanic males had a higher AIDS rate of 31.3, than Hispanic females, 9.5.[16] According to the National Center for Health Statistics, HIV/AIDS was one of the leading causes of death among Hispanics/Latinos in 2004. Although Blacks had the highest HIV diagnoses in 2006, Hispanics/Latinos had the second highest HIV diagnoses that same year and once again men were diagnosed with HIV at a higher rate than Hispanic women. There was an estimated 51 HIV diagnoses per 100,000 among Hispanics men (compared to 15 HIV diagnoses among Latina women.[17] From 2003 to 2006, with 33 states reporting, the annual rate of HIV diagnoses per 100,000 decreased from 37.0 in 2003 to 33.7 in 2006.[18]

 

In 2006, the most common mode of HIV transmission for Latinos in theU.S. was through male-to-male sexual contact. Of all male adults and adolescents living with HIV/AIDS in the U.S. at the end of 2006, male-to-male sexual contact was the primary mode of transmission for 17% of Latinos, 47% among Black men and 34% among White non-Hispanic men. [19] Among MSM, Blacks were estimated to have the highest rate of AIDS per 100,000 in 2006. The infection rate (per 100,000) of AIDS among black MSM (in 2006) was 10.8, compared with 6.3 among Hispanic MSM and 2.56 non-Hispanic white MSM. However, non-Hispanic white MSMs had the highest AIDS infection diagnoses (6,251), when compared to black MSMs (4,309) and Hispanic MSMs (2,816). [20]

Among Hispanics/Latinos living with HIV/AIDS at the end of 2006, 23.6% were female, and 74.8% were male.[21] For Latino men living with HIV/AIDS, the most common mode of HIV transmission is sexual contact with another man, followed by injection drug use (IDU), high risk heterosexual contact and, male-to-male sexual contact (MSM) and IDU combined.[22] At the end of 2006 in 33 states with confidential name-based reporting, 14,427 male adult or adolescent Hispanics living with HIV/AIDS became infected through injecting drugs with HIV contaminated needles, representing 23% of Hispanic males living with HIV/AIDS.[23] Latino males become HIV positive through IDU more often than other communities in the U.S.—IDU was the primary mode of transmission for 22% of African American males living with HIV/AIDS and 9% of non-Hispanic White males living with HIV/AIDS in the U.S.[24]Although Latinas represented 13% of the female population aged 13 and over in 2006, they accounted for 16% of estimated AIDS cases.[25]^, [26] 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-Hispanic women (1.9) in the U.S.[27] Among Latina females, high-risk heterosexual contact was the most common mode of HIV transmission, accounting for 71% of the cases among Latinos that were living with HIV/AIDS at the end of 2006, compared with 75% among black females and 65% white, non-Hispanic females. 

In the U.S., the risk of contracting HIV and other sexually transmitted infections among youth and children is disproportionately higher among minority races/ethnicities. As the youngest and fastest growing ethnic minority group in the U.S., the Hispanic/Latino population is witnessing the devastating effects of the HIV/AIDS epidemic.[28]

 

Male- to-male sexual contact:

The term “men who have sex with men” (MSM) refers to all men who have sex with other men, regardless of how they identify themselves (gay, bisexual, or heterosexual). In the U.S., HIV/AIDS has had a tremendous effect on MSM. HIV infection has been increasing steadily among gay and bisexual men since the early 1980s.[29] Since the beginning of the epidemic more than half a million MSM have been diagnosed with AIDS.[30] MSM are disproportionately affected by HIV/AIDS—although MSM made up only about 5% to 7% of men in the U.S., they accounted for more than two thirds (68%) of all men living with HIV in 2005. Approximately 62% (218,676) of males living with HIV/AIDS in the U.S. identified male-to-male sexual contact as the primary mode of transmission in 2006.[31]

Among Latino MSM, the HIV/AIDS rate is climbing at alarming proportions. Among MSM, the estimated rate of AIDS infection per 100,000 (in 2006) was 6.3 among Hispanics/Latinos, 10.8 among Blacks, and 2.56 among non-Hispanic Whites. For the same year, 2,816 Hispanics were estimated to be infected with AIDS through this way, compared with 4,309 among Blacks and 6,251 among non-Hispanic Whites; making non-Hispanic White MSM the group most affected by AIDS through male-to- sexual contact. Hispanics At the end of 2006, 57% of all Hispanic males living with HIV/AIDS in the U.S reported male-to-male sexual contact as the transmission category.[32] The percentage of Latino MSM living with HIV/AIDS in the U.S. varies by place of birth. 62% of Cuban-born and 59% of Mexico-born Latinos living with AIDS cited male-to-male sexual contact as the mode of transmission, whereas approximately 18% of people living with AIDS born in Puerto Rico became infected with HIV through male-to-male sexual intercourse.[33]

Several factors act as obstacles to prevention efforts and thus contribute to the high level of HIV infection specifically in the Latino MSM community. MSM are impacted by three socially oppressive forces—poverty, racism and homophobia—that often produce experiences of social alienation and personal shame.[34] Racism, homophobia, and poverty act as obstacles to prevention and access to care efforts because they contribute to a sense of stigma associated with the disease and what it represents about sexuality and powerlessness and lack of control in their personal lives and in sexual situations.  

Many Latino MSM turn to alcohol and illegal drug use as a means to cope with homophobia and the frustration caused by poverty, racism and other forms of social discrimination and abuse. The stigma associated with HIV/AIDS and homosexuality, known as “rechazo” (rejection), acts as a major obstacle to prevention efforts in the Latino community. The stigma creates a “sexual silence” in which Latino gay, bisexual and transgender men carry on a secret sex life cut-off from the support and familial network necessary to overcome isolation. Additionally, traditional rigid gender roles and norms such as “machismo” contribute to the sense of Latino gay men being “failed men”.

 

Latinas/Hispanas and HIV/AIDS

In 2006, Latinas represented 13% of the U.S. female population aged 13 and over, and accounted for 16% of estimated AIDS cases in that same year.[35]^, [36] In 2006, Latinas represented a much greater share (22%) of AIDS diagnoses among all Latinos and Latinas living in the U.S. compared with white women’s (15%) share of AIDS cases diagnosed among all non-Hispanic white males and females.[37] 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-Hispanic women (1.9) in the U.S.[38]

For Hispanic/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).[39] In 2006, the majority of Latinas living with HIV/AIDS were infected through heterosexual contact—approximately 71% of Latinas.[40] Latinas are more likely to have been infected through heterosexual transmission than non-Hispanic white women (65%), however, Black women (75%) are infected most often than Latina or non-Hispanic White women, through heterosexual contact.[41] Intravenous drug use (IDU) ranks as the second most common mode of HIV transmission for Latinas. In 2006, 28% of Latinas living with HIV/AIDS identified IDU as the source of HIV transmission, whereas, 23% of Black women, and 33% of non-Hispanic White women, living with HIV/AIDS, identified IDU as the source of transmission.[42] Reports of injection drug use among Latinas vary by country of origin. For example, opiate drug use, often injected intravenously, was highest among women who live in the U.S. and whose country of origin was Puerto Rico at 43% and 29% among women from Cuba.[43]

Latinas confront several obstacles when it comes to HIV prevention, testing, counseling, and seeking treatment once infected—embarrassment, fear of rejection and stigma, partner’s objection to testing, and lack of access to financial resources and health insurance coverage.[44] They also face barriers in accessing health care and HIV testing, preventing them from knowing their status.[45] Additionally, women have differential access to medical care, counseling, and information, making them less likely than men to receive accurate prognosis and treatment of HIV.[46] 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—in 2004, HIV infection was the 5th leading cause of death for Hispanic women aged 35–44 years.[47]

Another factor attributing to higher rates of HIV infection amongst Latinas is that traditionally in Latino cultures sex and sexuality are not discussed.[48] Latino men who have sex with men (MSM) and women but who do not identify as gay or disclose their bisexual activities to main female partners, also known as men "on the down-low" or as “bugarrones” in Spanish, have been cited as a primary reason for the increase in HIV infections in Hispanic women. In addition to being unaware of their partner’s risk of HIV, relationship and power dynamics of sexuality often acts as obstacles to prevention. For example, some women may not insist on condom use because they fear that their partner will physically abuse them or leave them or as a sign of the man’s faithfulness.[49] Finally, for many Latinas, the health of their family comes first and remains as the highest priority. Consequently, Latinas’ personal health often comes second to the family. This causes some Latinas to focus on HIV/AIDS only when infection directly affects their family.[50]

 

Latino/Hispanic Youth

In the U.S., the risk of contracting HIV and other sexually transmitted infections among youth and children is disproportionately higher among minority races/ethnicities. Hispanic/Latino adolescents in the U.S. face unique obstacles that help account for their disproportionately high rate of HIV infection. Hispanic/Latino teens aged 13-19 accounted for 19% of AIDS cases among U.S. teens in 2006 although they represented 17% of the U.S. teen population that same year.[51] This reality is especially alarming because in 2005, the proportion of Hispanic/Latino teens living with AIDS was 17%.[52] The margin is even greater for young adult Hispanics/Latinos aged 20-24. In 2006, Hispanic/Latino young adults ages 20-24 in the U.S. represented only 18% of the U.S. population, but accounted for 23% of AIDS cases.[53]   Latino youth aged 13-24 are at risk of contracting HIV for various behavioral and social factors, including inconsistent condom use, multiple sex partners, intravenous drug use, and the consumption of alcohol and other substances that impair judgment.[54] Although the HIV infection rates have declined for youth since the beginning of the epidemic, the rate of decline among Hispanics/Latinos has been slower than among non-Latino whites.[55]

Young Latinos living in the U.S. experience cultural factors and familial norms that act as barriers to HIV prevention. They are exposed to cultural stressors—discrimination, language barriers, and acculturation—that make them more vulnerable to maladaptive behaviors, which increase their likelihood of becoming infected with HIV.[56] [57] Another cultural factor attributing to higher rates of HIV infection amongst Latino youth is that sex, sexuality, and condom use are typically not openly discussed between parents and youth in traditional Hispanic/Latino families. [58] [59] Consequently, Latino adolescents are less comfortable and less successful in condom negotiation.[60] The lack of communication is concerning because studies show that communication between teens and their parents is associated with lower rates of sexual activity, less risky sexual behavior, and lower rates of teen pregnancy.[61]

 

Latinos/Hispanics in the Deep South

The new wave of Hispanic migration to the southern part of the U.S. is significant for various reasons, one of them being that the current public health infrastructure is unable to address the rapid population growth, including services related to HIV prevention. With a growth rate of 60.9 (per 100,000) in 2006, in states like Arkansas, 59.4 in Georgia, 57.4 in South Carolina, 55.5 in Tennessee and 54.9 in North Carolina,[62] states in the southern part of the country have not been able to address the rapidly growing population, especially because of the various characteristics that the wave of migration embodies. For example, high percentages of newly immigrated Latinos are undocumented residents. Additionally, the transient nature of the population and their avoidance of contact with official entities; creates problems in developing reliable and comparable prevalence and incidence statistics. However, the proportion of Latinos in the total HIV and AIDS diagnosis is rising steadily throughout the region. In North Carolina, Latinos comprise over 8 percent of new HIV cases and 10 percent of incident diagnoses in the Metro New Orleans health region. Service providers in the region consistently report an increase in the numbers of Latino clients they are seeing, and many are convinced that there is a ‘hidden epidemic’ in the region.

There are many barriers to better services for this population: lack of bilingual staff at agencies; fear and distrust of official institutions; lack of appropriate, sustained prevention education; low literacy and educational levels; high population transience; new restrictive laws limiting access to services for the undocumented; long working hours with few days off; substandard living conditions; and family separation.

 

Latinos, HIV/AIDS and Substance Use

From the onset of the HIV/AIDS epidemic, the use of any type of drug—regardless of whether a needle and/or syringe are involved, has put people at high risk for HIV infection. Alcohol use is associated with multiple risk factors for exposure to HIV infection, especially among youth, including risky sexual behaviors such as having multiple sexual partners and inconsistent condom use.[63] [64] According to a CDC study, users of non-injection drugs (such as some forms of crystal meth or cocaine, that is smoked) are three 3 times more likely to be infected with HIV than non-smokers [65] — risk also varies depending on drug use; for example, methamphetamine increases sexual desire and has been shown to lead to unsafe sex.[66] Drug use through injection and methods of drug delivery in general increases the risk for HIV transmission because of the tendency to engage in risky sexual behaviors while under the influence of a substance and the practice of sharing of needles or other injection equipment.[67]

Injection drug use (IDU) has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the U.S.[68] At the end of 2006, an estimated 353,825 male adults and adolescents were living with HIV/AIDS, 17% had been exposed through injection drug use and 7% had been exposed through both male-to-male sexual contact together with intravenous drug use.[69] A greater proportion of IDU-associated HIV/AIDS cases occur among adolescent and adult women.  A significant number of women diagnosed with HIV/AIDS in 2006 were infected through high risk heterosexual contact with a male who was infected with a history of intravenous drug use. The burden of IDU-associated HIV/AIDS is even greater for Latinas. Approximately 5,528 female adult or adolescent Latinas living with HIV/AIDS accounted for IDU-associated HIV/AIDS cases, representing 28% of Hispanic females living with HIV/AIDS at the end of 2006.[70] This statistic is alarming because the rate of IDU-associated transmission among Latinas climbed from the previous year’s rate—in 2005, Latina women represented 25% of the IDU reported HIV/AIDS cases.[71]

At the end of 2006 in 33 states with confidential name-based reporting, 14,427 male Hispanics living with HIV/AIDS became infected through injecting drugs with HIV contaminated needles, representing 23% of Hispanic males living with HIV/AIDS.[72] Latino males become HIV positive through IDU more often than other communities in the U.S.—IDU was the primary mode of transmission for 22% of African American males living with HIV/AIDS and 9% of non-Hispanic White males living with HIV/AIDS in the U.S.[73]

From 2003-2006, Latino/Hispanic males born in Puerto Rico that were living with HIV/AIDS, had the highest percentages of HIV infection through IDU among Hispanics/Latinos. During this period, 26% of Latinos born in Puerto Rico identified IDU as the transmission category, 12% were among Hispanics born in the U.S., 9% among those born in Mexico, and 8% were among those born in Central America.[74] The high rate of HIV transmission through IDU for Latinos born in Puerto Rico may be due to the fact that needle exchange programs and methadone treatment are used more often in the U.S. than in Puerto Rico; however HIV infections through IDU are the second highest among Latinos/Hispanics born in U.S.[75]

In the U.S., methamphetamine use is a significant problem among urban MSM. Until recently methamphetamine was perceived as a problem of the White MSM community and not for Latino MSM. However, recent studies show methamphetamine use among Latino gay men is similar to white gay men.[76] Approximately 72% of Latino gay men who use methamphetamine report at least one instance of unprotected anal intercourse within a period of 6 months.[77] This is the highest HIV risk rate ever reported for any Latino MSM group studied.[78]

 

Recommendations

There are a number of issues that need to be addressed in order to prevent the spread of HIV infection among Hispanics/Latinos. The alarming statistics on HIV/AIDS in the Latino MSM community indicate that current public health prevention efforts are not effectively reaching this unique population. There needs to be more support for the development of culturally relevant public health interventions for gay and bisexual Latino men that address the unique factors currently acting as obstacles to HIV/AIDS prevention efforts.

Despite the alarming trend among Hispanic methamphetamine users and their high risk for exposure to HIV, there are not nearly enough campaigns that are culturally appropriate for Hispanic methamphetamine users. There is a critical need for crystal meth prevention and treatment programs designed by Latinos rather than just translated programs designed for White non-Hispanic MSM.[79]

In the United States, women, particularly women of color, are at risk for HIV infection.

The female condom is the only female-initiated HIV prevention method presently available. These condoms can potentially help women to protect themselves from becoming infected with HIV if used correctly and consistently.[80] However, the female condom has the disadvantage of being relatively expensive—in fact, the average price in the U.S. is $2.50-$5.00, five to ten times the price of a male latex condom.[81] The majority of women with HIV were infected by unprotected sex with an infected man. Preventing transmission is the responsibility of both partners, and men must play an equal role in this. A new gender- and culturally- relevant intervention called “SISTA”, has been proven effective at increasing condom use with African American women. [81] Currently, a similar version of “SISTA” is being adapted for Latinas but has not yet been implemented and tested for its efficacy.

Finally, we should turn to families as an important tool in preventing the spread of HIV/AIDS. Families have a profound affect on an individual’s values, which shape the decisions that that individual makes about his/her sexual behavior and health. The frequency, quality, and topics of communication among couples, partners, and between parents and their children have been shown to predict teens’ sexual behavior.[83] Encouraging quality communication about sex, drugs, HIV, and other sexually transmitted diseases between families has the potential to promote safer sex practices and thus prevent the spread of HIV among Latinos/Hispanics. Overall, there needs to be a multifaceted approach to HIV/AIDS prevention for all Latinos, which includes individual, peer, familial, school, church, and community programs.[84]