E D I T O R I A L C O M M E N TA R Y
Latinos and HIV Care in the Southeastern United States: New Challenges Complicating Longstanding Problems Carlos del Rio Hubert Department of Global Health, Emory Center for AIDS Research, Rollins School of Public Health of Emory University, Atlanta, Georgia
(See the article by Dennis et al, on pages 480–487.)
''Of all the forms of inequality, injustice in health is the most shocking and inhuman.'' Martin Luther King Jr
In recent years, Hispanics/Latinos have become the largest immigrant group in the United States. Hispanics/Latinos represent the fastest growing minority group in the United States and have now surpassed 50 million, accounting for approximately 1 of 6 people living in the United States according to the most recent census data. The term ‘‘Latino or Hispanic’’ is applied to a very heterogeneous group from different countries and different cultures, and thus it is not possible to think of this population as a homogeneous group. Nevertheless, of the Hispanics living in the United States, almost 30 million are of Mexican origin. However, while Mexicans have been coming to the United States for centuries, the migration patterns have not remained the same. One relatively recent shift in Mexican immigration has been
Received 19 May 2011; accepted 24 May 2011. Correspondence: Carlos del Rio, MD, Department of Global Health, Emory University Rollins School of Public Health, 1518 Clifton Rd, Rm 754, Atlanta, GA 30322 (
[email protected]). Clinical Infectious Diseases 2011;53(5):488–489 Ó The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.
[email protected]. 1058-4838/2011/535-0014$14.00 DOI: 10.1093/cid/cir440
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the places where Mexican immigrants have settled. Whereas traditionally they tended to remain primarily in border states that formerly belonged to Mexico, such as California, Arizona, or Texas, more recently they have increasingly gone to other areas, such as the Midwest and the Southeast, in large part as a result of employment opportunities. As a result, between 1990 and 2000, the Mexican immigrant population in the Southern states grew more than 300% [1]. Hispanics/Latinos as a group tend to have less education and English language proficiency and frequently lack health insurance. At 41.5%, Hispanics are the demographic segment of the adult population in the United States most likely to be uninsured. Another salient feature of Mexican immigrants living in the United States is that approximately half are undocumented and thus further marginalized from the health care system. Of the approximately 46 million uninsured individuals in the United States, about 20% are undocumented and most are Hispanics. Thus, it should come as no surprise that Hispanics/Latinos experience substantial health disparities, because their access to medical care is suboptimal and, when ill, they commonly present late for medical care [2]. Contrary to popular belief, however, undocumented immigrants have lower rates of health
EDITORIAL COMMENTARY
care utilization than do native-born Americans and only seek medical care in the United States when an illness worsens or when they have a life-threatening medical emergency [3]. The existing disparities affecting the Hispanic/Latino population in the United States are also present in human immunodeficiency virus (HIV) infection. The Centers for Disease Control and Prevention estimates that the rate of HIV infection among Hispanics is 2.5 times that of whites and that Hispanics are more likely to be ‘‘late HIV testers’’ [4]. In general, it has been shown that HIV disease is diagnosed at a later stage in Hispanics/Latinos and that these patients have lower CD4 cell counts, higher HIV RNA levels, more AIDS-defining opportunistic infections, and longer hospital stays than whites [5, 6]. Latinos have also been shown to have significant delays in initiation of HIV care. Reasons for delay of care include lack of access to transportation, being too sick to go to the doctor, and having 1 or more competing needs on expenditures, such as rent and food costs. The article by Dennis et al in this issue of Clinical Infectious Diseases documents some of the challenges in providing care for HIV-infected Latinos in North Carolina, a state that has experienced a recent and rapid increase in the Latino population [7]. Their findings are
concerning but not all that dissimilar from those of prior studies. Although Latinos represented only 11% of their new patients entering care over a decade, they tended to enter care with more advanced HIV infection, including presenting with an AIDS-defining condition at diagnosis. Interestingly, in their cohort, late presentation was significant only for Latino men but not for women, likely because women receive a diagnosis at the time of pregnancy. The study did not document county of origin or immigration status of the patients, but it is safe to say that they were most likely Mexican and undocumented. Also, they do not tell us about the response to antiretroviral therapy among their patients, but it was likely good. Data suggest that the clinical progression of HIV disease in Latinos is similar to that in whites once the ‘‘playing field is leveled,’’ that is, once medical care is initiated and health care access is not a factor. In fact, they may even do better. In a recent study from Texas by Poon et al, undocumented Hispanics were diagnosed with more advanced HIV disease but once diagnosed and in care, they were more likely than other populations to be retained in care, with undetectable viral loads and with a significant increase in CD4 count [8]. How then should we address this challenge? The authors conclude that comprehensive public health programs focusing on early HIV testing and further studies to understand the barriers to use of public health resources by Latinos are needed. While I do not disagree with them, I think that the interventions necessary go well beyond public health and are both political and cultural. Illegal immigration and health care are the intersection of 2 broken systems, and unfortunately politicians have chosen to turn a blind eye on the public health consequences of further restricting access to health care for undocumented immigrants [9]. For example, in the southeast many states have recently
passed legislation that substantially limits undocumented immigrants’ access to medical care. Even the recently passed Affordable Care Act (ACA), while attempting to insure many who currently lack health insurance in the United States, specifically excludes undocumented immigrants. Thus, ACA will only increase the marginalization and discrimination against undocumented immigrants, further limiting their willingness to engage with the health care system before they develop symptoms that are severe enough to require medical care. As a result, undocumented Hispanic/Latino immigrants are likely to continue delaying or even forgoing medical care. Such an unequal system is not only unjust but also poor public health policy. Confronting an infectious disease like HIV infection requires sound public policies that do not restrict access to health care and prevention services on the basis of immigration status. A change in cultural norms will also be necessary. In the Hispanic community, where ‘‘machismo’’ is deeply rooted, there continues to be enormous stigma and discrimination around homosexuality, which limits prevention interventions, including acceptance of HIV testing. Finally, we must not forget that Latin America in general and Mexico in particular is our southern neighbor with a common border of nearly 2000 miles and that we share not only goods and services but also people and diseases. For this reason, investment in improving health in the Latin American region should be seen as a public health priority for the United States. In a difficult economic environment like the one in which we are now living, political leadership will be required to clearly articulate why it remains critically important to invest in global programs to control pandemic infectious diseases, such as HIV and tuberculosis. However, as the recent Institute of Medicine report entitled ‘‘The U.S. Commitment to Global
Health: Recommendations for Public and Private Sectors’’ makes it clear, improving health globally has enormous benefits locally [10]. Acknowledgments Potential conflicts of interest. The author reported no conflicts. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed in the Acknowledgments section.
References 1. Kochhar R, Suro R, Tafoya S. The New Latino South: the context and consequences of rapid population growth. Washington, DC: Pew Hispanic Center, 2005. 2. Todd Callahan S, Hickson GB, Cooper WO. Health care access of Hispanic young adults in the United States. J Adolesc Health 2006; 39:627–33. 3. Mohanty SA, Woolhandler S, Himmelstein DU, Pati S, Carrasquillo O, Bor DH. Health care expenditures of immigrants in the United States: a national representative analysis. Am J Publ Health 2005; 95:1431–8. 4. Centers for Disease Control and Prevention. Estimated lifetime risk for diagnosis of HIV infection among Hispanics/Latinos—37 states and Puerto Rico, 2007. MMWR Morb Mortal Wkly Rep 2010; 59:1297–301. 5. Swindells S, Cobos DG, Lee N, et al. Racial/ ethnic differences in CD4 T cell count and viral load at presentation for medical care and in follow-up after HIV-1 infection. AIDS 2002; 16:1832–4. 6. Menke TJ, Giordano TP, Rabeneck L. Utilization of health care resources by HIV-infected white, African American, and Hispanic men in the era before highly active antiretroviral therapy. J Natl Med Assoc 2003; 95:853–61. 7. Dennis AM, Napravnik S, Sena A, Eron JJ. Late entry to HIV care among Latinos compared to non-Latinos in a Southeastern US cohort. Clin Infect Dis 2011; 53:485–492. 8. Poon KK, Hartman C, Davila JA, Giordano T. Healthcare disparities: how does race and legal residency affect outcomes in HIV/AIDS? Presented at the 48th Annual Meeting of the Infectious Diseases Society of America. Oct 21–24, 2010; Vancouver, BC, Canada; 2010; Abstract 1127. 9. Okie C. Immigrants and health care—at the intersection of two broken systems. New Engl J Med 2007; 357:525–9. 10. Institute of Medicine. The U.S. Commitment to Global Health: recommendations for the public and private sectors. Washington, DC: National Academy Press, 2009.
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