octavio j. vallejo, md, mph aids project los angeles · octavio j. vallejo, md, mph aids project...

Octavio J. Vallejo, MD, MPHAIDS Project Los Angeles

Date: May 24th 2013

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

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

The Latino community is the fastest growing population in the U.S. and the group with the second-highest risk for HIV/AIDS1

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. The Henry J. Kaiser Family Foundation HIV/AIDS Policy Fact Sheet. Latinos and HIV March 20132. Source: American FactFinder: United States DP-1 <http://factfinder2.census.gov> and

<http://www.census.gov/prod/cen2010/briefs/c2010br-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/cb08-123.html>

8

Population in millions

Hispanic Population in the United States: 1970 to 2050

*Projected Population as of July 1

ProjectionsCensus

Source: U.S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050

9

Percent Hispanic of the Total Population in the United States: 1970 to 2050

*Projected Population as of July 1

ProjectionsCensus

Source: U.S. Census Bureau, 1970, 1980, 1990, and 2000Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050

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.

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

Data Source: U.S. Department of Commerce, 2010; Los Angeles County Department of Public Health, HIV Surveillance, 2011

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

1. Centers for Disease Control and Prevention, HIV/AIDS Surveillance Report, June 20022. Centers for Disease Control and Prevention: Late versus early testing of HIV – 16 sites, United States. 2000-2003. MMWR 2003, 52:581-5863. 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

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

Gender inequity

Machismo

Homophobia

Drug or alcohol abuse

Stigma associated to the disease

Traditional gender roles

• Predetermined roles and family pressures1

•Infidelity as part of the male social role and passive acceptance by female partners2

•Stigma3

•Gender Inequity4

•Domestic Violence1

•Machismo/homophobia1

1. Galanti. J Transcult Nurs.2003;14:180-185. 2. Hirsch JS. Am J Public Health. 2002;92:1227-1237. 3. Marin BV. J Transcult Nurs. 2003;14:186-192. 4. Murphy DA, et al. AIDS Care. 2003;15:217-230.

Poster: YWCA/WINGS Shelter services for victims of domestic violence

1. CDC. Supplement to HIV/AIDS Surveillance HIV/AIDS Surveillance Report. 2002.14:1-48.

Art work: Prof. Antonio Salazar, National School of Fine Arts UNAM Mexico 1990

Low self-esteem

Depression

Use of drugs

Denial

For many the process of acceptance of being homosexual is more difficult than being HIV positive.

Consequences of Homophobia and Latino MSMs 1

Picture: Courtesy IMPACTO LATINO/AIDS Project Los Angeles 2005

HOMOPHOBIA

HIGH RISK OF HIV

INFECTION

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

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. 11th 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

A person who is stigmatized “is reduced in our minds from a whole and usual person to a tainted, discounted one.” 1

•PERSON AFFECTED IS SEEN AS RESPONSIBLE FOR HAVING THE ILLNESS

•DISEASE PROGRESIVE AND & INCURABLE

•DISEASE NOT WELL UNDERSTOOD

•SYMPTOMS CAN NOT BEEN CONCEALED

1. Erving Goofman/ Stigma: Notes on the Management of Spoiled Identity (1963)Photography courtesy of IMPACTO LATINO. AIDS Project Los Angeles.

• 19% HIV-positive

• 912 men recruited in 35 Latino gay bars

New York: n = 309Miami: n = 302Los Angeles: n = 301

• 50% under age 30

• 82% self-identified as gay or homosexual

• 55% some college or more

• 27% unemployed

• 73% immigrant (including from Puerto Rico)

• 41% mostly Spanish-speaking (with friends)


Made fun of as a child

Violence as a child

Made fun of as an adult

Police harassment

Violence as an adult

As a child heard gays grow old alone

Had to move away from family

Job discrimination

Have had to pretend to be straight

As a child felt their gayness hurt family

As a child heard gays not normal 91% (89-94)

70% (66-75)

64% (59-69)

15% (12-18)

20% (17-24)

29% (25-33)71% (67-75)

10% (7-12)

50% (45-54)

18% (15-21)

64% (60-68)


Blacks and Hispanics are approximately 3 times more likely to live in poverty than whites1

Blacks and Hispanics less likely to have health insurance, compared with whites2

1. DeNavas-Walt. US Census Bureau. Income, Poverty, and Health Insurance. 2008. 2. Thomas M et al. Health Coverage for Communities of Color, Kaiser Foundation, 2009.

Insurance Coverage of Nonelderly, by Race/Ethnicity, 20082

Latinos and HIVAccess 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)

Delayed presentation, which is common among Latino patients1, results in •Disproportionately high number with

AIDS2

•High baseline viral load•Impaired immune status3

•Increased morbidity, hospitalization for OIs

•Increased mortality1. Suplemental HIV Surveillance Study Project. Los Angeles County, Department of Heatlh Services, January 20002. Turner et al, Delayed Medical Care After Diagnosis of Persons Infected with HIV. Arch of Int Med 16, 20003. Swindells S. AIDS. 2002;16:1832-1834.

There are 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

1. Lowell, BL How many undocumented: the numbers behind the US-Mexico migration talks. Report by the Pew Hispanic Center March 2002

2. 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

3. 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

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

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



vulnerability among Latinos Issues related to access to HIV care Immigration and HIV Health care reform and Latinos….

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

SummaryLatinos 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

octavio j. vallejo, md, mph aids project los angeles · octavio j. vallejo, md, mph aids project...

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