J Immigrant Minority Health (2014) 16:798–810 DOI 10.1007/s10903-013-9811-y
ORIGINAL PAPER
HIV Testing Histories and Risk Factors Among Migrants and Recent Immigrants Who Received Rapid HIV Testing from Three Community-Based Organizations Jeffrey D. Schulden • Thomas M. Painter • Binwei Song • Eduardo Valverde • Mary Ann Borman • Kyle Monroe-Spencer • Greg Bautista • Hassan Saleheen Andrew C. Voetsch • James D. Heffelfinger
•
Published online: 20 March 2013 Ó Springer Science+Business Media New York (Outside the USA) 2013
Abstract Migrants and recent immigrants in the US constitute a large population that is vulnerable to HIV. From March 2005 to February 2007, three community-based organizations conducted rapid HIV testing among migrants in five states. Participants were asked to complete a survey on sociodemographics, HIV-risk behaviors, and HIV-testing histories with the aim of understanding factors associated with HIV testing. Among 5,247 persons tested, 6 (0.1 %) were HIV-positive. Among 3,135 persons who completed surveys, more than half had never been tested for HIV previously (59 %). Participants reported high levels of HIV-risk behaviors in the past year, including 2 or more sex partners (45 %), sex while high/drunk (30 %), and transactional sex
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the National Institute on Drug Abuse, the Centers for Disease Control and Prevention, or any of the sponsoring organizations, agencies, or the US government. J. D. Schulden (&) National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), 6001 Executive Blvd, MSC 9589, Bethesda, MD 20892, USA e-mail:
[email protected] T. M. Painter B. Song E. Valverde A. C. Voetsch J. D. Heffelfinger National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA M. A. Borman United Migrant Opportunity Services, Milwaukee, WI, USA K. Monroe-Spencer G. Bautista AIDGwinnett, Lawrenceville, GA, USA H. Saleheen Connecticut Children’s Medical Center, Hartford, CT, USA
123
(29 %). Multivariate analysis identified several factors independently associated with decreased likelihood of prior HIV testing, including poor spoken English. Continued efforts are needed to ensure that migrant populations have improved access to HIV testing and prevention services. Understanding factors associated with migrants’ lack of previous HIV testing may help focus these efforts. Keywords HIV STD Migrants Immigrants Rapid HIV testing HIV prevention
Introduction The terms ‘migrant’ and ‘immigrant’ refer broadly to persons who travel from their country of origin to another country. They leave their country of origin for a wide range of reasons, including but not limited to the search for improved economic opportunities, educational opportunities, and freedom from political oppression or conflict. ‘Migrants’ can sometimes refer broadly to persons who travel periodically to the another country for work, but who may aim to eventually return to their countries of origin, and who may reside in the other country without legal documentation [1–3]. These temporary ‘migrants’ may ultimately choose to stay permanently in the host country for any number of reasons, such as marriage to a citizen of the host country, and may eventually obtain legal residency status. ‘Immigrants’ can sometimes be used to refer to persons who come to another country with the intention of settling permanently and who may or may not have legal immigration status [1–3]. The terms migrants and immigrants are sometimes used interchangeably, and we will generally use the term migrants to refer to both migrants and immigrants throughout this paper. Migrants around the world are subject
J Immigrant Minority Health (2014) 16:798–810
to a unique and complex range of factors that may affect their risk for HIV compared with native-born persons. This paper describes a demonstration project that took place in the United States and will focus on the unique issues faced by migrant communities in the United States with regard to HIV risk and HIV testing. Migrants may constitute a large population in the United States. Although there are no data on the actual numbers of migrants specifically, a 2009 report estimated that there were approximately 11 million foreignborn, undocumented persons living in the US [4, 5]. Multiple prior studies have found high rates of HIV risk behaviors among migrant communities in the US [6–10]. A study among 442 male Latino migrants in North Carolina found that 28 % had reported visiting a commercial sex worker in the past year [10]. A study of 180 male Latino migrants in Louisiana found that 52 % reported having paid for sex in the past month; 11 % of participants reported having had sex with another man in the past month [7]. Among participants in this study who had engaged in high-risk sex in the past month, over half reported inconsistent condom use [7]. Studies that have focused on migrant women have suggested overall low prevalence of individual HIV risk behaviors by the women, but high levels of sexual concurrency by their primary male partner [11–13]. These studies have suggested that the principal HIV risk factor for these migrant women is often unprotected sex with their spouse [11–14]. Research has suggested a wide range of factors that can contribute to migrants’ vulnerability to HIV and other sexually transmitted diseases (STDs). These factors include sexual risk behaviors, mobility, poverty, geographic and social isolation, being in the United States without required documentation, and inadequate access to HIV/STD prevention and other health-related services [2, 6–10, 15–20]. Some studies have suggested that foreign-born persons in the US who contract HIV are more likely to have heterosexual contact as their primary risk factor, compared to US-born populations where male-to-male sex and injection drug use are more commonly reported [21, 22]. Despite these studies suggesting high rates of HIV risk behaviors, there are limited data on HIV prevalence among migrant communities. Several recent studies of migrants in border areas have reported no to low levels of HIV infection [23–28]. Among a sample of 210 migrant and seasonal farm workers in southwest Texas with high rates of HIV risk behaviors, one individual (0.5 %) tested HIV-positive [28]. In another recent study, among a sample of 1,041 migrants who were tested for HIV at the California border, none tested positive for HIV [24]. Among a sample of 173 migrant and seasonal farm workers in California, no participants tested HIV-positive despite high rates of reported risk behaviors [27]. Given the high rates of risk behaviors and the range of contextual factors that heighten the
799
vulnerability of migrants to HIV, the low levels of HIV infection that have been observed thus far represent an important opportunity to educate and intervene before HIV infection takes hold further among migrant communities. In addition, despite the large number of migrants in this country and the range of circumstances and behaviors that can increase their risks for HIV/STD infection, there is currently no on-going surveillance-based information on HIV/STD prevalence or the associated risk behaviors that affect these populations. Given their mobility and poor access to health services, they can be difficult to reach using clinic-based approaches for screening for HIV/STDs. Further, while relatively little is known about HIV/STD testing patterns among migrant populations, available information suggests that they are tested infrequently and that the testing conducted is often prompted by clinical manifestations of AIDS [29–34]. Better information is needed on the factors that facilitate or impede migrants’ access to and use of HIV/STD testing, prevention, and care services. With the aim of reducing barriers to early HIV diagnosis and increasing participation in HIV-related services by racial/ethnic minorities and hard-to-reach populations such as migrants, the Centers for Disease Control and Prevention (CDC) announced the Advancing HIV Prevention (AHP) initiative in 2003 [35]. A key strategy of this initiative was to use new approaches to diagnose HIV infections outside of clinical settings. One of several AHP projects that addressed these barriers funded three community-based organizations (CBOs) to conduct rapid HIV testing among migrants [36]. Participants in this project were asked to complete a survey on sociodemographics, HIV-risk behaviors, and HIV-testing histories with the aim of understanding factors associated with HIV testing. This report describes the findings from this demonstration project.
Methods Project Sites The three CBOs conducted rapid HIV testing from March 2005 to February 2007: AIDGwinnett (AGI), based in Lawrenceville, Georgia; the Hispanic Health Council (HHC), based in Hartford, Connecticut; and United Migrant Opportunity Services (UMOS), based in Milwaukee, Wisconsin. AGI, founded in 1990, provides HIV prevention, testing, and supportive services to diverse populations, primarily in three metropolitan Atlanta counties [37]. However, prior to this project, AGI’s programs had not focused on the growing numbers of largely Mexican migrants in the areas it serves. HHC, founded in 1978, provides social and health services, including HIV
123
800
prevention, to the Puerto Rican community and the growing number of Latin Americans, particularly Mexicans, who live and work in the Connecticut River Valley [38]. UMOS, founded in 1965, serves primarily Mexican and other Latino migrant communities in Wisconsin, Minnesota, and South Dakota, providing a range of services, including classes in English as a second language, job training, child care services, housing assistance, and health promotion [39]. More recently, UMOS has developed outreach programs for African migrants, many of whom have come to the Midwest from east Africa through refugee resettlement programs. Since 1988, UMOS has offered extensive HIV prevention education and interventions to primarily Mexican and Puerto Rican urban communities in Wisconsin and to rural migrant farm workers in an eleven state area. Prior to this project, however, UMOS’ experience with offering HIV testing, including rapid HIV testing, to Latino or Africanborn migrants, was limited to three urban counties in Wisconsin. Rapid HIV Testing The three CBOs offered rapid HIV testing on an opt-in basis to any individuals who were at least 13 years old, stated that they had no previous diagnosis of HIV infection, and provided informed consent. Trained Spanish–English bilingual CBO staff provided testing and counseling. All persons who accepted testing were given risk-reduction counseling and were tested with rapid HIV test kits (OraQuickÒ AdvanceTM Rapid HIV-1/2 Antibody Tests [OraSure Technologies, Bethlehem, Pennsylvania] [40]) using oral fluid or fingerstick whole blood specimens. Individuals with reactive rapid test results were asked to provide an oral specimen for confirmatory testing by Western blot (OraSureÒ Oral Specimen Collection Device [OraSure Technologies, Bethlehem, Pennsylvania] [41]). Individuals who reported a prior HIV diagnosis were not offered HIV testing, but were offered assistance with referrals and linkages to HIV care services. Recruitment Strategies The CBOs used various strategies to implement their rapid testing activities. AGI conducted outreach at migrants’ workplaces, including poultry and meat processing plants; local businesses, such as hair salons and markets that serve migrants; and community events, including soccer matches and health fairs. AGI offered HIV counseling and rapid testing during routine health screenings that also included measuring participants’ blood pressure and blood glucose levels. Participants could choose to receive one or more of these tests. AGI also partnered with local primary care sites, community and perinatal clinics, and alcohol and drug treatment centers, training their staff to offer rapid HIV
123
J Immigrant Minority Health (2014) 16:798–810
testing on an opt-in basis as part of their services. HHC conducted HIV outreach testing to migrants at farms, nurseries, and other agricultural sites and at community gathering spots, such as markets, sporting events, health fairs, and bars. HHC also offered HIV counseling and testing in partnership with a University of Connecticut School of Medicine mobile clinical unit that provides medical services at agricultural work sites. UMOS utilized a promotores de salud model in which lay health workers from migrant communities were trained to provide HIV counseling and testing to other migrants at their worksites, including farms, meat processing plants, and canning facilities. UMOS also offered opt-in HIV testing as a routine part of other services provided, such as job training and classes in English as a second language. Survey and Data Analysis All persons who accepted HIV testing were asked to complete an approximately 20-min survey that collected information on sociodemographic characteristics, HIV/STD risk factors, and HIV testing and immigration histories. Outreach testing staff administered the surveys using paper forms during face-to-face interviews prior to delivering HIV test results. CBO staff entered the survey data into a QDSTM (Questionnaire Development System, Nova Research Co., Bethesda, MD) database [42]. Data was not collected that would have enabled a comparison of persons who accepted and refused HIV testing or of those who were tested but did not complete a survey. Survey data were analyzed using SAS version 9.1 [43]. Factors that were significantly associated (p \ 0.05) with prior HIV testing in bivariate analyses were introduced into a multivariate logistic regression model, and forward stepwise procedures were used to determine which variables remained in the final model as independently associated variables (p \ 0.05). Separate multivariate models were used for male and female participants because of substantial differences in their selfreported risk behaviors. The CBO rapid HIV testing project was determined by CDC to be a public health program activity rather than research, and approval by CDC and local Institutional Review Boards was not required. Participants A total of 5,247 persons were tested and 3,135 also completed surveys. Of those who were tested, 6 (0.1 %) were HIV-positive: 5 men and 1 woman. Of the five infected individuals who provided information on country of birth, two were born in Mexico, two in Honduras, and one in Guatemala. All persons with confirmed HIV diagnoses returned for their confirmatory test results and were provided additional risk-reduction counseling, referrals to partner services, and assistance with linkages to HIV care.
J Immigrant Minority Health (2014) 16:798–810
Among the 3,135 persons who completed a survey, 2,778 (89 %) reported that they were born outside the 50 US states and the District of Columbia. All results described below on participants’ sociodemographic characteristics, HIV risk behaviors, immigration, and HIV testing histories are based on responses from these 2,778 migrants (Fig. 1).
Results Sociodemographic Characteristics Most (93 %) of these 2,778 migrants were Latino, 5 % were black, and 1 % were white (Table 1); the median age was 29 years; 60 % were male. Most (70 %) were born in Mexico; the remainder were born in other Latin American (18 %), African (5 %) or Caribbean (1 %) countries, or Puerto Rico (5 %). Most had not completed secondary school education—i.e., the equivalent of 12 years of primary and secondary education (70 %); did not speak English well or at all (78 %); and did not have health insurance (77 %). Nearly 80 % self-identified as heterosexual, while approximately 4 and 3 % self-identified as homosexual and bisexual, respectively. Approximately 30 % reported working in construction; 14 % in meat,
5247 persons received rapid HIV testing.
3135 persons who received an HIV test also completed a survey.
2112 persons who received an HIV test did not complete a survey.
2778 persons who completed a survey were born outside the 50 U.S states and the District of Columbia. (Included in analyses for this paper.)
357 persons who completed a survey were born within the 50 U.S. states or the District of Columbia. (Not included in analyses.)
Fig. 1 Flow diagram of participants in this rapid HIV testing project. Note that only the 2,778 persons who were tested, completed a survey, and were born outside the 50 US states and the District of Columbia are included in the analyses presented in the results section of this paper
801
poultry, and fish processing; 15 % in restaurants and fast food services; 13 % in agriculture, farming, or landscaping; and 8 % in manufacturing or industry. The sociodemographic characteristics of these participants differed substantially by CBO (Table 1). Most AGI (76 %) and UMOS (67 %) participants were born in Mexico; most HHC (64 %) participants were born in Puerto Rico. Approximately 21 % of UMOS participants and B0.1 % of AGI and HHC participants were born in Africa. A greater proportion of AGI (52 %) than UMOS (27 %) or HHC (18 %) participants were married or partnered. Although most participants had not completed their secondary school education, this was more often true for AGI (76 %) and UMOS participants (65 %) than for HHC participants (34 %). Likewise, a greater proportion of AGI (85 %) than UMOS (64 %) or HHC (51 %) participants spoke English poorly or not at all. Approximately 90 % of AGI participants had no health insurance, compared with 52 % of UMOS and 28 % of HHC participants. Immigration History Forty-two percent of participants had been in the United States for less than 5 years; a greater proportion of UMOS participants than either AGI or HHC participants had been in the United States for less than 5 years (Table 1). Approximately 41 % had changed residence for work at least once during the past 2 years; however AGI participants were less mobile than those from UMOS and HHC. Most participants (63 %) considered their country of birth as their primary home and intended to return there to live; however UMOS participants, some of whom were resettled refugees, were least likely to report an intention to return to their country of birth. HIV/STD Risk Behaviors For men and women combined, HIV/STD risk factors reported for the past year included having 2 or more sex partners (45 %), sex while high on drugs or drunk (30 %), giving or receiving goods or money for sex (29 %), unprotected receptive anal intercourse (10 %), and having an STD diagnosis (6 %) (Table 2). Men were nearly three times as likely as women to report sex with two or more partners and sex while high or drunk. Among males, 22 % reported male-to-male sex and 9 % reported receptive anal sex without a condom; 43 % of females reported unprotected vaginal sex. Approximately 39 % of males reported having given money or goods for sex; 5 % of females reported receiving money or goods in exchange for sex. Of those men who reported sex with sex workers during the past year, 66 % reported using condoms only sometimes or not at all when engaging in exchange sex; of those women
123
802
J Immigrant Minority Health (2014) 16:798–810
Table 1 Characteristics of migrants who were administered surveys and rapid HIV tests by three community-based organizations, March 2005– February 2007 All sites combined No. (%) Total
2,778
AIDGwinnett No. (%) 1,940
Hispanic Health Council No. (%) 174
United Migrant Opportunity Svcs No. (%) 664
Gender Male
1,673 (60.2)
1,193 (61.5)
121 (69.5)
359 (54.1)
Female
1,061 (38.2)
745 (38.4)
53 (30.5)
263 (39.6)
2 (0.1)
0 (0.0)
42 (6.3)
Other, unknown, or refused
44 (1.6)
Age 13–19 years
177 (6.4)
90 (4.6)
9 (5.2)
78 (11.7)
20–29 years
1,176 (42.3)
850 (43.8)
50 (28.7)
276 (41.6)
30–39 years
828 (29.8)
630 (32.5)
48 (27.6)
150 (22.6)
C40 years
511 (18.4)
339 (17.5)
67 (38.5)
105 (15.8)
86 (3.1)
31 (1.6)
0 (0.0)
55 (8.3)
Unknown or refused Race/ethnicity Hispanic Black, non-Hispanic White, non-Hispanic
2,576 (92.7) 137 (4.9) 13 (0.5)
1,904 (98.1)
172 (98.9)
500 (75.3)
1 (0.1) 7 (0.4)
2 (1.1) 0 (0.0)
134 (20.2) 6 (0.9)
Other race/ethnicity
6 (0.2)
5 (0.3)
0 (0.0)
1 (0.2)
Unknown or refused
46 (1.7)
23 (1.2)
0 (0.0)
23 (3.5)
Educationa Less than secondary school education
1,957 (70.4)
1,465 (75.5)
59 (33.9)
433 (65.2)
Completed secondary school education or equivalent
409 (14.7)
274 (14.1)
33 (19.0)
102 (15.4)
Some college/university-level education or college/university graduate
229 (8.2)
130 (6.7)
25 (14.4)
74 (11.1)
Unknown or refused
183 (6.6)
71 (3.7)
57 (32.8)
55 (8.3)
Married/partnered Yes
1,210 (43.6)
1,002 (51.6)
31 (17.8)
177 (26.7)
No Unknown or refused
1,377 (49.6) 191 (6.9)
863 (44.5) 75 (3.9)
122 (70.1) 21 (12.1)
392 (59.0) 95 (14.3)
Health insurance Insured Not insured Unknown or refused
375 (13.5) 2,127 (76.6) 276 (9.9)
139 (7.2)
87 (50.0)
149 (22.4)
1,736 (89.5)
49 (28.2)
342 (51.5)
38 (21.8)
173 (26.1)
65 (3.4)
Birthplace Mexico
38 (21.8)
442 (66.6)
125 (4.5)
6 (0.3)
112 (64.4)
7 (1.1)
39 (1.4)
26 (1.3)
8 (4.6)
5 (0.8)
Other Central America
364 (13.1)
313 (16.1)
8 (4.6)
43 (6.5)
South America
149 (5.4)
115 (5.9)
8 (4.6)
26 (3.9)
Africa
138 (5.0)
1 (0.1)
0 (0.0)
137 (20.6)
Other
12 (0.4)
8 (0.4)
0 (0.0)
4 (0.6)
53 (2.7)
Puerto Rico Other Caribbean
1,951 (70.2)
1,471 (75.8)
Years since U.S. immigration \1 year ago
28 (16.1)
54 (8.1)
C1 to \5 years ago C5 years ago
1,028 (37.0) 1,366 (49.2)
742 (38.2) 1,004 (51.8)
31 (17.8) 84 (48.3)
255 (38.4) 278 (41.9)
Unknown or refused
249 (9.0)
141 (7.3)
31 (17.8)
77 (11.6)
123
135 (4.9)
J Immigrant Minority Health (2014) 16:798–810
803
Table 1 continued All sites combined No. (%)
AIDGwinnett No. (%)
Hispanic Health Council No. (%)
United Migrant Opportunity Svcs No. (%)
Moved or migrated for work during the past 2 years Yes
1,126 (40.5)
681 (35.1)
82 (47.1)
363 (54.7)
No
1,515 (54.5)
1,183 (61.0)
60 (34.5)
272 (41.0)
76 (3.9)
32 (18.4)
29 (4.4)
Unknown or refused Fluency with spoken English
137 (4.9)
Very well
179 (6.4)
86 (4.4)
25 (14.4)
68 (10.2)
Well
326 (11.7)
139 (7.2)
36 (20.7)
151 (22.7)
Not well
960 (34.6)
607 (31.3)
38 (21.8)
315 (47.4)
1,205 (43.4)
1,047 (54.0)
51 (29.3)
107 (16.1)
24 (13.8)
23 (3.5)
Not at all Unknown or refused
108 (3.9)
61 (3.1)
Percentages might not add to 100 % due to rounding a
Education categories: Completion of secondary school education would represent the completion of 12 years of primary and secondary school education. Some college/university-level education would represent any post-secondary (or tertiary) level of education, beyond the 12 years of primary and secondary school education
who received goods or money for sex during the past year, 71 % reported using condoms only sometimes or not at all when engaging in exchange sex. Participants’ self-reported HIV/STD risk factors varied considerably by CBO (Table 2). A greater proportion of all HHC than either AGI or UMOS participants reported injection drug use, sharing injection drug needles, an STD diagnosis during the past year, and having had a previous HIV test. A greater proportion of all HHC than either AGI or UMOS participants also reported sex with injection drug users and sex with HIV-positive persons during the past year. Among females, many more AGI participants than those at either of the other CBOs reported vaginal sex without a condom during the past year. A smaller proportion of all AGI participants than those from either of the other CBOs reported sex with persons of unknown HIV serostatus or anonymous sex. Compared to other CBO participants, a greater proportion of UMOS male participants reported having had sex while high on drugs or drunk and a greater proportion of female UMOS participants reported receiving money or goods for sex and anonymous sex.
self-identifying as homosexual versus heterosexual, reporting sex with a person of unknown HIV status, and having been diagnosed with an STD during the past year were associated with increased likelihood of prior HIV testing. In addition, having given money or goods for sex during the past year was associated with decreased likelihood of prior HIV testing among men. Among men, younger age (13–19 years and 20–29 years) was associated with decreased likelihood of prior testing when compared with men age C40 years. Among women, increased likelihood of prior HIV testing was associated with having been born in Puerto Rico, another Caribbean country, or an African country versus a Latin American country. In addition, considering one’s country of birth to be one’s primary home was independently associated with decreased likelihood of prior HIV testing among women. Among women, younger age (13–19 years) was associated with decreased likelihood of prior testing, whereas being 20–29 or 30–39 years old was associated with increased likelihood of prior testing, when compared with women age C40 years. Among both men and women, prior HIV testing was not independently associated with the CBO that performed the testing.
Factors Associated with Previous HIV Testing Fifty-nine percent of participants (66 % of male and 48 % of female) had never been tested for HIV. On multivariate analysis, several factors were identified as independently associated with prior HIV testing among participants. For both men and women, poor spoken English proficiency was associated with decreased likelihood of prior HIV testing (Table 3). Among men, having been born in Puerto Rico or an African country versus a Latin American country,
Discussion The three CBOs delivered rapid HIV testing to large numbers of migrants in a range of nonclinical settings. Overall, the frequency of self-reported HIV/STD risk behaviors was relatively high, while HIV infection rates were low. Our findings concerning the prevalence of risk factors are similar to those from studies of migrants
123
804
J Immigrant Minority Health (2014) 16:798–810
Table 2 HIV risk behaviors of male/female migrants who were administered surveys and rapid HIV tests by three community-based organizations, March 2005–February 2007 All sites combined
AIDGwinnett
No. (%)
No. (%)
Hispanic Health Council No. (%)
United Migrant Opportunity Svcs No. (%)
1,193
121
359 23 (6.4)
Male Total
1,673
Sexual risk behaviors in past yeara Sex with an injection drug user
61 (3.6)
12 (1.0)
26 (21.5)
Sex with person with HIV
29 (1.7)
9 (0.8)
9 (7.4)
11 (3.1)
Sex with person of unknown HIV status
528 (31.6)
189 (15.8)
70 (57.9)
269 (74.9)
Sex while high or drunk
684 (40.9)
454 (38.1)
39 (32.2)
191 (53.2)
Anonymous sex
374 (22.4)
233 (19.5)
32 (26.4)
109 (30.4)
Male-male sex
364 (21.8)
275 (23.1)
15 (12.4)
74 (20.6)
Receptive anal sex without a condom
157 (9.4)
105 (8.8)
8 (6.6)
44 (12.3)
Given money or goods for sex
657 (39.3)
475 (39.8)
39 (32.2)
143 (39.8)
60 (3.6)
23 (1.9)
9 (7.4)
28 (7.8)
108 (6.5)
71 (6.0)
26 (21.5)
11 (3.1)
Received money or goods for sex Diagnosed with a sexually transmitted disease Number of sexual partners (vaginal or anal), past year 0 partners
53 (3.2)
31 (2.6)
12 (9.9)
10 (2.8)
1 partner
489 (29.2)
365 (30.6)
33 (27.3)
91 (25.3)
2–5 partners
515 (30.8)
301 (25.2)
36 (29.8)
178 (49.6)
6–10 partners
313 (18.7)
247 (20.7)
15 (12.4)
51 (14.2)
[10 partners
152 (9.1)
137 (11.5)
5 (4.1)
10 (2.8)
Unknown or refused
151 (9.0)
112 (9.4)
20 (16.5)
19 (5.3)
Injection of street drugs
50 (3.0)
9 (0.8)
27 (22.3)
14 (3.9)
Injection of vitamins outside the care of clinical setting
43 (2.6)
36 (3.0)
1 (0.8)
6 (1.7)
Injection of antibiotics outside the care of clinical setting
34 (2.0)
28 (2.3)
0 (0.0)
6 (1.7)
Shared needles
19 (1.1)
0 (0.0)
16 (13.2)
3 (0.8)
1,096 (65.5)
910 (76.3)
32 (26.4)
154 (42.9)
Tested less than a year ago
214 (12.8)
125 (10.5)
34 (28.1)
55 (15.3)
Tested more than a year ago Unknown or refused
170 (10.2) 193 (11.5)
69 (5.8) 89 (7.5)
32 (26.4) 23 (19.0)
69 (19.2) 81 (22.6)
Injection risk behaviors in the past yeara
HIV testing history Never previously tested
Female Total
1,061
745
53
263 33 (12.5)
Sexual risk behaviors in past yeara Sex with an injection drug user
52 (4.9)
10 (1.3)
9 (17.0)
6 (0.6)
0 (0.0)
1 (1.9)
5 (1.9)
Sex with person of unknown HIV status
263 (24.8)
55 (7.4)
36 (67.9)
172 (65.4)
Sex while high or drunk
147 (13.9)
34 (4.6)
16 (30.2)
97 (36.9)
71 (6.7)
18 (2.4)
5 (9.4)
48 (18.3)
Receptive anal sex without a condom
122 (11.5)
74 (9.9)
7 (13.2)
41 (15.6)
Vaginal sex without a condom
Sex with person with HIV
Anonymous sex
460 (43.4)
389 (52.2)
0 (0.0)
71 (27.0)
Sex with a man who has sex with men
18 (1.7)
8 (1.1)
0 (0.0)
10 (3.8)
Given money or goods for sex Received money or goods for sex
13 (1.2) 55 (5.2)
3 (0.4) 3 (0.4)
0 (0.0) 3 (5.7)
10 (3.8) 49 (18.6)
Diagnosed with a sexually transmitted disease
50 (4.7)
24 (3.2)
8 (15.1)
18 (6.8)
123
J Immigrant Minority Health (2014) 16:798–810
805
Table 2 continued All sites combined
AIDGwinnett
No. (%)
No. (%)
Hispanic Health Council No. (%)
United Migrant Opportunity Svcs No. (%)
Number of sexual partners (vaginal or anal), past year 0 partners
60 (5.7)
45 (6.0)
1 (1.9)
14 (5.3)
1 partner
656 (61.8)
515 (69.1)
23 (43.4)
118 (44.9)
2–5 partners 6–10 partners
199 (18.8) 29 (2.7)
91 (12.2) 3 (0.4)
20 (37.7) 0 (0.0)
88 (33.5) 26 (9.9)
12 (1.1)
3 (0.4)
1 (1.9)
8 (3.0)
105 (9.9)
88 (11.8)
8 (15.1)
9 (3.4)
[10 partners Unknown or refused Injection risk behaviors in the past yeara Injection of street drugs
23 (2.2)
7 (0.9)
7 (13.2)
9 (3.4)
Injection of vitamins outside the care of clinical setting
35 (3.3)
33 (4.4)
0 (0.0)
2 (0.8)
Injection of antibiotics outside the care of clinical setting
16 (1.5)
15 (2.0)
0 (0.0)
1 (0.4)
9 (0.8)
3 (0.4)
5 (9.4)
1 (0.4)
Never previously tested
513 (48.4)
391 (52.5)
12 (22.6)
110 (41.8)
Tested less than a year ago
141 (13.3)
98 (13.2)
16 (30.2)
27 (10.3)
Tested more than a year ago
254 (23.9)
177 (23.8)
19 (35.8)
58 (22.1)
Unknown or refused
153 (14.4)
79 (10.6)
6 (11.3)
68 (25.9)
Shared needles HIV testing history
Percentages might not add to 100 % due to rounding a
Categories are not mutually exclusive
elsewhere in the United States [7, 24, 26, 44–46]. However, patterns of risk varied considerably by CBO. HHC participants, who were predominantly from Puerto Rico, more often reported injection drug-related risks than other CBO participants; however, they were also more likely to report prior HIV testing. The high levels of injection drug-related risks among the HHC participants are consistent with those reported by other studies of injection drug risk behaviors among populations that include persons having Puerto Rican origins [47–52]. Injection drug use is the second most common method of HIV transmission among Hispanic/Latino men and women in the United States [53]. Among studies of persons with HIV, those born in Puerto Rico have been described as more likely to report a history of injection drug use compared with U.S.-born and other foreign-born Latinos [46, 50, 51, 54]. Overall, the sociodemographic circumstances of AGI participants were more limited than other CBO participants. They were less educated, less proficient in English, and had less insurance coverage. Female AGI participants were the most likely to report having had unprotected vaginal sex, however, this may be explained by the fact that they were also the most likely to be married or partnered. Overall, AGI participants reported injection drug-related risk behaviors relatively infrequently. More than one-fifth of men across all CBO sites reported having had sex with another man in the past year, although rates were highest among both AGI and UMOS participants. Although studies of migrants have
shown that accurate estimates of this risk behavior are difficult to obtain, male-to-male sexual contacts may be more common in more isolated migrant communities in which men outnumber women [8, 26, 55–58]. Men who had a history of male-to-male sex were also potentially more likely to agree to participate in this testing project due to concern for possible increased risk for HIV infection. Nevertheless, given the high levels of HIV transmission risk that are associated with male-to-male sex, this finding highlights the need for HIV/STD prevention programs that work among migrant populations to include programs that address the prevention needs of men who have sex with men. The low HIV infection rates found in this project are also consistent with recent studies of migrants in the United States [23–28, 59]. This may reflect the relatively low HIV prevalence in the migrants’ countries of origin, particularly in the rural areas from which many migrants originate [24, 26, 60]. For example, the estimated adult HIV seroprevalence in Mexico, the country of origin for most Latino migrants in the United States and most CBO project participants, is 0.3 %, roughly half that in the United States [61]. Reported HIV prevalence is higher, however, in other Latin American countries such as Guatemala (0.8 %), El Salvador (0.8 %), and Honduras (0.7 %) [61]. Persons from these countries accounted for only 12 % of those who were tested and completed surveys in this project. Persons from African countries, many of which have much higher HIV prevalence rates, accounted for only 5 % of our
123
806
J Immigrant Minority Health (2014) 16:798–810
Table 3 Separate multivariate models for men and women showing demographic and behavioral characteristics independently associated with prior HIV testing among male and female migrants who were
administered surveys and rapid HIV tests by three community-based organizations, March 2005—February 2007
Men adjusted odds ratio (95 % confidence interval)
Women adjusted odds ratio (95 % confidence interval)
Age 13–19 years
0.05 (0.01–0.16)
0.42 (0.20–0.89)
20–29 years
0.58 (0.36–0.94)
1.75 (1.16–2.63)
30–39 years
0.63 (0.38–1.05)
1.87 (1.25–2.79)
C40 years
Ref
Ref
Sexual orientationa Heterosexual
Ref
–
Bisexual
1.68 (0.86–3.27)
–
Homosexual
3.81 (2.28–6.37)
–
Birthplace Latin American Country
Ref
Ref
Puerto Rico
16.15 (5.07–51.40)
9.48 (3.57–25.21)
Other Caribbean Country
1.64 (0.44–6.08)
3.33 (1.01–10.12)
African Country
4.59 (1.98–10.65)
3.29 (1.21–8.95)
Primary home, where intend to live long termb Country of birth United States
–
0.54 (0.39–0.73)
–
Ref
Ref
Ref
Fluency with spoken English Very well Well
0.99 (0.44–2.22)
0.97 (0.51–1.85)
Not well
0.43 (0.20–0.88)
1.06 (0.59–1.90)
Not at all
0.24 (0.11–0.50)
0.51 (0.28–0.92)
Sex with person of unknown HIV status
2.76 (1.93–3.96)
–
Given money or goods for sex
0.54 (0.36–0.79)
–
Diagnosed with a sexually transmitted disease
3.09 (1.79–5.36)
–
Sexual risk behaviors in past yeara,c
Factors that were significantly associated (p \ 0.05) with prior HIV testing in bivariate analyses were introduced into the multivariate logistic regression model, and forward stepwise procedures were used to determine which variables remained in the final model as independently associated variables (bold values). Separate multivariate models were used for male and female participants because of substantial differences in their self-reported risk behaviors. All variables which remained in the final multivariate models are presented. Unknown and refused categories have not been included. Participants whose prior HIV testing histories were unknown or refused (men n = 193, women n = 153) were not included in analyses a
‘Sexual orientation’ and ‘sexual risk behavior’ variables were not independently associated with prior HIV testing for female migrants and were not included in the final multivariate model for women
b
Primary home’ variable was not independently associated with prior HIV testing for male migrants and was not included in the final multivariate model for men
c
Categories are not mutually exclusive. Reference group was those respondents who reported ‘no’ for the given factor
participants. The low levels of HIV infection may also be due to participants’ limited exposure to sexual networks with higher levels of HIV infection [24, 55, 56, 62, 63]. Finally, some studies of migrants that describe frequent contacts by Latino males with female sex workers also describe relatively high rates of condom use. This may help explain the low HIV infection rates observed by studies that test migrants [10, 18, 64–67]. While this project only captured data on condom use during exchange sex encounters, these data suggest that participants’ condom
123
use in these potentially high-risk circumstances is limited. Most of the male participants who reported sex with sex workers and most of the female participants who received goods or money for sex during the past year used condoms only sometimes or not at all during those encounters. The paradoxical finding of relatively high levels of risk behavior and low levels of HIV infection that were observed by the CBOs and by studies of migrants elsewhere in the United States [23–26] merits further study. These findings underscore the need to clarify how factors
J Immigrant Minority Health (2014) 16:798–810
that are unique to migrants’ circumstances, but which are not currently reported by surveillance data, can affect their risk and protective behaviors. More than half of the CBO participants reported not having been tested for HIV previously. Persons from Puerto Rico, other Caribbean countries, or Africa, who were more likely to report prior testing than those born in a Latin American country, may have had greater exposure to information about and opportunities for HIV testing before or after arriving in the United States than those born in a Latin American country. For example, a much greater proportion of participants from Puerto Rico reported having health insurance compared to those from Latin America, suggesting they would have had greater opportunities for access to HIV testing services prior to this project. At the time of the demonstration project, those persons who sought admission to the United States as refugees were required to be tested for HIV before entry. An undetermined number of African participants who tested at the UMOS site were resettled refugees and may have been tested for HIV during the resettlement process [68, 69]. For all participants, poor English language proficiency was associated with decreased likelihood of prior HIV testing. Poor fluency with spoken English may have made it more difficult for individuals to obtain information about HIV services [70–72]. Women who were in their twenties or thirties were more likely to report a prior HIV test than younger women. Prior studies have found that many migrant women report receiving an HIV test as a part of prenatal care [12], which could explain the higher rates of prior HIV testing among women of childbearing age in our project. Also among women, the intention to return to their country of birth may have been associated with decreased likelihood of prior HIV testing due to a range of possible associated factors, including decreased awareness regarding HIV, reduced access to HIV services, and increased fear of stigma. Furthermore, some of these women may have had limited education and English language proficiency. Barriers related to English language proficiency, cultural values around sex-related communication, and differing degrees of acculturation to mainstream American values have been shown to have potentially negative effects on participation in HIV prevention, testing, and treatment services by migrants [71–73]. Among male participants, those who were younger and those who had given money or goods for sex in the past year were significantly less likely to have had a prior HIV test. This finding is of concern, given reports from numerous studies of frequent unprotected sex by migrant men with female sex workers [6, 10, 23, 26, 55]. Our finding that among male participants, identification as homosexual, having sex with persons of unknown HIV status, and an STD diagnosis during the past year were associated with a history of prior
807
HIV testing is consistent with other studies of male Latino migrants [8, 26, 55–58]. The findings in this report are subject to several limitations. The project participants were not recruited randomly and therefore are not necessarily representative of all migrants served by the CBOs. These projects were designed to implement rapid HIV testing among migrant communities rather than to conduct research to produce generalizable findings. While the project participants were not randomly selected, we are not aware of studies that describe patterns of risk factors among migrant populations as diverse as those who were tested by the three CBOs. In addition, all data on participants’ risk behaviors and testing histories are based upon self-report. Although interviews were conducted in a manner that aimed to maximize confidentiality, participants may have inaccurately reported HIV risks and testing histories to outreach staff to protect their privacy or due to issues of social desirability or recall bias. Participants were not asked about their immigration status. Having this information could potentially have been helpful for understanding differences in levels of participation in HIV prevention, testing, and related services. In addition, our data do not include measures of participants’ condom use with main or casual sex partners. This would especially limit our findings with regard to HIV risk among women participants, given that research has suggested migrant women’s primary risk for HIV may often be unprotected sex with a risky main partner [11–14]. A large proportion of persons who were tested for HIV as a part of this project did not complete surveys, either because they refused to do so or because the volume of HIV testing at times prevented CBO testing staff from administering surveys to all who were tested. Information was not collected that would have enabled a comparison of persons who accepted and refused HIV testing or of those who were tested and who did and did not complete surveys. The high prevalence of HIV risk behaviors reported by participants underscores the need for expanded HIV/STD testing and prevention in settings where migrants live and work, and for innovative approaches to engage migrant communities in prevention and health promotion. The considerable variation observed in the CBO participants’ sociodemographic characteristics and risk behaviors highlights the need for approaches to HIV/STD testing and prevention that are responsive to the diversity that characterizes migrants in the United States. Future efforts to provide HIV testing and related services to migrants need to be based on a sound understanding of how and why discrepancies occur between the substantial rates of reported risk behaviors and low rates of HIV infection. Early testing and diagnosis of HIV/STD infection can lead to earlier treatment, delayed progression of disease, reduced morbidity and mortality among HIV-infected persons, and decreased onward
123
808
transmission of HIV [24, 29, 30, 45]. Although CBOs in this project found low HIV infection rates, the high prevalence of a broad range of risk behaviors suggests that a range of circumstantial, socio-cultural, and behavioral factors could eventually coalesce to create a ‘‘perfect storm’’ of vulnerability and HIV infection among migrants in the United States. Low levels of infection such as these offer valuable opportunities to educate and intervene before HIV infection spreads further among migrants, their sex partners, and their families in the United States and their countries of origin. These findings highlight the need to seize opportunities for effective prevention sooner rather than later. Acknowledgments We would like to thank the many staff members at the CBOs who contributed to this project, including Gina Allende, Maria Caban, Bill Daldoum, Jeanette B. DeJesus, Luis Feliciano, Dara Fernandez, Kelly Hansen, Juan Hernandez, Ann Levie, Elida Lopez, and Juhem Navarro. We also wish to express our gratitude to the participants in this project.
J Immigrant Minority Health (2014) 16:798–810
12.
13.
14.
15.
16.
17.
References 1. Newland K. Circular migration and human development. New York: United Nations Development Program (UNDP); 2009. 2. Organista KC, Carrillo H, Ayala G. HIV prevention with Mexican migrants: review, critique, and recommendations. J Acquir Immune Defic Syndr: JAIDS. 2004;37(Suppl 4):S227–39. 3. United Nations Development Programme (UNDP). Human Development Report. Overcoming barriers: human mobility and development. New York: United Nations Development Programme; 2009. p. 2009. 4. Passel JS, Cohn D. Unauthorized immigration flows are down sharply since Mid-Decade. Pew Hispanic Center. Accessed December 12, 2011; Available from: http://pewhispanic.org/ reports/report.php?ReportID=126. 5. Passel JS, Cohn D. Trends in Unauthorized Immigration: Undocumented Inflow Now Trails Legal Inflow. Pew Hispanic Center. Accessed December 12, 2011; Available from: http:// pewhispanic.org/files/reports/94.pdf. 6. Apostolopoulos Y, Sonmez S, Kronenfeld J, Castillo E, McLendon L, Smith D. STI/HIV risks for Mexican migrant laborers: exploratory ethnographies. J Immigr Minor Health. 2006;8(3):291–302. 7. Kissinger P, Liddon N, Schmidt N, Curtin E, Salinas O, Narvaez A. HIV/STI risk behaviors among Latino migrant workers in New Orleans post-Hurricane Katrina disaster. Sex Transm Dis. 2008; 35(11):924–9. 8. Magis-Rodriguez C, Gayet C, Negroni M, Leyva R, Bravo-Garcia E, Uribe P, et al. Migration and AIDS in Mexico: an overview based on recent evidence. J Acquir Immun Defic Syndr: JAIDS. 2004;37(Suppl 4):S215–26. 9. Sanchez MA, Hernandez MT, Vera A, Magis-Rodriguez C, Ruiz JD, Drake MV, et al. The effect of migration on HIV high-risk behaviors among Mexican migrants. XVII International AIDS Conference. Mexico City, Mexico; 2008. 10. Parrado EA, Flippen CA, McQuiston C. Use of commercial sex workers among Hispanic migrants in North Carolina: implications for the spread of HIV. Perspect Sex Reprod Health. 2004;36(4):150–6. 11. Montealegre JR, Risser JM, Selwyn BJ, McCurdy SA, Sabin K. Prevalence of HIV risk behaviors among undocumented Central
123
18.
19.
20.
21.
22. 23.
24.
25.
26.
27.
American immigrant women in Houston, Texas. AIDS Behav. 2012;16(6):1641–8. Montealegre JR, Risser JM, Selwyn BJ, Sabin K, McCurdy SA. HIV testing behaviors among undocumented Central American immigrant women in Houston, Texas. J Immigr Minor Health. 2011;14(1):116–23. Hirsch JS, Meneses S, Thompson B, Negroni M, Pelcastre B, del Rio C. The inevitability of infidelity: sexual reputation, social geographies, and marital HIV risk in rural Mexico. Am J Public Health. 2007;97(6):986–96. Hirsch JS, Higgins J, Bentley ME, Nathanson CA. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. Am J Public Health. 2002;92(8):1227–37. Painter TM. Connecting the dots: when the risks of HIV/STD infection appear high but the burden of infection is not known– the case of male Latino migrants in the southern United States. AIDS Behav. 2008;12(2):213–26. Grzywacz JG, Quandt A, Early J, Tapia J, Graham CN, Arcury TA. Leaving family for work: ambivalence and mental health among Mexican migrant farmworker men. J Immigr Minor Health. 2006;8(1):85–97. Harawa NT, Bingham TA, Cochran SD, Greenland S, Cunningham WE. HIV prevalence among foreign- and US-born clients of public STD clinics. Am J Public Health. 2002;92(12):1958–63. Munoz-Laboy M, Hirsch JS, Quispe-Lazaro A. Loneliness as a sexual risk factor for male Mexican migrant workers. Am J Public Health. 2009;99(5):802–10. Caballero-Hoyos R, Torres-Lopez T, Pineda-Lucatero A, Navarro-Nunez C, Fosados R, Valente TW. Between tradition and change: condom use with primary sexual partners among Mexican migrants. AIDS Behav. 2008;12(4):561–9. Deiss R, Garfein RS, Lozada R, Burgos JL, Brouwer KC, Moser KS, et al. Influences of cross-border mobility on tuberculosis diagnoses and treatment interruption among injection drug users in Tijuana, Mexico. Am J Public Health. 2009;99(8):1491–5. Johnson AS, Hu X, Dean HD. Epidemiologic differences between native-born and foreign-born black people diagnosed with HIV infection in 33 U.S. states, 2001–2007. Public Health Rep. 2010;125(Suppl 4):61–9. Prosser AT, Tang T, Hall HI. HIV in persons born outside the United States, 2007–2010. JAMA. 2012;308(6):601–7. Brammeier M, Chow JM, Samuel MC, Organista KC, Miller J, Bolan G. Sexually transmitted diseases and risk behaviors among California farmworkers: results from a population-based survey. J Rural Health. 2008;24(3):279–84. Martinez-Donate AP, Rangel MG, Hovell MF, Santibanez J, Sipan CL, Izazola JA. HIV infection in mobile populations: the case of Mexican migrants to the United States. Pan Am J Public Health. 2005;17(1):26–9. Hernandez MT, Sanchez MA, Aoki BA, Ruiz JD, Magis C, Garcia EB, et al. Epidemiology of HIV and sexually transmitted infections among Mexican migrants in California. 14th Conference on Retroviruses and Opportunistic Infections. Los Angeles, CA; 2007. Sanchez MA, Lemp GF, Magis-Rodriguez C, Bravo-Garcia E, Carter S, Ruiz JD. The epidemiology of HIV among Mexican migrants and recent immigrants in California and Mexico. J Acquir Immun Defic Syndr: JAIDS. 2004;37(Suppl 4):S204–14. Ruiz JD, Da Valle L, Jungkeit M, Platek G, Mobed K, Lopez R. Seroprevalence of HIV and syphilis and assessment of risk behaviors among migrant and seasonal farmworkers in five Northern California counties. Office of AIDS, HIV/AIDS Epidemiology Branch, California Department of Health Services, editor.; 1997.
J Immigrant Minority Health (2014) 16:798–810 28. Varela-Ramirez A, Mejia A, Garcia D, Bader J, Aguilera RJ. HIV infection and risk behavior of Hispanic farm workers at the west Texas-Mexico border. Ethnicity & Disease 2005;15(4 Suppl 5):S5-92-6. 29. Levy V, Prentiss D, Balmas G, Chen S, Israelski D, Katzenstein D, et al. Factors in the delayed HIV presentation of immigrants in Northern California: implications for voluntary counseling and testing programs. J Immigr Minor Health. 2007;9(1):49–54. 30. Lopez-Quintero C, Shtarkshall R, Neumark YD. Barriers to HIVtesting among Hispanics in the United States: analysis of the national health interview survey, 2000. AIDS Patient Care & Stds. 2005;19(10):672–83. 31. Morin SF, Carrillo H, Steward WT, Maiorana A, Trautwein M, Gomez CA. Policy perspectives on public health for Mexican migrants in California. J Acquir Immun Defic Syndr: JAIDS. 2004;37(Suppl 4):S252–9. 32. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. J Acquir Immun Defic Syndr: JAIDS. 2004;37(Suppl 4):S240–51. 33. Wong W, Tambis JA, Hernandez MT, Chaw JK, Klausner JD. Prevalence of sexually transmitted diseases among Latino immigrant day laborers in an urban setting–San Francisco. Sex Transm Dis. 2003;30(8):661–3. 34. Ehrlich SF, Organista KC, Oman D. Migrant Latino day laborers and intentions to test for HIV. AIDS Behav. 2007;11(5):743–52. 35. Centers for Disease Control and Prevention (CDC). Advancing HIV Prevention: New strategies for a changing epidemic. Accessed: April 23, 2011; Available from: http://www.cdc.gov/ hiv/topics/prev_prog/AHP/default.htm. 36. Centers for Disease Control and Prevention (CDC). Funding Opportunity Number 04158. Demonstration Projects for Implementation of Rapid HIV Testing in Historically Black Colleges and Universities and Alternative Venues and Populations. Federal Register 2004;69(120):35035–35039. 37. AID Gwinnett. AID Gwinnett. Accessed: November 14, 2011; Available from: http://www.aidgwinnett.org/index.aspx. 38. Hispanic Health Council. Hispanic Health Council. Accessed: November 14, 2011; Available from: http://www.hispanichealth. com/hhc/. 39. United Migrant Opportunities Services. UMOS: Building Better Futures. Accessed: November 14, 2011; Available from: http:// www.umos.org/default.aspx. 40. OraSure Technologies Inc. Package insert for OraQuickÒ AdvanceTM Rapid HIV-1/2 Antibody Test. Accessed: October 21, 2011; Available from: http://www.orasure.com/uploaded/398. pdf. 41. OraSure Technologies Inc. Package insert for OraSureÒ Oral HIV-1 Western Blot Kit. Accessed: October 21, 2011; Available from: http://www.orasure.com/docs/pdfs/products/orasure_hiv_1_ western_blot/OraSure-HIV-1-Western-Blot-Package-Insert.pdf. 42. Nova Research Co. QDSTM (Questionnaire Development System): Version 2.5. Bethesda, MD: Nova Research Co.; 2005. 43. SAS Institute Inc. SAS: Version 9.1 Cary, NC: SAS Institute Inc.; 2003. 44. Webber G. The impact of migration on HIV prevention for women: constructing a conceptual framework. Health Care Women Int. 2007;28(8):712–30. 45. Centers for Disease Control and Prevention (CDC). HIV/AIDS among Hispanics—United States 2001–2005. Morb Mortal Wkly Rep. 2007;56(40):1052–7. 46. Espinoza L, Hall HI, Selik RM, Hu X. Characteristics of HIV infection among Hispanics, United States 2003–2006. J Acquir Immun Defic Syndr: JAIDS. 2008;49(1):94–101. 47. Robles RR, Colon HM, Matos TD. Risk factors and HIV infection among three different cultural groups of intravenous drug users. In: Brown BS, Beschner GM, editors. Handbook on Risk of
809
48.
49.
50.
51.
52. 53.
54.
55.
56.
57.
58.
59. 60. 61.
62.
63.
64.
65.
AIDS: injection drug users and sexual partners. Westport: Greenwood Publishing Group, Inc.; 1993. p. 256–74. Singer M, Himmelgreen D, Dushay R, Weeks MR. Variation in drug injection frequency among out-of-treatment drug users in a national sample. Am J Drug Alcohol Abuse. 1998;24(2):321–41. Williams ML, Zhao Z, Freeman RC, Elwood WN, Rusek R, Booth RE, et al. A cluster analysis of not-in-treatment drug users at risk for HIV infection. Am J Drug Alcohol Abuse. 1998; 24(2):199–223. Mino M, Deren S, Colon HM. HIV and drug use in Puerto Rico: findings from the ARIBBA study. J Int Assoc Physicians AIDS Care (Chic). 2011;10(4):248–59. Baez Feliciano DV, Gomez MA, Fernandez-Santos DM, Quintana R, Rios-Olivares E, Hunter-Mellado RF. Profile of Puerto Rican HIV/AIDS patients with early and non-early initiation of injection drug use. Ethnicity & Disease 2008;18(2 Suppl 2): S2-99-104. Singer M. Why do Puerto Rican injection drug users inject so often? Anthropol Med. 1999;6(1):31–58. Hispanic/Latino Executive Committee. HIV/AIDS among Hispanics/Latinos: Plan of Action 2009–2012. National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), editor. Atlanta, GA: US Department of Health and Human Services; 2010. Diaz T, Klevens M. Differences by ancestry in sociodemographics and risk behaviors among Latinos with AIDS. The Supplement to HIV and AIDS Surveillance Project Group. Ethn Dis. 1997;7(3):200–6. Magis-Rodriguez C, Lemp G, Hernandez MT, Sanchez MA, Estrada F, Bravo-Garcia E. Going north: Mexican migrants and their vulnerability to HIV. J Acquir Immun Defic Syndr: JAIDS. 2009;51(Suppl 1):S21–5. Rangel MG, Martinez-Donate AP, Hovell MF, Santibanez J, Sipan CL, Izazola JA. Prevalence of risk factors for HIV infection among Mexican migrants and immigrants: probability survey in the north border of Mexico. Salud Publica Mex. 2006;48(1):3–12. Lieb S, Fallon SJ, Friedman SR, Thompson DR, Gates GJ, Liberti TM, et al. Statewide estimation of racial/ethnic populations of men who have sex with men in the US. Public Health Rep. 2011;126(1):60–72. Parrini R, Castaneda X, Magis-Rodriguez C, Ruiz J, Lemp G. Identity, desire and truth: homosociality and homoeroticism in Mexican migrant communities in the USA. Culture, Health & Sexuality. 2011;13(4):415–28. Cargill VA, Stone VE. HIV/AIDS: a minority health issue. Med Clin North Am. 2005;89(4):895–912. Strathdee SA, Magis-Rodriguez C. Mexico’s evolving HIV epidemic. JAMA. 2008;300(5):571–3. Joint United Nations Programme on HIV/AIDS. Report on the global AIDS epidemic. 2008. Accessed: August 3, 2011; Available from: http://www.unaids.org/en/KnowledgeCentre/HIVData/ GlobalReport/2008/2008_Global_report.asp. Aranda-Naranjo B, Gaskins S, Bustamante L, Lopez LC, Rodriquiz J. La desesperacion: migrant and seasonal farm workers living with HIV/AIDS. J Assoc Nurses AIDS Care. 2000;11(2): 22–8. Viani RM, Araneta MR, Ruiz-Calderon J, Hubbard P, Lopez G, Chacon-Cruz E, et al. Perinatal HIV counseling and rapid testing in Tijuana, Baja California, Mexico: seroprevalence and correlates of HIV infection. J Acquir Immun Defic Syndr: JAIDS. 2006;41(1): 87–92. Viadro CI, Earp JA. The sexual behavior of married Mexican immigrant men in North Carolina. Soc Sci Med. 2000;50(5): 723–35. Strathdee SA, Mausbach B, Lozada R, Staines-Orozco H, Semple SJ, Abramovitz D, et al. Predictors of sexual risk reduction
123
810
66.
67.
68.
69.
J Immigrant Minority Health (2014) 16:798–810 among Mexican female sex workers enrolled in a behavioral intervention study. J Acquir Immun Defic Syndr: JAIDS. 2009; 51(Suppl 1):S42–6. Strathdee SA, Lozada R, Ojeda VD, Pollini RA, Brouwer KC, Vera A, et al. Differential effects of migration and deportation on HIV infection among male and female injection drug users in Tijuana, Mexico. PLoS ONE. 2008;3(7):e2690. Knipper E, Rhodes SD, Lindstrom K, Bloom FR, Leichliter JS, Montano J. Condom use among heterosexual immigrant Latino men in the southeastern United States. AIDS Educ Prev. 2007; 19(5):436–47. Centers for Disease Control and Prevention (CDC). Technical Instructions for Medical Examination of Aliens. Accessed: December, 2011; Available from: http://www.cdc.gov/immigrantrefugeehealth/ exams/ti/panel/technical-instructions/panel-physicians/introductionbackground.html. Borman MA. Personal communication with M.A. Borman; 2011.
123
70. Sena AC, Hammer JP, Wilson K, Zeveloff A, Gamble J. Feasibility and acceptability of door-to-door rapid HIV testing among latino immigrants and their HIV risk factors in North Carolina. AIDS Patient Care & Stds. 2011;24(3):165–73. 71. Kinsler JJ, Lee SJ, Sayles JN, Newman PA, Diamant A, Cunningham W. The impact of acculturation on utilization of HIV prevention services and access to care among an at-risk Hispanic population. J Health Care Poor Underserved. 2009;20(4): 996–1011. 72. Uribe CL, Darrow WW, Villanueva LP, Obiaja KC, SanchezBrana E, Gladwin H. Identifying HIV risk-reduction strategies for Hispanic populations in Broward County. Ann Epidemiol. 2009;19(8):567–74. 73. Solorio MR, Galvan FH. Self-reported HIV antibody testing among Latino urban day laborers. J Natl Med Assoc. 2009; 101(12):1214–20.
