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After the Entry Ban, Why Danger Persists for Immigrants Living With HIV in the U.S.

Veteran Advocates Agree, HIV May Not Be an Immigrant's Biggest Problem Anymore

December 18, 2013

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Immigration Status and Access to Care

Olivia Ford: Can you all elaborate a bit on some ways that not having a solid immigration status affects access to HIV care and services? I know that access tends to vary depending on what area of the country a person is in.

Cristina Velez: From my experience in New York City, I do find that it's somewhat of a safe haven for undocumented people living with HIV in that, for the most part, they can at least obtain access to antiretroviral medication and primary care related to their HIV. With the public hospitals that provide HIV clinical care in the New York area, I see a lot of undocumented immigrants who are able to at least have their basic medical needs met, in that regard.

The problem arises when they have medical needs that are considered to be unrelated to their HIV, although that may be debatable in some circles. If the AIDS Drug Assistance Program considers them to be unrelated medical problems, then they will not cover care for those conditions, and that can put some immigrants in a very precarious position, as far as their health.

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Many undocumented people are also in need of emergency housing assistance and, especially with the economy the way it's been the last few years, have also required cash assistance and food assistance just to get by. It's much more difficult for undocumented people to access those kinds of services. And so, we're seeing the gap grow larger between immigrants who can qualify for those additional services and those who cannot.

I can't speak to all the policy issues that have created this gap in services and care, but I can say that it's very difficult to see, from my vantage point, being involved in direct services and feeling like there is really a limited amount that I can do to help them bridge this gap.

N. Ordover: I just want to echo that, and underline how critical stable housing is to maintaining your health -- anyone's health, but especially folks who have ongoing issues like HIV. And New York is not a very hospitable place to try and find housing if you don't have some pretty serious means.

For folks outside of New York, you may know that we are about to get a new mayor. And in our outgoing mayor's term, he managed to rezone about 37 percent of the city. We're at this place where the power of real estate is hampering what were already some meager housing options for low- and no-income folks. Add to that an immigration status that is not recognized, and it's very difficult to get yourself in a situation where you can stay healthy.

Victoria Ojeda: From the perspective of the border region, there are community health clinics that are providing HIV care to the undocumented community, certainly. But one of the issues that we're facing here on the border is that, as folks get repatriated to Mexico, there's a disconnect in their treatment. Sometimes people are sent to immigration facilities while they're waiting to be repatriated, and they don't have access to their medications. And sometimes they're returned to Mexico without any medications, or without any documentation indicating that they're HIV positive, which also makes it difficult for them to get linked to HIV care.

"One of the concerns from a binational perspective is that the fact that folks are having a hard time accessing care, both in the U.S. and then subsequently in Mexico, means their health is deteriorating." -- Victoria Ojeda

One of the concerns from a binational perspective is that the fact that folks are having a hard time accessing care, both in the U.S. and then subsequently in Mexico, means their health is deteriorating. But a lot of these folks have, certainly, an intention of returning to the U.S. -- whether it's for economic reasons or because they're separated from their families. So, ideally, what we would like to see is some mechanism to facilitate linkages to HIV care, once folks are repatriated -- so that their health does not deteriorate, but also to prevent ongoing transmission and just protect their health and that of their intimate partners and other contacts. And that has not been very easy to do.

One of the things that we're trying to do through the University of California - San Diego, in partnership with the Autonomous University of Baja California, is through a student-run free clinic. We have over 1,200 patients that have been attending this free clinic in the last two years. And we have an HIV telemedicine service, so that we are linked with the state of Baja California's HIV/AIDS program. About half of our patient population is made up of deportees from the U.S., so for those that are HIV positive, what we're trying to do is promote exactly this linkage to HIV care and whatever other services. Because not only are they coming back to a city, and maybe a country, that they don't recognize, but housing and financial instability are huge issues, as has been mentioned previously. Those are, all three, major concerns for deportees. So, on both sides, we see that it's a worthwhile investment for both countries to make, to promote access to HIV care for this population.

Olivia Ford: Can you talk about what repatriation processes can look like, what they may entail, from the perspectives of your respective work?

N. Ordover: I do want to say that we're in a situation now where there are institutions, like hospitals, who are taking some extralegal initiative, we could say, to "repatriate" immigrants who are uninsured, whether they're documented or not.

I don't think there's a formal process, just because it is extralegal. And I certainly don't want to make it sound like this is happening in enormous numbers. But I will say that every once in awhile an email report comes through my inbox of a hospital that has transported one of their patients from the U.S. out of the U.S. -- usually at the Mexican border. And when we're talking about folks who don't have a lot of means and maybe already don't feel so entitled, their legal rights may not matter in the eyes of the institution, right, if they don't have the means and the power to exercise them? So this is a problem.

There are also some real language issues that are hampering folks' ability to exercise their rights. There is a belief that there are always translation services and interpretation services. That's not true. We've all heard stories of folks where there was nobody who spoke their language: They may be from Mexico, but their first language was not Spanish and they are in places in the U.S. where there aren't other folks who can help them understand.

Be they by-the-book or extrajuridical procedures and processes, nobody is really falling over themselves to make sure that folks know their rights and can access them. That's, I think, a lot of what we're seeing, and what we're going to continue to see.

Cristina Velez: From what I understand about the medical repatriation problem, it is quite varied across different jurisdictions. I've heard a lot of different horror stories about people -- not necessarily people who are HIV positive, but people who are incapacitated in some way, either through a workplace accident or some other kind of sudden event that may leave them unconscious for a long period of time, or unable to express themselves. These are people who may be eligible for relief from removal, but who don't know that -- or their families are unable to get them legal assistance in time.

The hospitals have been moving pretty quickly to send people back, once it's determined that there's no financial coverage for their care -- rather than wait for them to have their rights evaluated by a competent person, and the steps to be taken to get them immigration status that would make them eligible for coverage, and also allow them to continue living in the United States.

Even if it's an extrajudicial removal, once they are removed from the United States, there are immigration penalties that they incur that make it very difficult for them to come back to the United States, even if they are eligible for relief.

When we see people who are marginalized in such a way, as a legal services office, one of the things that we do is we conduct a really thorough immigration intake for them. And sometimes we discover that they're eligible for a form of relief that they are unaware of, such as the U Visa, for example, that they would never have approached an attorney to ask for. It's so important that there is some kind of intervention for people who are in danger of being repatriated without consent.

Victoria Ojeda: There are a couple of different mechanisms for getting returned to your country of origin. And it's not entirely clear to all of the people that are undergoing the process. Sometimes, people are signing documents, legal documents that will bar them from reentry from the U.S. And sometimes they go before a judge. It's a convoluted procedure that is not necessarily transparent to the immigrants themselves. That has serious implications for their abilities to return and, again, to reestablish their lives here, if that were a possibility. Sometimes they are waiving that right. That certainly could have important health consequences for those that are living with HIV.

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