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Combating HIV and AIDS: Protecting the Health of Latino Communities

July 2000

"HIV prevention in Latino communities will take the combined efforts of public health agencies, community organizations, churches, schools, leaders, neighbors, and friends."
-- Dr. Helene Gayle, Director,
National Center for HIV, STD and TB prevention,
CDC

Latino communities face a health crisis that threatens to imperil their future health, prosperity and human potential. That threat is HIV/AIDS.

The U.S. HIV epidemic has expanded from one which primarily impacted white gay men in the late 1980's, to an epidemic which, in 2000, affects a more diverse population than ever before. HIV prevention efforts must aggressively target a wide range of communities, from new populations of white gay men, who remain at high risk, to gay men of color, African-American and Latino women at risk, injection drug users of all races, and adolescents as they come of age.

While African Americans face the greatest HIV and AIDS burden in the United States -- accounting for an estimated 55% of new infections -- the toll of the epidemic among Latinos cannot be ignored. Latinos in some areas of the country, primarily the Northeast, Puerto Rico, and Florida, are among the populations now at greatest risk of infection. Overall, Latinos represent an estimated 20% of new HIV infections.

The breadth of the health crisis has prompted Latinos to respond to HIV/AIDS with a growing sense of urgency. According to the Henry J. Kaiser Family Foundation, 50% of Latinos surveyed in late 1997 said AIDS was the country's most serious health problem, and two-thirds of Latinos believe AIDS is more urgent now than it was few years ago.

The same survey found that Latinos are twice as likely as other Americans to agree that AIDS a problem for people they know. Ninety-four percent support government-sponsored HIV education and prevention, and three out of Latino adults say they need help in learning to discuss AIDS with young people.

There are important issues that make addressing HIV/AIDS among Latinos particularly challenging, most importantly the tremendous diversity within Latino communities. The many countries that Latinos emigrate from reflect a variety of cultures, attitudes and HIV risk factors. Because attitudes, knowledge, and risk behaviors vary significantly depending on country of origin, HIV prevention services need to be finely tailored to each culture to be most effective.


CDC, the nation's disease prevention agency, undertakes a broad array of programs to help communities fight HIV and AIDS. Through community funding for HIV prevention, research, and the transfer of vital information and know-how, CDC forms partnerships with communities affected by the epidemic to produce the most effective response possible. In its public health partnership with Latino communities, as with other groups, CDC operates in three distinct areas:

This three-pronged approach focuses on the communities hardest hit by HIV/AIDS. As Latinos have been increasingly impacted by the HIV epidemic, a growing proportion of CDC's prevention efforts in all three areas have focused on reaching Latinos at risk. At the same time, more Latino communities throughout the U.S. are mobilizing to respond to HIV and AIDS.

Yet, much more must be done. HIV prevention resources must be expanded to help Latino and other communities at risk mount proven prevention initiatives; additional sectors of Latino communities must join in the fight against HIV and AIDS; and the partnership between Latino communities and public health officials must be strengthened and sustained.

This report outlines CDC's efforts to work in partnership with Latino communities to prevent further HIV transmission. These important programs should be regarded as the building blocks for the long-term response that will be needed to turn the tide against the epidemic in Latino communities across the U.S.



Tracking the Epidemic

Since the beginning of the epidemic, CDC has closely tracked the course of AIDS. The first cases of AIDS were identified in 1981. By 1983, 14% of AIDS cases were occurring among Hispanics. In addition to providing weekly reports on emerging trends in the epidemic, in 1986, CDC issued a special report on AIDS among blacks and Latinos. The report indicated that the cumulative AIDS rate among these groups was already more than three times the rate for whites. This report -- and others that followed -- alerted national and community leaders of the need for increased prevention services for Latino communities.

On a local level, data on the status of HIV and AIDS are even more critical to ensuring that resources are directed where they are most urgently needed. The importance of accurate local data is underscored by the diversity of the HIV epidemic among Latino communities.

Early in the epidemic, CDC researchers identified distinct differences in the scope and makeup of the AIDS epidemic among Latinos of different ethnic origins. A CDC study of AIDS cases reported between June 1981 and December 1988 demonstrated that while Mexican-born Latinos living in the Southern and Western United States were at similar risk of developing AIDS as the white, non-Hispanic, population, Latinos of Puerto Rican descent were at several times greater risk than whites and other Latin-born individuals in each region of the country.1 As shown in the accompanying tables, AIDS rates among Latinos continue to vary by state, and prevention needs vary dramatically depending on the country of birth. Additional CDC studies have confirmed that risk behaviors and influences on behavior differ for each culture, and so must prevention efforts.2,3,4 While HIV-infected Latinos born in the U.S. or in Puerto Rico are most likely to have contracted the virus through injection drug use, those from Mexico, Cuba, and Central and South America most often become infected as a result of sex between men.5


In addition to analyses of data by place of birth, studies have demonstrated important differences in risk behaviors by ancestry. Because information on ancestry and social, economic, and cultural influences on risk is not routinely available, CDC conducts multi-state studies to supplement national HIV and AIDS surveillance and recommends that states with large Latino populations routinely collect data on ancestry. These data have proven invaluable in identifying and addressing unique prevention challenges:

Other ongoing CDC studies to monitor the course of HIV and AIDS among Latinos and others at high risk include multi-state studies of perinatal HIV transmission, the factors influencing the progression of HIV disease, and the level of HIV infection among young gay men and clients of inner-city STD clinics.


Latinos at Heightened Risk

While Latinos make up 13% of the U.S. population, they account for:
  • 18% of all AIDS cases ever reported
  • 17% of all AIDS deaths (more than 72,000) ever reported
  • 19% of all AIDS cases reported in 1999
  • 20% of all new HIV infections estimated to occur among men
  • 18% of all new HIV infections estimated to occur among women
  • It is estimated that 110,000-170,000 Latinos are infected with HIV, and more than 58,000 of these individuals are currently living with AIDS


The Impact of HIV/AIDS in Latino Communities


Future Directions: A Focus on HIV Surveillance

In addition to the need to expand these studies, it will become increasingly important to collect data on cases of HIV, in addition to AIDS. Current estimates of new HIV infections are rough, and are based on data from the specific studies mentioned above, combined with data from states that track HIV infection as well as AIDS cases. Prior to recent treatment advances, AIDS cases were generally accurate indicators of HIV infection, because HIV progressed to AIDS at predictable intervals prior to 1996. AIDS cases today, however, primarily represent people tested late in the course of disease, those who have not received needed care, or patients for whom combination therapy is not effective.

To monitor the actual course of the epidemic in the treatment era, it is necessary to track HIV infection itself, rather than cases of full-blown AIDS. Although CDC has called for one, there is currently no national system that tracks new HIV infections the same way that AIDS cases are monitored. Although roughly one half of states have historically maintained HIV reporting systems, they include few of the states with especially large Hispanic populations, such as New York, Florida, Texas, California, or Illinois (although New York, Florida, and Texas have recently begun to implement such a reporting system). As additional states begin to collect data on HIV cases, a clearer picture of the epidemic among Latinos will emerge.


HIV Prevention Research

Just as CDC's efforts to track the epidemic enable prevention programs to be targeted to those who need them the most, CDC-sponsored research ensures that these targeted programs are based on sound, scientific evidence of what works to prevent transmission. CDC develops and evaluates both biomedical and behavioral approaches to HIV prevention.

Behavioral research focuses on identifying the factors that influence risky behavior and transmission in different communities and evaluating approaches to reducing risk.

Biomedical research focuses on evaluating medical approaches (testing and treatment) to preventing HIV transmission. Effective risk reduction strategies, combined with new treatments for HIV and other sexually transmitted diseases, offer more hope than ever for reducing the spread of HIV.


Behavioral Research

Behavioral research to date in Latino communities has led to a number of findings important to the design of effective prevention programs, including:

CDC's ongoing research seeks to build upon this knowledge base, design effective programs based on this knowledge, and evaluate the impact on risk behaviors. Current projects include:


Biomedical Research

The CDC also conducts research to evaluate biomedical tools to reduce the risk of HIV transmission and ensure proven medical approaches to prevention are widely implemented. Examples of past and present research include the evaluation of therapies to reduce the risk of HIV transmission from a mother to her unborn child, the evaluation of microbicides and other female-controlled prevention methods, the evalution of HIV vaccine candidates, and the effect of antiretroviral therapy on viral load and HIV transmission.

Several CDC biomedical research initiatives have special importance for Latinos:

Mother-to-Child Transmission

Although Latinos make up only 13% of the population, they account for just over 20% of perinatally acquired AIDS cases. In 1994, research demonstrated that AZT, given to an HIV-infected woman early in pregnancy, during labor and delivery, and to her baby, could reduce the risk of transmission to her baby by two-thirds. For HIV-infected women and their infants to benefit optimally from AZT and other medical treatment, it is best for women to know if they are infected early in pregnancy. CDC guidelines therefore promote early HIV counseling and voluntary testing in the context of prenatal care. Swift integration of these recommendations in prenatal care settings led to a dramatic reduction in mother-to-child transmission -- a 73% decline in such cases between 1992 and 1998. Despite these successes, challenges remain for further reducing HIV transmission to Latino and other children at risk in the United States. Perhaps the greatest barriers in the U.S. are the continuing spread of HIV infection among African-American and Latina women and the lack of early prenatal care for many of these women. CDC perinatal research efforts are therefore currently focused on assessing strategies to increase access to prenatal care and treatment.

Further, for women not reached during prenatal care, a particularly high risk group, CDC is conducting research on the most effective approaches to counseling and testing using rapid testing technologies for determining HIV status at the time of labor and delivery. The research will also determine the best approaches to deliver therapy once HIV status is determined.

STD Prevention and Treatment

While STDs are widespread across all racial groups, STD rates have traditionally been somewhat higher among Latinos than among whites. Rates of STDs such as gonorrhea and syphilis are 2-3 times higher among Latinos, when compared to whites, largely because of disparities in access to care. Previous research has clearly documented the relationship between STDs and the spread of HIV. Because other STDs increase the likelihood of both spreading and acquiring STDs, CDC conducts research on the impact of STD treatment on HIV transmission and works to increase screening, treatment, and prevention services in Latino and other communities at risk.

HIV Treatment

It is estimated that 110,000-170,000 Latinos are living with HIV in the U.S., and this number continues to grow. A significant number of these individuals do not know they are infected. Increasing the number of Latinos at risk who are tested and offered treatment is critical for their own health and for preventing the spread of HIV to others. Studies have shown that knowledge of HIV status reduces risk behaviors. Additionally, because new HIV therapies reduce the amount of virus circulating in the body, it is possible that HIV treatments may prove to reduce the risk of transmitting HIV. CDC is designing studies to evaluate the impact of treatment on infectiousness to determine if, and to what extent, treatment will be effective as a prevention strategy. Further, CDC researchers are evaluating strategies for ensuring that any benefits of new therapies are not offset by increases in risk behavior. Even if treatment proves to reduce transmission, it will be critical to maintain safer behaviors.


Partnering with Local Communities

The most effective prevention programs are targeted to the specific needs of communities at risk for HIV transmission. While federally sponsored research has identified the fundamental principles of sound HIV prevention programs, local prevention programs must carefully tailor their own initiatives to address the real-world circumstances of their local constituents.

CDC funding enables local community organizations to mount targeted prevention programs that are based on sound science. CDC's efforts (described below) to ensure that prevention programs are effectively directed toward those in greatest need have resulted in a substantial increase in HIV prevention funding targeted to Latinos. Between 1988 and 1999, CDC funding specifically earmarked for Latino prevention programs increased by 715% -- from approximately $7 million to more than $58 million.

Additionally, a significant proportion of CDC's research and surveillance programs serve Latinos at risk, as do prevention programs not targeted by race. Of the nearly $615 million CDC currently spends on HIV prevention efforts for high-risk or emerging populations, roughly 19%, or an estimated $115 million, benefits Latinos.



"What is successful with gay white male communities cannot be just translated into Spanish. Outreach efforts must be adapted to reach our men and their beliefs about themselves."

-- Dr. Jane Delgado, President,
National Alliance for Hispanic Health


Community Planning

Perhaps the single most important effort to ensure that HIV prevention services reach Latino and other populations at greatest risk is CDC's prevention community planning.

The largest share of CDC's support for local prevention programs -- over $250 million in 1999 -- is channeled through state and local health departments through a process known as community planning. With these resources, health departments fund thousands of community-based organizations to deliver HIV prevention programs to individuals at greatest risk in their community. The process brings representatives from all affected communities together with public health officials and other experts to make decisions about funding based on the profile of the local epidemic.

Community planning effectively moved the nation away from federal directives and placed the decisions about prevention in the hands of those closest to the problem. CDC requires that the membership of state and local planning councils reflect the epidemic in these jurisdictions and that funding decisions be based on sound science.

Implementation of community planning has dramatically increased funds targeted to Latino communities, resulting in a seven-fold increase, from approximately $5 million in 1993 to more than $37.5 million in 1999.

CDC funds more than 200 Latino community-based organizations through the community planning process. Prevention programs supported by CDC address a wide range of behaviors that place Latinos at risk for HIV infection:

In an effort to evaluate the success of community planning, CDC analyzed state and local prevention spending patterns in three key areas, comparing funding to each racial/ethnic group's proportion of the AIDS epidemic:


Direct Funding for Community-based Organizations

CDC also directly funds community-based organizations serving Latinos to implement HIV prevention programs. While community planning is the ultimate answer to building long-term community capacity to fight AIDS, direct funding of community organizations has helped fill critical interim gaps. Nearly 35% of direct CDC funding of community-based HIV prevention programs reaches Latinos at greatest risk, including gay and bisexual men. Examples of organizations and activities include:


Strengthening Local Organizations

Recognizing that lack of infrastructure in many communities impedes effective delivery of HIV prevention services to people of color, in 1988 CDC began funding national and regional minority organizations to provide consultation, training and other forms of technical assistance to local community groups. These capacity building efforts have been steadily built over time and have evolved to address complex HIV prevention needs. In 1999, CDC's capacity building program totaled $14.5 million, over 20% of which is directed toward Latino communities. Organizations funded work to strengthen the hundreds of CDC-funded community-based organizations working to prevent HIV among Latinos. For example:


"Hispanics are the fastest growing minority group in the U. S. . . . To ensure a healthy and productive nation, it is critical that we meet the health needs of the Hispanic population."

-- Representative Lucille Roybal-Allard,
Chairwoman, Congressional Hispanic Caucus


Other Initiatives

Several other initiatives enhance HIV prevention services for Latinos at risk:


HIV Prevention in Correctional Facilities

Data released in 1999 at the first National HIV Prevention Conference documented levels of HIV and AIDS among inmates five times higher than the total U.S. population. These data also suggest that nearly one-fifth of all people with HIV and AIDS in 1996 had been released from a correctional facility during that year.

While inmates are not typically infected while incarcerated, these facilities provide a unique, but frequently missed, opportunity to reach some of the highest risk populations with HIV prevention and care. In 1999, CDC provided $7 million to state and city health departments to develop HIV prevention programs in correctional facilities to reach high-risk minority populations, including Latinos, who represent 25% of the U.S. prison population.


Targeted HIV Testing Campaign

In 1999, CDC began developing a national campaign to increase HIV testing among individuals at greatest risk for HIV infection. HIV counseling and testing provides an important pathway to prevention and treatment for both infected and at risk populations. The campaign, "X AIDS", will use highly targeted strategies and sophisticated marketing techniques to reach Latino and other communities with messages about the value of knowing your HIV status. The campaign is part of a broader CDC effort -- the Serostatus Approach to Fighting the Epidemic (SAFE). SAFE focuses on identifying and reaching the growing population of HIV-infected people with quality prevention and other needed services.


Faith Programs

Recognizing the critical role of the faith community in mobilizing community leaders and reaching and serving those at risk, CDC established a collaboration with the faith community in 1987. By partnering with a small group of national faith organizations and schools of public health, CDC leverages relatively modest resources into remarkable programs for HIV prevention with communities of faith nationally.


Expanding Efforts to Prevent Mother-to-Child Transmission

While the number of HIV-infected infants has declined dramatically over the last several years, nearly one-quarter of infants who develop AIDS in the U.S. through mother-to-child transmission are Latino. In 1999, CDC dedicated an additional $2 million to reach high-risk Latina women with early testing and preventive therapy.


Summary of Targeted Funding to Latino Communities (in millions)
1988199319981999
State and Local Health Departments
(Community Planning)
3.455.0635.1837.54
Capacity-building and Technical Assistance3.733.714.466.71
Community-based Organizations 6.516.746.74
Other Minority Initiatives0.021.141.35 1.83
Mother-to-Child Transmission   2.00
Gay Men of Color   2.00
Correctional Facilities   1.75
TOTAL7.2016.4247.7358.57
Note: In addition to these programs specifically earmarked for Latinos, a significant proportion of CDC's overall surveillance, research and program budget benefits Latinos at greatest risk.


"We need to take personal responsibility for the epidemic. We ought to be looking into our own families and communities for lasting solutions to this grave threat to our future."

-- Dr. Rafael Campo,
Harvard Medical School and
Beth Israel Deaconess Medical Center in Boston


Looking to the Future

Few communities, on their own, have the resources and expertise to defeat an enemy as complex and threatening as HIV/AIDS. The task is even more daunting for communities that have been historically underserved. Conversely, even the best public health programs will fail without the energetic support and involvement of affected communities.

Through years of working together, CDC and Latino communities have forged an important partnership to respond to HIV/AIDS. Yet, more -- much more -- must be done if we are to turn the tide against the disease in diverse Latino communities.

Additional resources must be devoted to HIV prevention research and services, and surveillance systems must improve to permit the timely deployment of prevention programs in response to changing circumstances.

As important as the public health response, though, is the mobilization of diverse Latino communities, organizations, and institutions throughout the country. More Latino organizations must become involved in the response to AIDS, and sectors of the Latino population that have remained on the sidelines must join in this fight.

There are important signs that this essential community mobilization is beginning to occur. CDC is committed to working in partnership with Latino communities to ensure that all people in the United States have the hope of enjoying a future without HIV and AIDS.


"Effective communication can definitively increase knowledge, promote behavior modification, and open new channels of communication on sexuality within Hispanic communities."

-- Carlos Soles,
HIV/STD/TB Project Coordinator,
National Council of La Raza


References

  1. Selik, R.M. et al. "Birthplace and the Risk of AIDS among Hispanics in the United States." Am J Public Health, 1989; 79:836-839.

  2. "Differences by Ancestry in Sociodemographics and Risk Behaviors among Latinos with AIDS." Ethnicity Dis, 1997; 7:200-206.

  3. Diaz, Theresa et al. "AIDS Trends among Hispanics in the United States." Am J Public Health, 1993; 83:504-509

  4. Klevens, Ruth Monina et al. "Trends in AIDS Among Hispanics in the United States, 1991-1996." Am J Public Health, 1999; 89:1-3.

  5. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 1998, No. 2.

  6. Diaz, Theresa et al. "Differences by Ancestry in Sociodemographics and Risk Behaviors among Latinos with AIDS." Ethnicity Dis, 1997; 7:200-206.

  7. Murphy, James et al. "Epidemiology of AIDS Among Hispanics in Chicago." Jou of AIDS and Human Retrovirology, 1996; 11:83-87.

  8. Flaskerud, Jacquelyn H. et al. "Directions for AIDS Education for Hispanic Women Based on Analyses of Survey Findings." Public Health Reports, 108, 298-304, 1993.

  9. Nyamathi A. et al. "AIDS-related Knowledge, Perceptions, and Behaviors among Impoverished Minority Women." Am J Public Health, 1993;83:65-71.




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