Via a Spanish translator, Daniel speaks carefully, his asylum case in mind. The 45-year-old gay man, who says he was diagnosed with HIV in 2010, recounts how he came to Miami from Caracas, Venezuela, on a tourist visa last year and immediately filed an asylum claim, saying he felt endangered as a gay man in Venezuela, bullied by authorities. But now that he is in Miami, he is also receiving HIV treatment and care via the federal/state Ryan White CARE Act/AIDS Drug Assistance Program (ADAP). Daniel says that after Venezuela's descent into economic and political chaos in recent years, his access to his HIV meds became sporadic.
"The state is having a crisis," he says. "I would get my HIV meds one month but not the next."
Daniel is now among countless HIV-positive Latinx immigrant men who have sex with men (MSM) living in the U.S., some documented, some not. They're part of a larger population of Latinx MSM, among whom the Centers for Disease Control and Prevention (CDC) reported recently that HIV rates were rising, even as they were dropping slightly among white MSM and remaining stable (although disproportionately high) among black MSM. But as the Trump administration cracks down on immigrants, advocates say that such a climate makes reversing HIV rates in Latinx gay men all the harder.
That is not to say that Latinx MSM's HIV rates are rising because of immigrants, according to Oscar Lopez of Valley AIDS Council, in the Texas border town of Brownsville, which serves about 2,000 HIV-positive clients. "These rates have been climbing for multiple years," he says. "But I think fears around deportation and racism toward immigrants, feeling unsafe, and the stress of having to provide for your family all contribute toward poor mental health and the potential to abuse substances and expose yourself to HIV. We're starting to see this definite pattern" around Latinx MSM immigrants, he says.
In the Trump era, amid a string of hostile policies toward immigrants, MSM are certainly not the only Latinx people or immigrants experiencing extreme stress and anxiety.
But now comes yet another stressor: In late September, the Trump administration released a proposed rule that would make it harder for documented immigrants to get green cards if they receive public assistance, including Medicaid, food stamps, and housing subsidies.
The proposal, if enacted (it will enter a 60-day public comment period once put on the Federal Register), would impact countless immigrants from many countries. That would certainly include documented Latinx MSM who rely on these programs for themselves or their family members.
Thus far, it doesn't appear that the proposal includes HIV services under the Ryan White CARE Act/ADAP, one of the few health programs accessible to undocumented immigrants, according to Mark Hannay, director of Metro New York Health Care for All Campaign, which works on such issues. "But again," he says, "until we see what's officially put out, nothing is for certain yet."
According to advocates for Latinx MSM immigrants, many factors create challenges to getting them tested for HIV and then keeping them in care. Luis Scaccabarrozzi, vice president of the Latino Commission on AIDS (LCOA), says that approximately 60% of new HIV cases among Latinx MSM are among foreign-born and immigrant men. In the first months of the Trump administration, he says, "We saw a rise in calls from people with HIV in [immigration] detention centers, mostly in California and Texas, who said they weren't getting their HIV meds. They knew they were being deported." Unlike in the Obama administration, he says, "ICE [Immigration and Customs Enforcement] had been waiting for them as they exited their political asylum hearings."
Shame and stigma also play a role. According to Leandro Rodriguez, director of programs at LCOA, he had an undocumented client recently in NYC who tested positive for HIV but rejected available physical and mental health care for fear that his family, whom he was living with, would come across his meds or his paperwork and learn that he was both gay and HIV positive. He killed himself.
The outcome might have been different, says Rodriguez, "if he'd been able to access his own housing." (However, unlike with ADAP, one must be documented to access HASA, New York City's housing support for low-income people living with HIV/AIDS.)
"We still have families not wanting to face that their son or daughter is gay," says Wilfredo Morel, director of Hispanic health for Hudson River Health Care in New York's Hudson Valley north of New York City, home to many undocumented Latinx workers, including migrant farmworkers. In small town and rural settings, particularly, he says, Latinx MSM may be afraid to come forward for treatment and care. That's why his agency plays a role in LGBT community events in the area, he says: to get out the word that they are there for MSM Latinx even if families are not.
On top of this, many advocates feel that HIV services for Latinx people have been underdeveloped and underfunded. "It's rare to have providers with a background in immigrants, HIV, and MSM who also speak Spanish," says Rodriguez.
Awareness of the epidemic among Latinx has lagged, says Stephen Fallon, executive director of Latinos Salud, which serves Latinx MSM in the Miami area. "Currently we have an explosion of consciousness-raising and prevention funding going to the transgender population, which is very much needed," he says, "but there haven't really been sufficient resources and a heavy enough lift to examine what has let this epidemic happen to the Latino community."
His agency's HIV-positive Latinx MSM clients break down into two groups, he says: "First we have guys coming here HIV negative from homophobic countries who've lived closeted most of their lives. It's exhilarating to be out and gay here, but sometimes they're exploited in the sex-for-security trade and economic insecurity leads them to compromising decisions" resulting in HIV acquisition.
Then, he says, there are already HIV-positive men leaving countries in upheaval, such as Venezuela or Puerto Rico after last year's Hurricane Maria, in search of stable HIV care and treatment. "They're coming here to stay alive," he says. "Many of them reach out to us in advance and come sign up for services the day after they get here."
A Federal Role?
Many advocates say that federal leaders have to play a bigger role in addressing the epidemic among Latinx MSMs. According to Charles King, founder of the NYC AIDS agency Housing Works, the national ACT NOW: END AIDS coalition, which he co-chairs, will soon be submitting recommendations to the Trump administration as it looks to rewrite a national AIDS strategy. The group's recommendations for reversing the epidemic among immigrants include the passage of comprehensive immigration reform that would legalize all undocumented immigrants with no serious criminal offenses, plus the rejection of proposed rules to further penalize green card seekers who access public benefits. These recommendations might seem pie-in-the-sky during such an anti-immigration administration.
A greater role is also required of the CDC, say advocates, adding that officials there, including Eugene McCray, M.D., who heads the CDC's Division of HIV/AIDS, have recently had meetings with them about the epidemic among Latinx MSM.
In an email, CDC representative Donnica Smalls acknowledged that "Latino gay and bisexual males experience factors that may increase their HIV risk," including the fact that such men "are geographically concentrated -- meaning some areas have high prevalence of HIV that, if not diagnosed and effectively treated, may spread within communities." She noted that, during 2010-2014, 84% of the increase in the number of HIV diagnoses among Latinx MSM was attributed to increases in Arizona, California, Florida, Illinois, New York, Texas, and Puerto Rico.
She also wrote that CDC was supporting prevention and programmatic efforts toward improving prevention and treatment outcomes for Latinx MSM, including data collection and analysis, research, health department and community-based organization funding, and social marketing campaigns.
For example, the CDC's recently funded Integrated HIV Surveillance and Prevention Programs for Health Departments focuses, in part, on supporting uptake of pre-exposure prophylaxis (PrEP, the HIV-preventing drug Truvada [FTC/tenofovir disoproxil fumarate]), and reducing HIV risk behaviors among Latinx MSM who are at high risk for HIV.
The CDC also funded a project, she wrote, that implements a strategy to pinpoint networks that include Latinx MSM in which active transmission is occurring and to deliver a combination of prevention services to the networks. Four directly funded state and local health departments -- New York state, Texas, New York City and Houston -- will conduct these activities. Finally, Smalls confirmed that the CDC has begun a series of discussions with leading Latinx HIV partners. "CDC aims to continue finding additional culturally sensitive and effective ways to prevent HIV by working with partners who understand the distinct experiences of Latino gay and bisexual males in their communities," she wrote.
But Scaccabarrozzi says that more is needed from the CDC. "I would like CDC to be really open about this and say that, right now, this community is quite vulnerable and needs its own special push for HIV testing and connection to care with culturally and linguistically competent programs," he says. "I want to see a press release from them that is solely about Latino MSMs." He also questioned how many high-level Latinx people were working on this issue at the CDC -- and pointed out that the programs Smalls mentioned were all developed in communities other than Latinx ones, then translated into Spanish.
In reply, Smalls wrote that "CDC ensures interventions are adapted to meet the needs of the diverse Latino populations disproportionately affected by HIV." She mentioned the Start Talking. Stop HIV. (STSH) campaign, launched in May 2014, which she says was designed to reach all gay and bisexual men -- and which reached out to people and groups with Latinx MSM expertise for feedback. "One-third of the research participants in these consultations were Latino gay and bisexual men," said Smalls.
However, she did not reply to two queries asking how many high-level Latinx people were working on this issue at the CDC and whether the CDC intended to issue a press release specifically about rising HIV rates among Latinx MSM.
Beyond the CDC, however, advocates concede that, amid an administration that is hostile to both immigrants and increased access to health care, the burden of trying to reverse rising HIV rates among Latinx MSM may fall, for the time being, on states, communities, and nonprofit networks.
"Many of us who work with undocumented immigrants are starting to see them fall out of care [due to fear of accessing government programs], and while we want answers from the federal government, we're also afraid to bring it up lest we get unwanted attention from them," says Lopez.
So, for time being, he says, "We're trying to have very candid conversations with clients when they come in about who in their household may or may not be documented, about whether they have legal representation, about whether they feel safe getting to and from our office. If they don't, we offer it."
His agency is also offering an upcoming client conference to address some of these issues and fears. "We'll talk about trying to make sure your children go to a family member or a friend instead of foster care if you get deported," he says. "The fact that we have to have these scary conversations is very unfortunate."
One of these conversations involves urging clients to open up about their HIV status to at least one family member or friend, "so they can bring your meds and paperwork if you're picked up by ICE or Border Patrol or deported. We're trying to empower clients to do this, but it's very challenging."
In Miami, Latinos Salud hosts dance parties complete with an open bar and drag performers to bring together Latinx MSM -- then interrupts the party with a presentation about how to get on free PrEP, which Florida will start to make available this month. "People pull out their phones and start taking pictures, which is amazing," says Fallon, adding that agency also accompanies clients to health care appointments with Spanish translators.
Meanwhile, as advocates do their best to help Latinx MSM in a tricky political climate, Daniel in Miami is biding his time amid his asylum proceeding, trying to stay fit and learning English. He hopes to obtain his green card, then one day go to school and become an HIV prevention specialist for the Latinx community. "I have no family here, but thankfully I've made some supportive friends," he says. "I'm afraid to go back to my country."