Immigrant women living with HIV often juggle multiple identities, all of which are the target of discrimination and stigma: HIV status, female gender, person of color, foreign accent and/or poor command of English. Many also come from countries with a high prevalence of HIV and/or have experienced trauma and abuse during their journey to the U.S. These disadvantages are compounded by policies that prevent immigrants' access to health insurance, fear of immigration enforcement, low socio-economic status and cultural belief systems that may be at odds with mainstream U.S. health care practices, panelists pointed out on the recent Health Beyond Borders: A Look at Immigrant Women on World AIDS Day webinar sponsored by the 30 for 30 Campaign.
Demographic information on HIV rates is often provided by race or ethnicity, for example, lumping foreign-born and U.S.-born blacks into one category, the African Services Committee (ASC) explained. There is some data on immigrants from Africa, though. The rate of HIV diagnoses in that community is about six times that of the general U.S. population, with 70% of these diagnoses among women, Amanda Lugg of ASC said.
Women who immigrated to the U.S. from Africa face a different set of challenges from African-American women. For one thing, many of the immigrant women come from countries with high HIV prevalence rates, speak limited English and may be afraid of deportation if they access any services -- including HIV testing and care. The women may also have suffered female genital mutilation or the trauma of war and displacement. To overcome such obstacles, ASC not only operates an HIV clinic, but also provides escorts for appointments with government institutions, legal help for immigration questions, ESL (English as a second language) classes, housing assistance and other services.
While the organization primarily serves people who recently arrived in the U.S. from Africa, its services are open to all. A significant number of ASC's clients are transgender Latinx women. The clinic's location in Harlem means they are unlikely to encounter someone from their own community there, thereby avoiding the stigma they might otherwise face. There is also a single waiting area, so someone visiting the facility could claim to be there for the food pantry or prenatal care, when they are in fact seeing an HIV doctor.
HIV rates among Latinx women are four times that of white women, although no statistics are available for U.S.-born versus foreign-born Latinas, Claudia Flores of the National Latina Institute for Reproductive Health (NLIRH) noted. Fear of immigration enforcement is a major issue in this community, even among U.S. citizens by birth. One 2015 study found that 45% of foreign-born callers to a domestic violence hotline said they were afraid to seek help because of their immigration situation; even 12% of U.S.-born callers expressed that fear. Flores suggested that the concept of sanctuaries could be used to ensure that clinics, hospitals and other medical facilities remain free of immigration enforcement officers.
All immigrants also face legal barriers to accessing health insurance. For five years after their arrival in the U.S., they cannot enroll in Medicaid or the Children's Health Insurance Program, even if their immigration status is documented. The Affordable Care Act specifically excludes anyone who is undocumented from signing up for subsidized health insurance. This prohibition includes those covered by the Deferred Action for Childhood Arrivals act.
If medical care is accessed, hospitals and clinics can be confusing to navigate for non-English speakers, the San Francisco AIDS Foundation (SFAF) noted. Having Spanish-speaking staff may not be enough for women who arrive in the U.S. from Central America, because those from rural areas may speak limited Spanish, communicating instead in local languages such as Quechua or Tzotzil. The focus on HIV testing among men who have sex with men means that testing women is not prioritized, Jorge Zepeda of SFAF said. Once tested, family responsibilities may also interfere with retention in care. He shared the story of Gabriela, who cares for three children and whose husband works two jobs to make ends meet. She sometimes has neither the time nor the childcare arrangements to go to her doctor's appointments.
The 30 for 30 Campaign has written a briefing paper with recommendations for policies that would address some of these issues. It proposes stigma reduction efforts, language services to overcome distrust of the health care system, removal of immigration status-based barriers to health insurance access and better data collection that separates information by country of origin, among others.