Now that the new "public charge" rule filed by the Department of Homeland Security is scheduled to take effect on Oct. 15, public health officials and providers of HIV programs say they are hearing that some immigrants with HIV are considering ending treatment in order to avoid jeopardizing their chances or other family members' dreams of obtaining a green card or permanent residence in the United States.
"The rule not only makes it more difficult for people living with HIV, hepatitis, and other chronic conditions to enter this country or apply for a green card, but it has also had a much broader chilling effect on access to a range of public health and health care services beyond the scope of the rule," said Terrance Moore, former acting executive director with NASTAD. NASTAD is nonprofit association that represents public health officials who administer HIV and hepatitis programs in the U.S. and around the world.
The public charge rule is not new. It has been one of the oldest provisions within federal immigration law that require legal residents applying for a green card to prove that they are "self-sufficient" and won't be a financial burden to the federal government.
What the Trump administration is doing is redefining the policy by expanding the list of federal subsidies that authorities can consider a "public charge." It would now include types of federal assistance that were previously excluded, such as Medicaid, nutrition assistance programs, and housing subsidies, like Section 8. It also raises the income requirements to at least $26,663 for a family of three.
The highly controversial rule is setting the alarm among HIV advocates. They are warning that this measure will be counter-productive to all the ground achieved in the fight against the spread of HIV.
The inclusion of Medicaid in particular directly impacts many receiving HIV treatment, since Medicaid is the largest source of health coverage for people with HIV.
The passage of the Affordable Care Act during the Obama administration expanded access to Medicaid, including for those with HIV. Federal and state health care subsidies have helped local governments to focus their efforts on reaching people not in care to bring the number of new infections down, given that 80% of new HIV cases are transmitted by people who are not aware they have HIV or are not in care.
Alejandro Acosta, HIV project coordinator from Equality Florida, an LGBT organization in St. Petersburg, says President Trump is not only contradicting his own plan to eradicate HIV but also is "compromising" national public health. Earlier this year, President Trump released his plan, called Ending the HIV Epidemic: A Plan for America, aiming to cut new HIV transmission by 90% by 2030.
"When we talk about access [to treatment], it is contradictory to his message of eliminating HIV. It should be for everybody regardless of immigration [status]," he said.
Florida is among the five states with the highest number of people with HIV. The others are California, Texas, New York, and Georgia.
In New York, Amanda Lugg of African Services Committee, an HIV care provider based in Harlem that serves mostly immigrants from Africa and the Caribbean, said that the policy is just "another attack on family-based immigration" to prevent family reunification. "That's what they are trying to stop, even though immigrants have the legal right to do so," she said.
She went on to say that the policy is discriminatory to those most vulnerable. "If you are trying to adjust your immigration status and you are HIV positive, that in itself is a disadvantage, as HIV is listed as a disability," she said. "If you are uninsured, it is a double negative."
Activists like Lugg are optimistic that the list of legal challenges against it in multiple states will push back the date it would take effect or even stop it. She is advising everyone not to stop treatment and recommends that individuals with HIV consult a lawyer, considering that every immigration case is different.
Two counties in California, including San Francisco, filed a joint injunction to stop the "public charge" policy. It charges the new measure would cause "irreparable harm" to their counties. "The risk of infectious disease will rise, forcing counties to make greater financial outlays to try to protect their communities," the document says.
New York State Attorney General Letitia James, joined by the City of New York and the states of Connecticut and Vermont, also filed a lawsuit alleging that the Trump administration is targeting immigrants of color and putting communities at risk. This lawsuit is challenging the new rule on the grounds that it violates the federal Administrative Procedure Act (the way federal agencies enforce regulations) and even the Constitution.
A December 2018 report by New York City estimated that 304,000 low- and middle-income New Yorkers would be discouraged from participating in public benefits because of the rule. The estimates included 72,000 children who are U.S. citizens and 29,000 people with disabilities.
By June of this year, in another analysis, New York City confirmed that the enrollment numbers for SNAP, the food stamp program, had gone down. Although officials say this can't prove that the public charge policy announcement is a factor, they did find correlation with anecdotal evidence and survey data.
The Affected Communities
About 1.2 million people in the U.S. live with HIV. Roughly 40,000 new cases are diagnosed each year. One in seven are unaware of their status. According to a study by the Centers for Disease Control and Prevention, in 46 U.S. states and five U.S. territories that reported new diagnoses of HIV from 2007 through 2010, 16.2% of those newly diagnosed were born outside the United States.
In New York, a 2017 report by New York City health officials found that 33% of city residents newly diagnosed with HIV were born outside the U.S. Jacquelyn Kilmer, CEO of Harlem United, one of the city's largest HIV providers, says the number of those with HIV may be larger, given that disclosing immigration status is not required in order to be tested or to receive HIV treatment.
She highlights that aside from language barriers, cultural beliefs and stigma have been the biggest barriers to reach immigrant people with HIV. "Trump's immigration policy is another barrier we didn't need," she added.
To approve a green card or request permanent status, federal officials need to -- at a minimum -- take into account a list of factors, such as health; family status; assets, resources, and financial status; and education and skills.
Immigrants face multiple disadvantages. Although most hold full-time jobs, they are less likely to have health care coverage through their employer, making Medicaid an option to subsidize the expensive costs of HIV treatment.
Black immigrants are less likely to be uninsured than U.S.-born black individuals, and
immigrants from Mexico and Central America constitute the largest proportion of non-U.S.-born individuals living with HIV in the United States.
Providers in New York highlight that not all of the state's subsidized health care plan is federal. States and cities like New York heavily fund HIV programs, and anything funded by local government does not fall into the federal "public charge" category.
It Is Changing How Organizations Are Doing Outreach
Luis Scaccabarrozzi from the Latino Commission on AIDS (LCOA) in New York says that this policy is adding another layer of fear to immigrants' lives. "We have homophobia, transphobia, xenophobia -- or what we call Latino phobia -- and now this," he says. "It has forced us to change how we are communicating."
Organizations like LCOA work with many other organizations, including faith-based communities, to do outreach, but the fact that churches have been targeted by ICE agents waiting outside is forcing them to rethink the process of reaching out to the community.
"No HIV organization has been targeted yet that we know, but we are seeing [homeless] shelters [targeted by ICE]," he said.