HIV/STD Prevention among Latino Migrants

1. HIV/STD Prevention among Latino Migrants Thomas Painter, Ph.D. Centers for Disease Control and Prevention Atlanta, Georgia Latino/Hispanic HIV Community Research Forum: Creando una Red para un Futuro sin VIH/SIDA July 22, 2012 Washington, D.C. The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

2. How many Latino migrants are there in the U.S.? • No accurate figures • In 2009, an estimated 9 million foreign-born, undocumented persons in the U.S. were from Mexico or other Latin American countries • Can we use this as crude a proxy measure? • For this presentation: Migrants = migrants & immigrants

3. What do we know about HIV and STD infection among Latino migrants? • No surveillance-based information is available • Recent studies (mostly in CA) report HIV infection rates of zero to 1.8% (2004 to 2012) • STD infection rates tend to be higher, but also vary • Despite relatively low HIV infection rates, studies describe risk-increasing actions among migrants • Evidence from Mexico suggests that HIV infection is spreading in part due to effects of the migratory process

4. What makes Latino migrants vulnerable to HIV and STD infection? • Migrants’ circumstances • Migrants’ actions Migrants’ circumstances shape their actions that shape their risks of infection • Frequent mobility • Disrupted family relationships; not accompanied by spouses • Weaker social controls on risk behaviors in U.S. settings • Social and geographic isolation, loneliness, depression • Residence and socializing in areas – urban apartment complexes or rural agricultural camps - where men may outnumber women, increasing the likelihood of alcohol consumption (binge drinking), drug use, and transactional sex.

5. What makes Latino migrants vulnerable to HIV and STD infection? Migrants’ circumstances shape their access HIV/STD prevention, care, and health promotion in general • Low wages, poverty, unemployment, and underemployment • Substandard housing and homelessness • Limited health insurance coverage • Undocumented status and associated risks and fears of discovery, detention, and deportation • Limited education and English-language proficiency; limited or no Spanish proficiency among speakers of indigenous languages • Limited access to culturally and linguistically appropriate information about HIV/STD prevention, health promotion, and care services • Satisfying basic material needs may outweigh concerns about HIV/STD risks

6. What makes Latino migrants vulnerable to HIV and STD infection? Migrants’ actions can increase their risks of infection • Sex with multiple partners • Unprotected sex by men with female sex workers • Some studies report high rates of condom use with female sex workers • Condom use may decline as migrants get to know their sex worker partners • Unprotected sex by men with other men who may or may not be sex workers • 22% of mostly Latino male migrants (n=1673) in a 5-state CDC rapid HIV testing project reported sex with other men during the past year • Unprotected sex with spouses and regular sex partners • Alcohol (beer) consumption, drug use associated with sex

7. What makes Latino migrants vulnerable to HIV and STD infection? Summing up • Studies frequently describe circumstances and actions that can increase migrants’ risks of infection • Studies may also describe relatively low HIV infection rates among Latino migrants • A Latino migrant paradox? • Evidence from Mexico suggests that HIV infection is spreading due in part to the migratory process

8. What are some resources for HIV/STD prevention among Latino migrants? • Evidence-based behavioral interventions designed for Latino migrants Some promising beginnings…. Tres Hombres Sin Fronteras (Three Men without Borders), for male Mexican farmworkers, evaluated in northern San Diego County, California between 1991 and 1995. • Used fotonovelas and radionovelas • Delivered as four weekly 2-hour group sessions • Intervention participants reported increased condom use with female sex workers at one month follow-up (included comparison condition) • Not currently being delivered

9. What are some resources for HIV/STD prevention among Latino migrants? Pilot intervention for Mexican migrant day laborers, evaluated in Berkeley, California in 2003 • Used vignettes and large loteria-like cards to illustrate risk behaviors • Delivered as three 2-hour group sessions during a single week • Increased protective actions by intervention participants at one month follow-up (pre- post- measures without comparison condition) • Not currently being delivered Both interventions were designed for low-literacy Latino migrants and incorporate elements of Latino popular culture Not included in CDC’s Compendium of Evidence-Based HIV Prevention Interventions

10. What are some resources for HIV/STD prevention among Latino migrants? More recent developments… HoMBReS (Hombres Manteniendo Bienestar y Relaciones Saludables - Men Maintaining Wellbeing and Healthy Relationships), a community-based intervention for recent immigrant, mostly Mexican farm and construction workers in central North Carolina; evaluated in 2009 • Soccer league members were selected by team mates for Navegante training, to offer guidance and support to others based on HoMBReS components • No formalized delivery of intervention activities • Navegantes worked with teammates and other Latino community members for 18 months

11. What are some resources for HIV/STD prevention among Latino migrants? HoMBReS(cont’d.) • Soccer team members who received Navegantes’ assistance reported greater increases in consistent condom use and HIV testing than comparison participants at 18 month follow-up • CDC added HoMBReS to the Compendium of Evidence-Based HIV Prevention Interventionsin 2011 as a Best Evidence community-level intervention • HoMBReS is the first immigrant (and migrant?) –focused intervention to be listed by CDC in the Compendium • Being packaged by Sociometrics for dissemination • Currently being delivered in central NC

12. What are some resources for HIV/STD prevention among Latino migrants? HoMBReS-2 • A small group intervention for the same North Carolina Latino populations as HoMBReS; evaluated in 2011 • Men were trained to serve as compañeros de salud (peer educators) to deliver the intervention • Delivered as 4-hour sessions on two consecutive Saturdays • More intervention participants than comparison participants reported consistent condom use and HIV testing at 3-month follow-up • Not currently being delivered • No known plans to package for dissemination

13. What are some resources for HIV/STD prevention among Latino migrants? 2. Adaptations of evidence-based interventions for use with Latino migrants The Young Latino Promotoresintervention for young migrant Latino men who have sex with men was adapted by a CBO from the Popular Opinion Leader intervention for gay men; evaluated in 2003-2004 • Participants reported a reduction in risk behaviors at 1 and 2-year follow-ups (pre- post- measures without comparison condition) • Last known delivery to Latino migrant farmworkers was in 2007 in San Diego County • Not currently being delivered

14. What are some resources for HIV/STD prevention among Latino migrants? Safety Countsaims to reduce drug- and sex-related risk actions among out-of-treatment drug users, and was adapted for use with Latino migrant farmworkers who use drugs • Effectiveness of the adaptation has not been evaluated • Being piloted in a small number of states 3. Other approaches to HIV/STD prevention education • Promotores de salud • Popular, culturally appropriate, but effectiveness not well-evaluated Summing up • There is a severe shortage of effective, available interventions for Latino migrants

15. What’s missing from prevention interventions for Latino migrants? • Women-- Most interventions are for men • Couples– Most interventions focus on individuals • Many HIV/STD risks are managed within couple relationships • Urban-based migrants-- Most interventions focus on farmworkers or rural based Latinos • Urban-based migrants may outnumber rural-based migrants • Many rural-based migrants are not farmworkers • Indigenous languages-- Most interventions are delivered in Spanish • A focus on circumstantial/structural factors that can affect migrants’ actions-- Most interventions focus on individual-level change • Community-level interventions may get at this Prevention interventions are needed to fill these gaps

16. Some considerations for prevention-related research - 1 Patterns of cyclical movement by Latino migrants are changing: more settling out, often as undocumented (or documented) individuals; less movement to the U.S. • Enforcement actions by ICE make cross-border movement difficult; better to stay in the U.S. (or at home) • Threats of violence during transit to and from the U.S.; better to stay in the U.S. (or at home) • Migrants’ families have joined them in the U.S • State and national-level policies and actions limit migrants’ access to jobs, transportation, housing, health, and other services • The slow-down in migrant-absorbing sectors of the U.S. economy • Deportations have increased • How have these changes affected migrants’ HIV/STD risks? • Do these changes create novel needs or opportunities for prevention?

17. Some considerations for prevention-related research - 2 How do we explain the apparent Latino migrant paradox? • Studies describe frequent actions by Latino migrants that can increase their HIV/STD risks • HIV infection rates among tested migrants are relatively low • Do migrants’ sexual networks have low levels of HIV infection? • Are migrants engaging in protective actions?

18. Some considerations for prevention-related research - 3 How can HIV/STD prevention efforts for Latino migrants benefit from resilience and social capitalin their communities? • What are the features and functions of migrants’ social support networks? • How do they shape migrants’ risk and protective actions? • Do these networks represent a community-based resource for HIV/STD prevention and health promotion efforts?

19. Thank you Thomas M. Painter tcp2@cdc.gov 404-639-6113 National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of HIV/AIDS Prevention, Prevention Research Branch 13