Latinos and HIV epidemic

[Editor's note: This is the first in a two-part series that examines the HIV/AIDS epidemic among Latinos in the United States. In this issue are stories about the extent of the problem and about an effective intervention that is aimed at reducing HIV transmission among Latino youths. In the January 2008 issue of AIDS Alert, there will be an article about an HIV intervention that spreads HIV education and condoms to Latino men in the rural, Southeastern United States.]

CDC is working on action plan to target HIV epidemic among US Latino population

Recent MMWR highlights concern

Nationally, public health agencies are turning their focus to the HIV epidemic in the Latino community, but some say it's long overdue.

"We're 25 years into this epidemic, and very little has been done addressing the Latino communities directly," says Jesus Ramirez-Valles, PhD, MPH, an associate professor in the School of Public Health of the University of Illinois at Chicago.

There has been too little basic research done to understand the epidemic's impact on Hispanics, and there have been too few prevention interventions studied and developed, Ramirez-Valles says.

"We know little about how Latinos are doing with therapists, talking about adherence, and quality-of-life issues," he says. "We have limited data on what's happening in Latino communities."

Hispanics in the United States are second only to African Americans in being disproportionately affected by the HIV epidemic.

According to the latest data available from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, 18.9 percent of people who received an AIDS diagnosis in 2007 were Hispanic, while Hispanics were 14.4 percent of the U.S. population in 2005.1

Yet there are few prevention interventions and public campaigns aimed at reducing HIV transmission specifically in this population.

"The CDC doesn't have one intervention that's appropriate for Latino men," says Scott D. Rhodes, PhD, MPH, an associate professor at Wake Forest University, division of public health sciences, in Winston-Salem, NC.

The main reasons why the Latino community has been sidelined in HIV/AIDS research and public health focus are three-fold, Ramirez-Valles says.

"First of all, although the Latino population is becoming a large size, Latinos still have a very limited voice in the political arena," he explains.

Secondly, when the gay white advocacy groups lobbied hard for more funding and action on the epidemic, the African American and Latino communities distanced themselves from the gay community's efforts, Ramirez-Valles says.

And lastly, there is a shortage of Latino researchers and public health officials who have the expertise to take public health leadership roles in fighting the epidemic among American Hispanics, he adds.

There have been some Latino advocacy groups working with the CDC and other government agencies to increase funding and programs directed at this population, but progress has been slow.

"I think it's terrible that in 25 years of the HIV epidemic there have been very few interventions targeting Latinos," says Antonia M. Villarruel, PhD, FAAN, a professor and the Nola J. Pender collegiate chair in health promotion and director of the Center for Health Promotion at the University of Michigan School of Nursing in Ann Arbor, MI.

For example, teenage Latinos largely have been ignored in HIV prevention research, Ramirez-Valles says.

This may change soon, however.

Villarruel and other investigators have developed a prevention intervention that is designed specifically for reducing HIV risk behaviors among Latino youths, ages 13 to 18. The CDC recently featured the intervention on its Web site as one of its examples under the Replicating Effective Programs.

Also, the CDC is in the early stages of developing an enhanced CDC action plan to target and reduce HIV infection among Hispanics, says Ken Dominguez, MD, MPH, a medical epidemiologist in the division of HIV/AIDS prevention at the CDC.

The plan also aims to increase access to culturally-appropriate care and treatment, he adds.

As part of this focused attention on the epidemic's impact on Hispanics, Dominguez participated in October in a radio media campaign.

"I was on the radio from 8 a.m. to 2 p.m. on Oct. 13, talking with numerous radio stations across the country," Dominguez says. "I gave people information about the epidemic and answered questions from Hispanic radio listeners."

One of the problems public health officials have had in developing specific prevention messages for Hispanic communities is the diversity of these communities and the diversity in their modes of transmission.

A CDC chart shows that most of the Hispanics who have been diagnosed with HIV/AIDS were born in the United States, followed by Mexico, South America, Puerto Rico, Central America, and Cuba. Also, a high number who were diagnosed have an unknown place of birth.1

"Infection rates do vary greatly by place of birth," Dominguez says.

The CDC noted a pattern in which HIV transmission via the men who have sex with men (MSM) route was more common among Hispanics who were born in the United States, South America, Cuba, and Mexico, he notes.

"Heterosexual transmission was more common among those born in Central America and the Dominican Republic, and injection drug use was more common among those born in Puerto Rico," Dominguez adds.

Another challenge involves developing Spanish-language materials, Dominguez says.

"Cuban Spanish is different from Mexican Spanish, which is a little different from Puerto Rican Spanish," he explains. "So when you develop messages you have to put them in the correct language."

These differences make it difficult to find one intervention in which culturally appropriate materials will stay appropriate for all Latino communities.

Immigration is itself a risk factor for HIV infection, especially when only the men immigrate to the United States to find jobs.

"There's loneliness when you're on your own and traveling, and there's isolation," Dominguez says. "You're separated from your partner, and this by itself makes you more likely to develop new relationships with new partners."

A further challenge is that in the past decade, Hispanic immigrants have changed patterns and moved toward smaller towns, Midwestern and Southeastern cities, and even rural areas that previously were not destinations. This makes intervention designs more complex since the health care infrastructure that's available to Latino laborers in California is entirely different from the infrastructure that's available to Latino laborers in North Carolina, for example.

"I think it's an important issue that the history of immigration from Mexico and, especially, Central America has been longstanding in California, Texas, and the Northeast," Rhodes says. "But the trends of immigration now in the United States are very different, and the Southeast's Hispanic population is growing very rapidly."

Developing HIV prevention interventions for the various Latino populations, divided culturally by nation of birth, geographically, and divided also by risk behaviors, is challenging, the experts say.

And there is very little research available to provide the basic groundwork for intervention study.

"We have a National Institutes of Health (NIH)-funded study to look at what's going on with gay Latinos in rural North Carolina," Rhodes says. "We don't know anything about what their lives are like, and so we're exploring that right now."

For example, investigators do not even have the basic information about how to reach out to rural Latino MSM, Rhodes notes.

"It's horrible that we don't know more," he adds. "Even the little we do know is based on early experiences in more urban environments, and now that the epidemic has evolved, some of that knowledge isn't applicable."

What compounds this problem is that some existing interventions targeting Latinos, and even some research, have been lost or ignored by federal funders because the research didn't meet the gold standard of having randomized, controlled trials, Ramirez-Valles says.

"I was one of the first researchers to publish an intervention for Latino gay men, but I didn't do a randomized, controlled trial, so when I asked the CDC to look at it, they wouldn't because it wasn't a randomized, controlled trial," he says.

"But there was some information you could learn from this research," Ramirez-Valles says. "By having this gold standard it eliminates a lot of knowledge we have about interventions, and it prevents us from moving forward."

The CDC recognizes that its standards for recognizing interventions poses challenges to researchers and community-based organizations, Dominguez says.

"We're in the process of bringing more of those interventions out into public use," Dominguez says. "They take a while to study and evaluate and see that they're truly effective."

Reference:

1. HIV/AIDS among Hispanics -- United States, 2001-2005. MMWR. Morb Mortal Wkly Rep. 2007;56(40):1052-1057.