It may come as a surprise to know that of the roughly 11 million Mexican-born migrant workers currently living in the United States, recent immigrants -- though poorer -- are healthier in several ways than the average American. But the longer they "acculturate" here, the worse their health gets. For migrant workers who have a chronic disease, this is a particular problem. Not only are they unlikely to get the regular checkups and basic care needed to stay healthy, they often fail to get proper treatment for life-threatening illnesses, including HIV/AIDS.
Perhaps more than any other illness, HIV/AIDS exposes the shortfall of health care for migrant workers, says Vivian Levy, MD, an adjunct clinical instructor of infectious diseases and geographic medicine at Stanford University School of Medicine. Levy and her colleagues recently studied a group of 391 HIV patients at a Northern California clinic. Seventy-four of those patients were Hispanic immigrants, including migrant workers. Remarkably, they were six times more likely than U.S.-born Hispanics to have the disease reach an advanced state before getting medical care. Early treatment for HIV is crucial, Levy says, and such delays can be deadly for both the patient and others in the community. "Prompt treatment with antiretroviral drugs can control the disease and reduce the chance of spreading the virus to others," she says.
There's no way to know exactly how many migrant workers in the United States are infected with HIV, says George Lemp, DrPH, director of the Universitywide AIDS Research Program (UARP) at the University of California at Berkeley. However, a 2008 pilot study of the sex habits of 458 male Mexican migrant workers in California hints at the potential for widespread HIV infection. The researchers found that risky behavior such as sex with prostitutes or sex while under the influence of alcohol increased by 11.3 percent and 16.7 percent respectively after arriving in the United States. With the rise in these high-risk sex behaviors, researchers see the makings of a possible calamity.
What's more, the living conditions and overall quality of life for migrant workers is degrading and can destroy their sense of self-worth, says Lemp. "I've seen workers in Northern San Diego County living in boxes or sleeping in the hills above the fields. Or there could easily be 15 to 20 guys living in one place," he says. "Faced with such dismal living conditions, many workers get involved in drugs and engage in unprotected and [otherwise] risky sexual behavior." Lack of jobs and poverty may be pushing others toward unprotected sex for hire. Some migrant workers in Northern California have told employers that day laborers are regularly solicited for sex by North American men and women as they wait for jobs in construction.
Social isolation may be the main thing that has protected Mexican migrant workers, Lemp says. Because they tend to stick together -- and because HIV isn't especially common in the country that they once called home -- they don't have many chances to get infected. However, says Lemp, if they're going outside of their community to bars or brothels where HIV may be more common and easier to pick up, the disease could quickly explode. "If we can't reduce risky behavior, we could have an epidemic," he says.
The AIDS Drug Assistance Program (ADAP) allows undocumented workers in California to get treatment for HIV/AIDS even if they aren't in the country legally. Still, there are many reasons why undocumented workers may be reluctant to get help, Levy says. "They can be afraid to show themselves if they are not legally documented, and they can be afraid of the costs," she says. Interviews with patients also uncovered a deep stigma around the disease. One patient said that "Since I told my family I have HIV, my wife's family does not talk to me. They do not dress my son with the clothes I send him." Such stigma could easily keep someone from getting tested for HIV even if they think they might be infected, Levy says.
Many workers don't know enough about the disease to even realize they might be at risk. As one worker told Levy and her colleagues, "I have no idea how I was infected with this. I am a clean, honest person." Another worker asked, "How did I get this? Can I pass it on to my children?"
Disease on the move
Around the world, migrant workers play a large role in the spread of HIV/AIDS from country to country and from region to region. In this part of the world, the disease seems to flow mainly in one direction: south. As far as anyone can tell, few Mexican migrants actually bring the disease with them when they cross into the United States. In 2002, researchers from San Diego State University ran HIV tests on more than 1,000 Mexican migrants entering the United States through Tijuana. Although some of the migrants had risk factors for infection, not a single one of them tested positive for the virus.
Levy estimates that most migrants who become infected with HIV contract the virus within their first five years in the United States. These infected migrants then bring the disease back with them during visits to their home towns in Mexico. "They end up bringing the disease from a place with a high prevalence of HIV, like Los Angeles, to rural areas where the disease is much less common," Levy says.
Levy and other experts are currently pushing for more aggressive screening and treatment of HIV/AIDS in the migrant worker population. A key part of the approach would be providing more voluntary bilingual counseling and HIV testing in areas with many migrant workers.
Lemp's organization has funded a few scattered projects showing that culturally sensitive outreach -- including Spanish-language comic books -- can dramatically increase the use of condoms. But such programs have reached only a tiny fraction of migrant workers. "Because of the state budget, there's no large-scale effort to prevent HIV in migrant workers," he says. For similar reasons, it's been a few years since anyone has checked the HIV rates in the migrant community. For all we know, Lemp says, his warnings of an epidemic may have already come true.
Interview with Vivian Levy, MD, adjunct clinical instructor of infectious diseases and geographic medicine at Stanford University School of Medicine
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