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 Wednesday 16 January 2008
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GLOBAL: Uncounted and unheard - HIV-positive immigrants in the US

Photo: Laura Lopez Gonzalez/PlusNews
Immigrants make up more than 12 percent of America's population.
WASHINGTON DC, 12 November 2007 (PlusNews) - Immigrants make up more than 12 percent - about 35 million people - of America's population, but the US federal government has almost no idea of how HIV is affecting them, especially Africans.

As the federal government debates who is American enough to receive federal health care in a country built largely on immigration, state governments, non-profit organisations and community activists have been providing health services to immigrants.

Most government forms pertaining to health services do not include a box for Congolese, Angolan, Malian or any other African country. In fact, if you are an African in America, you will find yourself labelled an "African-American".

"Currently, New York City is the only place data-coding by country of origin," said Andrew Spieldenner, director of programmes for the US National Association of People with AIDS. "So nobody really knows how HIV is affecting sub-populations."

This is a problem, not only regarding HIV-surveillance data but also in the way AIDS outreach programmes are targeted at "African Americans", according to Teri Wolan, director of operations for the DC-based Ethiopian Community Development Council (ECDC).

"There's a challenge of Africans being subsumed under the category of black Americans because between the two populations there is a tension," she said. "Africans seem to relate more to white culture in America than African-American culture, while within the African-American community, immigrants are often seen as taking jobs."

The politics

A study published in the American Journal of Public Health showed that the average immigrant in the US has a much lower per capita health expenditure than their native-born neighbour.

Undocumented adult immigrants, a group often criticised for driving up social spending, make up about 3.2 percent of the US population, but account for only about 1.3 percent of state health expenditure, according to a study by the RAND Corporation, a US-based think-tank.

In the 1990s, welfare reforms greatly restricted immigrants' access to programmes like state-funded health insurance, known as Medicaid, by requiring, among other things, that they wait 5 years after obtaining permanent residency to access federal benefits. In 2005, the introduction of the Deficit Reduction Act required all persons applying for or renewing Medicaid coverage to prove US citizenship.

In June 2007, a bipartisan group of senators, with White House backing, introduced a bill proposing health care reforms that would have improved immigrant access, but the bill was opposed by both the Democratic and the Republican parties, and did not become law.

In July, the Washington Post quoted Arizona Senator John McCain on the repercussions: "You will see the states and cities scrambling to pass their own laws and regulations. You're going to get a completely contradictory set of policies."

But the policy schizophrenia McCain described has been going on for years as states, counties and the District of Colombia have used their own funds to provide immigrants, even undocumented ones, with health services.

Fighting the good fight away from the limelight

The Dennis Avenue Health Clinic in Montgomery County, just outside downtown Washington DC handles a large number of uninsured clients. The clinic - which is partially funded by the government's Ryan White HIV/AIDS Programme, created in 1990 to improve care to the uninsured or underinsured -  has seen their typical profiles change with the times and the AIDS pandemic.

"In the 1990s we saw a lot of gay white men, then came African-Americans, then Latinos and then people from sub-Saharan Africa," said Dale Schacherer, the clinic's programme manager. The clinic's data, on its own specially designed forms, is coded by country of origin.

Like many other facilities at the county level, the clinic provides patients with antiretroviral (ARV) drugs through state-run AIDS Drug Assistance Programmes (ADAP), which are also funded by the Ryan White Programme.

HIV in the district
The District of Columbia (DC) is the name given to the area surrounding
the US capital, Washington, DC
It has just under 600,000 residents.
The District of Columbia has an HIV infection rate 10 times the national average
 African-American women make up 90 percent of all infected female residents
Source: Raymond S. Blanks, member of the District's Community HIV Planning
Group (2007)
The clinic also offers voluntary counselling and testing (VCT), case management, partner notification and substance abuse programmes, as well as mental health programmes, which are scarce in organisations caring for immigrants. "Many people come here with post-traumatic stress syndrome and don't even know it," said Schacherer. "This may be especially true if they came as refugees, if they were running from something back home."

Despite the clinic's range of services, the Dennis Avenue Clinic doesn't do much publicity; word-of-mouth has brought most of the small clinic's almost 700 patients, to whom fewer and fewer federal benefits are trickling down.

Such facilities are often hesitant to publicise the work they do for fear of a backlash from those who might object to state benefits being conferred upon non-citizens. "We're very protective of our clients and we also have to keep an eye on funding," Schacherer said. "Currently there is no restriction on using ADAP funds for immigrants, but it looks as though it could go that way [being restricted]."

Knowledge is light, ignorance is darkness

"There's a lot of misinformation, a lot of fear of death as well as stigma," Schacherer said of the immigrants he works with. "Most of our clients initially don't have the understanding that if we catch it [HIV] early enough, we can treat it and keep them alive a lot longer."

Misinformation and stigma are especially rife in Washington's large Ethiopian immigrant community, according to Ethiopian refugee Teodros Mekonnen*. "It's not something that is discussed in the Ethiopian community," said Mekonnen, who has not disclosed his status to others in his community.

"Americans are much more knowledgeable about this kind of thing. They understand that if you take care of yourself, take your medication, that you're going to be okay. In our culture, people are extremely judgmental," he said. "They don't understand that we didn't ask for this; we trusted someone and something went wrong."

The Ethiopian Community Development Council (ECDC) is a non-governmental organisation (NGO) that began working with the Ethiopian community about 25 years ago. Since then, the ECDC has extended its outreach programmes and services to other African immigrants. According to director of operations Tori Wolan, Somalis now comprise the largest portion of their client base.

An ECDC survey indicated that 70 percent of African newcomers in the Washington Metropolitan Area, a much larger area that includes the District of Columbia and has more than five million residents, have no insurance. Uninsured HIV-positive clients in need of treatment are referred to area clinics, where they are charged according to a sliding scale based on income, said Shimeles Bekele, an Ethiopian who works on ECDC's access project.

The organisation also provides housing assistance, employment assistance, translation services and loans through a partnering organisation. "The diversity of services we provide is a real advantage we have over purely AIDS service organisations. It's a way to recruit - they may be coming in for something else, but it gives us an opportunity to talk to them about HIV and AIDS," Wolan said.

Outreach specialist Asheber Gebru, who is also from Ethiopia, said, "You have to move from the general to the specific. When you talk to them [immigrants] about HIV, they take it personally, and that's why you have to talk about other immigration services."

Bekele explained that "In Africa, if someone has HIV, you don't say it directly - you have to say it in different ways." Gebru agreed: "Sometimes, there is the taboo that people don't want to talk to HIV or sexuality; then, sometimes, they don't have time to talk because they have to find a job, or work to earn their living."

ECDC produces health literature in Amharic and Tigrinya, languages spoken in Ethiopia and Eritrea, as well as in Arabic, French and Somali. Pamphlets originally aimed at African-Americans are adapted for immigrant clients by using African proverbs such as "knowledge is light, ignorance is darkness" to talk about HIV/AIDS, with pictures representative of the various communities.

Uncounted and still unheard

"The power, for me, is in using education, and education that is in appropriate mediums for these African newcomers, and using their own people to do it," Wolan said. While people like Bekele and Gebru have found ways to help their communities in the diaspora, others say African immigrants remain invisible to the US government.

Cameroonian native and activist Joseph Eyong said he does not see local government reaching out to his community. "I have seen both ends; I have been in Africa and America."

Eyong, who is president of non-governmental organisation, the African Community Gateway organisation, commented: "I want politicians to know there are newcomers here, and that the way they treat them cannot be like the way they treat people who are from here - there are issues that are particular to this group."

He and others are currently lobbying for the inclusion of an African immigrant liaison with Montgomery County, to serve alongside the established African-American liaison. According to Eyong, African immigrants, overlooked in sentinel data and under-represented in political power structures, continue to go unheard.


Theme(s): (IRIN) HIV/AIDS (PlusNews)


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