United States

Sex workers may be at an increased risk of contracting HIV because they may engage in sex without condoms with multiple partners. Few population-based studies have been done on HIV among sex workers and none among African migrant sex workers. One of the main HIV prevention challenges is the lack of data on sex workers in the U.S. The number of migrants who are sex workers is unknown, though the total number of sex workers is estimated to be 1 to 2 million people in the U.S. Given the diversity among this group, targeted prevention efforts are necessary to reduce the risk of HIV transmission.

The United States’ migration story is a complex and difficult one. The first migrants from Africa to the United States (U.S.) were forced to migrate as part of the trans-Atlantic slave trade. Between 1525 and 1866 a total of 12.5 million Africans were shipped to the Americas of which 10.7 million survived and disembarked in North America, the Caribbean and South America.

Voluntary migration from Africa to the U.S. did not begin until the 1980s. From 1980 to 2013, the sub-Saharan African immigrant population in the U.S. increased from 130,000 to 1.5 million. As of 2013, there were 1.8 million Africans of which 82% were from sub-Saharan African in 2013.

In 2014, there were a total of 11.1 million unauthorized immigrants in the U.S. a number that has remained unchanged since 2009. Though Mexicans make up a little over half of the population of unauthorized immigrants in the U.S., the number of unauthorized immigrants from countries outside of Mexico has grown from 325,000 since 2009, to an estimated 5.3 million in 2014. Migrants from Asia and Central America constitute a large part of the increase, however the number of sub-Saharan African migrants has also continued to grow. Additionally, the number of unauthorized adult migrants who have lived in the U.S. for at least a decade has grown from 41% in 2005 to 66% of adults in 2014.

The U.S. is considered one of the most desirable countries in the world to migrate to given its large economy. Immigrating to the U.S. is difficult and complex to navigate. From 1993 to 2010, the U.S. immigration policy response to HIV focused on preventing HIV-positive people from entering the country. Unless a waiver was granted, HIV-positive status was regarded as grounds for inadmissibility to the U.S. for applicants for short-term non-immigrant visas and for lawful permanent residence. While the removal of the ban on barring entry to HIV positive migrants to the U.S. was lauded as a victory, the removal of mandatory HIV testing is seen as a missed opportunity for HIV counselling and testing by some.

Though studies suggest that immigrants to the U.S. are generally healthier than the native-born population, the “healthy migrant” effect wears off soon after arrival. The African-born population in the U.S. is generally concentrated in large urban centres. Although African-born immigrants in the U.S. have typically had higher rates of English proficiency, advanced degrees and higher rates of employment than foreign-born U.S. residents overall, they also experience higher rates of poverty. In recent years, unemployment among African-born immigrants in the U.S. has risen.

Policies that limit healthcare access to immigrants have become prevalent in recent years given the increase in migration. In the U.S. access to healthcare is limited to those who have health insurance, and those who can pay out of pocket for their healthcare services and treatment.

The U.S. does provide some healthcare coverage to eligible populations via Medicare, the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicaid is a social healthcare program that provides free or low-cost medical services to eligible low-income adults, children, pregnant women, seniors, and people with disabilities. Both Medicare and Medicaid are only avaiiable to citizens and permanent residents of the U.S. Unauthorized immigrants and temporary visa holders (those with student or temporary work visas) are not eligible for Medicaid, except for Medicaid coverage of emergency room services.

A range of social, economic, and demographic factors affect migrants’ risk for HIV, such as stigma, discrimination, income, education, and geographic region. This problem is further compounded by lack of access to healthcare for many migrants in the U.S. Immigrants in the U.S. have extremely low rates of health insurance coverage and poor access to healthcare services. Almost half of all immigrants in the U.S. are uninsured. Uninsured immigrants face serious barriers to accessing medial care and have to pay more out-of-pocket for the healthcare services they do receive. This can drive many into debt or financial insolvency.

Immigrants and undocumented migrants in the U.S. often have to rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care, including state- and county-owned facilities, as well as charitable and religiously affiliated facilities. However, those who are unable to navigate this complex patchwork system are often left with no healthcare access.

Black men who have sex with men have experienced a number of challenges to accessing HIV services in the U.S. such as lack of access to culturally competent services, stigma and discrimination, inadequate HIV services in correctional institutions, and insufficient service availability in areas where these populations reside.

Black men who have sex with men also face structural barriers that increase HIV risk. These include unemployment, less education, lower income, and run-ins with the criminal justice system, compared to their white men who have sex with men counterparts. HIV care outcomes were also lower for Black men who have sex with men in the U.S. compared to men who have sex with men from other groups). Research suggests that while African-Americans may be confronted with challenges such as institutionalized racism and poverty, Black immigrants may face these challenges in addition to others such as language barriers.

Black men who have sex with men and Black women are disproportionately affected by the HIV epidemic in the U.S. Though there is a misperception that Black men who have sex with men and Black women engage in “riskier” behaviour than others, several studies have shown that these two groups have similar numbers of sexual partners and use condoms as often as their white counterparts. Though behaviroual risk factors are important, they do not fully explain the racial disparity of the HIV epidemic in the U.S. African American and African-born immigrants face serious challenges accessing housing, education, employment, and healthcare.  The high rates of HIV among Black communities are not the result of risky behaviour, but instead, structural inequalities that render this population more vulnerable to HIV infection.

The burden of the HIV epidemic affects the Black population the most severely in the United States (U.S.). Although African-Americans represented 12% of the US population in 2015, they accounted for 45% (17,670) of HIV diagnoses.  One of the main issues driving health inequities in the U.S. is the lack of affordable care and policies that limit access to healthcare for immigrants. The high costs of healthcare and the erosion of health insurance coverage given the recent change in government in the U.S. has left many without access. Immigrants in the U.S. have extremely low rates of health insurance and poor access to healthcare services. Eligibility criteria for healthcare coverage in the U.S. is very narrow and as a result many documented and undocumented migrants are unable to access healthcare services.

Policies should be designed to improve service delivery to reinforce migrant-friendly public-health services and establish minimum healthcare standards for all vulnerable migrant groups.  Increasing HIV testing and linkage to care for key populations such as African-American men who have sex with men and Black heterosexual women (two groups disproportionately affected by the HIV epidemic in the U.S.) can help to reduce the transmission of HIV.  Providing antiretroviral therapy early on to people with HIV has been shown to reduce the risk of transmitting the virus to others by 96%.

Implementing policies to increase prevention efforts, providing culturally appropriate care and increasing harm reduction efforts have been shown to be effective in reducing the risk of transmitting HIV, thereby reducing inequities in the epidemic.  There are a number of cost-effective approaches to reducing the risk of HIV infections. These approaches are especially effective when they are tailored to address the social, community, financial, and structural factors that place specific groups at risk. However, this remains difficult to do in the U.S. given that surveillance efforts among Black populations do not differentiate between American-born African-Americans and African-born immigrants.

In general, migrants are more vulnerable to HIV because of isolation, insecure jobs and living situations, fear of accessing government services and lack of access to sexual and reproductive healthcare and undocumented migrants have the additional barrier of lack of legal protection.

In the U.S. migrants face particularly difficult challenges in accessing healthcare. Given that healthcare services and treatment are very expensive and government run health insurance only affords coverage with very specific eligibility criteria, immigrants are more than three times as likely to be uninsured (44 percent) compared to U.S.-born citizens (13 percent).

Many Americans receive health insurance coverage through their employer. However, despite the high rates of employment among immigrants in the U.S., fewer immigrants have employer-sponsored health insurance. Lack of healthcare is further complicated by the fact that unresolved health problems can limit immigrants’ ability to maintain productive employment, particularly given that many work in physically strenuous jobs or in jobs in which there is a high incidence of occupational injuries. Labour policies that do not protect workers and instead favour employers has resulted in many employed immigrants not having access to employer sponsored health insurance. The health, labour and immigration sphere must be more integrated to provide equitable access to authorized migrants in the U.S. Given that the unauthorized migrant population in the U.S. is 11 million people strong, extending healthcare access to this group will keep this population healthier and further reduce healthcare costs in the future.