Enhanced immigration enforcement in US could worsen HIV epidemic

Since the 2016 United States elections, immigrants from Latin America with HIV have become more anxious about the possibility of being deported to their home countries and losing access to medical care, according to a recent Viewpoint published in The Lancet HIV.

Even though HIV treatment is available throughout Latin America, Kathleen R. Page, MD, associate professor in the division of infectious diseases at Johns Hopkins University School of Medicine, and colleagues said access varies depending on economic, social and political circumstances. After deportation, immigrants are frequently released at the border between the U.S. and Mexico with no identification and few personal belongings, the researchers reported. Most are unfamiliar with the area, which is often far from their home community.

As the political debate on enhanced immigration enforcement in the U.S. continues to grow, Page and colleagues said it will be important to develop a multidisciplinary approach to protect the wellbeing of undocumented immigrants with HIV and ensure they are maintained in care. The impact of immigration enforcement would extend beyond individual patients to public health, Page said.

“Local/national policies have a ripple effect not only in the U.S. but also for other nations,” she told Infectious Disease News. “In the case of HIV, where uninterrupted treatment is so critical to both the patient's health and to prevent transmission in the community, the rising number of deportations, especially within a system that has limited capacity to provide adequate health care, may lead to increased HIV transmission within the U.S. and across our borders.”

In January 2017, President Donald J. Trump signed an executive order enforcing immigration laws in the U.S. The order broadly defines enforcement priorities, placing all unauthorized immigrants at risk for deportation, including families, long-term residents and “Dreamers” who were brought to the U.S. as children, according to the American Immigration Council. It also orders the Department of Homeland Security to consider denying federal funding to “sanctuary cities” and promotes additional criminal prosecutions for individuals illegally entering the U.S. After the executive order was signed, the number of noncriminal immigration detentions more than doubled in the country, Page and colleagues reported. In 2017, Immigration and Customs Enforcement officials made 143,470 administrative arrests — the highest number of such arrests in the last 3 fiscal years.

“The Trump administration’s shift from prioritizing removal of immigrants convicted of serious crimes to any immigrants believed to have committed any crime (including minor offenses like traffic violations or driving without a license) has increased the fear of deportation among many undocumented immigrants,” the researchers wrote.

There is little evidence regarding the effects of increased deportations on HIV care. Only 0.5% of Latin American immigrants in the U.S. are known to have the infection, according to Page and colleagues. However, increasing anti-immigrant rhetoric may have a “chilling effect” on HIV testing and treatment, Page said.

“Immigrants living in fear of deportation often limit the use of services that they believe could expose them to authorities,” she added. “Although HIV testing and treatment is protected by [Health Insurance Portability and Accountability Act (HIPAA)], patients may not be aware of these protections and the perception of risk is as important a deterrent as a real risk.”

Even when immigrants are engaged in HIV care, it can be difficult to maintain access if they are placed in detention facilities, according to the researchers. The process for deportation proceedings is complex, and detainees are frequently transferred from one center to another, often across jurisdictional boundaries. ART is available to individuals who disclose their HIV status. However, Page and colleagues noted some immigrants are reluctant to disclose their status out of fear it would negatively affect their case. Stigma is particularly troublesome for transgender patients. Previous interviews with immigrant transgender women in detention centers revealed that most are held in men’s facilities and often experience trauma and abuse.

To address some of these issues, Page and colleagues recommend that health care providers inform patients of their right to care and encourage those in detention facilities to disclose their HIV status and report discrimination. They also urge providers who are treating immigrants with HIV to establish medical-legal partnerships and to work with human rights organizations to address certain immigration issues, such as asylum eligibility, as well as HIV-related stigma discrimination and violence in detention facilities.

In addition, Page and colleagues said providers should be familiar with resources such as the Migrant Clinicians Network, which provides a HIPAA platform for sharing medical records with international health care providers. Without medical records, patients could risk being prescribed an inappropriate treatment regimen because providers are unaware of their existing HIV resistance mutations. Finally, Page and colleagues noted that health care providers in the U.S. should be aware of safety net organizations that serve gender and sexual minority populations in Mexico and Central America.

“These are stressful times for undocumented immigrants,” they concluded. “For those who are HIV positive, clinicians can mitigate some of the uncertainty by providing accurate information and facilitating continuity of care.” – by Stephanie Viguers

References:

American Immigration Council. Summary of Executive Order “Enhancing Public Safety in the Interior of the United States.” https://www.americanimmigrationcouncil.org/immigration-interior-enforcement-executive-order. Accessed July 17, 2018.

Page KR, et al. Lancet HIV. 2018;doi:10.1016/S2352-3018(18)30074-2.

Disclosures: Page reports no relevant financial disclosures.

Since the 2016 United States elections, immigrants from Latin America with HIV have become more anxious about the possibility of being deported to their home countries and losing access to medical care, according to a recent Viewpoint published in The Lancet HIV.

Even though HIV treatment is available throughout Latin America, Kathleen R. Page, MD, associate professor in the division of infectious diseases at Johns Hopkins University School of Medicine, and colleagues said access varies depending on economic, social and political circumstances. After deportation, immigrants are frequently released at the border between the U.S. and Mexico with no identification and few personal belongings, the researchers reported. Most are unfamiliar with the area, which is often far from their home community.

As the political debate on enhanced immigration enforcement in the U.S. continues to grow, Page and colleagues said it will be important to develop a multidisciplinary approach to protect the wellbeing of undocumented immigrants with HIV and ensure they are maintained in care. The impact of immigration enforcement would extend beyond individual patients to public health, Page said.

“Local/national policies have a ripple effect not only in the U.S. but also for other nations,” she told Infectious Disease News. “In the case of HIV, where uninterrupted treatment is so critical to both the patient's health and to prevent transmission in the community, the rising number of deportations, especially within a system that has limited capacity to provide adequate health care, may lead to increased HIV transmission within the U.S. and across our borders.”

In January 2017, President Donald J. Trump signed an executive order enforcing immigration laws in the U.S. The order broadly defines enforcement priorities, placing all unauthorized immigrants at risk for deportation, including families, long-term residents and “Dreamers” who were brought to the U.S. as children, according to the American Immigration Council. It also orders the Department of Homeland Security to consider denying federal funding to “sanctuary cities” and promotes additional criminal prosecutions for individuals illegally entering the U.S. After the executive order was signed, the number of noncriminal immigration detentions more than doubled in the country, Page and colleagues reported. In 2017, Immigration and Customs Enforcement officials made 143,470 administrative arrests — the highest number of such arrests in the last 3 fiscal years.

“The Trump administration’s shift from prioritizing removal of immigrants convicted of serious crimes to any immigrants believed to have committed any crime (including minor offenses like traffic violations or driving without a license) has increased the fear of deportation among many undocumented immigrants,” the researchers wrote.

There is little evidence regarding the effects of increased deportations on HIV care. Only 0.5% of Latin American immigrants in the U.S. are known to have the infection, according to Page and colleagues. However, increasing anti-immigrant rhetoric may have a “chilling effect” on HIV testing and treatment, Page said.

“Immigrants living in fear of deportation often limit the use of services that they believe could expose them to authorities,” she added. “Although HIV testing and treatment is protected by [Health Insurance Portability and Accountability Act (HIPAA)], patients may not be aware of these protections and the perception of risk is as important a deterrent as a real risk.”

Even when immigrants are engaged in HIV care, it can be difficult to maintain access if they are placed in detention facilities, according to the researchers. The process for deportation proceedings is complex, and detainees are frequently transferred from one center to another, often across jurisdictional boundaries. ART is available to individuals who disclose their HIV status. However, Page and colleagues noted some immigrants are reluctant to disclose their status out of fear it would negatively affect their case. Stigma is particularly troublesome for transgender patients. Previous interviews with immigrant transgender women in detention centers revealed that most are held in men’s facilities and often experience trauma and abuse.

To address some of these issues, Page and colleagues recommend that health care providers inform patients of their right to care and encourage those in detention facilities to disclose their HIV status and report discrimination. They also urge providers who are treating immigrants with HIV to establish medical-legal partnerships and to work with human rights organizations to address certain immigration issues, such as asylum eligibility, as well as HIV-related stigma discrimination and violence in detention facilities.

In addition, Page and colleagues said providers should be familiar with resources such as the Migrant Clinicians Network, which provides a HIPAA platform for sharing medical records with international health care providers. Without medical records, patients could risk being prescribed an inappropriate treatment regimen because providers are unaware of their existing HIV resistance mutations. Finally, Page and colleagues noted that health care providers in the U.S. should be aware of safety net organizations that serve gender and sexual minority populations in Mexico and Central America.

“These are stressful times for undocumented immigrants,” they concluded. “For those who are HIV positive, clinicians can mitigate some of the uncertainty by providing accurate information and facilitating continuity of care.” – by Stephanie Viguers

References:

American Immigration Council. Summary of Executive Order “Enhancing Public Safety in the Interior of the United States.” https://www.americanimmigrationcouncil.org/immigration-interior-enforcement-executive-order. Accessed July 17, 2018.

Page KR, et al. Lancet HIV. 2018;doi:10.1016/S2352-3018(18)30074-2.

Disclosures: Page reports no relevant financial disclosures.

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