Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

U.S. Policy of Immigration and Travel Inadmissibility for People Living with HIV/AIDS Fails Reinforces Stigmatization – Sounivone Phanthavong

Section 212(a)(1)(A)(i) of the U.S. Immigration and Nationality Act defines the criteria for “General Classes of Aliens Ineligible to Receive Visas and Ineligible for Admission” to include anyone who “is determined to have a communicable disease of public health significance” (24). As of 1987, HIV/AIDS has been included on the list of communicable diseases classified to be of public health significance. The inclusion of HIV/AIDS occurred with the attachment of the “Helms Amendment”, proposed by Senator Jesse Helms (R-NC), to an extensive appropriations bill (26) supported by the Reagan Administration. The primary focus of the Helms Amendment was to ban the use of federal funds for any AIDS/HIV education and prevention materials that would “promote or encourage, directly or indirectly, homosexual activities”; the recommendation to add HIV/AIDS to the exclusion list and mandatory HIV testing of immigrants was enclosed in this amendment (2).

The Public Health Service (PHS) of the Department of Health and Human Services (DHHS) maintains the list of communicable diseases; with the passing of Immigration Act of 1990, sole authority for the list of communicable diseases was vested to the Secretary of Health and Human Services. Due to the original inclusion of HIV/AIDS by a mandate of Congress, it was argued that only a Congressional law could remove it. Thus, despite the recommendation of the HHS Secretary, Dr. Louis Sullivan, and the Centers for Disease Control to remove HIV/AIDS and all other infectious diseases, except for tuberculosis, from the exclusion list in February 1990, HIV/AIDS remained on the PHS list. Nested within the 1993 bill to expand appropriations of the National Institutes of Health, the immigration and travel inadmissibility policy was voted into legislation resulting in the permanent inclusion of HIV/AIDS HIV on the list of communicable diseases (7, 26). This legislation limited the applications of HIV-infected non-citizens seeking immigrant travel visas, refugee status, legalization, and adjustment of status.

HIV-positive individuals desiring to immigrate to the U.S. or those living in the U.S. attempting to change their legal immigration status may only apply to do so for reasons of family unity or humanitarian grounds (seeking asylum) (20, 24). HIV-positive foreign nationals seeking short-term travel (30 days or less) into the U.S. must apply for a waiver to establish that the danger to the public health and possibility of transmission would be minimal, as well as, provide proof that they would not become a public charge of any federal assistance program. Those applying for a temporary visa can meet these criteria with a statement from a qualified physician about their current asymptomatic HIV/AIDS status also noting that they have been properly counseled about modes of transmission as well as providing proof of private insurance (24). The legislation originally enacted in 1987, and further upheld in 1993, severely restricts the travel and immigration of people living with HIV/AIDS (PLWHA) into the U.S. and affects the legal immigration status of non-citizens with HIV/AIDS living in the U.S. This legislation has been intended to promote the best interest of the public, but actually poses a public health risk creating barriers to testing and care for those who fear the punitive effects on their immigration status. Furthermore, identifying HIV/AIDS as “a communicable disease of public health significance” from which the public must be protected simply reinforces the stigmatization of people living with HIV/AIDS.

U.S. Policy Regarding the Legalization Status of PLWHA Results in Delays in HIV Testing among Immigrants
Immigrants who have reason to believe that they may be HIV positive will view this policy as a deterrent to testing. Aware of the possible repercussions on their legal immigration status, non-citizens will be less inclined to get tested. These non-citizens may also be undocumented immigrants who have entered the U.S. illegally. Undocumented immigrants who may be concerned that their illegal status would be discovered and reported when they seek medical care will likely opt to forego HIV testing (13, 18).

According to the Health Belief Model (HBM), individuals employ a cost-benefit calculation accounting for perceived costs, perceived benefits, perceived susceptibility and perceived severity before choosing to undertake a health behavior (9), such as HIV testing. The punitive consequences that could affect non-citizen populations are perceived costs that may outweigh the perceived benefits of HIV testing. Undocumented immigrants’ fear of deportation/removal becomes a personal barrier to action. The possible denial of permanent residency for those seeking a change in legal immigration status also becomes a perceived cost. While the individual’s perceived susceptibility to HIV infection might be high as well as awareness of the perceived severity, in the cost-benefit analysis the HBM suggests, fear of removal and denial of permanent residency status will usually be more consequential than knowing one’s HIV status (6, 18).

As the policy results in delays in HIV testing, it poses a public health risk in terms of both primary and secondary HIV prevention. It is important for PLWHA to be informed of their infection status and delays in testing may also critically delay prevention efforts. Without proper counseling and education regarding modes of transmission, PLWHA may continue to transmit the disease to others. If those infected are not aware of their HIV status, they will not take the necessary precautions to try to prevent further transmission (19, 22). Primary prevention of HIV transmission is particularly important in immigrant populations, where lack of informed knowledge can be a serious barrier to action (19). Secondary prevention is aimed at early detection and treatment to slow disease progression; delays in HIV testing reduce opportunity for interventions of secondary prevention efforts (6, 10).

Limits Accessibility to Health Care and Social Services
By limiting the options of non-citizens infected with HIV/AIDS to become permanent residents, this policy also restricts their access to health care. Members of immigrant populations, both legal and undocumented, are often among the most marginalized populations in society. They often face many obstacles due to their lack of legal status, including lack of medical insurance and limited access to health care. Due to welfare reform, undocumented immigrants are ineligible for most federal assistance programs and legal immigrants face a number of restrictions to obtaining federal assistance (11, 17). Inability to change their legal immigration status also affects the ability to access employment that may provide benefits such as private insurance. Without insurance, publicly assisted or private, the cost of HIV treatment is substantial and becomes a financial barrier to treatment for these populations of non-citizens (3, 10).

Concerned with their legal status, HIV positive immigrants often delay seeking medical care or treatment until their disease is advanced and they are co-infected with other opportunistic infections (8, 18). Without access to insurance and advanced disease presentation, immigrant PLWHA may require hospitalizations that can place a large burden on the health care system and public resources. The policy would thereby create one of the effects it was intended to counteract, by providing no other option for these immigrants but to become public charges (7). A delay in accessing medical care and lack of access to appropriate treatment leads to poorer health outcomes among HIV positive immigrants. However, early initiation of treatment, such as antiretroviral therapy, can improve CD4 counts hopefully slowing the progression to AIDS disease and allowing for better control of overall health status (6). Concerns regarding legal immigration status may also interfere with the comfort level of these HIV positive patients to share information with their health care providers. Fear of reporting affects the rapport that is otherwise expected with the understanding of doctor-patient confidentiality (8, 21). If patients are not forthright with their medical care providers, their treatment and health outcomes could be severely compromised.

Confluent with the limited access to health care, immigrants will be less likely to take advantage of counseling and social support services. These services are intended to help individuals manage their illness and provide informed knowledge about their health, possible treatment and available support services. When PLWHA are fearful of disclosing their HIV/AIDS status to medical care providers, social workers, community outreach workers, peer groups and in some cases, their families, they lose opportunities to fully benefit from treatments and services (19, 22). When fears regarding immigration status are compounded with health concerns, social support becomes vital for the individual to cope with the demands of their illness.

Further evidence of the plight of immigrant populations to be adequately informed about available support is their lack of use of the AIDS Drug Assistance Programs (ADAP). Established by the federal government and regulated by each state, ADAP aims to assist the uninsured and underinsured, such as those of the immigrant population. ADAP removes the financial barriers to treatment by providing HIV-related drugs at no cost. However, the numbers of immigrants accessing these programs is relatively low compared to the proportion of immigrants composing the population of uninsured/underinsured (15, 19). Many undocumented individuals may not realize that they can qualify for services such as ADAP.
Reinforces Stigmatization of PLWHA

According to Brinlow et al of DHHS, “HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS” (4). The HIV-related stigma is not only experienced by immigrants but by all individuals perceived to have HIV/AIDS. A policy that treats HIV/AIDS status as a reason for exclusion only further reinforces negative public perception of PLWHA as a group of infectious individuals who should be shunned and from whom the public requires protection.

The reinforcement of this stigmatization can be examined with Labeling/Stigma Theory. According to the precepts of Labeling/Stigma Theory, individuals are likely to internalize the negative public perception, which may cause guilt, make individuals feel forced to hide their HIV status or drive them to adopt unhealthy behavior that may be considered associated with the stigma (4, 27). As such, stigma affects all aspects of the lives of HIV-positive individuals and thus, all phases of the management of their illness. Stigma may deter individuals from seeking testing, even if results are negative, they may fear the opinions of others for getting tested at all (6, 22). Due to fear of discrimination, PLWHA may choose to limit the disclosure of their HIV status, which may affect their access to treatment or social services and support (18). As medications must often be taken on a regimented schedule, concern about HIV status being discovered may interfere with adherence to treatment. With regard to the travel ban restrictions, PLWHA attempting travel to the U.S. who choose not to apply for a waiver may disrupt their treatment by choosing not to travel with their HIV/AIDS medications that will make them more likely to be questioned and barred entry (1).

The instatement of the policy in 1987 was reflective of the general public fear and lack of knowledge in regards to HIV/AIDS in the 1980s. Proponents of the immigration ban have argued that U.S. admission of HIV positive individuals will become public charges placing an excessive burden on public resources, as HIV/AIDS is a chronic disease (7). This idea further reinforces the stigma of HIV/AIDS, as no other chronic disease is included on Public Health Service list of criteria for immigration and travel inadmissibility.

Time to Move Beyond Inadmissibility
Since its introduction in 1987, the U.S. immigration/travel inadmissibility policy, later codified into legislation, has been a source of controversy. It was established for the protection of the public health; its advocates noted that it would inadvisable to fuel an epidemic by allowing HIV infected persons to enter the country and that it would be detrimental to the health of all U.S. citizens (7, 14). Upon evaluation of this policy with reference to the Health Belief Model, Labeling/Stigma Theory and social science literature, it is evident that rather than promoting the health of the public, the policy poses a public health risk to HIV positive members of the immigrant population by affecting their access to testing and care. Moreover, it fails to promote the health of the public at large, as it is also impedes prevention efforts and reinforces stigmatization of HIV/AIDS.

On World AIDS Day 2006, the White House produced a fact sheet entitled “The President is Dedicated to Ending Discrimination Against People Living with HIV/AIDS”. This fact sheet included a statement proposing a categorical waiver for HIV-positive people seeking to enter the United States on short-term visas; no further action followed the issuance of this statement (2). As of September 2007, H.R. 3337: HIV Nondiscrimination in Travel and Immigration Act of 2007 was introduced by Rep. Barbara Lee (D-CA): “To remove from the Immigration and Nationality Act a provision rendering individuals having HIV inadmissible to the United States, and for other purposes” (12). This bill is in the first step of the legislation process and has been referred to the Subcommittee on Immigration, Citizenship, Refugees, Border Security, and International Law (12, 14). Passing this bill would reverse the immigration/travel ban first initiated in 1987 and move beyond an inadmissibility policy that failed in its own aims to protect the public’s health by reducing HIV/AIDS transmission. The HIV Nondiscrimination in Travel and Immigration Act would affect the lives of PLWHA and the public health at large, succeeding where its counterpart legislation did not; it will promote public health by removing structural barriers to access and care and take a significant step towards eliminating stigmatization of HIV/AIDS.

REFERENCES
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