HIV and AIDS have become major threats in the Latino community, a community that has been disadvantaged even prior to AIDS due to minority status, economic disparities, and language barriers. HIV presents a particular threat to Latinos because of certain cultural issues that make HIV prevention challenging. At the same time, Latinos have resources and strengths in their culture that may be used to help combat this scourge. This chapter provides an overview of the AIDS epidemic as it has affected Latinos, focusing on both sexual transmission and drug-related transmission of HIV and emphasizing cultural issues that must be considered when developing prevention and treatment programs for this community. Promising HIV prevention strategies are presented.
| Latinos in the United States|
The 1990 Census recorded 22.4 million Latinos residing in the United States, a 53% increase since 1980 with 22.8 million Latinos estimated in 1993.(1,2) Puerto Rico, a U.S. possession, has an additional population of 3.6 million and is almost entirely Latino.(3) As a conservative estimate, Latinos represent 9% of the total U.S. population. Compared to non-Latino whites, Latinos are younger (median age, 27 vs. 36), are less educated (only 53% over age 25 have completed high school); and have lower family incomes ($20,054 vs. $31,765) with 40% of Latino children living in poverty as compared to 13% of non-Latino white children.(2)
The rate of labor force participation for Latinas is 51% compared to 57% for non-Latinas. Latino origin males have a higher participation in the labor force than do non-Latino males (78% vs. 74%).(1) Seven out of 10 of those Latino men whose earnings do not exceed the poverty level, however, lack any health insurance.(4)
Latinos in the United States are quite diverse racially and in their ethnic origin. Approximately 63% are Mexican, 11% Puerto Rican, 5% Cuban, 14% Central and South American, and 7% of other Latino origin (such as Spain and the Dominican Republic). The Latino population in the United States is more geographically concentrated than the total population, with 87% residing in 10 states: California, Texas, New York, Florida, Illinois, New Jersey, Arizona, New Mexico, Colorado, and Massachusetts. Unfortunately, 55% of Latinos in the United States reside in the top five U.S. AIDS epicenters, and those living in Puerto Rico are living in an area of highest concentration of AIDS cases after Washington, DC and New York.(3,5)
| Incidence of AIDS in Latinos in the United States|
According to the Centers for Disease Control and Prevention (CDC), Latinos account for 18% of the 612,078 AIDS cases reported through June, 1997.(5) Latinos account for 23% of pediatric cases, 17% of adult male cases, and 20% of adult female cases. Of all racial/ethnic groups, Latino women, along with Asian/Pacific Islander women, have the highest proportion (46%) of exposure to AIDS through heterosexual transmission.
The CDC HIV/AIDS Surveillance report of February, 1993 included a breakdown of Latino AIDS cases reported in 1992 by exposure category and place of birth.(6) Of the 8,119 cases reported, 32% were born in the United States and 29% were born in Puerto Rico. Persons born in Mexico, Central/South America, and Cuba each represented 7% or less of all cases. These data are consistent with the high concentration of HIV among Latinos in the Northeast region of the United States, which is residence predominantly for Latinos from Puerto Rico and the Dominican Republic. Lower incidence rates are reported for Latinos of the Western/Southwestern regions of the United States, where Latinos are predominantly of Mexican and Central/South American origin.(7)
These regional differences in HIV incidence have been attributed primarily to the higher injection drug use pattern among those residing in the Northeast vs. the West/Southwest combined with some differences in sexual behaviors, such as higher numbers of sexual partners and male-to-male sex.(8,9) It is also likely, however, that some AIDS cases in Latinos living in the Southwest are under-reported because of the current immigration policy of excluding HIV-infected persons from entry and residency in the United States. Under this policy, the Immigration and Naturalization Service (INS) can require HIV-infected illegal aliens to return to their countries of origin, and can require alien residents to apply for waivers that rarely are granted.(3) Because of their status as U.S. citizens, Puerto Ricans have no restrictions regarding travel to and from the island of Puerto Rico, regardless of HIV status.
| Sexual Behavior and Transmission of HIV in Latinos|
Of all adult and adolescent AIDS cases in Latinos reported through June, 1997, at least 56% of male cases and 46% of female cases fall under a sexual behavior exposure category.(5) These estimates are conservative because exposure categories are hierarchical and a person with more than one mode of exposure will be placed in the highest listed category. For example, heterosexual injection drug users will always be classified as being exposed through their injection drug use even if the actual transmission was through contact with an infected sexual partner. Although the United States is considered a pattern I country (groups most affected are homosexual men and intravenous drug users) in terms of epidemiologic patterns of HIV infections as described by the World Health Organization, the countries of origin of most Latinos (the Caribbean and Latin America) are considered pattern II areas, where most HIV infections are in sexually active heterosexuals.(10) These sexual patterns of transmission are likely to remain consistent when Latinos migrate to the United States.
Men who have sex with men account for 44% of Latino adolescent/adult male AIDS cases.(5) The rate of AIDS cases reported for Latino homosexual or bisexual men is twice the rate of the non-Latino white population and continues to rise disproportionately.(11,12)
| Sexual Risk in Latinos|
Given the higher than expected rates of HIV in the Latino community, it is important to ask whether sexual and drug using behaviors are different among Latinos than other groups. Sexual behaviors that might put Latinos at risk for HIV include multiple sexual partners, lack of condom use, and anal sex.
| Multiple Partners|
Latino women report fewer sexual partners in the previous 12 months than non-Latino whites of either gender or Latino men.(8,13) On the other hand, in a telephone survey done in nine states, we found that twice as many married Latino men reported multiple sexual partners in the previous year as non-Latino white married men (18% vs. 9%).(8) In addition, 60% of unmarried Latino men reported multiple sexual partners in the 12 months prior to interview.
| Condom Use|
Among those with multiple partners, Latino men and women are equally likely to report condom use with a secondary partner. In fact, about half of Latinos and non-Latino white adults reported "always" using condoms with secondary partners in the past 12 months.(8) Those with multiple partners, however, are far less likely to use condoms consistently with a primary partner. The dynamics of condom use in these two situations appear to be quite different. Other studies in Latin America also suggest that men in Latin American countries perceive condoms as more appropriate outside of marriage.(14)
Less acculturated Latino women, that is, women who have had less exposure and time for adaptation to U.S. mainstream culture, report less frequently carrying and using condoms than the more highly acculturated women.(13,15) Those Latino women who report less condom use with steady male partners had higher expectations that the partner will be angry if condom use is requested, were more likely to use some other birth-control method, had less confidence in their ability to use condoms, reported a more negative attitude toward condom use, had fewer friends who use condoms, and had less knowledge of how to use a condom than those who reported more condom use.(16)
| Anal Sex|
Data from a nationally representative survey of men's sexual behavior found that Hispanic men were far more likely than non-Latinos to report anal sex and reported it with more partners and as occurring more frequently.(17) Another study conducted in Puerto Rico found that 22% of 160 female partners of IV drug users who were not themselves IV drug users, reported that they engaged in anal sex during the previous 6 months, whereas only 3% reported always using condoms during anal sex.(18) Women university students in Puerto Rico report that the purpose of anal sex is to provide increased sexual pleasure for the man.(19)
| Homosexual/Bisexual Behavior in Latino Men|
Because of homophobia in the culture, it is difficult to obtain accurate statistics on homosexual behavior. In one study, 6% of unmarried men and 3% of married Latino men in a 9-state survey indicated that they had had sex with another man in the 12 months prior to interview.(8) In a subsequent survey of unmarried Latino men, 6% again reported same-gender sexual behavior in the prior 12 months.(20) Between 40 and 50% of Latino gay men report unprotected anal intercourse in the 12 months prior to interview.(21,22)
| Cultural Attitudes Regarding Sex|
Latino culture may contribute to high risk sexual activity in a number of ways, including: (1) the common idea that sexuality is embarrassing and not to be discussed either with one's children or with one's partner; (2) traditional gender roles and machismo; and (3) homophobia.
| Sexual Discomfort|
Sexuality appears to be even more intensely private and personal in Latino culture than in non-Latino white culture. Sexual issues are often not discussed even between sexual partners. In traditional Latino culture, the "good" woman is not supposed to know about sex, so it is inappropriate for her to bring up subjects like AIDS and condoms.(23,24)
Latinos report significantly higher levels of sexual discomfort than non-Latino whites.(16,25) Amaro found that married Latino women in Los Angeles had sexual relations infrequently and often perceived them as not particularly enjoyable.(26) In a national survey of unmarried Latino adults, 44% of unmarried Latino adults reported they were uncomfortable having sex with the lights on and 19% were uncomfortable discussing condoms with a sexual partner, rates of discomfort that are significantly higher than those found with non-Latino whites.(27)
Sexual discomfort and embarrassment has been associated with less frequently carrying condoms and with lower perceived ability to use condoms, making it important to address in intervention programs.(15,28)
Comfort with sexuality must be addressed at three levels: sexual socialization, information about sexuality, and greater openness about sexual behaviors. In order to socialize children more appropriately about sexuality, Latino parents must be taught both basic information about sex and methods to communicate with their children about this topic. Despite a strong emphasis on family interactions, Latinos are currently less likely than other groups to provide their children with critical information about sex and AIDS.(29) In many cases, parents do not have the necessary information. Increasing information and openness about sexuality among adults will also increase comfort with condoms and with discussion of sexual activities.
Programs that address sexual impulses are urgently needed, because sexual feelings are often not discussed at school or in the home, which may contribute to sexual discomfort and reports of many adolescents that sexual activity "just happened."(30) Acceptance and discussion of sexual feelings should make such feelings more accessible and therefore manageable. Careful examination of these issues is also likely to be productive in interventions aimed at adults in sexually transmitted disease (STD) clinics, men in prison, and other settings in which high risk men are found.
| Traditional Gender Role Beliefs|
According to traditional gender role beliefs in the sexual domain, Latino men are expected to be highly sexual beings.(23,24) When asked about abstinence in our open-ended interviews, some Latino men felt that not having sex would be nearly impossible as well as unhealthy for them. The differences between the expectations and attitudes of Latino men and women result in a fairly strong double standard that allows men to have sex outside of marriage. In a survey of the 10 states in which 87% of Latinos reside, 69% of unmarried Latino adults agreed that "Men want to have sex more often than women" and 51% disagreed that "Men can control their sexual desires as easily as women."(27)
There is strong evidence that traditional gender roles in Latino culture condone sexual coercion.(31) In a 10-state survey, 30% of men reported lying to get sex, while more 50% said they insisted on sex when their partner wasn't interested (and a comparable proportion of women reported their partners insisted on sex when they weren't interested).(27) Those men who reported more traditional gender role beliefs also reported greater sexual coercion, defined here as lying and pressuring a women to have sex when she's not interested.
Coercive sexual behavior and the attitude of sexual entitlement that encourages it deserve attention by those seeking to prevent HIV transmission. Addressing coercive behavior in Latino men will require challenging the underlying cultural assumptions about traditional gender roles of men and women in sexual situations. These include beliefs about the inability of men to control sexual impulses and the belief that women should please men rather than consider their own desires and needs, beliefs that simultaneously make men more coercive and women more submissive. These beliefs are so widespread that many Latino men and women would probably not perceive as coercive a situation in which a man insists on sex when the woman is not interested.(32) Latino men who reported multiple sexual partners in the 12 months prior to interview reported even greater levels of traditional gender roles and sexual coercion than those who reported only one partner, making them a particularly important group to consider in prevention efforts.(31)
To address sexual coercion and traditional gender roles effectively, it also will be necessary to intervene to improve sexual socialization practices, both with parents and in school settings. For example, lessons in family life or sex education curricula should examine gender-role beliefs that may encourage boys to be aggressive and girls to acquiesce, and should help children understand and manage their feelings, desires, and impulses. In 1995, Goleman described a number of innovative programs that teach "emotional intelligence," including programs to help children manage their aggressive impulses.(33)
Latino culture includes a fairly powerful homophobic component.(34,35) In a national survey of unmarried Latino adults, 62% reported that sex between two men was definitely not acceptable.(27) Men must often choose between their culture and their sexuality, so that some men turn to the mainstream gay community for support, thus losing their Latino identity, while others remain immersed in a culture that views their behavior as reprehensible, often hiding their sexual orientation from family and friends.
Internalized and community homophobia may contribute to a negative self-concept and rejection of their sexual behavior in Latino gay men, which can lead to anonymous sexual encounters and sex under the influence of drugs and alcohol.(21,22) In addition, the macho imperative to prove that one is a man may lead to a need for multiple sexual partners, both among heterosexual and gay Latino men.(36) In fact, homophobia in Latino men reporting sex with men is correlated with sexual discomfort, which in turn is correlated with lower confidence in their ability to use condoms.(20)
A more appropriate understanding of homosexuality, that sees it as a natural variation of human sexuality, must be promoted in Latino communities. Currently, levels of homophobia mean that Latino young people with homosexual feelings and fantasies will feel fearful and rejected by their peers. Consequently, many may experience severe depression, leading to suicidal ideation or attempts, or they may engage in more risky behaviors, such as drug and alcohol use and anonymous sexual encounters.(37)
| Self-Identification as Homosexual|
Other researchers have suggested that homosexual identification among Latino men may be linked to the "passive" or receptive partner while the "active" or insertive partner may identify as heterosexual.(38,39) This interpretation has been questioned, however, because no research effort has focused on the acceptance of "active" or insertive homosexual behavior among Latino men, in general, nor do Latino men who do identify as homosexual exclusively fall into the receptive partner category.(40) Latino men who are living heterosexual lifestyles while engaging in bisexual behavior may not see themselves as homosexual, meaning that messages directed specifically at "homosexuals" or "gays" may be ignored by a large proportion of those at risk. Latino gay-identified men, however, may resent the more inclusive "men who have sex with men" term, because they have struggled to attain their identity.(22)
| Injection Drug Use and Transmission of HIV in Latinos|
Latinos represent 24% of AIDS cases attributed to injection drug use (IDU).(5) Latinos who use intravenous drugs appear to be infected with HIV and/or diagnosed with AIDS at higher rates than non-Latino whites.(41) This difference between these populations could be attributed to differences in drug use patterns. One study of IDU found that Latinos had higher frequencies of injection drug use and were more likely than persons from other ethnic groups to inject in shooting galleries where used syringes and needles are rented by drug users.(42) Among Latino subgroups, Puerto Ricans seem to have the highest prevalence of illegal drug use, perhaps because close to 70% of Puerto Ricans living in the United States are found in New York City, New Jersey, and Chicago, where poor socioeconomic conditions exist and illegal drugs are more available than in other parts of the country.(43) Most AIDS cases related to IDU in Latinos are also concentrated in the New York/New Jersey metropolitan area, which is associated with a high prevalence of heroin use among Latinos, a high concentration of the HIV virus, and the likelihood of unsafe sexual practices as previously described.
Of all AIDS cases in Latino women, 66% can be linked to IDU by themselves or their partners, with more Latino (23%) than non-Latino white women (16%) reporting HIV infection as a result of sex with a male IDU.(5) A study of Latino and African-American women receiving methadone maintenance found that 60% had shared needles whereas 84% reported having sex with an IDU. Only 12% reported consistent condom use.(44) Other studies of female IDU, both in and out of treatment, have revealed similar patterns of high-risk sexual behaviors and often included the exchange of sex for drugs or money.(44,45) Given these patterns, Latino women who inject drugs will likely continue to be one of the fastest growing populations infected with HIV. Consequently, pediatric AIDS cases in the Latino population will also continue to grow, because 62% of pediatric AIDS cases from maternal exposure are linked to IDU.(5)
| Drug Treatment for Latinos|
The consequences of drug use are devastating to minority communities, including crime, health problems, prison terms, family disruption, violence, prostitution, and recently, spread of HIV and large numbers of AIDS cases in these communities. Currently available drug treatment resources are insufficient and often inappropriate for the communities they serve.
Latinos have tended to underutilize drug treatment facilities, but much of this underutilization may be explained by treatments that are inappropriate to Latino culture. In some ways, Latino culture can be incompatible with help-seeking for a drug problem. In Latino culture, difficult and embarrassing problems like drug abuse are solved within the family whenever possible.(46)
Traditional approaches to drug treatment (detoxification, methadone maintenance, and therapeutic communities) may be very unattractive to Latino drug users. Methadone maintenance has been criticized as an "easy way out," because the client remains addicted, which contradicts a "macho" image. In therapeutic communities, the recovering-addict community becomes the addict's "family," which is culturally inappropriate for Latinos who place special emphasis on their families and cannot substitute them easily.(47)In fact, the families of Puerto Rican addicts were found to be significantly more supportive and less pathologic and drug-involved than the families of white non-Latino addicts.(47)
All treatment approaches require the addict to admit they need help and are not in control, an admission that Latino men find difficult to make due to the cultural value of "machismo."(48) Any treatment approach that humiliates or degrades the individual in front of others is also problematic, because it would conflict with Latino cultural values of respect.(47)
Current drug treatment approaches might be improved by encouraging Latino family members to become more actively involved in the treatment process by providing vocational and educational services, including English as a second language, and by providing legal services and referrals, both for clients with criminal involvement and for those who are undocumented.(47,49)
At present, few drug treatment programs address sexual risk for Latinos, yet studies suggest that Latino women are at greater risk through sexual exposure from their drug-using partner than due to their own drug use, because drug use among women is much less common than among men.
| Other Sources of Transmission of HIV in Latinos|
| Needle-Use Behavior|
Some Latinos in the United States, especially those who recently arrived, use needles and syringes for activities other than drug use such as ear piercing and giving injections of vitamins and medications.(50) In most Latin American countries, prescription medicines (including injectables) are available over the counter. In fact, at least one case has been reported in which family vitamin injections spread HIV infection.(51) A survey of San Francisco Latinos, however, found that most respondents did not identify injection of vitamins or medicines in the home as a possible route of HIV transmission.(52) Needles are also used extensively for tattooing in prison, where sterile conditions are usually unavailable.
| Blood Transfusions|
Latino men and women from Mexico and Central America may have a higher likelihood of having contracted HIV through blood transfusions due to the delay in blood screening in these countries. In Mexico, as of June 1992, 60% of AIDS cases in women and 29% of pediatric AIDS cases were attributed to blood transfusions.(53) Fear of contracting HIV through blood transfusion may be high in the Latino population and may include misinformation such as assuming that donating blood could put one at risk of HIV infection. In fact, 3% of AIDS cases in Mexico are due to donating blood, because during the mid-1980s, commercial blood banks in that country reutilized syringes when collecting blood.(54)
| Interventions to Prevent Transmission of HIV|
Despite the fact that the AIDS epidemic has been devastating the Latino community for many years, there are still few proven strategies for HIV prevention. In fact, as this review suggests, interventions that can effectively address the multiple cultural issues that challenge those at risk will be difficult to develop. Such interventions should naturally include the skills building that has proven helpful with other groups, but they must also address the difficult cultural issues facing Latinos.(55) When considering studies of HIV prevention interventions for the Latino community that have been published, only one intervention, done with clients at STD clinics, has shown substantial effects.(56)
This intervention involves careful pretesting and focus groups to identify the reasons for using and not using condoms that would be most salient for Latino STD clinic patients.(57) Interviews with clinic personnel also help to assure the feasibility of the intervention. On the basis of this work, a culturally appropriate video for Latinos was developed, called "Porque si."(58) Combined with a 20-minute small group discussion, this intervention was twice as effective as usual care in promoting condom use. The intervention provides culturally appropriate reasons for using condoms, helps clinic patients identify their difficulties with condom use, and provides practice of condom-related skills.
Other intervention efforts are also worth mentioning because they are based on cultural issues and suggest encouraging results. One intervention with gay and bisexual Latino men uses four structured small group discussions with ongoing support groups and asks group members to keep diaries of their sexual episodes. These activities help the participants to explore the underlying cultural issues of homophobia, shame, and family attachments that may interfere with their efforts to change their sexual behavior.(22)
Needle exchange is another approach that deserves serious consideration. The evidence is overwhelming that this approach can decrease HIV transmission among drug users and their partners and offspring.(59,60) Among Latinos, it may be important to consider where these exchanges would be located, because confidentiality and the success of the exchange may be compromised when they are located where those exchanging needles fear being watched by their neighbors.
| Providing Culturally Appropriate HIV-Related Services|
To develop counseling and treatment services for Latinos with AIDS or HIV and their families, a number of cultural characteristics must be taken into account. Ideally, services for Latinos and their families will be designed and delivered by Latinos who speak both Spanish and English and will automatically understand and accommodate to the cultural issues outlined below. When this is not possible, special attention must be paid to the certain cultural characteristics.
One of the most important cultural characteristics of Latinos is "familismo," or the emphasis on the family as the primary social unit and source of support.(61,62) For the counselor or health care provider, familismo may mean that Latinos will avoid sharing their problems outside the family circle. Also, the importance of children to Latinos may increase the willingness of HIV-positive women to carry a pregnancy to term and to choose to conceive more children in the future. Data from intravenous drug using women, over half of whom were Latino, indicate that many choose to conceive a child even after learning they are seropositive.(63) Recent advances in therapy for HIV mean that such pregnancies are less likely to result in HIV-infected babies, but access to such treatments is not always easy for low-income and/or drug-using populations.
Although familismo may create special problems for AIDS prevention, the power of familismo might also be used in the fight against AIDS. The impact of AIDS on the family and especially on the children could be a key factor in motivating the behavior change of high-risk individuals. Probably due to familismo, Latinos were more likely to believe a family member should intervene with someone who was at risk of getting or transmitting HIV than non-Latino whites.(15)
The concept of "simpatia" has no direct translation in English, but refers to the importance in the culture of smooth social relations. This central cultural value mandates politeness and respect and shuns assertiveness, direct negative responses, and criticism.(64) "Simpatia" requires that the Latino listener appear to agree with a message, even though he or she has no intention of following the advice or did not understand it. Therefore, it is critical that intervenors ask questions to assure that AIDS information and behavior change messages have been correctly understood.
"Personalismo" refers to a preference by Latinos for relationships with others in their social groups that suggest a certain familiarity and warmth. In practice, personalismo means that Latinos may be more likely to trust and cooperate with someone with whom they have had pleasant conversations, often referred to as "la platica" by Mexican Americans. These conversations are not just about weather, etc., but rather could include caring questions about particular individuals in the family, remembering events shared in the past, or a simple sense of history in the relationship. The delivery of HIV/AIDS information, services, and treatment to Latinos will be most effective when educators, outreach workers, and providers can establish relationships that nurture "personalismo."
Respect or "respeto" is the need for mutual respect, especially toward authority figures, in social relationships.(65) "Respeto" requires maintaining one's sense of personal integrity in interactions with others. By implication, a person receiving medical or drug treatment must feel that he or she is treated with respect and valued, or treatment will be rejected.(66) Another dimension of "respeto" is that often patients will not question an authority, even if they do not understand something that is said. This respect for authority is also exemplified in data indicating that Latino respondents were more likely than non-Latino whites to feel that an older person should intervene with someone at risk for HIV.(52)
Latinos have a different perception of time than non-Latino whites, with a more flexible understanding of punctuality.(67) Latinos have a greater latitude before they would declare someone they are waiting for as "late," or feel that they themselves are "late." In addition, "saving time" is seen as less important than smooth warm social relationships. A hurried pace or focus on saving time on the part of a caregiver may be seen as rudeness, because in Latino culture, time is not as important as interpersonal relationships.
Even with major efforts to prevent the spread of HIV, AIDS will continue to affect Latinos disproportionately in the United States. Multiple sexual partners and use of intravenous drugs are prevalent in some areas. Homophobia and traditional sex roles may impede prevention efforts. At the same time, there are some hopeful signs for the future. Fifty percent of Latino men with multiple partners report consistent condom use with secondary partners. Cultural strengths such as strong family orientation can be used to encourage safe sexual and drug behaviors. A culturally appropriate intervention for Latino STD patients already exists and is available. Greater understanding of and respect for Latino culture will lead to better HIV prevention efforts.
This chapter was supported in part by grants from the National Institute of Mental Health, Nos. MH46789, MH51515, and Center grant MH42459.
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