1. HIV & Immigrant Communities Impact on Asians & Latinos Sneha Jacob, M.D., M.S. South Asian Total Health Initiative Robert Wood Johnson Medical School

2. The names and photos in the following presentation are not the actual names and photographs of the patients discussed, but rather fictional names and stock photo images taken from the Internet

3. Carlos 50 year old Mexican man, non English speaking Unable to find a job to support his family in Mexico so he crossed the border by foot into Texas in 2003 Found his way to NJ where he worked as a dishwasher at an Indian restaurant and sends money home to support his two daughters http://www.nytimes.com/2010/07/10/us/10enforce.html?pagewanted=all

4. Carlos Had to stop working this past September due to difficulty breathing Admitted to the hospital where he was found to have AIDS and to be in heart failure due to a rare heart valve infection Started on HIV treatment in January Back to work at another Indian restaurant in March http://www.sciencedaily.com/articles/m/mitral_valve.htm

5. Immigration Reform

6. Immigrants and access to Medical Care  Undocumented immigrants: not eligible for federally funded public health insurance programs, including Medicare, Medicaid and the Child Health Insurance Program (CHIP)  Exception: emergency care  Legal noncitizens (i.e. permanent residents)-- limited access to employer-based health coverage and restrictions: not eligible for Medicaid and SCHIP for the first 5 years  non-citizens (legal and undocumented) are far more likely to be uninsured than citizens (47% vs. 15%)

7. Latino Immigrants & Health Insurance Coverage Latino Commission on AIDS: http://www.latinoaids.org/hivlatinos.php

8. Immigrants with HIV/AIDS and access to Medical Care  HIV drug coverage  AIDS Drug Assistance Program (ADAP)  New Jersey= ADDP  Ryan White Federal Government Funding for HIV positive individuals  Federally Qualified Health Centers (FQHCs) and Migrant Health Cen­ters –  funded by the federal Health Resources and Ser­vices Administration (HRSA).

9. The HIV Ban- U.S. & Abroad US Public Health Service List of “Dangerous and Contagious Diseases” 1987 Reagan Administration: AIDS was added to that list Department of Health and Human Services (DHHS) in late 2009, published regulations to remove HIV from the list of “communicable diseases of public health significance,” in effect on January 4, 2010 45 countries still deport, detain or deny entry to people solely because they are HIV positive. http://ghalegroup.com/blog/2010/04/30/china-ends-travel-ban-on-visitors-with-hiv-and-aids /

10. Countries with Regulations restricting Entry Bahamas Brunei Equatorial Guinea Iran Iraq Jordan Papua New Guinea Qatar Russia Singapore Solomon Islands Sudan United Arab Emirates (UAE) Yemen

11. U.S Public Health Service List  “Communicable diseases of public health significance”  active tuberculosis,  infectious syphilis,  chancroid,  gonorrhea,  granuloma inguinale,  lymphogranuloma venereum,  Hansen's disease (leprosy) The Immigration Act of 1990

12. What is HIV? AIDS? HIV is a Virus that weakens your immune system Causes AIDS- Acquired Immune Deficiency Syndrome. HIV becomes AIDS when the immune system becomes severely weakened AIDS results in severe illness (infections, cancers) that cause death

13. Can HIV/AIDS be Treated? HIV/AIDS cannot be cured but it CAN be treated  Antiretroviral Therapy, the treatment for HIV/AIDS can allow people to live with HIV and be healthy on as little as one pill a day  The earlier one is diagnosed, the earlier treatment can be started, & the longer they can live

16. How do we test for HIV? HIV tests check for antibodies - immune system produces in reaction to HIV infection Rapid tests –preliminary results in as little as 20 minutes.

17. How does the HIV Test Work? Tests blood or a sample of cells from inside cheek for antibodies to the virus. Most people develop antibodies to the HIV virus within 3-6 months of infection. If this test is positive lab technicians run 2 more tests; results can take from a few days to 2 weeks

18. Who Should be tested for HIV? Current CDC Recommendations ALL individuals ages 13 to 64 be tested for HIV at least once in their lifetime Yearly testing if high risk of infection: unprotected sex with >1 partner or with an anonymous partner A man who has sex with men Use of intravenous (IV) drugs Diagnosis of tuberculosis, STD, hepatitis, or syphilis

19. Gabriella 44 year old woman came to the hospital with heavy bleeding, concerned she was having a miscarriage Tested positive for HIV Crossed the border from Honduras via Guatemala and Mexico in 2004, leaving her mother and 3 sons behind http://213project-mwecas.blogspot.com

20. Gabriella One of her sons, 19 years old was killed by guerillas in Honduras last year Sending her earnings as a housekeeper to help her sons cross the border however they were caught and detained in Guatemala Had to stop her HIV medications because her insurance lapsed -unable to read the application that came by mail in English https://www.russellsage.org/publications/crossing-border

21. HIV and Latino Immigrants

22. Latinos constitute a rapidly expanding proportion of People Living With HIV/AIDS in the U.S.

23. Latinos with AIDS: Where are they from? Latino Commission on AIDS: http://www.latinoaids.org/hivlatinos.php

24. How are Latinos becoming infected with HIV?

25. Vidhya 70 year old woman moved to the US from India in 2009 after becoming a widow Lives with her 35 year old daughter and in Central Jersey Husband died of kidney failure & diabetes in 2007 http://www.bolegaindia.com/gossips/Meenal_Patel_will_play_grandmother_in_Alakshmi-gid-13186-gc-16.html

26. Diagnosed on routine immigration testing in February 2009 History of two blood transfusions in India in 1999 for low hemoglobin Started on HIV treatment in 2011

27. HIV and Asian Immigrants

28. What is the Recorded Rate of HIV Among Asians in the U.S.? (CDC, 2005) Male Adults and Adolescents with HIV in U.S., 2005

29. What is the Recorded Rate of HIV among Asians in NJ?

30. Why are Asians NOT being tested?  Cultural Barriers  Language Barriers  Lack of Knowledge about HIV  Fear & Stigma

31. New Jersey: Proportion of Asians Tested for HIV

32. Rommel 27 year old Filipino man Worked at Major Network TV station in the I.T. Department in NYC One day found to have yellow eyes and yellowed skin, fever, stomach pain Went to the hospital and was found to have HIV and Hepatitis C http://fitness.bf-1.com/men_celebrities/michael-copon-a-filipino-making-it-in-hollywoo d

33. Rommel Migrated to the United States from the Philippines with his family at the age of 5 Injected crystal methamphetamine at parties on the weekends Has sex with men, yet has not disclosed this sexual orientation to his family Found to have AIDS at diagnosis and was started on HIV medication right away http://www.thehillscenter.com/addiction/iv-drug-use /

34. Asians in the U.S. have the highest percent of foreign born with HIV % HIV Diagnoses in US Among Foreign Born: Blacks (8614 of 86547) 10% of diagnoses Hispanics (17913 of 42431)42% of diagnoses Asians (1987 of 3088) 64% of diagnoses #1-Phillipines (449), #2- India (287), #3-VietNam(256), #4- Thailand (190), #5-China (137).

35. At Diagnosis Asians are more likely to have Advanced AIDS In 2004, the proportion of individuals who were found to have AIDS within 1 year after their HIV infection was diagnosed: 37% of Whites 40% of Blacks 41% of American Indians/Alaska Natives 43% of Hispanics 44% of Asians and Pacific Islanders

36. What is my role? Eric B. Chandler Health Center Federally Qualified Health Center (FQHC) Robert Wood Johnson Medical School (UMDNJ) New Brunswick, NJ

37. Eric B. Chandler HIV Clinical Services  450 patients with HIV  6 Different Counties (majority from Middlesex, Hunterdon, Somerset)  276 Men, 170 Women, 4Transgender  42% Black, 17% White, 35% Latino, 3% Asian  50% Heterosexual, 28% MSM, 18% Injection Drug Use, 1% Perinatal (mother to child), 0.4% Transfusion  89% live with a virus that is undetectable (controlled on Antiretroviral Therapy)  Chandler ranks as one of the top in the U.S. among 600+ HIV centers (average viral load suppression rate 72%)

38. Our Latino Population  130 Latino patients  Puerto Rico, Dominican Republic, Mexico, Guatemala, Honduras, Ecuador, Peru, Paraguay, Brazil, Cuba, Colombia  Risk Factors:  70 Heterosexual  45 Men who have sex with men (MSM)  14 Injection Drug Use  1 Perinatally infected (at birth)

39. How are YOU impacted by HIV? HIV AmongYouth Aged 13-24 in the United States

40. In 2009, young persons accounted for 39% of all new HIV infections in the US. (persons aged 15–29 comprised 21% of the US population in 2010) Those aged 20–24 had the highest number and rate of HIV diagnoses of any age group (36.9 new HIV diagnoses/100,000 people).

42. Thank you  Dr. Dutta, Rutgers University  SATHI South Asian Total Health Initiative  Sunanda Gaur, Shrivridhi Shukla  Robert Wood Johnson Medical Center Department of Family Medicine/Internal Medicine  Eric B. Chandler Health Center HIV Team  Joy Melendez, Cindy Leon, Betsy Medina, Jessica Ortiz, Connie Robinson, Kathy Sarnoski, Steve Levin

43. Questions?  Other Topics….  HIV “Cures” in the News