Impact of Immigration Policies on HIV/AIDS Care Access and Retention

1. Impact of Immigration Policieson HIV/AIDS Care Access and Retention Catalina Sol Chief Programs Officer La Clinica del Pueblo

2. La Clinica del Pueblo • Serves uninsured and low-income Latino immigrants in DC area with comprehensive health care • Majority of clients are Central American immigrants with history of war and trauma, rural origin, limited access to health care, lengthy process to obtain legalization in US • Since its inception in 1993, La Clinica has been a Latino community-based organization

3. La Clinica’s HIV Department • Provides HIV care and prevention services since 1985 • Funded locally with Ryan White since 1993 for direct services, directly-funded by CDC since 1998 for prevention • Services include primary medical care, case management, mental health and substance abuse services,, support groups, interpreter services, outreach, group interventions for vulnerable populations, CTR, system navigation

4. Barriers to Detection and Early Intervention • Lack of linguistically and culturally appropriate, geographically accessible services • Lack of access to health care • Health beliefs and attitudes related to knowledge of disease • Stigma

5. Barriers to Care for HIV Positive Latinos • Conflicts between work and medical care • Instability/lack of availability of housing • Lack of family/support structures • Lack of linguistically and culturally appropriate services, particularly mental health services • Stigma

6. Immigration and Daily Life • What does it mean to be undocumented? • Progressive criminalization of administrative status -- • Relationship to police, law enforcement, state/government entities • Effect on physical and mental health • Inability to obtain basic documents –social security #, ID • Driving, banking, home renting or ownership, access to services • Effect on social insertion and stability • Inability to obtain safety net benefits • Effect on socioeconomic status, relationship to employer • Notable exception – Ryan White, ADAP • Extreme vulnerability with respect to employer

7. Immigration and Daily Life • What does it mean to have a work permit? • Legalization, opportunity for identification • Temporary state • Still no benefits • Poorly understood category • What does it mean to have a green card (permanent residence)? • Permanent legalization, official “entry” to US • Still no federal safety benefits (must wait 5 years) – Medicaid, Section 8, Food Stamps • What does it mean to be a citizen? • Vote • Benefits

8. Immigration Policy – HIV specific • History of Immigration policy with respect to HIV/AIDS is a policy of exclusion • Life during the HIV Ban • Consular testing • Testing as condition of legalization • Life or death dimension of risk when exploring permanent residence option • HIV Ban lifted Jan 2010!

9. Immigration Policy, general • Even without ban, immigration policy poses multiple barriers to “entry” to low-income immigrants living with HIV • Family Based • Sponsor • Employment based • Asylum • Refugee • Public charge issues • Length of time

10. Impact of Immigration Policies -- States • Increasing number of states imposing restrictions on access to services for immigrants • Impacts on access for Ryan White • process for determining eligibility can be exclusionary • Confusing for eligibility workers – not immigration experts! • Public perception among immigrants • Where state funding for HIV is significant, excluding immigrants for services

11. Impact of Immigration Policies -- Individuals • Hostility towards immigrants, bigotry, reinforced by policies • Service providers – confused, fearful, unsure of how to proceed without hurting clients • Fear of immigrants, frequently disproportionate and based on traumatic experiences, seems to be more and more warranted

12. Recommendations • Voice of public health community must be louder in national dialogue on immigration • Negative impact on public health of immigration policies • Cost savings of inclusion • Cost burden of exclusion, including non-health areas • Health as a human right

13. Recommendations • At service provider level: • Reinforce availability of Ryan White services for immigrants • Examine how access points may be excluding immigrants unnecessarily • Ask about immigration status only to determine eligibility, ask the question correctly • Do not reinforce fears of patients, but be informed • Make alliances with community-based organizations that work with immigration issues to brief them on special needs of HIV positive patients