Immigrant Health: Implications for HIV care in California

April 23, 2018

Access to health care is a growing concern for immigrants living in the U.S. This brief report describes how immigrants may be deterred from seeking health care services, and how this may affect the continuity of HIV care and prevention. The report also features recommendations for HIV care providers who serve immigrant communities.

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Authors

Shannon Fuller Emily A. Arnold Emma R. Bohannon Wayne T. Steward

Anti-immigrant policy and rhetoric as barriers to care

The US has experienced a surge of anti-immigrant rhetoric and policies since January 2017, especially at the federal level.^1-3 Many of these policies increase federal immigration enforcement and limit the entrance of individuals from specific countries to the US.

According to a 2015 study, two of most commonly cited barriers to health care among immigrants were stigma and fear of deportation.⁴

Evidence suggests that immigration-related fears have intensified in the US during the past year.^1,2,5

In October 2017, a commentary published in the Journal of American Medicine noted an association between increased fears of deportation and a rise in clinic appointment no-show rates, even in sanctuary cities like San Francisco.²

Additionally, a clinic that serves immigrant communities in Austin, Texas found that appointment cancellation rates rose by 50% following a number of Immigration and Customs Enforcement (ICE) raids in February 2017.⁵

The studies described in this brief report show how immigration-related fears influence the health care-seeking behaviors of documented and undocumented individuals. Having immigrants in the US fall out of care has repercussions for individual and public health, and the state’s eﬀorts for “Getting to Zero” (i.e., zero new HIV infections; zero AIDS-related deaths; and zero stigma/ discrimination against people living with HIV).

Further research is needed to estimate the impact on prevention and care for immigrant communities aﬀected by HIV—approximately how many are failing to get regular testing, how many newly diagnosed individuals are not being linked to care, and among those previously diagnosed, how many are no longer engaged in care and adherent to treatment? Studies can also aim to learn what steps, if any, clinics that serve immigrant communities are taking to maintain HIV prevention, care and treatment.

What is the effect on human health?

Studies show:

Anti-immigrant rhetoric has a negative impact on the mental health and self-reported general health of all Latino Americans, regardless of immigration status.^{1, 6-8}
State-level policies, such as Arizona’s SB1070 law enacted in 2010, which required state law enforcement officers to check immigration paperwork, had a negative impact on health outcomes and utilization rates of preventive and routine health care.^6,9

How can I help my patients?

The following strategies have been suggested by primary care providers and legal resource centers to mitigate fears among immigrant communities and support access to medical care:

Combine appointments to minimize the number of clinic visits.¹
Arrange for home delivery of medications when possible and if desired by patients.¹⁰
Display non-discrimination posters in the clinic.^1,11
Help patients understand their legal rights by hosting information sessions or providing referrals.^1,11
Avoid asking patients about immigration status or recording such information in patients’ medical charts or billing records.¹¹
Understand your legal rights and obligations as a health care provider.¹¹

Access to health care is a growing concern for immigrants living in the United States. [i-iv]

California Context

An estimated more than two million undocumented immigrants live in the state of California, comprising approximately one-quarter of undocumented individuals in the US.^v The state is also home to the country’s largest population of migrant workers and documented immigrants.^vi
Impact on HIV care

Living with HIV requires consistent engagement with the health care system to achieve viral suppression and reduce the risk of onward transmission.^vii The barriers that immigrants face when accessing health care and supportive services pose challenge or managing HIV disease.
Barriers to care among immigrants
Some of these barriers to health care may include:
- Financial limitations ^viii
- Employment conditions or work hours that conflict with clinic appointments ^viii
- Lack of cultural sensitivity and inclusion (e.g., translation services) ^viii
- Shame and stigma ^viii
A 2017 study by the Kaiser Family Foundation explored the daily life and health of immigrant families in the current political climate.^iv Researchers found widespread fear, particularly among families with mixed immigration status. Some families limited the amount of time spent outside the home. In some cases, there was decreased enrollment in public programs such as Medicaid, due to concerns that participation could bring family members under scrutiny.^iv

References
i. Fernandez A, Rodriguez RA. Consequences of recent anti-immigration policy – reply. JAMA Intern Med. 2017;177(10):1535-36.
ii. Gomez S. Arizona’s immigration enforcement policies: implications for accessibility of care in immigrant families. The University of Arizona, ProQuest Dissertation Publishing, 2017.
iii. Dourgnon P, Das P. Consequences of recent anti-immigration policy. JAMA Intern Med. 2017;177(10): 1535.
iv. Artiga S, Ubri P. Living in an Immigrant Family in America: How Fear and Toxic Stress are Aﬀecting Daily Life, Well-Being, & Health. Kaiser Family Foundation. December 2017.
v. Hayes J, Hill L. Undocumented Immigrants in California. Public Policy Institute of California. 2017. https://www.ppic.org/publication/undocumented-immigrants-in-california/
(Accessed March 19, 2018).
vi. Hayes J. Immigrants in California. Public Policy Institute of California. 2017. https:// www.ppic.org/publication/immigrants-in-california/ (Accessed March 19, 2018).
vii. HIV Care Continuum. Available at: https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum (Accessed March 19, 2018).
viii.Hacker K, Anies M, Folb BL, Zallman L. Barriers to healthcare for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015;8:175-83.
1. Artiga S, Ubri P. Living in an Immigrant Family in America: How Fear and Toxic Stress are Aﬀecting Daily Life, Well-Being, & Health. Kaiser Family Foundation. December 2017.
2. Fernandez A, Rodriguez RA. Consequences of recent anti-immigration policy – reply. JAMA Intern Med. 2017;177(10):1535-36.
3. Dourgnon P, Das P. Consequences of recent anti-immigration policy. JAMA Intern Med. 2017;177(10): 1535.
4. Hacker K, Anies M, Folb BL, Zallman L. Barriers to healthcare for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015;8:175-83.
5. Ehley B, Collivery V, Rayasam R. Fearing deportation, immigrants forgo medical care. POLITICO. Published online July 17, 2017. https://www.politico.com/story/2017/07/17/deportation-fears-under-trump-have-immigrants-forgoing-medical-care-240635 (Accessed March 19, 2018).
6. Vargas ED, Sanchez GR, Juárez M. Fear by association: perceptions of anti-immigrant policy and health outcomes. J Health Polit Policy Law. 2017;42(3):459-83.
7. Philbin MM, Flake M, Haienbuehler ML, Hirsch JS. State-level immigration and immigrant-focused policies as drivers of Latino health disparities in the United States. Soc Sci Med. 2017 [Epub ahead of print].
8. Vargas ED, Ybarra VD. U.S. citizen children of undocumented parents: the link between state immigration policy and the health of Latino children. J Immigr Minor Health. 2017;19(4):913-920.
9. Toomey RB, Umaña-Taylor AJ, Williams DR, Harvey-Mendoza E, Jahromi LB, Updegraﬀ KA. Impact of Arizona’s SB 1070 immigration law on utilization of health care and public assistance among Mexican-origin adolescent mothers and their mother ﬁgures. Am J Public Health. 2014;104:S28-34.
10. Hoﬀman J. Sick and afraid, some immigrants forgo medical care. The New York Times. Published online June 26, 2017. https://www.nytimes.com/2017/06/26/health/undocumented-immigrants-health-care.html (Accessed March 28, 2017).
11. National Immigration Law Center. Healthcare Providers and Immigration Enforcement: Know Your Rights, Know Your Patients Rights. April 2017. https://www.nilc.org/issues/ immigration-enforcement/healthcare-provider-and-patients-rights-imm-enf/ (Accessed March 28, 2017).
Acknowledgements

This product was developed using funds from the California HIV/AIDS Research Program, Office of the President, University of California, Grant Number RP15-SF-096.

All images were used with permission from Twenty20 stock photos (https://www.twenty20.com).