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August 8, 2012

HIV Infection Among Persons Born Outside the United States

Author Affiliations

Author Affiliations: Los Angeles County Department of Health Services, Los Angeles, California. Dr Katz is also Deputy Editor of the Archives of Internal Medicine.

JAMA. 2012;308(6):623-624. doi:10.1001/jama.2012.8670

Immigration of persons to the United States from different parts of the world brings health challenges, including infectious diseases such as tuberculosis, hepatitis B, and Chagas disease. In 2011, the incidence of tuberculosis (new infection or reactivation of latent infection) among persons born outside the United States was 12 times greater than among persons born in the United States.1 The prevalence of hepatitis B infection is at least 10 times higher among those born outside but living in the United States than among those born in the United States.2 An estimated 300 000 persons born in Latin America and living in the United States are infected with Trypanosoma cruzi, the causative parasite of Chagas disease, with less than 10 cases of new infection occurring in the United States since 1955.3

In this issue of JAMA, Prosser and colleagues4 provide data on human immunodeficiency virus (HIV) infection among persons living in but born outside of the United States. Using data from 46 states and 5 US territories reported through the HIV Surveillance System from 2007 through 2010, the authors identified 191 697 persons who were diagnosed with HIV and for whom a country or continent of birth was reported. The authors report that of these persons diagnosed with HIV infection, 30 995 (16.2%) infections occurred among those born outside the United States, and the countries of birth origin with the highest number of persons diagnosed with HIV were Mexico, Haiti, Cuba, and El Salvador. Moreover, the 4 states with the highest proportion of persons born outside the United States and diagnosed with HIV (California, Florida, New York, and Texas) were also the 4 states with the highest numbers of HIV cases reported overall.

These findings demonstrate that the epidemiology of HIV among those born outside the United States is different and more complicated than is the case for other infectious diseases, such as tuberculosis, hepatitis B, or Chagas disease. For these infections, the substantially higher prevalence of infection among those born outside the United States is primarily due to high prevalence of these infections in the immigrants' countries of origin; however, with the exception of Africa, this is not necessarily so with HIV.

For example, Prosser et al4 report that the largest proportion of HIV diagnoses among those born outside the United States was among those from Central America (including Mexico; 41.0%) where HIV is not highly prevalent. The estimated adult HIV prevalence in Mexico is half (0.3) that of the United States (0.6).5 Although selective migration of HIV-infected persons from these other countries to the United States cannot be excluded, it is likely that the majority of those who immigrated from Mexico and other areas of the world where HIV infection is uncommon among adults, such as South and Southeast Asia (0.3) and east Asia (0.1%),5 acquired their infections in the United States. In contrast, it is likely that a higher proportion of HIV infections among those of Caribbean descent, for whom the adult prevalence of infection is 1.0%,5 may have occurred in the country of birth.

The prevalence of HIV among those born outside the United States also may be more likely to reflect poverty than country of origin. The US National HIV Surveillance System does not capture good data on income. However, a study of heterosexuals living in poverty areas in 23 US cities found that the seroprevalence rate was more than 20 times higher among those living in impoverished areas than the prevalence rate among heterosexuals in the United States overall.6 It is possible that if Prosser et al4 would have adjusted their data for socioeconomic status, they might have found a smaller percentage of HIV infections among those born outside than among those born within the United States.

Even though HIV poses no risk of casual transmission, the United States has had a very restrictive policy toward entry of persons with HIV. In 1987, the United States prohibited entry of HIV-infected travelers or legal residents. In 1991, the ban was lifted for travelers but remained in place until 2010 for those wishing to reside in the United States.7 During this time, the United States did not ban persons with latent tuberculosis infection or evidence of hepatitis B infection from traveling or immigrating to the United States, and reentry testing was not required for US travelers who returned home after having visited high-prevalence HIV areas.

The ban on entry of HIV-infected persons to the United States was not consistent with public health principles and may have had negative public health consequences. For those hoping to reside permanently in the United States, the ban raised concerns about HIV testing; among persons who sought anonymous HIV testing to avoid being reported, concerns about deportation or inability to reenter the United States may have dissuaded those who tested positive from obtaining needed medical care. These concerns, compounded with language barriers, lack of culturally appropriate educational materials, low literacy, and poor access to medical care, may have resulted in patients presenting later in the course of illness.

Immigration also can be a risk factor for HIV transmission. Immigrants who are poor and undocumented can more easily be subjected to sexual exploitation. Because these persons fear deportation, they are less likely to report crimes that are committed against them and are vulnerable to human traffickers.8 Lack of documentation and discrimination against immigrants makes it difficult for many to obtain paid work and some will resort to selling sex or drugs to support themselves.

The study by Prosser et al4 contributes timely information but has several important limitations. As the authors acknowledge, the major limitation is that it is not possible to determine where and when HIV infection occurred. The HIV case report form does not include data on time of first entry into the United States, and the time from HIV infection to report in the National HIV Surveillance System was not documented. The issue is more complicated than whether HIV infection was acquired before or after immigration to the United States. Immigrants are known to travel back and forth to their countries of origin, raising the possibility of HIV infection occurring in their country of birth but after immigration to the United States. In addition, immigrants to the United States may be joined by spouses from their country of origin who may have lagged behind and developed HIV infection in the intervening period. Another limitation is the lack of accurate data on the total numbers of persons in the United States who were born in other countries, in part because of the large numbers of immigrants who are undocumented.

Despite these limitations, the report by Prosser et al4 suggests that persons born outside the United States who reside in the United States are a heterogeneous group. This study and other studies suggest that these persons are in need of appropriate education and outreach, testing and treatment, and mental health services including specialized services for those who experience traumatic events in their home countries or during the immigration process, substance treatment for those addicted to drugs, as well as HIV care for those who are infected. Although these lessons may apply regardless of country of origin for HIV-infected persons, the effectiveness of these messages and interventions will require culturally relevant delivery to each specific population of immigrants.9

Although the United States historically is a nation of immigrants, earlier immigrants had been fearful and discriminatory against later generations of immigrants.7 The debate surrounding whether undocumented immigrants are entitled to benefits such as health insurance, driver's licenses, and publicly supported higher education is contentious. Although physicians may have a range of opinions about these issues, they should not be concerned about a patient's immigration status or country of birth when that patient needs care. A central tenet of medicine is to provide care to all of those in need. There is a lesson in that for a nation of immigrants.

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Article Information

Corresponding Author: Mitchell H. Katz, MD, Los Angeles County Department of Health Services, 313 N Figueroa St, Room 912, Los Angeles, CA 90012 (mkatz@dhs.lacounty.gov).

Published Online: July 22, 2012. doi:10.1001/jama.2012.8670

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Katz reported serving as a consultant to ETR Associates Inc and receiving royalties for a chapter on HIV/AIDS in Current Medical Diagnosis and Treatment.

Disclaimer: The views expressed do not necessarily represent the views of Los Angeles County, California.

Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association.

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