California has a potential epidemic on its hands. While the numbers are still small, HIV among undocumented immigrants is on the rise. The reasons aren't simple and the answers aren't easy. Statistics about undocumented workers are difficult to come by, but the trend is reflected in the general Latino population. Ten years ago, Latinos accounted for 13 percent of AIDS cases in Santa Cruz County. By 2006, that number had almost doubled, to 24.5 percent. Similarly, in Los Angeles County five years ago, 50 percent of AIDS cases were Caucasian and 25 percent were Latino. Now those numbers have reversed. HIV and AIDS experts throughout California say part of their mission is to confront this situation. But that's easier said than done. State funding for AIDS organizations is relatively healthy, but the task of educating and treating an ever-growing undocumented immigrant population is daunting. Without new culturally appropriate tactics, prevention isn't going to work.

Fernando Vega and Armando Hernandez probably know this better than anyone. Both are working out of the Santa Cruz AIDS Project's recently opened (in mid-October) Watsonville office. Vega focuses on needle exchange; Hernandez is an HIV/AIDS counselor who will be doing general outreach work among Latinos.

"Armando is on board to do HIV prevention in a culturally competent manner with Latinos all over the county," says SCAP education and prevention coordinator Susan Pratte. "He'll be having office hours, times when people can drop in ... and he'll definitely do a lot of street outreach. We have several different teams going out to places where people might be at risk, either having sex in the bushes or hanging out with people who might be drug injectors."

The two have their work cut out for them. AIDS workers report that there is no real protocol for educating a man or woman from a small town in Mexico. They describe the problem as being similar to that faced by health-care workers at the dawn of the epidemic.

In much of Mexico, HIV and AIDS are surrounded by potent stigma. While Mexico is working to bring its HIV awareness into this century—even hosting the 2008 International AIDS Conference in the capital—most undocumented immigrants who come here to work have very little knowledge of HIV or how to keep from getting it.

'I Lost My Life'
Pablo Rodriguez says that when he crossed the border 22 years ago, at the age of 18, and settled in Watsonville, he knew only vaguely about protection. He says he had never had sex with a man before coming to the United States, although he had thought about it. Rodriguez (who asked to be interviewed under an alias) says he was isolated without his friends and family, and began to drink heavily. He soon met and moved in with a man, but hid the fact that they were lovers. He says his partner never told him he was HIV-positive.

"I lost my life, the one that I knew," Rodriguez says. "I have worked here everywhere. The fields, the factories, the houses. I made it all the way here, and now I live with this. I live with this in all of my life."

Rodriguez is now on anti-retroviral medication. He says he can't go back to Mexico.

But many migrant workers do return, again and again. In 2000, data showed that up to 26 percent of HIV cases in parts of Mexico had lived in the United States. Health officials believe many of them contract the disease while here—where they're often lonely, struggling, far from family and constantly on the move. These factors can result in high-risk behaviors.

Maria Hernandez, epidemiologist with the University of California's HIV/AIDS Research Program (CHRP), says migrant workers are more likely to change their behavior and sexual activity if they don't have a family or social network here. This also often prevents them from getting tested.

In a survey hosted by CHRP, as many as one-third of day laborers questioned in Los Angeles said they had been propositioned by men to be paid for sex. Up to one-10th said they had accepted. According to surveys carried out by CHRP in Fresno and San Diego counties this year, as many as one-fifth of migrants reported they had used crystal meth (although they call it cocaine).

All of these statistics on undocumented immigrants are short-term and suffer a lack of cohesiveness. Progress has been made, but it will always be difficult to document the undocumented.

Taking Responsibility
Dr. George Lemp, an epidemiologist and the director of CHRP, says the United States needs to accept the bulk of the prevention responsibility, since the immigrants are often contracting the disease here, not in Mexico.

It's pretty much the only option. Mexico's Ministry of Health last year cut its funding for educating migrants from over $1 million to a paltry $150,000. In October, however, the Secretary of Health upped funding for HIV prevention programs.

The coalition between the Mexican National Center for HIV/AIDS Prevention and Control (CONTRASIDA) and the California Department of Public Health's Office of AIDS would like to see more funding go toward educating migrants before they leave Mexico. "Preferably prepare them six months to a year before they head out," says Dr. Lemp.

Mexico implemented a federal program in 2001 called "Vete Sano, Regresa Sano" (Leave Healthy, Return Healthy), which is supposed to do just that. But it's clearly not enough.

At home, family and local traditions create a comforting rhythm and provide an identity for workers. Uprooted, they put in long hours of intense labor, and afterwards many drink, abuse drugs or find solace in a casual sexual partner.

Mateo Lumbreras, a former South County outreach worker with SCAP, says his biggest hope is that the Latino faith community will get involved. He says they could help break the stigmas that prevent so many undocumented immigrants from getting tested and expand prevention efforts dramatically.

In addition, they could be a strong voice in calling for more recreational services for migrants, such as new soccer fields or later hours in public libraries.

The biggest challenge remains the cultural divide. Not only are migrant workers highly mobile, they also face intolerance in the United States. The combination of this pressure, along with the isolating experience of being HIV-positive, makes workers less likely to get help when they're sick. Even when a person knows where to get treatment, there is always the fear of being deported.

According to Dr. Jennifer Hirsch, professor of public health at Columbia University, the HIV epidemic in migrant workers simply illustrates what a problem the United States has in terms of immigration policy. "The public health programs can fritter away at the edges, but it's an immigration policy problem before it's a health problem," she says.

An Emergency
At a migrant-worker camp north of Santa Cruz, sex workers pay regular visits. The camp is also visited by an outreach worker who offers anonymous HIV testing. Grassroots efforts like these must suffice, because most undocumented workers lack proper access to health care and treatment. Lumbreras says the number of cases of HIV and AIDS in Santa Cruz could be much higher than it appears; the numbers might be artificially small because the undocumented population is hard to reach. He believes there's cause for alarm. He even uses the word "emergency."

What is especially worrisome is that the prevalence of Latino women contracting HIV from their partners is rising, both here and in Mexico. Leslie Goodfriend, of the County of Santa Cruz Health Services, adds that the agency now routinely tests Latina women for HIV when they come into the clinic for an unrelated reason. Undocumented women have discovered they are HIV positive often because of routine testing during a pregnancy.

The word "epidemic" is tricky. But right now, in a rural area of Mexico where there were zero cases of HIV, even one is great cause for concern.

"Mexico is sitting on the same tinderbox of an AIDS epidemic that China and India were 10 years ago," says Dr. Lemp. "But with binational efforts, it could be stopped. In Mexico we're hoping to prevent what China and India have now after years of denial: full-blown epidemics."

The obstacles to solving this problem are familiar; it's one piece of a broken immigration policy.Rodriguez recognizes that his medical condition is complicated by his status as an illegal. "I am not here, really, in this country," he says. "I am invisible and I can't get the support I need. I see others around me with the same situation and they can get more help because they are legal. It is lonely."

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