These results represent the first surveillance estimates for HIV cases among HBPs residing in the United States, with four important findings. First, HBPs constitute 1.2% (N = 416 divided by 35 934) of the estimated AIDS cases among adults and adolescents for 2007 (Table 1). Yet, HBPs account for only 0.18% of the total US population (using 2007 ACS data; N = 530 897 divided by 301 621 159), which suggests a seven-fold overrepresentation of Haitians in the CDC AIDS surveillance data (1.2% divided by 0.18%). In comparison, blacks/African-Americans constitute 48.7% (N = 17 486 divided by 35 934) of the estimated AIDS cases among adults and adolescents for 2007; and blacks/African–Americans account for 12% of the total US population, suggesting a four-fold overrepresentation (48.7% divided by 12%) in the CDC AIDS surveillance data . However, when population estimates from the Haitian Consulates are used, there is a 3–4-fold overrepresentation of HBPs in the CDC AIDS surveillance data (1.2% divided by 0.30–0.40%), which is similar to that for blacks/African–Americans overall. Population estimates for HBPs (0.30–0.40%) are calculated using Consulate estimates of the number of HBPs living in the United States, which range from N = 900 000 to 12 00 000 (divided by 301 621 159, using 2007 ACS data for the US population).
Although data from the ACS are reliable, they may reflect an undercount for Haitians living in the United States. Although Consulates do not run nationally representative surveys or censuses to estimate, or count, the number of their nationals living in the United States, their upper estimate of approximately 1.2 million HBPs living in the United States is twice that of the ACS (Augustin F, personal communication, 2008; Geneus J, personal communication, 2008; Joseph R, personal communication, 2008; Jospitre A, personal communication, 2008) [25,26]. Furthermore, the US Census Bureau acknowledges that foreign-born populations are often ‘hard-to-count’, if they are undocumented aliens, which might explain the difference in the population estimates used herein.
Second, compared to the national trends for AIDS diagnoses among the US population and non-Hispanic blacks, the trend among Haitians was similar with a peak in the early 1990s, a decline in the HAART era around the turn of the century and since then a plateau . However, important differences are recognized in the HIV risk profile for Haitian men compared to non-Hispanic black men. In the former, the primary transmission category (diagnosed during the period of 2004–2007) is high-risk heterosexual contact (68%), followed by sexual contact with other men (25%) and injection drug use (6%; Table 3). This pattern differs from trends in non-Hispanic black men living with HIV, for whom the primary transmission category is sexual contact with other men (51%), followed by injection drug use (21%) and high-risk heterosexual contact (20%) .
One possible explanation for differences describing sexual contact is that greater reporting of male-to-male sexual behavior among US-born African–American men may be due to greater social acceptance [28,29], whereas machismo is a central feature of masculine expression among men from the Latin American region, including Haiti . As little has been previously published on the sexual practices of Haitian men, this publication will help to serve as a benchmark to follow the patterns and prevalence of high-risk sexual behaviors in this immigrant group.
In addition, although injection drug use is the second leading cause of HIV infection for African–Americans, our results confirm lower transmission through this route among HBPs [31,32], which is consistent with other published findings on Haitians. A recent study on hepatitis C in Haiti reports that only 2% of study participants self-identified as having a prior history of IDU ; and Marcelin et al.  also report that Haitian youth in Florida express very negative opinions about crack, cocaine and heroin use. Therefore, future investigations may be useful to better characterize the protective attitudes and behaviors regarding substance use in Haitians that prevent IDU behaviors and HIV transmission.
Third, there was a greater proportional decrease in the number of incident AIDS cases for Haitian men, compared with women, since the HAART era (Table 3). Possible explanations include a sex difference in access to, or adherence to HAART, which is consistent with the literature on women's differential use of HIV medications [35,36]; or that Haitian women did not modify their sexual behaviors because their perception of HIV risk (and subsequent AIDS) may be obscured by their marital status. Decennial 2000 Census estimates show that at least 70% of all HBPs living in the United States, both men and women, have been married at some time . Also, some authors show that foreign-born pregnant women often refuse HIV-testing because they are in monogamous relationships  and they perceive their risk of acquiring HIV as low because of their relationship status. Data from the CDC Enhanced Perinatal Surveillance Project (1999–2001) support this hypothesis, showing that among foreign-born HIV-infected pregnant women, 42% are married compared to 16% of their US-born counterparts (Patel-Larson A, personal communication, 2006).
Another possible reason for the differential decrease, between Haitian men and women, in incident AIDS cases is explained by the ‘bisexual bridge’ of HIV transmission, which has been speculated for the African–American community linking black MSMs to black heterosexual women. These men are often referred to as being on the ‘down low’ (also known as DL), which defines them as heterosexuals who do not disclose their male-to-male sexual behavior to their female partners [39,40]. In a study conducted on down low-identified MSM in 12 US cities, it was found that they were more likely than nondown low-identified men to have had a female sex partner in the prior 30 days and to have had unprotected vaginal sex . Findings from this study also report that down low-identified MSM were less likely to have ever been tested for HIV than were nondown low MSM. Thus, Haitian women involved with down low men might have no knowledge of their sexual partners’ HIV behavioral risk factors, contributing to their lowered perception of HIV risk and decreased likelihood of seeking prevention services.
Little information is available about sexual risk or protective and disclosure practices among bisexual Haitian men, and how this behavior may be amenable to intervention [28,29]. What is known, however, is that the prevalence of bisexuality is reportedly higher in both black and Latino men compared to their white counterparts , and Haitian notions regarding masculinity are very similar to Latino men [30,43]. White MSMs are more likely to identify as being ‘gay,’ whereas black and Latino men are less likely to identify as ‘gay’, join gay-related organizations, read gay-related media  or disclose their male-to-male sexual behavior to female partners . The literature helps to predict these ethnic differences by explaining that black and Latino men see the gay culture in the United States as a white, and sometimes feminine phenomenon, that conflicts with their notions of masculinity . Black and Latino men also believe they may have to give up their ethnic identity if they self-identify as being ‘gay,’ including loss of the social support received from their ethnic community and that their communities will not accept male-to-male sexual behavior [46,47].
Fourth, study findings also show that Haitian men (53%) are more likely to be diagnosed with AIDS within 12 months after an HIV diagnosis compared to Haitian women (42%); however, when these figures are compared to non-Hispanic blacks overall (38%), HBPs have a higher proportion of late-stage diagnosis (Table 2 of the National Surveillance Report ). One possible explanation for the difference across sex is that women, in general, use more healthcare services than men, even after correcting for the use of healthcare services that are specific for women, such as gynecology [49–52], which may indirectly result in earlier stage HIV diagnoses for women. Additionally, a possible explanation for the differences in late-stage diagnosis between HBPs and non-Hispanic blacks may be related to healthcare insurance because HBPs who are not US citizens are among the most likely to be uninsured, compared to other immigrants living in the United States . Hence, the latter may significantly impact healthcare utilization patterns, resulting in greater emergency room use  and thus in later diagnosis.
In light of the study's findings, we recommend that HIV awareness and prevention efforts be customized for HBPs on HIV knowledge, behavioral risk factors, antiretroviral adherence [55,56], as well as prevention services use that encourage seeking routine medical care to reduce late-stage diagnosis, particularly in Haitian men. Tailored health communications are necessary for Haitian women who are married, in cohabitating monogamous relationships and/or pregnant (Patel-Larson A, personal communication, 2006) . Also, a model for HIV prevention for Haitian MSMs living in the United States is needed and could be adapted from available interventions for black MSMs , or adapted from the model for Haitian MSMs living in Haiti, which has already been launched (Genece E, personal communication, 2008).
There are several limitations to these analyses. In 2007, 17% of case reports were missing a country or continent of birth; thus, it is unknown whether there are HBPs among these cases. For the analyses of HIV reports, data from 34 states may not be representative of the whole United States because these states report only 66% of all AIDS cases diagnosed during 2004 through 2007. Data were not available for Massachusetts, which has the third largest number of Haitians residing in the United States according to the Census Bureau . Analyses were adjusted for reporting delay and multiple imputation was used to adjust risk for cases reported without a risk factor information ; these are standard surveillance data adjustments. We also cannot say definitively where foreign-born Haitians became infected, because date of arrival is not collected in HIV surveillance data. Persons may have acquired infection in the home country, during an immigration waiting period after they arrived in the United States or during travel outside, rather than in the United States.
This publication is the first to report on the trends in diagnoses of HIV infection for Haitians living in the United States. Study findings show the importance of having accurate denominators to estimate the AIDS rate for the Haitian population. Using estimates from the 2007 ACS, results suggest a seven-fold overrepresentation of Haitians in the CDC AIDS surveillance data. In contrast, using denominator estimates from the Haitian Consulates, HBPs in the United States, at this time, have a similar AIDS rate to blacks/African–Americans overall, which challenges beliefs that Haitian immigrants have a higher prevalence of AIDS than other groups. More to the point, the Haitian community remains steadfast in their beliefs that it is an ill-targeted effort to focus on linking Haitians to the introduction of AIDS in the United States. Rather, scientific methods need to be used to better understand what places Haitians at risk for HIV. Study authors recommend that research is urgently needed to adequately address prevention efforts for this ethnic group.
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