This article examines the vulnerability of Mexican migrants to the factors and experiences which contribute to HIV risk behavior. The term “Mexican migrant” is used in this article to refer to people who have moved from Mexico to live and/or work in the United States for a limited or undefined period. Most of the evidence cited herein is based upon work conducted in California and Mexico and is reflective of experiences documented in studies among Mexican migrants at other locations within the United States.
For addressing information on Mexicans while in the United States, we have included sources of data that only measure country of birth rather than migration pattern. Therefore, migrants represent a subset of our definition of “immigrants.”
General Aspects of Migration From Mexico to the United States
Mexican migration to the United States is influenced by many economic, social, and cultural factors that have maintained migration as a major phenomenon over the years and that have recently contributed to a rise in migration at the beginning of the 21st century.1,2 Economic factors have been the primary historical reason for Mexicans to migrate to the United States. In recent times, the length of stay in the United States has extended, potentially increasing the permanency of migrants and increasing the magnitude of the transplantation of support networks for more permanent migrants, including the migration of families and sometimes of entire villages. This has also led to a greater heterogeneity of the migrant's profile and a considerable diversification of workers by occupation and sector.3
The net annual flux of Mexican migration into the United States (the difference between immigration and emigration) has multiplied, in absolute terms, more than 13 times in the last three and a half decades, going from an average of 20,000 to 29,000 people per year in the decade of the 1960s to around 400,000 per year as of 2004.4 In relative terms, Mexicans represent 3.8% of the United States population and 29.5% of all migrants.3 California continues to lead the nation, serving as the home for 40% of all Mexican immigrants in the United States. However, the places of destination for Mexican migrants have been expanding to include locations throughout most of the United States.5 In fact, although two-thirds of the Mexican population resides in United States-Mexico border states (Table 1), there are 10 other non-border states that have more than 100,000 Mexican immigrants. Thus, the health of Mexican immigrant communities has an impact across the United States.
The AIDS Epidemics in Mexico
Based on the cumulative number of reported HIV/AIDS cases, Mexico ranks third in the American continent, after the United States and Brazil. However, based on HIV prevalence in the adult population aged 15-49, which was the indicator used by the Joint United Nations Programme on HIV/AIDS in 2002, Mexico was ranked 23rd in the Americas and the Caribbean and 77th worldwide.6 The Centro Nacional de la Prevención y Control del VIH/SIDA in Mexico estimates that 0.3% of its adult population 15-49 years of age is infected with HIV, totaling 182,000 persons.7 This prevalence is half of the estimate for the United States (0.6%) and is also significantly lower than the national prevalence estimates for neighboring Guatemala (0.9%), Belize (2.5%), Honduras (1.5%), and El Salvador (0.9%).8 In addition, based on the Joint United Nations Programme on HIV/AIDS epidemic classification nomenclature, Mexico is defined as having a concentrated, rather than a generalized HIV epidemic. The Centro Nacional de la Prevención y Control del VIH/SIDA estimates an HIV prevalence of 10% among men who have sex with men (MSM), 1% in female sex workers,9 and 4.5% among users of injected drugs.10
Surveillance data has linked the development of the HIV epidemic in Mexico with the migratory phenomena to the United States. In 1983, all of the cases registered in Mexico were people who had lived in the United States. This proportion decreased to 41.3% by 1991. In 1995, the Mexican HIV surveillance system discontinued the systematic recording of data on the history of migration, making it difficult to continue to assess the contribution of migration to the epidemic in Mexico. However, migration likely continues to play a strong role, given that 33% of AIDS cases in Mexico come from those states that export the highest number of migrants to the United States.11
Conducting research among Mexican migrants in the United States is challenging due to factors such as mobility and the marginalized “hidden” nature of many of these communities.12 There are few reports of HIV serosurveys of Mexican migrants while in the United States. Two studies were conducted among California farmworkers, one within Mexican migrant community and work settings and another at United States-Mexico border crossing points. The HIV prevalence estimates in these studies ranged from 0% to 0.16%.13-15
Migration as the Source of Vulnerability
The general relationship between migration and HIV/AIDS has been described previously.16-19 The migration experience often leads to a complex interplay of factors which influence an individual's decision to engage in a variety of behaviors and activities which may place them at increased risk for HIV infection.20,21
In an ethnographic study by Apostolopoulos et al.,22 the authors present a theoretical framework of risk for HIV infection for migrant farmworkers, that includes a macrosocial level with structural factors. To further examine the overarching nature of the vulnerability of Mexican migrants while in the United States with regard to HIV-related risk behaviors, we focus on structural and environmental vulnerability factors documented among Mexican migrant communities.
Structural and environmental factors play a significant role in shaping the vulnerability of Mexican migrants to HIV-related risk behaviors. Migrants are away from family and home for extended periods,21 which can lead to isolation, anxiety, and loss of familial and social support networks. These factors have been associated with seeking multiple casual sexual partners, engaging in sex with commercial sex workers, and using illicit drugs and alcohol abuse.21,22 Studies have also documented that migrants have low access to preventive health services due to no usual source of health care and no health insurance.23 A study by Levy et al.24 found that Mexican migrant men who were infected with HIV had cultural, geographical, and linguistic barriers to accessing health care services, particularly to HIV and sexually transmitted infection prevention and testing. Farmworkers and day laborers receive very low wages and have higher levels of occupational health risk.23,25 These factors limit the ability of migrants to manage their health and risk behaviors and can potentially lead to greater transmission of HIV.26
Migrants often live in substandard, isolated, male-only, group housing such as farmworker camps, overcrowded rooms, or apartments that can concentrate exposure to high-risk behavior opportunities.21,22,27 In the California-Mexico Epidemiological Surveillance Pilot, conducted in Mexican migrant venues in California from 2004 to 2005, squalid living conditions were commonly observed for many male Mexican migrant farmworkers. Some male migrants were observed to live in isolated encampments in the hills above the fields where they worked, and lived in cardboard boxes covered with black trash bags taped on them for protection from the elements. Farmworker bungalows or apartments were usually overcrowded and poorly maintained. In this surveillance pilot, opportunities for purchasing services from female sex workers were prevalent in these male-dominated sites.28
Other studies have documented that the prevalence of sexual contact with sex workers ranges from 18% among agricultural workers in the East Coast to 30% in California.11 The greatest mode of access to sexual partners among Mexican migrant men has been associated with purchasing sex work services.29,30 Sex work services can also be solicited from male Mexican migrants, as was found in a study among day laborers in Los Angeles, among which 38% had been solicited by other men at their job pickup locations.31
Social and cultural factors also play a major role with regard to vulnerability to risk behaviors. Mexican migrants living and working in the United States often enter into a society with cultural norms which differ from those in their home towns or cities. They are exposed to a social culture which is often more open and permissive with regard to sexual and drug-using behaviors and which may be unique to the specific local settings where they live and work. The exposure to different cultural norms combined with more opportunities to engage in high-risk behavior in specific settings may influence some migrants to adopt drug use behaviors and increase the number of sex work partners.32 Migrants have also been shown to adopt new sexual practices such as oral and anal sex and same-gender partners.21,32 The exposure to specific sexual behaviors may be unique to particular Mexican migrant settings. For example, in the California-Mexico Epidemiological Surveillance Pilot, Mexican migrant men from a few sites reported transgender and male sexual partners.28 In one dance club in a rural area in San Diego, the social scene seemed to change from heterosexual in the early evening to gay and transgender in the late evening. As was the case in other bars and clubs, illicit drug use became more prevalent in the late evening. This exemplifies the often hidden nature of risk among male Mexican migrants, where issues of machismo and hidden sexual identity are played out.
Other cultural factors that increase vulnerability to HIV include the prevalent use of needles to inject vitamins and antibiotics.28,33 This practice is common in Mexico, where sterile, sealed syringes or syringes preloaded with antibiotics or vitamins can be purchased over the counter. Migrants bring this cultural practice with them across the border into the United States, where access to and purchase of unused syringes are more difficult than in Mexico and, thus, may foster needle re-using or sharing without adequate disinfection.
Other factors associated with the vulnerability of migrants to HIV infection include transmission knowledge and condom use practices. With regard to HIV transmission knowledge, studies among migrants report erroneous beliefs about the transmission of HIV through common household contact or HIV tests.29,30 Migrants have also been found to have a low incentive and a lack of negotiation skills for condom use in sexual encounters.30,34
Migration and Risk for HIV
From December 2004 to January 2005, as part of the activities of the California-Mexico Epidemiological Surveillance Pilot, a study was implemented in five Mexican states with high migration indexes (Jalisco, Michoacán, Estado de México, Oaxaca and Zacatecas). The survey utilized respondent-driven sampling with population-based quotas per municipality. The sample consisted of 1539 migrants and 1236 nonmigrants. Previous analysis of this study suggests that the migrant population as compared to nonmigrants had better knowledge of the transmission of HIV through sexual practices, sharing of needles, and prenatal transmission. However, more than a quarter of migrants also had erroneous beliefs about the transmissibility of the virus through coughing, kissing, or eating from the same plate of a person infected with HIV.35 Male migrants reported more multiple sexual partners as compared to nonmigrants (Table 2, 28.4% vs. 20.4%; chi-square, P < 0.05). With regard to risk behavior, migrants had a greater number of sexual partners and were more likely to use non-injected illicit drugs in comparison to nonmigrants.35 The frequency of vaginal condom use was defined by whether a condom had been used during the last vaginal sexual encounter with the most recent six partners in the past 12 months. Vaginal condom use was greater among male migrants than male nonmigrants (40.9% vs. 30.8%; chi-square, P < 0.05) (Table 2). Though migrants reported higher condom use, migrants also reported higher HIV-related risk behaviors. With respect to HIV testing, 28.0% of the male migrants reported ever having been tested in comparison to 17.6% (chi-square, P < 0.05) of male nonmigrants (Table 2).
DISCUSSION AND CONCLUSIONS
Research indicates a link between migration of Mexicans to the United States and behavioral changes that place them at risk for HIV infection. Mexican migrants have reported a high prevalence of HIV-related sexual and drug-using behaviors while living or working in the United States. To date, the elevated risk behaviors among migrants do not seem to have translated into a detectable rise in HIV infection in this population. However, given the historical impact of migration on the transmission of HIV in other countries, it would be prudent to carefully monitor future HIV incidence and prevalence among migrants and assess the potential impact on the HIV epidemic in Mexico. To estimate the future direction of the AIDS epidemic in Mexico, it is necessary to undertake studies that allow evaluation of the impact of international migration.
Given the characteristics and vulnerability of migrant populations, there is increasing recognition of the need to address population mobility as a key element that may promote HIV/AIDS vulnerability in socially disadvantaged groups. The underlying structural, environmental, cultural, and individual vulnerabilities which impact HIV-related risk behaviors need to be addressed in a systematic effort, with significant support through policy change which acknowledges the social and economic value of migrant labor and provides support systems to address the health and psychosocial needs of this population on both sides of the border. New forms of organizations and service delivery systems must be developed that offer services to the migrant population, regardless of their place of origin or current status and location. Binational efforts to develop and improve these service delivery systems will enhance the potential to significantly impact the HIV epidemic in this population in the future.
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