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HIV Infection Returning to Mexico With Migrant Workers

An Exploratory Study

Sowell, Richard L., PhD, RN, FAAN1; Holtz, Carol S., PhD, RN2; Velasquez, Gabriela, MD3

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Journal of the Association of Nurses in AIDS Care: July-August 2008 - Volume 19 - Issue 4 - p 267-282
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Abstract

Mexico ranks 13th globally and 3rd in the Western Hemisphere in number of HIV cases; in 2005, more than 160,000 individuals in Mexico were known to be living with HIV infection (Organización Panamericana de la Salud, 1997; United States Agency for International Development [USAID], 2005). Historically, HIV in Mexico has been primarily an urban problem, with sexual transmission being the most frequent mode of transmission. While cases among men who have sex with men accounted for the largest number of cases of HIV and AIDS (37%) in 2004, 22% of all cases were a result of heterosexual contact (USAID, 2005). In rural areas of Mexico, it has become increasingly apparent that heterosexual transmission of HIV is a growing problem, and a problem that disproportionately affects disadvantaged and vulnerable groups (Zuniga, Rodriguez, & Garcia, 1998). Additionally, cross-border migration is increasingly recognized as a significant factor in the spread of HIV in Mexico. An influx of migrants into Mexico from Central America and the return of migrant workers from the United States has become a great concern in the increasing cases of HIV and AIDS in rural Mexico (USAID, 2005).

Until recent months there has been little awareness of this growing problem beyond the public health officials who are responsible for responding to the growing HIV epidemic in rural Mexico. Recent news stories, published in the International Herald Tribune and the New York Times (Lacey, 2007a; Lacey, 2007b), have brought the spread of HIV by migrant workers returning from the United States out of the closet. Those provinces in Mexico that have the largest number of men migrating to the United States for work are the same areas that are experiencing the most rapid spread of HIV among rural inhabitants. Although epidemiologists are beginning to identify the relationship between men migrating to the United States to work and the increasing number of cases of HIV in rural Mexico, there has been little research into the causes and consequences of this phenomenon. This study sought to gain greater insight into factors influencing increased vulnerability of men migrating to the United States for contracting HIV as well as the consequences of their HIV infections upon returning to Mexico.

Background

Mexico is the most populous Spanish-speaking country in the world, and its population continues to grow rapidly. Almost half (43.5%) of all Mexicans are under 18 years of age. Economic growth has made Mexico an upper-middle income country, but tremendous disparities in the distribution of wealth exist, with large numbers of Mexicans living in poverty. An estimated 24 million Mexicans live in extreme poverty and are unable to provide minimum food, housing, and medical care for their families (Carballo & Nerukar, 2001). Poverty has been a driving force in the rapidly increasing migration rates of Mexican citizens to the United States, both legally and illegally. There are two different scenarios for this migration. The first scenario occurs when Mexican families seek to permanently migrate to the United States to acquire a better life. These individuals enter the United States with no intention of returning to Mexico. A second group of migrants, primarily men, cross into the United States for various periods of time to work and support families who remain in Mexico. Some men may travel to the United States on one occasion to obtain seed money for a business or other enterprise in Mexico; others return a number of times seeking to earn money to support their families.

An estimated 12 million illegal immigrants live in the United States, with the vast majority entering the United States from Mexico (Knickerbocker, 2006; Lewis, 2007). Political leaders and policy makers in the United States are facing the challenge of the desire to control the flow of migrant workers from Mexico, coupled with the need for the cheap labor they provide. While deeply divided factions in the United States debate how best to manage the immigration issue, little attention has been focused on the circumstances and threats that migrant workers face in traveling between the United States and Mexico (Mora, 2007).

There is growing understanding that the process of migrating to the United States to work results in migrant workers entering an environment in which they face a number of potential threats. Violence, robbery, and exploitation can occur during the process of illegally crossing the border and can continue while immigrants live in the United States. But Mexican men coming to the United States as migrant workers face another serious threat that is less obvious. These men, knowingly or unknowingly, face the reality of increased risk for contracting HIV infection and spreading it to their family members. Compared with the United States, Mexico continues to have lower incidence rates of HIV and AIDS (Lewis, 2007). Historically, HIV has been a disease of large urban areas and, until recently, the incidence of HIV in remote and rural regions of Mexico has been low (Organización Panamericana de la Salud, 1997; Zuniga et al., 1998). Often there has been little awareness of the disease, how it is transmitted, and the risk it poses to individuals who engage in risk behaviors. At present, men from rural areas make up a significant number of those migrating to the United States for work and then returning home to Mexico. A man who engages in risk behaviors in his rural village exponentially increases the risk of contracting HIV infection when engaging in these same behaviors in a higher HIV-prevalence area either in the United States or along the U.S.-Mexico border.

Men migrating across the U.S.-Mexico border encounter increased HIV risk for a variety of reasons. Border towns have long been known as places where drugs, commercial sex work, despair, and poverty intersect (Kaiser Daily HIV/AIDS Report, 2007). Further, loneliness, isolation, lack of family, fewer women, and loss of cultural ties often result in migrant men having an increased number of sex partners, having sex with male partners, and participating in increased drug use (Kaiser Daily HIV/AIDS Report, 2007; Magis-Rodriguez et al., 2004). Even when men successfully enter the United States and find work, these same factors can continue to operate in their daily lives, influencing behaviors and thus increasing the risk of contracting HIV.

Recognizing the growing threat of HIV in Mexico, the Mexican government created the National Council for Prevention and Control of HIV/AIDS (Consejo Nacional de Prevención y Control del VIH/SIDA [CONASIDA]) in 1988 (Secretario de Salud-Mexico, 1988). This agency was renamed the National Center for the Prevention and Control of HIV/AIDS (Centro Nacional para la Prevención y el Control del VIH/SIDA [CENSIDA]) in 2001, with decentralized regional agencies (State Council for Prevention and Control of HIV/AIDS [Consejo Estatal para la Prevención y el Control del VIH/SIDA, or COESIDA]) in each of the Mexican provinces. The role of these agencies is to take leadership in the prevention and treatment of HIV throughout Mexico. The agency that has served the State of Oaxaca over the past 13 years is a recognized regional model in the COESIDA system. COESIDA, headquartered in the city of Oaxaca, provides comprehensive prevention and treatment services to the six districts of the State of Oaxaca. Individuals with HIV infection can access medical treatment, case management, emotional and psychological support, and education, from a team of physicians, nurses, case managers, social workers, health educators, and psychologists. Additionally, two satellite clinics operated by COESIDA are located in other parts of the State (D'Adesky, 2002; Servicios de Salud de Oaxaca, 2007).

The State of Oaxaca has a population of 4 million and is located in the south central region of Mexico, 1,337 miles south of Mexico City. Whereas the city of Oaxaca is located in the central mountains of Mexico, the state of Oaxaca extends west to the Pacific Ocean. Much of the state of Oaxaca is rural, with a significant part of the population living in remote rural areas and villages. The majority of the population of Oaxaca is indigenous Indians, and 15% of this group does not speak Spanish. The state of Oaxaca is recognized as one of the two poorest states within Mexico, second only to the state of Chiapas (Population Council, 2007). This economic reality significantly influences the increasing number of men from Oaxaca who migrate to the United States to find work.

During the period from 1986 to 2007, 3,630 cases of HIV were reported in Oaxaca, with the largest number of these cases being attributed to heterosexual activity. Male bisexual and homosexual activity account for the second and third largest numbers of HIV cases, respectively, in the state of Oaxaca. HIV cases in Oaxaca have steadily increased since statistics were first recorded in 1986 to an HIV incidence rate of 10.41/100,000 people in 2006. In recent years, the COESIDA staff in Oaxaca have noted a growing incidence rate of HIV in members of families in which the husband had migrated to the United States to work and returned with HIV infection (G. Velaquez, personal communication, July 14, 2007).

Fueled by lack of education, traditional family structure, cultural expectations, and fear of stigma, the topics of infidelity and the increased risk of HIV related to migration are often taboo. These taboos exist even between husbands and wives. The complementary concepts of machismo and marianismo, which are deeply rooted in Mexican culture, support the dominance of men and the submissive and/or dependent status of women. While machismo demands that men be strong and domineering in response to an exaggerated concept of masculinity and sexual virility, women are expected to exhibit marianismo, or characteristics of female purity that mirror those traits attributed to the Virgin Mary. Culturally, it may be acceptable for men to engage in extramarital sexual relations, but such behavior by women is inconsistent with the behaviors acceptable for a wife or mother. This cultural norm allows men to engage in sexual relations while away from their families during periods of migration. However, it prohibits wives from engaging in similar behaviors or even questioning husbands about their sexual activities while away from their families. Women often learn they are HIV-infected when they become pregnant and are tested as part of increased surveillance by local health departments (D'Adesky, 2002; Servicios de Salud de Oaxaca, 2007).

Whereas the overall number of cases of HIV and AIDS in the state of Oaxaca is relatively low compared with the United States and many urban centers in Mexico, the increasing introduction of HIV into rural regions of the state is very concerning. The high level of poverty in the region almost certainly assures continued transient migration of men seeking work in urban centers in Mexico and the United States. There is a need to better understand the growing relationship between migration and incidences of HIV infection among men and their families in rural regions such as Oaxaca. Data about the factors that contribute to the growing incidence of HIV in men who migrate to the United States and the consequences of their infections are limited. Researchers have contributed valuable information related to the spread of HIV in migrant workers, especially focusing on communities along the U.S.-Mexico border (Kaiser Daily HIV/AIDS Report, July 2007; Parrado, Flippen & McQuiston, 2004; Urizar & Winkleby, 2003; Zambrana, Cornelius, Boykin, & Lopez, 2004). However, a critical need still remains to gain greater understanding of the issues surrounding migrant workers who contract HIV in the United States and take it back to rural regions of Mexico.

Methodology

This exploratory study used face-to-face interviews with HIV-infected individuals whose infection was linked to men migrating to the United States to find work. The methodological approach for the study was rooted in phenomenology (Knaack, 1984; Merleau-Ponty, 1964), in that it sought to illuminate the experiences of Mexican men who acquired HIV while migrating to the United States and the experiences of their wives. The study had two interrelated aims. The first was to identify factors that increased the HIV risk for Mexican men migrating to the United States. The second aim was to explore the consequences of and responses to HIV infection among men returning to Mexico with HIV infection and their families.

Participants in the study represented a convenience sample of men and women living in the state of Oaxaca, Mexico, who had documented HIV infection and who (or whose husband or partner) had likely acquired HIV while in the United States. Factors that influenced the men's risks of acquiring HIV in the United States were examined primarily from the perspective of the male participants. The consequences of HIV infection on men and their families were explored, both from the perspective of men who had acquired HIV in the United States and from the perspective of women whose HIV infection was the result of their husbands acquiring the disease in the United States. Individual interviews were determined to be the most appropriate method of data collection because of the exploratory nature of the study and the potentially sensitive information being sought. Additionally, the individual interview format provided in-depth information because each participant was able to fully tell his or her own story in a confidential environment.

Procedure

The problem of increasing cases of HIV in the state of Oaxaca, Mexico relating to the migration of men to the United States was initially discussed with the executive director of the local HIV/AIDS treatment and service organization (COESIDA) in May 2007. The current study was conceptualized and developed from these discussions. The study was approved by the institutional review board of Kennesaw State University. After institutional review board approval was obtained in the United States, the study proposal and accompanying study documents were translated into Spanish and submitted for approval to the secretary of health for the state of Oaxaca. Study procedures were also approved by the staff of COESIDA. Two researchers from the United States traveled to Mexico to conduct the study.

The study was conducted over 3 days in July 2007 in the city of Oaxaca. Criteria for inclusion in the study were: (a) documented HIV infection, (b) HIV infection acquired in the United States by a man migrating to work or by a woman whose husband had been infected while working in the United States, (c) able to speak and understand Spanish, and (d) cognitively able to provide informed consent. Individuals who met the criteria were made aware of the study and its purposes by a staff member of COESIDA. A total of 10 individuals met the study criteria and were willing to participate in the study. The exact number of individuals attending the clinic who met the study criteria and who were made aware of the study during the 3-day interview period is unknown. A number of the COESIDA clinical staff participated in screening potential participants and making them aware of the study. They were unable to determine the exact number of individuals with whom they had interacted. However, they did report that many individuals who might have been appropriate for the study declined because of concerns about privacy and stigma.

All study interviews took place in a private office within the COESIDA complex. This location was chosen to minimize the inconvenience for participants and to eliminate any expense that might have occurred if participants had been required to go to another location. All interviews were conducted in Spanish by a female researcher from the United States. A second researcher took observational notes and managed audio recorders during each interview.

Before each interview, the researchers introduced themselves and explained their interest in the study topic. The purpose of the study and study requirements were again described to the participant, and informed consent was obtained. Participants were instructed not to provide their real name on any study documents or during the interviews. All participants were assured that they could drop out of the study at any time and that the care they were receiving from COESIDA would not change in any way if they dropped out of the study. Each participant was asked to respond to a series of questions designed to elicit demographic data at the beginning of the interviews. Based on information from the COESIDA staff, it was anticipated that while all the participants spoke Spanish, a number of them would not be able to read or write Spanish well. Therefore, the researcher leading the interviews read all questions to each participant and recorded the responses to maintain consistency in data collection and to prevent any embarrassment to participants.

Initial questions about the individual and his or her family provided a way for the researcher to get to know the participant's life situation and establish a beginning level of comfort between the researcher and each participant. A predetermined interview guide using open-ended questions and probes was used to conduct the interviews and to assist participants in describing their experiences, feelings, and perspectives around being HIV-infected as a result of men migrating to the United States to seek work. Tables 1 and 2 provide overviews of the interview guide used to conduct interviews with male and female participants, respectively.

Table 1
Table 1:
Semistructured Interview Guide (Men)
Table 2
Table 2:
Semistructured Interview Guide (Women)

Interviews lasted from 30 minutes to 1 hour. After each interview, a number was assigned to study documents to link the audiotaped interview, informed consent form, the demographic data sheet, and observational notes. Each interview was confidential; the staff of COESIDA were not made aware of any information discussed by the participant or even if the participant had withdrawn from the study or provided usable data. The content of the stories told by participants began to be repeated by the fourth man and third woman interviewed, respectively. This situation suggested that the researchers had captured the major perspectives and experiences of the participants and reached content saturation.

Data Analysis

The audiotape of each interview session was transcribed verbatim and translated from Spanish to English. Names and other identifying information that might have been unintentionally shared by the participants were removed. Transcripts of the audiotapes, field notes, and demographic information constituted the study data. Analyses of the data were accomplished using thematic content analysis. Key words and phrases from each participant's transcribed interview were defined, developed, and integrated into common themes (Chenitz & Swanson, 1986). Two of the researchers initially reviewed the transcripts independently, coding and organizing the data into tentative groupings. Subject groupings were refined into theme designations by reading and rereading the transcripts. From the identified themes, two overall categories were constructed. When independent analyses of the data were completed, the researchers compared their coding schemes and resolved discrepancies as to the themes and categories. Coding was then examined by an outside researcher who agreed with the organization and coding of the data. To validate the study results, the Mexico-based researcher, who had extensive experience in providing services to the study population, reviewed the study results. Additionally, data were audited by the outside researcher who agreed with the decision trails, organization, and coding of the data (Guba & Lincoln, 1981).

Sample Characteristics

The study sample (see Tables 3 and 4) consisted of 10 individuals who completed interviews; 6 of the participants were men and 4 were women. Of those individuals completing the study, 6 were married (4 women and 2 men), and 1 man was divorced. However, only 1 man and 1 woman who participated in the study were married to each other. The participants ranged in age from 25 to 44 years, with a mean age of 34 years for all participants. The largest number of the participants in the study (n = 7) identified as indigenous Indians (primarily Zapotec). The remaining 3 participants were Mestizo, people of mixed Indian and Spanish or northern European ancestry. One half of the participants (n = 5) had a primary school education. A total of 3 participants had either some college education or had completed college. The majority of study participants lived in rural villages and remote areas (n = 7). A total of 6 individuals had to ride a bus 6 to 8 hours to obtain treatment at COESIDA in the city of Oaxaca. One man admitted that, to insure confidentially, he traveled the long distance (approximately 8 hours) to the city of Oaxaca for treatment, although there was a satellite clinic closer to his home.

Table 3
Table 3:
Demographic Characteristics of Participants in Study
Table 4
Table 4:
HIV-Related Information Reported by Participant

Except for 2 homosexual men, all of the participants had children. Study participants had a total of 10 children among them. Most of the participants reported having a wife, husband, or partner who was HIV-infected. However, only 1 woman had children with HIV. In her family, the husband, wife, and all three children had HIV. The children of the 3 other female participants did not have HIV. The women with uninfected children had been diagnosed with HIV during pregnancy and placed on antiretroviral therapy, or their children were born before their husbands migrated to the United States. Most participants (n = 8) reported that that they were on medication and in good health. Only 1 participant was in poor health, having reported diarrhea for more than 8 months. This man was new to the clinic and was just starting treatment.

Results

Data obtained in the study interviews provided a vivid picture of the context that served to underpin the life stories of participants. Participants described a life context of severe poverty and trying to make enough money to support their families. Some male participants reported migrating to earn money to send home to support their family, whereas others worked to obtain enough money to start a business back home in Mexico. The families represented by the participants in this study planned to stay in Mexico, and the risks associated with migration to the United States were taken out of necessity. This need to migrate for work provided the stage on which the rest of their stories were played out. All of the men in the study reported migrating to large urban centers in the United States to work.

Interviews with participants described a wide range of influences that resulted in the men contracting HIV as well as results of the infection on themselves and their families. The analysis of these descriptions revealed two overarching categories: HIV Risk and Living with HIV. The category of HIV Risk consisted of four interrelated themes: (a) social isolation, (b) lack of knowledge/denial, (c) machismo, and (d) bringing HIV to Mexico. Themes within the category of Living with HIV were: (a) powerlessness and (b) making the best of it. Each category and its component themes are described in the following sections.

HIV Risk

Men in the study reported leaving their home, family, and culture in Mexico and traveling into a very different environment in the United States. Men faced a number of risks both as they traveled across the border and after they reached their destinations. Only one of the participants indicated that he had entered the United States legally. This participant traveled to the United States as part of a cultural dance troupe exchange. The remainder of the men entered the United States as part of a subculture of individuals whose daily lives focused on working and avoiding the consequences associated with discovery. Whereas all of the men worked in public in jobs such as construction or restaurant work, they lived secret personal lives, avoiding interaction with mainstream society. The realities of the men's daily lives facing language barriers and illegal status defined their social interactions. These restricted social interactions, interrelated with cultural norms, access to sex partners, and limited knowledge of HIV, led to an environment that promoted the spread of HIV infection to these men. When infected with HIV, the men were a conduit for bringing HIV infection back to Mexico. This situation was exacerbated by the fact that cultural norms, as well as women's dependence on their husbands to survive, prevented wives from questioning their husbands' sexual behaviors or implementing condom use to decrease the risk of acquiring HIV during sexual intercourse.

Social isolation

Social isolation was described by all of the men in the study. The men reported that because of language and cultural barriers as well as concerns about being discovered, they remained within communities primarily composed of other migrant workers and poor immigrants from Latin America. The men soon learned where it was safe to live and which businesses welcomed their money. Although one man had traveled to the United States with his brothers, most of the men were alone. They knew no one when they arrived and had to establish themselves in communities where they could find work and some level of support from others like themselves. Even the young man who had traveled legally to the United States reported that he remained within the Latino community for any personal social interactions, including sexual encounters. He commented, “It was just easier that way, the language, I was just more comfortable with Latino men.”

Another man, describing his feelings of isolation, stated, “I got lonely and I was away from my family for a long time.” Another man agreed, saying, “I am in a country where I don't speak the language and don't have papers. I missed having sex.” Such loneliness provided the motivation to seek companionship and sex. Whereas all of the men who identified as heterosexual denied any sexual encounters with men, two men did report that they were aware of sex between heterosexually identified men in their living situations while in the United States. One of the homosexual men reported that he regularly picked up other men for sex in parks. However, even though he was in a large northeastern city with a defined gay community, he reported having sex only with other Latino men.

All of the men reported that sexual companionship was not hard to find. One man said, “There were certain bars or clubs that I frequented, and women would come there specifically to meet men.” He reported that most of the women were engaging in sex for money, and they knew that the migrant men would have money to spend. He said, “You know you are married and should be faithful to your wife, but you are alone and the girls are so beautiful and available…. Mix loneliness with alcohol or drugs and a man is going to go with one of these girls.” In contrast, one of the men said that he had not been involved with sex workers. He was infected by having sex with what he described as “girlfriends.” He stated, “I never was with prostitutes. I was involved with a few girls in the area…they were born in the U.S. but were Mexican—Chicanos.”

Regardless of sexual orientation or relationship status, all of the men acknowledged that sex was easily available to them at a time when they were lonely and isolated from their family and home. Men's descriptions of their experiences in the United States supported that there was a group of women and/or club owners who were aware of migrating men's situation and actively sought to profit from the loneliness and social isolation.

The isolation of men from their families was validated by women in the study. Women said that men may be gone from home for months or years with little interaction with the family. Two of the female participants reported that their husbands were currently in the United States, but the women did not know exactly where their husbands were working or what kind of work they did. Another woman describing her contact with her husband while he was in the United States said, “I would get a telephone call about once a month, and he would send money home to support the family.” Women remained in their villages, managing families and waiting for their husbands to return. In contrast to the men, women reported staying faithful to their husbands with no options for addressing loneliness or sexual needs.

Lack of knowledge/denial

Lack of knowledge concerning HIV or denial that they were at risk increased the chances of men acquiring HIV infection in the United States. One half of study participants reported having limited or no knowledge about HIV before they were diagnosed. The majority of the study participants lived in small villages and remote areas of Oaxaca where HIV had not been a problem. Despite efforts by local health authorities to conduct HIV education programs, participants said that HIV was not believed to be relevant to their families until they or their husbands were diagnosed.

Participants shared examples that underscored the lack of knowledge or awareness of HIV in their rural communities. One of the men described the lack of knowledge about HIV by saying, “The health department in my village teaches some about HIV, but no one really takes it seriously, thinking that it could not happen to them.” Another man said he had never known anything about HIV until he was told that he had it. A female participant describing the lack of understanding by her family said, “When I found out I was HIV-positive, I told my parents. They asked if I was OK, and I said, ‘Since I have been taking my medicine, I am healthy now….’ They said to me, ‘Well then, there is no problem!’” Two other men shared that they learned about HIV while in the United States when they saw signs for free HIV testing. The men said they just went to learn more about HIV and both tested positive for HIV. When asked about HIV education and prevention efforts in their villages, all of the participants acknowledged that education efforts were increasing. However, a number of the participants were not sure it was enough to change people's behaviors. One man put it this way, “I didn't learn that much about HIV when I was in school, but now young people get more information, but the boys still don't use condoms.”

Machismo

All of the men agreed that culture played a large part in the spread of HIV infection. Each man in some way referred to the cultural attribute of machismo as being a major reason for not using protection (condoms) to prevent HIV infection. When asked about the use of condoms when having sex with sex workers or girlfriends, men consistently admitted that even if they knew about HIV, they did not use condoms. One man said, “The bar sells condoms, but no one uses them.” Another man described his reason for not using condoms in this way: “It's part of the Mexican culture, the machismo thing, you know, which means it's not cool to use a condom.” Regardless of sexual orientation, male participants reported that using condoms was in some way linked to the perception of decreased masculinity. When asked if their sex partner had asked to use a condom during sex, one heterosexual man seemed to represent the general consensus, “Men are in charge and the women don't make us use a condom; they [women] never mention it.” This sense that the man is in charge was not only expressed by the men in relationships with women in the United States but was evident as a cultural belief accepted by the wives in Mexico. Female participants repeatedly showed their acceptance of the dominance of their husband in all aspects of their lives. This played heavily into the theme of powerlessness of women, which is discussed later.

Bringing HIV home to Mexico

For married women in rural Mexico, the greatest risk for HIV is a husband who has migrated to the United States. Women and their children are often infected because of their husbands bringing HIV home to Mexico. Although it was acknowledged by participants that men were sometimes unfaithful to their wives while in Mexico, study participants reported that most of the cases of HIV in the rural areas of Oaxaca were connected to men going to the United States to work. Men returning to Mexico brought HIV infection home to their families. The majority of the men represented in this study did not know or did not acknowledge that they had acquired HIV infection in the United States until their wives were diagnosed during pregnancy. One woman said, “I didn't know I had the disease until I got pregnant after he came back from the United States and they gave me a test in the prenatal clinic.” Some husbands refused to take responsibility for bringing HIV home, even after the wife and a baby tested positive for HIV. Another woman shared, “My baby and I are HIV-positive. My husband still hasn't been tested, but he says he is not infected.” When asked how she thought she got infected, the woman replied, “I got a tattoo. It must have been from the tattoo.” A third woman insisted that her husband had been infected through contact with animal blood in his workplace. Not surprising, the husband, who was also a study participant, told the researchers the same story. However, after his wife's interview, he asked to speak to one of the researchers privately and admitted he had been infected through sex with sex workers. Still, the wife never gave any impression of doubting her husband's animal blood story.

Only 3 of the men (2 heterosexual and 1 homosexual) had taken the initiative to be tested before returning to their families. Although these men brought HIV home to Mexico, they were taking precautions to prevent further transmission to family members and sex partners. In one case, a man's wife divorced him and moved to Mexico City with his child after learning of his HIV infection. The homosexual man reported that he remained sexually active but that he always used a condom. The third man returned to his wife and children and consistently used condoms to protect his wife from infection. He stated, “Now I use condoms with my wife because I don't want her to get it. I told her I was sick and we need to use a condom.”

Living With HIV

All of the study participants' lives focused on trying to move on with their daily activities while living with HIV. Men went to the United States in hope of a better life for their families in Mexico. However, the men and their wives now faced the hardships of poverty compounded by the need to manage a life-threatening disease. Whereas most of the participants had disclosed their HIV status to immediate family members, they reported going to great lengths to prevent others from finding out that they had HIV. One man reported that even his brothers and sisters “treated him like dirt” once they found out that he had HIV. “They will not come into my house and do not want me or my child around them.” He continued to have a relationship with a female sex partner who was the mother of his young son but lived alone with his son, for whom he provided care.

Other participants reported having not only to deal with stigma that would come with disclosure but also with very real challenges in getting care and remaining healthy. Access to treatment and care was an issue. Whereas COESIDA provided free medication and treatment to all of the participants, reaching COESIDA for treatment was often a time-consuming process and a financial hardship. This situation was particularly poignant for women who had been infected by their husbands. Women were almost always dependent on their husbands and culturally expected to be submissive to their husbands' will. Having HIV did not change what was expected of women in caring for their husbands and families while trying to care for their own health needs.

Powerlessness

An overall theme of powerlessness emerged from the descriptions of the lives of participants. In general, men went to the United States seeking work because of a sense of powerlessness in providing for their family or obtaining the money needed to establish a better life in rural Mexico. Families represented in this study had little hope of rising above a state of poverty without taking extreme measures. However, the theme of powerlessness was particularly prevalent in the lives of women. Women were dependent on their husbands for almost everything. Without their husbands, these women would not be able to survive and support their children. Such powerlessness was based on both economic factors and cultural traditions.

The sense of powerlessness often emerged in interviews as women's unquestioning acceptance of whatever they were told by their husbands related to the source of their HIV infection. Although information about HIV transmission has become more readily available in rural areas of Mexico, wives in this study seemed ready to accept their husbands' explanations rather than dealing with the consequences of confronting infidelity. The woman who said that her husband had gotten HIV infection from cleaning up animal blood in a restaurant rejected any other explanation for his infection, even though COESIDA provided accurate information on HIV transmission to all clients. A second woman, when pressed to explain how her husband had become infected, said, “My husband has no idea how he got it…if he says he does not know, that is the way it is.” Another woman said, “There is talk among some women in the village about men being unfaithful while they are gone from home…but a woman could never discuss this with her husband; you just can't.”

Although none of the female participants in the study used the terms machismo or mariansimo, their experiences and descriptions of what was required of them as wives underscored the male-dominated culture in which they lived. Women's stories showed that most of them were uneducated, had children, and were economically powerless to survive without a husband. It was clear that these women had few options. Therefore, the women seemed willing to ignore or deny any knowledge or information that might threaten the relationship with their husbands or reflect negatively on their families. Women in the study showed a willingness to accept a submissive role as a dutiful wife, even if they internally realized that their husbands had been unfaithful and had infected them with HIV. In fact, one woman seemed to view her HIV infection as an acceptable consequence of her husband going to the United States for work and obtaining money to support the family. She commented, “My husband got HIV and gave it to me, but he made good money in the U.S…. Look at my sweater, isn't it beautiful?”

Making the best of it

All of the participants in the study understood that HIV would change their lives forever, but they all expressed a determination to survive as well as possible. Women were particularly focused on caring for their children, even though most believed that their extended families would care for their children if they died. There was less optimism about the future if their husbands died. Interview data showed that all of the participants were trying to make the best of the situation. However, dealing with HIV placed new hardships on participants and their families. Accessing care and treatment was a major challenge for most of the participants. The majority lived in rural parts of the State of Oaxaca, resulting in long travel distances to access treatment at COESIDA. Even though medication and treatment were free at COESIDA, a number of the participants had to travel 6 to 8 hours to Oaxaca for care. The time and expense required to reach COESIDA placed extreme hardship on some families. One woman said, “I have to travel 8 hours on a bus to reach COESIDA to receive my medications…. I also had to travel to Mexico City to obtain pediatric care for my children.” This travel took her away from work at home and could cost as much as $25 (U.S.) bus fare each way, an extremely large amount of money for her family. She said, “My husband and I can't both come to Oaxaca, because we can't afford it, so only I go to get my treatments.” This woman's husband could not miss work or they would not have food to eat. In some cases women depended on family for financial support to get treatment. A female participant said, “My whole family helps me pay for my bus ticket to Oaxaca to get my HIV treatments.” The expense of traveling to Oaxaca for treatments was so great that even when participants were able to obtain the money for the bus, they could not afford to stay overnight. Rather than spend the extra money, they traveled 16 hours on a bus, making the round trip to the clinic and home again on the same day. Clinic staff reported that they feared that many women received medicine from the clinic for themselves but actually gave it to husbands who were not able to come for treatment.

Study participants consistently expressed optimism that they would remain healthy for a long time with the help of the clinic and medications. All of the participant interviews reflected a spirit of going on with life. Even the man who was experiencing severe symptoms expressed hope of getting better. He said, “My family and God help me deal with my situation.” One man who had a wife and two uninfected children reached out to the researcher and began to cry at the end of his interview session. He said, “One mistake and I will have to pay for the rest of my life…. I have to keep going.” Other participants expressed a desire to help educate others about HIV, but they were careful to stress that they would not be able to do such education in their own community. Clearly, the majority of the study participants already faced many hardships. HIV represented one more challenge that they were determined to overcome.

HIV did not change the participants' level of poverty or their struggle to provide for their families. In fact, HIV infection made their situation even more tenuous, but they knew they had to go on with life. One man even asked the researchers if he would be able to get his medication in the United States if he returned there to work. Further, 1 of the female participants reported that her husband was currently working in the United States. She did not know if he was getting medications or treatment for his HIV infection, she just knew he had to work if the family was to survive. All of the participants described trying to make the best of their situation and to maintain control over their lives, even with HIV.

Discussion

Little attention has focused on factors that increase the HIV risk of Mexican men migrating to the United States or the consequences of having HIV infection when they returned home. The lack of data related to this situation supported the exploratory nature of the study. However, because the results of this study were based on a small convenience sample, they cannot be generalized either to all Mexican men who migrate to the United States to work or to members of their families who remain in Mexico. This study provided a unique insight into the influences and consequences associated with acquiring HIV by migrant workers from a region of central Mexico not previously explored. The study is one of the first to allow individuals living with the consequences of U.S.-acquired HIV infection to tell their stories. Additionally, a growing number of reports in the poplar media support the importance of this information (Kaiser Daily HIV/AIDS Report, 2007; Lacey, 2007a; Lacey, 2007b).

Participants in this study represent the new face of HIV in Mexico. The study's participants were primarily rural residents of the second poorest state in Mexico. Although HIV has historically been a disease of homosexual and bisexual men in large cities, there is growing recognition that HIV is spreading to rural Mexico because of heterosexual contact (USAID, 2005). Statistics reported by COESIDA in Oaxaca City show that heterosexual transmission has accounted for the single largest number of reported cases of HIV in the region (Servicios de Salud de Oaxaca, 2007).

The inclusion of 2 homosexual men and 1 bisexual man in the study provided important insight into possible differences in homosexual and bisexual men's experiences in the United States as compared with heterosexual men's experiences. Interestingly, the homosexual and bisexual men's stories were in many ways consistent with those of the heterosexual men's, and they provided a more comprehensive view of the experiences of men migrating to the United States for work. Whereas the homosexual and bisexual men in the study reported greater knowledge concerning HIV before going to the United States, they consistently reported loneliness, isolation, and the influence of cultural expectations of men (machismo) as factors that contributed to acquiring HIV. Additionally, they acknowledged bringing HIV home to Mexico and were struggling to deal with both the health and social consequences of the infection.

In this study, all of the male participants including the husbands of the female participants had acquired HIV while in the United States. This result underscored the significant role poverty plays in migration patterns. Migration allowed men to meet the cultural expectation for the man to be the provider for his family. Further, men working in the United States gave families some control over the local economic conditions they were otherwise powerless to control. However, men bringing HIV back to their families was an unanticipated consequence. The results also underscored the critical need to develop strategies to increase HIV prevention and treatment efforts to address a rural epidemic that may be poised to explode.

Study results showed that the interrelationship of social isolation, lack of knowledge, and the cultural norm of machismo reported by male participants served to significantly increase the risk for HIV infection for male and female participants. These results are consistent with previous study results. Magis-Rodriguez et al. (2004) noted that migration to the United States inserted Mexican men into a more open society that resulted in loneliness and isolation while away from their wives. As a result, the men increased sexual relations with male or female partners or sex workers who often used drugs. Further, Knipper et al. (2007) reported that, in a sample of Latino migrants working in North Carolina, more than one third of unaccompanied men (those not living with a wife or sex partner) exchanged money, shelter, drugs, and/or alcohol for sex in the previous 3 months.

The lack of condom use among men in this study was consistent with previous research results. Knipper et al. (2007) reported that approximately one half of the men in their study did not use a condom during their last episode of vaginal intercourse. When comparing accompanied men to unaccompanied men, it was reported that 60.6% of accompanied men and 41.3% of unaccompanied men did not use a condom during their most recent sexual encounters with female partners.

Interestingly, none of the men in the study reported condom use while in the United States, and none of the sex workers, girlfriends, or male sex partners had even mentioned the use of condoms. This result might not be surprising when considering that all of the men reported having no or limited knowledge concerning HIV before leaving Mexico. Further, many of the men's U.S.-based sex partners may also have had limited knowledge about HIV risk and prevention measures. Levy et al. (2007) reported that Latinos in the United States have a higher incidence of not knowing when they are at risk for infection with HIV. Additionally, Latinos, especially those in immigrant communities, face barriers that prevent them from being tested for HIV or result in them being tested later in the course of their disease (Centers for Disease Control and Prevention, 2003).

This lack of HIV knowledge among the HIV-infected sex partners of migrant men suggests a need to strengthen outreach to sex workers in areas with large migrant populations and among women who target migrant men for sex. Enlisting sex workers in HIV prevention efforts has shown success in decreasing HIV transmission in other populations (Basu et al., 2004; World Health Organization, 2004). A second potential strategy for reaching migrant workers with HIV information is through targeted social marketing (Olshefsky, Zive, Scolari, & Zuniga, 2007). Social marketing programs that use Spanish-language radio broadcasts to reach individuals who may otherwise be hard to reach can be effective (Arbitron, Inc., 2004). In border regions, such a strategy could be a joint venture between the United States and Mexico, because broadcasts can reach individuals on both sides of the border. Knipper et al. (2007) reported that greater knowledge about HIV transmission and prevention significantly influenced condom use.

The ability to successfully reach migrant workers in the United States with HIV information and resulting behavior change was supported by results in the current study. A total of 3 of the male participants in this study were tested for HIV in the United States as a result of ads and flyers offering free HIV testing in their neighborhood. After these men were found to have HIV, they increased their awareness and started using condoms, thereby preventing HIV transmission to their wives. This result supports the value of accessible and free HIV testing programs targeted to migrants. For programs to be effective, they will have to be culturally appropriate and promote trust in a population that fears discovery and deportation. Additionally, these results support the value of more widespread HIV testing of pregnant women in rural Mexico. A number of the participants' children were uninfected because the mothers used antiretroviral medications after a positive HIV test in a local health clinic.

Men in the study underscored the role of machismo in infidelity to their wives and in not using condoms during sex. Extramarital sex is a common and accepted cultural norm in Mexico (Pulerwitz, Izazola-Licea, & Gortmaker, 2001). The majority of the men in the study expressed no guilt in being unfaithful to their wives; their regret was that they had acquired HIV infection. The men consistently reported that using condoms during sex and abstaining from sex with women was not deemed consistent with being a man. Interestingly, homosexual and bisexual men in the study had similar views of what it means to be a man.

Female participants, even if they had heard of HIV or had concerns, were not in a position to refuse sex or to require condoms because of the norms of a male-dominated hierarchical society (Horwitz, 1998). Only 1 woman divorced her husband because he had acquired HIV, a relatively unusual occurrence. Several of the women accepted an unrealistic explanation of how their husband acquired HIV. One woman in the study outwardly accepted her husband's denial of having HIV infection even after she was diagnosed with HIV.

COESIDA and the public health department in Oaxaca have increasingly responded to the need for education throughout the state. As noted by one participant, children now get more education about HIV, but most young men still do not use condoms. Mexican men who migrate to the United States need prevention messages that help them understand that “HIV can happen to you.” One male participant noted that peer education might help. He expressed a willingness to go out as a person with HIV to talk to groups. However, he was quick to say he would only be willing to do such testimonials in communities distant from his own. Disclosure and related stigma remain a significant issue. Peer education and support have repeatedly been shown to be an effective means of facilitating education and behavior change (Adamchak, 2006; Population Council, 2007). There is value in exploring the development or expansion of such programs in rural Mexico.

Summary

Participants in this study showed a spirit of perseverance. They exemplified people who, despite the challenges of HIV, were moving forward with their lives and making the best of their situation. Dealing with a diagnosis of HIV, traveling long distances for treatment, and having to work to survive would seem overwhelming for individuals living in poverty, yet the majority of participants expressed hope for the future. Participants sought treatment and consistently stated that they were healthy and thought they would remain well. It may be that these participants had always had a hard life with men having to leave home to support families and women managing on their own for long periods of time. For these individuals, dealing with HIV was just one more challenge in a life characterized by struggle.

The results of this study add to knowledge of the relationship of the spread of HIV in rural Mexico and of men migrating to the United States seeking work. Although there is a significant debate concerning the value and approach to controlling legal and illegal migration across the U.S.-Mexico border, migration is likely to continue. It was estimated that in 2004, more than 140 million people crossed the Mexican border into the United States. It is commonly believed that at least 12 million illegal migrants are working in the United States at any given time (Lewis, 2007). Regardless of the approach to controlling and monitoring migration, men from rural Mexican families living in poverty will be motivated to risk repeated border crossings to find work. Such migration patterns have serious implications for the spread of infectious diseases. For that reason, it is clearly in the best interest of both countries to develop collaborative prevention programs that accurately acknowledge the realities of current and future population migration between the two countries. The results of this study provide a beginning understanding of the phenomenon of the spread of HIV in rural Mexico related to men migrating to the United States to work. These results can inform larger quantitative investigations as well as development of HIV prevention strategies in rural Mexico.

Clinical Considerations

  • Migrant workers going from Mexico to the United States need detailed education about HIV infection, including culturally appropriate general information about the disease, methods of disease transfer, prevention strategies, testing, and follow-up care.
  • Migrant workers from Mexico working in the United States need culturally appropriate HIV education, access to HIV testing, and access to HIV care.
  • Commercial Latino sex workers in the United States need culturally appropriate HIV education, access to HIV testing, and access to HIV care.
  • Wives and sex partners of Mexican migrant workers need detailed HIV education, including culturally appropriate general information about the disease, methods of disease transfer, prevention, testing, and follow-up care.
  • HIV diagnosis, treatment, and education centers within Mexico need to be accessible, adequately funded, and a general resource for both adult and pediatric medical, nursing, and related health care.
  • Cultural and social issues such as social stigma, machismo, marianismo, male-dominated hierarchical systems, social isolation, language, and resource barriers to health care need to be addressed when planning and implementing HIV prevention and treatment programs.

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Keywords:

AIDS; HIV; machismo; Mexico; migrant workers; powerlessness; social isolation

© 2008Elsevier, Inc.