Geographic mobility impacts vulnerability to HIV among gay and bisexual Latino migrants to the US

Gay and bisexual Latino migrants in the United States, especially but not only those who are undocumented, are vulnerable to higher rates of sexual risk behaviours and HIV transmission, a recent study published in Social Science and Medicine found. The study identified homophobia and HIV related stigma in their residential communities, barriers to well-paid work, access to affordable, appropriate healthcare, and isolation from the LGBTQ+ community as the main contributing factors for their increased vulnerability.

In 2018, geographers based at the University of California Santa Barbara conducted life-history interviews with 16 Latino gay and bisexual men in San Bernardino County. Fourteen participants were from Mexico, and two were from were from El Salvador, with their time spent in the US ranging from two months to 32 years. Ten of the participants were living with HIV. Three were documented workers, four were undocumented workers, three had temporary protected status, one was a citizen, and six had unknown documentation status.

The interviews were conducted in Spanish and participants were asked about areas where they lived, socialised, and engaged in sexual relations, sex (including hook-up apps), and drug use. They were also asked about access to health care and HIV/STI testing, immigration to the US, and short-term mobility (for example, daily travel, travelling to Mexico for short visits).

Reasons for migrating

“They would basically make fun of me all the time. They would call me princess or girl, or things like that, so like they bullied me.”

In describing their decision to migrate to the US, participants highlighted violence, discrimination, bullying and general feelings of cultural intolerance towards their sexual identities. Many participants saw the US as being more accepting of sexual minorities and of people living with HIV. These experiences of discrimination were also linked to episodes of depression after migration for a few participants. Some participants also highlighted their financial insecurity, often related to discrimination or lack of education.

“So, I know that if I say that I am HIV positive, I will get fired from my job, so I would lose many things. The same with my family, I know that perhaps one or another person might understand but I know that no. I know that no. I know them.”

Barriers to work

Migrating to the US with limited financial resources made it difficult for some of the participants to secure legal documentation status. This, in turn, made it difficult to secure consistent work that paid a living wage. Limited financial resources and barriers to well-paid work forced participants into insecure or low-cost housing, located in areas that offered only low-paid work.

As a result, participants were faced with two options, each of which came with its own financial cost. They could commute long distances to better-paid jobs, which was difficult due to the lack of reliable transportation, or they could work more locally, but for lower wages. Consequently, participants became trapped in a cycle where low wages forced them into housing that was located far away from well-paid work, which in turn forced them into jobs with low wages. Many experienced unstable living situations, temporary and transitional housing, and homelessness.

Residential isolation

The neighbourhoods where participants lived affected their wellbeing and their connection to LGBTQ+ communities. Participants often felt emotionally and socially detached from where they lived. Some participants felt that they had to keep their sexual identities private at home and viewed their residence as a place to sleep rather than as a place where, for example, they could bring a sexual partner. In neighbourhoods populated by other Latinx (people of Latin American origin or descent) groups, participants often faced the same homophobia and HIV-related stigma they had sought to escape by migrating.

“I preferred to go far, like I said, I go where I feel free, where no one could be like “Oh, I know him”, “oh, he’s here”, “oh, him” so like I have never liked it when they make that type of comment. I have never liked it.”

To avoid negative reactions from their neighbours, participants limited their sexual and social encounters with gay and bisexual men to gay community areas that were located far away from their own neighbourhoods, such as West Hollywood in Los Angeles.

“There’s no gay bars, there’s no- nothing here. So, it’s like, the only gay bar or restaurant near is all the way into [city approximately 30 miles away]. And that’s the only one, other than I need to travel all the way to [city approximately 70 miles away] or LA to find something like that. So, I can at least be comfortable.”

Sexual relationships

“Regularly when you meet a stranger on Grindr, you can ask about the status, you can ask them about STDs or about HIV, but I think that it is a dumb question because they aren’t going to tell you the truth. People are going to say “Oh, I have HIV”. “I have STDs” no, no one, that’s a dumb question ... because no one will say the truth, they are strangers.”

Participants felt that the LGBTQ+ community in the US could offer them more social stability and acceptance, and physical spaces to safely meet other gay and bisexual men, than their home countries. Participants also associated the LGBTQ+ environment with online communities through which they could meet other men for sex. Participants highlighted that it was through these community spaces, both online and offline, that they gained understanding of social and sexual norms, for example whether to discuss HIV risk.

"Many experienced unstable living situations, temporary and transitional housing, and homelessness."

Because travelling to LGBTQ+ spaces was time consuming and expensive, participants rarely travelled to seek out these connections. More often they relied on hook-up apps such as Grindr for sexual encounters or social companions. Hook-up apps allowed participants to engage in sexual encounters in ways they considered private and safe, while also reinforcing the separation of different parts of their lives into residential, social, and sexual places: they lived, worked, and met sexual partners in different areas, often many miles apart.

Many participants highlighted “party and play” activities as their primary means of forming social connections and having sexual encounters, but did not always trust their sexual partners to be honest about their HIV status. Many participants described their encounters as being risky and expressed concern over their sexual behaviours.

“I don’t know, I felt like it was just for fun being over there, but I just realised, like all these guys that could have been HIV positive, and they didn’t tell me anything.”

Accessing healthcare

“I, at the time, well, still working on it, did not have papers, because I was brought illegally here when I was a little kid. Um, I couldn’t go to school ... or get proper healthcare ... [after high school] Yeah, that’s when I started realizing how hard it was getting medical attention.”

Being undocumented was a barrier to affordable healthcare, as these participants could neither secure well-paid jobs that provided health insurance nor qualify for publicly funded healthcare.

Clinics that accepted participants’ insurance or offered affordable healthcare were located far from where they lived, raising the same issues with transportation that participants faced in accessing LGBTQ+ spaces.

“There are some barriers on not being a resident or citizen of this country brings barriers to not being able to get the proper medical attention. For example, if you appear from a chronic disease, like HIV, it’s more difficult because you have to pay off of your own tab and it is more difficult getting medical insurance for people that are like in my situation.”

As a result, participants often returned to their home countries, where costs were much lower, for healthcare. Those who did have access to healthcare in the US were concerned about the quality of care they received. They said that doctors working in general care were disinterested in and uncomfortable with them as patients, and that they were uncomfortable discussing their HIV-related healthcare needs with the doctors assigned to them. Language barriers and the inability to find translators made communication even more difficult.

"Normally if you have friends within the community, they are the ones that can guide you."

Participants did sometimes find and link to healthcare that met their needs, but only after being referred to bilingual healthcare professionals and dedicated HIV services by friends, health care professionals or mobile HIV testing centres. Unless they were referred to specific clinics or services, these testing centres were often the only HIV services of which participants were aware.

“Normally if you have friends within the community, they are the ones that can guide you because ... you can go to the internet and search but ... it is not ... like how a friend would tell you, “oh, I’ll take you there”, or “I’ll take you over here where I go normally”.

These services and mobile testing units – and the Latinx LGBTQ+ community in particular –connected them to other social services that were key to their health and wellbeing such as housing services. Participants without family support were especially vulnerable to unstable housing and relied on housing services to find better housing and to avoid homelessness.

Participants’ experiences of HIV-specific care were more welcoming and affirming, as the staff were more likely to be bilingual and to understand their unique needs and experiences as MSM, migrants, and Latinx. As one participant said, “If you go to a place within the gay community, it is more probable that you will get the care that you want”.

Policy recommendations

The authors conclude by drawing attention to the distinctive ways in which Latino migrant men who have sex with men (MSM), especially those who are undocumented, are unequally exposed to financial, cultural, and structural factors that lead them to higher rates of sexual risk behaviours and HIV transmission. They stress the significance of barriers to affordable health care for sexual health, as Latino MSM migrants may not be receiving preventative care, such as PrEP, STI testing, and HPV vaccines.

They recommend that community-based health organisations and social services become more proactive in educating these migrants about HIV, and in connecting them to basic resources like housing and employment assistance. Alongside state agencies, they should focus health interventions in geographical areas where the riskiest behaviours take place. Federal and state agencies should also provide community-based health services with resources to help with transportation (for example, bus vouchers or pre-paid petrol cards) to make it easier to get HIV care. Organisations seeking to support this population should prioritise anonymity and confidentiality. Finally, federal and state level policies should be expanded to provide undocumented migrants with affordable healthcare.