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The purpose of this article is to describe possible reasons for the increase in HIV/AIDS among childbearing Hispanic/Latinas and to discuss the implications for maternal child nurses. The median age of Hispanic/Latinas is 27 years compared to 36 years for all other races combined. Hispanic/Latinas have the highest birth rate among all women in the United States; they also have a five times greater rate of HIV/AIDS infection compared to non-Hispanic White women. Most commonly, Hispanic/Latina women first discover their HIV status when they receive prenatal care. Gender and cultural roles, poverty, lack of health insurance, poor health literacy, limited English proficiency, and low educational level all contribute to this emerging crisis. Educating Hispanic/Latina women about prevention methods, early testing/counseling, and treatment options is a first step in decreasing the suffering and devastation associated with HIV/AIDS among childbearing Hispanic/Latinas and their families.
This article describes the circumstances surrounding the increase in HIV/AIDS among childbearing Hispanic/Latinas and discusses the implications for maternal child nurses. Hispanic/Latinos are the fastest growing minority population in the United States and are considered the new "majority minority." The rate of new HIV/AIDS cases has soared to 11.9/100,000 among Hispanic/Latinas, compared to 2.4 /100,000 among non-Hispanic White women, which translates to nearly a five times greater rate of infection (Centers for Disease Control and Prevention [CDC], 2011). Reasons for this increase are multifaceted, and include migration patterns, gender and cultural roles, poverty, lack of health insurance, lack of formal education, misconceptions, limited English proficiency (LEP), and poor health literacy. Disturbingly, many Hispanic/Latinas first discover their HIV status when they receive prenatal care or give birth, which makes it crucial that maternal child nurses understand the dimensions of this crisis.
Currently, Hispanic/Latinos constitute 16.3% or approximately 50.5 million of the total U.S. population (U.S. Census Bureau, 2011) and are projected to comprise 29% or 132.8 million of the U.S. population by 2050 (Pew Hispanic Center, 2008). Approximately nine out of 10 Hispanic/Latinos residing in the United States are U.S. born (Pew Hispanic Center, 2011). It is estimated that 63% are of Mexican origin followed by Puerto Rican, 9.2%; Central America, 7.9%; South America, 5.5%; Cuban, 3.5%; Dominican, 2.8%; and 6.6% from other Hispanic/Latino countries (U.S. Census Bureau, 2011). Hispanic/Latinos are the largest and youngest minority group in the United States (Pew Research Center, 2009). In fact, one-in-five school children and one-in-four newborns is Hispanic/Latino (Pew Hispanic Center, 2009).
Historically, Hispanic/Latinos have settled in a limited number of states, including Arizona, California, Florida, Illinois, New York, and Texas, but this trend has changed in the last 10 years. Hispanic/Latinos now reside in unprecedented numbers in states such as North Carolina, Nevada, Washington, Pennsylvania, Oregon, Michigan, and Utah (Pew Hispanic Center, 2010).
Hispanic/Latinas are, on the average, younger than non-Hispanic women, with a median age of 27 years compared to 36 years (Pew Research Center, 2009). Hispanic/Latinas experience the highest birth rate among all women in the United States, with 22.1 live births per 1,000 population, followed by Asian or Pacific Islanders, 16.9 per 1,000; non-Hispanic Blacks, 16.5 per 1,000; American Indian or Alaska Native, 14.5 per 1,000; and non-Hispanic Whites 11.4 per 1,000. Hispanic/Latinas have a higher rate of preterm births than non-Hispanic Whites (National Center for Health Statistics [NCHS], 2010), and by 19 years of age, one in four Hispanic/Latinas have become mothers (Pew Research Center, 2009).
HIV/AIDS morbidity and mortality among Hispanic/Latinas is increasing at an alarming rate. Women comprise 25% of the cumulative reported AIDS cases, and 72% of these women are Hispanic/Latinas (CDC, 2008). The northeastern and southern United States constitute the highest geographical growth rate for AIDS diagnosis among Hispanic/Latinas (CDC, 2011). The HIV/AIDS death rate among Hispanic/Latina women is approximately three times greater than the death rate for non-Hispanic White women (National Center for Health Statistics, 2011). Heterosexual contact accounts for 83.1% of all HIV/AIDS cases in Hispanic/Latinas, whereas 16.5% of cases are attributed to injection drug use (CDC, 2011). Frequently, Hispanic/Latina women have been shown to be diagnosed with HIV/AIDS later than women in other cultures, which results in premature death within 18 months of diagnosis (National Council of La Raza, 2006).
Considering that Hispanic/Latinas have the highest birth rate among all U.S. women, there is cause for concern about perinatal transmission. Alarmingly, one-quarter of all HIV-infected pregnant women transmit the virus to their newborns (CDC, 2007). Perinatal transmission accounts for 91% of all AIDS cases in children; however, when a woman receives adequate HIV/AIDS treatment during pregnancy, the rate of perinatal transmission drops to less than 2% (CDC, 2007). The CDC recommends that all pregnant women be screened for HIV as a standard prenatal care practice and reports that when healthcare providers strongly recommend HIV testing, women are more likely to get tested (CDC, 2007).
Migration patterns fueled by food insecurity and economic disadvantage often force Latino men to come to the United States to seek basic necessities for their children (Espinoza, Hall, & Hu, 2009). The men leave their families behind for months or even years, during which time some of the men and some of the women left behind engage in unprotected sexual behaviors due to fear, anxiety, or loneliness (Sowell, Holtz, & Velasquez, 2008). After reuniting with their partner, HIV transmission can occur (Sowell et al., 2008).
Within the Hispanic/Latino community prescribed gender roles may contribute to female disempowerment, deter preventive measures such as negotiating condom use and delay HIV testing (Davila, Gonzalez-Ramirez, & Villarruel, 2007). Familismo (family) is the single most important component of the Hispanic/Latino culture and demands that a woman place her family's needs above her own while maintaining simpatia, the appearance of harmony in all relationships (Davila, 2005). Machismo portrays men as the ultimate authority of the family and places great value on a man's masculinity, often providing tacit permission to engage in sexual relationships outside marriage (Sowell et al., 2008). Similarly, machista, a belief that men must oversee and sanction all women's activities, may make it difficult for a Hispanic/Latina woman to seek confidential testing and care associated with HIV/AIDS. The female counterpart of machismo, marianismo, requires Hispanic/Latinas to espouse qualities of submissiveness, purity, and sexual naivety, fostering a code of sexual silence and restricting control of a woman's sexual and reproductive choices (Moreno, 2007).
According to the United Nations, "poverty is a key factor leading to behaviors that expose people to the risk of HIV infection, and poverty exacerbates the impact of HIV/AIDS," (2005, p. 3). Hispanic/Latina women are twice as likely to live in poverty compared to non-Hispanic women and are almost three times as likely as non-Hispanic women to be uninsured (Pew Hispanic Center, 2008). Poverty and lack of health insurance may preclude access to preventive care, quality prenatal care, and HIV/AIDS testing, counseling, or treatment (CDC, 2009). After adjusting for age, gender, race/ethnicity, poverty, income ratio, education, unemployment, smoking, regular alcohol use, physician-rated health, and body mass index, lack of health insurance is the most significant factor that increases mortality risks in U.S. adults (Wilper et al., 2009).
Lack of formal education may place Hispanic/Latinas at greater risk for HIV/AIDS as women with lower levels of education practice fewer health-promoting behaviors and have poorer health outcomes when compared to women with higher levels of education (Robert Wood Johnson Foundation, 2009). More than 42% of Hispanic/Latina mothers have less than high school education compared to 5.9% of non-Hispanic White women, and only 10% of Hispanic/Latina mothers have completed some college as compared to 31.7% of non-Hispanic White women (U.S. Department of Education, 2007). Lack of formal education as well as limited knowledge about sexuality and reproductive health promotes even greater HIV/AIDS disparity in Hispanic/Latinas (Davila, 2005; Davila et al., 2007).
Misconceptions about HIV transmission and prognosis, coupled with denial and stigma, fuel the HIV/AIDS crisis in the Hispanic/Latino community. Case in point, a California survey reported that 48% of Hispanic/Latinos believed that they could get HIV/AIDS by using public toilets, while 24% thought that one could become infected from kissing an HIV-positive person on the cheek (Ritieni, Molkowitz, & Tholandi, 2008). Furthermore, fear and anxiety related to HIV misinformation may encourage denial of risk factors and symptoms, postponing treatment and may foster a sense of fatalism (Ritieni et al., 2008). For these reasons, late diagnosis of HIV status as well as rapid progression to AIDS reinforces the misconceptions and stigma of HIV/AIDS in the Hispanic/Latina community (CDC, 2009).
In addition to the conditions already mentioned, LEP among Hispanic/Latina women may add further barriers to obtaining prenatal care and HIV testing and counseling (Durham & Pollard, 2010). Seven out of 10 Hispanic/Latino immigrants report that they do not speak English at home or that they do not speak English well (Pew Hispanic Center, 2010). Non-English-speaking Hispanic/Latina women are more likely to report worse health status and access to care than their English-speaking counterparts (DuBard & Gizlice, 2008).
Health literacy is defined as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions," (U.S. Department of Health and Human Services [U.S. DHHS], n.d.a). Health literacy impacts a person's ability to seek preventive care services, navigate the healthcare system, complete health forms, or manage a chronic illness. Hispanic-Latinos represent over two-thirds of all people with basic, or below basic, health literacy skills, which is exemplified by the ability to read a pamphlet or recognize what drinks are allowed prior to a medical test, but does not include the capacity to read or understand a prescription label. People with poor health literacy skills and LEP have an increased propensity for inappropriate care, nonadherence to treatment regimens, or even misdiagnosis (Flores, 2006).
Strategies such as increasing the number of bilingual and bicultural nurses, becoming educated about culturally competent care, and addressing language and health literacy issues form the foundations for reducing this health disparity. In addition, identifying the changes in healthcare policies and comprehending the underpinnings of poverty will allow maternal child nurses to effect change at a systems level (Table 1).
According to Thacker (2005), "failure to educate an ethnic diverse nursing workforce will translate to failure to deliver effective healthcare to our ethnic and racial minority citizens" (p. 58). Therefore, it is essential to increase the number of bilingual and bicultural nurse leaders who may provide care for this population. Disturbingly, Hispanic/Latino nurses represent only 3.6% of all nurses in the United States (U.S. DHHS, 2010a).
Because of the cultural code of sexual silence, Hispanic/Latina women may be unwilling or uncomfortable discussing private health concerns. When the nurse asks questions in a safe and nonjudgmental setting, many women are willing to discuss their concerns. In order to foster this kind of self-disclosure, it may be necessary to talk with and educate the woman separately from her partner. In its report "Redefining HIV/AIDS for Hispanic/Latinos," the National Council of La Raza (2006) advocates a "family-centered paradigm" that capitalizes on the strength of the Hispanic/Latino family system. Health education may be presented as a resource to strengthen the family unit. The council also promotes empowerment of Hispanic/Latina women so that they may participate in social and political events and effect change.
Strategies to combat poverty include investing resources in Hispanic/Latino communities that address environmental, social, and economic deficiencies. Local community health clinics, increased employment opportunities, safer neighborhoods, adequate housing, stronger school systems, and a decrease in community and personal violence may drastically improve the well-being of any population. Moreover, access to low-cost health insurance may decrease the disproportionate number of HIV/AIDS cases among Hispanic/Latinas. The Affordable Care Act of March, 2010, promises to provide health insurance coverage to more U.S. citizens than ever before, thereby improving access to care (U.S. DHHS, 2010b). A preexisting condition insurance plan will make options available for those who have been uninsured for 6 months or more due to a preexisting condition such as AIDS. In addition to health insurance policy changes, the Ryan White HIV/AIDS Modernization Act of 2006 provides federal monies to support free or low-cost HIV testing services and AIDS drug assistance programs to those who cannot afford such assistance (U.S. DHHS, n.d.b). Unfortunately, unauthorized immigrants often do not qualify for such services.
Title VI of the Civil Rights Act of 1964 prohibits discrimination based on national origin or language spoken and mandates that care cannot be postponed, delayed, or impeded due to language barriers (U.S. Department of Justice [U.S. DOJ], n.d.). In the absence of bilingual healthcare professionals health institutions are obligated to provide professional interpreters, telephonic language lines, or another acceptable source of translation for all non-English-speaking clients, including Hispanic/Latinos (U.S. DOJ). Use of professional interpreters may increase patient satisfaction, promote nurse-patient trust, and support adherence to treatment plans. Some Hispanic/Latinas may be uncomfortable disclosing private information to a professional interpreter, especially a male interpreter (Smith, Sudore, & Perez-Stable, 2009). Use of ad hoc interpreters such as family members and hospital support staff increases the chances of serious or life-threatening errors and should be discouraged (Flores, 2006). Children under the age of 18 should never serve as interpreters. A mistake in interpretation of even a simple word may have grave consequences.
Maternal child nurses may serve as advocate for their Hispanic/Latina clients by encouraging HIV testing, especially during prenatal care, explaining the testing process, and providing education on HIV/AIDS risk factors and culturally appropriate HIV health education materials. Nurses may be called upon to assist clients to seek free confidential testing (Table 2). Many HIV health education materials are available in Spanish at no or low cost (Table 2). Before offering printed materials, maternal child nurses should assess their client's ability to read and write in Spanish or English. Culturally, many Hispanic/Latinos do not wish to ask questions or offend a healthcare professional who is seen as an authority figure, so they will simply nod or say "yes" when asked "do you understand?" even if they do not comprehend what has been said. Maternal child nurses may wish to ask their Hispanic/Latina clients to repeat health instructions or education provided by healthcare professionals.
Because most Hispanic/Latinas interface with the healthcare system during pregnancy, maternal child nurses have the unique opportunity to provide health education, encourage HIV testing and counseling, and assist in obtaining affordable HIV/AIDS treatment for their Hispanic/Latina clients. Poverty, access barriers, cultural traditions, migration patterns, language deficiencies, and health literacy inhibit sexual and reproductive health education, delay early HIV detection, and preclude access to treatment. A maternal child nurse's understanding of these issues is a first step to decreasing the suffering and devastation associated with HIV/AIDS in Hispanic/Latinas.
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