Disproportionate HIV rates found among African immigrants

By Karin Brulliard, Washington Post

Jeanne Tshibungu imparts her lessons wherever African immigrants agree to listen — at apartments, hair braiding salons, taxicab stands and, on one particular rainy morning, inside a steamy garage at a Silver Spring day-labor center packed with Cameroonians. Standing with a plastic bag filled with condoms, she began explaining in lilting French how they could contract HIV and especially how not to.

Tshibungu, a Congolese-born HIV outreach specialist, was there to emphasize that the disease that has killed millions in Africa affects Africans in the United States, too. It is a message health researchers say is growing in importance as they become increasingly concerned that the AIDS epidemic ravaging sub-Saharan Africa is following migrants from that continent to America.

Some local studies elsewhere in the United States have found greatly disproportionate infection rates among Africans, and care providers in the Washington region are seeing similar trends. But they are running into a common obstacle as they try to gauge the scope of the problem: Because many health departments do not ask patients where they were born, most HIV-positive African immigrants are typically categorized — obscured, experts say — in surveys as “black” or “African American.”

African immigrants are a relatively small group. In the Washington region, one of the nation’s top destinations for African immigrants, they make up about 3 percent of the population, and those with HIV are a small subset of that group. The danger, experts say, is that outreach efforts are missing immigrants because they are not counted, allowing the problem to grow.

“Quite frankly, many providers don’t distinguish between Africans and African Americans,” said Garth Graham, deputy assistant secretary for minority health at the U.S. Department of Health and Human Services, which is hosting a seminar this month on Africans and HIV in Rockville as part of a new nationwide initiative. “It doesn’t take into account the different cultural backgrounds and perceptions of wellness and disease that these individuals have . . . that’s one of the glaring challenges that we’re facing.”

Providers said the problem is exacerbated by stigma, language barriers and fears of deportation. Many African immigrants are unacquainted with the concept of preventative medicine, providers say — and don’t realize that early diagnosis can mean long life, not a death sentence.

“You have to be sick to go to the doctor in Africa,” said Ashenafi Waktola, an Ethiopian-born District physician who treats many HIV-positive patients. “That is disastrous with AIDS.”

There are no precise national HIV or AIDS data for African immigrants. But studies in places that include Minnesota and the Seattle area, both home to relatively large African immigrant populations, have found vastly higher rates among Africans, as have surveys in Canada and Europe.

In the Washington region, information on country of birth varies so much by jurisdiction and is so spotty that it provides only a blurry snapshot. But a recent District Health Department survey of groups providing HIV-related services to poor clients in the region found that 10 percent of those clients were African-born.

Of 31,256 AIDS cases reported in Maryland through last September, African immigrants accounted for 716, or 2.3 percent, slightly higher than their percentage of the population, which is about 2 percent. But in Montgomery, 392, or 15 percent, of all reported AIDS cases were among Africans, who represent about 4 percent of the population.

Officials with the state’s AIDS Administration are unsure how to explain the disparity between the statewide and Montgomery figures because country-of-origin reporting by health-care providers is “often inconsistent or incomplete,” said William Honablew Jr., an administration spokesman. It is possible that health-care providers in Montgomery offer HIV testing to immigrants more routinely and record their national origin more reliably, officials said.

The vast majority of Maryland AIDS cases among African immigrants have been reported in Montgomery and Prince George’s counties, a pattern that has prompted the state’s AIDS Administration to plan an HIV-prevention program targeting African communities in those counties, Honablew said.

In Virginia, country of origin was recorded for just 26 percent of 1,062 new HIV infections reported in 2006, according to the state Health Department. Even so, African immigrants, who represent less than 1 percent of the population, accounted for 5 percent of all 1,062 cases. They almost certainly would account for a higher share if national origin were consistently recorded.

In 2003 and 2004, African immigrants accounted for at least 13 percent of the 639 new HIV infections in nine Northern Virginia counties, according to a study by a Seattle-King County epidemiologist, “HIV Among African-born Persons in Selected Areas of the U.S.: A Hidden Epidemic?”

Many providers and researchers interviewed said they thought most HIV-positive African immigrants were infected in their homelands, in part because in many cases the virus is diagnosed in later stages. Studies have found that most African immigrants contract HIV through heterosexual contact.

Tshibungu’s organization, the Ethiopian Community Development Council in Arlington, is the main group educating African immigrants in the region about HIV. Its brochures are printed in French and Amharic, and outreach workers speak those languages and others spoken by Africans.

But because few educational materials targeting African immigrants are available, outreach workers sometimes rely on those written for native-born black residents and have little cultural relevance for Africans. Among the English-language stories used to teach the value of protected sex, one begins, “Yo, my name is Tre . . . On the real, I consider myself an equal opportunity lover — Black, White, whatever.” Outreach workers do their best to translate.

The worst obstacle is stigma. African immigrant communities are segmented and tight-knit. Although Spanish-speaking patients often prefer Latino doctors or interpreters, providers say it is just the opposite for Africans. They fear that they would know a doctor or interpreter from the same community and that word of their condition would spread.

At the Inova Juniper program, the largest HIV-AIDS care provider in Northern Virginia, most African clients will communicate through an interpreter only via speakerphone, and many wait for appointments in private rooms because they fear seeing someone they know in the waiting room, said the director, Karen Berube.

One of the program’s clients, an HIV-positive Sudanese woman, who did not want her name published, understands such fear. The woman, 36, said she was infected 13 years ago by a Sudanese soldier who raped her. She learned her status a few years later during a medical exam at the Kenyan refugee camp where she lived.

She arrived in the United States in 2001 on a refugee waiver. Now she is a file clerk, and anti-retroviral drugs are keeping her healthy. But a Sudanese social worker who used to visit her stopped after he learned that she was HIV positive, she said. She has told few of her friends and no one at her mosque.

If they knew, “they would stay far away,” she said on a recent day, her face surrounded by a black headscarf. “Some people think that just by greeting [you], you can give it.”

To even gain access to the various African communities, Tshibungu and her colleagues recruit “gatekeepers” — volunteers who arrange meetings with people from their native countries, ethnic groups or villages.

At the Silver Spring day-labor center, the gatekeeper was Rabelais Batchaji, one of the many Cameroonians who gather there.

“In my country, to talk about AIDS is not easy,” said Batchaji, a tall and affable man who said he has a fondness for community service. “They read it in the paper, but I don’t know if they discuss it.”