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Abstract

US immigrants of Caribbean origin are overrepresented in the HIV/AIDS prevalence statistics. Bidirectional travel between the United States and the Caribbean region by providing opportunities for sexual mixing may contribute to these high HIV rates. Caribbean immigrants face further risk because of limited health care access, social isolation, and stigma. Additionally, although substance abuse may not represent a major health issue in their countries of origin, Caribbean immigrants are composed disproportionately of adolescents who are at greatest risk of substance abuse. There is little information on the health care characteristics of these migrants, especially regarding HIV care. This article describes how the social and economic circumstances that surround the lives of people from the Caribbean and the challenges of the acculturation process have placed these individuals at risk of substance abuse and HIV infection. The article draws on findings from the literature and analysis of data from several sources.

Keywords

access to health care Caribbean immigrants HIV/AIDS substance abuse

Introduction

Like many other immigrant groups before them, Caribbean-born individuals have left their countries of origin to seek better opportunities in the United States. These migrants have settled primarily in large urban centers such as New York City and Miami, as well as in much smaller medically underserved communities where they confront serious socioeconomic and health challenges. With some of the highest HIV sero-positivity rates in the country, US immigrants of Caribbean origin are overrepresented in the HIV/AIDS prevalence statistics. Evidence also suggests that these migrants may be severely limited in their ability to access health services. There is, however, little information on the health care characteristics of these migrants, especially in regard to HIV care. Also lacking is an understanding of the factors that put these individuals at risk for HIV. While many come from countries where HIV is highly prevalent (Shedlin, Drucker, Decena, Bhattacharya, Barreras, 2006; CAREC/PAHO/WHO, 2004), these immigrants are also impacted by the epidemic while in the United States. These individuals may also be subject to the challenges of the adaptation and assimilation processes inherent to their acculturation into US society. Yet, the proximity of their countries of origin to the US mainland and their multiethnic and multicultural backgrounds set these individuals apart from other immigrant groups and may play a unique role in their HIV risk trajectories.

This article uses findings from the literature, published data, and data from patients attending an HIV primary care clinic to examine the role that socioeconomic factors and the process of acculturation play in US Caribbean-born immigrants' risk for substance abuse and HIV.

Methods

We conducted a search through Medline and Google Scholar for all articles that were published for the past 20 years on substance abuse, HIV/AIDS, and acculturation among people originating from the Caribbean. The information obtained from the review was supplemented with data from three publicly funded surveys: The American Community Survey (ACS), the National Survey on Drug Use and Health (NSDUH), and the National Health Interview Survey (NHIS). A local data component was added to the article by including the results of basic analysis conducted on data collected from a group of HIV-positive Haitian immigrants who were attending primary care at a clinic located at the Jackson Memorial/University of Miami Medical Center in Miami, Florida. The American Community Survey (ACS) is an annual survey conducted by the US Census Bureau. It collects sociodemographic and other related data on the nation overall, all states and the District of Columbia, all congressional districts, approximately 1800 counties, and 900 metropolitan statistical areas. The data are published as 1-year estimates for geographic areas with a population of 65 000 or more, and 3-year estimates for geographic areas with a population of 20 000 or more. This paper presents 2006 ACS data on US Caribbean-born residents which we compare to the US general population.

NSDUH is conducted annually by the Research Triangle Institute (RTI) on behalf of the Substance Abuse and Mental Health Administration (SAMHSA). It provides national and state-level data on the use of tobacco, alcohol, and illicit drugs and mental health in the United States. Data collected in 1999-2001 are presented in graphs that compare the drug use prevalence of the US general population to that of US immigrants in general and survey participants from Puerto-Rico, Cuba, and Jamaica.

NHIS is a cross-sectional household survey that is implemented continuously by CDC among a probability sample of the US non-institutionalized population. NHIS data are used to monitor trends in illness and disability, to track progress toward achieving national health objectives, and to evaluate Federal health programs.¹ This paper presents health care access and substance use prevalence rates from data collected in 2007 from US-born survey participants and participants who were born in Mexico, Central America, and the Caribbean.

Finally, a group of HIV-positive Haitian immigrants who were attending care at an HIV primary careh clinic in Miami, Florida, were interviewed between October 2007 and July 2008, as part of the Haitian SMILE study. The aims of that study were to examine barriers and facilitators of regular use of HIV care by this population group. Participants were administered a questionnaire to assess their sociodemographic characteristics, knowledge of HIV/AIDS, use of HIV primary care services, and perceptions and attitudes toward health. Analysis was conducted on data from the 96 Haiti-born adults who were aware of their HIV status for at least a year. The paper presents information on health care access and sociodemographic characteristics of these participants.

Findings

As reflected in Table 1 (from ACS data) there were 3 387 004 Caribbean-born individuals living in the United States in 2006 (excluding Puerto-Ricans), which represented slightly more than 1% of the total US population. We assume these figures to be below the true number of Caribbean-born US residents since the census tends to underestimate the size of migrant populations due to the undercount of undocumented residents.² Based on the 2006 Caribbean estimates, Cubans constitute the largest group (983 454) of immigrants, followed by Jamaicans (755 539). Dominicans (597 940) are the third largest group; Haitians (530 897) are fourth; and, finally, people originating from Trinidad and Tobago (225 528) constitute the smallest group of immigrants from the Caribbean. Caribbean-born US residents are almost equally divided between women and men, and their marital and family circumstances are similar to those of the US general population—approximately 50% of Caribbean-born residents are married, and on average occupy 3-person households (Table 1).

Table 1.

SES of US Residents from Selective Caribbean Countries, the Caribbean as a Whole, and the General US Population (%)^a

	United States	Caribbean	Cuba	Jamaica	Haiti	Dominican Republic	Trinidad and Tobago
Male	49	46	50	44	49	43	43
18 years+	75	94	95	92	91	94	96
65 years+	12	16	29	10	11	13	9
Family households	67	74	71	81	79	70	70
Female householder	18	14	15	11	9	17	18
Average family size	3	3	3	4	4	3	4
Married	50	49	56	44	49	45	50
Never married	31	27	16	31	32	32	29
<High school	15	27	28	40	27	20	14
Naturalized US citizen	7	56	60	49	50	63	56
English < very well	9	42	62	66	52	2	1
Poverty rate	9	15	11	26	14	10	10

^a Adapted from published 2006 American Community Survey data.

More than 50% of non-Caribbean US residents have attended college and have a median household income of $50 740, while only 42% of Caribbean-born residents have attended college and have a median family income of $41 428. Poverty is also more widespread among Caribbean-born residents (poverty rate is 14.9%) than among non-Caribbean-born residents (9.5%). More than half of the Caribbean-born US residents have been in this country for at least 2 decades; they have settled primarily in large urban centers such as New York City and Miami. This paper describes the experience of Caribbean-born immigrants in the US, the challenges of poverty, acculturation, and the resulting vulnerabilities to substance abuse and HIV infection.

Caribbean-Born US Residents and Substance Abuse

Information on substance use behavior of Caribbean-born residents is scant as research on substance abuse among blacks has joined together Caribbean blacks and African Americans.³ This hinders distinguishing between the 2 groups.⁴ The situation is similar for Hispanic immigrants originating from the Caribbean who are not differentiated from other Hispanics in published data.²

Immigrants in general have an advantage over native-born Americans, particularly regarding health status, behaviors, and longevity.⁵ This Healthy Immigrant Effect coupled with the fact that substance abuse is not a serious health issue in most of the Caribbean region contribute to keeping substance use to a controllable level among US residents of Caribbean origin. However, immigrants' health advantage tends to decline as their length of residence in the United States increases and these individuals become more acculturated.⁶

Figures 1 and 2 (from NSHDA data) show that for all substances listed, there were proportionally more US-born residents involved in abuse than foreign-born residents. While 5.1% of US residents had reported marijuana use in the past 30 days, only 2% of Puerto-Ricans and 0.9% of Cubans had reported marijuana use in the same time frame. Similarly, while 6.6% of US residents had reported illicit drug use in the previous 30 days, only 0.5% of Cubans, and 5.6% of Jamaicans had reported similar use.

Figure 1.

Past month alcohol, marijuana, any illicit drug, and tobacco use among US-born and foreign-born persons aged 18+ living in the United States (from 2005 SAMHSA report).

Figure 2.

Past month tobacco, marijuana, and any illicit drug use among US-born and foreign-born residents aged 18+ (from 1999 to 2001 NSDUH data).

Racial and ethnic minority groups, including immigrants, in the United States are however composed disproportionately of adolescents who are among the demographic groups at greatest risk of substance abuse. The rapid growth of these racial and ethnic populations, paired with their relative youthfulness and socioeconomic disadvantages, makes substance use and abuse an issue that will increasingly become important among these groups. The use of substances in this population will affect society in general in the long term if efforts are not made to curb the growth of risky behaviors among these youth.⁷

Substance Abuse and Acculturation

Acculturation has been defined as the process of change that occurs when culturally distinct groups and individuals interact with another culture.^8,9 There is overwhelming evidence showing that rates of substance use are associated with the length of time immigrants reside in the United States. For instance, an analysis adjusting for demographic differences showed that immigrants who had been in the United States for 5 or more years were more likely than immigrants who had been in the United States for fewer than 5 years to use alcohol, marijuana, or other illicit drugs in the past year or month and to binge drink.^10,11 In a comparative analysis, Warheit¹² concluded that as Cubans became more acculturated, their substance use behaviors came to resemble those of native-born non-Hispanic white adolescents who tend to have higher rates of substance use than Hispanic adolescents. Among black US residents of Caribbean origin, those born in the United States had a much higher prevalence rate of substance abuse than those born outside the United States. Moreover, third-generation US-born Caribbean blacks had higher rates of substance dependence than did first and second generation Caribbean blacks. These findings replicate those by Alaniz¹¹ that each of the marginal populations studied in different areas of the world increased their use of substances with increased time in the host society/culture; these findings indicate that migration to a more modern society was accompanied by initiation and/or increase in substance use.

Acculturation is related to fluency in the language of the adopted country as well as the ability to function in formal and informal social settings and institutions. Acculturation negatively affects behaviors by disrupting adherence to the inhibiting values, norms, and social bonds of the country of origin, while simultaneously introducing and reinforcing behaviors of the dominant culture that may be at odds with the culture of origin.¹³ The acculturation process may also induce stress as the individual tries to resolve conflicting differences between several cultures. Attempts to reduce this stress may lead to a variety of destructive behaviors such as drug use, risky sexual behaviors, and a higher level of depression.^8,13–15 The use of substances is therefore a method of desensitizing the day-to-day stressors and is increasingly adopted with higher levels of exposure to the practices of new surroundings.

Caribbean-Born US Residents and HIV

Caribbean-born US residents are severely impacted by the AIDS epidemic. In New York City for instance, the largest number of people living with HIV are from Haiti, the Dominican Republic, Cuba, and other Caribbean countries, although these individuals represent only a small segment of the population.⁶ Among black New Yorkers diagnosed with HIV, 23% are foreign-born, and of these individuals, 50% originate from the Caribbean.⁶ In Florida, persons of Haitian origin represent only 2% of Miami-Dade County’s population; they currently account for 7% of the cases of HIV infection and AIDS. Heterosexual contact is the most prevalent mode of transmission of HIV among these migrants.¹⁶

Researchers have linked several factors to these high rates of infection among US Caribbean-born residents. Foreign-born individuals are disproportionately represented among the age groups most at risk for HIV.¹⁷ Although Caribbean immigrants rank higher on various economic indicators than their US-born counterparts, they still face formidable social challenges. For example, while Caribbean immigrants are more likely to be homeowners and employed,¹⁸ they continue to experience racial discrimination,⁶ fear of deportation, HIV-related stigma, and, for some, communication difficulties.¹⁹ As a result, immigrants from the Caribbean tend to settle primarily in urban HIV epicenters such as New York City and Miami,¹⁷ residing in the poorest neighborhoods that typically have the highest rates of STIs, including the highest HIV prevalence rates.

Conditions in the countries of origin may also shape the risks of Caribbean immigrants, increasing their risk for HIV and other STIs⁶ due to poor health environments and practices.¹⁷ UNAIDS (2006) estimates that there are 250 000 HIV-infected persons in the Caribbean, a region which is second only to sub-Saharan Africa in levels of prevalence of HIV. AIDS is currently one of the leading causes of death among 15-24 year-olds in the Caribbean, and only between 27% and 40% of those infected receive antiretroviral therapy.²⁰ Risks among new and more established immigrants differ, in which incidence is higher among new immigrants,¹⁹ indicating that these new migrants have carried with them some residual impact of the more severe HIV epidemic of their countries of origin, while the more established immigrants are more likely to acquire the infection while in the United States.

The predominant migration pattern among Caribbean immigrants has been for women to emigrate first, as US employment opportunities favor them. This can be a protective factor when dealing with traditionally prominent gender inequalities in these countries.¹⁹ Gender inequalities may promote conditions of risk and contribute significantly to the HIV/AIDS epidemic as gender norms are known to influence risk behaviors. Multiple partnerships in Caribbean countries are viewed as normal for men but not women.¹⁹ Nevertheless, individuals from the Caribbean have lower sexual risk behaviors than their US counterparts. They are less likely to be promiscuous and to have casual or one-time sex partners.⁶ However, Shedlin and colleagues¹⁹ have reported that both men and women experienced more ease in engaging in multiple sexual partnerships while in the United States compared to being in their home countries. Caribbean immigrants may feel there is “anonymity” in US communities compared to the close-knit nature of communities in their countries of origin. Thus, the US context increases the likelihood of multiple partnerships because of fostering attitudes that such activities can go undetected.¹⁹

Moreover, according to Hoffman and colleagues,⁶ Caribbean immigrants have less favorable attitudes toward using condoms and are less likely to intend to always use condoms than do US-born African Americans. Likewise, Caribbean women are not as confident as US-born women in convincing their partners to use condoms or undergo STI testing, or notifying a partner of an STI infection.

As explained earlier, immigrants may feel acculturation pressures to assume risky behaviors they perceive, perhaps erroneously, as common among peers born in the United States, as well as pressure to retain their cultural values and traditions. Different levels of acculturation have been shown to be associated with different types of risk behaviors for HIV infection.²¹ Immigrants who want to “fit in” may be particularly vulnerable to the pressure of engaging in unprotected sex.^2,22 Immigrants have reported a loss of self-esteem, feelings of failure, and increased levels of frustration and disappointment. Periodic travel between home countries and the United States reduced acculturative stresses. However, travel and migration patterns, especially when involving mobility to higher risk environments, have been related to increases in risky sexual behaviors and HIV seroprevalence.¹⁹ Postmigration experiences such as being homeless, having difficulty with employment, and lacking interpersonal social support tend to exacerbate unstable sexual partnerships and empowerment issues for Caribbean-born women as they experience a greater need to rely on partners for housing and support.¹⁹

Access to Health Care for HIV-Positive Caribbean Immigrants

Despite being disproportionately affected by the AIDS epidemic in the United States, minority ethnic groups in general are less likely to receive much needed medical care. Patients that do not receive adequate care eventually present with more serious illnesses, are less likely to receive antiretroviral therapy, more likely to develop resistance to antiretroviral therapy, and are less likely to achieve viral suppression. Culturally relevant issues such as stigma, discrimination, reliance on self-care, and distrust of medical interventions and medications have been shown to impact HIV-positive Caribbean-born US residents' decisions to access care.^20,23 For instance, a study conducted during the pre-HAART era found that Haitian ethnicity was associated with a lower CD4 count at presentation for initial primary care for HIV-positive persons. A more recent study found that Haitians (compared with African Americans) were more likely to be hospitalized for HIV-related complications and were more likely to delay seeking care.²⁴ These groups with traditionally restricted access to health care services are thus at a great disadvantage; ironically, these groups are among those that have been hardest hit by the HIV epidemic.

There is little information on the health care characteristics of Caribbean immigrants, especially in regard to HIV care. While research is beginning to target HIV-related issues among blacks, few studies have been conducted examining these issues specifically for Caribbean-born US residents. Below we present health care access and substance use data from 2 sources: the 2007 National Health Interview Survey (NHIS) and the Haitian SMILE Study.

NHIS

As shown in Table 2 , US-born and Caribbean-born residents were equally divided between male and female. The immigrants were, however, on average younger than the US natives and less educated, had lower earnings, and were confronting greater health care access challenges. Six and half percent of immigrants have never seen a health care professional in their lifetime, compared to 1.3% of natives. Compared to the natives, proportionally more than 3 times as many immigrants were without any type of health care coverage (44% vs 13%), and only 67% had a usual place of care compared to 86% of natives. Immigrants were less likely to use substance. Only 6.5% of immigrants reported being a smoker compared to 16% of natives. Forty-five percent of immigrants reported they ever had 12 drinks in any 1 year, compared to 62% of natives.

Table 2.

Access to Care and Substance Use by US-Born Residents and US Immigrants from Mexico, Central America, and the Caribbean (Source: 2007 National Health Interview Survey)

Variable	US Born N = 18 815	Immigrants^a N = 2528
	%/Mean ± SD	%/Mean ± SD
Age	48.3 ± 18.2	42.1 ± 15.6
Male	43.9	45.8
Female	56.1	54.2
<High school	14.0	55.4
High school+	29.7	22.9
College+	56.3	21.7
White	79.1	85.3
Black	18.0	10.4
Other	2.8	4.3
<$10,000	14.6	17.4
$10 000-24 999	24.6	45.3
25 000-54 000	38.8	30.6
55,000+	22.0	6.7
No insurance	13.2	44.3
Have usual place of care	86.1	67.2
Have never seen a health care professional	1.3	6.5
Ever had 12 drinks in a year	62.4	44.6
Everyday smoker	16.2	6.5

^a Born in Mexico, Central America, or the Caribbean.

Haitian SMILE Study

The study sample was divided equally between male and female (Table 3 ). Approximately 75% of the participants did not graduate from high school, reported an annual income of $5000 or less, and were older than 44 years of age. Seventy-nine percent of the participants had completed four or more visits with a medical provider in the past year, and 31% had received care at the emergency room. Ninety-one percent had a case manager. The participants reported very low substance use—only 2% of participants reported past 4 weeks alcohol use; 12% reported past 4 weeks smoking; and none reported marijuana or hard drug use (data not shown).

Table 3.

Access to Care and Substance Use by HIV-Positive Immigrants in Miami, Florida (n = 96; Source: Haitian SMILE Study)

Variable	%
26- to 44-year-old	24.0
45- to 54-year-old	44.8
55+ year old	31.2
Male	50.0
Female	50.0
No formal education	24.0
Elementary education	47.9
Secondary education	28.1
Earned $5000 or less in past year	78.1
$5001-10 000	13.5
$10 001+	8.3
Received care in ER in past year	31.2
Had 4+ primary care visits in previous year	79.0
Had a case manager	91.1
Admitted to hospital in past year	28.1
Had no drinks in past 4 weeks	97.9
Had smoked cigarettes in past 4 weeks	12.1

Discussion

This article describes the circumstances that place an important and distinct group of immigrants at high risk for substance abuse and HIV. Originating from countries with low rates of substance abuse, an increasing proportion of these immigrants will adopt a lifestyle of drug use related to their relative youthfulness, the rigor of the acculturation and adaptation process, cultural and social isolation, and socioeconomic challenges. For many, their acculturation trajectory entails adapting from a traditional culture, which emphasizes parental and community control over adolescent behavior, to the more modern American culture, which places fewer restraints and offers less opportunity for external control.

Interventions that incorporate a family approach with activities designed to reconnect family bonds that have been disrupted by the acculturation process can enable immigrant parents to maintain their cultural traditions and monitor their children’s peer group membership, and possibly prevent or reduce delinquent and unhealthy behavior.

The Caribbean immigrant community exhibits among the highest rates of HIV in the country. This likely is related to findings showing that these immigrants originate from countries with the highest rates of HIV infection and AIDS outside of sub-Saharan Africa. This pattern is maintained by sexual mixing, concurrency, and disease transmission exacerbated by bi-directional travel between the United States and the Caribbean countries of origin. Substance use has not been a primary factor contributing to the HIV epidemic among most Caribbean communities both in the islands and in the United States. However, once in the United States., Caribbean immigrants face additional HIV transmission risks and complications because of barriers to adequate health care, combined with cultural isolation, insecure living situations, immigration concerns, cultural beliefs and misconceptions, and distrust of government services. Access to effective HIV treatment allows seropositive clients to potentially extend their life through aggressive treatment with increasingly more powerful drugs.^25,26 Because antiretroviral (ARV) regimes that lower HIV viral load also reduce infectiousness of HIV transmission to others,^27–29 timely access to medical care would likely slow HIV transmission in these communities, while reducing risk for HIV-related illness and death. Individuals who present at an advanced stage of immunosuppression are at high risk of clinical events and death as well as being more likely to experience a poorer response when they do start ARV therapy.³⁰ Preventive efforts among Caribbean HIV-positive populations would most beneficially focus on promoting the timely use of health services and dispelling myths and stigma about HIV infection and medical care. There is also a need to encourage regular HIV testing among Caribbean immigrants who are subject to higher than normal risk of HIV transmission than the general US population.

Conclusion

Given that data on Caribbean US residents has often been combined with that for other blacks and Hispanics, the information presented here offers unique insights into the HIV and substance abuse profile and risk of US-based Caribbean populations.³ Detailing the immigration experiences of US Caribbean residents can contribute to understanding the mental health implications of racial/ethnic identity and acculturation strategies.³¹ A window of opportunity may exist particularly for adolescents after they first immigrate to the United States, when health promotion and primary prevention programs might be successfully implemented and integrated into schools to delay or prevent high-risk behaviors from occurring during the process of acculturation.³² The high rates of HIV infection and AIDS among these populations call for an urgent and comprehensive program of early detection of HIV infection, timely linkage to care, and targeted education among persons living with HIV as well as the general Caribbean immigrant populations.

Footnotes

The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

The author(s) received no financial support for the research and/or authorship of this article.

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Substance Abuse,Acculturation,and HIV Risk among Caribbean-Born Immigrants in the United States