HIV Infection Among Persons Born Outside the United States

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IMMIGRATION OF PERSONS TO THE UNITED STATES FROM different parts of the world brings health challenges, including infectious diseases such as tuberculosis, hepatitis B, and Chagas disease. In 2011, the incidence of tuberculosis (new infection or reactivation of latent infection) among persons born outside the United States was 12 times greater than among persons born in the United States. The prevalence of hepatitis B infection is at least 10 times higher among those born outside but living in the United States than among those born in the United States. An estimated 300 000 persons born in Latin America and living in the United States are infected with Trypanosoma cruzi, the causative parasite of Chagas disease, with less than 10 cases of new infection occurring in the United States since 1955. In this issue of JAMA, Prosser and colleagues provide data on human immunodeficiency virus (HIV) infection among persons living in but born outside of the United States. Using data from 46 states and 5 US territories reported through the HIV Surveillance System from 2007 through 2010, the authors identified 191 697 persons who were diagnosed with HIV and for whom a country or continent of birth was reported. The authors report that of these persons diagnosed with HIV infection, 30 995 (16.2%) infections occurred among those born outside the United States, and the countries of birth origin with the highest number of persons diagnosed with HIV were Mexico, Haiti, Cuba, and El Salvador. Moreover, the 4 states with the highest proportion of persons born outside the United States and diagnosed with HIV (California, Florida, New York, and Texas) were also the 4 states with the highest numbers of HIV cases reported overall. These findings demonstrate that the epidemiology of HIV among those born outside the United States is different and more complicated than is the case for other infectious diseases, such as tuberculosis, hepatitis B, or Chagas disease. For these infections, the substantially higher prevalence of infection among those born outside the United States is primarily due to high prevalence of these infections in the immigrants’ countries of origin; however, with the exception of Africa, this is not necessarily so with HIV. For example, Prosser et al report that the largest proportion of HIV diagnoses among those born outside the United States was among those from Central America (including Mexico; 41.0%) where HIV is not highly prevalent. The estimated adult HIV prevalence in Mexico is half (0.3) that of the United States (0.6). Although selective migration of HIV-infected persons from these other countries to the United States cannot be excluded, it is likely that the majority of those who immigrated from Mexico and other areas of the world where HIV infection is uncommon among adults, such as South and Southeast Asia (0.3) and east Asia (0.1%), acquired their infections in the United States. In contrast, it is likely that a higher proportion of HIV infections among those of Caribbean descent, for whom the adult prevalence of infection is 1.0%, may have occurred in the country of birth. The prevalence of HIV among those born outside the United States also may be more likely to reflect poverty than country of origin. The US National HIV Surveillance System does not capture good data on income. However, a study of heterosexuals living in poverty areas in 23 US cities found that the seroprevalence rate was more than 20 times higher among those living in impoverished areas than the prevalence rate among heterosexuals in the United States overall. It is possible that if Prosser et al would have adjusted their data for socioeconomic status, they might have found a smaller percentage of HIV infections among those born outside than among those born within the United States. Even though HIV poses no risk of casual transmission, the United States has had a very restrictive policy toward entry of persons with HIV. In 1987, the United States prohibited entry of HIV-infected travelers or legal residents. In 1991, the ban was lifted for travelers but remained in place until 2010 for those wishing to reside in the United States. During this time, the United States did not ban persons with