HIV/STI risks in Latino day laborers in central Texas: a mixed-method study

Abstract

Background: Latinos in the USA have been disproportionally affected by HIV and sexually transmitted infection (STI) epidemics and the prevalence of heterosexual transmission of HIV among this population is increasing. Latino day laborers (workers who seek jobs at day labor sites) are especially vulnerable to these risks due to their immigration status, poverty, and social isolation. While day laborers remain marginalized and vulnerable, studies on their HIV-related risks are limited. Methods: A total of 40 male day laborers were recruited from a day labor site in a semi-rural area in central Texas. Semi-structured interviews were conducted in Spanish by male interviewers and subsequently transcribed and translated. Results: Most day laborers were from Mexico, and ranged in age from 21 to 51 (mean = 43, SD = 11.5); about three-quarters of them were undocumented. More than 80% of the men were married, 65.8% of men were married but their wives were in their country of origin. Many participants had short-term or multiple sexual partners; some patronized commercial sex services, but condom use rate was low. While the great majority of participants knew that HIV was transmitted through sexual contact, participants perceived themselves at low risk of HIV infection. Conclusion: Poverty, limited education, isolation, high mobility, and limited access to healthcare were the main structural factors that put these day laborers at high risk of HIV/STI transmission. Culturally appropriate interventions targeting vulnerable populations, such as day laborers, are urgently needed.

Keywords:

• Latino
• day laborers
• immigrants
• sexual risks
• HIV/STI

Introduction

The incidence of new HIV infections in the USA has been stable in recent years, thanks to prevention and treatment efforts; however, some groups are affected more than others (Skarbinski et al., 2015). Latinos represent about 16% of the total US population, but account for 21% of new HIV infections. In 2010, the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new infections for Latino females was 4.2 times that for white females (CDC, 2014).

Public health literature has documented a link between HIV risks and migration (Herdt, 1997; Organista, Carrillo, & Ayala, 2004; Sanchez et al., 2004; Wong, Tambis, Hernandez, Chaw, & Klausner, 2003). In 2012, an estimated 11.2 million unauthorized immigrants lived in the USA, about 87% of them were Latinos (Center for Migration Studies, 2013). Unauthorized immigrants make up 5.1% of the US labor force and have become an indispensable part of the economy (Passel & Cohn, 2014). Immigrants, especially unauthorized Latinos, face physical, social and cultural isolation, poor working and living conditions, constant mobility, low literacy, and limited access to health services. These circumstances place them at a heightened risk of HIV infection and transmission. Moreover, their “illegal” and marginalized status has kept them from most public health service, and outreach prevention (Leclere & Porez, 2012; Organista & Ehrlich, 2008; Valenzuela, 2003; Valenzuela, 2006). With this in mind, Organista's (2007) structural–environmental model informs our work on the HIV and sexually transmitted infection (STI) health risks of undocumented Latino day laborers. This theoretical model uses a “context of risk” perspective when analyzing the impact of super-structural, structural–environmental, and individual factors associated with the transmission of HIV among undocumented Latino immigrants (p. 96).

Within the vulnerable Latino immigrant population, Latino day laborers are often described as the most vulnerable and exploited Latino workers in the USA (Valenzuela, 2003). Studies of this population are limited due to the hard-to-reach nature of the population. Existing studies related to day laborers’ HIV and STI health risks often are focused on migrant farm workers or conducted in large metropolitan areas (Apostolopoulos et al., 2006; Wong et al., 2003). There is a lack of data from non-farming day laborers working in semi-rural areas. Accordingly, this pilot study aims to examine the HIV/STI risks of day laborers in a semi-rural town in central Texas, exploring the environmental and structural factors of their HIV/STI risks.

Methods

Study site

The current study was conducted in a semi-rural area in central Texas. Designated as an “urbanized area” by the U.S. Census Bureau, local residents considered it semi-rural since it is the commercial center for outlying smaller communities and ranches. The population has more than doubled since 1980, reaching over 170,000 in 2010. The Latino population, an important portion of which is foreign-born, has tripled since 1980, increasing from 10.3% to 36.2% of the population (Town Charts Think Tank, 2013; U.S. Census Bureau, 2013). According to a new searchable database based on augmented Public Use Microdata Areas data, the Center for Migration Studies estimates the unauthorized population in this Texas County to be 19%. Nearly 85% of that unauthorized population is from Latin America (Center for Migration Studies, 2013).

Interview guide

The semi-structured interview guide used was based on a previous questionnaire on immigration history and working conditions of day laborers in post-Katrina New Orleans (Fussell, 2011), insights from prior fieldwork and ethnographic observations, and literature reviews on HIV risks among Latino immigrant workers. The instrument was pre-tested prior to field use.

Data collection

Data collection took place in a four-block area surrounding a highway intersection, located in one of the oldest Latino neighborhoods, known as the day labor corners. Groups of 3–5 men gathered on these corners daily from 6 am to early afternoon, waiting for potential employers to drive up, with approximately 20–25 men on weekdays and 10–15 on the weekends. The recruitment or participation criteria were Latino day laborers over age 18 and were present at the street corners for work.

Given the sensitive nature of questions on immigrant status and sexual practices, a trained team of male graduate students conducted the interviews. In order to access a diverse sample of day laborers, researchers recruited participants on the day labor corners throughout the week in 2012 and 2014. During those visits, researchers explained the purpose of the study and invited day laborers to participate in the research. About half of those asked agreed to participate. Interviews were conducted in Spanish and took between 35 and 90 minutes. After the interview, the participant was given information on HIV/STI prevention, local medical resources, and a $25 gift card. No names or identifying information was collected to assure confidentiality and anonymity. The study protocol was approved by the Texas A&M University Institutional Review Board. All data were entered into SPSS and MS-Word for analysis.

Data analysis

Interviews resulted in both qualitative and quantitative data. Quantitative data were analyzed in SPSS 22.0, with frequency analysis performed. Due to the small sample size, we did not run comparison analysis. All qualitative data were retrieved from SPSS to Word for further analysis. Preliminary coding started with the reading and re-reading of transcripts by the research team members. Coding themes were developed from the interview guide. In the second stage of data analysis, each participant's information and data were transformed into individual profiles (Miles, Huberman, & Saldaña, 2013). This data reduction allowed us to focus on HIV/STI risks and social environment. All co-authors independently read all transcripts and profiles to identify the relationships between social environment and HIV risks. Detailed summaries were prepared to facilitate discussion and elaboration. The findings presented in this paper reflect the range of participant responses with some indication of more consistent responses.

Results

Demographic profile

As shown in Table 1, participants ranged in age from 21 to 51 with a mean age of 40. About half of them had primary education or less and the rest had more than 6 years of education. A majority of day laborers (37 out of 40) were from Mexico, while the rest were from Central America. Three-quarters of them (30 out 40) were unauthorized immigrants. Of all the participants, eight did not speak English at all, most could speak some English, but none was fluent. Over 80% were married and 92% of day laborers had children; however, the great majority of their families (65.8%) lived in the country of origin. More than 85% of participants remitted money regularly to support their families.

Table 1. Socio-demographic characteristics of Latino day laborers by HIV risk groups.

Characteristics	Total (N)	No risk	At risk	p-value
Age (Mean, SD)	40	32.25 (14.3)	45.25 (9.9)	.026*
Education (N, %)
Primary education or less	19	2 (10.5%)	17 (89.5%)	.239
More than primary education	20	5 (25%)	15 (75%)
Country of origin (N, %)
Mexico	37	8 (21.6%)	29 (78.4%)	.368
Other countries^a	3	0	3 (100%)
Living arrangement
Not living with partners	7	3 (42.9%)	4 (57.1%)	.096*
Living with partners	33	5 (15.2%)	28 (84.8%)
Immigrant status in the USA
Documented	10	2 (20%)	8 (80%)	1
Undocumented	30	6 (20%)	24 (80%)
English-speaking
None	8	0	8 (100%)	0.138
Some English	31	7 (22.6%)	24 (77.4%)
Frequency of traveling to the USA for work
Low (1–2 moves)	14	4 (28.6%)	10 (71.4%)	.064*
Medium (3–10 moves)	19	1 (5.3%)	18 (94.7%)
High (11 or more)	7	3 (42.9%)	4 (57.1%)
Period of in the USA
60 months and under	19	6 (35.3%)	11 (64.7%)	0.176
61–120 months	10	1 (10%)	9 (90%)
121 months or more	10	1 (10%)	9 (90%)

Note: ^aGuatemala and Honduras.

*p < .1

Living and working conditions

Before coming to the USA, participants worked in agriculture, manufacturing, construction, or owned small businesses in their home countries. 58% used the day labor corners as their primary job source. The remainder worked for landscaping companies and movers, and sought work at the corners as supplementary income. The payment they received ranged from 0 to $200, with a median of $72. During their time in the area, 55% shared a house with other workers, 22.5% lived in an apartment, and 22.5% lived in trailers or mobile homes. When asked about their food needs, 35% reported they sometimes or often did not have enough food to eat. Food preferences were also an issue, with 35% reporting they had enough food, but not the kind of food they wanted.

Migration and mobility

Day laborers’ stay in the USA varied from a few months to more than 20 years; most of them made frequent trips between the USA and their home country. More than two-thirds of participants worked in other cities prior to arriving in the area with the rest making the small Texas City their first stop in the USA upon migration. Almost 60% migrated to the city because they had relatives in the area, with about 30% following the news of job opportunities. Some participants had lived in the USA for 37 years, while others arrived a couple of years ago. Those who had been in the USA long enough had worked in other states or cities before coming to this town and made frequent trips between the USA and Mexico. Some had been able to “fix their papers” and return to Mexico regularly, especially during holidays. More than one-third of the participants indicated that they would return home in a few years because their families were still in their home countries; some have family with them in the USA and plan to stay; and some were undecided and would continue to travel between the USA and their country of origin as long as work was available.

Social and sexual relationships

The majority of day laborers’ families lived in their country of origin and most participants lived with fellow immigrants. Day laborers socialized in the local community through sports and religious services. A third of the day laborers played or had played a sport in town and two-thirds attended a religious service. All but three of those religiously actively participated in a large working class Catholic parish, home to over 2000 immigrant families, which was located just blocks from the day labor corners.

Less than a quarter of migrants lived with their family. About 23% of participants defined their current relationship as one with a long-term female sexual partner, while another 21% described it as a short-term yet stable sexual relationship. Seven participants reported having several casual sex partners; and they only used condoms with their casual partners but did not do so with their stable partners or wives.

Use of commercial sex and other HIV risks

About 42.5% reported having used commercial sex at some point with 25% having done so during their time in this semi-rural area. Day laborers reported that female sex workers were commonly seen at the day labor corners, living quarters, and bars. When asked where one would go to find a female sex worker, one participant responded, “They come themselves. [They come] to the highway [corner] or to the store. There is no need to search for them; they find you.” Several mentioned that sex workers “go and knock on your door”. Use of commercial sex was acceptable among them because “we are alone and need to find someone … ” The most common reason given for the use of female sex workers was loneliness, with the second being responding to “needs and desires”. Those who purchased commercial sex reported using condoms with female sex workers, with about 42.5% not using condoms consistently. Three participants reported having had a STI before and two had STI while in town.

Day laborers in stable relationships used female sex workers at lower rates than those who did not describe themselves as partnered. Among those who described themselves as not being in a stable relationship, 42.5% used female sex workers. Among those with stable relationship, about 33% ever used commercial sex and only 22% had done so in the current area. Among those participants who self-reported using commercial sex, 52.5% reported inconsistent condom use with their current stable partner. These men often did not use condoms with female sex workers; as some men commented, “they [sex workers] would charge a little extra (for not using condoms)”. Other times, sex workers did not even require the use of condoms.

Alcohol and drug abuse increase the risk of HIV and STIs. Socializing among day laborers included alcohol. 70% of participants reported drinking alcohol at least once a week, with 40% drinking one to three times weekly. About 17.5% abused alcohol, drinking more than eight times a week. None reported drug abuse.

Access to healthcare and preventive services

About one-third of the participants had a health checkup while in the area. These people did so because several clinics offered outreach services. Another received a checkup when he was in jail. Most participants (42%) did not receive regular medical checkups, mainly because they did not have any insurance and it was too expensive to visit a clinic. Some did not know where to go or believed it was illegal to use local health services. Six participants waited until they returned to Mexico to obtain medical care.

Knowledge of HIV transmission and perceived risks

When we asked participants to offer their knowledge about how HIV is transmitted, the majority of participants (92%) understood that HIV could be spread through sexual contact. Still, some participants had misperceptions about how HIV was transmitted. For example, one person believed HIV could only be transmitted between men, another thought that HIV was transmitted by “dirty” or “contaminated” women, and others were under the impression that the virus could be transmitted through saliva. Furthermore, when asked if HIV was a problem in the local Latino community, most participants reported a general concern. One worker summarized the concern by explaining, “the majority of Latinos don't take precautions, sometimes they need an outlet and suffer the consequences”. Though the majority of participants said that HIV was a problem in the community, participants in this study reported a low perceived personal risk of HIV transmission.

Summary of HIV risks

Public health scientists advocate for using HIV risk indices for better reporting and understanding the degree of risks of the target population (Fisher & Fisher, 1992; Susser, Desvarieux, & Wittkowski, 1998). We created an HIV risk index based on our interviews with the study participants. Higher numbers of HIV risk behaviors denote higher risk for HIV infection.

Table 2 summarizes HIV risks among participants. The most typical risk was inconsistent condom use with partners (52.5%), followed by use of commercial sex (42.5%). Among the 17 participants who used commercial sex services, 7 (41.2%) did not use condoms consistently. Approximately 17.5% of the participants abused alcohol, 17.5% had multiple sexual partners, and 12.5% had poor or no knowledge of HIV transmission. In total, only 20% of participants had no HIV risk, 30% had one risk, and 50% had more than two risks.

Table 2. HIV risks among Latino day laborers (n = 40).

HIV risk factor	N	Percentage
Poor or no knowledge of HIV transmission	5	12.5
Alcohol abuse	7	17.5
Use commercial sex services	17	42.5
Do not use condoms consistently with FSWs	7	41.2^a
Ever had STI infection	3	7.5
Having multiple sexual partners	7	17.5
Inconsistent use of condom with partner	21	52.5
HIV risks level
No risk (0 risk factor)	8	20
Low risk (1 risk factor)	12	30
High risk (≥2 risk factors)	20	50

Note: ^aBased on 15-day labor workers who agree to ever using FSW (female sex workers).

Discussion

Our data suggested that day laborers lived in poverty; 35% struggled with feeding themselves or having stable living places. They also faced isolation and separation from their families. Many coped by having casual sexual partners or using commercial sex services. They possessed a number of HIV risk behaviors, but perceived themselves to be at low or no risk of HIV infection. Their insecure immigrant standing, poverty, social isolation, and language barriers have kept them from most preventive services or other healthcare services. While these factors indicate that these day laborers were vulnerable to HIV/STI infection, culturally appropriate interventions for this population were scarce.

Recent reports on the HIV/AIDS epidemic in the USA suggest that rates of HIV infection among young Latinos are increasing while the overall HIV epidemic has been leveling off (CDC, 2014). Decades of prevention efforts have helped keep the rate of new HIV infections stable, but some hard-to-reach groups, such as Latino day laborers, have not been effectively targeted. Further, among the 1.2 million estimated HIV infection cases, one in seven are not aware that they are infected. Most of the Latino day laborers in our study have never been tested and therefore if they are infected, it is unlikely that they are aware of their HIV/STI status. Consequently, as Organista has argued, an SE model would allow researchers to examine the wide range of interacting factors – macro-structural to individual – impacting day laborers’ risks for HIV/STI transmission and inform the creation of appropriate preventative heath interventions (Organista, 2007).

Our pilot study was limited by a small sample size and convenience sampling; it was also subject to self-report bias. Although this study is one of the first studies on Latino day laborers in a semi-rural area, our findings corroborate previous studies on Latino immigrants in large metropolitan areas. The high rates of HIV-related risks underscore the urgent need for public health interventions. Day laborers’ poor working and living conditions, social isolation, low literacy and limited access to health services suggest the need for culturally appropriate structural interventions that go beyond individuals to provide basic health care and preventive services to this population. We also call for more resources for HIV/STI prevention for Latino immigrants in semi-rural areas.

Disclosure statement

No potential conflict of interest was reported by the authors.