On July 25 2019, Chief of Customs and Border Patrol Brian Hastings testified to the House Judiciary Committee that HIV can be used as grounds for family separation among migrants and asylum seekers at the southern US border. This shocking claim seemed to capture the attention of only a limited cache of HIV providers, policy experts, and patient advocacy organizations. HIV status should never be used to guide immigration policy. No physician was present at the Committee hearing to respond to this assertion with established facts: HIV is not transmitted by casual contact. People with HIV pose no risk to their family or community.
Why was this testimony given? Last year, a federal court order attempted to halt all family separations as part of immigration enforcement. However, more than 900 families have still been separated since that order, according to Justice Department reports. When asked why this practice continues, Hastings noted that migrant children can be separated from parents who are deemed “unfit” or dangerous to their child. Hastings stated that he believed parents living with HIV meet these criteria because HIV “is a communicable disease.” His testimony is one of many recent instances where policies implemented by Department of Homeland Security emerge in direct contradiction to those of the Department of Health and Human Services (HHS).
HHS provides specific guidance regarding safe conception practices precisely to support people with HIV having children. Federal agencies, including the National Institutes of Health and the Centers for Disease Control and Prevention (CDC), state that people living with HIV who maintain suppressed viral loads on antiretroviral therapy cannot transmit the infection to others, even through sexual contact. Indeed, the Undetectable = Untransmittable public health campaign is based explicitly on this principle and provides the foundation for the Trump administration’s End the HIV Epidemic initiatives. The key strategies in this framework are to diagnose all persons living with HIV and quickly initiate treatment to suppress the virus.
Migrants And Asylum Seekers Living With HIV
Over the past five years, US immigration policy has undergone a seismic shift, and people living with HIV have not fared well under these changes. Credible reports have documented recent family separations on the basis of a parent having HIV. In November 2018, a father was denied custody of his three daughters, ages 11–14 years old, because of his HIV status. He was ultimately deported to Central America, while his daughters were confined in separate detention centers, according to lawyers familiar with his case.
Estimated HIV prevalence among asylum seekers in the US who undergo screening can be as high as 13 percent, according to a Washington, DC-based study. People who enter the US seeking asylum face growing challenges, even though HIV is frequently a credible component of asylum claims due to widespread stigma in several countries. Discrimination against people living with HIV is detailed in many of the State Department’s annual Country Reports on Human Rights Practices. A vast backlog in asylum cases awaiting judicial review means this population is spending more time living in uncertainty about their futures and safety, which imperils their longitudinal care and consistent access to antiretroviral therapy. Asylum cases are being denied at record high rates, and concerns have risen that the process is becoming more arbitrary. This was highlighted by a case of one mother living with HIV who arrived in the US with several of her children last year to claim asylum. The mother was separated from one of her daughters, and they each underwent individual credible fear interviews (the initial screening evaluation for asylum cases). The mother “passed” the screening evaluation while her separated daughter, who also is living with HIV, was denied asylum and deported to the very city they were escaping.
Prolonged detention has also introduced new risks for migrants at the southern border, particularly for those living with HIV. For people with HIV, detention can prompt interruptions in antiretroviral treatment, which put them at risk of disease progression and acute illness. Immigration and Customs Enforcement (ICE) facilities have been characterized by overcrowded and unhygienic conditions, according to reports from the Office of Inspector General for the Department of Homeland Security. Onsite inspections of detention facilities have specifically noted the presence of expired food in kitchens and mold permeating bathroom facilities.
Cohabitation in close quarters and frequent transfers of detainees between facilities combine to facilitate rapid propagation of infections. The CDC reports more than 900 cases of mumps in detention facilities across several states over the past year. Outbreaks of influenza resulted in the deaths of three children last year, yet immigration officials have reported that there are no plans to vaccinate detainees ahead of the upcoming influenza season. Such infections pose grave risks to immunocompromised hosts, especially those with HIV, who are more likely to progress to severe disease. Several individuals have died while in ICE custody, including two young, transgender women living with HIV.
Legal Immigrants Living With HIV
For immigrants who are in the US with legal documentation, the current immigration climate is also hazardous.The Department of Homeland Security recently announced the implementation of a “public charge” rule, which could prevent immigrants from obtaining permanent residency status if they received some forms of public assistance, including Medicaid. Experts believe this would disincentivize migrants from seeking preventive and even acute care services. This policy has the potential to delay HIV screening for foreign-born people who are unaware of their diagnosis. A public charge rule would also harm immigrants who know their HIV status but rely on social welfare programs to access antiretroviral therapy and maintain virologic suppression. Public health efforts for HIV elimination in the US already face many obstacles. The long-term clinical and public health effects of people disengaging from care will likely offset any potential savings derived from the misguided “public charge” rule.
Immigration Restrictions And HIV: Historical Precedents
Current immigration restrictions have recent precedents. From 1987 to 2010, the US maintained the so-called HIV Travel Ban, a policy that restricted immigration to the US among people living with HIV even though it was known then, as it is known now, that HIV is not transmissible by casual contact. Despite decades of expert opinion to the contrary, these misconceptions have now been revived in Chief Hastings’s testimony that HIV is “a communicable disease” that justifies family separation. One of the justifications for the HIV Travel Ban was also the public charge argument—specifically, that the costs imposed by immigrants living with HIV would be prohibitive. For decades, this argument was selectively applied to HIV: Immigrants with other chronic diseases were never systematically excluded from entry to the US. Indeed, the public charge argument perpetuated HIV-related stigma and contributed to delayed diagnoses and poor engagement in care for people with HIV. Repurposing this argument in today’s immigration climate will inhibit migrants from accessing clinical care, which could impede important public health efforts.
Correcting The Contradictions
While many migrants have been affected by the immigration policies outlined above, people living with HIV are especially vulnerable to the policies’ downstream health consequences. The latest example is the use of HIV as grounds for family separation—a practice that has no justifiable basis in medical science or in public health policy. HIV should not be used as pretext for a broader agenda of curtailing immigration. Such practices turn the clock back on decades of public health messaging against HIV-related stigma, run antithetical to federal health agencies’ own policies, and undermine the federal End the HIV Epidemic initiative. The contradictions between immigration and health policy can be promptly corrected. The Departments of Homeland Security and Health and Human Services should immediately end this inaccurate interpretation of HIV as a “communicable disease” meriting family separation and double efforts to stop family separation, prolonged detention, and discriminatory immigration practices for migrants and asylum seekers with HIV.