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. 2012 Nov;102(11):2129–2134. doi: 10.2105/AJPH.2012.300672

HIV/AIDS Surveillance Data for New York City West Indian–Born Blacks: Comparisons With Other Immigrant and US-Born Groups

Susie Hoffman 1,✉, Yusuf Ransome 1, Jessica Adams-Skinner 1, Cheng-Shiun Leu 1, Arpi Terzian 1
PMCID: PMC3477934  NIHMSID: NIHMS433076  PMID: 22994194

Abstract

Objectives. Although the risk of HIV among New York City West Indian–born Black immigrants often is assumed to be high, population-based data are lacking, a gap we aimed to address.

Methods. Using 2006–2007 HIV/AIDS surveillance data from the New York City Department of Health and Mental Hygiene and population data from the US Census American Community Survey 2007, we compared the rate of newly reported HIV diagnoses, prevalence of people living with HIV/AIDS, and distribution of transmission risk categories in West Indian–born Blacks, 2 other immigrant groups, and US-born Blacks and Whites.

Results. The age-adjusted rate of newly reported HIV diagnoses for West Indian–born Blacks was 43.19 per 100 000 (95% confidence interval [CI] = 38.92, 49.10). This was higher than the rate among US-born Whites (19.96; 95% CI = 18.63, 21.37) and Dominican immigrants and lower than that among US-born Blacks (109.48; 95% CI = 105.02, 114.10) and Haitian immigrants. Heterosexual transmission was the largest risk category in West Indian–born Blacks, accounting for 41% of new diagnoses.

Conclusions. Although much lower than in US-born Blacks, the rate of newly reported HIV diagnoses in West Indian–born Blacks exceeds that among US-born Whites. Additional work is needed to understand the migration-related sources of risk.

Immigrants from English-speaking Caribbean basin countries, often referred to as the West Indians, have been migrating to the United States for many decades, and they and their descendants constitute a large and culturally significant population in major Eastern seaboard cities, including New York City (NYC). The majority (81%) identify as Black, with a significant minority identifying as East Indian.1 Considering only those who are first-generation immigrants, the latest estimates (2007–2008) show that West Indians represent 21% of foreign-born persons in NYC and almost 25% of the NYC Black population.2 Despite the size of this immigrant group, in HIV/AIDS surveillance reports they have not been disaggregated from all Blacks nor from the Caribbean-born population overall, although some data suggest their HIV risk may be high.3

CHARACTERIZING IMMIGRANTS FROM THE CARIBBEAN REGION

The Caribbean region is culturally diverse, having been conquered in the late 16th and early 17th centuries by various western European colonial powers that subjugated the native populations and imported African slaves.4,5 The language and traditions of each conquering European nation—the Spanish, French, Dutch, and British—exerted a powerful influence on social and cultural formation in the respective nations that emerged in the postcolonial era.

The 18 Caribbean nations that comprise the English-speaking Caribbean, also referred to as the West Indies—including Jamaica, Trinidad and Tobago, Barbados, Grenada, and many smaller nations—were occupied for the longest period by the British. Besides the island nations, Belize (in central America) and Guyana (in South America) typically are included in the West Indian grouping, as those nations are related politically, economically, and culturally to other West Indian nations (data available as a supplement to the online version of this article at http://www.ajph.org).5–8 Today, West Indian nations are predominantly English speaking and comprise a multiethnic population (including East Indians, whose ancestors were brought to the region as indentured servants after the abolition of slavery in the British empire in 1833 and who constitute a sizeable population in Guyana and Trinidad and Tobago9). However, the majority of the West Indian population is Black, both in their countries of origin and in the United States.9,10

WEST INDIAN–BORN BLACKS IN THE UNITED STATES

Although they originate from different nations, West Indian–born Blacks share not only a common colonial history and language but also similar migration processes, including circumstances in their countries of origin, reasons for migrating, and challenges in their new homes. Black West Indian immigrants from various nations frequently inhabit the same neighborhoods, intermix socially, and engage in commonly developed cultural traditions such as the West Indian Day Parade.10,11 They may identify as Trinidadian or Jamaican (or with another country of origin), yet they also have formed elements of a common culture12 that is distinct from the culture of West Indian immigrants of East Indian descent as well as from the cultures of other Caribbean immigrants, such as those from the Dominican Republic and Haiti.10,13

The acculturation experience of West Indian–born Blacks differs from that of other immigrant groups in several respects. As native English speakers, they are already familiar with US popular culture and arrive with an advantage over non–English-speaking immigrants. The history of West Indian–Black upward mobility and high rate of home ownership has been widely celebrated,14 and their apparent success in terms of educational and economic advancement has been contrasted with the difficulty faced by some segments of the US-born Black population to move out of poverty.15 Yet the degree of Black West Indian upward mobility remains highly contested.16 And, despite the apparent success of these immigrants, their “Blackness” renders them subject to racial discrimination and stigmatization.10,11,17 Indeed, some evidence suggests that economic advancement among second-generation Black immigrants lags behind that among second-generation non-Black immigrants.18

To inform prevention policies and interventions, we need to explore how these and other features of the Black West Indian immigration experience shape immigrants’ risk behaviors and exposures to HIV. Disaggregating surveillance statistics for West Indian–born Blacks is a first step toward understanding the burden of disease and sources of risk in this community, developing targeted interventions, and advancing theory on migration, acculturation, and sexual health.

CHALLENGES IN ASSESSING THE RISK AND BURDEN OF HIV

HIV incidence and prevalence among West Indian–born Blacks, as well as among other Caribbean immigrant groups, often is assumed to be high for numerous reasons. Research from diverse global settings demonstrates that population movements associated with migration often increase the risk of HIV transmission.19–23 Moreover, US Blacks and Latinos have been disproportionately affected by HIV since the start of the epidemic24 and the Caribbean region overall has the highest HIV prevalence outside Africa,25 with reported prevalence of 1.60% in Jamaica, 1.50% in Trinidad and Tobago, 1.90% in Haiti, and 0.09% in the Dominican Republic.26

By contrast, the “healthy-migrant” effect—the finding that immigrants fare better than do their US-born counterparts across a range of health behaviors and outcomes—renders plausible an expectation that rates of HIV are lower among immigrant than native-born groups.27 Compared with native-born residents, foreign-born residents overall have a lower rate of newly reported HIV diagnoses,3 a pattern that has also been demonstrated for Black men.28

Published HIV/AIDS surveillance statistics rarely include separate analytic categories for West Indian immigrants as distinct from those of other immigrants from the Caribbean region, nor do they compare them to US-born Blacks and Whites. Routine HIV/AIDS surveillance reports follow federal guidelines that specify 5 racial categories (American Indian or Alaskan Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander; and White) and 1 ethnic category (Hispanic or Latino vs not).29 Although country of origin is included in NYC HIV/AIDS reporting forms, statistics by country of origin are not routinely reported, making it difficult to assess the burden of HIV among immigrant groups. To address this gap in knowledge of immigrant health, the New York City Department of Health and Mental Hygiene (NYC DOHMH) recently has begun to generate special reports summarizing the number of newly reported HIV diagnoses and prevalence of people living with HIV/AIDS (PLWHA) by country or region of origin. Nevertheless, as we describe below, challenges remain in determining the burden of HIV among West Indian immigrants.

A 2010 NYC DOHMH report noted that of all NYC foreign-born persons newly reported with HIV, 881 (39%) were born in the Caribbean (regardless of cultural group) and that this region accounted for the highest percentage of reports of newly diagnosed foreign-born persons.30 Although they are correct, these data can potentially lead to the unfounded conclusion that Caribbean—and, by extension, West Indian—immigrants have high rates of newly reported cases of HIV. This percentage needs to be understood in the context of the total number of Caribbean immigrants living in NYC.

In a 2006 report on immigrant health,3 rates of newly reported HIV diagnoses were given for all foreign-born New Yorkers (19/100 000) and for immigrants from some Caribbean nations (e.g., 71/100 000 in Haitian immigrants, 48/100 000 in immigrants from Trinidad and Tobago, and 21/100 000 in Guyanese immigrants). These country-specific rates demonstrate the diversity with respect to HIV infection in immigrants from the region, yet they do not account for the cultural grouping of Black West Indian immigrants.

To extend our knowledge of immigrant health, in this descriptive epidemiologic surveillance study we disaggregated NYC HIV/AIDS surveillance data and NYC census data and calculated population-based rates of newly reported HIV diagnoses and prevalence of PLWHA for West Indian–born Blacks, immigrants from Haiti and the Dominican Republic, and US-born Blacks and Whites. We also compared the distribution of transmission risk categories across these groups.

Several considerations drove our choice of comparison groups. Given that we included only West Indian immigrants who identified as Black, it was important to compare them with native-born Blacks as well as with a nonminority population, that is, native-born Whites. Comparisons with other immigrant groups were also of interest, so we chose immigrants from the Dominican Republic and Haiti, who constitute the largest NYC immigrant populations from the Spanish- and French-speaking Caribbean, respectively.

METHODS

We defined US-born persons as those who were born in the United States as well as in US dependencies such as Guam, Samoa, and Puerto Rico. In accordance with the procedures the NYC DOHMH HIV/AIDS surveillance unit used in 2007 to categorize race/ethnicity, we excluded individuals who identified as Hispanic from the categories of White and Black.29 We defined West Indians as NYC residents who were born in one of the nations in the Caribbean region where English is the predominant language and who identified as non-Hispanic Black. Thus, the 5 population groups of interest were NYC residents who are

  1. West Indian–born Black,

  2. Dominican-born,

  3. Haitian-born,

  4. US-born non-Hispanic Black, or

  5. US-born non-Hispanic Whites.

Because race/ethnicity does not define different cultures in the Dominican and Haitian immigrant groups (as it does for Black and East Indian immigrants from the West Indies), we did not made any restrictions according to race/ethnicity for these groups.

Data

Data on cases of HIV/AIDS are from the NYC DOHMH HIV/AIDS surveillance reporting system. This data collection system has been described in detail elsewhere.28 We obtained summary data by age group for the native and foreign-born groups of interest, presented in the same format as standard surveillance reports.31 Data included total persons newly diagnosed with HIV in 2006 and 2007 and number of PLWHA as of December 31, 2007, as reported to the NYC DOHMH by September 30, 2008. We obtained denominators from the American Community Survey 2007 1-year Public Use Micro Sample data, which provided the best approximation of the current population of NYC to match the HIV/AIDS surveillance data for 2007.1

We grouped age data from the Public Use Micro Sample according to age categories used in the NYC DOHMH HIV/AIDS surveillance reports and computed weighted cross-tabulations by age to generate age-specific denominators for each population group. We adjusted all calculations for the complex survey design of the American Community Survey with the weights provided in the data set using Stata 10.0 (StataCorp LP, College Station, TX).32

Calculation of Rates

We treated the entire NYC population as the standard population against which we calculated the age-adjusted measures. Because numerators represented totals for 2 years, we annualized rates of newly reported diagnoses, and therefore they represent the average rate for 2006–2007.

We entered data for the numerators, denominators, and standard population into Stata and analyzed them using a user-written command called DISTRATE, which calculates directly standardized rates and confidence intervals (CIs).33 We calculated CIs using the γ distribution method,34,35 an approach that is most appropriate for data that violate the normality assumption and for situations in which there is variability in weights across age groups (i.e., when the proportion of specific population over standardized population is highly variable across strata).

Statistical Tests of Differences Among Groups

We used the Rao-Scott test, a design-adjusted version of the Pearson χ2 test,36 to compare the age-adjusted measures for West Indian immigrants with those of the other groups. We first conducted a test among all 3 immigrant subgroups and, if we found a significant difference, we followed with 2 pairwise comparisons (West Indian vs Dominican immigrants and West Indian vs Haitian immigrants). We conducted the χ2 test to compare West Indian immigrants to US-born Whites and to compare West Indian immigrants to US-born Blacks. We assessed the P values for all tests using Bonferroni adjustments to account for multiple comparisons. We also obtained odds ratios (ORs) and 95% CIs comparing each group to West Indian immigrants (the reference category) using the SAS version 9.0 (SAS Institute, Cary, NC) SURVEY FREQUENCY command.37

To gain an understanding of risk characteristics, we conducted the χ2 test of the frequency distributions of transmission risk categories across the 5 population groups, following the same comparison strategy.

RESULTS

The age-adjusted rate of new HIV diagnoses per 100 000 population in West Indian–born Blacks was 43.19 (95% CI = 38.92, 49.10; Table 1). In immigrants from the Dominican Republic it was 28.77 (95% CI = 25.22, 32.22), and in immigrants from Haiti it was 70.46 (95% CI = 57.15, 88.72). By comparison, the age-adjusted rate for US-born Whites was 19.96 (95% CI = 18.63, 21.37), and for US-born Blacks it was 109.48 (95% CI = 105.02, 114.10).

TABLE 1—

Crude and Age-Adjusted Rates of Newly Reported HIV Diagnoses per 100 000 Population: HIV/AIDS Surveillance Data, New York City, 2006–2007

Population Group New HIV Diagnoses,a No. Population, No. Crude Rate of New HIV Diagnoses/100 000 Population Age-Adjusted Rate of New HIV Diagnoses/100 000 Population (95% CI) Pb Group Comparison, OR (95% CI)
West Indian–born Blacks 199.5 402 668 49.54 43.19 (38.92, 49.10) 1.00 (Ref)
Dominican immigrants 121.5 362 724 33.50 28.77 (25.22, 32.22) ≤ .001 0.67 (0.57, 0.78)
Haitian immigrants 77.0 100 949 76.28 70.46 (57.15, 88.72) ≤ .001 1.63 (1.31, 2.04)
US-born Whites 417.5 2 186 976 19.10 19.96 (18.63, 21.37) ≤ .001 0.47 (0.41, 0.53)
US-born Blacks 1188.0 1 301 723 91.26 109.48 (105.02, 114.10) ≤ .001 2.53 (2.27, 2.83)
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Note. CI = confidence interval; OR = odds ratio.

a

Number of new diagnoses represents the average for 2006–2007.

b

P value is derived from the Rao-Scott χ2 test comparing each group to West Indian immigrants and is the Bonferroni-adjusted value.

Relative to West Indian–born Blacks, the OR of a newly reported diagnosis among US-born Whites was 0.47 (95% CI = 0.41, 0.53) and among US-born Blacks it was 2.53 (95% CI = 2.27, 2.83). Considering the immigrant groups, the OR of a newly reported diagnosis for Dominicans was 0.67 (95% CI = 0.57, 0.78), and it was 1.63 (95% CI = 1.31, 2.04) for Haitians.

The age-adjusted prevalence of PLWHA (per 100 population) for West Indian–born Blacks was 0.53 (95% CI = 0.51, 0.56); for immigrants from the Dominican Republic it was 0.38 (95% CI = 0.36, 0.40), and for Haitian immigrants it was 1.28% (95% CI = 1.22, 1.34; Table 2). By comparison, the age-adjusted prevalence of PLWHA for US-born Whites was 0.65 (95% CI = 0.64, 0.66) and for US-born Blacks it was 2.95 (95% CI = 2.92, 2.99). The ORs comparing each group to West Indian–born Blacks are shown in Table 2.

TABLE 2—

Crude and Age-Adjusted Prevalence of People Living With HIV/AIDS per 100 Population: HIV/AIDS Surveillance Data, New York City, 2007

Population Group PLWHA, No. Population, No. Crude Prevalence of PLWHA/100 population Age-Adjusted Prevalence of PLWHA/100 Population (95% CI) Pa Group Comparison, OR (95% CI)
West Indian–born Blacks 2673 402 668 0.66 0.53 (0.51, 0.56) 1.00 (Ref)
Dominican immigrants 1728 362 724 0.48 0.38 (0.36, 0.40) ≤ .001 0.72 (0.67, 0.77)
Haitian immigrants 1775 100 949 1.76 1.28 (1.22, 1.34) ≤ .001 2.41 (2.26, 2.57)
US-born Whites 13 862 2 186 976 0.63 0.65 (0.64, 0.66) ≤ .001 1.22 (1.16, 1.27)
US-born Blacks 30 024 1 301 723 2.31 2.95 (2.92, 2.99) ≤ .001 5.68 (5.44, 5.93)
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Note. CI = confidence interval; OR = odds ratio; PLWHA = people living with HIV/AIDS. As of December 31, 2007, as reported to the New York City Department of Health and Mental Hygiene by September 30, 2008.

a

P value is derived from the Rao-Scott χ2 test comparing each group to West Indian immigrants and is the Bonferroni-adjusted value.

Among West Indian–born Blacks, 23.8% of cases were among men who have sex with men, 41.4% were heterosexually transmitted, and 33.6% were of unknown origin (Table 3). The distribution according to transmission risk group did not vary between West Indian–born Blacks and Dominican immigrants, but there were substantial differences between West Indian–born Blacks and each of the other groups.

TABLE 3—

Transmission Risk Categories for Newly Reported HIV Diagnoses: HIV/AIDS Surveillance Data, New York City, 2006–2007

Population Group Men Who Have Sex With Men, No. (%) Injection Drug Use History, No. (%) Heterosexual, No. (%) Other and Unknown,a No. (%) Pb
West Indian–born Blacks 95 (23.8) c 165 (41.4) 134 (33.6)
Dominican immigrants 59 (24.3) 7 (2.9) 101 (41.6) 76 (31.3) .8
Haitian immigrants 14 (9.1) c 61 (39.6) 78 (50.6) ≤ .001
US-born Whites 619 (73.8) 57 (6.8) 61 (7.3) 102 (12.2) ≤ .001
US-born Blacks 770 (32.4) 199 (8.4) 667 (28.1) 40 (31.1) ≤ .001
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Note. Totals are for 2006–2007.

a

Includes 13 perinatal infections among US-born Blacks.

b

Bonferroni adjusted, comparing each group to West Indian immigrants.

c

Cells representing 1–5 persons; for these, we used the median for χ2 calculations.

DISCUSSION

To our knowledge, only a few studies have estimated HIV diagnosis rates or prevalence for immigrant groups,28,38,39 and to date, rates for West Indian–born Blacks have not been disaggregated from those of other Blacks or other Caribbean immigrants. We have shown that West Indian immigrants have an age-adjusted rate of newly reported HIV diagnoses of 43/100 000, which is substantially higher than the rate of 20/100 000 in US-born Whites and substantially lower than the rate of 109/100 000 in US-born Blacks. We also have shown that the rate in West Indian–born Blacks is lower than that in Haitian immigrants, at 70/100 000, and higher than the rate in Dominican immigrants, at 29/100 000.

Considering PLWHA, the same pattern exists, except that the prevalence of PLWHA among West Indian–born Blacks is slightly lower than is the prevalence among US-born Whites, possibly because of higher incidence in the past among White men who have sex with men as well as to this group’s good access to life-extending treatment. West Indian–born Blacks had a higher proportion (41%) of cases attributable to heterosexual transmission than did both US-born Blacks and Whites.

Our findings, therefore, add to the growing literature demonstrating considerable diversity in health outcomes in the US Black population40–42 and argue, as have others,38 for the importance of collecting country of origin data in HIV/AIDS surveillance statistics to enable the development of targeted interventions.

Limitations

There are several important caveats that need to be considered in evaluating these data. First, country of origin information was missing (i.e., not reported to the NYC DOHMH) for 18% of newly reported diagnoses of HIV and 23% of PLWHA. It is also possible that for some West Indian immigrants the assumption was made by the physician completing the HIV case report form that the individual was native born. Because West Indian immigrants speak English as their first language, this misclassification might occur more often for them than for other Caribbean-born persons. Such errors would result in the differential misclassification of West Indians relative to the other immigrants as native born, resulting in lower estimates of rates among West Indian immigrants. Another caveat is that immigrant populations tend to be undercounted by the US Census, leading to the inflation of rates of HIV estimated for foreign-born groups by reducing the size of the denominator. The restriction on the entry of HIV-positive individuals into the United States, which was lifted only recently, is likely to have depressed the number of HIV-positive people in the 3 immigrant groups, possibly affecting comparisons between West Indian–born Blacks and US-born residents but not comparisons among the immigrant groups.

With respect to the use of voluntary HIV testing to estimate new HIV diagnoses and prevalence of PLWHA, there are 2 important considerations. One is that lower levels of HIV testing among immigrants could result in lower numbers of newly diagnosed cases of HIV. Immigrants may be reluctant to test for HIV because of fear of deportation and high levels of HIV/AIDS stigma in their social groups and because they are more likely to lack health insurance.42,43 Indeed, delayed testing among Caribbean immigrants (not disaggregated) is suggested by 35% of new diagnoses being concurrent (meaning that HIV and AIDS were diagnosed at the same time) compared with 20% concurrent diagnoses among European immigrants.30 However, data from the NYC DOHMH Community Health Survey indicate that West Indian–born Blacks are about as likely to have undergone HIV testing in the past year as are US-born Blacks and more likely to have done so than are US-born Whites (Ransome Y, Sandfort T, Hoffman S, Griffith DM, unpublished data, December 2011).

Relatedly, when a person tests positive, uncertainty often exists regarding whether the diagnosis is “new.” Such uncertainty may exist for positive tests regardless of nativity, but ascertaining whether the case is a new diagnosis is a greater challenge among immigrants. If a person was first diagnosed outside the United States, this information would not be available to a US health department, as it would be if a person were first diagnosed in another US health jurisdiction. The application of newer testing algorithms to identify recent seroconversions44 may minimize but not eliminate these challenges, which arise especially when comparing groups with differing testing rates.

Conclusions

Despite these potential biases (the overall direction of which is not possible to determine), we have provided one of the first estimates of the diagnosis rate, prevalence of HIV/AIDS, and distribution by transmission risk categories in NYC West Indian–born Blacks, a significant but often hidden immigrant group.45 These findings are important for at least 2 reasons. First, they provide context for emerging work on factors that may promote risk in West Indian–born Blacks,46-49 among whom it has been assumed, but not known if, the rate of HIV is high. With a crude rate of newly reported HIV diagnoses of almost 50/100 000 and a crude prevalence of 0.66%, it is clear that HIV presents a challenge in this immigrant community. Here we have shown that interventions need to focus on heterosexual transmission as well as transmission among men who have sex with men, who may be far more hidden than are US-born men who have sex with men.49

More broadly, this work can help build theory around the ways migration contexts, circumstances, and experiences shape sexual health. In this regard, the data we have presented are merely a beginning that hopefully will stimulate additional research. Our findings are consistent with those of Wiewel et al.,28 who found that NYC foreign-born Black men had lower HIV prevalence and rates of new diagnoses than did native-born Black men. This difference may be partly because of the ban on the entry of HIV-positive persons into the United States, making it important to track changes now that this ban has been lifted. Although HIV-positive individuals from the Caribbean region may always have been motivated to migrate to obtain treatment in the United States, they may now face less stigma and have greater ability to do so.

Our data leave open the question of whether the forces influencing HIV acquisition among West Indian–born Blacks are different from those among US-born Blacks. Further work is needed to understand sources of risk in countries of origin and the United States and the degree to which HIV-positive West Indian–born Blacks become infected in each locale. Another important question is whether the risk of West Indian–born Blacks increases with longer time in the United States or among second- and third-generation immigrants, as would be predicted by acculturation theory27 and as has been shown for mental health outcomes in this group.50

In sum, much more work needs to be done to understand how the structural aspects of West Indian–born Black migration shape immigrants’ experiences, how these experiences compare with those of other global US immigrants, and how the various migration trajectories generate risk. Equally important, we need to understand the role that race assumes for foreign- and native-born Blacks in creating risk for and protection from HIV/AIDS.

Acknowledgments

This work was supported by the National Institute of Mental Health (grant P30 MH43520) and the Initiative for Maximizing Student Development (grant 2R25GM62434-06).

An earlier version of this article was presented at the AIDS Impact 2011 Meeting, Santa Fe, NM, September 13, 2011.

We thank Raymond Smith, PhD, and Colin Shepard, MD, for comments on an earlier draft.

Human Participant Protection

No protocol approval was necessary because data were obtained from secondary sources.

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