State and Local Policies as a Structural and Modifiable Determinant of HIV Vulnerability Among Latino Migrants in the United States

Abstract

We explore how state and local policies in labor, health, education, language, community and neighborhood environments, deportation, and state-authorized identification can reduce or exacerbate HIV vulnerability among Latino migrants in the United States. We reviewed literature on Latino migrants and HIV risk, on the structural–environmental contexts experienced by Latino migrants, and on the many domains in which policies influence those contexts. To illustrate the pathways through which policies across multiple sectors are relevant to HIV vulnerability, we describe how policies shape 2 mediating domains (a climate of hostility toward Latino migrants and the relative ease or difficulty of access to beneficial institutions) and how those domains influence behavioral risk practices, which increase vulnerability to HIV. This argument demonstrates the utility of considering the policy context as a modifiable element of the meso-level through which structural factors shape vulnerability to HIV. This approach has specific relevance to the consideration of HIV prevention for Latino migrants, and more generally, to structural approaches to HIV prevention.

It is widely recognized that migration increases vulnerability to HIV transmission by putting individuals in situations that lead to unprotected sex, sex with multiple partners, and excessive alcohol and drug use.^1–3 A population-level prevention approach requires a focus on the contexts that shape those behaviors, rather than just the behaviors themselves, and thus this article presents a framework that highlights how the multisectoral policy context shapes Latino migrants’ vulnerability to HIV. We describe 2 critical mediating domains and 3 sets of behavioral practices through which policy determinants operate to affect vulnerability.

Policy climates also shape health disparities for other populations and other outcomes. Research has documented the health impacts of varying policy climates for lesbian, gay, bisexual, and transgender populations.⁴ Given the HIV vulnerability of Latino men who have sex with men (MSM),⁵ our analysis contributes to an intersectional approach to policy by filling a gap in the research on policy climates affecting Latino migrant populations. Many of the policy responses we examine are not health policies, and some are not even directed toward migrants; nonetheless, they may have significant unintended consequences for Latino migrants’ vulnerability to HIV. The intent is not to enumerate every possible policy relevant to HIV risk for this population, nor to suggest that all Latino migrants face the same contexts of reception, but to advance understanding of the pathways through which policies shape HIV vulnerability by using the notion of the meso-level,⁶ while still acknowledging that factors other than policy, such as cultural norms relating to openness to sex and drug-use practices, influence HIV vulnerability for migrants.⁷

As elaborated elsewhere, the meso-level is defined as

[I]nstitutions, ideologies, or social processes that are 1) neither at the micro, individual, or interpersonal level (such as beliefs or characteristics of interactions) nor at the macro-social level (such as socially-structured inequalities of race, gender, sexuality), 2) characterized by a “sociologically-plausible” or empirically-described causal relationship to a health-relevant practice, and 3) conceivably modifiable through sustained strategically-organized collective action.^6(p38)

A focus on state or municipal policy can be considered a meso-level approach to modifying the determinants of HIV risk because policies can mitigate the adverse effects of structural inequalities without requiring wholesale transformation of systems of economic and gender inequity. This offers a practicable structural approach to HIV prevention, in this case for Latino migrants. This attention to structure is relevant even in the context of the National AIDS Plan’s heavy emphasis on biomedical approaches to HIV prevention.⁸ Particularly for severely socially disenfranchised populations, the potential impact of prevention efforts may depend on the effective development of structural approaches to facilitate access to health care and to promote engagement with biomedical prevention.

METHODS

This article builds on the second author’s previous work on the social context of migrant health,^9,10 on a literature review conducted by the first author on HIV and social policy, and on both authors’ advocacy work for immigrants’ rights and food justice. For the review, the authors selected keywords (immigrant, immigration, foreign born, migrant, HIV, AIDS, state, local, policy, policies, unauthorized, undocumented, Latino, Hispanic) to search the National Library of Medicine’s PubMed online database and the Social Sciences Citation Index. We reviewed titles, abstracts, and reference lists of citations turned up by the search and assessed the sources for accuracy, credibility, and relevance to the HIV vulnerability of Latino migrants. To review state policies that affect migrants, we used the National Council of State Legislatures online database. As part of other ongoing work, the second author consulted with 2 national immigration law experts about the range of policies discussed here; both affirmed that the selection was comprehensive.

Latino Migrants’ Vulnerability to HIV

Migrants are defined as living and working in the United States without intent to settle permanently, whereas immigrants are generally defined by their intent to stay, although the line between migrant and immigrant is not clearly defined.¹¹ Our focus is on Latino migrants, irrespective of immigration status or intention to stay in the United States. Notably, some policy domains are not relevant to the Latino migrant population in its entirety but, rather, to specific subgroups such as MSM, Puerto Ricans, migrants without legal authorization, or migrants who came to the United States as children (although these populations are not necessarily mutually exclusive). Of the 54 million people who identified themselves as Latino living in the United States in 2013, 35% (19 million) were foreign-born (almost half of the foreign-born population).¹² There were 11.2 million unauthorized immigrants in the United States in 2012; about 71% were from Mexico and Central American countries and 7% were from South America.¹²

Compared with the US population as a whole, Latino migrants face a disproportionate risk of HIV. Latinos constitute 16% of the population but account for 21% of new HIV infections—an infection rate 3 times higher than that of Whites.⁵ Men account for 87% of new Latino infections, and slightly more than three quarters of those infections occur among MSM.⁵ Although the prevalence of HIV infection among the unauthorized Latino migrant population is unknown, migrants face multiple intersecting inequalities of ethnicity and race, socioeconomic status, sexuality, and citizenship status, all of which may render them even more vulnerable to HIV.⁵ Migrants are more likely to face barriers to health care services and HIV testing than nonmigrants.¹ Among Latinos diagnosed with HIV infection in the United States, migrants were more likely to be diagnosed later during the course of infection than US-born Latinos,¹³ and those who test positive for HIV are more likely to have a dual diagnosis or experience rapid progression to AIDS.¹⁴

Pathways to HIV Vulnerability

A great deal of work links poverty,¹⁵ living and working conditions,¹⁶ social isolation,¹⁷ limited recreational opportunities,¹⁷ discrimination,¹⁸ and even migration itself^1,19 to HIV. Yet, there is little research that articulates the specific pathways through which socioeconomic and environmental factors shape behaviors and render migrants vulnerable to HIV infection. We build on work emphasizing the importance of context by articulating 2 critical mediating domains that produce HIV vulnerability by shaping sexual risk practices, drug and alcohol use, and engagement with health care: (1) climates of hostility toward Latino migrants and (2) the relative ease or difficulty of access to beneficial institutions, including education and health services. These domains reflect, respectively, the internal experience of social exclusion that leads to substance use and sexual risk taking, and the structural barriers that limit engagement with health-promoting institutions. Our conceptual model is depicted in Figure 1.

FIGURE 1—

Conceptual Framework for Policy Determinants of HIV Vulnerability for Latino Migrants

Note. Key pathways linking structural factors to HIV vulnerability through (1) climates of hostility toward Latino migrants and (2) ability to access beneficial institutions; these mediating domains shape behavioral risk practices, influencing HIV vulnerability.

Climates of hostility.

Fear and alienation are not intrinsic to the migration process; they reflect the specific circumstances encountered by many Latino migrants in the United States, including living and working environments characterized by a climate of hostility. This is experienced at the individual level as anxiety, stress, perceived isolation, frustration, depression, or as an amalgamation of these factors, which in turn creates vulnerability to HIV by rendering individuals more likely to engage in sexual risk practices, to abuse drugs or alcohol, or to refrain from seeking health care services.^20,21 Research extensively documents the relationship between these behaviors and HIV transmission.^19,22 Harsh working and living conditions and chronic under- or unemployment exacerbate stress and create a sense of powerlessness and alienation.²¹ The limited recreational options available to some Latino migrants can intensify feelings of loneliness and social exclusion.²³ Social isolation is associated with depressive symptoms and poorer physical and mental health.²⁴ Restricted opportunities for wealth accumulation hinder economic and social mobility, which may lead to negative mental health consequences.²⁵ For unauthorized Latinos (and their loved ones), immigration- and deportation-related fears and hypervigilance are commonplace.²⁰ Fear of arrest and interactions with law enforcement have been reported to aggravate health conditions, such as depression, high blood pressure, and anxiety,²⁶ and are shown to be associated with risky drug-use practices, such as needle sharing, among the Latino migrant population.²⁷

The links between harsh socioeconomic conditions, climates of hostility, and HIV risk may be particularly relevant to Latino MSM. Although sex between men is not intrinsically high risk (and many migrants may come from countries in Latin America where public opinion about same-sex sexual relations is changing rapidly²⁸), the fact that three quarters of new infections among Latino men are reported as MSM transmission and that the US epidemic is increasingly concentrated among MSM⁵ suggests that in this case same-sex sexual relations may be likely to be contexts of HIV vulnerability. A study with Latino gay men found that oppression-related psychological distress increased sexual HIV risk through participation in substance-related situations that lead to risky sex.²⁹ In addition, cultural norms regarding gender roles in both home and host countries can manifest in reluctance to disclose risk behaviors or sexual orientation to health professionals and may prevent men from seeking testing, health care services, and social support.^1,7

Ability to engage with beneficial institutions.

Social exclusion in the form of structural barriers to health and educational institutions affects Latino migrants’ ability to access HIV testing, primary health care, and social services, and limits economic and educational opportunities. In light of well-documented barriers limiting Latino migrants’ access to care,³⁰ it is unsurprising that unauthorized Latino migrants engage with US health care services at significantly lower rates than their documented counterparts.³¹ Structural barriers related to geographic access, health insurance, and affordability drive reduced levels of primary care engagement, which limits individuals’ opportunities to receive sexual risk and health education, sexually transmitted infection (STI) testing, HIV testing and counseling, and linkages to AIDS treatment and care for those who are HIV-positive.¹⁰

The Latino population has the highest uninsured rates in the country, and among foreign-born Latinos, uninsured rates are nearly 5 times that of White Americans.³² Migrants face additional cultural, geographic, and linguistic barriers that may affect quality of care and access to knowledge about HIV prevention and sex and drug use.⁵ In general, foreign-born Latino migrants consistently report lower levels of satisfaction and more discrimination when engaging with providers than US-born Latinos.³³ Undocumented Latinos living with HIV enter care later than Latinos who are documented and later than Whites and Blacks, indicating how marginalization based on immigration status reduces individuals’ ability to utilize health care services.³⁴

Exclusion from educational institutions also increases HIV vulnerability by limiting Latino migrants’ social and economic opportunities. Education offers a pathway out of precarious low-paying jobs, creates opportunities for social mobility and economic stability, and increases health literacy.³⁵ Higher levels of health literacy are clearly associated with the use of preventive services,³⁶ and greater educational attainment is well-known to be associated with safer sexual practices.³⁷ Latino migrants consistently have lower levels of education than Whites and experience widespread barriers to educational opportunities.³⁸ According to data from the 2012 American Community Survey, about one third of foreign-born Latinos have less than a ninth-grade education compared with 7.3% for native-born Latinos and less than 3% for Whites. Among Latino immigrants, a college degree is shown to be associated with the possibility of reaching occupational status comparable to that of Whites.³⁹

RESULTS

In this section we review the meso-level determinants of HIV vulnerability. Our review is also outlined in Table 1.

TABLE 1—

Policies That Shape Latino Migrants’ HIV Vulnerability

Policy Category	Examples	Link to HIV Vulnerability Through Hostility, Fear, and Stress	Link to HIV Vulnerability Through Access to Institutions
Policies that reduce HIV vulnerability
Labor	Protections for farmworkers and domestic workers Occupational safety and health laws	Reduce stress via increasing economic and job security for individuals and families Reduce job stress by protecting the health of workers in dangerous occupations	Enhance access to labor market and health care services through the provision of benefits Increase points of access with health care services for work-related injuries
Policing	Policies that limit law enforcement’s cooperation with Immigration and Customs Enforcement	Reduce fear of deportation	Reduce fears of accessing health care and social services
Health	Policies that provide access to basic health care services for low-income migrants (e.g., health care reform in San Francisco, CA, and Massachusetts)	Reduce fears of accessing health care services	Remove structural barriers to preventive health care services for unauthorized migrants
Education	In-state tuition and scholarships for unauthorized migrant youths	Promote inclusive climate for unauthorized youths	Enhance access to education and related social and economic opportunities for unauthorized youths
Language	Laws that promote linguistic diversity (e.g., English Plus resolutions)	Promote linguistic and social inclusion	Reduce language barriers to accessing health care and social services
State-authorized identification	Policies that expand access to driver’s licenses and identification	Reduce fear by limiting opportunities for detainment by law enforcement	Enhance access to labor market, public services, and bank accounts
Community and neighborhood environments	Policies that promote recreational activities, use of public space	Promote stress relief, social integration, and communication with families and partners	Enhance access to community institutions and public services
Policies that exacerbate HIV vulnerability
Labor	Immigration and Customs Enforcement Mutual Agreement Between Government and Employers	Intensify fear of deportation and related stress	Reduce access by limiting economic opportunities
Policing	US Immigration and Nationality Act (1996); Arizona’s Support Our Law Enforcement Safe Neighborhoods Act (SB 1070)	Increase local law enforcement’s involvement in deportation-related activities	Contribute to fear of accessing health care and social services
Health	Personal Responsibility and Work Opportunity Reconciliation Act (1996); Patient Protection and Affordable Care Act (2010)	Contribute to fears of seeking health care services	Create structural barriers to enrollment in federal public assistance programs and limit access to health care services for authorized migrants
Education	Policies prohibiting unauthorized students from receiving in-state tuition	Contribute to a climate of hostility by marginalizing unauthorized youths	Limit access to educational opportunities for unauthorized youths
Language	“English-only” laws	Contribute to a climate of hostility by marginalizing Hispanics	Create barriers to accessing health care and social services
State-authorized identification	Laws that prohibit access to driver’s licenses and identification for unauthorized migrants	Increase opportunities for detainment by law enforcement	Limit access to labor market, public services, and bank accounts

Labor

Labor laws and extralegal forms of worker organization protect workers against wage theft and employer discrimination, enable collective bargaining, and improve wages and working conditions. Farm work and domestic work, occupations disproportionately filled by Latino migrants,³² are excluded from the National Labor Relations Act and thus lack many basic protections.⁴⁰ Some states have addressed this through enacting policies that provide these occupations minimum wage, workers compensation, and other basic rights.⁴¹ Legislation need not be migrant-specific; living wage ordinances, which have been passed in municipalities including Miami, Florida; Los Angeles, California; and Boston, Massachusetts; and in transportation and hospitality sectors elsewhere, including airports in San Francisco, California, and Seattle, Washington, have a direct impact on Latino migrants’ wages.^42,43 Also relevant is legislation that prevents employers from punishing immigrant workers for work-related complaints solely based on their legal status.⁴⁴ Working conditions, influenced by occupational safety and health laws, can contribute to stress and anxiety, thereby affecting vulnerability to HIV; this is significant given immigrants’ overrepresentation among those working in the most dangerous occupations.⁴⁵

Recent organizing efforts within food service, hotel, and janitorial sectors, in which unions have traditionally been weak and in which many Latino immigrants work,⁴⁶ point to the possible connections between collective bargaining laws (which might raise wages and improve working conditions) and reduced vulnerability to HIV. Nonunion organizations and campaigns that advocate workers’ rights (e.g., the Coalition of Immokalee Workers⁴⁷) are also relevant, and are taking shape within immigrant-heavy sectors in which traditional forms of union organizing are difficult to establish.

Labor policies can also create economic vulnerability and a climate hostile to immigrants. For example, the Immigration and Customs Enforcement (ICE) Mutual Agreement Between Government and Employers outreach program, a voluntary partnership between the government and the private sector that aims to enforce worksite laws and curtail the employment of unauthorized workers, has been described as inducing anxiety and fear of deportation.⁴⁸ (Immigration and Customs Enforcement is the arm of the Department of Homeland Security responsible for border patrol and enforcement.)

Policing

In 1996, the Immigration and Nationality Act authorized ICE to work with state and local police to enforce federal immigration law during its daily activities. More recently, there has been a great deal of legislative activity in the domain of local policing practices regarding migrants. States including Alaska, Montana, New Mexico, and Oregon⁴⁹ and several dozen cities have enacted policies to restrict local law enforcement’s ability to engage in immigration enforcement.⁵⁰ Conversely, however, other states have sought to expand the police force’s cooperation with ICE. For example, Arizona’s Support Our Law Enforcement Safe Neighborhoods Act (SB 1070) permits the police to detain individuals on “reasonable suspicion” that they are in the United States illegally and makes the failure to possess immigration documents a crime.⁵¹ The presence of ICE in communities has been shown to be related to reduced engagement with health services, increased fears related to immigration status, and decreased likelihood of receiving health care.^20,51 With concern to HIV vulnerability specifically, Latino migrants’ fears of disclosing immigration status have been shown to reduce the likelihood of accessing HIV-prevention services; getting tested for HIV and other cofactors, including STIs; or receiving adequate treatment if they are living with HIV.⁵¹

Health Care Services

Several states and municipalities have removed documentation status as an eligibility requirement to access public services. Though imperfect, policies that directly facilitate the provision of at least basic health services may create opportunities for HIV prevention. For example, Healthy San Francisco (2007) legislation and Healthy Way LA’s “Unmatched” program provide access to primary care services at certain hospitals and federally qualified community health centers for all low-income uninsured adults regardless of documentation status; for Latino migrants interested in preexposure prophylaxis, access to primary care is of paramount importance.⁵² State-level reform in Massachusetts in 2006, which served as the model for the Patient Protection and Affordable Care Act (ACA), expanded Medicaid to all eligible low-income residents with legal documentation and granted access to basic services for individuals without legal status.⁵³ Currently, some state-funded programs provide substance-abuse treatment programs and mental health services, which may reduce migrants’ vulnerability to HIV by addressing substance-use behaviors.⁵⁴

Other policies have limited migrants’ access to health services. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act instituted, among other restrictions, a 5-year residency requirement for legal immigrants to be eligible to receive federal public assistance.⁵⁵ This barred unauthorized immigrants outright from receiving Medicaid and other means-tested benefits, such as the Supplemental Nutrition Assistance Program, regardless of how many years they have lived in the United States.⁵⁵ The Personal Responsibility and Work Opportunity Reconciliation Act was enacted the same year as the Illegal Immigration Reform and Immigrant Responsibility Act, a policy that contributed to the climate of hostility by making noncitizens subject to deportation for minor criminal offenses such as traffic violations.

The ACA intends to expand medical coverage, but actually reduces access to health care services for some Latino immigrants,⁵⁴ barring unauthorized immigrants from the purchase of private insurance via the exchanges.⁵³ Even for legal migrants, the residency requirement to enroll in Medicaid and the mandate to pay 2% of their income for insurance premiums combined with language and bureaucratic barriers experienced in municipal, state, and federal health insurance programs may serve as structural barriers to enrollment.⁵⁴ Efforts to screen individuals for citizenship status during enrollment may deter individuals from seeking care.^51,53 Latino migrants’ access to HIV-prevention services, specifically, may be further limited under the ACA, as clinics will not be reimbursed for screening for some STIs or for STI-prevention counseling for high-risk adults and sexually active adolescents.⁵¹

Education

According to the National Council of State Legislatures, 15 states have passed legislation that allows undocumented students to qualify for in-state college tuition and other financial aid. Some states, including Hawaii and Michigan, have acted on their own to approve in-state tuition rates at their public colleges and universities for students who meet certain criteria, regardless of legal status.⁵⁶ One study found that young people who were legally allowed to stay in the United States (as a result of the Deferred Action for Childhood Arrivals program) experienced substantially increased economic opportunities, including obtaining a new job, opening their first bank account, and obtaining their first credit card.⁵⁷ These policies may also ease financial burdens and stress on young people and their parents.

Other states, including Alabama, Arizona, and Colorado, have acted oppositely, prohibiting undocumented immigrant students from receiving in-state tuition, effectively considering them out-of-state, or even international students despite the fact that they reside in-state. Bills such as California’s Proposition 227 have restricted bilingual education, setting a precedent for English-only public school instruction.⁵⁸

Language

The language barrier is a well-documented impediment to accessing health and social services. Some states have explicitly enacted “English-only” laws, which generally require official government functions to be conducted in English and future immigrants to pass an English-proficiency test as a requirement of citizenship.⁵⁹ Others promote linguistic inclusivity and diversity through “English Plus Resolutions” as part of a movement to oppose “English-only” laws,⁶⁰ and several cities have language access and communication policies that require municipal agencies to translate key documents and forms and provide translation services.^50,58 More distally, these policies communicate social and political inclusion.

State-Authorized Identification

In 2013, lawmakers in at least 19 states pushed for bills to expand migrants’ access to driver’s licenses.⁵⁶ Many of these state-level policies allow individuals who cannot show proof of authorized presence in the United States to obtain temporary visitor’s licenses. Because many undocumented migrants drive without a license out of necessity, increased access to licenses will likely diminish fears of arrest and deportation²⁶ by reducing instances in which local authorities detain undocumented persons for driving without one.⁵⁶ Research has demonstrated an association between driving without a license and increased stress,⁶¹ and an association between car ownership and higher levels of employment and earnings for low-income workers.⁶² A report on this topic argues that these policies help facilitate immigrants’ economic and social contributions to their communities.⁶¹

Similarly, policies that grant legal identification to residents regardless of immigration status, including driver's licenses and municipal identification cards, expand access to a variety of municipal services and promote social integration and economic stability. Legal identification can be used to easily access services, such as hospitals, public libraries, banks, and stores.⁵⁰ Legal identification that allows undocumented migrants to open US bank accounts reduces their dependence on exploitative check-cashing and remittance services.⁵⁰ Increasing wealth overall provides access to a variety of health-supporting (and HIV-vulnerability–reducing) factors, including food, housing, and education, which is also likely to dramatically reduce daily stressors.

Community and Neighborhood Environments

Policies that promote supportive environments reduce the social and residential exclusion characteristic of climates hostile to migrants, instead promoting social cohesion, community integration, and neighborhood- and individual-level support.^10,21,23 Community institutions and public spaces such as parks and libraries that provide places to spend leisure time and promote socializing are often created through local policies (and funded through municipal budgets). Recreational activities held in these spaces or in religious ones, such as church events, English classes, or locally organized soccer leagues, further facilitate social interaction. Several studies have reported that low-income neighborhoods in which Latinos and people of color are concentrated are significantly less likely than White neighborhoods to have recreational spaces for public use.⁶³

Recent attention has been given to place-based interventions to address health inequities, with research emerging around the connections between access to physical activity settings and open spaces such as parks, playgrounds, and gardens, and better physical and mental health.^64,65 Community institutions such as libraries offer access to computers, facilitating communication with families and partners that could conceivably deter high-risk behaviors,²¹ and provide classes that promote social and legal integration. Recreational options and immigrant-friendly environments provide outlets for stress relief that can occur without—and even deter—alcohol or sexual activity with multiple partners, and have the potential to reduce loneliness and isolation.¹⁰

DISCUSSION

This article discusses how state- and municipal-level policies can either exacerbate or mitigate Latino migrants’ vulnerability to HIV through the creation of supportive or hostile climates and facilitating or limiting access to institutions. Latino migrants are not the only migrant group vulnerable to HIV, but their disproportionately late entry into care³⁴ and high rates of concurrent diagnoses⁶⁶ suggest that it is critical to consider the modifiable structural factors that would need to be addressed for biomedical prevention to be effective.

We have described the pathways through which pro-migrant policies that increase economic opportunity, diminish fear of deportation, and foster community cohesion may do more than support migrants’ social incorporation; they may also reduce HIV vulnerability. First, inclusive climates can reduce the day-to-day stressors and anxieties that deter care engagement and stimulate high-risk sexual practices and excessive drug and alcohol use. Second, policies may also enhance access to educational institutions and health care services, including regular primary care and HIV and STI testing, especially in combination with the provision of official identification cards and bilingual services.

Our articulation of the relation between policy contexts and HIV vulnerability advances structural approaches to HIV prevention by highlighting plausible and empirically grounded points of intervention between structural factors and HIV vulnerability. The notion of working at the meso-level can play a critical role in understanding the impact of state-level policies on public health and ensuring that transportation and policing policies, among others, are considered when one is introducing preexposure prophylaxis to vulnerable populations.

The conceptual model presented here underlines how legislation across multiple sectors affects migrants’ HIV vulnerability. Looking ahead, future research should add to this list of meso-level policies relevant to the HIV vulnerability of Latino migrants, further developing the conceptual model. There may certainly be entire policy domains other than those we have enumerated that also work through these pathways and prove relevant to HIV vulnerability—state-level drug policy, for example. The domain of policies that shape health is much broader than what is generally recognized as health policy, and so it is vital to incorporate an examination of these policies across multiple sectors in any discussion of factors beyond the behavioral level that shape HIV vulnerability—or, for that matter, any health vulnerability. This model is relevant to understanding other key outcomes for the Latino migrant populations in the United States as well as HIV and health disparities faced by migrant groups elsewhere.

Finally, policies may be a determinant of health, but they do not enact themselves. The field of American public health has long advocated social reforms alongside scientific advances, and public health work that involves collective social activism and alliances with labor and social movements has played a critical role in areas ranging from improvements in occupational safety to increased access to clean needles.⁶⁷ That tradition of activist public health, political action, and advocacy on the part of civil society groups, and the migrant populations affected by those policies will be crucial to create the circumstances that either make full-scale immigration reform possible or, in the absence of immigration reform, to press for policies that enhance the health of all members of American society regardless of immigration status.