Intersecting Stigmas: Being Black African, Immigrant, and Living With HIV in the United States

Nationally, HIV incidence among African immigrants is six times higher than in the general population and nearly twice that of US-born Black individuals.^1,2 The precise number of African immigrants living with HIV (ALWH) in the United States is unknown, because of the lack of disaggregated HIV surveillance data on Blacks or African Americans by country of birth. Compared with the HIV epidemiological profile for US-born Black people, among ALWH there are higher rates of heterosexual transmission and higher rates among women. Although some ALWH may have acquired HIV prior to migration, a significant proportion acquire HIV after migration.² HIV risk after migration is due to complex sociocultural, psychosocial, and structural conditions, such as xenophobia and racism. African immigrants are less likely to test for HIV and often present late to care.^3,4 HIV-related stigma is higher among African immigrants than among other groups, further exacerbating risk factors and systemic barriers.³ As this population grows, it is critical to understand their unique experiences with HIV-related stigma and address intersecting stigmas associated with race, nativity, immigration status, ethnicity, language, and HIV status.

SOCIOCULTURAL CONTEXT OF HIV-RELATED STIGMA

Cultural values and norms determine perceptions about the causes of diseases, influence behaviors, and shape prevention and care decisions. Stigmatizing attitudes about HIV need to be understood within the context of African cultural values and norms that migrated with African immigrants from their home countries to the United States.⁴ HIV continues to be seen as a “death sentence” and aligned with behaviors that are considered deviant and immoral, such as having multiple partners, homosexuality, and premarital or extramarital sex.⁵ Hence, merely going to get tested is sufficient to elicit stigma. In some African societies, HIV is understood as a divine punishment for a sin or a spiritual curse.⁵ African immigrants living with HIV often experience distancing, gossiping, and shunning from family, friends, and the community. This leads to denial, social isolation, nondisclosure, and fear of integration into the larger US community. Given the collectivist culture of African communities, the impact of HIV stigma extends to the whole family, bringing dishonor and harming the family’s reputation.⁴ Consequently, ALWH would rather hide their diagnosis from family and community members in the United States, as well as in Africa, and not seek care than face censure and shame.⁵ Gender biases within some African cultures limit women’s sexual and reproductive autonomy, prevent communication about sexual health with partner(s), and fuel intimate partner violence.⁶ Concurrently, African masculinity stigmatizes men’s willingness to engage with HIV testing and care. Across the continent of Africa, anti-homosexuality bills are criminalizing lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual (LGBTQIA+) individuals, which multiplies the stigma and shame experienced by these communities.

INTERSECTIONAL STIGMA AMONG AFRICAN IMMIGRANTS

While navigating the challenges of HIV-related stigma, African immigrants in the United States are also socially marginalized because of multiple identities based on race, nativity, immigration status, ethnicity, and language (Table 1). Stigmas associated with African immigrants’ intersecting identities (e.g., being Black, foreign-born, and a non-English speaker) compound their vulnerability to HIV and discrimination based on their HIV status.

TABLE 1—

Intersectional Impact of Stigmatized Identities on HIV Engagement

Social Identity Categories	Societal Oppressions	Marginalized Identity	Intersectional Impact
Race	Anti-Black racism	Black	HIV stigma State-sanctioned violence Targeted racialized criminalization Economic instability Linguistic discordance Denied or limited health coverage Lack of access to health resources	Poor communication between sexual partners Gender inequity Intimate partner violence Nondisclosure Isolation Low condom use Late HIV testing Delayed engagement in HIV care Lack of culturally and linguistically appropriate services
Nativity	Nativism, xenophobia	Foreign-born
Immigration status	Nativism, xenophobia	Undocumented, Deferred Action for Childhood Arrivals (DACA), Temporary Protected Status (TPS), asylee, nonimmigrant visa or refugee
Ethnicity	Ethnocentrism	African country of origin
Language	Language oppression	African languages, dialects, and accents

Although there are similarities in terms of anti-Black interactions with US systems, the experiences of African immigrants in the United States differ from those of US-born Black people because of converging socially oppressed identities related to being an immigrant. As noted by Castañeda et al.,

being an immigrant limits behavioral choices and, indeed, often directly impacts and significantly alters the effects of other social positioning, such as race/ethnicity, gender, or socioeconomic status, because it places individuals in ambiguous and often hostile relationships to the state and its institutions, including health services.^7(p378)

Being Black

African immigrants are subjected to anti-Black racism and related injustices and health disparities experienced by US-born Black people. State-sanctioned violence, for example, is a reality underscored by the murders of Amadou Diallo, Alfred Olango, Ousmane Zongo, and other African immigrants unjustly killed by the police. Health disparities among African immigrants are a consequence of living longer in the United States, adopting local behaviors, and having racialized experiences that affect health outcomes, similar to their US-born counterparts.

Being Black and an African Immigrant

Despite the growing efforts of national movements, such as #ImmigrationIsABlackIssue (a social media mantra coined by UndocuBlack Network), Africans are often excluded from the US immigration narrative. Stigmatizing beliefs and stereotypes toward racialized immigrants, including African immigrants, are reflected in anti-immigrant rhetoric and policies,⁸ making African immigrants more vulnerable because of their Blackness as well as their status as foreigners. Racist rhetoric, such as a US president referring to African nations as “shithole” countries, fuels existing stereotypes about Africans being lazy, poor, dirty, and constantly seeking aid. Examples of harmful policies that specifically stigmatized African immigrants include the 2017 travel bans preventing nationals of selected African countries from entering the United States, and the fluctuating authorization of Deferred Enforced Departure and Temporary Protected Status for individuals from Liberia, Sierra Leone, Somalia, Sudan, and Guinea. African immigrants are targeted and criminalized by both local law enforcement and immigration enforcement, thus facing arrest, detention, and deportation at disproportionate rates.⁹ Anti-immigrant stigma leads to worse health outcomes by targeting distinct racial/ethnic populations and limiting health resources, including HIV services, to immigrants with specific statuses.⁷ Overall, restricted access to health insurance, uncertainty regarding eligibility for health services based on immigration status, and fears of rejection of one’s citizenship request or deportation if one tests HIV positive impede engagement in HIV testing, treatment, and prevention efforts.¹⁰ Often, immigrants living with HIV who are detained or in deportation proceedings live in unhygienic conditions, are denied interpreters and access to their medical records, and receive subpar treatment, with no access to HIV specialists.¹¹

Being Black, an African Immigrant, and Multilingual

Language is used to reinforce existing oppressions and reiterate the differential status of immigrants in the United States. Being able to speak American English like a native speaker and not having a foreign accent is tied to career mobility, higher income, and ease of navigating US institutions, including the health care system. African immigrants tend to be multilingual—including colonial and native languages—and prefer to speak dialects that are not considered mainstream in the United States. Linguistic discordance with health care providers, inadequate interpreter and translation services, and lack of linguistically appropriate health materials contribute to delays in engagement in care, late initiation of antiretroviral therapy, and increased risk of onward HIV transmission for African immigrants.

CONCLUSION

Explicit efforts to illuminate and address the nuances of HIV-related stigma and interlocking systems affecting the lives of African immigrants are needed. Specifically centering African immigrants requires examining intersecting stigmas based on race, nationality, ethnicity, immigration status, and language that influence their uptake of HIV services and overall well-being. This has implications for HIV surveillance, research, and practice. It is critically important for national and local HIV data sets to disaggregate race and ethnicity data by “country of birth.” This will provide a more accurate account of the national epidemic in the United States, and document the HIV epidemiological profile of African immigrants to support targeted interventions. More research is needed to understand immigration as a social determinant of health, which influences access and utilization of HIV services. Various immigration-related factors are relevant for HIV research, such as immigration status, length of time in the country, age at time of migration, preferred language, and English-language proficiency. Moreover, interventions addressing HIV stigma among African immigrants are limited. Much of the effort to address HIV stigma among African immigrants has been developed locally, led by or in partnership with communities. Strategies incorporate cultural activities, storytelling and media, and bundling HIV testing with other health screenings to maximize prevention while destigmatizing HIV services.¹² HIV stigma-reducing interventions need to be culturally and linguistically tailored, multilevel, and conducted in partnership with the community. More specifically, direct funding to community-based organizations is needed to evaluate and scale up community-defined HIV interventions to reduce HIV stigma.

Failure to recognize the widespread issue of HIV among African immigrants has resulted in a lack of HIV prevention and care initiatives for this growing US population. An intersectionality framework can serve as a useful tool to improve documentation and understanding of the HIV epidemic among African immigrants, implement targeted solutions, and create policies that directly address their unique positioning in the United States.