The Impact of HIV in East Africans
Living in the United States
Meti Duressa, MSW
David Lee, MSW, MPH
Sponsoring Organizations
African American Reach & Teach
Health Ministry (AARTH)
Northwest AIDS Education & Training
Center (NW AETC)
PIFs and Evaluation Forms
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Please complete the Participant
Information Form (PIF) which is used
to track educational events conducted
by AARTH & NW AETC.
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Funding grants are based upon the
type and quantity of educational
events and the number of attendees!
Learning Objectives
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Understand how HIV impacts East African
Immigrants in King County.
Explore cultural differences among East
African immigrants.
Discuss barriers to care for African
immigrants.
State and County Census
Washington
2000
King County
2005
2000
2005
Population
Change
(Est.)
Ethiopian
5, 966 16,647
+52% 18,693 29,868
+60%
Somali
2,486
+71%
2,459
4,231
+72%
Kenyan
556
2,010 +262%
380
1,216
+220%
4,261
2000 numbers from Decennial Census
2005 Numbers from American Community Survey
King County HIV Statistics
US –born
Foreign –born
No.
(%)
No.
(%)
White
3,924
(98)
89
(2)
Black
627
(67)
305
(33)
Male
503
(75)
167
(25)
Female
124
(47)
138
(53)
Hispanic
215
(43)
289
(57)
Asian/PI
48
(34)
95
(66)
NA/AN
78
(95)
4
(5)
Other
51
(88)
7
(12)
Total
4,943
(86)
789
(14)
Public Health Seattle King County, 12/31/2006
Summary of the Data
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HIV cases increasing among African immigrants
but level among African Americans.
Most HIV transmission among African
immigrants is heterosexual, while most African
Americans with HIV are men who have sex with
men.
About 1.8% of African immigrants are infected,
vs. about 1.1% of native-born Blacks.
Jim Kent, Public Health Seattle King County
Cultural Considerations
Religion
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More than 99% of Somalis are Sunni Moslem.
Many Somalis are much more religious now than they were
at home before the civil war.
Allah’s will determines life and death, health and illness.
Prayer is done 5 times a day, wherever you are, preceded by
ablutions.
Fasting during Ramadan is a tenet of the faith. This
alteration of eating schedule needs to be factored into
assessment and treatment.
Many Somali women in Seattle wear hijab and almost all
Somali women in Seattle cover their heads. Health care
workers need to support Somalis who wish to maintain
modesty.
Family
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Islam allows up to four wives, if a man is able to
provide well and justly for four families.
Divorce is common in Somalia and here.
The US government only allows one wife to
immigrate with one husband.
Children who emigrated with their father may be
living in a family where the woman is not their
mother.
Family is defined as extended family.
Patient Identification
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Somali names have 3 parts: the first name is the
given name, the middle is the father’s surname, and
the last is the grandfather’s surname.
Back home it was rare to use the last name, but
common in the U.S. and a potential source of
confusion.
Women do not change their last names when they
marry.
Birthdates are not important in Somalia. Many
Somalis were assigned January 1st birthdates when
they entered the U.S.
Etiquette
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The right hand is the correct and polite hand to use
in daily life (eating, greeting, etc.).
Greeting is with a handshake and Salam Alechem,
but traditionally hand shakes do not occur across
gender.
Women hug and kiss (on both sides or on the hand)
when they meet each other.
It is considered impolite to not ask, “how are you
and how is your family?”
Dying
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It is considered uncaring for a physician to tell a
patient or their family that they are dying.
It is acceptable to describe the extreme
seriousness of an illness.
A special portion of the Qur’an, Yasin, is read at
bedside when a patient is dying.
Relationship Building and Communications
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Time spent establishing a relationship will pay off
for the patient and the provider.
Somalis are traditionally oral historians and are not
prone to brevity.
The evil eye and “Mashallah”.
A loud and serious tone of voice is not unusual for
a Somali speaker and doesn’t necessarily imply
anger.
Ethiopia
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There are 80 languages and 200 dialects among
Ethiopians.
The predominant language among Ethiopians in
Seattle is predominantly Amharic, Tigrigna,
Oromiffa.
The predominant religions are Ethiopian Orthodox,
Moslem, Pentecostalism, and Catholicism.
Greetings
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Women, and women & men who know each
other, hug and kiss on the cheeks three or four
times.
Handshakes are exchanged between people who
do not know each other.
Observant Moslems do not touch across genders.
Modesty is highly valued.
Eritrea
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Achieved independence from Ethiopia in
1991 after a protracted armed struggle
Religion: Coptic Christian Orthodox,
Islam, Catholic, Pentecostal
Languages:
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Tigrigna,Arabic
Under Ethiopian rule people were forced to
learn/speak Amharic
Eritrean Immigration
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Began in the 70s, peaked in late 80’s and
early 90’s
Refugees, asylees, before 1991, then as
visitors, sponsored by residents, lottery
winners
Etiquette
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Greeting: Women and women and men
who know each other hug and kiss on the
cheeks three or four times. Handshakes are
exchanged between people who don’t
know each other. Observant Moslems will
not touch across genders.
Modesty is highly valued.
Elders
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Are held in high regard and are
traditionally cared for at home by the
family.
Death and Dying
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“In Ethiopia, we have burial societies that operate
when there is a death in a neighborhood
community. Members of a burial society pitch in
money every month for membership.
Delivery of news about death is one of the largest
issues of difference for the Ethiopian community
as compared with other communities.
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Back home when there is a death, the
immediate family usually isn't told right
away. An elder is called upon to deliver the
news. The Ethiopian CCM explained, "If a
death happened in my family back home,
my husband or my husband's family would
be informed first, and they would tell me at
the right time, early in the morning before I
left the house." (www.ethnomed.org)
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Back home, the news of death is
orchestrated very carefully. If someone
dies late in the day, the news is kept quiet,
because there is not enough time left in the
day to organize the burial. The
announcement of the death is made the
next morning when there is enough time
for people to prepare for the burial.
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Sometimes, family members may know of a
loved one's death but remain quiet if it happens
late in the day, in order to give enough time for
people to organize. Burials don't happen after
4:00 PM, so a person who dies later in the day
will be buried the next day. A burial may happen
on the same day as death when the death happens
early in the day. The services may last all night
long.
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When there is a death, the society is
responsible for making the announcement
and for taking care of all the organizational
details of the funeral. In this way, death is a
community responsibility. For three days
after a death, a family doesn't have to do
anything except to mourn. The society
members prepare food.
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Here in the United States, this news-telling
tradition is not quite the same. A close friend or
family relation, other than an immediate family
member, is still told first. Often, this person is an
elder.
Back home, the family will wash the body. Here,
the funeral home washes the body and the family
brings the clothing.” (www.ethnomed.org)
Pearls
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Hospitality is offered to visitors. Relationships
will be by accepting the offer to drink tea or
coffee.
Time spent establishing a relationship will pay
off.
The answer to “ How are you?” will likely be
“Thank God, I am fine.” This may not be an
accurate statement concerning the patients state
of being.
A numeric assessment of pain is not usually
helpful.
What are the barriers to accessing
care?
Lack of HIV/AIDS Information
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Prevention v. treatment.
Ignorance.
Some cannot read.
Lack of trust.
It cannot happen to me.
Women are strong support
System for those exposed
to HIV/AIDS
Responsibility of raising
grandchildren for those lost
their parents to AIDS
Stigma
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Stigma perpetuates denial and silence.
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Stigma prevents acknowledgment of problem
and care-seeking.
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Stigma is associated with shame.
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Stigma prevents dissemination of accurate
information.
Concerns
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Fear that prevents them from testing or disclosure.
Fear of Stigma.
Isolation.
Hopelessness.
Relationship between men and women (and the
cultural context for that relationship).
Women’s Rights Issues.
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Rapes occur without legal attention
Shame
Harmful traditions
Female genital circumcision
Abduction
Forced marriage
Underage marriage
exposes to HIV/AIDS
Respecting Women’s
rights one of the
consequences of AIDS
prevention
Immigration Issues
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Concern that as part of the application they
would be required to take an HIV test.
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FALSE for citizenship status
If in asylum program…
Fear of deportation.
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Especially for those who are in the asylum
process
Western v. Traditional Medicine
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It differs from culture to culture.
It has to be visible to the patient.
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Must have symptoms
Weakness
Losing weight
Unable to work or move
To be bed ridden
Meanings Related to Having HIV/AIDS
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Getting Thinner
Death Sentence
It is a punishment
It is unfair
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I am not that kind of person
Guilt -- it should not happen to me
Only one time relationship
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I only dated one person in my life!
Waited long time to have a sexual relationship and this
is what happened
I am not promiscuous
Financial Concerns
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Will not seek HIV-testing because they
believe that they cannot afford it.
Some immigrants will not seek medical
care or take medications because they that
they will not be able to afford it.
Sending money back home is a priority and
will cause immigrants to neglect their own
health needs.
Belief of Bad Spirit/Witchcraft
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I am under a spell-some witchcraft that was done
to me.
My girlfriend/boyfriend, wife/husband is negative
so that means it is a bad spirit or witchcraftwouldn’t my sexual partner have it too?
People wanting to make money put this
spell/witchcraft on me.
Looking for “traditional” medicine; meaning
traditional religious cure to exorcise or cure the
bad spirit.
To Take Meds or Not
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Once past the original denial they are now ready
and eager to take medications as soon as possible
Confusion
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If I have it then give me the medications-do not want to
wait, cannot understand the “wait” until the CD4 drops
and the Viral Load increases…
Undetectable Viral Load vs. Detectable-what does this
mean? Either I have it or I do not have it…
Important to stress that Undetectable does not mean
Cured!
Language Issues
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No providers that speak native tongue.
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Translators are usually from same
community.
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Medical words do not translate or have
different meaning once translated.
Confidentiality
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Given the size of the community people are
VERY concerned regarding confidentiality.
Avoid as much as possible to be seen at the
clinic, especially if they see someone from
the same country or their same origin.
They suffer due to lack of cultural and or
emotional support.
Health Care Decisions and Family
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Some choose to move away from their
family to avoid the constant interference on
their health care decisions.
Examples:
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23 y/o female moved back to home country.
38 y/o female moved to another state.
Coping with Illness & Living Well
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Denial.
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Once they get past the denial process and
established in care they are very engaged in
medical care.
Patients gain hope (and weight!) and think
of family and of having children once they
start feeling well.
Strengths Perspective
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Family
Children
Future plan
Hope
Copying skills
Religious belief
Summary
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HIV in African Immigrants differs from
other groups in King County.
Cultural considerations are important for
building rapport.
There are several barriers that prevent
African Immigrants from receiving the care
that they need.
Resources
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AARTH 206-850-2070
NW AETC 206-543-3319
Community House Calls 206-744-9256
Ethnomed www.ethnomed.org
Madison Clinic 206-744-5100