Interventions for HIV prevention should be informed by an understanding of the long-term source of infection, and not just by recent distribution (Mishra & Boily (STIs)). Amongst recent studies that have sought to inform future interventions are investigations of known subgroups thought to be a potential bridge into the wider population – such as migrant workers, or sex workers (STI/Kissinger & Shedlin; STI/Faisel & Cleland). There are other investigations that seek to refine on the definition of such groups (STIs/Davies & Tucker; STIs/Bayer & Coates). But could there be instances where classifications established for the purposes of data collection actually mask the existence of the groups that could have epidemiological importance?
Puerto Ricans in the north-east of the US may be an interesting case in point. A recent article (Deren & Santiago-Negron(D&S)) claims that the classification “Hispanic”, generally applied to Puerto Ricans for the purpose of data collection, may have obfuscated the distinctiveness of a Puerto Rican subgroup with its own specific risk profile, and considerable unmet medical health needs. As though to illustrate the point, D&S assemble various data relating to strong correlations, for example: between AIDS diagnosis and being Hispanic; between residence in the North East of the US and IDU-associated HIV; between HIV incidence and being a Hispanic IDU. Cumulatively – and taken along with the concentration of Puerto Ricans in the NE, and what is known of the high incidence of IDU-associated HIV in Puerto Rico itself – these data indicate the probability of a strong association, at least for the US North Eastern states, between Puerto Rican Hispanic identity and a high risk of drug-derived or heterosexually-transmitted HIV. Furthermore, it is not only the subgroup of US Porto Ricans that have tended to slip under the net, according to D & J; high levels of IDU-transmitted HIV in the island of Puerto Rico itself have failed to attract due attention, on account of the peculiar status of Puerto Rico – which is a US territory, without being a US state. As a result, Puerto Rico tends to figure neither in statistics for the Caribbean (as a US territory), nor in statistics for the US (since it is not a US state).
For Puerto Ricans – with an AIDS fatality at six times the US average and rates of new IDU and heterosexual infection twice that of the US – the problems of their anomalous status do not end with inadequate reporting. Budgets for syringe exchange programs (SEPs) are only a fifth of what they are in the US Northeast, while Puerto Rican IDUs are only a fifth as likely to be in treatment. SEP schemes cannot be funded by the US federal government, while the local Puerto Rican response to the drugs problem has, until recently, been largely provided through faith-based programs, with addiction defined by the Mental Health Law (2000) as a spiritual and social problem rather than a mental disorder. Relocation to the US Northeast for drug treatment has become a commonly recommended option, with 85% of Puerto Rican admission to drug treatment taking place in the US Northeast.
In view of all this, D&S recommend partnership between federal, local and private entities to develop a cross-regional approach to the Puerto-Rican epidemic. They also point out the challenges posed for such an approach by the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast.