understanding the abstract concepts of disease latency and probabilities of transmission; and injection drug use and homelessness. Apart from the multiplicity of problems created by homelessness, frequent changes of address or no home address jeopardizes their ability to receive Medicaid.

Immigrants

Immigrant women face a number of barriers in relation to prevention of perinatal HIV transmission. The most formidable are cultural, financial, and legal, including denial of residency or citizenship, as discussed further below. Insight into the experiences of Hispanic immigrants was offered to the IOM committee by a community organization serving Dominicans, the Community Association of Progressive Dominicans (ACDP). This organization counsels women and refers them to testing and treatment, among its other services to the community.

With a population approaching 500,000, Dominicans represent the second largest Hispanic group in New York City. The vast majority (68%) are immigrants whose flight from the Dominican Republic was the result of deteriorating economic conditions over the past decade. In New York City, 46% of Dominicans live below the poverty rate, a proportion higher than that of any other ethnic group in New York City (Hernandez and Rivera-Batiz, 1997). The proportion of undocumented Dominicans is not fully known, but was estimated in 1994 by the U.S. Immigration and Naturalization Service at less than 1% (Hernandez and Rivera-Batiz, 1997). From the perspective of ACDP, however, which serves the neediest, the figure is much higher.

For many Hispanic women, motherhood represents the pinnacle of their lives. It is a sacrosanct right of passage that imbues women with a sense of purpose, achievement, and bolsters their self-esteem and optimism about the future. Children are viewed as a "creation of God," according to one program administrator. With this cultural and religious mindset, the idea of prenatal testing for HIV is thought, in some cases, to verge on the preposterous.

The problem is exacerbated early in pregnancy by women's reluctance to seek prenatal care. Prenatal care is seen as a lesser priority than housing and employment, which frequently are more problematic. Further, many immigrant women distrust the health care system. The foreignness of the language and the institutional atmosphere inspire fears of deportation and death. Equating hospitals with death is not uncommon among other minority groups as well (see patient profiles, and workshop testimony from the National Medical Association from Appendix C). Another obstacle is the women's perceived inability to pay for prenatal care. Many providers and programs offer free care or care at reduced cost, but federal law explicitly prohibits undocumented immigrants and certain categories of legal immigrants from receiving Medicaid. Instead of seeking prenatal



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