Cultural competency is one of the hottest issues discussed by HIV prevention professionals and activists trying to find the best way to put across simple and effective public health messages. Whether trying to reach young people, people of specific ethnic, religious, or language background, or communities facing economic hardship or social stigmatization, those who work to stem the spread of the virus continually wrestle with the question of how to deliver messages about safer sex and the risks of sharing needles in ways that will be heard, understood, and acted on by the people most at risk.
Imagine trying to structure a culturally competent prevention program that meets the needs of a community made up of 49 distinct racial and ethnic groups.
That is one way to describe the mission facing the Asian Pacific Islander Coalition on HIV/AIDS, or APICHA.
The agency, founded in 1989 by a group of elderly Japanese American women and which now has an annual budget of roughly $3.3 million, provides HIV education and prevention, advocacy, and direct client services, including primary health care, for New York City’s exploding API population, which based on 2000 census data now likely represents more than ten percent of city residents.
For most New Yorkers outside the API community, the face of the Asian community may be the sizeable Chinese American communities in Lower Manhattan, Flushing, Queens, and Sunset Park, Brooklyn, or perhaps the Korean American grocers who play a critical role in delivering fresh vegetables and flowers to neighborhoods across the city.
Yet only a little more than a third of those that APICHA serves are Chinese Americans, with less than eight percent tracing their ancestry to Korea. Fourteen percent of the agency’s clients—who currently number about 200, with roughly 100 active in any given month—come from Southeast Asian backgrounds. More than 12 percent are descended from South Asian countries, including India, Pakistan, Bangladesh, Sri Lanka, and Nepal. Another 12 percent of APICHA’s clients are Japanese immigrants, and nearly seven percent Filipino. About ten percent have mixed ancestry.
There has been significant attention in recent years about HIV infection in people of color communities, but at least in mainstream AIDS circles little of that discussion has addressed the epidemic among Asian Americans. Yet, according to Dr. Frank Wong, an HIV expert at Georgetown University, perhaps seven percent of all Asian American men who have sex with men (MSMs)—a category that includes gay and bisexual men, as well as those with a looser identification with those communities—are infected with HIV. According to the city’s health department, through the end of 2001, there were nearly 900 cumulative cases of AIDS among APIs in New York City, with 40 to 50 new cases of full-blown AIDS diagnosed each year. More than 85 percent of those cases are among men.
These numbers alone point to a significant public health problem, but adding to that is the fact, emphasized both by city health officials and APICHA, that Asian Pacific Islanders in New York who are HIV-positive tend, on average, to access health care later than others infected with the virus. In fact, city statistics suggest that the rate of delayed access among APIs is twice the citywide average. Therese Rodriguez, APICHA’s executive director, in a recent interview, complained that city and other public health officials tend to view this issue as a cultural problem specific to Asian American communities. She emphasized that delays in accessing health care must also be understood in the historical context of insufficient outreach to the city’s API population. It was nearly a decade, she noted, before Asians and Pacific Islanders were broken out from the “other” category in statistical tabulations that initially accounted only for white, African American, and Latino infections and deaths.
Whatever the explanation for the failure of New York City’s health care system to tend to HIV infection among Asian Americans more quickly, the gap clearly indicates the hurdles facing APICHA, and also the value of an organization premised on the notion of cultural competency.
Rodriguez and her colleagues spelled out the nuts and bolts of serving a population as diverse as New York’s API community. The agency provides in-person services, including counseling, and also produces a wide array of printed materials, including subway ads, palm cards, pamphlets, and a comprehensive guide to living with HIV and AIDS—covering treatment, nutrition, exercise, wellness, legal considerations, and financial advise—called “Navigator.” According to Shu Hui Wu, a client services official at the agency, most written materials are provided in at least five languages, “Navigator” is published in eight languages, including English, and the full range of languages in which APICHA works includes Chinese (both Mandarin and Cantonese), Korean, Japanese, Hindi, Thai, Vietnamese, Tagalog, Bengali, and Urdu.
With its full-time staff of 24 (supplemented by between 40 and 50 peer educators, most of them young people, and roughly 60 fairly active volunteers), the agency tries to cover as many bases as possible, but there are limitations. Among the professional staff, nearly half have Chinese as their primary Asian language, with about one quarter most fluent in Southeast Asian languages, and 15 percent each in Japanese and Korean. Outside consultants—translation professionals, but also scientifically literate experts able to discuss complex medical terms and address sensitive issues of sexuality in culturally specific ways meaningful to lay readers—are required, and that places strains on scarce resources available to fund individual initiatives.
Simply finding a printer who has the appropriate fonts to publish in all the languages required, meet the other work specifications, and do so cost effectively can be a challenge.
Beyond the language, ethnic, and cultural hurdles, APICHA must of course also deal with the myriad issues every HIV group must address. The agency estimates that about two thirds of all APIs living with HIV contracted the virus through sexual intercourse, and that about 60 percent are MSMs. At APICHA, however, less than half of the clients self-identify as MSM, with about half saying they are heterosexual. Men outnumber women roughly three to one, and about two percent described themselves as transgendered.
Rodriguez and her colleagues, however, recognize that their client mix in part reflects where they are most successful at outreach, and APICHA has developed an “incubator program” called Trans Asian Pacific Alliance, or TAPA, for gender variant members of the community. The effort is funded out of a variety of other larger programs, but Rodriguez understands well the problems of finding long-term funding from government sources (which supply most of the agency’s budget) for such a narrowly focused effort. She said the push to keep the project growing is not without “expectation risks” for clients.
APICHA also has a program for newly out gay men as well as those not yet public about their status as MSMs, called Gay Asians Anonymous, which addresses the cultural barriers clients feel about being open about their sexual choices in their ethnic communities, and a Queer Asian and Pacific Islander film series, which meets on Sunday afternoons and targets youth. The agency pulls in between 50 and 75 young people for each screening, many of them people they might not otherwise reach.
As a story elsewhere in this issue about proposed new regulations from the Centers for Disease Control and Prevention (CDC) spells out, APICHA must also deal with longstanding federal regulations that forbid any government-funded prevention efforts from promoting sexual activity, a stipulation Rodriguez referred to as “no promo-homo.” She said concerns about running afoul of such regulations have increased significantly during the three and a half years of the Bush administration, and that adhering to the rules is particularly difficult when materials are prepared in several languages. Wu related how the agency labored long to develop a subway ad campaign showing pairs of young men with the text, “More than just friends and it’s OK. Remember to protect yourself. We understand it’s difficult and we can support you.”
The agency’s decision to move from education and advocacy into direct client services in 1997 led to a substantial increase in the scope of its work. From six government contracts then, the agency’s support has grown to 17 such grants, but the oversight of such a diverse portfolio is, in Rodriguez’s words, “nightmarish.” With its new primary care facility, APICHA now delivers health care directly to about 35 clients on an ongoing basis.
The agency has also offered HIV testing since 2001, since which time nearly 2,000 people have been tested, with 30 coming up positive, 28 of them MSMs. With rapid-test capabilities that can offer results within 30 minutes, APICHA is now testing roughly 100 people each month.
The group also works with the city’s health department on periodic Health Men’s Night Out outreach efforts in which HIV testing if offered on site at nightclubs around town. At one recent outing as Splash, four out of 49 men tested were positive. APICHA will offer rapid HIV testing at this Sunday’s PrideFest in the West Village, with a booth set up at Spring and West Houston Streets.
According to Bric Bernas, APICHA’s project manager for HIV counseling, testing, and referrals, the group is currently working with other AIDS groups serving communities of color to engage bathhouse owners and other proprietors of sex venues in dialogue about how to better engage their patrons in discussions of safer sex, both regarding HIV and other STDs, and about the risks of crystal meth use, particularly when engaging in sex. Bernas acknowledged that the effort is novel, and could prove controversial, but also argued that such a population can be difficult to reach and is critical to successful prevention work.
For more information about APICHA, visit the agency’s website at apicha.org.
The organization maintains a multi-lingual information hotline at
866 APICHA9 weekdays between 10:30 a.m. and 4:30 p.m.
©2004 Community News Group