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"What we've started to believe," Prado says, "is that it's not so much that the adolescent becomes subsumed in the American culture per se that puts them at risk; it's that they also lose the values of their country of origin." That's nothing new, of course, for a country that's been attracting immigrants for a few hundred years, but there's a twist here.
"The reason we believe this is such a risk factor is that their parents tend to be older, and coming to an area like Miami where Hispanics have political and economic power, they really don't need to speak English. They don't tend to gain American values." Meanwhile, the kids Americanize quickly, which heightens a cultural mismatch that affects family communication and can, Prado says, lead to risky behavior.
Haitian immigrants also face a readjustment in thinking about HIV when they arrive in America, says Edele Firmin, the HIV/AIDS outreach worker at Minority Development & Empowerment, a Fort Lauderdale agency that serves the Haitian community.
"To be honest, it's the newer immigrants that are more motivated about prevention, more open," says Firmin, who sports chin-length dreadlocks and round, black-rimmed glasses and speaks with a distinctive Creole accent. "When I recently had a focus group here, they were so shocked, the new immigrants, that there were Haitians living here who were not willing to disclose their status when they find they're HIV-positive."
But Firmin knows that many of those same Haitians will clam up as the realities about AIDS in America become clear. Many immigrants send money home, sometimes supporting an entire family. Some Haitians learn that they have a lot to lose in America by disclosing their HIV status, whether that's a job, spouse, or the support of friends.
By 1987, Darrow had been studying the transmission of HIV for more than five years, but he'd grown frustrated that he couldn't work directly on preventing the spread of the disease. His bosses at the CDC kept telling him they wanted him to work on vaccine studies, telling him that a vaccine was "just around the corner." Fifteen years later, there's still no vaccine.
Darrow transferred out of the infectious disease branch in 1987, taking charge of a section that developed intervention programs and community pilot programs, although at times he was called upon for AIDS research projects.
"I tried to start and guide this effort to get CDC and state and local health departments involved in interventions in health promotion in the absence of a vaccine," he recalls.
Darrow left the CDC in 1994, primarily because his wife had had enough of his workaholic ways. He landed a professorship at FIU, a location that made his wife happy because of the Miami airport's direct flights to Holland. Since then, he's coauthored a number of peer-reviewed articles concerning HIV and gay men living in South Beach.
Darrow saw a chance to increase HIV prevention work in a Clinton administration initiative intended to eliminate health disparities among minority groups. Out of that was born Darrow's Reach 2010 Coalition to Reduce HIV in Broward's Minority Communities, which was to receive just under $1 million a year until 2007.
The project contracted with several community organizations, including Hispanic Unity and Minority Outreach & Development, to work on prevention outreach and education.
"The difference between our plan and others in Broward County is that we were going out to the community and looking for residents who are at risk and delivering them prevention messages specifically at their houses, laundromats, houses of worship wherever they hang out," says Claudia Uribe, the project coordinator, a serious young woman with long dark hair.
Unlike most prevention efforts, Reach 2010 meticulously measures whether its outreach is actually having an effect. Kenneth Obiaja, the research coordinator, whose desk is surrounded by stacks of interview notes received from outreach workers, says that the data doesn't point toward the kind of behavior changes they'd expected. But with funding cuts, he adds, "We haven't been able to spread our wings as wide as we'd have liked."
"The problem is that just about all the money currently being spent in South Florida to prevent HIV infections is federal," Darrow says. "Few Florida general-revenue dollars, if any, are used to prevent HIV infections, unless you count the matching funds the state legislature puts up to support Gov. Bush's 'It's Great to Wait' teen pregnancy prevention program."
The health department's Castrataro, a young man with a shaved head and buffed physique, admits that prevention money has been and will likely remain flat. That has meant shifting prevention money among certain groups with rising HIV rates.
Tallahassee's way of dealing with the static funding, Castrataro says, has been to instruct local health departments to "be more creative, be more efficient, find new opportunities to use what you have to address everyone's needs without hindering any one population."
One casualty of low funding was local prevention plans. The state had mandated that local health departments, in partnership with community-based organizations, produce three-year prevention plans tailored to meet the needs of the groups most affected by HIV. Last year, the state stopped requiring the plans, which it had never sufficiently funded in the first place. (Castrataro says his office is developing a five-year plan anyway.)