Social Work Practice with Latinos Living with HIV / AIDS

This article explores social work practice with persons living with HIV/AIDS within the Latino community. It presents a general discussion of social work practice HIV/AIDS, followed by an exploration of culturally sensitive social work practice with Latinos. The authors then synthesize these bodies of knowledge into a discussion of HIV/AIDS in the Latino community, and social work practices that can be useful when working with this population. A case example of group work practice with Latinos living with HIV illuminates many of the themes explored throughout the paper. Finally, implications for social work practice are examined.


INTRODUCTION
Social Work as a profession is concerned with helping and empowering vulnerable populations.The two vulnerable populations that have garnered national attention in the last three decades now come together to create a new population that presents both challenges and opportunities for the social work profession, are people living with HIV/AIDS (PLWHA) and Latinos.Social Work practice with Latinos living with HIV/AIDS encompasses several areas of knowledge that include practice interventions for people living with HIV/AIDS, knowledge of cultural values of Latinos that affect treatment, and effective strategies for dealing with HIV/AIDS based on those cultural values.The authors seek to explore the aforementioned issues in this article and will provide a case study to illustrate certain principles related to working with this vulnerable population.

SOCIAL WORK WITH HIV/AIDS HIV/AIDS
HIV or human immunodeficiency virus is a virus that destroys the immune system.HIV is transmitted through sexual contact (via such fluids as semen, vaginal, cervical, and anal secretions), blood, and breast milk.The HIV virus progressively develops into AIDS (Acquired Immune Deficiency Syndrome) while the person living with the disease eventually succumbs by way of opportunistic infections associated with the later stages of the disease.HIV/AIDS is considered a pandemic with sixty million people infected worldwide.The United States prevalence for the disease is 1.2 million cases with 16% affecting Latino Americans (Centers for Disease Control and Prevention, 2005).

Social Work Case Management
Case management, formerly called social casework, is a staple characteristic of the social work profession.Chernesky and Grube (2000) describe case management's core functions or activities as consisting of: intake, assessment, care or services planning, linkage with formal and informal resources, advocacy, and follow up and monitoring.The Case Management Standards Work group acknowledges that social work case management distinguishes itself from other forms of case management because it "addresses both the individual client's biopsychosocial status as well as the state of the social system in which case management operates" (2002, p. 248).Therefore the social worker plays a vital role in helping the client manage all of their needs and accomplish this task by moving fluidly through distinct helping processes.

Social Worker Roles and HIV/AIDS
Providing services to clients with HIV/AIDS can be daunting to even a seasoned social worker simply because of the sheer magnitude and scope of services these clients need.Chernesky and Grube (2000) noted several themes in the HIV case management process that highlight both the characteristics of the clients and the roles of the social workers in servicing those clients.
The first theme noted was that HIV/AIDS clients are an extremely vulnerable population and thus are often in need of advocacy services from social workers.The functions of an advocate include interventions on both a micro and macro level.Social workers providing case management services can help clients by assisting them with the disability determination process.Macro level social workers can affect change by lobbying for increased funding from varied sources to assist in the treatment of clients with HIV/AIDS and prevention efforts (Krisberg, 2006;Linsk & Keigher, 1997).
The second component of HIV case management involves linkage with other services and systems and requires that social workers take on the role of a services broker.The most common overlapping systems that clients and workers interface with are the governmental, medical, and legal systems.Linkage with the governmental system includes receiving subsidized housing for People Living with AIDS (HOPWA funding, 1999) and assistance in procuring HAARTs (Highly Active Anti-Retroviral Therapies) and medications from federally funded AIDS Drug Assistance Programs (ADAPs) (Subways, 2005).The medical system provides PLWHA referrals to physicians specializing in infectious diseases and experimental clinical trials that may offer free medications in exchange for participation.The legal system also provides relevant services to HIV/AIDS clients by assisting them in the preparation of living wills, estate planning (Shernoff, 1998), power of attorney orders, and documentation of domestic partnerships.Also, the stigma surrounding HIV/AIDS can make clients a target for discrimination and harassment and they may require help with legal proceedings.
The third theme is that the case manager is often the central support system.Serving as a vital part of a client's support system requires that workers often simultaneously work as counselors and educators.PLWHA experience many losses and grief work is an essential component of counseling (Guilino, 1998).Clients often express a variety of fears, including fear of isolation, rejection, and abandonment.They may express fear over developing painful symptoms associated with diagnosis with one of the 23 AIDSdefining illnesses and opportunistic infections (OIs).Social workers also work on educating the client and their support network of family and friends about the disease.

SOCIAL WORK PRACTICE WITH LATINOS
In culturally competent practice with other groups, social workers must develop the skills, values and knowledge for working with a diverse population (Leigh, 1985).In this section, we will briefly address the areas of relevant values and knowledge.Important skills for working with Latinos with HIV/AIDS will be addressed more fully in a subsequent section.

Knowledge
Social work practice with Latinos is as diverse and complex as the group itself (Furman & Negi, 2007).The term Latinos, usually used interchangeably with the term Hispanics, refers to people whose ancestry can be traced to the countries of Latin American and the Caribbean.However, many Latinos did not "arrive" in the United States, but were actually Mexican nationals whose ancestral territories were annexed by the United states as part of the treaty of Guadalupe Hidalgo at the end of the Mexican American War.The same can be said for Puerto Ricans living on mainland Puerto Rico, who have been citizens of the United States for nearly a century.The United States population consists of nearly 14% Latinos, according to the latest census statistics (Marotta & Garcia, 2003).It is thought that by the year 2025, 25% of the population of the United States will Latinos (U.S. Bureau of Census, 1998).
For many Latinos, the term itself is a social construction which is perhaps less important to their identity than other factors (Furman & Negi, 2007).Most Latinos, for instance, identify primarily by their nation of origin.Some, for instance Guatemalan decedents of the Maya, identify primarily by their ethnic group (Little, 2004).However, in spite of the diversity within the Latino population, thinking of Latinos in terms of group identity is useful for several reasons.First, with the exception of Brazilians who speak Portuguese and those who primarily speak indigenous languages, Latinos are bound by the historical use of Spanish.Second, many Latinos have come to view themselves as being an increasingly powerful political entity whose unity is a considerable source of power (Gregory, Steinberg, & Sousa, 2003).National and local elections are increasingly influenced by Latino votes.Recent legislative actions concerning immigration have, in part, been slowed by politicians' concern about the impact of legislation on Latinos as a voting block.Third, Latinos share many similar values which are rooted within the lives of post-colonial Latin America.The centrality and importance of these values contrast to those of the dominant U.S. society and set Latinos apart as a distinct and evolving group.

VALUES AND THEIR TRANSLATION INTO SKILLS
Several key values are extremely important to all social work practice with Latinos.While the several presented are only a partial list, they form a core that binds Latinos and will help social workers who are new to providing services to the population.Each of these values has important practice implications for working with Latinos with HIV/AIDS.In general, the values expressed below are extensions of the overall collectivist values that many Latinos hold, which compares to the more individualistic values of the dominant American culture.These collectivist values have been shown to be adaptive in that they have lead to historical group cohesion during times of social disruption and distress (Cabrera & Padilla, 2004) and have been shown to be a protective factor inculcating against some types of psychosocial problems, such as substance abuse (Sale, et al., 2005).

Familismo
Social workers and other professionals new to working with Latinos often misinterpret the importance of family and its centrality in how Latinos view identity and existence (Lugo Steidel & Contreras, 2003;Valenzuela & Dornbusch, 1994).For white Americans, the individual is viewed as the most essential unit of analysis.We tend to think of people as individuals who live in the context of environments and groups (Williams, 2003).Social work in the United States is largely a reflection of this individualistic focus.For instance, one of the most central organizing principles of social work practice is "person in the environment" (Ashford, LeCroy, & Lortie, 2001).In this perspective, the individual is located within various levels of systems that form its social context and create its reality.However, implicit within this perspective is the centrality of the individual to the practice model.This perspective breaks down for work with Latinos who view themselves as inextricably connected to family life in ways that white Americans cannot understand (Garcia & Zuniga, 2007).Social workers often express confusion at Latinas' willingness to sacrifice their well-being for their families and may "diagnose" them as having poor boundaries or insufficient individuation.The worker may seek to help women develop individual goals and more "ego" strength.These concepts are largely inconsistent with Latinos' culture in which such concepts will sound selfish (Cauce & Domenech Rodríguez, 2002).When working with Latinos, workers need to suspend or "bracket" their negative assumptions about how their clients relate to their family members and adopt a strengths-based orientation.

Personalismo
Personalism, or personalismo, refers to Latinos preference for warm, personal and engaged relationships (González-Ramos, Zayas, & Cohen, 1998).This applies to both the helping relationship and the nature of agency life itself.For instance, cold, impersonal, highly structured and bureaucratic services often make Latinos feel unwelcome.While respecting professional roles and expertise is extremely important, this respect is not of a detached and distant manner.Professionals are expected to be engaging, warm, kind, and empathic.It is also valuable for social workers to share some personal information about themselves and especially their own families.Self-disclosure of this nature is an important practice skill.It helps Latinos feel a sense of trust and view their social workers as authentic, real and caring people.This is especially important when providing services to Latinos, such as newly immigrated or undocumented residents, who have good cause to mistrust mainstream institutions.

Orgullo and Respecto
Orgullo, or pride, is an extremely important value within Latino communities.Orgullo manifests as pride for one's cultural identity, pride about one's skills and capacities, and pride for the ability to maintain one's family.Orgullo at times may make it difficult to seek and receive help, as Latinos often perceive the need for help as harming their sense of self (Delgado & Humm-Delgado, 1982).Respecto, or respect, is a key value within Latino communities.As treating individuals with dignity and respect is a core social work value, social workers should find adhering to this value congruent with their practice.However, what constitutes respect can differ greatly between Latinos from different countries of origin and between individuals within groups.It is therefore important for social workers to ask their clients about their own understanding of respect and what the worker can do to make them feel respected.As a general guideline, social workers can demonstrate respect by attempting to value the cultural and personal worth of all of their clients.It is also important that social workers spend a great deal of time establishing a quality helping relationship before they "intervene" in a manner that would make a Latino feel judged or criticized.Analysis and clinical interpretations, while an important part of some clinical systems, should be used judiciously with Latinos by those from other cultural contexts, especially early in treatment.Critical analysis can often be viewed as being disrespectful, as tact and delicacy are important cultural means of expressing respect.

Machismo
Within Latino society, machismo is considered the constellation of ideal male characteristics which include physical power, social domination, and a discounting of feminine characteristics.The roots of machismo have been traced to the influence of Catholicism on indigenous peoples and the reaction of indigenous men to their own subjugation at the hands of Spanish Conquistadors (Hardin, 2002).Too often, the "negative" aspects of machismo have been highlighted.Taylor and Behnke (2005) contend that a central component of machismo is centered on the role of the Latino father and their capacity to provide for the family and the lengths they will go to do so.Latino men who for socioeconomic reasons are unable to engage in this pro-social aspect of machismo may engage in other, less positive ways of proving their worth and masculinity.When working with Latinos, it is important to recognize that machismo can often be a double edged sword.On one hand, many Latino men believe they can handle problems on their own and will therefore neglect to seek services.On the other hand, Latino men can be helped to tap into the more positive aspects of machismo, their responsibility to family and community, as a motivation for seeking help and resources.The other side of machismo is Marianismo.In Marianismo, women are expected to be subservient and obedient to their men (Sherraden & Barrera, 1997).As we shall see, this has important implications in terms of safe sex and sexual choice.

SERVICE DELIVERY CONSIDERATIONS FOR LATINOS WITH HIV/AIDS
As noted, culturally sensitive practice with Latinos with HIV/AIDS is influenced by a large degree of within-group variation.Therefore, the information presented must be carefully applied after assessing the specific needs of each client and their system.The following are specific suggestions for delivery of effective, culturally relevant social work interventions to Latinos with HIV/AIDS.They draw upon important ideas from the previous discussion on values and extend to other important clinical and macro level issues.

Spanish Speaking Service Providers for Less Acculturated Clients
There exist various degrees of acculturation within the Latino culture.For those clients that are less acculturated and speak mostly Spanish, services should be provided in Spanish to reduce misinformation and miscommunication (Aronstein, 1998;Deren, Shedlin, & Beardsley, 1996;Giulino, 1998).For example, specific details about antiretroviral medication regimens may be complex and difficult to understand even without a language barrier, so the potential for miscommunication should be removed whenever possible.Furthermore, medical terminology regarding AIDS symptomology and pharmacology should be phrased to clients in easy to understand, jargon-free language.

Culture-Bound Illnesses and Folk Healing in Medical Care
When working with HIV, the client's sicknesses and ailments are often a subject of discussion with the social worker.Culturally sensitive practice entails awareness of culture-bound illnesses such as empacho, which is a stomach ailment, embrujado, which is erratic behavior possibly due to bewitchment (Koss-Chioini & Canive, 1993), and ataque de nervios, a panic reaction following a time of grief (Guarnaccia, DeLaCanceela, & Carillo, 1989).Being acquainted with these conditions within the Latin culture can help the practitioner determine what is a culture-bound syndrome and what may indicate the need for medical or psychiatric intervention.
In evaluating culture-bound syndromes in Latin American culture, the social work practitioner must also maintain an awareness of the role of folk healers, priests, etc., who treat such illnesses.In immigrant populations coming from Mexico and Central America, the curandero, or folk healer, would treat such illnesses.A potential problem is that curanderos sometimes claim that they can "cure" HIV (Bowden, Rhodes, Wilkin, & Jolly, 2006) and also numerous culture-bound illnesses through less traditional interventions such as the use of herbs (Land, 2000), teas purchased at a botanica (botanical shop) (Delgado & Santiago, 1998), and intercession and healing services, which could lessen the clients' efforts to avoid infection or participate in traditional medical treatments.Social workers should be sure to advise clients to use the alternative herbal therapies only with physician approval.
Sometimes the culture-bound traditions impede care or place an individual at risk.Consider a case where uninfected Latino immigrants were known to wear amulets (available at local Latino grocery stores called tiendas) around their wrists to protect them from sexually transmitted diseases (Bowden, Rhodes, Wilkin, & Jolly, 2006).Myths such as this should be addressed with facts in order to save lives.

Recognition of Importance of Traditional Religion
Recitation of prayers, praying to the saints, blessing oneself with holy water, wearing holy artifacts (Land, 2000) and lighting religious candles are important elements of Latino practice of Catholicism.Prayers to the Our Lady of Guadalupe or other representations of Mary are common especially during times of crises.Acknowledgement that these are important practices to Latino clients may be helpful to their establishing a bond with the social worker.

Sexuality and Latino Culture
One Latina service provider interviewed in the Bowden, Rhodes, Wilkin, and Jolly ( 2006) study reported, "The Catholic influence that sex is for procreation and not for pure enjoyment, combined with the idea that talking about sex encourages more sexual activity, poses barriers to educating the Hispanic population about HIV/AIDS (p.553)."This silence surrounding sexuality in Latino culture affects different Latino sub groups in varying ways and poses different challenges to social workers.Diaz (1998) reports that open discussion of sexuality is often seen as taboo in Latino culture.When this sexuality taboo and the concept of machismo collide, many gay Latinos often feel alienated from their own culture.Hunter and Hickerson (2003) note that "the primary allegiance for Latino lesbian and gay persons usually remains with their ethnic identity, their community, and most prominently, their family" (p.24).By disclosing both their HIV status and homosexuality, it can cost these individuals their family support (Hunter & Hickerson, 2003).Also, to complicate matters, there are men who identify as heterosexual yet engage in risky (unprotected) sexual behavior with other men without informing their female partners (Wolitski, Jones, Wasserman, & Smith, 2006).This is a significant problem in the Latino community as Fernandez et al. (2005) found that 43% of Latino MSM (men who have sex with men) are having unprotected sex, with 22.5% of those men being HIV-positive.To address the needs of Latino MSM, The Sex Check was developed (Katz et al., 2005).Katz et al. (2005) describe The Sex Check as a brief, one-on-one, telephone-delivered HIV prevention intervention used to target individuals who were at risk for HIV infection or transmission but were not seeking support or engaging in harm-reduction strategies.Social workers can use interventions such as The Sex Check to aid them in discussing issues around sexuality with their clients.Also, social workers working with HIV-positive gay, Lesbian, bisexual, transgender, and MSM Latinos must maintain a constant awareness of the role that their culture plays on expressing their sexuality.

Latina Women's Sexuality
Women of color have a history of disenfranchisement, oppression, and marginalization in both the U.S. and global community.This oppression expresses itself in a myriad of ways.One method of controlling women's sexuality is to control their access to reproductive health services and information.Latina women have suffered such oppression and as a result are reluctant to encourage condom use "because women fear verbal and physical abuse and because condoms are associated with prostitution, poor hygiene, and contraception" (Land, 2000, p. 90).Social workers can help confront the oppression present in Latinas' primary relationships by making referrals to culturally sensitive physicians and other medical professionals who can educate them about issues surrounding their reproductive health.Social workers can also provide assertiveness training techniques to Latina clients to help facilitate more equality in their relationships.

The Family as a Supportive and Preventative Mechanism
The value that Latinos place on the family has been well-documented.However, a scarcity exists in the availability of HIV prevention literature about the role of the Latino family in helping to mitigate risk factors associated with the HIV virus.Despite this scarcity, social workers can examine and draw from research focused on other minority populations to gain knowledge and find some relevant practice guidelines.Icard, Schilling, and El-Bassel (1995) found that when comparing two groups of African American parents who had received standard HIV prevention training, the experimental parental group that received communication and problem solving skills training were found to feel more comfortable talking with their children about sex and safer sex practices.Social workers can adapt certain techniques and strategies for use with this population to reflect a cultural practice that is sensitive to their client's needs.
Latino families also, as noted before, provide much tangible as well as intangible support to their families.However, special attention must be paid to Latina women.Latina women are often the main caregivers in the home, and when they are HIV-positive they must carry the burden of caring for themselves and the other people in the household.Often their own needs for rest and reduced stress are ignored (Remor, Penedo, Shen, & Schneiderman, 2007).In addition to the numerous responsibilities taken on by HIV-positive Latina women in the household, the pervasive cultural attitude mandates that the caretaking activities of household members be placed solely on the immediate family, making the hiring of a personal assistant prohibited.Social workers should provide education to caregivers about issues regarding burnout and provide linkages to organizations offering respite care in an effort to help clients deal with the stress of caretaking.

LATINO SUPPORT GROUP CASE STUDY
A common method of service delivery in ASOs (AIDS service organizations) targeted at sub-groups of the HIV/AIDS population is the use of culture-specific or agespecific support groups.At a local ASO in the community of Charlotte, North Carolina, targeted support groups are offered for adolescents and Latinos with HIV.Based on actual group dynamics seen at the ASO, the following is a composite case example of a Latino social worker facilitating a support group for Latinos infected or affected by HIV.Notice the following Latino-related themes: the worker establishing personal contacts with the clients, viewing the group as an extended family, the need for Spanish-speaking practitioners and culturally sensitive agency procedures, the machismo tendency to see females as caregivers, and the importance of spiritual beliefs and practices.The following AIDS-related themes are illustrated: the need for support at times of crisis such as hospitalizations, PLWHA's lack of support due to isolation or death of partner, judgments made about the mode of one's transmission, the presence of debilitating symptoms such as forgetfulness due to AIDS-related dementia, and struggles around if, when, and/or how to disclose one's seropositive status to family members.The group is led in Spanish, but for purposes of usage, dialogue will be presented in English.
Isabel heads down the hall of her workplace, an urban AIDS service organization (ASO) located on the outskirts of a Latino community.She is on her way to lead a support group offered once a month for Latino clients of the agency.She mentally thinks through who will be in attendance.She knows who will be at the group meeting because she is conscientious to call each of her members the day before to remind them of the meeting time and find out if they will attend.She knows this practice is much more effective than the use of mailings or flyers.Her group population responds well to her personal contacts.(Isabel has effectively utilized the value of personalismo to reach her clients and encourage attendance for the support group).
As she enters the group room, an older lady named Rosa is talking with other members about their visit to see Maria in the hospital earlier in the week.Maria, a group member, has had back to back hospitalizations for kidney failure, as a consequence of her AIDS."Who will visit Maria tomorrow?"Rosa asks."I will.Do you want me to pick you up, also?" responds Jose, a young man who contracted HIV through an IV drug habit.(Jose is offering tangible support to Maria and providing others the opportunity to participate by offering transportation to the hospital; He views the group as an extended family).
"Yes, I would.She needs visitors.We're all she has …I don't have anyone to visit me since my dear husband died of respiratory failure from his AIDS so I'll be there for Maria," says Rosa. (Rosa shows compassion for Maria and provides support as she is aware of the hardships associated with dealing with the illness without a partner).
After a few minutes of group discussion about Maria and the importance of feeling connected to a group of supportive people at times of crisis, the door to the group room opens.
"Sorry we're late," says a young couple, in unison."We had trouble finding the place.""Did the receptionist lady give you directions?Because I got lost my first time, too.I couldn't follow all those crazy street names.Look, just remember to turn left at the fire station, then another left at the funky pink daycare center and you're here," explains Chico.(Chico fills in a gap regarding culturally sensitive agency procedures by providing directions with landmarks so that the couple may better find the meeting location).
Isabel smiles because she has noticed that her clients respond well to following directions using landmarks.She's learned to use that method to help get them to their numerous medical and resource appointments around the city.She knows it is the young couple's first meeting, but she doesn't want to lose an opportunity to point out the importance of promptness.Chico, a gay man who contracted the virus from a partner who did not disclose his own positive status, says, "Honey, your man needs to take care of his own stuff…and mister, you need to take responsibility for your own treatment."(The group notices the cultural values of machismo and confronts both Lupe and Jose to take responsibility for themselves and how the disease is affecting each of them).
Julio seems threatened and volleys back, "What do you know about marriage anyway, you (Spanish gay slur)!" (Julio demonstrates prejudice and bias regarding Chico's sexuality by insulting him with a derogatory slur).
Jose chimes in with "Hey, we're all family in here.We don't put each other down.It doesn't matter how you got it, now you have to deal with it."Isabel intervenes, interjecting the importance of personal responsibility and of someone taking ownership for care."Mr.Sullivan may extend you more grace in your case management meetings," says Isabel, making reference to the fact that Mr. Sullivan, a non-Latino practitioner may be overcompensating in an effort to be culturally sensitive."I will not allow group family members to be disrespectful in this place," adds Isabel.
"That is the truth," adds Rosa.
"Julio, you may not understand this now, but from now on if you need something from me, I'd like you to make the call, not Lupe," explains Isabel.She feels that his disengagement from the coordination of his care is part of Julio's denial at being HIV positive and shows he doesn't want to deal with it.
The group discussion continues, with various members drawing out the new couple and finding out their story.They have both recently been diagnosed as positive, and are struggling with the decision of whether or not to tell their families back in Guadalajara.(Lupe and Julio struggle with whether or not to reveal their HIV status to their families, which is a major decision that could result in reduced support from their families).
"I'd like to close the meeting with a prayer to Our Mother Mary, for help for Maria in the hospital," says Rosa, gathering up the hands of those on each side of her.(By closing the meeting with a prayer to a Catholic saint, group members feel validated and that their religious beliefs are valued and respected).The group closes in prayer for one of their "family" members.

CONCLUSION
The preceding case study demonstrates examples of how values and skills are implicated in providing services to Latinos with HIV/AIDS.The case example also points out the complexities of providing culturally competent services.It is important to note that developing cultural competence is a lengthy process; and while we have explored many key issues in working with HIV-positive Latinos, social workers are encouraged to view the development of cultural competence as a life-long journey.This is especially true when working with a population as diverse as the Latino community.Working with Latinos suffering from HIV/AIDS challenges social workers to understand the confluence of complex and varied psychosocial factors; social workers providing services to this population are also working with two groups who have been the recipients of tremendous discrimination.In addition to direct practice interventions, social workers are encouraged to engage in advocacy on the organizational and community levels to insure that increased and competent services are developed for Latinos.Future research is needed on effective means of providing services to this population.

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Try to be on time, because it's important to get in that habit.What happens if you're late with a dosage of medications or you're late for your new doctor or late for your appointment for emergency rent help?" Isabel asks."Theyskip over you.Yep, they do," confirms Rosa."Remember, if anyone needs a calendar I have some free ones from drug companies to share with you.It's very important to keep your appointments written down so you won't miss them if you have memory difficulties," explains Isabel."I'vebeen having a hard time with forgetting things the last couple of months," confides Jose."I found something that helps.I have Chico call me the morning of my appointments to make sure I remember and I do the same thing for him."(Notice how the group members find supportive solutions to dealing with such symptoms like AIDS related dementia by calling each other on the day of their appointments).