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In response to efforts of unlikely coalitions of feminists, fundamentalist Christians, non-profit service providers, liberal and conservative politicians, The Trafficking Victims and Protection Act (TVPA) was passed in 2000 as a global attempt to reduce human trafficking (Stolz, 2005). President George W. Bush, in an emotional 2003 “Rescuing Women and Children from Slavery” speech to the United Nations, announced a $50 million initiative to combat human trafficking around the world (U.S Department of Homeland Security, 2005). According to the Trafficking Victims Protection Act (TVPA), trafficking is defined as: (a) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; (b) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of fraud, force, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery (Trafficking Victims Protection Act of 2000).
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The Trafficking Victims and Protection Act (TVPA) was designed to protect victims and to increase prosecutions against traffickers. Included in TVPA are provisions that allow illegal immigrants access to legal status and government benefits. Qualified trafficking victims may apply for “T visas” allowing them to remain in the United States and to receive federal government benefits. Requirements include agreement that victims cooperate with federal law enforcement in the prosecution of traffickers (Bales, 2005; Chuang, 2004; Webber & Shirk, 2005). T-visas allow many potential benefits not available to other illegal immigrants, including waiver of health screening requirement and HIV tests, protection against criminal prosecution for trafficking related offenses, and waiver of the “public charge” expectations. Qualified victims may petition to have family members admitted to the United States. United States anti-trafficking policies include attempts to encourage other countries to comply with anti-trafficking efforts by threatening lack of fiscal support to non-compliant countries (Stolz, 2005).

T-visa programs have been criticized by some as “free green cards” with potential for abuse and fraud (Allen, 2004). Other groups have expressed concerns that illegal immigrants may exploit the policies and use “the trafficking defense” to avoid criminal prosecution for unauthorized immigration and prostitution (Chuang, 2004). Despite these concerns about potential misuse of the program, actual utilization remains extremely low (Webber & Shirk, 2005). From 2001-2005, only 752 trafficking victims applied and 491 received T-visas (p. 1). It is believed that these numbers represent less than 1% of all trafficking victims (Chuang, 2004). The reasons for under-representation are not well understood. Some believe the emphasis on criminal justice needs to prosecute traffickers as opposed to victim needs and protections are factors. Victims may risk retaliation from traffickers, risk deportation by officials unfamiliar with policies, and face continued stigmatization.

Human trafficking or “modern human slavery” is an issue of increasing media and public policy attention. Although it is believed that human trafficking in some form has always existed, there were no specific United States policies on human trafficking prior to 1994 (Hopper, 2004). Human trafficking is almost always related to immigration, with trafficking victims initially making conscious decisions to enter other countries illegally. ”Push factors” including poverty, gender-based discrimination, and community violence likely contribute to the potential victims’ willingness to engage in risky migration practices. “Pull factors” include global labor needs and a market for illegal workers (Chuang, 2004). Many trafficking victims are lured into illegal immigration with promises of legitimate work opportunities (Bales & Lize, 2005; Coonan, 2004; Dougherty, 2006; Hopper, 2004).

Estimates of the numbers of victims are extremely variable. The U.S. Department of State estimated that between the years 2004-2005, 600,000 to 800,000 victims of human trafficking crossed international borders with between 14,500 and 17,500 coming into the United States (U. S. Department of State, 2005). Others have estimated that as many as 100,000 people are trafficked into the United States each year (Richard, 2000). It is generally believed that human trafficking numbers are underestimated (Hopper, 2004; Loff & Sanghera, 2004). High percentages of these victims are reportedly women and children, although the specific characteristics of victims, as well as the numbers of victims remain unknown (Bales, 2005; Hopper, 2004; Webber & Shirk, 2005). Moral, political, and fiscal motivations may distort reported human trafficking demographics in favor of groups supported by public sympathy and public funding targets (Loff & Sanghera, 2004). There some difficulties identifying potential numbers of victims and disagreement as to the accuracy of the numbers, types of victims, and potential solutions. Many advocates see trafficking as human rights or more specifically, women’s rights concerns. Women and girls are believed to be vulnerable to both human trafficking and HIV/AIDS given their traditionally subordinate position in societies (Chuang, 2004; Perkins, 2004). Involvement in the commercial sex industry is considered to be an important potential source of HIV transmission, especially among migrant laborers (Maxwell, Cravioto, Galvan, Ramirez, Wallisch, & Spence; 2005).

Although many believe human trafficking is related to organized crime and often connected to both other criminal activities and legitimate businesses, others believe this is overestimated (Feingold, 2005). There is some evidence that victims, traffickers, and customers are usually within the same ethnic group, with many traffickers recent immigrants themselves (Bales, 2005). Traffickers may be highly respected members of the ethnic communities where victims are recruited, often trusted friends or even family members of potential victims (Bales, 2005; Loff & Sanghera, 2004; Stolz, 2005).

Immigrants with HIV/AIDS may apply for HIV waivers if they are relatives of United States citizens and can meet conditions of “public charge” requirements. The “public charge” test requires that potential permanent immigrants demonstrate that they are not likely to become dependent on government benefits in the future. The average costs for HIV/AIDS medications alone are $10,000-$15,000 per person per year in the United States (Eckenfels, 2002; Kaplan, Tomaszewski, & Gorin, 2004). Due to the expense of HIV treatments and related health care costs, many immigrants without considerable financial resources or private health insurance will not be allowed to legally enter the United States. It is important to note that it is extremely unlikely for an immigrant to be deported from the United States based on HIV positive status, thus, the challenge is to avoid health screenings prior to entering the United States. Illegal immigrants already in the United States are more likely to be deported based on their illegal presence in the country as opposed to their HIV status. Immigrants entering the United States illegally are eligible for emergency medical services, including services related to pregnancy and delivery. Children born in the United States are considered legal citizens and are eligible for government benefits, regardless of the immigration or health status of parents (Cosman, 2005). The average lifetime cost to treat an HIV+ infant in the U.S. is between $46,170-$102,675 (Sansom, Jamieson, Farnham, Bulterys, & Fowler, 2003). Despite the restrictive policies, immigrants, including illegal immigrants, are eligible for public health care benefits and AIDS medications through Aids Drug Assistance Program (ADAP) (Kaplan, Tomaszewski, & Gorin, 2004). HIV positive immigrants, including those with legal immigration status may not be allowed to return to the United States in the event they leave the country. HIV waivers may be denied if the applicant has criminal charges or is not “of good moral character” (U.S. Department of Citizenship and Immigration, 2006).

Marisol is probably one of hundreds of undocumented sex workers infected with AIDS. This single case study is an illustration of the complex policy and practice issues involving immigration, human trafficking, and HIV/AIDS. HIV/AIDS and other infectious diseases create ethical, legal, and economic dilemmas for health care practitioners serving undocumented immigrants.

Immigration and HIV/AIDS
The United States is ambivalent about treatment of undocumented persons with HIV/AIDS. Public policies tend to be contradictory and are in a continuous state of change. In the current political climate of uncertainly for undocumented persons, fear of deportation and lack of access to health care may be increasing concerns.

Human groups in all societies have tended to maintain security and cultural identity through labeling other groups as different, deviant, or dangerous. Freud (as cited in Petkrova, 2006) was one of the first to recognize the human desire to categorize people into categories of “own” and “alien.” Persons perceived as “alien” or different from the dominant culture might encounter a range of public and reactions from sympathy to xenophobia. These range of emotions and attitudes are reflected in social policies and practices. The events of September 11, 2001 are believed to have escalated United States citizens’ fear and hostility towards “outsiders.”

Recent federal policy changes have impacted immigrants in the United States. These include the Personal Responsibility and Work Opportunity Act of 1996 and The Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (Pendelton, 2004). In general, these policies have made access to legal immigration status and public benefits more challenging for undocumented immigrants. Immigration policies traditionally attempt to protect United States citizens by limiting or denying entrance to immigrants with potential health, dependency, or criminal risks. Immigrants with HIV/AIDS may encounter increased public and policy hostility, as fear of AIDS may contribute to additional discrimination. Immigration policies currently consider being HIV positive as grounds for inadmissibility to those attempting to enter the United States. Any non-citizen entering the United States is asked if “you have a communicable disease of public significance” (Gavagan & Brodyaga, 1998; Lambda Legal and Immigration Equality, 2005; Pendelton, 2004). Persons applying for permanent immigration must undergo health screening including an HIV test. HIV positive applicants will be denied unless granted an HIV waiver. In order to qualify for HIV waivers, applicants must show: (1) danger to public health is minimal; (2) possibility of the spread of infection is minimal; (3) no United States government agency will incur expense because of admission (Lambda Legal and Immigration Equality, 2005, p. 5).

Human trafficking or “modern day slavery” has been the subject of increasing media and public policy attention. This single case study is an illustration of the complex policy and practice issues involving immigration, human trafficking, and HIV/AIDS. HIV/AIDS and other infectious diseases create ethical, legal, and economic dilemmas for health care practitioners serving undocumented immigrants. This paper provides an overview of policies impacting immigrants with HIV/AIDS, the Trafficking Victims Protection Act (TVPA) of 2000, and potential “real life” implications of these policies. Suggestions for policy and practice that may provide both individual justice and protection of the larger society are offered. Health education, both domestic and on a global level, has potential to reduce the risks to both individuals and community public health.

Marisol is a beautiful young woman with large brown eyes and shiny black hair flowing past her waist. To most people, she is the picture of good health. Marisol and her young son, Sergio, are both infected with AIDS. Marisol became aware of her HIV+ status when Sergio was extremely ill at birth. When the baby was discovered to be HIV positive, Marisol was tested and found to have AIDS. Sergio was fortunate to have been born a United States citizen and is eligible for government benefits including health care, access to medications, and government disability checks. Marisol, an undocumented or illegal immigrant, is not so lucky.

Marisol was brought across the border by “Uncle Ned” who promised her a well-paid job at a California resort. Marisol believed she had an opportunity to escape the poverty and family violence in her home country. She had her first child at age 14 after being raped by a relative. That child, Serena, remains in her home country. Marisol had only planned to stay in the United States for a short time. Hopeful that she could save money from her resort job, Marisol believed she could return to her country and use her earnings for a new start. Instead of the promised job at a glamorous resort, Marisol found herself forced into prostitution with most of her earnings going to “Uncle Ned.” Her dreams of a “new start” have been shattered by finding herself a single mother with living with AIDS. After becoming aware that she and her son were infected with AIDS, Marisol felt little choice but to remain. “If you think it is bad having AIDS here, you should see what it is like in my country.”

When Marisol first came to the attention of health care workers, she was living in a small, neat apartment with her baby son. Every month, Marisol and Sergio traveled more than 100 miles for Sergio’s medical appointments, accompanied by “Uncle Ned.” There was no pediatrician treating children with AIDS closer to her home in a small, rural community. The trip was a challenge as Sergio was often ill. Marisol did not speak English and relied on “Uncle Ned” to provide information and translation services to medical providers who assumed he was her husband or boyfriend. Marisol received her own medical care and medications through a local clinic where she was not required to provide documentation of her immigration status. She worried that she would be deported or that she would become too ill to continue to care for her son. “Uncle Ned” warned her that she would be arrested and separated from Sergio if her immigration status was known.