The Latino Health Institute is one of several organizations around the country that now make altares as a way to honor the memory of Latinos who have died of AIDS. "For many people, the altars bring healing," Vlassidis says. "They also provide a safe place to talk about the epidemic."

Vlassidis believes that this outlet for grief-and this reminder of AIDS-is critical for Latinos, who are now incurring HIV infections at a rate faster than that of the general population.

The Latino Community
The more than 27 million Latinos living in the United States comprise a community of communities. Approximately two-thirds are of Mexican descent, while the remaining one-third, or their ancestors, came to this country from Central or South America, Puerto Rico, Cuba, or Europe.

"For an example of the diversity of Latinos in this country-I am Chilean, but in making the altars, I was helped by Puerto Ricans, Guatemalans, Salvadorans, and Colombians-all in recreating a Mexican tradition," Vlassidis says.

Latinos do not share a single race, religion, or social class. Although few generalizations can be made, compared to non-Latino whites, Latinos tend to be younger, poorer, less likely to be high school graduates, and more likely to be unemployed.

These socioeconomic realities-often combined with language barriers, limited social supports, and little or no medical insurance-have placed many Latinos at relatively high risk of HIV infection. While Latinos account for less than 9 percent of the total U.S. population, they make up more than 17 percent of all cumulative AIDS cases. Nearly 90,000 Latino AIDS cases have already been reported to the Centers for Disease Control and Prevention.

HIV infection rates among Latino men are highest among those who have sex with men and those who use injection drugs. Most Latinas are exposed to HIV either through their own injection drug use or-increasingly-through heterosexual contact. As more Latinas have become infected, the number of HIV-positive Latino children has also risen. In New York City alone, nearly 40 percent of infants with HIV are Latino.

A Multilingual Epidemic
Experts agree that new and redirected energies must be focused on HIV prevention among Latinos. Language barriers are often the first impediment to overcome. "Not all Latinos speak Spanish; many speak Portuguese or indigenous languages," Vlassidis says. "Moreover, Spanish speakers have hundreds of different dialects."

According to Heriberto Crespo, director of health education at the Latino Health Institute, prevention efforts need to be directed toward Latinos with limited English language skills. "Some institutions still provide AIDS brochures in English only," he says. "Spanish-language materials, when available, are often literal translations of English materials and therefore culturally inappropriate. Human reproductive anatomy, for example, may be discussed in ways that won't bother Anglos but will shock Latinos."

Even within different Spanish-speaking groups, Crespo notes that it is important to use language carefully. "If I'm giving a workshop on HIV to Puerto Ricans, I can use the word condones for condoms. But if the audience is Dominican, I must use the euphemism profilacticos. Otherwise, they will be offended, and I will lose them."

In Austin, Texas, Elvia Mendoza begins conversations about AIDS in whatever language will get people to listen, whether English, Spanish, or Tex-Mex, a mixture of the two. "People are initially hesitant, so you have to gain their trust," says Mendoza, an HIV outreach educator at Informe SIDA. "You have to keep talking-not preaching-in a way that makes them feel like you're their next-door neighbor."

I Can Hear It in Your Voice
For Mendoza and other outreach workers, conversations about AIDS can be held anywhere-in homes, on street corners, in grocery stores, at religious festivals. This integration of HIV outreach within the Latino community must be carefully negotiated, however, as it links the fight against AIDS to traditions that can both help and hinder prevention and care.

"My mother called and asked, 'What's the matter? I can hear it in your voice,'" says Michael Melendez, president of the board of the Latino Health Institute. "I told her I have HIV. From that point, my parents' response couldn't have been better. My father told me, 'I don't ever want you to feel alone. You are never alone; you have your family.'"

Like Melendez, many Latinos retain close ties to their families, yet the very closeness of these bonds can make it difficult for some individuals to be open about their personal lives. "In immigrating here, many of us lost our countries, our land, our communities," Vlassidis says. "For many immigrants with HIV, family members are all they have, and they don't want to risk losing them by saying they're infected."

In addition, the centrality of the family to Latino culture has often served to reinforce traditional sex roles. People who either fall outside these roles-such as men who have sex with men-or are caught within them-such as young Latinas-may be at increased risk of HIV infection.

"When my cousin died of AIDS, his mother found it easier to think of him as having become infected through drugs rather than through sex with another man," Melendez says. "Because of homophobia, it's not uncommon for Latinos who have never done a drug in their lives to suddenly die of AIDS because of injection drug use."

Homophobia in the Latino community has forced same-sex behavior underground, where it is harder for HIV prevention programs to take hold. Moreover, the limited data available suggest that, among men who have sex with men, Latinos are more likely to have sex with women as well. Yet bisexuality is rarely discussed within the community, a silence that places both men and women at higher risk of HIV infection.

The Latinas with whom Mendoza works tell her that "the only women who get HIV are those who sleep around." Others have told her they thought that being married and having children made them immune to HIV.

Misconceptions are not the only source of vulnerability to HIV. Many Latinas may also be at risk due to traditional gender roles. "Machismo still lingers," Mendoza says. "If a Latina suggests using a condom, her partner may think she's implying that he's been sleeping around, or that he's gay."

These traditional gender roles can make the negotiation of safer sex more complicated, but not impossible. Working with women in Hartford, Connecticut, Carlos Toro, AIDS health educator at Latinos Contra SIDA, says, "It's give and take. We try to empower women, to get them to take a stance. If not just for their own health, then also for their kids. We try to get them to think about where their kids would be without them."

Dual Roles of the Catholic Church
Latinos Contra SIDA also targets adolescents, since much of the Latino population is in-or about to enter-the age groups in which most new HIV infections are now occurring. Moreover, studies have shown that young Latino males, in particular, are less likely than their peers to use condoms during sexual intercourse-a reluctance that may, in part, be attributable to machismo.

Condom use is further complicated for some Latinos because of the Catholic Church's stance on contraception. Although the expression of Catholicism is not monolithic across Latino cultures, the religion still influences the lives of millions of Latinos in both subtle and direct ways.

In terms of HIV prevention, Mendoza says, "Catholicism is a barrier in that you're not supposed to discuss sex, and if you do, you're admitting to feelings that are considered shameful. These feelings effectively close the door on our outreach efforts."

Yet to dismiss the Catholic Church simply as an obstacle is to deny the broader cultural role it plays in the lives of many Latinos and to overlook how it has supported Latinos with HIV and their families. "A lot of Catholic churches are really liberal," Toro says, "because their focus is on youth and they want to protect them."

Barriers to HIV Health Care
For many Latinos with HIV, obtaining the care they need remains a challenge. "Treating HIV is only part of the picture," Melendez says. "Latinos frequently face poverty, poor nutrition, violence in the community. Those with HIV are often very sick by the time they seek treatment. Many have jobs that won't give them time off for medical or social service appointments. For some, the time off can become a survival issue-they can lose the income or even their jobs. One step providers might take in response to these problems would be to stand back and review clinic hours."

Communicating with physicians can pose further problems. "Hospitals don't have enough interpreters on staff," says the Latino Health Institute's Crespo. "I know of cases where doctors asked cleaning staff to interpret. While these interpreters may be bilingual, they don't have the skills necessary to convey medical information and choices. More importantly, their involvement presents a serious breach of confidentiality." In some cases, Latinos are even asked to bring their bilingual children to interpret for them. "Perhaps the worst feature of this practice is that it makes the child responsible and the parent dependent, a reversal of the normal parent-child dynamic," Crespo says. In Boston, the Latino Health Institute provides treatment advocates who act as interpreters, maintain confidentiality, and inform clients of additional services.

Such advocacy is crucial, according to Jane Delgado, president of the National Coalition of Hispanic Health and Human Services Organizations. "Latinos don't have enough information about treatments, outcomes, or available options," she says. "Many people still believe HIV is a death sentence, when in fact it's slowly becoming more of a chronic disease, something that can be managed."

The political climate brings additional challenges, as some members of the Latino community are particularly affected by federal laws that restrict people with HIV from entering the country and demand the deportation of those found to be living here temporarily. The fear of deportation in particular may keep HIV-infected people without documentation from seeking health care.

Access to AIDS care may also become more difficult for Latinos who live and work here on a permanent basis. California's Proposition 187, for example-which was passed by a statewide referendum but is unimplemented pending a court challenge-would require agencies receiving state funds to determine the residency status of all clients. The agencies would then be forced to deny state-funded social services-including HIV services-to those without the appropriate documentation.

Forging a Different Future
"Latinos need AIDS programs that are located where people live, take their decision-making into account, and involve their family members," Delgado says.

Outreach workers such as Maria Cristina Vlassidis are incorporating AIDS education into people's lives. Last year, on World AIDS Day, Vlassidis's fourteen-year-old son helped her build an altar for Latino children who have died of AIDS. Together, they pinned up carousel horses, laid out baby shoes, and placed a teddy bear against a basket of fruit.

"What does our future hold if our children are dying?" Vlassidis asks. "Children are a symbol of hope. With these altars, we do more than acknowledge our losses. We express our hope and commitment to fighting AIDS as a community."