Use your noodle. Simply stated, this slogan combines the noodle-a staple of most Asian cuisines-with a clever reminder to think before acting. "Everyone in our community eats noodles, so the campaign plays on the importance of food in our cultures," says Karen Kimura of the Asian Pacific AIDS Intervention Team. "With wit and humor, it also encourages people to think before taking risks associated with HIV."

Kimura developed the campaign to focus more attention on the epidemic among Asians and Pacific Islanders (APIs), many of whom have been reluctant to admit that AIDS is a problem in their community. "Like other groups, we still hold HIV and AIDS in shame," she says. "If an Asian stands up and says he or she is HIV positive, many times the reaction is 'sit down,' or 'don't tell anyone.'"

While silence has been a hallmark of the API epidemic thus far, campaigns such as "Use Your Noodle" invite people not only to consider their own personal risks, but also to think about factors that increase the entire community's risk of HIV infection. These factors include denial of an HIV epidemic among APIs, sexuality taboos, familial expectations, and perceptions of API success in this country. A final risk factor is the paradoxical role of the community's tremendous diversity-generally considered to be one of its greatest strengths, this same diversity has also made it more difficult to develop an effective response to the epidemic.

Snapshot of the Epidemic
According to the U.S. Census Bureau, APIs compose a single group. In reality, however, APIs, or their ancestors, have come to the United States from more than forty countries and territories and speak over a hundred languages and dialects. Thus, the millions of people placed within the API category-ranging from Chinese Americans whose families have lived in the United States for generations, to recent immigrants from Southeast Asia, to Pacific Islanders-form a community marked by distinct cultures, histories, and voices.

"How do you get lifesaving AIDS information to such a linguistically, culturally, and geographically diverse group?" asks Kiyoshi Kuromiya, director and founder of Philadelphia's Critical Path AIDS Project. "This is an urgent question, because more and more APIs are becoming infected all the time."

For many APIs, the AIDS epidemic thus far has been a murmur within the background of their lives. Compared to other communities in the United States, AIDS figures for APIs appear to be relatively low: The Centers for Disease Control and Prevention's (CDC) most recent data show a total of approximately 3,500 cumulative cases. It was not until 1988, however, that the CDC created a separate API category for HIV and AIDS-a lapse that precludes true cumulative totals for the community.

Moreover, according to those fighting AIDS in the API community, the actual number of cases is much higher. Accurate epidemiologic data are desperately needed, especially in light of changes that may bring AIDS to the fore of the community's attention in the next few years. Among these changes is a projected growth in the API population-from nearly 9.5 million people today to more than 12 million by the year 2000-which is expected to bring an attendant increase in HIV infections.

The API epidemic in this country may also be influenced by the rising number of HIV infections in South and Southeast Asia, where the total number of new infections is projected to exceed that of Africa by the end of the decade. "In the coming years, AIDS will profoundly affect our home communities," says Paul Kawata, executive director of the National Minority AIDS Council. "For those of us who care passionately about where we come from, we will no longer be able to look at what's happening in those countries and deny the effects of AIDS." Confronting denial has been a particular challenge for the API community, where cultural norms have often operated against acknowledgment of the epidemic.

The Silence and the Stigma
"The silence comes because we're talking about sex, we're talking about needles-things we're not good talking about as a community," Kawata says. "But silence is also perpetuating this epidemic, and we have to speak out against it."

Speaking out-especially about sexual matters-can be difficult, as many APIs are not accustomed to discussing sexuality. "APIs know that their friends are having sex, but no one wants to talk about sexual practices on a personal level," Kimura says. "In our 'Love Your Asian Body' campaign, we try to show positive Asian images and to affirm that we're sexual beings and it's okay-which isn't a message APIs usually hear."

Kimura believes that campaigns such as "Love Your Asian Body" are important for improving self-esteem and for fostering better decision-making about HIV risks. Although understanding the risks associated with specific behaviors is important for everyone, to date, the epidemic has had a disproportionate effect on API men who have sex with men. For many of these men, cultural reluctance to talk about sex openly, homosexuality taboos, and slow acceptance by the community have made it difficult to come to terms with their sexual orientation.

"APIs need to see lesbian and gay people as part of the community, as people who lead full, productive, and loving lives-but who are also forced to live in the shadows because of shame," Kawata says. This kind of shame-debilitating in itself whether based on one's sexuality or HIV status-can lead to even further isolation for some APIs, who may be afraid to disclose the truth about their lives to their families and friends.

In many API cultures, this fear of telling the truth takes root in the idea of "saving face," where an individual keeps up appearances to maintain the family's dignity and to avoid incurring shame. "For APIs who are HIV positive, these issues are very real," Kimura says. "They are not only dealing with how the virus affects them personally, but also with how it impacts their families."

Fine-Tuning Prevention
To begin to break this silence around AIDS, a number of community-based organizations have increased their HIV prevention efforts among APIs. In response to an apparent rise in the number of HIV infections among recent immigrants and refugees, for example, some service providers have begun to stress prevention and outreach programs specifically targeted to them. Unable to access the services they need in English, API immigrants and refugees may become HIV infected long before they can obtain prevention materials in their first languages.

For APIs whose English skills are limited, language can prove the most significant barrier to effective prevention. Even when language is not a factor, however, one's cultural identification can be. "With prevention, it doesn't necessarily follow that Filipinos will have legitimacy when talking to the Chinese community, or vice versa," says Peou Lakhana, case management supervisor at San Francisco's Living Well Project. "You have to fine-tune and find the best approach for each situation."

Living with the Virus
The popular perception of APIs as high economic and academic achievers-APIs have the highest median income after whites-has at times made it harder for them to get needed AIDS funding. "The model minority myth is good and bad-it's nice to be thought of as the 'perfect' ethnic group, but it's not true and we can't live up to it," Kimura says. "What's worse is that it allows APIs to deny problems in our community such as AIDS, drug use, and homelessness." Many APIs live far below the poverty line, and efforts to obtain care for individuals at high risk have been hampered by the same shortage of funds and lack of government support witnessed in other communities of color. "The government has made no effort to provide treatment or prevention information to the API community," Kuromiya says.

For clients seeking either Asian language or culturally specific services, the problem can simply be one of geography-such care is rarely found outside a few major metropolitan areas. Even APIs with AIDS in those cities may worry whether they have the proper documentation to remain in this country, and may subsequently forgo medical treatment for fear of deportation. Still others may be more likely to get sick and die at home because of a lack of familiarity with accessing the U.S. health care system.

Despite these barriers, more APIs continue to seek HIV care. "Early on we saw lots of people who didn't come in until they had late-stage AIDS," Lakhana says. "Since then, people have been coming in just a little bit healthier, maybe with 250 T-cells." For APIs who do make the initial effort to seek care, she and others at the Living Well Project work to change cultural norms that can hinder clients from obtaining the best treatment.

"Some Asians tend to accept authority al-most blindly, and you have to work really hard to change that mentality," says Vince Crisostomo, volunteer/client organizer at the Living Well Project. "We try to help clients become more empowered." Empowerment for some APIs with HIV begins with becoming proactive about medication. Due to side effects or difficulty tolerating Western medicines, for example, many APIs choose to supplement their treatment with acupuncture, Chinese herbs, or other traditional therapies.

In the Pacific
While Asian Americans living with HIV on the continental U.S. face many difficulties, at times the problems-and certainly the isolation-can seem even greater for those on the Pacific Islands. These islands-Guam, the Commonwealth of the Northern Mariana Islands, and American Samoa-retain ties to the United States, and are included in U.S. census and AIDS statistics.

On these islands, as elsewhere, AIDS has been met with a fear heightened by a lack of information. "Sometimes families will isolate people with HIV, by making them use paper plates or plastic utensils-things that can be thrown out," says Crisostomo, who disclosed his HIV status at home in Guam in 1992. Crisostomo believes, however, that changes are beginning to take place. Providing better treatment for people with AIDS on the Pacific Islands may begin with improving comprehensive health care. A dire shortage of funds and a host of diseases that pose major threats to public health have contributed to a situation where many island health workers still have not received adequate HIV training. Even so, Crisostomo says, "It used to be that Pacific Islanders were not tested until they had their first opportunistic infection. But now some service providers are working to learn about AIDS before there's a bigger problem."

On the Horizon
For people with HIV, activists, service providers, and others fighting the epidemic among APIs, the future will hold renewed and additional efforts to overcome language barriers, to call into question cultural norms regarding sexuality, to develop targeted programming, and to provide accessible, state-of-the art care. More broadly, the challenge will be to begin fresh dialogues and to break the silence that has defined much of the API epidemic thus far.

"APIs are watching their loved ones die and are feeling isolated because of the stigma attached to AIDS," Kawata says. "But they're also burying their families in a deafening silence. We need to speak explicitly and clearly to make sure that our messages are getting out. Otherwise, we may save face for now, but we may also condemn another generation to die."