Almost exactly one year after the death of a transgender asylum seeker who fell ill in a privately operated detention center, the death on Saturday of another transgender woman who spent weeks in a similar facility has raised new questions about the treatment of LGBT and HIV-positive migrants by immigration enforcement—and whether the U.S. government plans to change its practices to prevent such deaths in the future.

Johana Medina León, a 25-year-old woman from El Salvador who was seeking asylum in the United States, died on Saturday at Del Sol Medical Center in El Paso, Texas, one week after complaints of chest pains prompted her transfer to the hospital from a New Mexico detention center, according to a statement released by Immigration and Customs Enforcement (ICE) on Sunday. She was the first of three migrants in three days to die after being detained at the border.

“This is yet another unfortunate example of an individual who illegally enters the United States with an untreated, unscreened medical condition,” said Corey A. Price, field office director for ICE Enforcement and Removal Operations in El Paso, in a statement released on Sunday, which was later amended to remove the word “illegally.” Seeking asylum is not illegal, and León passed a “credible fear” interview on May 18, more than a month after she was first detained.

“Many of these aliens attempt to enter the United States with untreated or unknown diseases, which are not diagnosed until they are examined while in detention,” Price added.

But activists in contact with other trans detainees at the Otero County Processing Center, a private detention center operated by Management and Training Corporation (MTC), allege that León, a trained nurse in her home country, did not have access to proper medical treatment while being held at the facility, which has been criticized for its treatment of LGBT detainees in the past.

“Her health deteriorated,” said O.J. Pitaya, an activist with Diversidad Sin Fronteras, an organization that advocates for the rights of LGBT people migrating north from Central America. Pitaya, who has been in contact with León’s family as well as other transgender detainees in the Otero facility, said that after first encountering immigration officials on April 11 at the Paso del Norte port of entry near El Paso, León had made numerous requests for proper medication before complaining of chest pains and being transported to Del Sol on May 28, the same day that she tested positive for HIV.

“She was a certified nurse so she knew she was unable to take medication orally and in repetitive occasions she told ICE officers she needed an [intravenous] solution,” which she offered to administer herself, Pitaya said, but those requests were refused.

In the eyes of LGBT legal advocates, León’s death amounts to criminal negligence on the part of ICE and MTC.

“Johana Medina lost her life due to extreme neglect by the U.S. government,” said Aaron C. Morris, executive director of Immigration Equality, an immigrant rights organization that represents LGBTQ and HIV-positive immigrants and their families. “ICE clearly cannot detain transgender women safely, and therefore should not detain them at all.”

“These deaths are a direct result of U.S. government policy, and will continue unless we force dramatic change,” said Kris Hayashi, executive director of Transgender Law Center. “We mourn Johana, and renew our pledge to seek justice for her, for Roxsana, and for all black and brown trans women detained in migrant prisons.”

MTC did not respond to requests for comment regarding the kind or quality of medical care available to detainees at the Otero County Processing Center in time for publication, but told The Daily Beast in March that the private prison company “is committed to the highest level of safety and care to those we serve regardless of transgender identity.”

Other transgender detainees at the facility where she was held have complained that they are routinely denied access to medication by on-site medical staff without explanation, part of what LGBT legal advocates told The Daily Beast is a system-wide problem—with potentially deadly results.

“The government has proven and failed to provide even the bare minimum standards of care for the LGBT people, and in particular HIV-positive people,” said Nishan Bhaumik, staff attorney at Immigration Equality. “Many, many times we hear clients tell us that they have identified that they have a chronic health condition like HIV… They identify at every stage [of detention] and the government either refuses or does not provide any kind of medical evaluation.”

“Sometimes it is months until medication is given, or a correct dosage is given,” Bhaumik added.

ICE has denied that insufficient medical treatment in custody lead to León’s death, and explicitly mentioned her HIV-positive status in its initial release following her death, a release which also included her male birth name. An official cause of death may be a long time coming: As a condition of its federal funding, ICE is legally required to release a report detailing investigations into any in-custody death within 60 days of such a death, but because León was released from ICE custody the same day she was sent to the hospital, her death is not considered “in-custody.”

ICE did not specifically respond to requests for comment regarding the allegations that León was denied access to medical care in the Otero facility, but decried “many unfounded allegations and blatant falsehoods have been published that have absolutely no basis in fact.”

“All ICE detainees have access to religious, legal and medical services. ICE treats all detainees with dignity and respect,” Price said. “ICE takes seriously all allegations and investigates them thoroughly. However, ICE cannot research or provide individual comment on any allegations, including alleged medical mistreatment without the specific details.”

Legal and medical experts told The Daily Beast that for people with compromised immune systems, immigrant detention is inherently dangerous even under optimal circumstances.

“Detention in and of itself puts people at high risk of complications,” said Dr. Robert Goldstein, medical director of the Massachusetts General Hospital Transgender Health Program and an infectious diseases specialist. “In a place like ICE custody, people are exposed to a tremendous number of viruses and bacteria, many of which can pose a risk even to people with a fully functioning immune system... things like a common cold or a simple respiratory virus could be devastating to people with HIV.”

Goldstein, who has treated HIV-positive patients fleeing persecution abroad, told The Daily Beast that the stress of detention is itself a risk factor for people with compromised immune systems, particularly if they are facing mistreatment based on their gender.

“Stress will decrease your immune system even further,” Goldstein said. “The stress and mental health impact of that individual being in custody, not being affirmed with her gender, is enormous.”

Consistent medical treatment is crucial for successfully managing HIV infection, Goldstein said, particularly if someone is newly infected, as many HIV-positive immigrants traveling migrant routes in Central America are thought to be, due to increased exposure to sexual violence and sex work on the journey north.

“Acute HIV can be quite severe for some people,” Goldstein said, referring to the initial stage following HIV infection that typically presents a fever, lethargy, body aches and swollen lymph nodes, as well as occasional gastrointestinal symptoms and vomiting. “Experiencing that with limited access to bathroom, food or water... can really be a terrible experience for someone.”

The corresponding drop in immune system function, Goldstein added, puts someone with acute HIV at “really high risk” for acquiring infections in cramped and close quarters like a detention center. The risk isn’t merely limited to the newly infected, either.

“When someone is acutely infected with HIV, they are in some ways at their most infectious to other people,” Goldstein said. “In a setting where there are a lot of people in very close quarters, with potential exposure to blood and other bodily fluids, there is an increasing risk of exposure to others in detention as well.”

The U.S. government’s long history of mistreating HIV-positive migrants stretches back long before the Trump administration’s hardline immigration policies came into effect. Prior to 2010, HIV-positive people were prohibited by federal law from entering the United States, and HIV status alone could mean that immigrants and asylum seekers faced exclusion, removal, or deportation from the country.

Although persecution because of a positive HIV status is now recognized as a potential basis for asylum, as are sexual orientation and gender identity, HIV-positive migrants still face stigma in immigration detention facilities, and there are many disincentives against disclosing, including potential violence by other detainees. LGBT people are at a much higher risk of violence in immigration detention centers than the general population, according to government data: Although the population accounted for a mere 0.1 percent of ICE detainees in 2017, they accounted for 12 percent of victims of reported sexual assault while in detention.

President Trump’s own highly publicized anti-immigrant rhetoric about people with HIV/AIDS, as well as the administration’s limp response to persecution of LGBT abroad, further discourage vulnerable detainees from speaking out.

There are also other, more practical hurdles to effective treatment for HIV-positive people in immigrant detention. Due to the complex and decentralized nature of detention and deportation proceedings, migrants face frequent changes in custody, housing and location, all of which pose a potential risk of lapses in access to proper medical care, treatment and medication.

As borderland detention facilities face dangerous levels of overcrowding, transfers to new facilities are increasingly common, and privately run detention centers are rarely forthcoming about the state of their medical staffs or facilities.

“We don’t always know what their standards for medical care are, and there seems to be very little accountability, regardless of what those standards are,” Bhaumik said. “In these terrible detention centers, where overcrowding is an issue, where they have repeatedly told detention staff that they have chronic health conditions, their health continues to deteriorate, and they are affirmatively denied and refused additional treatment.”

According to Human Rights Watch, systemic substandard medical practices and unqualified medical staff at detention centers have contributed to HIV-related deaths—and that’s only for in-custody deaths. Global healthcare experts have warned that the deportation of HIV-positive people to places where access to medical treatment and pharmaceuticals is even more inconsistent than immigration detention could worsen the HIV epidemic worldwide.

Leon’s case is eerily reminiscent of the death of another transgender migrant who was held in immigrant detention for weeks. Roxsana Hernández Rodriguez, a 33-year-old transgender woman from Honduras, died on May 25, 2018, after being hospitalized following detention at the Cibola County Correctional Center in New Mexico, operated under contract by CoreCivic, the second-largest private prison company in the United States. CoreCivic said she was at the facility for 12 hours.

An independent autopsy found that she had likely been physically abused, and that she had died after several days of severe, untreated dehydration, although New Mexico’s chief medical investigator later determined that she died due to AIDS complications.

But in Leon’s case, it is unclear why she even remained in U.S. custody after passing her credible fear interview, the first step towards successfully pursuing an asylum claim.

Until the government can prove that transgender and HIV-positive detainees can be safely cared for, Bhaumik said, “these vulnerable populations should be released from these detention centers.”