a program of the U.S.-Mexico Border AETC Steering Team

Presentación del tema: "a program of the U.S.-Mexico Border AETC Steering Team"— Transcripción de la presentación:

1 a program of the U.S.-Mexico Border AETC Steering Team
We are pleased to present this slide set for use by educators who work in Border Communities and with care providers who work with patients/clients who migrate between the United States and Mexico. This slide set should be used in conjunction with the one-page handout entitled Recommendations for Providers Assisting HIV Patients Returning to Mexico. This, as well as other materials, are available at the UMBAST Web site ( This slide set is meant to be a comprehensive overview that can be used to teach in a variety of situations and for a variety of audiences. Use of this slide set: You do not have to cover everything in this slide set during one educational program. The intent of the set is to provide you with MORE information than you need so that you will feel well prepared to teach about HIV infection in migrant communities. We feel that the most critical components of this presentation are the slides that cover continuity of care issues. If you have limited time, focus on those slides and consider skipping some of the background and epidemiology information. The one-page hand out mentioned above is an excellent teaching tool for this topic. You will notice that it matches the slides and it has the added advantage of being a take-home reminder for participants. Feel free to select only those slides that are appropriate for your presentation. Base your selection on the audience (profession, level of knowledge, etc.), an assessment of need/desire from the audience, time available, and topics selected after assessment. Also: You may have to revise the slides to meet your needs and approach to teaching. Trying to use the slides without revisions for your specific needs/style may lead to a less effective presentation. For instance, you may list to use more animation/transition effects than are used in the slide set. Feel free to add those as you like. We purposefully used only a few animations so that you could add as desired and would not have to remove animations that you didn’t want. Try not to give “straight lecture” – intersperse lecture/slides with interactive activities, cases, discussions, etc. Crossing the Border: Continuity of Care for HIV-Infected Patients Returning to Mexico a program of the U.S.-Mexico Border AETC Steering Team

2 Acknowledgments Mountain Plains AETC Pacific AETC Texas/Oklahoma AETC
AETC National Evaluation Center (NEC) AETC National Resource Center (NRC) HRSA HIV/AIDS Bureau The entire UMBAST Team

3 Acknowledgments Laura Armas, MD (Texas/Oklahoma AETC)
Lucy Bradley-Springer, PhD, RN, ACRN, FAAN (Mountain Plains AETC) John Brown, MA, LMHC (New Mexico AETC) Mona Bernstein, MPH (Pacific AETC) Tom Donohoe, MBA (Pacific AETC) Oscar Gonzalez, MA (Texas/Oklahoma AETC) Kevin Khamarko, MA (NEC) Nicolé Mandel, BA (NRC) Janet Myers, PhD, MPH (NEC) Henry Pacheco, MD (Texas/Oklahoma AETC) Michael Reyes, MD (Pacific AETC) Elaine Thomas, MD (New Mexico AETC) Yolanda Cavalier, MPH Capt. Wendell Wainwright Lynn Wegman, MPA

4 Objectives At the conclusion of this session, participants will be able to: Discuss the HIV epidemic along the U.S.-Mexico border Briefly review health care delivery systems in Mexico, including those for HIV services Facilitate continuity of care for HIV-infected patients returning to Mexico Objectives may be revised according to the needs of the learners and the teacher’s objectives. We think that the final objective is the most important and suggest that you focus on those slides if you have limited time and consider skipping some of the background and epidemiology information. This slide set should be used in conjunction with the one-page handout entitled Recommendations for Providers Assisting HIV Patients Returning to Mexico. This, as well as other materials, are available at the UMBAST Web site (

5 Discussion Questions Are antiretroviral medications available to Mexican citizens in Mexico? Does Mexico have universal health care? Does Mexico have a federally funded anti-homophobia campaign (radio, TV)? What is the most frequently crossed border on the planet? Pilot presentations of this slide set have suggested that some participants strongly resist accepting the fact that ARVs are available in Mexico and that the government is mounting a nation-wide HIV treatment policy and program. It will help if the presenter to be prepared to respond to this resistance. Some resistance may come from participants who have lived/worked in Mexico in the past when this kind of support was not available. Some resistance may come from participants who have attempted to refer patients and encountered barriers. Resistance can be addressed by reminding participants of the following: Continuity of care problems exist everywhere, even in highly developed countries. Availability and quality of care vary within the United States too. For example, HIV care may be widely available in urban areas, but it may be very hard to find in rural and underserved areas. Mexico is a developing nation, and large scale health care efforts will encounter funding setbacks, delays, and problems with the development of infrastructure. Using this Slide: Answers to the questions: The first 3 are true and the answer to the 4th question is the U.S.-Mexico Border You can use this slide in a number of ways: If you have time, use it to start a discussion either with the whole group or in small groups of 3-6 people Have participants write their answers on a sheet of paper without their name on it. Then have them trade their papers with others in the room. Have them trade several times so that they don’t know whose paper they have. Then go through each question and ask the participants to stand if the paper they are holding (not their own) says “true” for the 1st three questions or “U.S.-Mexico Border” for the 4th question. This will give you an idea of what your participants know and can give you a chance to cover problem areas as you move through the slide set.

6 Recommendations for HIV Patients Returning to Mexico
Necessary: Positive HIV antibody test result (confirmed with Western blot) Patient’s CURP number (“Clave Única de Registro de Población”) Be sure to have copies of the hand out available to give to the participants. In some areas of Mexico it can be difficult for a health care provider to obtain an HIV antibody test. For this reason, it is a good idea, therefore, to send a copy of the Western Blot confirmatory test results with the patient who is returning to Mexico. The CURP number stands for “Unique Population Registry Number.” It is a registry number that the Mexican Federal Government needs to enroll a patient in the Seguro Popular program. Patients can register and obtain the CURP number online at the ISP address listed in the slide and below:

7 Recommendations for HIV Patients Returning to Mexico
Recommended: 3-month supply of current HIV medications Recent CD4+ T-cell count (not free in all Mexican states) Recent viral load test result (not free in all Mexican states) Copy of patient’s chart including complete ART history The recommended 3-month supply is important if a patient has trouble getting immediately registered in a CAPASITS; this is more of a problem in rural areas, but all patients need to have a cushion in case of unexpected delays. This will probably not be possible for ADAP patients, but they should have at least a month’s supply on hand. Patients on complex regimens may have difficulty obtaining certain drugs, depending on where they are going and what drugs they are taking. The Directory of CAPASITS contains the name, phone number, and address of each CAPASITS medical director. UMBAST experience has been that the medical directors are accessible, interested, and can be contacted easily. If you are not bilingual, it will help to have translation assistance when you make the call Other tests and chart information. For example, genotype and phenotype testing are usually not available or covered by insurance, so a record of genotype and phenotype testing will be extremely helpful for the physician in Mexico. Several CAPASITS medical directors have indicated to UMBAST that many patients in Mexico arrive at a CAPASITS clinic with a new HIV diagnosis, often with low CD4+ T cell counts and often with an acute OI. Many of these patients have to be referred to an acute care hospital for appropriate care because CAPASITS are usually ambulatory clinics. For this reason, the more complete the medical records that can be sent with the patient, the better in terms of continuity and rapid referral.

8 Overview of the Epidemiology of HIV Infection in Mexico

9 HIV and AIDS in Mexico Mexican population: 106,500,000
Cumulative cases of HIV/AIDS at the end of 2005: 182,000 Data from: Panorama Epidemiologico del VIH/SIDA e ITS en Mexico December 31, Consejo Nacional para la Prevención y Control del VIH/SIDA. [PDF] Casos de SIDA, PVVIH y Defunciones SS/DGE. Registro Nacional de Casos de SIDA. 11/15/2007. [PDF] As reported in the AETC National Resources Center website

10 HIV/AIDS Cumulative Cases along the U. S
HIV/AIDS Cumulative Cases along the U.S.-Mexico Border (as of June 30, 2007) Data were reported by the Mexican government Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud. Registro Nacional de Casos de SIDA. Datos al 30 de junio del Procesó: SS/CENSIDA/DIO/SMI Baja Cal Norte: 5,172 Sonora: 1,726 Chihuahua: 3,052 Coahuila: 1,466 Nuevo León: 3,118 Tamaulipas: 2,586 TOTAL: 17,120 A 2007 study entitled HIV/AIDS Along the U.S.-Mexico Border: Preliminary Findings from a Multi-State, Binational Epidemiologic Profile, produced by the epidemiology bureaus of the departments of health of California, Arizona, New Mexico, and Texas, in conjunction with several counties, AIDS NGOs, and CENSIDA, and presented at the National HIV Prevention Conference in Atlanta, Georgia on December 4, 2007, report the following: As of 2005, 16,236 cases of HIV on the U.S. side of the border region (defined as 100 km/61 miles north of the border) As of 2005, 5,652 cases of HIV on the Mexican side of the border region (defined as 100 km/61 miles south of the border) On the U.S. side: 88% of the cases are men 66% MSM 9% IDU and 8% MSM/IDU 70% between the ages of years 49% White, 38% Latino, 11% African American. Rates per 100,000 = for Whites, for Latinos, for year-olds. Geographically: San Diego, CA, cases/100,000 Pima, AZ, cases/100,000 El Paso, TX, cases/100,000 Compare these numbers to: Gonorrhea: 74 cases/100,000 Syphilis: 12 cases/100,000

11 Cumulative AIDS Cases by Gender
The Mexican HIV epidemic is more similar to West Coast epidemic in the United States, in that it is predominantly among men. The Mexican HIV epidemic is dissimilar to the East Coast epidemic in the United States, in the percentages of women (there are more women with HIV infection on the East Coast of the United States), but similar in both epidemics are among people living in poverty with little access to regular health care. From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry. From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry.

12 HIV/AIDS in Mexico Cumulative Cases, 1983-2007
Male (91,734) MSM: 36.5% Heterosexual: 25% IDU: 0.7% Blood/Non-IDU: 1.5% Unknown: 36% Female (18,127) Heterosexual: 59% IDU: 0.5% Blood/Non-IDU: 7% Unknown: 33% Data related to heterosexual contact is a reporting issue for men, and probably reflects self-identification as heterosexual and not to specific MSM behavior. Large “unknowns” (>36%) is likely related to un-reported MSM, IDU, and sex workers, behaviors that are highly stigmatized and therefore underreported. Also note that these figures are inconsistent with UNAIDS figures for cumulative cases (see earlier slides). Statistical range could be from 99,000 to 440,000. Data are from: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, as of June 30, (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). SS/DGE. Registro Nacional de Casos de SIDA. Datos al 30 de junio del Procesó: SS/CENSIDA/DIO/SMI. From: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, as of June 30, 2007. (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). SS/DGE. Registro Nacional de Casos de SIDA. Datos al 30 de junio del Procesó: SS/CENSIDA/DIO/SMI.

13 Mexico’s Adult HIV Prevalence
in Regional Context Mexico 0.3% United States 0.6% El Salvador 0.7% Guatemala 1.1% Honduras 1.8% Belize 2.4% Main point: HIV rates in Mexico are among the lowest in the region; they are half those seen in the United States. Within Mexico, HIV is often viewed as an “imported” disease, since the vast majority of early cases were in individuals who had lived in the United States. Data from: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: UNAIDS Report on the global AIDS epidemic, Geneva, 2004 From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: UNAIDS Report on the global AIDS epidemic, Geneva, 2004

14 Blood Transmission of HIV & Government Response
: 1,839 cases 1993: Official testing norms implemented countrywide 1996: First year in which no cases of blood transmission reported : No new cases reported The basic message of this slide is that the blood supply is safe, and that Mexico uses screening procedures similar to the United States. Data from: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry. From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry.

15 Pediatric HIV/AIDS: Cumulative Cases 1983-2007
Male (1,478) Perinatal: 55% Blood: 12% Sexual: 3% Unknown: 29% Female (1,242) Perinatal: 66% Blood: 4.5% Sexual: 2% Unknown: 27% In Mexico, “pediatric” is defined as 14 years of age or younger for purposes of HIV reporting The high percent of unknowns may again signal highly stigmatized issues in reporting, including sexual transmission and sex work. Mexico’s response to prevention of perinatal transmission has been similar to the U.S. response, although delayed. Although delayed, the numbers of perinatal transmission cases are decreasing. Data from: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, as of June 30, 2007. (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). SS/DGE. Registro Nacional de Casos de SIDA. Datos al 30 de junio del Procesó: SS/CENSIDA/DIO/SMI From: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, as of June 30, 2007. (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). SS/DGE. Registro Nacional de Casos de SIDA. Datos al 30 de junio del Procesó: SS/CENSIDA/DIO/SMI.

16 Perinatal HIV Transmission
Mexico’s response to prevention of perinatal transmission has been similar to the U.S. response, although delayed. Although delayed, the numbers of perinatal transmission appear to be decreasing. Data from: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry. From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: CENSIDA based in National AIDS Cases Registry.

17 Stigma and Discrimination
“I will not live in the same house with a person… …of a different race” = 40% …of a different religion” = 44% …with HIV/AIDS” = 57% …who is homosexual” = 66% This information is taken from the “National Survey of Political Culture and Citizen Practices” conducted jointly by the governmental agencies National Institute of Statistics, Geography, and Computer Science and the Secretariat of Government as part of a national development plan. Survey was conducted from a nationwide random sampling of adults, 18 and older, sampling from home registries as the population base. The sample size was 5,256, and included 77% re-surveys from a sampling done for the same survey in 2001. For more information on the structure of this survey, visit Data from: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: “Encuesta Nacional de Cultura Política y Prácticas ciudadanas 2001”. Revista Cambio, 17 de Agosto del (National Survey of Culture, Politics and Citizen Practices, 2001, Change Magazine, August 17, 2002). From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: “Encuesta Nacional de Cultura Política y Prácticas ciudadanas 2001”. Revista Cambio, 17 de Agosto del (National Survey of Culture, Politics and Citizen Practices, 2001, Change Magazine, August 17, 2002).

18 Condom Use in Mexican Heterosexual Migrant Men
Last commercial sex = 64.8% Last sexual intercourse with a non-regular/non-commercial sex partner = 50.9% Last 12 months, all sexual partners = 2.1% The take home message is that people are most likely to use condoms in commercial sex (64.8%), a little less likely with non-commercial sex partners, and unlikely to use consistently with all sexual partners (including regular partners) over a year. The good news is that condom use is more likely in commercial sex encounters and with an unknown partner. Data from: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: Second Generation HIV Surveillance (Mexico, 2001) From: Update on HIV/AIDS in Mexico, June, 2007, Dr. Jorge Saavedra, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). Source cited in original slide: Second Generation HIV Surveillance (Mexico, 2001)

19 HIV in the U.S.-Mexico Border Region

20 U.S.-Mexico Border You may want to use a laser pointer, and pick and choose talking points. “Border” is identified as 61 miles or 100 kilometers on either side of the border. The border is approximately 2000 miles long. Approximately 12 million inhabitants within the Border region. 4 US states, with 62 million inhabitants. 6 Mexican states with 13 million inhabitants.

21 U.S. Border Characteristics
3 of the 10 poorest counties in the U.S. 21 counties designated as economically distressed areas Unemployment rate % higher than U.S. average 432,000 people live in 1,200 colonias in TX & NM; unincorporated, semi-rural communities, often with unsafe water supplies and substandard housing In general, educational attainment is lower along the border when compared to the rest of the United States.  With the exception of San Diego, 25 year olds in the border counties average 2-3 fewer years of school than in the United States as a whole. Due primarily to rapid industrialization, the communities on the Mexican side of the border have less access to basic water and sanitation services than the rest of the nation. Data from: United States Mexico Border Health Commission, United States Mexico Border Health Commission,

22 U.S. Border Characteristics
Higher incidence of infectious diseases compared with U.S. average If made a state, border region would rank: Last in access to health care 2nd in death rates due to hepatitis 3rd in deaths related to diabetes Last in per capita income 1st in number of school children living in poverty 1st in number of uninsured children According to the Health Resources and Services Administration (HRSA), if made the 51st state the United States side of the U.S.-Mexico border region would: Rank last in access to health care; Second in death rates due to hepatitis; Third in deaths related to diabetes; Last in per capita income; First in the numbers of school children living in poverty; and First in the numbers of children who are uninsured.

23 Immigration 43 points of entry on U.S. border
Nearly 195M passenger vehicle crossings & 49M pedestrian crossings/year at 25 ports of entry Numbers do not include undocumented crossings Not all people who enter from the U.S.-Mexico border are Mexican, numbers include people from further south The U.S.-Mexico Border is recognized as one of the busiest in the world.  Every day, 800,000 people arrive in the United States from Mexico.  In 2001, over 300 million two-way border crossings took place at 43 points of entry (POEs) on the border between the United States and Mexico.  Although significant economic changes have occurred as a result of international trade agreements with Mexico, major problems associated with the general poverty of the border area continue.  Without increases and sustained federal, state, and local government funds as well as in private funding for health programs, infrastructure and education the border populations will continue to lag behind the rest of the United States. Data from: University of Oklahoma Center for Applied Research, HIV AIDS Along the US Mexico Border University of Oklahoma Center for Applied Research, HIV AIDS Along the US Mexico Border

24 Mexican Immigration People of Mexican origin make up 29.5% of all immigrants in the U.S. In 2005, 11 million Mexican immigrants were living in the U.S. 66% located in the 4 border states 70% are years of age 59% have no health coverage 55% are undocumented People of Mexican origin represent 29.5% of the immigrant population in the United States. 55% of the 11 million Mexican immigrants in the United States are of undocumented/in process/unknown immigration status. Data from: Conasida 2008: Manual para la prevención del VIH/SIDA en migrantes Mexicanos a Estados Unidos. Conasida 2008: Manual para la prevención del VIH/SIDA en migrantes Mexicanos a Estados Unidos.

25 HIV along the U.S.-Mexico Border
Prevalence difficult to assess due to different methodologies in surveillance reporting and transient populations Border region is unique and rates cannot be extrapolated accurately from national statistics The populations of the large Mexican border cities (Juarez, Tijuana, Mexicali) have high turnover rates in their populations as people arrive there to crossover and often do not stay for long periods of time. Many Mexicans living on the border test for HIV and seek HIV services in the U.S. Therefore the number of Mexican HIV cases reported in the northern border states is likely underreported. Source: University of Oklahoma Center for Applied Research, HIV/AIDS Along the US Mexico Border University of Oklahoma Center for Applied Research, HIV/AIDS Along the US Mexico Border

26 U.S.- Mexico Border AETC Steering Team Who Is UMBAST?
Promote high-quality, culturally sensitive education & capacity building programs Provide focused collaboration through joint planning, resource sharing, & evaluation U.S./Mexico Border AETC Steering Team (UMBAST) Mission To promote high quality, culturally sensitive education and capacity building programs for health care providers and agencies that provide HIV/AIDS related prevention and clinical management services in the U.S.-Mexico border region; and to serve as the coordinating body to provide focused collaboration through joint planning, resource sharing and evaluation of AETC border activities. Web address:

27 Who Is UMBAST? UMBAST includes members from 3 AETCs that serve border region: Mountain Plains AETC (New Mexico) Pacific AETC (Arizona & California) Texas/Oklahoma AETC (Texas) In collaboration with AETC National Resource & Evaluation Centers, HRSA representatives, & others with an interest in HIV and the border

28 Regional AETCs Note: This slide is animated. It shows the 3 regions that work together in UMBAST. When you press the advance button, a circle will appear to highlight the border area.

29 Mexican Health Care Delivery Systems

30 U.S. Health Care Guaranteed only for military, prison, and special programs for poor or elderly Most obtain coverage through an employer, but employers are not required to provide coverage Employees often must share plan costs 30 million without coverage often use ER or pay-for-service clinics Special programs provide insurance to the elderly (Medicare), poor and some programs for infants. ALL prisoners and members of the military have health insurance, as do members of Congress. In general, health care in United States is funded by employers, but employees are increasingly having to share the costs of these plans as health care inflation is higher than general U.S. price inflation. More than 30 million U.S. citizens do not have coverage. Because of this, many people without coverage do not get preventive care and wait until their conditions deteriorate before seeking services. Many will seek care in busy emergency rooms or in pay-for-service clinics. These are some of the most expensive ways to get care and the public often ends up paying for care to the uninsured with increased taxes or increased service fees. U.S. health care costs per capita are the highest in the world, despite a large percent of uninsured citizens.

31 U.S. HIV Health Care Funding
Private insurance Public insurance Ryan White HIV/AIDS Treatment Modernization Act of 2006 Clinical trials Compassionate release People living with HIV (PLWH) in the United States have better access to publicly-funded programs for their HIV disease than for other conditions they may be living with (diabetes, for example). A PLWH who is living in the United States and is not able to obtain HIV medication through these 5 broad categories, probably lacks information (rather than availability) or lives in a remote area (hundreds of miles from major city). However, many state ADAP programs will mail medications to clients, so this is more of a “lack of information” issue. Most people living with HIV in the United States obtain HIV medications and services through the Ryan White HIV/AIDS Treatment Modernization Act of 2006. Sources of Care for PLWH in the United States: PRIVATE INSURANCE - HMO, PPO, other employer or self-paid coverage PUBLIC INSURANCE - i.e., Medicare, and special programs for elderly, poor, youth RYAN WHITE Treatment Modernization Act of covers medications through the AIDS Drug Assistance Program (ADAP), other titles cover other services, including medical care; costs share between state and federal governments CLINICAL TRIALS - Medications and some limited services can be obtained through University and other clinical trials COMPASSIONATE RELEASE - Pharmaceutical companies also have special programs offering HIV medications at low or no cost to those who can not obtain them through above means

32 Mexico: Health as a Constitutional Right
Mexican Constitution establishes the right of health care for all Mexican citizens Secretary of Health, appointed by the President, oversees Secretaria de Salud Secretaria de Salud charged with health surveillance, reporting, prevention, and management Constitution protects migrant populations, indigenous populations, children, youth, women, and agricultural laborers In contrast to the United States, Mexico provides universal health care for all citizens, including migrant workers returning to Mexico, unemployed, and indigenous and rural populations. However, as a developing country, resources may be limited in some areas, and, in reality, universal health care may not be uniformly available. Title I, Chapter I: Individual Warranties; Article 4 “Every person has the right to protect their health. The law will define the basis and modalities for access to health services and will establish concordance within the federation and the federal entities in the matter of general public health, according to the fraction XVI , 73 article of this constitution…” Title I; Chapter I: Individual Warranties; Article 2 VIII. To establish social policies to protect the migrants from indigenous villages, in the national territory as well as in foreign lands, through actions that provide warranty of their labor rights of the farmer workers, improve the health conditions for women, support through special educational and nutritional programs the children and youth of migrant families and be vigilant of their human rights and promote their cultural heritage

33 Health Care Funding Sources
Secretaría de Salud SSA Secretaría de Salud SSA Secretaría de Salud SSA Health Care Funding Sources Note: This slide is animated. The first thing you will see is a title slide, when you it the advance button, you will see the diagram of the various agencies (as to the left). Health Services in Mexico In general, health services in Mexico can be pictured as multiple government-based institutions and some private efforts (university hospitals, private practitioners, private insurance). More and more people with higher incomes are purchasing extra coverage through private insurance companies. Companies might provide Social Security, but these individuals want better access to preferred physicians or specialties, decreased waiting times, and perceived personalized attention. Employers in Mexico pay for health care for employees & their dependents through Mexican Institute of Social Security (IMSS). Federal employees & their dependents covered through the Institute for Security and Social Services for the State Workers (ISSSTE). Other smaller or state based agencies cover special groups or populations. Those who have no coverage get services through the Secretary of Health and Assistance (SSA). Translations: IMSS: Instituto Mexicano de Seguridad Social/Mexican Institute of Social Security SSA: Secretaria de Salud y Asistencia/Secretariat of Health and Assistance ISSSTE: Instituto de Seguridad y Servicios Sociales para Trabajadores del Estado/Institute of Security and Social Services for State Workers Cruz Roja Mexicana/Mexican Red Cross Hospitales Universitarios/University hospitals PEMEX: Petróleos Mexicanos. Mexican Petroleums SDN: Secretaría de la Defensa Nacional/Secretariat of National Defense Secretaría de Marina/Secretariat of the Navy Servicios Médicos Estatales/State Medical Services Servicios Médicos Municipales/Municipal Medical Services DIF: Desarrollo Integral de la Familia/Integrated Family Development Servicios Médicos Privados/Private Medical Services

34 HIV Care: A Priority CONASIDA: Policy-setting body
Consejo Nacional para la Prevención y Control del SIDA (National Council for the Prevention and Control of HIV/AIDS) CENSIDA: Funding, care, prevention, & education Centro Nacional para la Prevención y el Control del VIH/SIDA (National Center for the Prevention and Control of HIV/AIDS) HIV is a priority for the Mexican government Two national agencies respond directly to the Secretary of Health CONASIDA: Policy-setting body Consejo Nacional para la Prevención y Control del SIDA National Council for the Prevention and Control of HIV/AIDS CENSIDA: Provides funding, treatment, prevention and education Centro Nacional para la Prevención y el Control del VIH/SIDA National Center for the Prevention and Control of HIV/AIDS

35 Seguro Popular 2001: Secretaria de Salud instituted Seguro Popular insurance program to provide health care coverage to uninsured/underserved populations 2005: 5.1 million families covered by Seguro Popular 2007: Seguro Popular becomes law For those people who, in the past, did not fall under a major insurer, Mexico created a safety net called Seguro Popular. Because a portion of the population was un-insured, a pilot program, called Popular Insurance, was developed in 2001 for a few of the poorest states. Over time, the program was shown to be effective and it became law in 2007. Mexican consulates provide information on how Mexican citizens residing in the U.S. can receive health coverage upon their return to Mexico. Mexican citizens living with HIV who do not have health coverage are able to receive care through Seguro Popular. In other words, Mexico has a health care system that is accessible to all of its citizens. As in the U.S., services and knowledge vary from region to region and state to state. A patient’s capacity for self advocacy are always essential in accessing care.

36 Antiretroviral Coverage
28,600 The trend in the graph suggests that fewer and fewer people are “uncovered” by health insurance for ARV coverage. Coverage for the uninsured has been through the Seguro Popular program. 1997 Free ARV coverage to insured population. 1998 FONSIDA starts coverage for <18 and pregnant women without insurance. 1999 Starts coverage for non-insured adult population. At the end of 2003 universal access to HAART, originally planned for 2006. Data Source: CENSIDA based in National AIDS Cases Registry Source: CENSIDA based in National AIDS Cases Registry.

37 HIV Health Care Funding Sources
Translations: See slide 33 for translations for agencies. The entities in orange are those that provide HIV services. The various sizes represent the degree of funding for HIV services. SSA and IMSS take the lead in clinical services and provision of ARVs. SSA CENSIDA Seguro Popular SME Health Services IMSS DIF SM SDN Hospitals & Universities CRM ISSSTE SMP SMM ONG PEMEX SSA, through CENSIDA, obtains the appropriate epidemiological data, coordinates research, and is in charge of strategic planning and public education, as well as HIV prevention. CENSIDA, in collaboration with the scientific community in Mexico and IMSS, ISSSTE, and others, has developed National Guidelines for Use of Antiretroviral Therapy in Adults and Adolescents, as well as for pediatric and perinatally-infected patients. A person employed either by a private organization or with his/her own business, will qualify to acquire/pay for IMSS benefits, also called Social Security (but very different in Mexico from Social Security in United States). Dependents also qualify. So say you have a young migrant whose wife in Mexico currently works and has IMSS. He can qualify for IMSS based on her coverage. IMSS clinics can be found in many counties, but HIV services are usually centralized to major metropolitan areas, since they are considered specialty services. For more information, go to: Other organizations also contribute to HIV care and services. These organizations coordinate efforts with CENSIDA, particularly with their State and County Health Departments, which are in charge of surveillance. Although there is the general concern about under-reporting due to confidentiality issues, these problems are decreasing in frequency and a concentrated effort is in place to decrease disparities among states. Recently, CENSIDA developed and implemented a plan to create Health centers for HIV and STD care in several states and municipalities, those centers are called CAPASITS The role of NGOs in the continuum of care for HIV-infected clients is mostly to provide support services, but a few still provide health services. In the past their role was more important as they were the main providers of medications, mostly obtained through donations from private sources. With universal access to ARV and the cost of medications, this practice is not only not widely supported, but also recognized as poor management, especially if there is change in treatment and the NGOs do not have a store of the new drug. In some instances, however, when official agencies can’t deliver ARVs, the NGOs have been instrumental in providing medications for clients. Beware: if your client is paying an agency for medications that seem to be coming from government sources, corruption may be a problem.

38 Major HIV Care Sources Most public employees: ISSSTE (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado) Insured private sector employees: IMSS (Instituto Mexicano del Seguro Social) Uninsured/Migrant: SSA/CENSIDA (Secretaria de Salud/Centro Nacional para la Prevención y el Control del VIH/SIDA) Referred to CAPASITS Clinics Insured under Seguro Popular PEMEX employees, though public, have their own coverage The vast majority of migrants returning to Mexico will be uninsured and without access to other sources, thereby receiving coverage under SSA/CENSIDA/CAPAISTS. For a parallel to the U.S. system: In the United States, an uninsured patient would likely receive care through the Ryan White Program funding. In Mexico, that same uninsured person would receive care through a CAPASITS clinic.

39 CAPASITS Centro Ambulatorio de Prevención y Atención en SIDA y
Infecciones de Transmisión Sexual Outpatient Center for Prevention and Attention in AIDS and Sexually Transmitted Infections Outpatient Center for Prevention and Attention in AIDS and Sexually Transmitted Infections Administered by CENSIDA Services funded through Secretariat of Health and Seguro Popular

40 CAPASITS Locations Ribbons indicate location of current or planned CAPASITS Clinics Data from: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). From: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud).

41 CAPASITS Ciudad Victoria Nayarit La Paz Mexicali Veracruz Zacatecas
This slide demonstrates a “bricks and mortar” investment in CAPASITS clinics, to address the resistance to believing the existence of an HIV care system in Mexico. Disbelief was voiced during presentations of this information. In terms of resistance, questions may arise regarding limited availability of medications, health care provider expertise, etc. In responding to this resistance, the presenter should emphasize that the same struggles of consistency and quality of care exist in the United States. From: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud). Mexicali Veracruz Zacatecas From: National Center for Prevention and Control of HIV/AIDS, Operative Investigation Administration, Mexico Secretariat of Health, (Centro Nacional para la Prevención y el Control del VIH/SIDA Dirección de Investigación Operativa, Secretaría de Salud).

42 Referral to CAPASITS Referral from a general medical clinic
HIV diagnosis Antiretroviral history Basic labs Clinical summary Patients returning to Mexico from the United States can take medical records from the United States that fulfill these requirements. CAPASITS are outpatient care clinics; a patient requiring acute care would be immediately referred to a hospital. Be sure to provide patients returning to Mexico with a HIPAA-compliant release of information form for additional records. It is not always feasible for patients to have their medical records, but these records will facilitate rapid referral. Epi notification needs to take place according to the local laws in Mexico to which the patient returns.

43 Referral to Care Once referred to a CAPASITS clinic, the patient will receive assistance to obtain coverage through Seguro Popular, and will need: Proof of address/residence Birth certificate CURP Proof of address can be simple electric bill, rental agreement, etc. CURP, or “Unique Population Registry Number,” is a registry number that the Mexican Federal Government needs to enroll a patient in the Seguro Popular program. Patients can register and obtain the CURP number online at These requirements have not been a major obstacle – the CAPACITS will help the patient meet these requirements

44 CAPASITS Services Behavioral health services General medical care
Social work services Adherence counseling STD screening Outreach General medical care HIV care ART treatment Laboratory testing Specialist referrals Dental care These are the services that CAPASITS Clinics may provide. Each CAPASITS has a different lay out, and services may vary from clinic to clinic.

45 ARVs in Mexico: full chart available at www. aetcborderhealth
ARVs in Mexico: full chart available at Antiretrovirals Available in the United States Antirretrovirales Disponibles en México Generic Brand Name Genérico Nombre Comercial Nucleoside/Nucleotide Analogues (NRTIs) Inhibidores de la Trascriptasa Reversa Análogos a Nucleósidos (ITRAN) Abacavir Ziagen Ziagenavir Didanosine Videx Didanosina Emtricitabine Emtriva Emtricitabina Lamivudine Epivir Lamivudina 3TC Stavudine Zerit Estavudina* A full range of antiretroviral medications are available in Mexico. Please visit the UMBAST Web site ( to see complete tables for Mexican names of drugs. When helping a patient return to Mexico, it will help to provide a list of medications using the Spanish terms.

46 Recommendations for HIV Patients Returning to Mexico
Necessary: Positive HIV antibody test result (confirmed with Western blot) Patient’s CURP number (“Clave Única de Registro de Población”) Be sure to have copies of the hand out available to give to the participants. In some areas of Mexico it can be difficult for a health care provider to obtain an HIV antibody test. For this reason, it is a good idea, therefore, to send a copy of the Western Blot confirmatory test results with the patient who is returning to Mexico. The CURP number stands for “Unique Population Registry Number.” It is a registry number that the Mexican Federal Government needs to enroll a patient in the Seguro Popular program. Patients can register and obtain the CURP number online at the ISP address listed in the slide and below:

47 Recommendations for HIV Patients Returning to Mexico
Recommended: 3-month supply of current HIV medications Recent CD4+ T-cell count (not free in all Mexican states) Recent viral load test result (not free in all Mexican states) Copy of patient’s chart including complete ART history The recommended 3-month supply is important if a patient has trouble getting immediately registered in a CAPASITS; this is more of a problem in rural areas, but all patients need to have a cushion in case of unexpected delays. This will probably not be possible for ADAP patients, but they should have at least a month’s supply on hand. Patients on complex regimens may have difficulty obtaining certain drugs, depending on where they are going and what drugs they are taking. The Directory of CAPASITS contains the name, phone number, and address of each CAPASITS medical director. UMBAST experience has been that the medical directors are accessible, interested, and can be contacted easily. If you are not bilingual, it will help to have translation assistance when you make the call Other tests and chart information. For example, genotype and phenotype testing are usually not available or covered by insurance, so a record of genotype and phenotype testing will be extremely helpful for the physician in Mexico. Several CAPASITS medical directors have indicated to UMBAST that many patients in Mexico arrive at a CAPASITS clinic with a new HIV diagnosis, often with low CD4+ T cell counts and often with an acute OI. Many of these patients have to be referred to an acute care hospital for appropriate care because CAPASITS are usually ambulatory clinics. For this reason, the more complete the medical records that can be sent with the patient, the better in terms of continuity and rapid referral.

48 Online Resources for Border and Migrant HIV Treatment and Prevention

49 UMBAST Online http://www.AETCBorderHealth.org
Contact information Border Resource Directory Updated fact sheets & medication lists Links to border and migrant organizations, reports, and events

50 Border Resource Directory http://www.AETCBorderHealth.org

51 Border Region Resources
Clinician training HIV treatment facilities HIV prevention and service organizations

52 Border Region Overviews http://www.AETCBorderHealth.org
Epidemiologic overviews about HIV/AIDS in the border counties

53 Search “Mexico border AIDS”