Assisting HIV-Infected (and other) Patients Who May Return to Mexico (or Central America)

Thursday, February 28, 2013

Los Angeles, CA

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Disclosure InformationHelping HIV Patients Who May Return to Mexico

Tom Donohoe

Continuing Medical Education committee members and those involved in the planning of this CME Event have no financial relationships to disclose.

Tom Donohoe

I have no financial relationships to disclose-and

I will not discuss off label use and/or investigational use in my presentation

At the conclusion of this session, participants will be able to:

Review health care delivery systems in Mexico, including those for HIV and other services

Facilitate culturally competent continuity of care for HIV-infected patients returning to Mexico and Central America

Utilize 7 one-page bilingual HIV-referral fact sheets for Mexico and 6 Central American Countries

Objectives 4

AETCWarmline: (800) 933 -

3413

PEPline: (888) HIV – 4911

(888) 448 – 4911 Perinatal Hotline:

(888) 448 – 8765

http://www.aids-etc.orghttp://www.AETCBorderHealth.org

Tom Donohoedonohoe@ucla.edu

UCLA CHPDP HIV/AIDS Training Programs Delivered in Mexico: 1995- 2005

Which of these US metropolitan areas has the highest PERCENTAGE of Spanish-speaking households?

15%

60%

0%

13%

13% 1) Miami, FL

2) Los Angeles, CA

3) Santa Ana, CA

4) El Paso, TX

5) Las Cruces, NM

The richest private citizen on the planet is currently a man named?

26%

2%

19%

29%

24% 1) Carlos Slim

2) Bill Gates

3) Warren Buffet

4) Ted Turner

5) Charles Delgado

The ‘US/Mexico border region’ is how many miles above the border with Mexico?

16%

23%

37%

9%

14% 1) 5

2) 10

3) 50

4) 62

5) I have no idea

“The Border”

I have had at least 1 patient born in Mexico

7%

93% 1. True

2. False

I can explain how Mexican health care systems work

83%

17% 1. True

2. False

Case 5Juan is a 23 year-old HIV-infected patient from Mexico who calls the clinic to say he has to return to Mexico in 2-3 days. He does not remember all his medication names, except “Sustiva, 2 colored pills…and Bactrim.” He asks if he can get HIV care in Mexico and shares he has not been there since he was a child. He was born in Zacatecas and tells you he thinks he may have to return there to live with his grandparents.

Questions 6 Would you be able to connect Juan to HIV

care in Mexico? Why do you think Juan is returning to

Mexico? What other information would you need to

assist Juan? Why?

4) Most Mexicans are covered by the largest health insurance program in Mexico. It is paid for by the employer and is known by the acronym______.

7%

2%

19%

33%

38% 1. IMSS

2. ISSSTE

3. PEMEX

4. RED

5. TOTAL

7) CAPASITS are _______ HIV/STI care clinics funded through the Secretariat of Health and ______; referral to CAPASITS requires an HIV diagnosis, antiretroviral history, basic labs, clinical summary and a referral from a general medical clinic.

0%

100%

0%

0%

0% 1. Inpatient; CENSIDA

2. Inpatient; PEMEX

3. Outpatient; CENSIDA

4. Outpatient; Seguro Popular

5. None of the above

3) How many HIV antiretroviral medications are currently available in Mexico?

31%

12%

26%

17%

14% 1. Fewer than 5

2. Between 5 and 10

3. Between 11 and 15

4. Between 16 and 20

5. More than 20

Overview of the Epidemiology of HIV

Infection in Mexico

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HIV and AIDS in Mexico

Mexican population: 106,500,000

Cumulative cases of HIV/AIDS at the end of 2005: 182,000

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HIV/AIDS Cumulative Cases 9 along the U.S.-Mexico Border

(as of Dec 31, 2011)

Baja Cal Norte: 6,863Sonora: 2,748Chihuahua: 6,457 Coahuila: 1,783 Nuevo León: 4,367Tamaulipas: 3,737

TOTAL: 25,955

From: Update on HIV/AIDS in Mexico, Dec, 2011, General Director, National HIV/AIDS Program (Centro Nacional para Prevención y Control del VIH/SIDA CENSIDA). http://www.salud.gob.mx/conasida Source cited in original slide: CENSIDA based in National AIDS Cases Registry.

Cumulative HIV by Gender10

2) In the US, HIV prevalence is .6%, which of the following represents the HIV prevalence in Mexico?

10%

40%

15%

33%

3% 1. .1%

2. .3%

3. .6%

4. 1.8%

5. 2.4%

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). http://www.salud.gob.mx/conasida Source cited in original slide: UNAIDS. 2004 Report on the global AIDS epidemic, Geneva, 2004

Mexico’s Adult HIV Prevalence 11 in Regional Context

Mexico 0.3% United States 0.6% El Salvador 0.7% Guatemala 1.1% Honduras 1.8% Belize 2.4%

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). http://www.salud.gob.mx/conasida Source cited in original slide: “Encuesta Nacional de Cultura Política y Prácticas ciudadanas 2001”. Revista Cambio, 17 de Agosto del 2002. (National Survey of Culture, Politics and Citizen Practices, 2001, Change Magazine, August 17, 2002).

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%

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HIV in the U.S.-Mexico Border Region

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U.S.-Mexico Border18

3 of the 10 poorest counties in the U.S. 21 counties designated as economically

distressed areas Unemployment rate 250-300% 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

United States Mexico Border Health Commission, 2008 http://www.borderhealth.org/border_region.php

U.S. Border Characteristics19

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

U.S. Border Characteristics20

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

Immigration

University of Oklahoma Center for Applied Research, 2005. HIV AIDS Along the US Mexico Border

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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 18-44 years of age

• 59% have no health coverage

• 55% are undocumented

Conasida 2008: Manual para la prevención del VIH/SIDA en migrantes Mexicanos a Estados Unidos. www.salud.gob/conasida

Mexican Immigration22

Who Is UMBAST?

U.S.-MexicoBorderAETCSteering Team

Promote high-quality, culturally sensitive education & capacity building programs

Provide focused collaboration through joint planning, resource sharing, & evaluation

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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

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Regional AETCs

L

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Mexican Health Care Delivery Systems

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US Health Care (1968 through 2014)

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

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U.S. HIV Health Care Funding

Private insurance

Public insurance

Ryan White HIV/AIDS Treatment

Modernization Act

Clinical trials

Compassionate release

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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

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Health Care Funding SourcesIMSS

Servicios MédicosPrivados

DIF

ServiciosMédicos

Municipales

Servicios Médicos Estatales

SecretaríaDe

Marina

SDN

PEMEX

Hospitales Universitarios

Cruz Roja Mexicana

ISSSTE

Health Services

Secretaría deSaludSSA

IMSS

Servicios MédicosPrivados

DIF

ServiciosMédicos

Municipales

Servicios Médicos Estatales

SecretaríaDe

Marina

SDN

PEMEX

Hospitales Universitarios

Cruz Roja Mexicana

ISSSTE

Health Services

Secretaría deSaludSSA

IMSS

Servicios MédicosPrivados

DIF

ServiciosMédicos

Municipales

Servicios Médicos Estatales Secretaría

de Marina

SDN

PEMEX

Hospitales Universitarios

Cruz Roja Mexicana

ISSSTE

Health Services

Secretaría de Salud

SSA

Health Servicesin Mexico

L

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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)

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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

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Seguro Popular> 250 medical interventions covered

Diabetes……….YES (# 78. “Diagnosis and pharmacological treatment

of diabetes mellitus 2 (blood sugar)” TB Treatment…YES Family Planning Services…YES STI Treatment (CAPASITS) HIV Treatment (CAPASITS) Hepatitis C Treatment…NO

http://www.seguropopular.org

Antiretroviral Coverage

0

5,000

10,000

15,000

20,000

25,000

30,000

1997 1998 1999 2000 2001 2002 2003 2004

Social Security SEGURO POPULAR Uncovered

Source: CENSIDA based in National AIDS Cases Registry.

28,600

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SSACENSIDA

Seguro Popular

SME

Health Services

IMSS

DIF SMSDN

Hospitals & Universities

CRM

ISSSTE

SMPSMM

ONG

PEMEX

HIV Health Care Funding Sources34

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

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CAPASITS

Centro Ambulatorio de Prevención y Atención en SIDA y Infecciones de Transmisión Sexual

OutpatientCenter forPrevention andCare forAIDS and Sexually TransmittedInfections

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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). http://www.salud.gob.mx

CAPASITS Locations37

CAPASITS Border Locations Tijuana (San Diego, CA) Mexicali (El Centro, CA) Nogales (Nogales, AZ) Cd. Juarez (El Paso, TX) Piedras Negros (Eagle Pass,

TX) Nvo Laredo (Laredo, TX) Reynosa (McAllen, TX) Matamoros (Brownsville, TX)

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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). http://www.salud.gob.mx

CAPASITS

Ciudad Victoria Nayarit La Paz

Veracruz ZacatecasMexicali

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Referral to CAPASITS

Referral from a general medical clinic

HIV diagnosis Antiretroviral history Basic labs Clinical summary

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CAPASITS Services

General medical care

HIV care ART treatment Laboratory

testing Specialist

referrals Dental care

Behavioral health services

Social work services

Adherence counseling

STD screening Outreach

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ARVs in Mexico:full chart available at

http://aidsetc.org/pdf/p02-et/et-03-00/mexicodrugs.pdfAntiretrovirals

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 Abacavir ZiagenavirDidanosine Videx Didanosina VidexEmtricitabin

e Emtriva Emtricitabina Emtriva

Lamivudine Epivir Lamivudina 3TCStavudine Zerit Estavudina* Zerit

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UMBAST Fact sheet: Mexico 47

48

↑

50

CAPASITS link 51

Search “Mexico border AIDS”

T

57

4) Most Mexicans are covered by the largest health insurance program in Mexico. It is paid for by the employer and is known by the acronym______.

7%

2%

19%

33%

38% 1. IMSS

2. ISSSTE

3. PEMEX

4. RED

5. TOTAL

7) CAPASITS are _______ HIV/STI care clinics funded through the Secretariat of Health and ______; referral to CAPASITS requires an HIV diagnosis, antiretroviral history, basic labs, clinical summary and a referral from a general medical clinic.

0%

100%

0%

0%

0% 1. Inpatient; CENSIDA

2. Inpatient; PEMEX

3. Outpatient; CENSIDA

4. Outpatient; Seguro Popular

5. None of the above

Comments, Questions and Answers

Post Test, Evaluation

and Needs Assessment

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