DRAFT/BORRADOR (se traducirá al español una vez que se

apruebe la versión en inglés) Barreras Para Implementar

Medidas de Prevención de la Infección por el VIH

Barriers to Implementing HIV Prevention

HIV/AIDS Prevention PROJECT TIES

María Luisa Zúñiga, Ph.D.University of California, San Diego

Saturday July 29, 2006

Workshop Goals:

1. To describe individual, provider and structural/system barriers to preventing transmission of HIV

2. To provide first-hand experience with patient realities and needs through direct interaction with patients

(Discussion with Persons living with HIV and Field Trip to Las Memorias HIV Hospice )

3. To learn methods of overcoming barriers to HIV prevention

Workshop Topics

1. Stigma and discrimination2. Mexico’s health care system and its limitations3. Examples of implementing prevention in settings

with limited resources4. Opposition to harm reduction5. Human rights and protection of human subjects6. Role of systems: church, police, pharmacies,

jails/prisons7. Understanding the Patient’s Perspective8. Overcoming barriers to HIV prevention

Southern California Border HIV/AIDS Project Service Delivery Model (SYHC)

INTAKE

QUALITY OF LIFE

ASSESSMENT

OUTREACH

TESTING & COUNSELING

EARLY INTERVENTION

CASE MANAGEMENT

PROJECT EVALUATION

TRANSPORTATION

BENEFITS COUNSELING

SUPPORT & ART THERAPY GROUPS

DENTAL CARE

TREATMENT EDUCATION

ADAP

COORDINATED CARE & SERVICES

VOLUNTEER SERVICES

LEGAL SERVICES

SPECIALTY CARE

MENTAL HEALTH

FOOD VOUCHERS

INTAKE REFERRAL

Client Hand-off

INTERPRETATIONTRANSLATION

PRIMARY CARE

Southern CA Border HIV ProjectPartner Clinic Sites

Clínicas de Salud del Pueblo

Vista Community Clinic

San Ysidro Health Center

Family Health Centers

“From an epidemiological perspective, the border population must be considered as one, rather than different populations on two sides of a border; pathogens do

not recognize the geopolitical boundaries established by human beings” (Weinberg M., et al., 2003)

Stigma and Discrimination Qualitative study from the Southern California Border

HIV/AIDS Project

Qualitative Study with Male and Female Latinas living with

HIV/AIDS• concerns with seeking care at locations

where these women could be identified and stigmatized by others

Qualitative Study with Male and Female Latinas living with

HIV/AIDS• Some women expressed dissatisfaction

with services for women because they perceived that HIV/AIDS services are geared toward homosexual men, namely gay identified MSMs. This issue was raised three times during the focus group.

Qualitative Study with Male and Female Latinas living with

HIV/AIDS• Many responses were linked to stigma and respondents

referred to a fear of being stigmatized by the surrounding community, – “What if they see you in a place where only infected people go,

then they’ll know you’re infected.” – Participants mentioned that a lack of knowledge of HIV/AIDS in

the Latino community also affects them, “Within the Hispanic community their not knowing anything about AIDS is worse…that is they are still afraid that if you touch them, or if they drink from your soda.”

– Fear of the participant’s families being stigmatized if anyone knew of the participant's HIV status was also discussed.

Qualitative Study with Male and Female Latinas living with

HIV/AIDS• . Other responses included cultural issues

in reference to approaching physicians, such as not voicing concerns because of deference to doctors and the perception that the doctor is always right.

Qualitative Study with Male and Female Latinas living with

HIV/AIDSAnother barrier identified was not being able

to receive vitamins or medications for secondary complications of HIV. One participant mentioned that those without a social security number face barriers in accessing services.

Qualitative Study with Male and Female Latinas living with

HIV/AIDSOne barrier to acceptability of services was

that instructions for prescriptions or some informational brochures are written in English: “I took the precaution of calling to ask what it meant [a prescription], and they told me it was for gargling…otherwise I would have been drinking three doses [of it], three times a day!”

2. Mexico’s health care system and its limitations

Healthcare System in México

Dra. Adriana Carolina Vargas OjedaUniversidad Autónoma de Baja California March 2, 2006

31 states

1Federal District

2428 counties

•Covers an area of 1’964 375 sq.km

•Mexico shares a 3,152 km. border with the United States to the north

•102 000 000 people (2002)

Health Care System in México

Historical and social aspects

1943: Department of Public Health

Ministry of Health and Services (S.S.A.)

Mexican Social Security Institute (I.M.S.S.)

Children’s Hospital of Mexico (H.I.M.).

1960: Social Security and Services Institute for Civil Servants (I.S.S.S.T.E.)

Mexican Healthcare System

Mexican Social

Security Institute

(IMSS)

Mexican Social

Security Institute

(IMSS)

Health Services

Security Institute

(ISESALUD)

Health Services

Security Institute

(ISESALUD)

Social Security

and Services Institute

for Civil Servants

(ISSSTE)

Social Security

and Services Institute

for Civil Servants

(ISSSTE)

Ministry of Health

S.S.A

Ministry of Health

S.S.A

County Medical ServicesCounty Medical Services

Medical Services For the Department of

Federal District

Medical Services For the Department of

Federal District

Zonal Hospital

Peripheral clinicsPeripheral clinics

Public Health CentersPublic Health Centers

Military HospitalMilitary Hospital

Red CrossRed Cross

National Health InstitutesNational Health Institutes

Private Health ServicesPrivate Health Services

DIFDIFNational Indigenes InstituteNational Indigenes Institute

PEMEXPEMEX

System

Financialsupport

Social Security* General health care** Private

Organization

Providers

Users

Federal government

l(Fed taxes)

Employers Employees Federal

Government(GeneralTaxes)

Lowest feesOnly to recuperate

The spends.

Recuperativefees.

Variablefees.

ISSSTE IMSS

PEMEX

Others

IMSS-SolidarityHealth Ministry Private insurance

CompensationPrepaid

care

Public Hospitals,Public Hospitals,Public clinics andPublic clinics andMDs. under wagesMDs. under wages

Public Hospitals,Public Hospitals,Public clinics andPublic clinics andMDs. under wagesMDs. under wages

Private Hospitals Private Hospitals Private clinicsPrivate clinics

MD. feesMD. fees

WorkersUnder wages

Beneficiariesof the insured

Retired

LowIncomePopula

tion

Rural Commu

nities

FreeLance

workers

SelfEmployees

Open to all populationHigh income/low income

* Incluye IMSS, ISSSTE, PEMEX, SEDENA, SM ** Incluye SSA, IMSS-Solidaridad

PUBLIC HEALTH UNITSPublic Health services Units

Public Health laboratories

HOSPITALSNational Health Institutes

Regional Hospitals of high specialties

General Hospitals First and second level

Community Hspitals

Mental Health Hospitals

Mental Health Rehab. Centers

SPECIALTIES UNITSImagenology

Advanced clinical lab.

Dialisis

Cancer

Short stay surgery

Emergencies

Shock and Trauma

AIDS

Rehabilitation

COMMUNITY HEALTH UNITSAdvanced centers for primaty heath care (CAAPS)

Mental health care centers

Centers for senior citizens

Prenatal care centers

Centers for women suffering from domestic violence

Mobil units

House calls

COMMUNITY SUPPORT UNITSWorkshops

Shelters

NETWORK SERVICES

TYPE OF UNITS

Mexican Healthcare System

• Functions:

– Health Services

– Financing services

– Management

– Generator of human resources

Challenges

1. The demographic challenge

2. Geographic and social challenge3. Epidemiological challenge4. Scientific technologycal challenge5. Medical schools and acreditation

2000 20500 – 15 years Population

0 – 15 years Population

33.5 millions

65 years or more

Population

21.7 millions

65 years or more Population

4.7 millions 27.8 millions

35 %Decrease

591 %Increase

DEMOGRAPHIC TRANSITION

Mexican Healthcare System

Financement • 5.6% of PIB(GDP) goes to health services

– (2.5% public)

– (3.1% private)

• States uses only 3% of their budget

• 75% of IMSS budget is distributed in 2nd and 3rd. level

Mexican Health Care System

• Main Obstacles:– Inequity– Insufficiency– Inefficiency– Lack of quality– Un satisfaction– Insecurity

First ten causes of mortality in15-24 years

• Accidents• Injuries, homicides• Malignant tumors• Suicides• Heart disease• Pregnancy and postpartum problems• AIDS• Renal failure• Congenital malformations• Epilepsy

Mexican Health Care System

• We still have a lack of control or regulation in the practicing of

– Alternative medicine– Homeopathy – Acupuncture– Reflexology– Naturism– Iridology– Aromatherapy

3. Examples of implementing prevention in settings with

limited resources

Tu No Me Conoces Social Marketing Campaign to Promote Risk Awareness and HIV Testing

in Latinos in the US-Mexico Border Region

Campaign overview

• Cost

• Period of time

• Media used (radio spillover effects in border region)

• Web site

• Results

• Lessons Learned

4. Opposition to harm reduction

What is harm reduction?

5. Human rights and protection of human subjects

6. Role of systems: church, police, pharmacies, jails/prisons, US Immigration policy

• U.S. immigration policy on HIV varies by type of immigration status, and for some Mexican immigrants the threat of deportation may prevent them from seeking HIV testing or treatment for their disease (American Foundation for AIDS Research, 2001).

7. Understanding the Patient’s Perspective

(invite panel of persons living with HIV/AIDS)

8. Additional strategies to address barriers to HIV prevention

Quality of Services

Monitoring patient health

How up to date is patient contact information?

Community-based work: involving members of the target community to reduce barriers to testing and

reducing high-risk behavior

• “El Cohete” Project