Assisting HIV-Infected (and other) Patients Who May Return to Mexico (or Central America) Thursday, February 28, 2013 Los Angeles, CA 1

Disclosure Information Helping 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

AETC Warmline: (800) PEPline: (888) HIV – 4911 (888) 448 – 4911 Perinatal Hotline: (888) 448 – Tom Donohoe

UCLA CHPDP HIV/AIDS Training Programs Delivered in Mexico:

Which of these US metropolitan areas has the highest PERCENTAGE of Spanish-speaking households? 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? 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? 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 1.True 2.False

I can explain how Mexican health care systems work 1.True 2.False

Case 5 Juan 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______. 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. 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? 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 7

HIV and AIDS in Mexico Mexican population: 106,500,000 Cumulative cases of HIV/AIDS at the end of 2005: 182,000 8

HIV/AIDS Cumulative Cases 9 along the U.S.-Mexico Border (as of Dec 31, 2011) Baja Cal Norte: 6,863 Sonora: 2,748 Chihuahua: 6,457 Coahuila: 1,783 Nuevo León: 4,367 Tamaulipas: 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). Source cited in original slide: CENSIDA based in National AIDS Cases Registry. Cumulative HIV by Gender 10

2) In the US, HIV prevalence is.6%, which of the following represents the HIV prevalence in Mexico? 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). Source cited in original slide: UNAIDS Report on the global AIDS epidemic, Geneva, 2004 Mexicos Adult HIV Prevalence 11 in Regional Context Mexico 0.3% United States0.6% 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). Source cited in original slide: Encuesta Nacional de Cultura Política y Prácticas ciudadanas Revista Cambio, 17 de Agosto del (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% 15

HIV in the U.S.-Mexico Border Region 17

U.S.-Mexico Border 18

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 United States Mexico Border Health Commission, U.S. Border Characteristics 19

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 Characteristics 20

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, HIV AIDS Along the US Mexico Border 21

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 Conasida 2008: Manual para la prevención del VIH/SIDA en migrantes Mexicanos a Estados Unidos. Mexican Immigration 22

Who Is UMBAST? U.S.- Mexico Border AETC Steering Team Promote high-quality, culturally sensitive education & capacity building programs Provide focused collaboration through joint planning, resource sharing, & evaluation 23

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 24

Regional AETCs L 25

Mexican Health Care Delivery Systems 26

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 27

U.S. HIV Health Care Funding Private insurance Public insurance Ryan White HIV/AIDS Treatment Modernization Act Clinical trials Compassionate release 28

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 29

Health Care Funding Sources Secretaría de Salud SSA Secretaría de Salud SSA Secretaría de Salud SSA Health Services in Mexico L 30

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) 31

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 32

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

Antiretroviral Coverage Source: CENSIDA based in National AIDS Cases Registry. 28,600 33

SSA CENSIDA Seguro Popular SME Health Services IMSS DIF SM SDN Hospitals & Universities CRM ISSSTE SMP SMM ONG PEMEX HIV Health Care Funding Sources 34

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 35

CAPASITS Centro Ambulatorio de Prevención y Atención en SIDA y Infecciones de Transmisión Sexual Outpatient Center for Prevention and Care for AIDS and Sexually Transmitted Infections 36

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). CAPASITS Locations 37

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) 38

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). CAPASITS Ciudad VictoriaNayaritLa Paz VeracruzZacatecasMexicali 39

Referral to CAPASITS Referral from a general medical clinic HIV diagnosis Antiretroviral history Basic labs Clinical summary 40

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 42

ARVs in Mexico: full chart available at Antiretrovirals Available in the United States Antirretrovirales Disponibles en México GenericBrand NameGenéricoNombre Comercial Nucleoside/Nucleotide Analogues (NRTIs) Inhibidores de la Trascriptasa Reversa Análogos a Nucleósidos (ITRAN) AbacavirZiagenAbacavirZiagenavir DidanosineVidexDidanosinaVidex EmtricitabineEmtrivaEmtricitabinaEmtriva LamivudineEpivirLamivudina3TC StavudineZeritEstavudina*Zerit 43

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UMBAST Fact sheet: Mexico 47

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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______. 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. 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 60