Sistema de Salud EEUU y Acceso a Servicios de Salud en la Frontera México-EEUU María Luisa Zúñiga, Ph.D. Assistant Professor UCSD School of Medicine Proyecto TIES Febrero 3, 2007
Border Region ~3000 km (1,863 miles) North/South 100 km (62 miles) CA/Baja CA 322 km (200 miles) US-Mexico Border Region Source: Pan American Health 2 Organization
Desde una perspective epidemiológica, la población fronteriza se debe considerar como una en vez de diferentes poblaciones en dos lados de una frontera; los patógenos no reconocen límites geopolíticos establecidos por los seres humanos (Weinberg et al., 2003) 3
Overview of California border ports of entry (urban/rural perspective) San Ysidro, busiest border crossing in the world: 41.8 Million north-bound crossings in 2000 (US Customs Services) San Diego population 2.8 million (US Census 2000) Tijuana is the eighth largest city in Mexico, 1.3 million (INEGI 2000) *U.S. Census Information, 2000 1 4
According to a recent study from the Colegio de la Frontera Norte, 42 thousand persons cross from Tijuana to San Diego every day to work: This represents about 8% of local employment for persons who reside in Tijuana 5
U.S. side of the border Counties with the highest proportions of Hispanics are along the southwestern border of the US (US Census 2000) More than 1/3 of US border families live at or below the poverty line Unemployment rate along border is 250-300% higher than in the interior of the U.S. Infectious disease incidence much higher than in other parts of the US Proportion of Latinos on US side varies by region: San Diego, CA 28% Latino El Paso, TX 78% Latino 6
County of San Diego 2005 Population Estimates Race/ Male Female Total Ethnicity Hispanic 438,186 441,844 880,030 (28.8%) White 788,430 786,187 1,574,617 (51.6%) Black 85,111 75,922 161,033 (5.3%) Asian/ 209,166 226,434 435,600 other (14.3%) Total Source: SanDAG 1,520,893 1,530,387 3,051,280 7
U.S. side of the border Health Care Designated as Medically Underserved Areas Lack primary care physicians Of the 13.7 million Latinos in the US 33% do not have health insurance ~ 3 million border residents do not have health insurance Shortage of bilingual health professionals (HRSA, 2001) 8
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Mexican border states Some of most economically prosperous cities are at the northern border of Mexico (Tijuana is the eighth largest city in Mexico) Sub-standard living conditions resulting from infrastructure development & maintenance (i.e. water, sewage, electricity) challenges due to influx of migration. As in the US, health indicators vary by proximity to border 10
Country-level Comparisons in Health Care Delivery UNITES STATES Decentralized, private insurance w/ some public insurance for poor and elderly MEXICO Centralized system with several governmentsponsored insurance programs and a growing private insurance industry Health care is constitutional right A growing number of US insurance companies in CA are offering care coverage in Tijuana for workers in the US who prefer to receive services in Mexico 11
What we share Transborder and migratory populations Environmental pollutants (air, sewage, pesticides) Economic and cultural interaction Communicable disease burden Chronic and Infectious--Double burden of disease 12
Sistema de Salud en México* Contribuido por: Dra. Vargas Ojeda, Vicerrectora, UABC Campus de Tijuana Secretaría de de Salud SSA Instituto Instituto Mexicano Mexicano de de Seguro Seguro Social Social (IMSS) Instituto Instituto de de Servicios Servicios de de Salud Salud Pública Pública del del Estado Estado (ISESALUD) Instituto Institutode de Seguridad Seguridad y Servicios ServiciosSociales Socialesde de los los Trabajadores Trabajadores del del Estado Estado (ISSSTE) Hospitales Generales Servicios médicos del condado Servicios médicos del condado Institutos Nacionales de la salud Institutos Nacionales de la salud Clínicas Periféricas Clínicas Periféricas Servicios Servicios médicos médicos privados privados Servicios Servicios médicos médicos para para el el distrito distrito federal federal Centros de la salud pública Centros de la salud pública Instituto Nacional para Indigentes Instituto Nacional para Indigentes Hospital Militar Hospital Militar Cruz Roja Cruz Roja PEMEX PEMEX DIF DIF 13
Cumulative AIDS Incidence, Mexican States (June 2006)* Distrito Federal Baja California Yucatán Morelos Jalisco Veracruz Quintana Roo Nayarit Guerrero BC Sur Campeche Puebla Colima Oaxaca Chiapas México Chihuahua Tamaulipas Tlaxcala Tabasco Michoacán Nuevo León Sonora Sinaloa Durango Querétaro Aguascalientes Coahuila Guanajuato San Luis Hidalgo Zacatecas 76.8 75.4 74.0 73.1 70.4 69.4 68.4 65.4 63.2 62.1 57.6 55.8 55.7 54.9 50.8 50.0 45.1 38.7 114.8 103.9 94.4 92.5 92.2 88.2 141.0 140.7 134.1 129.7 125.4 121.0 National Average 165.3 U.S. Mexico border states * * per 100,000. Source: Registro Nacional de Casos de SIDA, CONASIDA 14 229.2
San Diego Tribune, March 1, 2006 15
San Diego County Latino HIV/AIDS Data Dr. Samantha Tweeten Department of Health and Human Services County of San Diego January 5, 2007
County of San Diego Year AIDS Case Rate per 100,000 population Hispanic White Black 2000 22 13 49 2001 18 13 45 2002 18 13 47 2003 18 11 48 2004 16 11 34 2005 15 12 25 17
Hispanics as Percent of Total Cases, 2000-2005 600 50.0% 500 45.0% total AIDS cases 400 300 200 40.0% 35.0% 30.0% 25.0% 20.0% % of cases that are Hispanic 100 15.0% 0 2000 2001 2002 2003 2004 2005 10.0% 18 year
Mode of Transmission in Hispanic AIDS Cases by Gender, County of San Diego Mode MSM Male cumulative 2001-2005 76.7% 76.3% Female cumulative 2001-2005 NA NA IDU 9.3% 9.3% 24.4% 16.2% MSM+IDU 9.1% 6.0% NA NA Heterosexual 2.6% 7.7% 61.5% 78.1% Other* 2.3% <1% 14.1% 5.8% *Includes, transfusion/transplant, mother/hiv, risk not specified 19
Country of Origin Hispanic AIDS Cases Origin United States Cumulative 40.5% Male Cumulative 2001-2005 24.8% 34.8% Female 2001-2005 22.9% Mexico 52.9% 71.6% 54.8% 67.6% other 6.6% 3.6% 10.4% 9.5% Number of cases 2,560 612 299 105 20
Time from HIV to AIDS Diagnosis, 2001-2005 70 60 percent of cases 50 40 30 20 10 0 White (n=974) Black (n=319) Hispanic (n=711) less than 1 year 1 year or more 21
Challenges to Coordinating Binational Health Efforts Case definitions & lab disease confirmations may differ Disparity in resource availability (funding, medication, physicians, clinics, labs) Research infrastructure needs Under-reporting of cases - passive surveillance Access to unregulated prescription drugs Antibiotic resistance Possible medication interactions Population mobility 22
Implications for policy and programs Policy Federal agencies should consider the border region as unique to other communities in the U.S. with corresponding funding. Border populations share certain characteristics but are not homogeneous: Service provision must be responsive to local needs. Programs Culturally effective and linguistically adequate service provision is fundamental to effectively engaging and maintaining this population in care. 23
Acknowledgements El Cuete Project Staff and Co-Investigators Funding by NIDA (DA09227-S11, DA019829); USAID (GSM-025); NIMH (5K01MH072353) CFAR Developmental Grant Funding University of California San Diego Patronato Pro - COMUSIDA Tijuana, A.C. County of San Diego, Health and Human Services Agency Public Health Services 24
The impact of the border Concerns over crossing and having antiretrovirals with one (Zúñiga, et al. 2006) Some patients feel stress and anxiety when they cross (Zúñiga, et al. 2006) When the border is closed there is a direct impact on access to care Sept.11, 2001 A study by Dr. Ruiz and colleagues documented reports of high-risk sexual behavior and sexual networks in persons who live int the Tijuana/San Diego border region (Ruiz, et al. 2002) 25
Cross-border Healthcare Utilization 27% (94/354) reported having received HIV medical care in Mexico in the last year 36% (126/354) reported having received non-hiv medical care in Mexico 43% (152/354) reported having purchased prescription medications in Mexico 14% (50/354) reported having received traditional medications or herbs in Mexico 15% (30/354) reported having used a traditional healer in Mexico, the U.S., or both countries 26
Overview of Findings from the Southern California Border HIV/AIDS Project
Metas del Proyecto 1. Aumentar la detección temprana de VIH en poblaciones Latinas necesitadas quienes trabajan in la región fronteriza entre el sur de California (EEUU) y Baja (México) 2. Aumentar el acceso a servicios integrales de VIH/SIDAy de acceso a atención primaria en servicios de VIH/SIDA 3. Aumentar la capacidad de brindar atención que sea culturalmente sensible en los centros comunitarios de salud 28
Comportamientos riesgosos en el VIH reportados (actual o en el pasado) por sexo (n=4,493 personas inscritas a través de tamizaje del VIH) RISK ACTS Unprotected sex with males Unprotected sex with females Unprotected sex with IDU (intravenous drug user) Unprotected sex with HIV+ person Sex worker/survival sex Victim of forced sex Needle sharing Received a blood transfusion MALES N (%) 653 (26.1%) 2140 (85.5%) 262 (10.5%) 102 (4.1%) 200 (8.0%) * 88 (3.5%) 190 (7.6%) 56 (2.2%) FEMALES N (%) 1889 (95.1%) 115 (5.8%) 188 (9.5%) 56 (2.8%) 135 (6.8%)** 177 (8.9%) 77 (3.9%) 91 (4.6%) * Of the 200 male sex workers, 42% (n=83) were men who have sex with men **Over 95% (n=128) of female sex workers were women who have sex with men 29
Southern CA Border HIV Project Partner Clinic Sites Vista Community Clinic Clínicas de Salud del Pueblo Family Health Centers San Ysidro Health Center 30
Southern California Border HIV/AIDS Project Service Delivery Model (SYHC) COORDINATED CARE & SERVICES PRIMARY CARE INTERPRETATION TRANSLATION ADAP FOOD VOUCHERS TREATMENT EDUCATION MENTAL HEALTH DENTAL CARE Client Hand-off INTAKE INTAKE QUALITY OF LIFE ASSESSMENT REFERRAL SPECIALTY CARE SUPPORT & ART THERAPY GROUPS LEGAL SERVICES BENEFITS COUNSELING VOLUNTEER SERVICES TRANSPORTATION OUTREACH TESTING & COUNSELING EARLY INTERVENTION CASE MANAGEMENT PROJECT EVALUATION 31
Actividades Alcance (a Trabajadores Agricultores, Hombres quienes tienen sexo con otros hombres, Mujeres Latinas, y Latinos quienes viven una realidad binacional (cruzando la frontera con cierta frequencia) Consejería y tamizaje de pruebas de VIH Manejo de Casos/Trabajo Social Consejería en la adherencia a un régimen de medicinas de VIH/SIDA Campaña de Medios Masivos para promover la prueba del VIH (Tu No Me Conoces) La campaña incluyó: Radio Número gratuito para informes de donde hacerse la prueba del VIH Foyetos Sitio de Web (http://www.tunomeconoces.org/) 32
Resultados Selectos del Estudio
Aplicación de la Prueba del VIH: Resumen demográfico 4,493 personas fueron inscritas a través de servicios de tamizaje (March 01-Sept 04) Sexo Hombre 55%; Mujeres 44.2%; Transgéneros H>M.1% Edad Promedio: 35 años (dee 12 84 años) Orientación Sexual 8.6% Gay/Lesbiana 6.9% bisexual 83.5% heterosexual 1% desconocido/faltando info Seguro Médico Principal 68.8% No tiene seguro; 15% Medicaid; 10% Privado; 3.1% Medicare; 1.5% otro seguro público; 1.7 desconocido/faltando info HIV Testing: Testing results were available for 84% (3,787) of participants (of these only 56.1% returned for results) We documented a prevalence of 2.4% in persons who underwent testing and for whom results data was available; that is, 92 of 3,787 persons tested HIVpositive during the study period. 34
Manejo de Casos/Trabajo Social: Resumen Demográfico 354 personas viviendo con el VIH inscritos a través de la Manejadora/Manejador de Casos (Marzo 01-Sept 04) Sexo Men 82.2%; Women 17.2%; MTF Transgender <1% Etnicidad Mexican/Mexican American: 79%; 4.8% other Hispanic; 16.1% non-hispanic Edad Promedia: 38 years (range 18 74) most participants were 25 to 44 yrs of age Orientación sexual 47% Gay/Lesbian 11% bisexual 40% heterosexual 2% undecided/don t know/refused Estado Civil 54% single; 16% married; 10% live w/ same sex partner; 7% live w/ opposite sex partner; 12% separated/divorced/widowed (1% unknown) 35
Orientación Sexual de personas inscritas en el estudio a través de manejadora/o de casos (n=354) Males Females 2% Gay 3% 2% 2% Gay/Lesbian 29% Bisexual Bisexual 56% Heterosexual Heterosexual 13% Undecided/Don't Know/Refused 93% Undecided/Don't Know/Refused 36
Seguro Médico de personas inscritas en el estudio a través de manejadora/o de casos (n=354) Primary Medical Insurance 5% 3% 2% 7% 11% No insurance Medicaid Medicare Private Other Public 72% Unknow n/no Response 37
RANK 1 Principales referencias a servivicios médicos/sociales REFERRAL TYPE Primary Care NUMBER (%) OF CLIENTS WHO RECEIVED REFERRAL 197 (77.9%) NUMBER (%) OF CLIENTS WHO PRESENTED FOR SERVICES 174 (88.3%) NUMBER (%) OF CLIENTS WHO DID NOT PRESENT (SERVICE WAS NO LONGER NEEDED) 9 (4.6%) 2 Mental Health 174 (68.8%) 147 (84.5%) 14 (8%) 3 AIDS Drug Assistance Program (ADAP) 173 (68.4%) 160 (92.5%) 8 (4.6%) 4 Support Groups 130 (51.4%) 89 (68.5%) 33 (25.4%) 5 Treatment Education 116 (45.8%) 104 (89.7%) 5 (4.8%) 38
Conocimiento del/de la paciente sobre servicios disponibles antes y después de que la/el paciente accediera servicios de la trabajadora social Before Seeking HIV Care After Enrolled in Services N % N % *p-value Know where to get HIV primary care? No 154.0 79.0 27.0 13.8.000 Yes 41.0 21.0 168.0 86.2 Know where to get case management services? No 161.0 82.6 15.0 7.7.000 Yes 34.0 17.4 180.0 92.3 Know where to get enrolled into ADAP? No 173.0 88.7 28.0 14.4.000 Yes 22.0 11.3 167.0 85.6 Know where to get HIV treatment education? No 168.0 86.2 20.0 10.3.000 Yes 27.0 13.8 175.0 89.7 Know where to get interpreter services? No Yes 152.0 43.0 77.9 22.1 30.0 165.0 15.4 84.6.000 39
Percepciones de barreras a servicios de VIH/SIDA Perceived Barrier Before Seeking Perceived Barrier Now? Medical Care? Perceived Barrier to Care Number Percent Number Percent Thought services cost too much 144 74.2% 13 6.7% HIV medications might make me sick 133 68.6% 32 16.5% Others might think badly of me because I am HIV+ 129 66.5% 50 25.8% Worried that doctor does not specialize in HIV/AIDS 103 53.1% 8 4.1% Concerned others will find out about HIV status 99 51.0% 21 10.8% Thought staff would not speak the same language 74 38.1% 2 1.0% Concerned others might think I am gay/lesbian 64 33.0% 17 40 8.8%
Percepciones de su salud en general Time 1 Time 2 Fair 28% Poor 10% Excellent 10% Very good 15% Good 37% Fair 15% Good 38% Poor 4% Excellent 15% Very good 29% 41
Resumen de necesidades para la población Latina identificadas a través del Proyecto SPNS Entre personas que se hicieron la prueba de VIH, auto-reporte de comportamientos de riesgo indican una necesidad de mejor alcance y tamizaje, especialmente entre mujeres quienes no piensan que están a riesgo Entre personsa inscritas a través de una manejadora de casos: Aproximadamente una mitad de participantes espereraon más de un año para obtener servicios médicos después de enterarse de su estado positivo Muchos participantes nos relataron que les faltaba información sobre servicios disponibles antes de insribirse en servicios de la manejadora de casos Los programas que mejoran el alcanze eficaz a personas recientemente diagnosticados con el VIH podrían mejorar las oportunidades de integrarlos a servicios 42
Findings About half of study participants enrolled through case management waited more than one year to enroll in care after having a positive test. Lesson learned: important to identify when and where the person received their first positive test. Sixty-one (121/199) percent of Latino participants made two or more round-trip border crossings per month in the last year. About 72% (108/149) of Latino participants are spending seven or more months visiting or living in Mexico. Latino participants receiving care in the US also access care and medications in Mexico. 43
Findings cont HIV+ Latinos access HIV and non-hiv medical care on both sides of the border. At the individual level, it is important for health care providers to be aware of trans-border health care access and its potential relevance to the patient s health. At the local planning level, understanding the health care access issues and service utilization choices that HIV+ individuals make may provide useful data for planning of cross-border collaborations. 44