Barriers to Implementing
HIV Prevention
Project TIES: HIV/AIDS Prevention in
the US-Mexico Border Region
María Luisa Zúñiga, Ph.D.
Assistant Professor
Division of International Health and Cross-Cultural Medicine
Department of Family and Preventive Medicine
University of California, San Diego
September 17, 2006
1
Collaborators
Steffanie A. Strathdee, PhD
Professor and Harold Simon Chair
Chief, Division of International Health
and Cross Cultural Medicine,
University of California, San Diego
Thomas L. Patterson, PhD
Professor
Department of Psychiatry
University of California, San Diego
Rosana Scolari
Director of HIV/AIDS Services
San Ysidro Health Center
José Luis Burgos, MD
Coordinator
Project TIES
Adriana Vargas Ojeda
Vice Chancellor
UABC, Campus Tijuana
Gudelia Rangel Gómez, MD, MPH
Academic Director
Colegio de la Frontera Norte
Remedios Lozada Romero, MD
Director COMUSIDA y CIRAD
Acknowledgements:
USAID & National Institutes of Mental Health (Grant # 5K01MH072353)
2
Session Objectives
I. To describe barriers to HIV prevention
including:
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
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Individual-level barriers
Social-level barriers
Structural- and system-level barriers
II. To describe strategies for reducing
barriers to HIV/AIDS prevention
3
Primary and Secondary
HIV/AIDS Prevention
 Primary Prevention: Health promotion measures taken to prevent
transmission of the virus to uninfected persons
 Condoms, Clean needles, antiretroviral medications for HIVpositive pregnant women to prevent vertical transmission
 Vaccines: Work in progress
 Secondary Prevention: Measures taken once infection has occurred

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HIV testing—early detection
Reduction in or prevention of complications from HIV including
progression to AIDS
Effective treatment of HIV complications
Promotion of low viral load through effective treatment
Promotion of health behavior change to reduce risk behavior (e.g.
Prevention with Positives)
4
Theoretical framework and
models to describe barriers
to HIV prevention
5
Context of prevention behavior
6
Southern California Border HIV/AIDS Project
Service Delivery Model (SYHC)
COORDINATED CARE & SERVICES
PRIMARY CARE
INTERPRETATION
TRANSLATION
INTAKE
INTAKE
ADAP
FOOD VOUCHERS
TREATMENT
EDUCATION
MENTAL HEALTH
DENTAL CARE
SPECIALTY CARE
SUPPORT & ART
THERAPY
GROUPS
LEGAL SERVICES
BENEFITS
COUNSELING
QUALITY OF LIFE
ASSESSMENT
VOLUNTEER
SERVICES
TRANSPORTATION
OUTREACH
TESTING & COUNSELING
CASE MANAGEMENT
EARLY INTERVENTION
PROJECT EVALUATION
7
Confluence of Barriers
Individual/personal
Barriers
Social
Barriers
Structural
Barriers
Confluence of barriers can negatively impact
population-level prevention efforts and patient health
8
Individual/personal-level
barriers
Individual/personal factors that
can impede access to care or
prevention of HIV transmission
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
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Stigma
Low self esteem
Depression
Disclosure of HIV status
Being in denial about illness
Domestic violence
Addictions (e.g. methamphetamines, IDU)
Others…
Access to transportation
Child care
10
Individual factors, cont.
Complexity of factors related to disclosure &
mental health
Gorbach PM, et al. (2004) Don't ask, don't tell:
patterns of HIV disclosure among HIV
positive men who have sex with men with
recent STI practising high risk behaviour in
Los Angeles and Seattle
11
Individual and social…
Individual & Family “La Manzana”
School & community
Homophobia
Adictophobia
Qualitative study: Focus Groups with
Latinos living with HIV
Concern with seeking health services where one could
be identified or stigmatized by others
“¿Qué pasa si te ven en un lugar donde no más acuden
las personas infectadas?, van a saber que estás
infectada” (“What happens if they see you go to a
place where only infected people go?, they are going
to know that you are infected”)
* Zúñiga ML, et al., 2006
13
Qualitative Study, cont.
Female participants expressed dissatisfaction
with health services, perceiving that some
clinic environments were geared primarily
towards homosexual males
14
Qualitative study, cont.
Impact of social stigma…

Lack of information in the community about
HIV/AIDS can affect the individual..
“Within the Hispanic community, the lack of
knowledge about AIDS is worse… they are
even afraid of you touching them, or if you
drink from their glass”
(Zúñiga, ML, et al., 2006)
15
Social leading to system
barriers..
“Isolation, notes in clinical histories pointing
to HIV, obligatory testing and delays in
surgeries for PLHA were constant
practices.”
Infante C, et al. (2006). HIV/AIDS-related stigma and
discrimination: the case of health care providers in Mexico.
Salud Pública de Pública de México. 48(2):141-50.
16
System barriers..
Public policy
Use of sexual history in court: “California
justices rule that those who don't inform
their partners of previous relationships can
be liable for transmitting diseases”
(Weinstein H, Los Angeles Times, July 5,
2006)
What might be the impact of this headline
on prevention efforts?
17
Structural Barriers
Impediments that limit access to health services, are
beyond the control of the individual, and not linked
to social barriers
 Clinic hours of operation
 Clinic location
 Lack of financial or personnel resources in clinics
Funding issues
 Some groups may feel that they deserve health
care dollars more than others
 Sense of social guilt (Ryan White Care Act)
18
Health Care Delivery
Structure in US and Mexico
MEXICO
UNITES STATES
 Decentralized health
care system; primarily
private insurance w/
some public insurance
for poor and elderly
 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
19
Selected structural barriers for
Latino patients in the US
 Lack of bilingual clinicians and staff
 Patients have reported poor access to
vitamins or medications to mitigate side
effects
 Access barriers reported by immigrants who
do not have a social security number
20
21
Selected structural barriers in the
US: communication
 A Spanish-language dominant patient who
was unable to understand his prescription
instructions (written in English) reported:
“I took the precaution of calling to ask about the
administration and they told me it was for
gargling…if not I would have been drinking
three doses a day!” (Zúñiga, et al., 2006)
22
Selected structural barriers
in Mexico
System-level challenges to efficiency and availability of
laboratory tests exist
Laboratory costs of CD4 cell count or viral load

~ $100 US dollars
The centralized system of processing laboratory analyses
through government-sponsored health care systems can
result in delays in getting vital information to patients and
providers
> in some circumstances, obtaining lab results
may take weeks or months
23
Selected barriers to treatment
in Mexico
 Government-sponsored clinics may run out of
antiretroviral medications and patients must to pay out of
pocket
 Antriretrovirals are not available in many pharmacies and
cost from ~ $600 - $1,000 US dollars per month
 Some patients who have received care in Tijuana report
that due to insufficient availability of their ARV’s, they have
had to change regimens—which can contribute to
problems with drug resistance
24
Other structural barriers
 Police have confiscated clean needles from
IDU’s (Tijuana)
 Opposition to needle exchange programs—
even with sufficient scientific evidence to
support them (US & Canada)
25
Selected examples of barriers
fostered by institutions
 The Catholic Church and lack of support
for condom use
 US Immigration policy against HIVpositive persons: The US denies entry to any
non-US citizen living with HIV (both to
immigrants and visitors)
(Source: AIDSandtheLaw.com - An HIV/AIDS Law & Policy Resource
Summary of U.S. Law on Entry of Noncitizens with HIV
http://www.aidsandthelaw.com/issues/entry%20to%20US.htm)
26
The US-Mexico border
In what ways does the border
region impact HIV prevention
efforts?
27
US-Mexico Border Region
Border Region ~3000 km (1,863 miles)
North/South 100 km (62 miles)
CA/Baja CA 322 km (200 miles)
Source:
Pan American Health
28
Organization
“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)
29
Impact of the border…
 Stress and anxiety related to crossing the
border (Zúñiga, et al. 2006)

Including crossing with ARV medications
 When US ports of entry are closed to north-
bound traffic there is a direct impact on
access to health care

September 11, 2001
 Both Tijuana and San Diego residents at risk
for HIV infection report high-risk sexual
behavior with persons from both sides of the
border (Ruiz, et al. 2002)
30
IV. Strategies for reducing
barriers to HIV/AIDS prevention
Southern California Border HIV/AIDS Project was part of a multi-center
initiative including five demonstration projects extending from San Diego,
California to Harlingen, Texas
 Funding Agency:
Health Resources and Services
Administration (HRSA)
Special Projects of National
Significance (SPNS)
(Grant # 1 H97 00179 02)
 Multi-site Evaluation Agency:
Centro de Evaluación
 Lead Agency:
San Ysidro Health Center
 Local Evaluation:
University of California, San
Diego
 Funding Period:
7/2000-6/2006
(University of Oklahoma)
32
Southern CA Border HIV Project
Partner Clinic Sites
Vista Community Clinic
Clínicas de Salud
del Pueblo
Family Health Centers
San Ysidro Health Center
33
Project Goals
1. Increase early detection of the underserved
HIV+ Latino/a population living or working in the
border region between Southern California (US)
and Baja California (México)
2. Reduce barriers to comprehensive HIV/AIDS
primary care services through case
management and integrated care
3. Enhance the capacity of community health
centers to provide culturally sensitive care
34
Target Populations1
Latinos/as at risk for HIV or living with HIV/AIDS who
live or work in the U.S./Mexico border region
 Latino/a migrant farm
workers
 Latino/a youth sex
workers
 Latino/a sex workers
 Latinos/as who cross
the border on a regular
basis
 Newly-immigrated
Latino MSM
 Latinas
1 Note: Risk categories were defined based on individual
clinic target populations and are not mutually exclusive
35
Methods
 HIV-positive persons seeking case management
services were invited to participate and enrolled
through four community clinics in San Diego and
Imperial Counties
 Participants underwent structured interviews
 Project was approved by the UCSD Human
Research Protection Program
36
Selected participant demographics
 354 Participants recruited during case management (03/28/01-09/20/04)
 82.2% (291/354) male
 79% (280/354) Mexican-origin


16.1% (57/354) non-Hispanic
4.8% (17/354) other Hispanic group
Sexual Orientation of Males
Sexual Orientation of Females
3%
2%
2%
2%
Gay
Gay/Lesbian
Bisexual
Bisexual
Heterosexual
Heterosexual
Undecided/Don't
Know/Refused
Undecided/Don't
Know/Refused
29%
56%
13%
93%
37
Participant border crossing
frequency
Roundtrip border crossings in the last year were
assessed for all HIV+ clients.
 Seventy eight percent (277/354) reported
crossing the border at least once during the
last year.
 Twenty two percent (76/354) reported never
crossing the border in the last year.
38
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 obtained prescription
medications in Mexico
 14% (50/354) reported having received traditional
medications or herbs in Mexico
39
Study implications
 Patient level: health care provider awareness of
trans-border health care access and its potential
impact on patients
 Public health planning level: health care access
issues and service utilization choices may
provide useful data for planning of cross-border
collaborations
40
Southern California HIV/AIDS
Project:
Promoting HIV testing through
mass media
Tu No Me Conoces mass media campaign to
promote testing in Latinos at risk for HIV
infection in the California/Baja California
border region
 One-minute radio ad aired 650 times over the
course of 8 weeks (6/15/03 to 8/16/03)
41
42
What we learned from this
campaign
 Of 172 persons who recalled an HIV message when
they came for an HIV test, 28% specifically identified
the Tu no me conoces radio campaign
 Imperial County needed to have the campaign run
during different months
 Positive spill-over effects in border region assumed
but difficult (costly) to measure—structural barrier of
where funding can be used
 Additional research needed to determine binational
effects of using Spanish-language educational
messages in a border region
43
Southern CA Border HIV/AIDS Project:
Barriers to Care reported by project participants
Top 10 barriers (Of 157 study participants living with HIV/AIDS who
reported at least one barrier to health care)
44
Additional strategies for reducing
barriers to HIV prevention
 Community-based services and
research
Proyecto “El Cuete” y PREVEMOVIHL
 Community-based participatory
research
 Delivery of culturally-effective care
45
AFABI, A.C.
Agencia
Familiar
Binacional
Avenida Rio
Tijuana
46
Binational model for coordinated health care: CURE TB y CURE+ TB
County of San Diego Health and Human Services Agency
http://www2.sdcounty.ca.gov/hhsa/ServiceDetails.asp?ServiceID=437
47
48
San Diego Tribune, March 1, 2006
49
Challenges to binational health care
coordination
 Differences in surveillance and laboratory
protocols
 Availability of resources (medications,
clinicians, clinics)
 Delays in case reporting
 Population mobility
 Lack of HIV surveillance data and changes in
reporting requirements
50
Additional considerations for
promoting HIV prevention
1. What could be done to reduce access to
care barriers in the border region?
2. What may be some of the effects of
implementing routine HIV testing?
on individuals
on care delivery
51