1. Cross-Border Infectious Diseases: HIV/AIDS Preliminary data from SYHC’s Southern CA Border HIV/AIDS Project – a HRSA SPNS Demonstration Grant (DHHS, HRSA grant # H97HA00179-05-01) Rosana Scolari Director of HIV Services San Ysidro Health Center November 2004

2. Presentation Goals  The impact of HIV/AIDS – Latinos and the border  Provide a brief overview of HIV/AIDS services available at SYHC and funding sources  Present preliminary data on SYHC’s HRSA funded Special Projects of National Significance (SPNS) Grant in order to:  Inform health care providers and potential funders about trans-border health care access patterns of people living with HIV and its potential relevance to the patient’s health and the need for a binational funding approach for HIV programs  Plan and develop cross-border collaborations with an understanding of the health care access issues and service utilization choices of HIV+ individuals along the border

3. Donde comienza la frontera/Where the border begins

4. Latinos and HIV/AIDS  Latinos in the US represent 13% of the population and account for 18% of the AIDS Cases  Latinos in CA are more likely than other racial/ethnic groups to be less than 30 years of age at time of AIDS diagnosis (CA DHS, 2002)  Latinos tend to seek medical care at later stages of disease: they also wait longer after finding out HIV+ status prior to coming into care (Mathews, 2002)

5. HIV/AIDS in Baja California & San Diego Baja California (2000) Population: 2.5 million Population in Tijuana: 1.2 million HIV  New Cases (Reported from 1/1/04-6/30/04) = 93 (Reported from 1995-2004) = 1,209 AIDS  New Cases = 44 ( Reported 6/30/2004 )  Cumulative Cases (1983-2004) = 3,055 Consejo Nacional para la Prevención y Control del VIH/SIDA Centro de Salud y Asistencia, Junio 2004 San Diego (2000) Population in SD: 2.8 million HIV  New Cases (Reported 7/1/02-10/31/04) = 4,598 (Reported 7/1/02-10/31/04) = 4,598AIDS  New Cases (2004) = 286  Cumulative Cases = 12,382 (up to 10/31/04) County of San Diego HIV/AIDS Epidemiology Report 2004 HHS

6. Source: Registro Nacional de Casos de SIDA. Data as of December 31st 2003. National Average (69.6) Baja California ChihuahuaTamaulipas Nuevo Leòn CoahuilaSonora Accumulated Incidence Rate of AIDS Cases in the Northern Border States of México

7. SYHC HIV/AIDS Services  1998 - Expansion of RWCA Title I Funding to create CASA  CASA Case Management – from an average of 5 new patients per month (1998) to an average of 8 new patients per month (2004)  2000 - Awarded RWCA Title III Funding for HIV Specialty Care Services  SYHC HIV patient load went from 50 patients in October 2000 to 300 patients November 2004  2002 – County Funding for HIV Testing  Expanded access for testing services, from one day of testing to three days and two sites  Testing an average of 83 and identifying an average of 3 HIV+ (last quarter numbers) a 3.6% positive rate compared to the 2.5% County average.  1999-2004 - Growth in Prevention Services (local and state funding)  Starting with one prevention program and 100K in funding in 1999 to five programs (including a binational P3 program) totaling 425K in 2004  2000 & 2004 - Research & Evaluation Projects  HRSA Special Projects of National Significance (SPNS) in 2000  CDC Behavioral Surveillance Project in 2004

8. HRSA HIV/AIDS Bureau Special Projects of National Significance (SPNS) GENERAL OVERVIEW: In July 2000, HRSA HIV/AIDS Bureau, Special Projects of National Significance (SPNS), made awards to a total of five demonstration service projects along the US/Mexico border (from San Diego to Brownsville, TX). The objectives are to implement unique models of HIV/AIDS care for high-risk populations living on the US/Mexico border. Project locations/lead agencies include:  California – San Ysidro Health Center  New Mexico – El Rio Health Center  Arizona – Camino De Vida  Texas (El Paso) – Centro Familiar La Fe  Texas (Harlingen) – Valley AIDS Council

9. Southern California Border HIV/AIDS Project, SYHC SPNS Project FUNDING PERIOD: July 2000 - June 2005 DESCRIPTION: A five year demonstration project intended to improve HIV/AIDS outreach, and access to testing and primary care services and cross-border linkages for people who live or work in San Diego or Imperial counties. STRUCTURE: A collaboration of four community health centers in San Diego and Imperial Counties, including SYHC (lead agency), FHC, VCC, CSP (Imperial Co.) EVALUATION: A multi-level evaluation component - local evaluation oversight provided by UCSD and the University of Oklahoma’s Centro de Evaluación responsible for multi-site evaluation TARGET POPULATIONS: Newly immigrated Latinos, migrant and permanent farm workers, Latinas, transborder Latinos and Latino men who have sex with men (MSM)

10. SPNS Project Study Aims  To describe the socio-demographic, risk and health care access characteristics of a predominantly Mexican-origin population of HIV+ persons living in the border region between Southern California (US) and Baja California (México)  To improve early access to HIV counseling & testing for HIV+ individuals in the San Diego/Tijuana border region and  To enhance the capacity of CHC’s to provide culturally sensitive care and promote early entry into primary care and social services for HIV+ individuals in the San Diego/Tijuana border region

11. Methods  HIV+ clients who live or work in the US-Mexico border region are recruited from four partner sites  Voluntary and informed consent is obtained and a series of six survey instruments and a medical chart review are completed on each person  Questionnaires are administered primarily on site at the clinics (on the US side of border only)

12. Preliminary Data on HIV Positive Participants (N=269) A total of 269 HIV+ participants have been enrolled into the study from July 1, 2001 to June 30, 2004 RACE/ETHNICITY:  87% (233) are Latinos/as  13% (36) are non-Latinos (29 White, 6 Black, 2 Asian, 1 Native Hawaiian or P.I., 2 American Indian)  92% (214) of Latino/a participants reported having ties to México (e.g. family, social, business) NOTE: Subsequent presentation data provided on Latino study participants

13. HIV+ Latino/a Demographic Profile (N= 233) 7/01-06/04 GENDER Male = 85% (197) Female = 15% (36) AGE (average yrs) Male= 37 (range 19-73)Female = 37 (range 19-66) SEXUAL ORIENTATION Gay/Lesbian= 50% (117) Heterosexual = 37%(86) Bisexual = 12%(28) refused = 1%(2)

14. Exposure and Years Since Diagnosis (N= 233) 7/01-06/04 EXPOSURE CATEGORY* MSM (Men-who-have-Sex-with-Men)= 56% (131) Heterosexual Contact= 28% (66) IDU (Intravenous Drug Use) & Hetero Contact= 7%(17) Blood Transfusion = 4%(9) Other/Unknown= 4% (10) AVERAGE # OF YEARS SINCE DIAGNOSIS Male= 3.2 years (range 0-19) ~50% were enrolled less than one year after diagnosis ~50% were enrolled less than one year after diagnosis Female= 2.5 years (range 0-12) ~56% were enrolled less than one year after diagnosis ~56% were enrolled less than one year after diagnosis * Percentage does not equal 100% due to rounding

15. Border Crossing Frequency Study participants who crossed the US/México border at least one round-trip per year during the last year (N=199) N %  Low frequency (1 time/year to <2 times/month) 78 39%  Medium frequency (2 to 4 times/month)53 27%  High frequency crossers (>4 times/month)68 34% Note: Months are implied based on the number of round-trip crossings per year

16. Number of Months Lived in or Visited México (≥1 month within the past year, N=149, 36% of total respondents (84/233) lived/visited less than 1 month) N (149) %  One to two months22 15%  Three to 6 months19 13%  Seven to 11 months24 16%  12 months84 56%

17. Medical Care Seeking Behavior within the last year (N= 233) N% Non-HIV medical care in México 99 42% Non-HIV medical care in the U.S.70 30% HIV medical care in México 77 33% Obtain RX medications in México 123 53% Obtain traditional medications 43 18% in México

19. Conclusions…  About half of study participants enrolled through case management waited more than one year to enroll in care after having a positive test result  121 of 199 Latino participants (61%) 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 México  Latino participants receiving care in the US also access care and medications in México  Preliminary data indicates that many HIV+ Latinos access HIV and non-HIV medical care on both sides of the border

20. Impact…  Health care providers and potential funders need to be aware about trans-border health care access patterns of people living with HIV and its potential relevance to the patient’s health and the need for a binational funding approach for HIV programs and services  At the local planning level, understanding the health care access issues and service utilization choices of HIV+ individuals along the border may provide useful data for planning of cross-border collaborations

21. Future Plans…  Dissemination of SPNS project data and actively seek publication of outcomes - manuscripts, journal articles, etc.  Active efforts will continue to share data collection instruments, data & databases, and program technical information with researchers on both sides of the US/Mexico border.  Continue to seek funding for transborder research projects such as SPNS to enhance knowledge of the impact of the border on behavior and diseases

22. The Border That Unites Us

23. Contact Information Rosana Scolari Director of HIV Services San Ysidro Health Center 4004 Beyer Blvd San Ysidro, CA 92173 (619) 662-4192 rscolari@syhc.org