Project to reduce the Incidence of STI/HIV Among Border Youth

The purpose of the year-long project was to reduce the incidence of STI/HIV among border street youth by developing collaborative prevention strategies. On Thursday, August 31, Rick Holland participated in BHI's First Annual Core Partners' Conference. Friday, September 1, Rick met with Blanca Lomeli and Carmen Cutter at BHI's office in National City to discuss wrapping up this project. This final report describes results of the previous year's work, with recommendations for future efforts dealing with HIV prevention work along the border.

This project was funded by the California Wellness Foundation and the California Endowment as follow-up to the previously funded work on the research project: The HIV/STD Prevalence and Risk Behaviors of Street Children Living in the San Diego / Tijuana Border Region. This research was presented as a doctoral dissertation by Gisele Norris to the UC Berkeley School of Public Health, Division of Maternal and Child Health on April 24, 2000. As has been previously documented, the results were presented at a workshop held December 2, 1999 in San Diego. In June of this year, the research was translated into Spanish for its use in this border project.

Copies of the research can be obtained by contacting Rick Holland (contact information follows). Chapter six presents the conclusions and recommendations, which should be referred to for a more complete discussion of recommended interventions, and following is a summary that pertains directly to the actions taken for the current project:

In order to reduce the substantial cost of treating new STDs and their sequelae, general health policies should seek to reduce the reproductive rate of STDs by funding and implementing:
1. Programs to reduce the rates of new partner acquisition (e.g., alternative income generation activities for commercial sex workers);
2. Programs to reduce the susceptibility of exposed individuals (e.g., increase safe sex behaviors);
3. Programs that reduce the duration of infection and infectivity of those who are infected (e.g., improve access to care; offer screening programs for asymptomatic infection).

One mechanism to expand prevention/early intervention services is through further development of international collaborations such as the Pan American Health Organization (PAHO) and the U.S. Mexico Border Health Association (USMBHA). Channeling STD prevention and treatment funding through these programs is appropriate for several reasons: first, entities such as PAHO and the USMBHA have a long history of collaboration with non-governmental organizations (NGOs). Thus, provision of prevention and services through NGOs may be more acceptable to immigrants who are hesitant to utilize government services because of a perceived risk of deportation.

Furthermore, despite policy changes that reduce immigrant access to publicly funded domestic programs, immigrants still have access to infectious disease control and some other public health programs. Educating immigrants about what they can legally receive without fear of deportation is an important task and NGOs, often seen as advocates for immigrants, may be the optimal locations for such education efforts. In addition, bi-national collaboration (especially along the border) has the potential to increase coordination of services between the U.S. and Mexico and thus reduce contradictory policies and duplication of services, resulting in more efficient allocation of resources.

Finally, Mexican and U.S. entities can work together to improve the cultural appropriateness of prevention messages and service provision targeted towards migrants. Funding for collaborations such as the USMBHA should be increased to enable CBOs to reach a larger number of clients in a more extensive service area (e.g., target California areas with large concentrations of high-risk groups).

Similar collaborative efforts are necessary to create and maintain cross-border exchange of disease monitoring and surveillance information. HRSA, PAHO and several other players have recently begun collaborating with state epidemiologists on both sides of border to improve/standardize epidemiologic data collection, analysis and dissemination through paper and electronic means. Such efforts should be supported by state and federal policies and financing.

The results of this investigation point to several specific strategies for prevention and treatment. In general, it is apparent that condom use is low in the entire population and that sub-populations are at increased risk of contracting STDs, including HIV. In addition to general interventions that promote condom use during sexual activity with women, interventions should be targeted at specific risk groups: men who are or have been incarcerated in prison or juvenile facilities (e.g., commercial sex workers who are likely to have been previously incarcerated).

All interventions being planned need to take into account: 1) Street children in general and those who are infected with an STD in particular are likely to have low levels of education and limited literacy. It is particularly important that literacy be considered whenever educational interventions are planned. Therefore interventions which utilize pictures and verbal language are likely to be more effective, as are interventions that utilize peer educators to "spread the word."
2) Interventions should take into account the Mexican classification of sexual self-identification; having sex with men does not necessarily mean that one considers oneself "gay." Even though almost half of all boys in the study population report engaging in sexual activities with other men, they often do not identify themselves as gay or bisexual. Thus prevention mechanisms should emphasize that one's risk of contracting an STD is not necessarily associated with the gender of one's partner, but more importantly with activities and protective behaviors that one chooses.

Commercial sex workers are a high-risk group for STDs and traditionally have been targeted for public health interventions. This population also has presented "public safety issues" and has been dealt with by authorities in a variety of ways--not infrequently incarceration. In Tijuana the police were known to harass female sex workers, a group that has become increasingly organized and stood up for its human rights. Organización SIDA Tijuana and other NGOs helped organize the Maria Magdalenas, which has improved the treatment of the women and provided public health education. The women have access to condoms and most are believed to be practicing "safe sex."

The gay and transgender population of Tijuana continues to receive harsh treatment from police and authorities. There is definitely intentional persecution, as well as "rounding up the usual suspects" due to street crime, petty theft and hustling. The homeless youth are easy targets, as the males will engage in exchange sex when in need of money, as well as steal and commit other crimes to survive. So although not identified as gay, male street youth frequently come into contact with the police and often are perceived as guilty solely due to their situation.

In California HIV prevention efforts are concentrating on "men who have sex with men" / MSM, injection drug users / IDU, and their sexual partners; as these are the populations at greatest risk of contracting HIV. In Mexico MSM and their sexual partners are the populations at greatest risk, although IDU appears to be increasing. One of the best preventive measures of HIV is to treat STIs. Male street youth engage in sex with males as well as females--with males primarily to make money--placing them in the MSM category. STDs are prevalent among street youth. The majority abuse drugs as well. Most HIV+ males are believed to have become infected while adolescents. All these factors place homeless youth in a priority position to be included in HIV prevention efforts.

Those of us involved in the research and this current project have sought to communicate the facts described above. As counties in California have gone through a process--often with intense community involvement--to prioritize and direct resources and efforts at high-risk populations, Mexico has not yet achieved the same focus. Many Mexicans--including public health workers, activists, and others--believe there is a concerted effort by the authorities to not address these issues, as it requires confronting social norms and cultural values, while people in power are putting forth a conservative agenda.

We have found that many NGOs and collaborative groups also are focusing their reproductive health education, HIV prevention, and social marketing efforts on a wide audience--often mainstream society. There is a lot of work to be done and it is commendable that advances have been made in schools to inform young people. A lot of effort and resources are directed to these programs, yet HIV is increasing in Mexico and California will have a difficult time reducing incidence of HIV if the numbers are increasing across the border.

Our message has been that male street youth are a priority for HIV prevention and that HIV incidence in California is directly linked with HIV status in Mexico. It is in everyone's best interest to deal with both these facts if there is truly a desire to reduce HIV. Fortunately, several steps have been taken in this regard.

Efforts to improve reproductive health have been going on for some time, but the year 2000 has seen some marked improvements. California has increased support for the Binational Health Office and is establishing closer ties with Mexican health officials. HRSA and the federal government are providing more resources to border health issues. Private insurers and health providers are breaking down barriers to cross-border services. Counties along the border are working in greater collaboration with CBOs, NGOs and Mexican agencies.

During the past year we have had the opportunity to work with and attend meetings with the many stakeholders in the region. We have been able to advise, support, and facilitate efforts to further the prevention of HIV. The data we have provided and information shared will help focus future endeavors. If our involvement could provide further benefit in the future, we look forward to continuing our collaboration.

In consultation with people and groups working in HIV prevention, we have developed an Action Plan that would contribute to greater impact in the reduction of HIV. We are not seeking involvement in the implementation of this plan, but offer this as possible next steps. The action plan as a whole is not presented on behalf of specific organizations, rather, various agencies and organizations have expressed an interest in collaborating in pieces of the plan.

We would like to mention challenges and threats that face this plan as well. Many people and groups that have worked on issues of HIV/AIDS binationally have dealt with the problem of access to services and medications in Mexico. Although solutions to these problems have improved, efforts are underway to guarantee healthcare to people that are HIV+. While improving the situation for people that are HIV+ and addressing issues that include preventing the further spread of HIV, prevention efforts are not the main focus and may be seen as competing for some of the same resources.

Mexican authorities have not wanted to publicize information and data regarding HIV/AIDS. Whereas counties in California have published reports and involved the community in policy decisions, Baja California authorities have been reticent to collect epidemiological information, share data either locally or binationally, and collaborate with non-governmental organizations. There has been some collaboration, but apparently an official policy exists to only collaborate if there is a potential for financial benefit.

On both sides of the border and within governmental as well as non-governmental agencies there is the issue of bureaucracy. It has been exciting to see officials of San Diego County willing to be creative and support new ideas, fund new initiatives and promote new programs. It has been frustrating to experience committees and collaborations not taking action because of lack of leadership, turf issues, personal grudges--sometimes going back years--or misinformation.

There are extremists and trouble-makers who hang around to create problems without offering solutions. Some people may just be negative, espousing their opinion that "that will never work." Others have an ax to grind, and will put forth any excuse to put people down: whether they rave against male or female, heterosexual or homosexual, white/Anglo or Mexican, work for the government or work for an NGO, etc. Unfortunately, not only extremists voice these "excuses," but some agency and organizational staff as well.

It is our desire to see existing efforts be taken further and greater collaboration, especially binationally. County funded programs can benefit both sides of the border. The HRSA funding for the San Ysidro Health Centers and Family Health Centers should have a great impact. BHI's funded work should strengthen collaboration that truly will bring about results. The universities ought to greater strengthen community linkages and conduct meaningful applied research. State officials must continue to break down cross-border barriers. And funders must seek ways to benefit the border region as a whole.

The following Action Plan provides concrete steps to achieve these results:

Project to Reduce the Incidence of STI/HIV Among Border Youth

Mission

To reduce the incidence of STI/HIV among border street youth by developing collaborative prevention strategies.

Goals and Objectives

1. Improve reproductive health services to homeless youth.
1.1 Obtain agreement from three clinics in each San Diego and Tijuana, and one clinic each in Imperial County and Mexicali to increase clinic visits for reproductive health from homeless Latino adolescents in a year by 100%, or if currently not providing these services, do so for a minimum of 12 teens.
1.2 Provide reproductive health services and treatment for STIs to a minimum of 50% of incarcerated Latino adolescents in at least one incarceration facility in each San Diego, Tijuana, Imperial County and Mexicali for a year.

2. Train outreach workers to provide reproductive health education to homeless Latino youth.
2.1 Within six months, train at least one staff member in a "training of trainers" at three agencies/organizations in each San Diego and Tijuana, and at two in each Imperial County and Mexicali.
2.2 Within a year, train at least twelve peer educators to provide outreach to homeless Latino youth in each San Diego and Tijuana, and at least four peer educators in each Imperial County and Mexicali, who in turn will provide outreach to a minimum of ten homeless teens each (totaling a minimum of 320 "outreached teens").
2.3 Produce at least three training/informational videos about reproductive health in Spanish with corresponding guide to be used by outreach workers and promotores.

3. Fund the Tijuana AIDS Center.
3.1 Within a year, secure three year funding in the amount of at least $150,000 for continued operation of the Center by Organización SIDA Tijuana.
3.2 Within a year, provide 24-hour attention, primarily targeting sex workers and street youth, demonstrating a minimum of 400 monthly interventions/contacts.

4. Sustain Programa Amigo in Mexicali.
4.1 Within a year, produce a five-year plan for the continued operation of the program, including expanded services for sex workers and street youth.