Mexico City s Center for HIV Prevention and Comprehensive Care Condesa Specialized Clinic Mexico City s experience: The Sanctuary Clinic Program The 2018 National Latino HIV and Hepatitis C Conference Worshop Continuity of Care for Immigrants and the Repatriated May 18th, 2018- The Omni Collonade, San Antonio, Texas Nathalie Gras Allain Deputy Director of Care for Key Populations and Specific Programs Andrea González, Florentino Badial, Ubaldo Ramos, Steven Diego Díaz, Luis Manuel Arellano, Israel Macías, Eduardo Rodríguez, Ricardo Niño, René Leyva, Alejandro Brito, María Paula Castañeda (UNHCR)
Presentation Mexico City is a sanctuary city and the protection of the migrants and refugees health that live with HIV constitutes a human rights imperative, of no discrimination, as well as an essential measure for the control of an epidemic that does not recognize territorial boundaries or border walls.
Alfonso Rodríguez Ogaz. https://www.flickr.com/photos/69781981@n00
Context Mexico City Population: 8,918,653 (2015) Metropolitan Area ~25 million people Divided in 16 political delegations Source: INEGI http://cuentame.inegi.org.mx/monografias/informacion/df/poblacion/
Source: UNHCR
Source: UNHCR
In the regional context, the population from the North of Central America is highly mobile even following arrival in Mexico, which is a barrier for persons of concern to have information and access to services. In addition, SGBV (sex and gender violence) is a main reason that refugees flee their countries of origin and they continue to face serious risks of SGBV in transit. The creation of a network of safe spaces is fundamental to address the specific needs of survivors of SGBV in need of international protection. Safe Spaces provide a minimum package of basic services to SGBV survivors in a place, or during outreach and awarenessraising activities, which use a survivor-centered and best interests approach to foster an atmosphere of non-discrimination and inclusivity. Safe Spaces support coordination and strengthening of multi-sectoral services to improve a survivor s network of care.
Posters at Condesa Specialized Clinics
Sanctuary Clinic Program The Sanctuary Clinic Program was created on February 2017, although since 2009 we have been providing care to the migrant population through other programs. The Sanctuary Clinic Program provides services at Condesa Specialized Clinic and at Condesa-Iztapalapa Specialized Clinic. The purpose is to speed up the access to treatment for migrants with HIV from Central America and other countries as well as returning Mexicans to the country. Service integration is done quickly and personalized for all services at both clinics.
Target Population Migrant men, women, and transgender population (adolescents and adults) in conditions of social vulnerability, emphasizing persons from Central America, residents or in transit through Mexico City, independent of their migratory situation, including asylum seekers, as well as Mexican that return to the country with or without documentation. Objective Recognize the right to Health protection of migrant individuals that is equivalent to the rest of the population.
Services offered at Condesa and Condesa-Iztapalapa Clinics for Migrants and Repatriated Mexicans Intervención Human Rights Module Francisco Galván Díaz Letra S, Sida, Cultura y Vida Cotidiana A.C. As-Par: Peer navigators CHECCOS A.C. Counselling and Diagnosis Care for victims of sexual violence Sexual and Reproductive Health and STI Objetivo Counselling, follow-up services in the presentation and follow-up of complaints, linkage to legal services for discrimination or violation of human rights. Counselling and support for the integration to care of persons recently diagnosed with HIV. It is complemented through phone contacts and social networks, as well as workshops. HIV, Hepatitis B and C, Syphilis diagnosis. Linkage to appropriate service. Prophylaxis treatment for HIV and STI transmission, as well as pregnancy. Syndromic management of Sexually Transmitted Infections, prevention of perinatal HIV transmission and prenatal care for women in high vulnerability situations, as well as long lasting birth control methods.
Services offered at Condesa and Condesa-Iztapalapa Clinics for Migrants and Repatriated Mexicans Intervention Mental Health Assessment HIV Care Referrals to 2nd/3rd levels of care Follow-up Punto Seguro Harm reduction in non-injectable drugs Ponte a Prueba Transgender Clinic Objective Diagnosis and treatment of mental health conditions and interventions to improve adherence to HIV treatment. Ambulatory medical care for HIV that includes ARV treatment following the national and international guidelines. Medical referrals to services not available at the Condesa clinics based on medical assessment. Counselling and linkage to social programs offered by non-governmental organizations, private, and public agencies. Personalized care for male sex workers with or without HIV. Focused on mitigating risks and harm associated to drug use by persons with HIV. Detection, Treatment and HIV Care in prisons in Mexico City. Hormone therapy for sex change transformation.
National HIV Foreigners Registry by country March 2018 Country Men Women Total Country Men Women Total Honduras 238 149 387 Israel 3 0 3 United States 315 56 371 Japan 2 1 3 Venezuela 299 17 316 Nigeria 0 3 3 Colombia 222 27 249 Netherlands 2 1 3 Guatemala 126 88 214 Paraguay 3 0 3 El Salvador 145 63 208 Austria 2 0 2 Argentina 125 16 141 China 2 0 2 Cuba 103 4 107 Congo 1 1 2 Spain 64 15 79 Dominica 2 0 2 Brazil 53 2 55 Egypt 2 0 2 Peru 38 9 47 Greece 2 0 2 France 41 3 44 Guinea 0 2 2 Chile 36 2 38 Kenya 1 1 2 Nicaragua 29 8 37 Lebanon 2 0 2 Italy 30 3 33 Norway 1 1 2 Belize 17 15 32 Czech Republic 2 0 2 Canada 25 3 28 Senegal 2 0 2 Germany 24 0 24 Ukraine 2 0 2 Costa Rica 21 2 23 Uganda 1 1 2 Haiti 11 9 20 Afghanistan 1 0 1 Dominican Republic 14 4 18 Antigua and Barbuda 1 0 1 Mexico 11 3 14 Ivory Coast 0 1 1 Cameroon 5 8 13 Fiji 1 0 1 Uruguay 10 2 12 Gabon 1 0 1 Australia 8 1 9 Ghana 1 0 1 Ecuador 9 0 9 Hong Kong 1 0 1 United Kingdom 8 1 9 Hungría 1 0 1 Panama 6 2 8 India 1 0 1 Portugal 7 0 7 Ireland 1 0 1 Puerto Rico 5 2 7 Islas Aland 1 0 1 Russia 6 1 7 Lithuania 1 0 1 Bolivia 6 0 6 Micronesia 1 0 1 Denmark 4 2 6 Mozambique 1 0 1 Switzerland 4 1 5 Romania 1 0 1 Jamaica 4 0 4 Sierra Leone 1 0 1 Poland 3 1 4 Thailand 1 0 1 South Africa 3 1 4 Taiwan 1 0 1 Sweden 4 0 4 Turkey 1 0 1 Belgium 3 0 3 Vietnam 1 0 1 South Korea 3 0 3 Zambia 0 1 1 Philippines 2 1 3 Total 2,138 534 2,672 34% come from Central America, gathering 909 people Source: National System (SALVAR) 31st March, 2018
National HIV Foreigners Registry by state March 2018 State Total registry Total foreigners Proportion Foreigner men Foreigner women Ciudad de México 21,417 881 4.1 776 105 Chiapas 6,022 347 5.8 196 151 Jalisco 9,083 253 2.8 226 27 Quintana Roo 3,937 190 4.8 145 45 Baja california 4,986 112 2.2 84 28 Nuevo León 5,247 104 2 95 9 Tamaulipas 4,269 67 1.6 52 15 Yucatán 3,322 60 1.8 54 6 Veracruz 12,135 57 0.5 35 22 Oaxaca 3,506 49 1.4 35 14 Guanajuato 2,978 48 1.6 34 14 Puebla 4,380 43 1 30 13 Chihuahua 3,290 39 1.2 29 10 Tabasco 5,185 36 0.7 22 14 México 9,982 32 0.3 24 8 Coahuila 1,653 30 1.8 24 6 Querétaro 1,502 29 1.9 23 6 Morelos 2,346 23 1 21 2 Michoacán 2,319 22 0.9 19 3 San Luis Potosí 1,505 20 1.3 18 2 Sonora 2,034 17 0.8 14 3 Baja California Sur 972 15 1.5 15 0 Nayarit 1763 14 0.8 14 0 Hidalgo 1,232 13 1.1 10 3 Sinaloa 1,784 12 0.7 11 1 Campeche 1,604 11 0.7 5 6 Durango 923 11 1.2 10 1 Aguascalientes 877 8 0.9 8 0 Colima 1,068 8 0.7 6 2 Guerrero 3,938 3 0.1 3 0 Tlaxcala 966 3 0.3 2 1 Zacatecas 670 3 0.4 3 0 Nayarit 1,311 0 0 0 0 Institutos y Hospitales 670 112 0.4 95 17 Total 128,876 2,672 2.1 2,138 534 Source: National System (SALVAR) 31st March, 2018
National HIV Foreigners Registry March 2018 Historically at the national level, 2% of the total of the patients are foreigners The largest proportions take place in these cities: Chiapas with 5.8% Quintana Roo with 4.8% Mexico City with 4.1% 34% come from Central America, gathering 909 people Source: National System (SALVAR) 31st March, 2018
Foreigners women and men receiving HIV care at the Condesa Specialised Clinic VS Chiapas HIV Program March 2018 Mexico City 881 foreigners 4.1% State Total registry Foreigners registry Proportion Mexico City 21,417 881 4.1% Chiapas 6,022 347 5.8% Chiapas 347 foreigners 5.8% Country Men Women Total Country Men Women Total Venezuela 165 11 176 Portugal 3 0 3 Colombia 131 14 145 Austria 2 0 2 United States 60 7 67 Congo 1 1 2 Argentina 61 5 66 Dominica 2 0 2 Honduras 35 12 47 Guinea 0 2 2 Spain 30 14 44 Jamaica 2 0 2 Cuba 41 2 43 Japan 1 1 2 Brazil 32 0 32 Paraguay 2 0 2 El Salvador 27 3 30 Puerto Rico 2 0 2 Peru 19 7 26 Russia 1 1 2 Chile 23 1 24 South Africa 1 1 2 France 20 1 21 Sweden 2 0 2 Guatemala 13 3 16 Switzerland 2 0 2 Costa Rica 13 1 14 South Korea 1 0 1 Germany 9 0 9 Philippines 0 1 1 Italy 8 0 8 Fiji 1 0 1 Cameroon 2 5 7 Greece 1 0 1 Uruguay 6 1 7 Hong Kong 1 0 1 Ecuador 6 0 6 Ireland 1 0 1 Nicaragua 5 1 6 Israel 1 0 1 Great Britain 6 0 6 Kenya 1 0 1 Belize 3 2 5 Netherlands 0 1 1 Bolivia 5 0 5 Czech Republic 1 0 1 Denmark 3 2 5 Romania 1 0 1 Dominican Republic 5 0 5 Senegal 1 0 1 Australia 4 0 4 Taiwan 1 0 1 Canada 4 0 4 Turkey 1 0 1 Haiti 2 2 4 Vietnam 1 0 1 Panama 2 2 4 Poland 2 1 3 Total 776 105 881 Country Men Women Total Honduras 62 57 119 Guatemala 51 54 105 El Salvador 57 35 92 Nicaragua 9 4 13 Cuba 6 0 6 Argentina 2 0 2 Chile 2 0 2 Colombia 1 1 2 Mexico 2 0 2 Costa Rica 1 0 1 Spain 1 0 1 Jamaica 1 0 1 Panama 1 0 1 Total 196 151 347 Source: National System (SALVAR) 31st March, 2018
Foreigners Voluntary HIV Counselling and Testing (VCT) Datum from January 2017 to February 2018 Country Frequency Total % of all the patients VENEZUELA 109 109 17 Central America HONDURAS 33 GUATEMALA 17 EL SALVADOR 15 COSTA RICA 5 NICARAGUA 4 PANAMA 7 81 12.6 North America UNITED STATES 66 CANADA 5 71 11.1 South America COLOMBIA 81 ARGENTINA 36 BRAZIL 19 CHILE 16 PERU 10 BOLIVIA 4 ECUADOR 4 URUGUAY 4 PARAGUAY 3 177 27.6 Caribbean CUBA 15 DOMINICAN REPUBLIC 5 PUERTO RICO 3 23 3.6 TOTAL 461 71.9 The Counselling and Testing Service gathers the largest number of foreigners (641 people) attended at the Condesa Specialised Clinic (from January 2017 to February 2018) The number of people from Central America (81) and Colombia (81) are equal HIV Prevalence 15.3% 98 HIV positives from 641 foreigners Country Frequency Other countries SPAIN 43 FRANCE 40 ITALY 16 GERMANY 12 ENGLAND 11 JAPAN 5 AUSTRALIA 3 CHINA 3 KOREA 3 CROATIA 3 DENMARK 3 HOLLAND 3 INDIA 3 SWITZERLAND 3 BULGARY 2 GREECE 2 NIGERIA 2 PORTUGAL 2 SWEDEN 2 CONGO 1 AUSTRIA 1 BANGLADESH 1 BELGIUM 1 CAMEROON 1 SOUTH KOREA 1 SCOTLAND 1 SLOVENIA 1 GRENADA 1 HONG KONG 1 INDONESIA 1 ISRAEL 1 MALAYSIA 1 NEW ZEALAND 1 PAKISTAN 1 MOLDAVIAN REPUBLIC 1 ROMANIA 1 TUNISIA 1 UKRAINE 1 Total from all the countries 641 Source: Condesa Specialized Clinic s- Laboratory report
Voluntary HIV Counselling and Testing (VCT) Datum from January 2017 to February 2018 HIV Positives Age group Men Women Transgender Total % 18 to 25 16 0 2 18 18.4 26 to 40 55 2 5 62 63.3 More than 40 15 3 0 18 18.4 Total 86 5 7 98 100.0 n= 641 HIV Negatives Age group Men Women Transgender Total % HIV Prevalence 15.3% 98 HIV positive from 641 foreigners < 18 7 2 1 10 1.8 18 to 25 116 43 9 168 30.9 26 to 40 234 61 6 301 55.4 More than 40 51 13 0 64 11.8 Total 408 119 16 543 100.0 Source: Condesa Specialized Clinic s- Laboratory report
HIV prevalences by country UNAIDS 2016 Country Population group Prevalence Cameroon Adult prevalence 3.8% From 15 to 49 years [3.1% - 4.5%] Venezuela Adult prevalence 0.6% From 15 to 49 years [0,5% - 0,7%] Mexico Adult prevalence 0.3% From 15 to 49 years [0.2% - 0.3%] Central America Country Population group Prevalence Belize Adult prevalence From 15 to 49 years 1.8% [1,5% - 2,3%] Costa Rica El Salvador Guatemala Honduras Nicaragua Adult prevalence From 15 to 49 years Adult prevalence From 15 to 49 years Adult prevalence 15 a 49 años de edad Adult prevalence From 15 to 49 years Adults prevalence From 15 to 49 years 0.4% [0.4% - 0.5%] 0.6% [0.5% - 0.7%] 0.5% [0.3% - 0.7%] 0.4% [0.3% - 0.5%] 0.2% [0.2% - 0.3%]
Migration and HIV in Central America and Mexico Central American Migrants in Transit through Mexico have a 0.71% HIV general prevalence and a 3.45% HIV prevalence among transgender people. 23. 5% of transgender people and 5.8% of women reported sexual violence. Only 46.6% of the survey respondents accepted the HIV test. Source: Leyva-Flores et al 2016
Profile by Region I. Central Americans: Men, women, Trans women, children and adolescents with low educational levels Fleeing gang violence (Discrimination towards the LGBT population) Travel by foot, by bus and raft: risks (sexual violence, muggings, kidnapping ) Referred by NMI, COMAR and NGO s Mainly diagnosed in Mexico City Few support networks II. South Americans: Middle class men: students and professionals Flight Referred by COMAR and NGO s besides contacts thorugh the social networks Diagnosed and previously treated: come to continue with care Have support networks II.1. Venezuela: Fleeing the political and economic crisis They face hostilities when they arrive Flight Referred by COMAR and NGO s besides contacts through the social networks Diagnosed and previously treated: come to continue with care (shortage of medications) Have support networks
Profile by Region III. Africans: Men, women and children: professionals Fleeing political conflict: repression and prison to sympathizers Flights (long travel times) Diagnosed and previously treated: come to continue their treatment Few support networks IV. Europeans and North Americans: Middle class men and women: students and professionals The majority have regular residency Flights Diagnosed and previously treated: come to continue their treatment Have support networks V. Mexican Repatriated from the USA Working class men Detention center (ICE)/prison Buses and flights Diagnosed and previously treated: come to continue their treatment Have support networks but CULTURAL SHOCK
Guidelines of Seguro Popular for foreigner people Proof of residency. Foreigners must prove their residency on mexican territory. If foreigners are not able to show the evidentiary documentation nor their legal residency in the country, a temporary incorporation will proceed: only for 90 days.
Migration status of population served (transit, temporary and permanent) Migration status Temporal or Permanent Residency Treatment Access according to the guidelines of Seguro Popular Turist Humanitarian visa Refugee Applicants Refugees Indocumented Repatriated? Without country
Interagency contributions (good practices) Currently, Clínica Condesa is co-chairing with UNHCR the safe spaces network in Mexico City. UNHCR, the Mexican Refugee Agency (COMAR), Clínica Condesa and partner NGOs including migrant shelters, regularly coordinate for cases with special needs, such as pregnant woman, LGBTI persons, persons with STIs/HIV. A special referral system was established for these cases. Awareness raising activities on sexual and reproductive health to persons of concern are also implemented, for example, Condesa Clinic along with partner NGOs and UNHCR organized a sexual and reproductive health fair in the migrant shelter Cafemín offering free HIV/ITS detection tests. In addition, UNHCR and COMAR gave a joint training to Condesa staff on identification of persons with international protection needs and the asylum process. In turn, Clínica Condesa offered a training to COMAR, UNHCR, and NGO partners on sexual health and HIV/STIs.
Conclusions Access to health services for the migrant population, specifically in HIV prevention and care, should be a Health System objective and should be audited by international organisms. The diagnosis and treatment of immigrants with HIV is a needed component of the strategy for epidemic control, for the prevention of Aids cases as well as death and for virus transmission prevention which is achieved when treatment is offered to persons with HIV (Treatment as Prevention).
Conclusions The Condesa and Condesa-Iztapalapa Clinics are safe spaces for the migrant population, repatriated, and refugees. Health services Access is necessary to guarantee the right to live, physical wellness, free transit, and evidently to health. The Young population is the age group with the highest need for HIV services, pregnancy care, and sexual violence, and at the same time, a population group with great mobility inside and outside country borders. The refusal of such services due to migratory status is a discriminatory act of grave consequences for world youth.
UNHCR Information at the Condesa Clinic
Source: UNHCR
Referencies Administrative Manual for the Sanctuary Clinic Program (February 2017) Affiliation and Operation Manual for the Seguro Popular (2013): https://transparencia.info.jalisco.gob.mx/sites/default/files/manual%20de%20organizacio n%202013.pdf Annual Activity Report 2017: http://www.condesadf.mx/pdf/diamundialcdmx2017_vfinal_.pdf Antiretrovirals Administration, Logistics and Surveillance System (SALVAR): https://www.salvar.salud.gob.mx/ (March 2018) Condesa Specialized Clinics Laboratory report (February 2018) Leyva, René et al. Chapter VI. Migrants in transit through Mexico: Health status and access to health services in: Migration and Health. Perspectives on the immigrant population. Secretariat of Government/National Population Council, Health Initiative of the Americas, School of Public Health, University of California, Berkeley. Mexico, 2016. National Institute of Statistics and Geography (INEGI) Report 2016: http://cuentame.inegi.org.mx/monografias/informacion/df/poblacion/ The Joint United Nations Programme on HIV/AIDS (UNAIDS): http://www.unaids.org/en (October 2017) United Nations High Commissioner for Refugees (UNHCR): http://www.unhcr.org/ (October 2017)
THANK YOU Clínica Especializada Condesa Clínica Especializada Condesa Iztapalapa Dr. Jaime Sepúlveda Amor www.condesadf.mx nathalie.gras81@gmail.com condesasantuario@gmail.com +52 55 26 14 29 58 and +52 55 50 38 17 00 ext. 6446