HIV and AIDS. in Mexico Until Findings, trends, and thoughts

Transcription

1 HIV and AIDS in Mexico Until 2008 Findings, trends, and thoughts Carlos Magis Rodríguez Enrique Bravo García Cecilia Gayet Serrano Pilar Rivera Reyes Marcelo De Luca ÁNGULOS DEL SIDA

2 HIV and AIDS in Mexico Until 2008 Findings, trends, and thoughts Carlos Magis-Rodríguez Enrique Bravo-García Cecilia Gayet-Serrano Pilar Rivera-Reyes Marcelo De Luca México, 2008 Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA) National Center for the Prevention and Control of HIV/AIDS

3 First edition, December 2008 Ángulos del Sida Collection 2008, CENSIDA National Center for the Prevention and Control of HIV/AIDS (CENSIDA) Herschell Street 119, 6 th floor Col. Verónica Anzures Del. Miguel Hidalgo Mexico City, Mexico CP Printed and made in Mexico Ángulos del Sida Collection Complete Works ISBN Number 9: HIV and AIDS in Mexico Until 2008: Findings, trends, and thoughts. ISBN Cover design by Eduardo Rodríguez-Nolasco Translated by Ana Laura Magis-Weinberg We thank the United Nations Joint Programme on HIV/AIDS (UNAIDS) as well as the Pan American Health Organization (PAHO) for their help in various projects developed by CENSIDA in the last five years, which allowed for generating new epidemiological information which was included in this book. Written authorization of the authors is needed for the reproduction of the whole or any part of this work. For brief citations, mentioning the source will suffice.

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5 Directory Dr. José Ángel Córdoba Villalobos Health Secretary Dr. Mauricio Hernández Ávila Health Prevention and Promotion Subsecreatry Dr. Jorge A. Saavedra López General Director of the Nacional Center for the Prevention and Control of HIV/AIDS Dr. Carlos Magis Rodríguez Operative Research Director Dr. Javier Cabral Soto Prevention and Social Participation Director Dra. Griselda Hernández Tepichín Integral Attention Director Ángulos del SIDA Collection Collection Direction Dr. Carlos Magis Rodríguez Editorial Coordinator of Number 9 in the Collection Marcelo De Luca

6 The contents of the following publication are the sole responsibility of their authors. The Health Ministry and CENSIDA disengage themselves from any liability.

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8 Table of Contents Foreword Introduction Motives and Study Subjects Brief Outline of the HIV/AIDS Situation Strategies Applied in the Study Subjects and Results HIV Cases Accumulated to HIV Infection Prevalence in the General Population Estimates Obtained from National Surveys with Serology Estimates Obtained from Surveillance in Pregnant Women Estimates Obtained from Blood Donor Surveilance Prevalence of HIV Infection in Higher Vulnerability Populations Brief History of Tried Aproximations to Follow HIV/AIDS in the Sectors with most Vulnerability Approximations and Figures of HIV Presence in Higher Vulnerability Populations HIV/AIDS Expansion and Specific Vulnerability Conditions...45

9 3.4.1 Mexican Migrants and HIV/AIDS Epidemic Expansion in Rural Areas Vulnerability of the Indigenous Population HIV/AIDS in Women Injecting Drug Users: A Wide Spectrum Vulnerability HIV/AIDS and Vulnerable Children Population Recent Studies Regarding Sexual Behaviors Recent Studies Regarding Sexual Behaviors in Young People Recent Studies About Sexual Behaviors in Key Populations The Treament of People Living with AIDS Mortality and Impact of Antiretroviral Treatment What has happened to AIDS mortality in Mexico? Conclusions...96

10 Table Index Table 1. AIDS Cases in Year of Diagnosis and Notification Date...27 Table 2. New diagnosed, notified and timely registered AIDS cases between 2004 and Table 3. New diagnosed, notified and timely registered AIDS cases by institution between 2005 and Table 4. Accumulated AIDS cases by age and sex...31 Table 5. AIDS accumulated cases, accumulated incidence and year of diagnose, according to state...32 Table 6. New and Accumulated AIDS Cases in Adults by Transmission Category and Sex at the End of Table 7. HIV Detection in Pregnant Women in Public Health Institutes Table 8. National Percentage of Blood Donations with Positive Tainting Corrected by False Positives in Table 9. Estimates of People Living with HIV in Mexico Table 10.Masculinity rate of AIDS cases per year in Mexico, Table Year Old Teenagers with Sexual Initiation and Protection in the First Relation by Sex and State in Mexico Table 12. Main Indicators of Sexual Behaviors in MSM, MSW, WSW, and IDU, In Transversal Samples Table 13. Distribution by Sex of People who Received ART by Institution, March Table 14. Age Distribution of People Receiving ART by Institution, March Table 15: People who Received Antiretroviral Treatment by Institution, Table 16. Health Ministry Patients who Receive Antiretroviral Therapy by State and Sex,

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12 Graph Index Graph 1. Active Process of the General Joint Epidemiology Direction for Lowering the AIDS Cases Subregister in 2002 and Graph 2. Accumulated AIDS Cases in Adults incidence Rates by Sexual Transmission Category, Graph 3. AIDS Mortality in General and in the years age group, Mexico Graph 4. General AIDS Mortality in some Latin American Countries at the Moment of Universal ART Access and Afterwards...84 Graph 5. AIDS Mortality in Male Population, General and in the Age Group, Mexico Graph 6. AIDS Mortality in female population, general and in the age group, Mexico Graph 7. General AIDS Mortality by State: General Population, Mexico, Graoh 8. General AIDS Mortality by State: Male Population, Mexico, Graph 9. General AIDS Mortality by State: Female Population, Mexico

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14 HIV and AIDS in Mexico until 2008 Acronyms and Initialisms AIDS 2008 XVII International AIDS Conference ARV Antiretroviral drug(s) AZT Azidothymidine National Center for the Prevention and Control of CENSIDA HIV/AIDS Consejo Nacional de la Población [national population CONAPO council] Consejo Nacional para la Prevención y Control del CONASIDA VIH. [national council for the prevention and control of HIV] VL Viral load Dirección General de Epidemiología [general DGE epidemiology direction] ELISA Enzyme Linked Immunosorbant Assay Encuesta Nacional de Salud realizada en 2000 ENSA [national health survey that took place in 2000] Encuesta Nacional de Salud y Nutrición realizada en ENSANUT 2006 [national health and nutrition survey 2006] Encuesta Nacional de Salud Reproductiva realizada en 2003 ENSAR [national reproductive health sourvey that took place on 2003] ENSE National Seroepidemiological Survey 1987 FHI Family Health International FONSIDA Fondo Nacional para Personas que Viven con el 13

15 Magis, Bravo, Gayet, Rivera y De Luca VIH/SIDA [national funds for people living with HIV/AIDS] Facultad Latinoamericana de Ciencias Sociales sede México FLACSO [Latin American faculty of social sciences, Mexican seat] MSM Men who have Sex with Men MSW Male Sex Worker(s) TI Trust Interval Instituto Mexicano de la Seguridad Social [Mexican IMSS social security institution] INDRE Instituto de Diagnóstico y Referencia Epidemiológicos Instituto Nacional de Estadística, Geografía e INEGI Informática [national institute of statistics, geography, and informatics] INSP Instituto Nacional de Salud Pública IO Opportunistic Infections PI Protease Inhibitors Instituto de Seguridad y Servicios Sociales de los ISSSTE Trabajadores del Estado [institution of social and security services for state workers] STI Sexually Transmitted Infection(s) Fundación Mexicana para la Planeación Familiar AC MEXFAM [Mexican foundation for family planning] WSW Woman Sex Worker(s) NGO Non-Governmental Organization UNAIDS United Nations Joint Programme on HIV/AIDS PEMEX Petróleos Mexicanos [Mexico s national oil company] IP Indigenous Population NIP Non-Indigenous Population RDS Respondent Driven Sampling Secretaría de la DEFENSA Nacional [national defense SEDENA ministry] AIDS Aquired Immunodeficiency Syndrome 14

16 HIV and AIDS in Mexico until 2008 SSA Secretaría de Salud [health ministry] SVS Sentinel Vigilance System ART Antiretroviral Treatment TLS Time Location Sampling IDU Injecting Drug User HIV Human Immunodeficiency Virus WHO World Health Organization 15

17 Magis, Bravo, Gayet, Rivera y De Luca Foreword This book represents the end of a year of hard work because of the activities in which the Health Ministry was involved with the goal of promoting and supporting actions needed to bring to a halt the HIV/AIDS expansion and the mortality it provokes. This year a series of agreements of great transcendence for Mexico and Latin America and the Caribbean were achieved. On August 1 st, 2008, the Primera reunión de Ministros de Salud y educación para detener el VIH e ITS en Latinoamérica y el Caribe [first health and education ministers meeting for stopping HIV and STIs in Latin America and the Caribbean] was celebrated in Mexico City. This event, led by our country, brought thirty one Latin American and Caribbean countries together. The declaration Preventing with education deals with the subject of integral sexual education in all levels, under the government s responsibility and the promotion of sexual health services available to teenagers and young adults; this due to the fact that in 2007 the estimated number of new HIV cases in the region was of 160 thousand, and the total number of people living with HIV reached 3.1 million; and taking into account that in a world scale it is estimated that half of all the new infections takes place in young people from 15 to 24 years of age. Also on August 1 st Mexico City was the seat of the V meeting of the Latin American first ladies and female leaders coalition regarding women and AIDS that met under the slogan: Stopping the femenization of the epidemic: Prevention Actions and Women s Health. The Coalition gathers more than two hundred regional leaders with the goal of being an alliance that mobilizes resources in response to the epidemic. Latin America and the Caribbean face the feminization of HIV/AIDS, as one third of the registered cases take 16

18 HIV and AIDS in Mexico until 2008 place in women. The forum considers that in order to stop this feminization it is necessary to take prevention strategies and attack gender discrimination, domestic violence, and other factors that make this group more vulnerable. In this book themes related with the feminization of HIV/AIDS in Mexico are looked into and developed. Furthermore, after long negotiations, and because of the importance for AIDS patients not to abandon their treatments and so that the Health Sector can abide by their agreement of supplying them, several laboratories agreed to reduce the price of antiretroviral medicines. Obtaining more accessible prices was an important achievement of the Health Ministry. Once the social security institutions benefit from the lower prices in 2009, savings for the public buying antiretroviral drugs could amount to 620 million pesos per year. Thus, and as it is proposed in this work, the universal coverage achieved five years ago could be maintained to continue decreasing the AIDS mortality reate in our country. The year 2008 will be remembered as a year in which diffusion was touched upon regarding HIV/AIDS-related themes; some of the causes for this have already been mentioned. Nevertheless, a good part if not most of this expansion in communication is owed to the XVII International AIDS Conference (AIDS 2008) that took place from August 3 rd to the 8 th in Mexico City. The event had a summoning power that has been very rarely seen in Mexico s history. From the scientific point of view, the institutes and centers that are a part of the Health Ministry took on a cheif role regarding the presentation of works about Mexico and HIV/AIDS with 95 approved research summaries. The National Center for the Prevention and Control of HIV (CENSIDA) collaborated in the majority of the works with 38 research papers. This book integrates a good part of the most recent results obtained by these researches that deal with epidemiological aspects about Mexico presented in AIDS Another fact about the context in which this edition is presented is this: as well as being the world AIDS day, December 2 nd, 2008 was the 20-year anniversary of the institutional response to HIV/AIDS. That is, the creation of CONASIDA that years later delegated the prevention, research, and attention monitoring tasks to what today is CENSIDA was celebrated. The Operative Research Direction of CENSIDA took the busy year as an opportunity to conceive a conceptual tool, analyze and inform of 17

19 Magis, Bravo, Gayet, Rivera y De Luca the epidemiological data recently obtained. Without a doubt, all of the professionals who intervene every day in HIV/AIDS prevention and attention will find information, concepts, and methodological considerations useful to better do or understand our task and our dedication to improving the response to the epidemic. Many were the motivations for having developed a work of this kind in 2008; among other things because the 25-year anniversary of the first diagnosed AIDS case in our country took place. Carlos Magis, PhD MD, and an interdisciplinary team of researchers offer us a work dense and full of figures, with a horizon of themes and aspects related with the development of the epidemic in Mexico a way in which the subject has rarely been dealt with in our country. The current situation of the information contained in this 9 th volume of the Ángulos del SIDA collection is strategic in order to observe how this terrible epidemic is acting upon Mexico s population. The present edition represents a great effort in the integration of the different studies about AIDS s situation in our country. The various analysis successfully combine the history of the development of the epidemic in our country with the latest findings, many of which were communicated just months ago in AIDS Furthermore, it has the virtue of exposing the detailed and accessible explanations regarding some details of the dirty work of research, which helps us understand better the outreach that the developed inferences have. Without there existing any vaccine or cure at the moment, the best rational action that we can take to safeguard life from the horrors that HIV/AIDS produces is prevention. The research work that follows provides elements to decide where, how, and with whom it is appropriate to prioritize the information, education, timely detection, and epidemiological follow-up actions. Treatment is the last resource response that we can offer as a society and as a government through the Health Ministry. Prevention is still the measure that must be privileged over any existing other. Today we can see that, if we do not confront this challenge approprietly and in such a way that decelerates incidence, we will hardly be able to count with the necessary resources to offer treatment to all the new cases that will be presented in some years. I want to point out that the information presented is originated in the individual and institutional effort of many of the professionals 18

20 HIV and AIDS in Mexico until 2008 committed to a response to the epidemic throughout the nation, and to show my recognition to all these people. December, 2008 Jorge A. Saavedra López General Director Center for the Prevention and Control of HIV (CENSIDA) 19

21 Magis, Bravo, Gayet, Rivera and De Luca Introduction Motives and Study Subjects According to the utmost authority of the World Health Organization (WHO), AIDS is the most complex, the most challenging, and probably the most devastating infectious disease humanity has ever had to face The AIDS response expanded the frontiers of public health and showed the power of a can-do attitude. It changed the face of public health in profound ways, opening new options for dealing with multiple other health problems. 1 It is an epidemic of which we cannot lose track of, as the concrete actions that are instrumental to halting its incidence require the participation of various society sectors, which need to be well informed and coordinated. The present work gathers and analyzes recent information related to the current situation of HIV/AIDS in Mexico, which was published or presented in Congresses, including the XVII International AIDS Conference, which took place from August 3 rd to the 8 th of 2008 in Mexico City. 2 In order to contextualize and rightly give place to changes in the tendencies and other findings, key moments in the epidemic s trajectory have been taken into account, since this allows to better place and understand its current development style. The experience accumulated through the exercise of answers and studies which have been done for almost a quarter of a century, in epidemiological research, attention, and prevention grounds, in international levels as well as in Mexico has been in the need of taking into account new focuses that, sometimes, have not represented the simple adjustment introduction but the epistemological changes regarding how to conceive certain points in HIV/AIDS behavior. Some of these perspectives have recently been adopted in order to focus 20

22 El VIH y el SIDA en México al 2008 certain interventions or innovate methodologies that enable projecting and creating new research problems, which has also allowed to broaden the global understanding of the problem through the inclusion of new themes and techniques, which, without a doubt, have improved the measurement and strategy diffusion better designed to respond to the epidemic, all of which has made easier to better understand the role that the near and immediate determinants play in the expansion and contention of the epidemic. The principal questions that guide this study observe whether changes in the diffusion and the control of the epidemic are being made. We pretend to understand the dynamic that the illness has acquired since the beginning of the 21 st century, in which direction the indicators move, through which means of transmission, in which sectors of the population, and under which contexts do new infections and casualties take place. The more general objective that is sought with this integration and information interpretation exercise is to try to understand at which development phase the epidemic is in Mexico. Some of the reflection lines developed in this book were previously published in another document. 3 Brief Outline of the HIV/AIDS Situation The United Nations Joint Programme on HIV/AIDS (UNAIDS) has estimated that in the year 2007 there were 33 million [30 36 million] people living with HIV world-wide, half of which were women and 2.5 million under 15 years of age. It was estimated that AIDS casualties reached 2 million [ million]. Every day, more than 6,800 people contract HIV and more than 5,700 die because of AIDS. The HIV pandemic remains one of the most important challenges regarding public-health illnesses. The evaluation of world and regional tendencies suggests that the pandemic has formed two general patterns: epidemics scattered in general populations of many Sub- Saharan African countries, especially in the southern part of the continent, and epidemics in the rest of the world that concentrate chiefly in the so-called key populations, like men who have sexual relations with men, injecting drug users, and sex professionals, as well as their sexual partners. 4 21

23 Magis, Bravo, Gayet, Rivera and De Luca The HIV/AIDS epidemic in Latin America remains stable in general, and HIV transmission keeps ocurring mostly in key populations due to their larger exposure risk. The estimated number of new HIV infections in Latin America in 2007 were hundred thousand [ thousand], which makes the total number of people living with HIV in the region 1.6 million [ million]. According to estimates, approximately 58 thousand [49 91 thousand] people died because of AIDS during If we consider the total number of reported cases, Mexico holds the third place in the continent, after the United States and Brazil. This correlates perfectly with the number of inhabitants; however, according to HIV prevalence in the adult population (rate relative to the population size used by UNAIDS to take into effect international comparisons), Mexico presents a relatively low prevalence rate of HIV in the adult population of 15 to 49 years of age (0.3%); which means being under the Latin American average set at 0.5% and world average at 0.8%. Furthermore, Mexico registers a rate lower than its neighbors, which oscillates between 0.6% (US), 0.8% (Guatemala), and 2.1% (Belize). 4 In order to describe HIV/AIDS epidemiology, schematic forms have been developed according to the transmission origin from the observations taken place in AIDS cases accumulated in the region: Epidemics with predominant heterosexual transmission: This is the case in most of Central American and Caribbean countries with around 70% of accumulated cases. Epidemics with predominant men-who-have-sex-with-men transmission: Which are the ones that North American countries such as Mexico present. Epidemics with mixed transmission variants: When none of the transmission modalities is greater than fifty percent of the cases. In the southernmost countries (Argentina, Chile, Paraguay, and Uruguay), the proportion of accumulated cases is homogeneously distributed between homo-bisexuals (30%), heterosexuals (30%), and injecting drug users (27%). 5 In Mexico, since the first case was reported in 1983, a concentrated epidemic in men who have sex with men (MSM) has been observed. 22

24 El VIH y el SIDA en México al 2008 However, it must be taken into consideration that the way in which the epidemic is classified imposes an important limitation: the central criterion is to observe AIDS cases instead of people infected with HIV. In other words, given the long incubation period of the infection (estimated in a ten-year average), there is a reference to the epidemic having taken place many years before, whose pattern does not necessarily correspond to the actual forms of the infection s spreading. 6 In this sense multiple efforts are being made, and every time they are better adjusted to the instruments and gathering systems for facts to observe the current HIV epidemiology. Even when MSM continue being the most affected group, recent investigations are showing that the infection has started to rapidly grow among other populations, which shows the importance of returning our attention to all those people, groups, or communities who could be at risk. 23

25 Magis, Bravo, Gayet, Rivera and De Luca Strategies Applied in the Study With an interest in making a study that integrates and compares facts and information that allows to infer how the HIV/AIDS epidemic is evolving, especially from the year 2000 on, the most recent information was included from primary and secondary sources and documentaries of statistic facts such as the National AIDS Cases Register, the first basal samples obtained through sentinel studies, Second Generation Epidemiological Vigilance and those more recently applied to vulnerable populations studies; census, counts and estimations done by the National Institute of Statistic, Geography, and Informatics (INEGI) and the National Population Council (CONAPO), together with the use of concepts, facts, mathematical models, observations, and analysis that have produced or recuperated a series of studies of a various nature. In 1986, little more than twenty years ago, a formal surveillance system was established to observe the HIV/AIDS epidemic. 7 Advance in the knowledge regarding the epidemic in Mexico is substantial; however, problems subsist at the moment of the fact construction that affect the elaboration and the quality of the available information. Thus, it is recognized that there are specific qualities of HIV/AIDS that enable a high uncertainty degree, like the moment and the means of transmission, given that the average incubation period is of about ten years. Another important problem is the size estimates of some key populations: MSM, injecting drug users (IDU), male and female sexual workers (MSW and FSW); because we are dealing with populations that are difficult to access, besides the possibility that they suffer quantitative modifications through time and these may not be 24

26 El VIH y el SIDA en México al 2008 attainable with the desired celerity and precision. There are also difficulties generated from the subregister and delay in the notification of HIV and AIDS cases, absences that are tried to be mitigated through estimated calculations. All these issues are dealt with in this work. Through the making of the quantitative comparisons and qualitative inferences with the facts presented by the different sources, the study tries to gather the moment s certainties. 25

27 Magis, Bravo, Gayet, Rivera and De Luca Subjects and Results HIV Cases Accumulated to 2007 The method of accumulated HIV cases is used to make reflections on the absolute and relative numbers the history of the infectious expansion. It should be noted that the methodology implies a fictitious increase of the affected population in that all people that had been diagnosed with AIDS are still being taken into account even when they have passed away. The problem here is that accumulated cases (both living and dead patients) are used in the numerator, while the denominator contains the population estimated at the moment, which brings a temporality problem between numerator and denominator. Using this method has the advantage of allowing to observe certain lines of the infection s development despite the huge problem of delay in the AIDS case notification, because cases have been presented which have been delayed five or more years before entering the national register. The data regarding accumulated AIDS cases provides information that allows us to make a length-wise evaluation of the epidemic, especially when it is presented in relation to the average year size of the population (rates). Furthermore, an evaluation of the appearance of new yearly cases, both of HIV and of AIDS and its distribution among population subgroups, could indicate the evaluation of the actual degree of the epidemic concentration in order to establish which are the population groups that most intensively require preventive measures being taken. It should be mentioned that currently for the analysis of tendencies the year of diagnosis is taken into consideration when settling each case, 26

28 El VIH y el SIDA en México al 2008 since the year of notification did not adequately reflect the epidemic s behavior. 8 Table 1. AIDS Cases in Year of Diagnosis and Notification Date Year Date of Diagnosis Notification Date , , ,840 1, ,716 2, ,869 3, ,352 3, ,502 4, ,055 4, ,538 4, ,888 4, ,071 3, ,663 4, ,768 4, ,531 4, ,391 4, ,223 13, ,806 7, ,538 22, ,448 8, ,550 7, ,031 7, , ,915 Source: CENSIDA. Operative Investigation Direction, with figures from the National AIDS Case Register to December 31, Both the subregister as well as the notification delay are problems that affect, in a greater or lesser scale, the quality of the data in all the world. These phenomena are the result of multiple mechanisms, 27

29 Magis, Bravo, Gayet, Rivera and De Luca among which stand out the ignorance or disobedience of the norm, the lack of opportune diagnosis, the non-deliverance or hiding of the notification, and certain bureaucratic inbalances that foster delay. In order to improve the quality and opportunity of the epidemiological information, the Health Ministry started several actions focused on strengthening the National AIDS Cases Register, among which the following stand out: to strengthen the communication with the executive instances of the other health institutions, to widely spread normativity in the matter, to confront the databases of the National Register with those of the notifying institutions in order to validate the information, and making an intensive search of non-registered AIDS cases. As a result, when confronting their databases, the National AIDS Cases Register and the Mexican Social Security Institution (IMSS) up to the year 2000, a subregister of 7,608 cases was found. Moreover, in the analysis of the AIDS cases registered in eight of the country s states, a 34% subregister in IMSS and an 18% one in the State Health Services were found. 3 This procedure was repeated during 2004 (see Graph 1), when 22,379 notified cases were recovered, of which 4,171 (18.6%) corresponded to opportunely presented cases, that is, diagnosed during the course of The rest had to be placed in the previous years regarding the date of diagnosis. 9 It is important to observe in Graph 1 how in 1999 opportune notification is raised; this is due to the antiretroviral treatment offered in great part by IMMS and less so by the Health Ministry. For the years in which the case register is practically complete ( ), the highest numbers in the yearly cases are between 8,223 y 8,

30 El VIH y el SIDA en México al 2008 Graph 1. Active Process of the General Joint Epidemiology Direction for Lowering the AIDS Cases Subregister in 2002 and 2004 Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, This information allows us to state that from 2004 on there are better and more complete databases. However, the General Epidemiology Direction (DGE) of the Health Ministry, responsible for the National AIDS Cases Register in the country, considers that since 2003 the numbers have been incomplete due to the delay in the case notification. Epidemiological analysis of the tendency of AIDS cases included in the National Register show that a five year period must go by for AIDS cases of a given year to be completed, 10 which has been a motivation for using estimates. However, the percentage of opportunely registered cases has substantially increased in the last years, which is allowing to analyze information of recently diagnosed cases (see Tables 2 and 3) more rigorously. Unlike 2004, when only 18.6% of opportunely registered cases had been entered into the National AIDS Cases Register, between 2005 and 2007 a 50 60% of opportune registry had been achieved, which indicates the presence of a progressive improvement of opportune register in the newly diagnosed cases of each year. 29

31 Magis, Bravo, Gayet, Rivera and De Luca Table 2. Newly Diagnosed, Notified and Opportunely Registered AIDS Cases Between 2004 and 2007 Year of Diagnosis New AIDS Cases to the End of Each Yar Registered AIDS Cases to the End of Each Year Percentage of Opportunely Registered AIDS Cases ,171 22, ,382 8, ,055 7, ,031 7, Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, The great majority of AIDS cases are treated by the Health Ministry institutions or by IMSS, which is why timely declaration of the cases that these institutes handle are key in order to attain a high percentage of opportunely registered cases. Table 3. Newly Diagnosed, Notified, and Opportunely Registered AIDS Cases by Institute Institute Number of Registered AIDS Cases Percentage of Opportunely Registerd AIDS Cases SSA 5,530 4,908 5, IMSS 2,160 1,830 1, ISSSTE PEMEX SEDENA other private TOTAL 8,720 7,829 7, Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, From the beginning of the epidemic and up to December 31, 2007 (see Table 4), in Mexico 117,915 accumulated AIDS cases 11 had been registered; most of these cases relate to people that have already passed away and the rest (46,496) to those who live with the disease 30

32 El VIH y el SIDA en México al 2008 and are under antiretroviral treatment (ART). 12 Men make up 82.7% of accumulated cases (97,464), and women the remaining 17.3% (20,451 cases). This means that from the beginning of the epidemic approximately one woman for every five men has been infected. The age group that goes from 15 to 44 years accumulates 78.5% of the cases, followed by 19.1% in people older than 45, and those under 14 host the remaining 2.4%. 13 Table 4. Accumulated AIDS Cases by Age and Gender Age Group Men Women Total Cases % Cases % Cases % , , , , , , years or more 18, , , Unknown 886 (0.9) 146 (0.7) 1,032 (0.9) Total 97, , , Note: The unknown category was excluded from the percentage calculations, however, said figure is given in a parenthesis in order to show its size. Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, Of the cases, 55.3% (see Table 5) is concentrated in only six states: Distrito Federal (21,187), Estado de México (12,417), Veracruz (10,550), Jalisco (9,944), Puebla (5,768) and Baja California (5,455). 14 The appreciation of the incidence size of the historically accumulated cases in each state can be improved by building relative figures that consider the size of each entity s population in mid Accumulated AIDS incidence rates show Distrito Federal as the state most accosted by the illness with cases for every hundred thousand inhabitants, followed by Baja California (182.2), Morelos (161.4), Yucatán (155.2), Jalisco (144.1), Veracruz (145.7), and Nayarit (154.5). The national rate is located at cases for every hundred thousand inhabitants. 31

33 Magis, Bravo, Gayet, Rivera and De Luca State Table 5. Accumulated AIDS Cases, Accumulated Incidence and Diagnosis Year According to State Accumulated Cases Accumulated Incidence Diagnosis Year (yearly) Aguascalientes Baja California 5, Baja California Sur Campeche Coahuila 1, Colima Chiapas 4, Chihuahua 3, Distrito Federal 21, Durango Guanajuato 2, Guerrero 4, Hidalgo 1, Jalisco 9, México 12, Michoacán 3, Morelos 2, Nayarit 1, Nuevo León 3, Oaxaca 3, Puebla 5, Querétaro 1, Quintana Roo 1, San Luis Potosí 1, Sinaloa 2, Sonora 1, Tabasco 1, Tamaulipas 2, Tlaxcala Veracruz 10, Yucatán 2, Zacatecas Foreigners Unknown National * 117, ,054 5,031 Note: Accumulated incidence is for every hundred thousand inhabitants, and the national category does not include foreigners in transit through Mexico or unknown. Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, % 32

34 El VIH y el SIDA en México al 2008 The growth that the epidemic has shown in different states of the country between 2006 and 2007 is a provisional fact, since the register of those years has not been completed given that a five year period is needed in order to obtain relatively complete figures. However, under the supposition that all states possess the same percentage of register delay in diagnosed cases for those years, there are states that could be suffering a quick incidence growth in HIV/AIDS, which are the cases of Colima, Coahuila, Guanajuato, and Querétaro. On the other hand, there are states that evince a great lag for registering diagnosed cases in 2007, such as Chiapas, Chihuahua, Guerrero, and QuintanaRoo. It is important to note that, approximately, in one in every three registered cases the risk factor associated to the means of transmission is unknown. Transmission in 35.3% of all registered cases in men (see Table 6) is unknown; however, the prevalence of sexual transmission is very clear in those cases in which the transmission category is known (96.2%), especially the MSM modality (56.5%), followed by heterosexual transmission (39.6%). Blood transmission accumulates 3.5% of the cases in men and had a substantial incidence in the first years of the epidemic, but except in those cases related with injecting drugs (1.3% of accumulated cases), other types of blood transmission cases have not been reported since A look at causes registered for 2007 in men allows us to observe changes in the transmission categories regarding the historical distribution of accumulated cases. Even when dealing with provisional data, a strong increment in IDU transmission and the heterosexual modality can be perceived to exist, at the same time that MSM transmissions seem to have diminished. 33

35 Magis, Bravo, Gayet, Rivera and De Luca Table 6. New and Accumulated AIDS Cases in Adults by Transmission Category and Sex at the End of 2007 Transmission Category Cases Diagnosed in 2007 Men Accumulated Cases ( ) Cases Diagnosed in 2007 Women Accumulated Cases ( ) Num. % Num. % Num. % Num. % Sexual Transmission 3, , , , Homosexual 1, , Bisexual , Heterosexual 1, , , , Blood Transmission , , Blood Transfusion , Hemophile Paid donor Injecting Drug User (IDU) Work Experience Other (Homo/ IDU) Unknown * 54 (1.4) 33,856 (35.3) 8 (0.8) 6,160 (32.2) Total 3, , , , Note: The unknown category was excluded from the percentage calculations, however, said figure is given in a parenthesis in order to show its size. Source: CENSIDA. Operative Investigation Direction, with numbers from the National AIDS Case Register to December 31, The transmission categories in women have a different distribution than those of men. In this point it should be restated that the quantity of cases in women is significantly smaller than in men: one for every five men. Therefore, blood transmission has a higher relative importance (10.6%) than with men (3.5%) despite having taken place in women half of the time. The way in which the illness was contracted is unknown in 32.2% of cases in women and, just as in men, this represents certain limitations in order to raise the analysis 34

36 El VIH y el SIDA en México al 2008 level. Also it can be perceived that lately there has been a rise in the IDU and heterosexual categories among women. HIV Infection Prevalence in the General Population In order to estimate the HIV prevalence in Mexico s general population, national surveys with serologies, sentinel surveillance surveys in pregnant women, and the results of antibodies in voluntary blood donors are used. Of these, the most reliable measuring instrument is the national survey, given its geographical coverage and probabilistic precision. However, its high cost implies that it is little used in Mexico. Sentinel surveillance in pregnant women 16 collects information with previously selected groups in defined places and with a determined periodicity, which allows to detect changes in the tendency or distribution of the epidemic without the need to study all the population. The operative definition says that those women who attend to any medical service during pregnancy or labour aid must be included. It is considered that pregnant women are a very low-risk group and, therefore, represent the general situation of the adult women population before the illness, without mentioning the possible superposition of other groups of women with higher-risk practices (FSW and IDU) in certain contexts. Voluntary blood donors are also supposed to be a low-risk population, but here the representation bias take on a more general and active role: few women are donors, there is no complete certainty of excluding donors who have high-risk practices, and it is not known which population sector is predisposed voluntarily to donate blood (for example, the family designation of the healthiest ). Therefore, the lack of randomness could enable going into non-representative measurements. Estimates Obtained from National Surveys with Serology In the first National Seroepidemiological Survey (ENSE) of 1987, serums were collected through a probabilistical home sampling frame. 78,536 blood samples were obtained and, for the determination of antibodies against HIV-1; 10,921 serums of men older than 15 years old were selected, obtaining a seroprevalence in adult men of 0.04%

37 Magis, Bravo, Gayet, Rivera and De Luca 18 Sentinel surveys of HIV in pregnant women started in Between 1991 and 1996, 3,085 pregnant women s serums were analyzed and a seroprevalence of 0.09% was found, with a plausibility limit that runs In the same period, 1,104,512 tests were made in voluntary blood donors in the Health Ministry s laboratories; 19 an infection prevalence of 0.04% ( ) was observed. Based on the former results, it was established that in the mid-nineties HIV prevalence in the general population from 15 to 49 years of age was lower than 5 in every 10,000 adults. 20 In the National Health Survey that took place in the year 2000 (ENSA 2000), 21,271 persons older than 20 years of age and of both sexes were randomly selected in order to take the ELISA test (HIV1/2 antibody determination), confirmed by inmunoelectrotransference and the main factors related to seropositivity. The HIV-1 antibody prevalence already supposed in the adult Mexican population was of 0.25% (IC 95%: ). The prevalence in men was of 0.48% (IC 95%: ) and in women of 0.05% ( ). 18 The ENSA 2000 numbers showed a significant increase in HIV prevalence in the general population (six times greater) next to that of 1987 (ENSE), which does not coincide with other indicators. A possible explanation is that the figure obtained by ENSA 2000 for men (0.48%) was overestimating the real expansion that the epidemic had acquired during the nineties, in this sense it would be more cautious to consider that the inferior error margin allowed to estimate the probability (0.26%) agrees with a better approximation to HIV prevalence in men. An important point that supports this hypothesis is that from 1996 to 2007 there have been between 4 and 5 AIDS cases in men for every case in women presented annually, which means that to a 0.05% incidence in women, as ENSA 2000 marks, a 0.25% incidence in men and 0.14% in the general population would have corresponded, which translates into 73,000 infected people of both sexes and older than 20 years who do not belong to most vulnerable groups. These last figures show a greater congruence with the results of various approximations obtained through other methods and with HIV/AIDS evolution in Mexico. Towards the end of 2001 the existence of around 150 thousand people living with HIV in Mexico was estimated, which represented a prevalence of 0.3% and meant that three of every thousand adults in 36

38 El VIH y el SIDA en México al 2008 the general population and in the more vulnerable groups could be HIV carriers in our country. 6 The last of the national surveys with serological studies was the National Health and Nutrition Survey 2006 (ENSANUT 2006). The prevalence results obtained in the ENSANUT 2006 are provisional, given that they are still in the revision stage. With this note, the HIV prevalence figures that are being handled right now in the general population older than 20 years are 0.09% (IC 95%: %), with prevalences of 0.14% in men and of 0.06% in women. 22 Just as in ENSA 2000, the prevalence in women matches other estimations and an infection increase was expected in this greater sector of the population. However, the figure that does not agree with the projections formerly made is the low prevalence in men (0.14%). Again, under the supposition that after ENSA 2000 the men/women transmission ration had continued descending in order to place itself in a three to one, it could be estimated that prevalence in men is situated around 0.18% touching upon an error margin superior to that probabilistically allowed. This last number would signify that the epidemic has not grown among men nor, because of the weight that prevalence has among them, in the general population. In the meantime, the proportion found in adult women (0.06%) living with HIV increases the need to put special attention to transmission through unprotected sexual relations with the opposite sex to which women are being exposed. Estimates Obtained from Surveillance in Pregnant Women In addition to surveys, a way of making estimates is by taking samples in pregnant women. Between 1990 and 1999, 12,068 pregnant women were examined under the frame of sentinel surveillance and 11 of them resulted infected by HIV (seroprevalence of 0.09%; IC 95%: ). 20 A result that, if it were true, and in relation to the heterosexual transmissions established years later based on AIDS cases, would have meant a prevalence of about 0.20% in men of the general population, which would mean that during the nineties they did not belong to the more vulnerable groups. 37

39 Magis, Bravo, Gayet, Rivera and De Luca Table 7. HIV Detection in Pregnant Women in Public Health Institutes Concept Total women with prenatal monitoring HIV tests in pregnant women AIDS cases in pregnant women AIDS cases through perinatal transmission Year ,245,376 2,190,138 1,988,881 1,791,679 2,020,317 2,033,849 2,093,029 8,520 8,043 8,637 27, , , , Sources: CONASIDA. Comité de Monitoreo y Evaluación. Boletín del Grupo de Información Sectorial en VIH/SIDA, (4), December 2006 Outside the sentinel surveillance, difficulties have arisen when trying to get an adequate and systematic probabilistic control in order to detect HIV presence in pregnant women. The taking of blood tests has not been generalized in the majority of the pregnant women who every year attend social security institutions, and the taking of tests in pregnant women who have been in risk situations is not representative of pregnant women in the general population. The figures reported in Table 7 indicate how far we are from being able to provide great HIV control among pregnant women who attend social security institutions. Even if in the last years the seroprevalence studies number have been enlarged, there is still a long way to go in this instance. The Health Ministry is operationalizing a strategy to detect HIV in all pregnant woman who attend its health centers through quick tests, but at the time there are no definite facts. The AIDS case base analysis shows that during the nineties the amount of transmissions among women were gradually increased; however, the prevalences detected in pregnant women between 2000 and

40 El VIH y el SIDA en México al 2008 show percentual prevalences with decreasing tendencies in those years: This leads us to conclude that there is an indicator that presents bias and should be revised and cleared up. A punctual case that unleashed an interesting polemic was presented because figures reported in a sample of 1,000 women who were giving birth in Tijuana s General Hospital in 2003, where a 1.2% prevalence was found. That is, an HIV prevalence approximately 12 times greater to the estimated national average for pregnant women. The explanation of this phenomenon considers the need to methodologically discriminate among women who attend in order to have a perinatal control from those who simply go to the clinic for the first time when about to give birth, and all indicates that those are different populations. Thus, it was observed among IDU women or those with IDU partners who gave birth that the prevalence was of 6%, while those who did not present that risk showed a 0% prevalence. In order to confirm that hypothesis, during 2005 information was collected in Tijuana General Hospital, which revealed that on 2,456 women who attended prenatal control there was a 0.4% HIV prevalence, while among the 2,373 women who only went to the hospital exclusively to give birth without prenatal control the reported prevalence was of 0.63%, that is, it had grown in over 50%. The total prevalence found among the 4,829 women was of 0.52%, 25 a figure less than half of that which was reported in The results found confirm that Tijuana has a subepidemic whose prevalence rate is sensibly higher than the national one. Estimates Obtained from Blood Donor Surveillance As an accurate indicator, there have also been estimates for the general population obtained from the controls done in blood donors. Since 1986, in Mexico there are legal dispostions that prohibit blood commercialization and require all altruistically-donated blood to be analyzed before its use. During the first five years of the ninetines, the National HIV Laboratory Network of the Health Ministry took 1.5 million tests to detect antibodies against HIV-1 in voluntary blood donors, which resulted positive in 7,855 scrutiny testes (ELISA of hemaglutination) 39

41 Magis, Bravo, Gayet, Rivera and De Luca and only 654 were true positives confirmed through the Western Blot test, representing a 0.05% prevalence. 9 Based on the latest reports published about blood donation, a correction to unestimate the false positive results was made as to not overestimate the numbers. The most frequent record among blood donor population since 2002 is a 0.1% prevalence. Table 8. National Percentage of Blood Donations with Positive Tainting Corrected by False Positves in Year Positive Tainting Test Corrected by False Positive ** (**) Note: Predictive possitive value = PxS/PxS+(1-P).(1-E) P=Prevalence S=Sensitivity E=Specificativity Source: CONASIDA. Comité de Monitoreo y Evaluación. Boletín del Grupo de Información Sectorial en VIH/SIDA, No.3, December Given that it is assumed that such a population is representative of the low-risk population and that general prevalence in adults from 15 to 49 years of age is of 0.3%, it can be inferred that the majority of the total of the HIV-infected population belongs to the general, low-risk population, which in absolute numbers would come close in 2007 to 66 thousand infected people, mostly heterosexual men and women. The estimates by CENSIDA after 2001 and published by UNAIDS in their biannual reports show that the increases in the number of HIVinfected people that are produced year after year do not surpass the relative annual increase of the adult population. This means that the prevalence rate for the population from 15 to 49 years old would have been stabilized at 0.3% in 2003, 2005, and 2007 (see Table 9). At the start of 2006, about 35 thousand infected people would have received antirretroviral treatment, while there could have been 180 thousand people living with HIV at the end of The most recent 40

42 El VIH y el SIDA en México al 2008 available estimates were made using UNAID s Workbook method. In this way, for 2007 the existence of 198,000 HIV carriers is estimated, which again represents a 0.3% prevalence in the adult population. 27 Table 9. Estimates of People Living with HIV in Mexico Year (*) Adult population living with HIV [inferior and superior range] 170, , ,000 [91, ,000] [99, ,000] [113, ,713] HIV prevalence % [inferior and superior range] [ ] [ ] [ ] Women 34,000 42,000 44,000 (*) E. Bravo-García, C. Magis-Rodríguez, E. Rodríguez-Nolasco, Recent HIV estimates in Mexico: 198,000 people living with HIV, Int Conf AIDS. 17, CDC0233 (abstract no ), Mexico City, 2008 Aug 3 8. Source: UNAIDS. Report on the global AIDS epidemic (2004, 2006 y 2008). Prevalence of HIV Infection in Higher Vulnerability Populations High risk practices (such as sexual relations with no condom use and material-sharing when injecting drugs) can increase the degree of exposition to the infection These concepts were understood by the sanitary authorities in Mexico. Brief History of Tried Aproximations to Follow HIV/AIDS in the Sectors with most Vulnerability In 1985 serological studies as well as surveys including basic questions were started in order to detect HIV presence in paid and voluntary blood donors. In those days the surveys about behaviour of MSM in Mexico City were tested Between 1987 and 1988 the information, the attitude and the practices are studied through surveys applied to the general population over 15 years of age in Mexico City. The first interventions developped with this information and a large part of the questions that had been designed and validated in the first 41

43 Magis, Bravo, Gayet, Rivera and De Luca studies were used to establish the sentinel surveillance system (SVS) of the first generation. 7 In 1990, the General Epidemiology Direction (DGE) published the first HIV/AIDS Epidemiological vigilance manual 7 16, formally starting sentinel surveillance. However, studies with those characteristics had been done previously in various cities in the country since Since then serological studies were complemented with the search for demographical and behavioural information in MSM; MSW, incarcerated persons, and haemophiliacs. In 2001, according to UNAIDS guidelines, a series of great changes was proposed. 7 The traditional epidemiological surveillance system, which founds its analysis mainly on AIDS cases information, had shown severe limitations because it did not consider routine measuring of risk practices in different sectors of the population By then several studies had already included both serologies and questions in order to identify risk practices and situations that made people vulnerable, in fact MSM, MSW, migrants, and teenagers follow-up was already being practiced. 28 All these studies were the basis for developing second generation surveillance vigilance focusing on behaviours that put people at risk of HIV/AIDS transmission. The relevance of the second generation surveillance system is that it captures the risk level that various sex practices in the population reach, at the same time that it considers possible changes that can be taking place when preventive actions are taken. Its usefulness lies in that it provides information about how conduct patterns influence the epidemic development and the possible ways in which HIV can be advancing in the general population. 29 The AIDS epidemic has also generated rejection to different lifestyles, mainly because of fear of transmission. All this has been manifested in discrimination acts such as the denial of medical services, unjustified lay-offs, and stigmatization Based on resolutions that were approved on 1989, in 1996 the guidelines and obligations that governments have to assume so that, in the HIV/AIDS context, the most vulnerable sectors of the population were protected from breaches in human rights were agreed upon in the UN; 34 all of which determined the creation of indicators that measure these problems

44 El VIH y el SIDA en México al 2008 These facts have promoted a new generation of epidemiological studies that, besides behaviours and sexology, seek to inform about stigma and discrimination related to HIV/AIDS. During its participation in the plenary session of the XIV International HIV/AIDS Conference with the conference New health, development, and human rights global agenda, the then Mexican Health Minister affirmed that care and support for people living with HIV/AIDS towards the most vulnerable sectors and affected communities is a necessary condition in order to achieve an effective prevention. Therefore he proposed establishing a surveillance system to evaluate stigma and discrimination in which the affected population of each country is in order to know with precision if they are being reduced. 37 In summary, epidemiological surveilance in our country has explored different forms of addressing the problem that could well be framed in the scheme of the three surveilance generations where each one possesses its own methodology and indicators: 38 First generation, mainly focuses on AIDS cases, HIV infection, sentinel serological surveilance, HIV detection in donors and AIDS mortality. Second generation, together with the former, risk behaviors in the general population and in MSM, FSW, MSW, IDU, migrants, convicts, etc, are studied. Stigma and discrimination surveilance, besides the former, information is tried to be obtained through indicators that watch stigma and discrimination suffered by HIV/AIDS carriers and other sectors of the population that have been conected with the infection. Approximations and Figures of HIV Presence in Higher Vulnerability Populations Before the end of the eighties in Mexico, it was observed, with the limitations that sentinel surveillance imposed, that the HIV/AIDS epidemic was concentrated in some social sectors that maintained risk practices: 15% of HIV prevalence in MSM, 12% in MSW, and 6% in IDU. 39 In sentinel studies that took place during the period 6,274 MSM were observed. It was calculated that 15.5% of that population 43

45 Magis, Bravo, Gayet, Rivera and De Luca had HIV. 19 Towards the end of 2003, already in the second generation frame, in Guadalajara, Jalisco, an MSM study took place through a probabilistic sample that obtained 399 blood samples; the punctual HIV prevalence there obtained was of 13.8%. 40 In 2005, a second generation and surveilance study of stigma and discrimination, with a probabilistic study in 1,111 MSM in the cities of Acapulco, Monterrey, Tampico, and Nezahyalcóyotl found an HIV prevalence of 10.0%. 41 The MSW observations that took place between 1991 and 1996 found that 13.6% were HIV carriers. 19 The study that took place at the end of 2003 in Mexico City and Guadalajara MSW collected 174 blood samples where a 20% HIV prevalence was found. 40 While in 2005 the study with second generation technology with TLS with stigma and discrimination vigilante done in 284 MSW in the cities of Acapulco and Monterrey detected a 15.1% MSW prevalence. It is important to note the vast prevalence disparity found, since in Acapulco the figure was of 3.1% while in Monterry it was of 25.5%. That same year a study in MSW with RDS technology took place in Nezahualcóyotl, Estado de México, where 102 MSW were involved who presented a 5.9% prevalence among the participants but estimating, because of their contact network, a 12% for MSW in Nezahualcóyotl. 41 Sentinel surveillance of the surveilance on 24,500 MSW 19 counted a 0.3% prevalence. In 2003 the second generation MSW survey in the city of Veracruz, in Boca de Río, Veracuz, and in Tijuana, Baja California, found that in 371 analyzed blood samples there was a 6.4% HIV prevalence in Tijuana and 4.2% in Veracruz. 40 Afterwards, in MSW were studied in Acapulco and Monterrey, and the prevalence was of 1%, very similar in both cities. 41 Sentinel studies done among IDU population concluded that in the period HIV prevalence in 1,004 observed cases was of 3.6% 19 Ending in 2003, 405 IDU blood samples were obtained in Tijuana, where for 355 men a prevalence of 3.7% and of 6% among the 50 women was observed. 40 In the beginning of 2005 a prevalence of 1.9% in Tijuana (n=207) and of 4.1% in Ciudad Juárez (n=197) was found. 42 Studies done in 2004 and 2005 with 412 MSW in Tijuana and of 408 MSW in Ciudad Juárez found that 21 and 12% were also IDU that presented a 16% HIV prevalence, against 4% in non-idu MSW

46 El VIH y el SIDA en México al 2008 Another population with high vulnerability that has been recently studied, for the first time with serology, are long-distance truckers. A study done in Monterrey during 2005 among 312 truckers allowed noting a 0.6% prevalence among them. Ihe main risk situations in which some of these people incur are non-protected sexual practices with the following: occasional and commercial partners, together with the multiplicity of stable partners and sharing needles for drugs or other substances such as medicine, vitamins, or vaccines. 41 This sector can be considered as similar to the one defined as MSW clients in the models with which the estimations are done. Towards the end of 2001, according to estimations done by CENSIDA, there were in Mexico about 150 thousand adults infected with HIV, of which more than hundred thousand corresponded to MSM, almost 40,000 to the heterosexual population, and 4,500 to the incarcerated, almost 3,000 to IDU, and about 2,500 to sexual workers. 21 The last available estimation that was done in 2007 shows that the distribution of the 198,000 people living with HIV for that year was of 125,000 MSM, 44,000 women, 13,000 WSW and MSW clients, 4,300 WSW, 1,800 MSW, 3,100 incarcerated, and 3,000 IDU. 27 HIV/AIDS Expansion and Specific Vulnerability Conditions Since the appearance of HIV/AIDS a conceptual evolution in the way of characterizing the epidemic has been produced. Thus, from a first idea of risk groups there was a transition to risk practices and then to risk situations and contexts, followed by vulnerability. This conceptual development responded both to the results of epidemiological studies as well as to a paradigm change where the emphasis, gradually, was put in structural factors (sociocultural, economical, and political), overcoming moralistic postures and individualistic conceptions regarding the complex decision-taking processes. It is in this dialectic that ideas related to socially dysfunctional risk groups and of deliberately assumed individual risk are displaced in order to incorporate the concept of risk situations and contexts, which allows to establish new focuses that deal with social vulnerability and associated risk. In other words, individual risk is circumscribed in a social structure historically constructed that makes some sectors more vulnerable than others In order to establish public policies with integral and long-term regarding the response to 45

47 Magis, Bravo, Gayet, Rivera and De Luca the HIV/AIDS epidemic problem it is fundamental to adopt a vision that is as ample as possible, that is: we are all vulnerable to the epidemic, only that there are those who have more probabilities of contracting the infection. The notion of risk does not disappear but, together with the concept of vulnerability, continues being used when talking about the different levels that must be attended regarding the probabilities of HIV infection. The observed complexity makes HIV/AIDS not only an illness, but a social problem that goes beyond individual practices and health systems. Recent conceptual developments have required including political, economical, cultural, ethnical, generational, and sex and gender factors which express a certain structural or key conditions in order to comprehend vulnerability regarding HIV/AIDS acquisition. This complexity must be investigated and specified from interdisciplinary work that broadens the horizon of studies, actions, and policies directed to controlling the epidemic Thus, this new approach allows us to understand why it is more suitable interpreting that it is about lives that take place in risk, more than simply risk practices. 47 In this section we will deal with the HIV/AIDS situation in different population groups, attending to their respective situations in the social structure. This task requires the job of specifying the reigning known conditions, which allows explaining how is it that a sector of the population is left in a more vulnerable position regarding the possibility of contracting the illness. In order to understand this concept we can exemplify it with the hypothetical case of a teenager in the low socioeconomical end, who simply by being in the wrong place and time is arrested and accused of breaking a law; he does not have the resources necessary for hiring defence or for making bail, and therefore is incarcerated for a year while awaiting a sentence which clears him of all accusations. In the course of this time he becomes the victim of sexual abuse within prison and is infected with HIV. It is clear that the teenager did not deliberately partake in any risk practice. The problem lies in that if new cases are to be avoided through this transmission category we must at least start asking, what is it that makes an institution whose purpose is to correct bad conduct become a space where risk of transmission is amplified? and, what can individuals, authorities, and society do for this not to 46

48 El VIH y el SIDA en México al 2008 happen again? The concept of vulnerability is key to developing solutions that pretend to safeguard individuals and groups from a possible transmission. Mexican Migrants and HIV/AIDS Large scale Mexican migration to the United States (US) has been considered in many studies as an important factor of the HIV/AIDS spread, it has also been related to the infection in rural parts of the country, together with a larger prevalence of MSW, MSM, and IDU of both sexes in fronteer regions. 52 The history of the disease in the US shows that by 2001 accumulated incidence rate of AIDS cases for every 100 thousand inhabitants had already been produced, while in Mexico there were only 51.7 cases per 100 thousand For Mexican migrants, even without increasing risk practices, the possibilities of having been infected were 5.5 times larger. In this sense, since the beginning of the infection and until 1990, fifty percent or more of the registered cases every year in Mexico had antecedents of US residence. Up to December 31, 2000, 12.7% of the accumulated cases in Mexico had been produced in people who had previously lived in the US, with a greater incidence (27.8%) among the cases that had been presented in areas with less than five thousand inhabitants. The states of Michoacán and Zacatecas possess more than 20% of the accumulated cases of the US residence history. 48 The borderland of the US is a region with elevated prevalence indexes. According to 2005 data, the HIV/AIDS epidemic in the 23 counties that border with Mexico reached a prevalence of 239 infected per 100 thousand inhabitants. There, it is an epidemic greatly concentrated in men (88%), especially MSM (65.7%) and in IDU; the combined category of IDU/MSM the prevalence reaches 16.6%. 54 The epidemic in Mexico s northern frontier seems to be acquiring a similar development as that in the US southern border. Mexican workers travel to the US in search of work in productive sectors such as agriculture, services, and industry, both in rural and urban areas. Most of these workers are impovrished young men who are willing to sacrifice themselves travelling from one place to another to find work, do not speak English, and some do not even speak 47

49 Magis, Bravo, Gayet, Rivera and De Luca Spanish. Many do not have access to or do not know of the available health services, are in a cultural context very different to their own, and are filled with fears due to their illegal situation. Access to prevention messages and education that have been traditionally adopted is limited because of their mobility and lack of stable residence Considering the vulnerability acquired in these circumstances, some reaserchers have estimated that immigrant Mexican workers have a risk ten times higher of contracting HIV than the general US population. In Mexico, qualitative and quantitative studies show that immigrant populations tend to alter their sexual habits established in their place of origin, which substantially increases their risk of acquiring HIV. 48 In quantitative studies it has been observed that non-transnational migrant men and women had had an average of 1.8 and 1.2 sex partners respectively; when crossing the border, each had 3.3 and 1.5 respectively. Furthermore, 9.8% of migrant men used intravenous drugs, as opposed to 1.2% non-migrant men. 58 Presently, Mexico and the US have two vast difficulties for estimating HIV/AIDS incidence and prevalence among migrants, as well as for following migratory patterns or drawing the diagnostic and treatment history of the migrant population. The current migration surveillance systems are limited, since it is improbable that a representative sample can be taken in a population characteristically composed by various groups that posses different behaviours in time and space. There is not a single migratory pattern, but various that are being constantly modified as migratory policies, the economy of both countries, experience, settlements, the strengthening of migratory networks, sanitary policies and their instrumentation, characteristics of the new groups that are being incorporated to the migratory flux, and other changes are produced. Information from migrants that use health services can be gathered, but this does not prevent that bias from being introduced to the data. Those who use these services could be different from the ones who do not, by having the following: more information regarding health services, prevention, and the risk of contracting HIV; of greater access to medical attention given their location or other situations of the sort. 8 48

50 El VIH y el SIDA en México al 2008 Recent studies done specifically in Mexican migrants in the US or returning to the US are not abundant. The border location with the greatest quantity of recent studies is Tijuana. From 1999 to 2002, young MSM (18 29 years) in both sides of the California Baja California border were surveyed. In Tijuana (n=249) a 18.9% prevalence was found, while in San Diego there was a 35.2% prevalence. 52 While this numbers are not representative of the migrant whole, since the great majority does not practice that sexual orientation, it shows that the possibilities of MSM acquiring HIV could almost double in the California side of the border. A study with 600 Mexican migrant workers in San Diego and Fresno District, California, reported an HIV 0.9% prevalence, 59 that is, three times greater than the one estimated for the general Mexican population. More recently, studies done in the frame of the Epidemiological Surveillance Pilot between Mexico and California to analyze HIV and STI vulnerability compared risk conducts assumed by those who migrated the year prior to the interview and non-migrant adults (18 49 years of age) from Jalostotitlán, Jalisco. The sample included 181 migrants and 215 non-migrants, 76% were men and 24% were women. The survey allowed establishing that the risk behaviours associated with the fact of being a male migrant, having little education, being married or having a partner, and having from 18 to 49 years at the time of the interview. The probability of having incurred in risk conducts associated with HIV/AIDS and STI transmission resulted 59% higher among those who had a recent migratory history as opposed to those who had not emigrated. 60 A sample on 500 young men (18 to 35 years) that had emigrated and returned to Mexico recently or that thought about emigrating soon threw as a result that only one out of every seven men had used a condom in sexual encounters with non-stable partners. 61 The situation of being an immigrant shows a significant effect on the adoption of risk conducts that facilitate HIV acquisition in male Mexican immigrants, according to a probabilistic study done in 2005 with a sample of 364 workers in rural and urban areas in the State of California. When observing the conducts adopted before and after migration, it was discovered that immigrants had increased condom use fom 65.3% to 83.1%, while needle-sharing was reduced from 18.4% to 3%. However, other risk practices were increased, such as: 49

51 Magis, Bravo, Gayet, Rivera and De Luca sexual encounters with commercial sex workers grew from 21.9% to 31.6%, sexual work from 2.5% to 5.5%, and sexual relations under the influence of alcohol or drugs form 21.2% to 50%. These figures leave no doubt towards a significant growth of risk behaviours that can lead do HIV transmission among Mexican migrants in California. 62 The tendency above mentioned has also been reported by qualitative studies with young migrants returning to two communities in Mexico. The research took place through in-depth interviews with 47 young persons from 15 to 24 years of age. One of the communities presented a high density migration to the US, while the other community presented a low density migration. Half of the participants had returned from the US and the other half had never been there but had family members living there. The results refer that young migrants have more positive opinions towards risk and uncertainty, together with the adoption of risk behaiviors in practice as opposed to those who do not emigrate. 63 In a probabilistic sample that took place between February 2001 and December 2003 among Mexicans who were crossing the border in Tijuana, 1,518 complete questionnaires and 1,041 HIV tests were obtained. There were no positive serology cases, but the survey made clear that 7.22% had had multiple sex partners during the last six months, 1.16% had exchanged sex for money, drugs, or food, 3.74% had shared syringes, and 4.48% reported having had an STI during the past six months. 64 The importance of this study is that it included people who lived near the border and people who legally cross the border; it was not a sample where illegal immigrants abound. Two important hypothesis can be maintained from the already described results: first, that in the north border HIV prevalence is not great among the general population which we could say has low vulnerability, which makes us think that it is in the most vulnerable sectors (deportees, MSM, FSW, MSW, and IDU) related to the migratory flux where the infection settles. Second, if the risk behaviors that could signify transmission among the general public appear, these are not presented with the high frequency that has often been noted among undocumented migrants. Recent measures taken by the US government to stop illegal immigration in the Mexican border have turned into a factor that 65 increases migrant s vulnerability. For cultural reasons, young 50

52 El VIH y el SIDA en México al 2008 people tend to adopt risk conducts, however, these have been increasing in function of new conditions (greater times and distances, transport characteristics, and shelters used during the journey) that impose themselves in front of the increase in control and the persecutions throughout the border. During the realization of these more and more complicated journeys, young people are left more exposed to risk situations, which materialize when forced sexual relations appear, or those that take place during emotional breakdowns or motivated by the exchange of sex for drugs, together with the higher propensity to share needles and syringes, etc. Closely related to the previous point, the increase in the quantity of deportations in recent times must be considered. It is about an instance in the migratory process that, as a theme related to HIV/AIDS, has been little studied. However, the consulted qualitative indicators are enough to maintain that there is a growing vulnerability to the transmission of HIV among deportees. In 2006 La Casa del Migrante in Ciudad Juárez collected data from 86 thousand men who had been deported. Deportations have incremented since then and the situation of teenagers older than 17 is particularly worrying many of them do not have the resources to return to their families and live on the streets. There are deportees who look for shelter in NGOs that care for migrants and start using drugs. The presence of deportees who think that they have lost family ties and start frequenting places where sexual work, drugs, and alcohol abound has also been detected. These are particularly vulnerable to HIV transmission either sexually or intravenously. 66 Epidemic Expansion in Rural Areas According to INEGI, in 2000 and 2005, 25.3% and 23.5% respectively of the Mexican population inhabited rural areas (places with less than 2,500 inhabitants), which represents about 24 million people. In 1986 the first AIDS cases in rural localities were registered. 67 By the end of ,617 cases had been registered, where 2,089 (4.6%) cases were of rural origin and 893 (2.0%) were situated in communities that can be considered transitioning from rural to urban (2,500 4,999 inhabitants), at the time that great cities (half a million or more inhabitants) concentrated 58.3% of the accumulated cases. 51

53 Magis, Bravo, Gayet, Rivera and De Luca The main differences observed in accumulated cases of these regions are the following: in rural areas heterosexual transmission is very high, present in 43% of the cases MSM gets as high as 47.4%, while in cities it is only accountable for 28.2% and MSM have 63.0% of the cases. Therefore, the ratio of men/women cases in rural areas was 4:1 in 2000, when in urban areas it was 6:1. The study also revealed that since 1994 (when 4.7% of cases were in rural areas) an important tendency of growth of rural cases is seen in relationship to urban ones, which derived in 1999 for these to represent 8.0% of those diagnosed that year. 50 As we can see, rural cases do not pose an alarm regarding their numbers and rate, since they do not attain the relative weight of rural population in the country (around 24%), but are a problem because of the extra difficulties that arise regarding prevention strategies and treatment that can be undertaken in cities. With greater frequency, the rural population has less schooling, greater indigenous language use, and high gender inequality; all factors that tend to increase the difficulty to access and interpret information about the illness. Isolation also hinders the exposition to preventive campaigns. Scattering and remoteness of treatment centers implies higher transport costs and time and, consequently, lack of income, which difficults treatment adherence. 68 Complications such as the mentioned above and others that can be associated impose adopting a supplementary alert about infection propagation in rural areas, since the response actions become more complex there. Vulnerability of the Indigenous Population Mexico is the eighth country in the world in indigenous population figures and the first in the American continent. This tightens the relationship with the previous section and according to the 1990 census, in the Mexican territory there officially are 68 indigenous groups distributed among 545 municipalities, which represent 22.7% of all municipalities in the nation. 93% of the indigenous population is located in the Center, South, and South East of the country, and one of the typical characteristics of these settlements is the dissemination: seven of every ten indígenas lived in one of the 156,602 locations of less than 2,500 inhabitants

54 El VIH y el SIDA en México al 2008 It has been calculated that there were 10,253,627 indígenas in Mexico in the year By the end of 2004, CENSIDA 71 counted 1,786 accumulated AIDS cases in the municipalities that contain 70% or more of indigenous population (IP), which represent the 1.9% of a total 93,979 cases accumulated at the moment. The 20.7% of the IP cases are presented in women, while women represent the 16.5% of cases accumulated in non-indigenous population (NIP). In IP the chief means of transmission is heterosexual contact (54.1%) while in NIP this category is of 43.1%, surpassed by MSM means (48.6%), which possibly accounts for there to have been a greater proportion of perinatal transmission cases in IP (2.9% in relation to the 2.2% of NIP). In all other transmission categories NIP have greater percentages, IDU standing out with a difference seven times greater in NIP (0.7% against IP s 0.1%). Among the twelve states with a greater IP concentration, the 80.8% in the cases in municipalities with IP majority has concentrated only in four states: Quintana Roo, Hidalgo, Yucatán, and Oaxaca. There are few investigations and publications that have addressed the HIV/AIDS situation in IP. Studies developed by CENSIDA and the Latin- American Faculty of Social Sciences (FLACSO) have detected a amount of risk situations and conducts greater in IP than in NIP, which has allowed to observe certain specifications that the IP presents as opposed to NIP. One of the studies that focalized migratory (n=1539) and non-migratory (n=1236) populations in the states of Zacatecas, Michoacán, Oaxaca, Estado de México, and Jalisco, found that 7% of 2775 (202) surveyors spoke an indigenous language. In average, these had had a greater number of sexual partners, besides using condoms less frequently compared to interviewed NIP. Another study that took place in the cities of Acapulco and Monterrey, between MSW (n=284) and FSW (n=603) in 2005 proved that the number of sexual partners during the previous year was greater among speakers of an indigenous language (indigenous MSW represented 5.3% and FSW 5.8% in the sample) when compared to non-indigenous commercial sex workers, with which these segments of IP also presented a lower condom use. 72 One of the most recent studies was made in indigenous communities in the municipalities of Mezquitic and Bolaños, in the north of the state of Jalisco during November Here a sample of 359 cases, out of 11,360 inhabitants, among men (n=171) and women (n=188) 53

55 Magis, Bravo, Gayet, Rivera and De Luca from 15 to 49 years was applied. The report indicates that 20.5% of men have had more than five sex partners throughout their lives, and another 37.3% from two to four. Women expressed having had less sex Partners: 10.3% expressed 5 or more and 21.8% between 2 and 4 partners through their lives. 76.1% of interviewees admitted to never having worn a male condom during their sexual encounters; just 4% admitted having used condoms in some occasions and 2.1% did not know about the existence of condoms despite having had sex. 20% of women and 16.3% of men were oblivious to AIDS and only 22.9% of women and 24.4% of men knew that condoms help prevent its transmission. The ignorance there recorded was massive; half of the interviewed people did not know that AIDS can be transmitted through sexual contact. 73 In cities in the state of Chihuaha a small survey was made that included 166 HIV detection blood tests in twelve sample urban points. The sample was made up by 134 women and 32 men from 15 to 65 years of age, all speakers of an indigenous language. Only in one single case a person living with HIV was found, but 25 had syphilis which shows a high degree of risk of being exposed to HIV. Even if the source does not specify the trust interval nor the sample error range, HIV presence among indigenous people in Chihuaha is confirmed. On the other hand, the study uncovers the little knowledge that exists regarding HIV/AIDS and other STIs, drastically below the information that the NIP deals with, despite the fact that many of the study participants have been living in cities for many years. 74 One research that included several of the so far exposed vulnerability conditions (migrant population, both rural and indigenous), was made with rural Mixteco workers. The Mixtecos are among the largest Mexican immigrant groups that work in United States agriculture. The interviews were carried out in the origin communities (Oaxaca) and in San Diego County, California, including a total of 285 Mixteco men coming from 18 different communities, to whom an HIV test (Orasure) was applied. It was observed that a third part of the interviewed had sexual encounters while in San Diego. Of those, 21% reported having exchanged sex for money, food, or drugs; 50% reported having had relations with commercial sex workers; the mean of their sexual companions was of In the same manner 25% informed of having maintained anal sex with their companions and in three out of four 54

56 El VIH y el SIDA en México al 2008 cases condoms were not used. Even if HIV prevalence was low (only one participant resulted seropositive), it is very clear that in the high risk context in which the sexual activities of the Mixteco migrants was undertaken added to the vulnerability which this carries to the origin population of these migrant rural workers has created a situation that will enable a rapid infection expansion inside the origin communities. 75 A qualitative study that took place in 2003 and 2004 in Oaxaca and California, in which 22 representatives of social and governmental organizations involved with health, and 31 Zapoteco migrants of both sexes, marks the awareness of HIV/AIDS risk while they remain in California, especially in women. Regardless of this awarness and the knowledge of institutions that freely offer HIV tests, Zapoteco men do not use them for fear of being deported. In Oaxaca the availability of sexual health services if very deficient and in both countries they lack interpreters needed to give and receive information. In this case, Zapotecos have spread in their networks the HIV/AIDS risk preventions, but are marginalized from the sexual health services in both countries for being an ethnic minority. 76 There are Latin American studies that signal social exclusion as the primary risk factor for contracting HIV. A growing HIV prevalence can be observed among the Latin American indigenous populations, and the necessity of applying a multidimensional socio-epidemiological analysis has been suggested in order to cover the problem in all of its complexity. According to Wang, 77 the main indicators to find the factors that are facilitating the introduction of HIV/AIDS in the indigenous communities have to consider that: globalization relates to injustice, which intensifies poverty and forces migration; the lack of protection for indigenous rights promotes socio-economic marginalization and discrimination against indigenous peoples; discriminations reduces access to cultural and linguistic means suitable for attaining knowledge that helps promote health protection; and marginalization is causing the loss of traditional etho-medical knowledge, which causes difficulties for finding a knowledge system 55

57 Magis, Bravo, Gayet, Rivera and De Luca through which the incorporation of notions of new health evils can be mediated. All these combined factors are affecting the building of a community capital that is a key factor when communicating, understanding, and organizing in order to face the new ocurrences, that in this case consist in achieving adequate information and prevention in order to avoid HIV transmission. Decreasing community capital is contributing to the loss of elemental links that facilitate the adequate functioning of society, which brings an increase in gender violence, lack of community commitment, economic activities unsuitable for the community, or the choice of jobs that endanger physical integrity, together with the promotion and practice of unhealthy lifestyles. These would be some of the conditions that are enabling HIV expansion among the indigenous peoples. HIV/AIDS in Women In Mexico, the first AIDS case in a woman was due to postransfusional transmission and was diagnosed in In the past 24 years 20,451 women cases have been notified, which represents the 17.3% of the total registered AIDS cases up to The average of accumulated cases in the nineties shows that one woman had been infected for every six men, 79 but in 2007 the womenmen ratio had descended to 4.8 men for every woman (see Table 10). Furthermore, since 2003 the annually diagnosed cases are showing a masculinity ratio lower than four male cases for every female one. It is estimated that in 2007 there were around 44 thousand woman from 15 to 49 years of age living with HIV of an estimated total of 198 thousand seropositives. 27 Apparently, the latest estimations are considering that the population of infected woman amounts to 22.2%, which means that one of every four people that know or ignore that they live with HIV is a woman. The progression of AIDS cases in adult women show an evident growth of the epidemic in the female population of the country. This growth is absolute regarding the numbers that women presented in the past as relative against the cases observed in men. The heterosexual transmission route is responsible for these changes. However, this information must be placed in the infection record context for each 56

58 El VIH y el SIDA en México al 2008 population, indicating that the rate distribution by transmission category (Graph 2) shows a difference of almost a hundred between the cases present in MSM in relation to the rates that show the epidemic s behaviour in heterosexual men and women. Table 10. Masculinity rate of AIDS cases per year in Mexico, Diagnosis year Women Sex Men Masculinity Ratio Total of Casos , , , , , , , , , , , , , , , , , , , , , , ,135 5, , ,460 7, , ,511 7, , ,541 6, , ,557 6, , ,380 5, , ,329 5, , ,326 5, , ,224 4, , ,113 3, ,031 Total 20,451 97, ,915 Note: AIDS cases appear according to the year of diagnosis without of corrections for subregister and delay in notifications. For these rehaznos the numbers that appear in the last five years can be modified in the following years. Source: CENSIDA. Operative Investigation Direction, with figures from the National AIDS Case Register to December 31, A retrospective analysis on one hundred women from 18 to 45 years of age living with HIV/AIDS and coming from low socioeconomical strata in urban and rural zones detected that all had been living at least 57

59 Magis, Bravo, Gayet, Rivera and De Luca eight years without being diagnosed and had had partners that were previously infected. In seven out of ten cases their partners never used condoms prior to diagnosis and no woman reported having used the female condom. Graph 2. Accumulated AIDS Cases in Adults incidence Rates by Sexual Transmission Category, Rates per hundred thousand Year Hetero Women Hetero Men MSM Note: All the cases diagnosed from 2001 to 2005 have not yet been completed due to the delay in their notification. Source: CENSIDA. Operative Investigation Direction, with figures from the National AIDS Case Register to November 15, 2005 and population projections and by CONAPO. In the meantime, the average in the frequency of vaginal intercourse was of two events per month, which adds up to about 340 events in an exposure period of ten years. 45% of these couples practiced anal intercourse with a frequency range from one to six events per year, to which must be added that 93% of the partners reported having maintained bisexual conducts that seven of every ten cases were undertaken with unknown men and without condom use as protection in approximately half of the encounters. Also, six of every ten men had alcoholism problems. For these women who were infected with HIV while maintaining heterosexual relations with their partners, it can be clearly perceived 58

60 El VIH y el SIDA en México al 2008 that there were no protection possibilities in practice; they consider that they were not exposed to sexual health promotion campaigns nor that they possessed the knowledge or the attitude necessary to oppose unprotected sexual relations with their stable partners. Contrary to what may be believed, it was not theirs but their partner s sexual activity which proved to be the critical factor of HIV transmission; all this in a sociocultural context averse to negotiation regarding the conditions of sexual exchanges and marked by a disinformation that does not enable the adopting of protection means. 80 In 2006, in five Mexican regions, 80 in-depth interviews were done in order to observe the biography of the sexual life in different sectors of the population and the conditions in which it develops. The study confirms that predominating social rules condition men to have more sexual partners than women. Among women the need to keep with the mother-wife role hinders the negotiation power of protection conditions during the sexual act, especially if they have not yet had children. In rural areas the infection risk increases during pregnancy, given that it is frequent that the father maintain relations with a sex worker. In urban areas, men tend to have more sex partners while single, and a higher number of occasional partners during the separation from the stable partner. 81 Gender conducts and predominant stigma and homophobia in the country increase men s risk to contract HIV at the same time that women acquire vulnerability because of the trust that they must have for their stable partners, a product of de subordination condition of women to men. For some years it has been seen that in the state of Chiapas annually a third of the reported AIDS cases is in women, rate that is very much above the national average (5:1). This region of the country is characterized by possessing a high poverty index, rural inhabitation, and an elevated ratio of indigenous population. Most of the 52 women included in a qualitative study, indigenous as well as non-indigenous, reported having been infected through their partner within a stable relationship. At the moment it is very hard for these women carriers of HIV to use protection during sexual relations with their partners in order to avoid being re-infected; they do not accept condom use. Also 59

61 Magis, Bravo, Gayet, Rivera and De Luca these partners do not enable the women to visit health services in order to be treated and given antirretrovirals; the men express that we must get sick and die together. All the gender inconviniences that these women suffer for preventing and treating HIV/AIDS considerably worsen due to extreme poverty and the distances that must be undertaken in order to have access to health services capable of treating HIV/AIDS and providing ART. 82 Internationally, comparative studies have been done between Mexico and other countries that show how a low empowerment of women enables HIV transmission. Particularly for young women in Mexico, intervention would be required in order for them to have control over their sexual and reproductive health. Sadly, such interventions should take place in the midst of a cultural atmosphere that does not encourage adopting that posture, given the traditional gender roles established. 83 Thus, in the state of Guanajuato, Mexico, it has been detected that women living with HIV/AIDS have little information about the illness, which in the end determines a deterioration of living quality. Social confinement, discrimination, and poor treatment from health service institutions weight them down, encouraging the internalization of stigma which, among other things, hinders adherence to ART. 84 Without a doubt, in relation to the number of infected men, more and more cases of woman with HIV/AIDS arise. The structural conditions of social inequality in which women live are the principal factor of their vulnerability. The main vulnerabilities that affect women are biological, epidemiological, social, and cultural. Biological vulnerability proves that in heterosexual relations women have from two to four times more probability of contracting HIV than men, among many factors because HIV concentration is generally higher in semen than in women s sexual secretions. Furthermore, given that in the majority of societies gender and sexuality are closely related, culturally speaking, social men-women interactions have become power relationships in which masculinity must dominate femininity. Sexual differences are therefore transformed into inequalitites where women become subordinated subjects. This entails that, for example, in negotiations for condom use during the sexual act it will be, most probably, men who have the last word

62 El VIH y el SIDA en México al 2008 Injecting Drug Users: A Wide Spectrum Vulnerability The first AIDS case in IDU was notified in The growth of the epidemic by this transmission source has been slow. In 2000, when some Latin American countries such as Argentina (41.9%), Uruguay (26.3%), and Brazil (21.7%) showed great percentages of IDU cases, Mexico showed an accumulated AIDS cases by IDU of just 0.6%, 86 that would grow into 0.9% in 2006 or 1.2% when adding the category of MSM who use injected drugs. 87 Cases diagnosed during 2007 were of 4% in men and 1.6% in women (see Table 5). The last numbers confirm the already expected tendency of the expansion of the epidemic among IDU and the higher relative weight that this transmission category is starting to acquire. Sharing needles and syringes is a usual practice in many IDU groups, which is why infections can be quickly passed on among these populations. Furthermore, already infected IDU can transmit the disease sexually even if their partners are not drug users. 88 In Mexico, the use of injected drugs as a risk factor for acquiring HIV has been of lesser importance when compared to other transmission categories. However, in some groups and regions, a dramatic increase in the use of injected drugs has been observed, which has helped to anticipate that HIV prevalence in IDU will increase. This dynamic has been related to the growth of Mexican opium production and heroin traffic to the United States, since this has provoked a decrease in the drug s prices as well as the rise of the number of consumers, especially in the routes that lead to the northern fronteer of our country. 91 The estimates of the Consejo Nacional Contra las Adicciones [national council against addictions] show a great growth of illegal drug users in the past fifteen years, especially in the North of the country. Injected drug use is most dramatic in the Baja California-Chihuahua strip. The percentage of population from 12 to 65 years old who report having consumed illegal drugs in Tijuana during 1998 is three times higher (14.7%) than the national average (5.3%). 92 The greatest quantity of recent studies about HIV/AIDS in IDU have been made in Tijuana, among other reasons because there lies the most travelled frontier pass between Mexico and the United States. The situation there proves to be as dynamic as its migratory flux. In 61

63 Magis, Bravo, Gayet, Rivera and De Luca 1991, an epidemiological study that took place among people with risk practices in Tijuana found HIV prevalence among IDU of 1.92%. 93 In 1995, through sentinel surveillance studies in Tijuana and Mexicali, a HIV prevalence of 9% was reported in IDU. 94 Generally, surveys made in the eighties and first half of the nineties among IDU showed prevalences lower than 2%, 86 when recent data already point out prevalences from 2.3% to 6.5%. In 2003, the existence of 6 thousand active IDU who frequent picaderos in Tijuana was estimated, but considering that there are IDU that do not go to these places the numbers could be blown up to ten thousand. An anonymous transversal sample among 402 IDU that had injected at least once during the last month took place in November 2003 in Tijuana. The HIV prevalence found among the 399 analysed blood samples was of 4.01% (IC 95%, ). In 265 cases (66%) they had not shared needles the last time that they used, but they did in 137 cases (34%). Besides, 48.8% reported being an MSM, mostly bisexual (42.8%) and only 24.5% admited having used a condom in their last sexual encounter. 95 In a sample of one thousand women during childbirth in Tijauana General Hsopital in 2003 a prevalence of 1.2% was found. It should be noted that among women who did not use drugs prevalence was of 0%, but among IDU or with IDU partners it was of 6%. 23 Based on prevalences found in the last years in the total population and in the most vulnerable sectors, an estimate of maximum possible prevalence was done (0.8%), which means that in Tijuana there were 5,472 people from 15 to 49 years old living with HIV/AIDS, and a minimum prevalence of 0.26%, which would correspond with a scene representing the existence of 1,803 infected people. In both scenes little more than 70% would be men and the most affected groups would be MSM (1,146 to 3,300) and IDU (147 to 650). However, it is necessary to consider that there is an important degree of overlapping between both groups (48% of IDU is MSM), which enables to state that the maximum estimate would be overestimating. 24 During 2006 and ,056 IDU (898 men and 158 women) living in Tijuana were interviewed using Respondent Driven Sampling (RDS) and HIV tests.the general prevalence ascended to 4.4%. 96 Other results that were obtained from that sample refer that the prevalence in IDU women is three times greater than in men (10.5% vs. 3.4%), and 62

64 El VIH y el SIDA en México al 2008 that the main factors associated with transmission in women are these: being young, having had syphilis, and a greater time living in Tijuana. Among men the associated factors are the following: having had syphilis, having been arrested for showing IDU track marks, having used recently in large groups, and having lived little time in Tijuana. However, the factor that showed the highest independent association level with HIV prevalence in men was having been deported, with a probability four times greater than those who were never deported. 97 Regularly, when the IDU situation in the north border is exposed, it is considered as the same as the vulnerability structure of IDU in Ciudad Juárez and Tijuana. Recent studies start to point out that there are aspects that make them very different regarding risk environment in which they find themselves. In Ciudad Juárez, drug use and risk of HIV infection take place in an environment close to the family and strongly established social networks and this configures a particular vulnerability. In Tijuana, on the other hand, IDU appear supporting a different structural and environmental vulnerability in that here deportees, homeless, and arrestees for illegal drug possession predominate. Therefore, intervention planning, the results of studies that took place in these cities, and the evaluation of programs should contemplate these different vulnerability forms in relation with the different styles of drug use socializing in general and injected drugs in particular. 98 Studies that took place in 2002 concluded that in Ciudad Juárez there were from 3,500 hard addicts that had injected heroin 2 3 times in the past six months, 99 to almost 6 thousand IDU frequenting one of the 186 existing picaderos in the city. 100 Tightly linked to this, another research calculated that 10% of the FSW injected drugs during 2001, 101 while recent studies suggest half of FSW in Ciudad Juárez could also be IDU. 90 Using Respondent Driven Sampling (RDS) in 2007 a study took place with the goal of examining behavioural backgrounds that promote HIV/STI transmission among IDU living in the border of El Paso/Ciudad Juárez. Information and seroprevalence tests were collected among 361 IDU. The behaviors that showed greater association with HIV infection without the presence of hepatitis C are these: having different drug and sexual partners, injecting outside of 63

65 Magis, Bravo, Gayet, Rivera and De Luca home, having casual sexual partners or maintaining sexual encounters with men and women indistinctively, and using heroin combined with other drugs; while factors associated with non-hiv transmission and the presence of hepatitis C are the following: sharing drugs with the same sex partner, heterosexual conduct, generally injecting heroin without combining it with other drugs, injecting at home or at longterm friends homes. The study shows that the risk level that IDU partake is different according to the type of social network in which intravenous drug use is practiced. The need for better sex education and condom use in order to actually reduce the risk of acquiring HIV/ STI is also observed. 102 In the the center and southern areas of the state of Chihuahua a surveilance study was made to measure de prevalence of STS. The survey comprised 1000 IDU and 500 blood samples obtained with an HIV prevalence of 1.3% and a hepatitis C prevalence of 70%. It was noted that beside de risk of being IDU, the vulnerability is increased by other factors such as 74% having no medical insurance whatsoever, 40% having tattoos, 24% having been at some point in prison, 2% having a partner with HIV, 4% being comercial sex providers, 10% participating in same-sex encounters, and 3.5% having partners who are also IDU. 103 Finally, it should be tried to understand why IDU do not usually take measures to protect from HIV. In 2003 a qualitative study with twenty active IDU (ten men and ten women) in Tijuana revealed that half IDU men are also MSM, 80% reported regularly sharing needles with other IDU, 90% inject daily, 15% (women) receive drugs or money in exchange for sex, and 50% have a partner who is also an IDU. It was also established that most IDU do not prefer sharing needles with blood remainders, but that they do however using drugs in picaderos that have the means to performe an adequate cleansing of the syringes, together with the need to take advantage of the dose to its maximum without removing the drops that are left of the previous user in the needle, all under a great anxiety to consume the drug. There are exceptions: the existence of IDU groups in a better socioeconomical situation where each one uses their own syringe has been reported. These circumstances are aggravated because there are pharmacies that oppose selling syringes to IDU or abusively increase their price. Also various IDU said that they are not comfortable 64

66 El VIH y el SIDA en México al 2008 carrying syringes even in the absence of drugs, since it is highly probable that the police may detain them for a 36-hour period despite syringe possession not being a crime. Thus, increasing repression against IDU comes with an increase in syringe sharing, as was shown in a recent report where 71% and 42% of IDU in Tijuana and Ciudad Juárez were arrested for syringe possession. 104 Sterilized needles can be legally obtained over the counter in Mexico. In Tijuana, where an estimated ten thousand IDU live, a series of issues for acquiring them in drugstores can be seen. In April 2006, 602 IDU were interviewed, of which 83% are men with an age average of % of the interviewed reported having had difficulties when buying syringes in drugstores during the six months previous to the interviews, 7.3% were denied the purchase of syringes, 2% suffered price inflation, and 7.3% suffered both these drawbacks when attempting to acquire them. IDU that reported having these problems have, statistically, probabilities 2.34 times higher of sharing or reusing syringes, 1.9 times higher probabilities of being destitute, and 1.03 times higher probability of injecting more often than the general average. 105 With the object of starting to answer the above mentioned problems, in 2006 the Harm Reduction Program was instrumented to prevent HIV transmission among IDU throughout the country. Health personnel was trained regarding the cities where IDU have to be foreseen, the need to renew syringes, and, when this is not possible, coaching about the sterilization technique, besides offering free HIV tests. 5,420 IDU have been contacted in 23 states, many of which are incarcerated. 1,591 HIV tests were done, finding a 1.3% prevalence. Sadly, the insalled capacity proves insuficient in some parts of the Country and health services have not been able to cover the majority of IDU population in order to continue extending the benefit of this program whose aim is to reduce harm in IDU. 106 During 2007 a sample made up by 684 IDU of different parts of the country, who showed up voluntarily to health centers or were in prison was taken, and it was found that 18.1% are HIV carriers. 48% expressed having used sterilized needles the last time that they had used injected drugs. 107 It is necessary to note that the pointed out prevalence does not count with statistical representation of IDU population, since the sample is made up by IDU 65

67 Magis, Bravo, Gayet, Rivera and De Luca who consider having incurred in higher-risk practices and therefore attend in order to take the HIV/AIDS test. HIV/AIDS and Vulnerable Children Population In 2006 people under 18 years of age represented 35% of the Mexican population. 108 Children do not constitute one of the areas most affected by this disease; however, it is important to focus there research to put into perspective the vulnerability conditions that could make the epidemic grow in some sectors of this age group. Phenomena such as living in the streets, being deprived of freedom and under guardian advice, being subject to commercial sexual exploitation, drug abuse, the early commencing of sexual practices and having been sexually abused; all have a tight relationship with frailty and the exercise of risk practices regarding HIV/AIDS. Using the epidemiological information reported in the National AIDS Cases Register, the information of the population structure, registers, surveys, and estimates done about the sectors of interest, along with interviews with institutions with childcare, it could be observed that: AIDS cases in minors represented 3.1% of all accumulated cases towards the end of 2005; in 30% the means of transmission is unknown. Among those that can be categorized by source of transmission the highest relative means is perinatal transmission (67.5%), followed by 18.6% by sexual transmission (8% in MSM and 10.5% in heterosexual contact), and 13.8% by blood (8% during transfusion, 5.3% in haemophiliacs and 0.5% in IDU); during the period a progressive increase of AIDS cases can be observed in minors, being 1999 its highest point (6.4 cases for each million of children under 18 years old). Given that empirical studies of boys and girls living in vulnerable conditions regarding HIV/AIDS are practically nonexistent, the HIV prevalence infection was estimated according to suppositions of risk practices present in adults living under analogical vulnerable situations. It should be pointed out that estimates or registers of the number of children living in the streets, subject to commercial sexual exploitation, and victims of sexual abuse present an important level of 66

68 El VIH y el SIDA en México al 2008 subregister. The existing registers recognize the no-report problem, as well as the difficulties that invisibility and non-denunciation of phenomena such as commercial sexual exploitation or sexual abuse bring about. Therefore, the estimates made in order to determinate the size and characteristcs of these groups are considered as approximations to the subject. Applying prevalence suppositions to boys, girls, and teenagers younger than 18 that suffer from one of the vulnerability situations already mentioned, it was estimated that there could be from 12 to 22 thousand minors living with HIV in Mexico. 109 Recent Studies Regarding Sexual Behaviors With an AIDS epidemic predominantly transmitted sexually, it becomes indispensable to know the sexual behaviours of different sectors of the population. Practically since the existence of HIV/AIDS was recognized, there have been studies about what has been called risk conducts related to the infection s transmission. The efforst and experiences developed through years in Mexico and other countries finally integrate what WHO and UNAIDS had formalized in 2000 as Second Generation Epidemiological Surveilance. 110 This method tries to measure the risk levels assumed by different sectors of the population in their sexual practices. It consists of identifying and situating the populations most vulnerable to transmission in order to construct localized samples, with a simple design that can be implemented by local authorities in order to collect information regularly. 29 International studies have shown that not using a condom in the first sexual relation is in itself a predictor of subsequent high-risk conducts. Using Durex Sexual Wellbeing Global Survey, data on 26 countries was collected among those Mexico during July and August. Through a multiple logistic regression model it could be deteremined that the main variables that predict condom use are associated with gender, age, income, schooling, age of first encounter, partner relationship status, and having forced or planned sex. Variables such as being under the influence of alcohol or drugs, living area, conscience of the risk of acquiring STI or fear of pregnancy

69 Magis, Bravo, Gayet, Rivera and De Luca Recent Studies Regarding Sexual Behaviors in Young People It is important to point out the greater context in which the behaviors we try to understand are situated. In this sense there has been observed a growth in condom use among the general situation, while in the last 20 years several surveys have marked its growing use among young people. Considering the first relation, in 1985 very few single young people reported having used a condom (only 6.8% of men and 4.8% of women). Years later, the 1999 MEXFAM Surrey indicates that 43.7% of men and 1.5% of women used it Taking into account those who declared having used a condom in their last sexual relation, in % of Mexico City men already did. According to facts of the National Health Survey (ENSA 2000), with a sample that spanned the whole country in 2000, condom use in the first sexual relation among single young people was of 50.9% in men and 22.9% in women. 113 Recently, the ENSANUT 2006 shows that 29.6% of teenagers from 16 to 19 years of age had already begun their sexual life. In this group 62.9% of young men manifested having used a condom in their first relation, as well as 38.9% of the surveyed female teenagers. 116 Because these are recent facts, it is important to observe more closely some of the ENSANUT 2006 results. According to the operating definition of ENSANUT 2006, teenagers correspond to the 10 to 19 year age group. This group has interesting chacarteristics that obey to their demographical dynamic and its growing importance in public health. 25,056 teenagers were interviewd that, when applying statistical expansion factors, represented 22,874,970 young Mexicans of both sexes. 116 The obtained results about sexual initiation before 19 years of age are revealing of the possibility of HIV exposition through sexual transmission (see Table 11). 68

70 El VIH y el SIDA en México al 2008 Table Year Old Teenagers with Sexual Initiation and Protection in the First Relation by Sex and State in Mexico State % of 19 year old teenagers with sexual initiation % of condom use in the first sexual relation Men Women Total Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Chihuahua Distrito Federal Durango Guanajuato s/d Guerrero Hidalgo Jalisco Estado de México Michoacán Morelos Nayarit Nuevo León Oaxaca Puebla Querétaro Quintana Roo San Luis Potosí Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz Yucatán Zacatecas Nacional Average Source: CENSIDA. Operative Investigation Direction, with figures from National Survey of Health and Nutrition 2006, by state results - ENSANUTEF Online consultation on 06/23/2008, If we concrete our attention on the total of the 16 to 19 year old population we observe that almost a third part of these teenagers have 69

71 Magis, Bravo, Gayet, Rivera and De Luca already begun their sexual life. However, when we focus exclusively on the 19 year old teenagers in whether they have already had sexual relations or not the number grows to almost 50%. The propotion disparity of 19 year olds in the country attracts attention. While some states show an initiation percentage that exceeds 50% (D.F., Baja California, Baja California Sur, Colima, Durango, Edo. de México, Tamaulipas, and Quintana Roo), in other states it is under 35% (Jalisco, Morelos, Oaxaca, Querétaro, San Luis Potosí, Tabasco, Tlaxcala, Veracruz, Yucatán, and Zacatecas). Regarding the percentage of young people that have used a condom in their first sexual relation, it could be said that, generally, half used protection. Even when disaggregating this average showing gender behavior it is evident that men used it much more than women (63 vs 39%), which leaves no doubts about the lower negotiation power that women have in order to maintain protected sex. There are marked differences in male condom use among different states, especially in women. The largest percenteges of women who were protected in their first sexual relation are in Colima, Tamaulipas, Estado de México, and Baja California. While the opposite situation has presented in Coahuila, Chiapas, Chihuahua, Guerrero, Nuevo León, Sinaloa, Tabasco, Tlaxcala, Yucatán, and Zacatecas. The largest percentage of teenage men who were protected during their first sexual relation was in Coahuila (89.7%), followed by Zacatecas (87.7%). The Distrito Federal (76.9%) has an important level of protection, higher than the national average (63%). There are states that show a very marked insufficiency in men that use a condom in their first relation, especially Yucatán, Veracruz; Baja California Sur, Baja California, Puebla, and Guerrero. The referred facts allow us to appreciate that there is still a long way to go in order to reach the adequate levels of protection, particularly a big delay is perceived in some of the states where the protection levels are insufficient. Generally in Mexico the study of sexual and reproductive conducts has been concentrated in women and teenagers. Few works have explored the conducts of adult men in the general population. With information form the National Reproductive Health Survey (ENSAR) 70

72 El VIH y el SIDA en México al , it was observed that 8.5% of Mexican men from 20 to 49 years of age report having had more than one sexual partner during the year previous to the interview; in the same group 77.8% of those from 20 to 24 years report having used a condom during the last sexual encounter, at the time that only 14.3% of men from 25 to 49 used it. It was also observed that only 1.4% of the Mexican population had taken the HIV test during The percentage of men who adopted risk practices is significant, and that of the protection level among men older than 25 is very low; together with the low level of HIV tests taken, it can be concluded that among adult men it is not common to adopt HIV prevention and detection. 117 Recent Studies About Sexual Behaviors in Key Populations The results of studies concentrated in the most vulnerable populations when regarding HIV/AIDS can be used for multiple purposes, such as the identification of specific conducts that need to be modified and collection of information that can be used to push for political and financial support. There are various variables measured by second generation studies, with the effect of showing a synthetic approximation of its results and utility, only the findings referring to condom use (with occasional and commercial partners) and number of partners during the last year will be shown, since, if not practicing protected sex, the risk increases together with the number of sexual partners. In Mexico, between 2001 and 2003 a study was done that framed the Second Generation strategies in four states that have programmes to combat AIDS (Morelos, Michoacán, Puebla, and Chihuahua), which we call CENSIDA-INSP-ONUSIDA Survey. The selected groups were ,543 MSM, 2,399 MSW, and 624 IDU, all from 15 to 60 years. In another study ( CENSIDA Survey in Vulnerable Groups ) done towards the end of 2003 in Mexico City, Guadalajara, Veracruz, and Tijuana, we worked with 401 MSM, 396 WSW, 233 MSW, and 408 IDU. 118 Finally, a study called FLACSO-CENSIDA-FHI is included, which was developed during 2005 in Monterrey, Acapulco, Tampico, and Nezahualcóyotl. The sample sizes and groups considered for this work were 1,111 MSM, 603 WSW and 386 MSW

73 Magis, Bravo, Gayet, Rivera and De Luca Table 12. Main Indicators of Sexual Behaviors in MSM, MSW, WSW, and IDU, In Transversal Samples Survey and Focalized Population Men who Have Sex with Men (MSM) CENSIDA-INSP-ONUSIDA Survey, 2001 Condom Use in the Last Sexual Relation With Occassional Partner (non-regular and non-commercial partner) Condom Use in the last Sexual Relation with Commercial Partner Average Number of Sexual Partners in the last Year b 8.6 d MSM (n= 2,543) (n=456) (n=306) (n=1,439) CENSIDA Survey in Vulnerable Groups, b 1.87 e MSM (n= 394) (n=194) (n=75) (n=255) FLACSO-CENSIDA-FHI Survey, a 77.0 b 9.4 d MSM (n= 1,111) (n=580) (n=151) (n=841) Injecting Drug Users (IDU) Second Generation Survey, IDU Men (n= 536) (n=177) (n=74) (n=287) f 42.3 IDU Women (n= 87) (n=25) (n= 42) (n=81) CENSIDA Survey in Vulnerable Groups, IDU Men (n= 357) (n=172) (n=150) (n=309) IDU Women (n= 51) (n=28) (n=30) (n=44) Women Sex Workers (WSW) CENSIDA-INSP-ONUSIDA Survey, c WSW (n=2399) (n=53) (n=2308) (n=2355) CENSIDA Survey in Vulnerable Groups, WSW (n=395) (n= 289) (n= 380) (n= 365) FLACSO-CENSIDA-FHI Survey, c WSW (n=603) (n=103) (n=603) (n= 603) 72

74 El VIH y el SIDA en México al 2008 Table 12. Main Indicators of Sexual Behaviors in MSM, MSW, WSW, and IDU, In Transversal Samples Survey and Focalized Population Condom Use in the Last Sexual Relation With Occassional Partner (non-regular and non-commercial partner) Condom Use in the last Sexual Relation with Commercial Partner Average Number of Sexual Partners in the last Year Men Sex Workers (MSW) CENSIDA Survey in Vulnerable Groups, MSW (n=223) (n= 93) (n=223) (n=223) FLACSO-CENSIDA-FHI Survey, c MSW (n=386) (n=71) (n=383) (n= 386) a For those who declare haveing had at least one sexual partner in the reference period. b Bought and paid for sex. c Annual estimate of information of sexual partners in the last week. d Annual estimate of information of sexual partners in the last six months. e Weekly estimate of information of sexual partners in the last week. f Paid sex. NOTE: in the columns where variable values are expressed, the figures for the n in parenthesis refer to the number of people who answered the question. Source: Gayet C, Magis C, Sacknoff D, Guli L. Prácticas sexuales de las poblaciones vulnerables a la epidemia de VIH/SIDA en México. Serie Ángulos del SIDA, Mexico: CENSIDA, Facultad Latinoamericana de Ciencias Sociales, Sede México, This Second Generation study succession, given that they are transversal studies promptly located in different contests, limits the possibility of making inferences for the entire Republic. However, the information that they offer in time facilitates obtaining an approximation to the sexual behaviors in the different key groups observed and their possible changes. The studies exposed (see Table 12) about MSM show that condom use with occasional partners could be becoming more common. Partner alternation and sexual contact with occasional partners are risk practices frequent in an important fraction of MSM. 73

75 Magis, Bravo, Gayet, Rivera and De Luca Less frequent is the exchange of commercial sex in this group, but those who practice it could be taking less precautions in recent times. The numbers of sexual partners seem to be similar among the three samples. IDU men have a lesser quantity of sexual dealings than MSM, however they assume incredibly risky practices in sexual relations. In the two samples they declare scarce condom use in all kinds of sexual relations. IDU women, many of which are also WSW, seem to use protection a bit more frequently than the men in this group, but they are very far from adopting satisfactory protection levels. The three WSW samples obtained find according to the women interviewed important and growing condom use proportions in their work. However, the level of precaution that they assumed with occasional, non-commercial partners is insufficient. The answer is still in the air to whether the number of clients is growing in time or if they are numbers of the contexts where they were approached by the studies. In an attempt to give answers to the mentioned questions, there are more recent facts about WSW prevalence that come from the Vulnerable Population Monitoring Survey by CENSIDA with an outreach to 22 of the 32 Mexican states during In that sample frame 2,152 WSW were observed out of which 1% resulted HIV carriers. This finding confirms other transversal observations that were done in previous years and that already insinuated the growing of the epidemic in this highly vulnerable sector of the population. This facts insinuate that the epidemic has begun to settle in a bridge population, which enables the dissemination among the general population, or at least this hypothesis can be sustained until counting with more information from studies with WSW clients. 119 Researches about MSW show a relative high condom use in all kinds of encounters. However, it also reveals how a population that covers a great number of sexual partners and, possibly this be the motive of the high prevalence that is reported. In other words, those who do not use protection or seldom protect are relatively few, but given the frequency of sexual exchanges that they practice, the few slips allow to accumulate a high level of vulnerability. 74

76 Treatment of People Living with AIDS El VIH y el SIDA en México al 2008 The death of human beings is a tragic and irreversible fact. In its relation to HIV/AIDS, each death represents many lost battles, since each life taken by HIV/AIDS makes us reconsider what has been done up to the moment in our tries to stop the mortality advance. For effects of bettering our knowledge and the effectiveness of practices developed up to now, it seems necessary to verify the determinants and contingents that operate as a series of immediate and direct antecedent aspects of AIDS deaths, such as: the inexistence of a vaccine that prevents infection, the failure of being unable to prevent transmission, and, in some cases, the lack of opportune detection of the disease, the impossibility of access or of an early beginning of the treatment, be it because of difficulties for attending medical controls or because antiretroviral medicines cannot be purchased, and then, even when having begun treatment this has to be carefully proscribed and followed according to a precise observation and following of the virus in the patient, and, finally, the patient has to follow the treatment strictly for it to be effective, which only then makes possible the control of the virus for many years while enabling leading a dignified life. As can be understood, it is not simple that opportune HIV detection and all the stages of the treatment be carried out closely, especially for those people who were already undergoing personal, social, and economical disadvantages that hinder their access or adherence to treatment. In Mexico three important dates or moments can be identified in the universalization of ART: 1997, 2001, and In 1993, the Social Security Institutions start monotherapyh treatment (AZT) to some HIV/AIDS patients. In 1995, Social Security Institutions and CONASIDA (through protocols) start providing Bi-Therapy (AZTddCóAZT-ddi). In 1997, with the results presented in the International AIDS Conference in Vancouver, groups of people living with HIV/AIDS organize themselves and start doing protests which they do anonymously by covering their faces to demand ART access for all. By the end of 1997, the community movement started agreements with the Mexican Social Security Institute (IMSS) in order to insure consistent ART stockpiling in double and triple combinations. In 1998 a private 75

77 Magis, Bravo, Gayet, Rivera and De Luca trustfund (FONSIDA) is created to provide ART to pregnant women and children. The protesting groups call this policy Titanic Syndrome. In 2000 the first ambulatory center specialized in HIV/AIDS medical attention is created (Condesa Clinic) in Mexico City. Finally, in 2001 FONSIDA disappears to give way to a new Free Universal ART Access policy. In December 2003 this access is achieved in practice. In Mexico it was estimated that towards the end of 1997 around 6,000 patients did nod have access to ART, which is approximately 50% of people living with AIDS. 120 During 1998 ART coverage for children younger than 18 and pregnant women, all infected without access to social security, was achieved. 121 By 1999 ART coverage was extended to more than 1,000 thousand patients that did not have access to social security. 122 Already in 2004 almost 28 thousand HIV/AIDS patients were being treated, which practically signifies universal ART access. In ,951 people reported having received treatment and in 2006 a cuantitative jump was observed in the number of treatments administered, since the number of patients that received ART ascended to 39, Table 13. Distribution by Sex of People who Received ART by Institution, March 2008 SSA ISSSTE IMSS Total Sex Num. % Num. % Num. % Num. % Female 6, , , Male 17, , , , Total 23, , , , Source: CENSIDA. Operational Research Division, based on information provided by each institution at March 31, In Mexico most ART is given out through three Social Security instututions: the Health Ministry (SSA), the Mexican Social Security Institution (IMSS), and the Security and Social Services Institution for State Workers (ISSSTE). The most recent available numbers correspond to March 2008 and show a total of 46,496 patients in 76

78 El VIH y el SIDA en México al 2008 treatment distributed in these institutions in the following way: 23,245 in SSA, 19,836 in IMSS, and 3,415 in ISSSTE. 124 Women present 22.6% of all ART patients. Most women with HIV/AIDS are treated firstly by SSA and secondly by IMSS (see Table 13). It is interesting to point out that ISSSTE is characterized by giving ART to a very high population (45.3%) over 45 years of age (see Table 14), which makes us suppose that they are larga data ART patients, while the majority of infantile and juvenile AIDS cases are treated in SSA. IMSS shows a high concentration of ART administering to people from 25 to 44 years of age. Table 14. Age Distribution of People Receiving ART by Institution, March 2008 Age SSA ISSSTE IMSS Total (years) Num. % Num. % Num. % Num. % < , , , , , , , , , , y + 3, , , , Unknow 4, , Total 23, , , , Source: CENSIDA. Operational Research Division, based on information provided by each institution at March 31, % of the country s population is covered by IMSS, % of people who received ART during 2006 did so through that system of healthcare attention. However, in 2000 IMSS had given out approximately 62% of the year s ART, which means that its participation diminishes as the Health Ministry (See Table 15) increases its ART beneficiary number (from 23.5% in 2000 to almost 4% in 2006). These two institutions concentrate 91% of the people who received ART in In an attempt to actualize and deepen the analysis we proceed to show numbers corresponding patients with ARV treatment by state during the second semester of These facts correspond exclusively to 77

79 Magis, Bravo, Gayet, Rivera and De Luca the people with AIDS treated by branch offices of the Health Ministry, given that the same information is not yet available for other institutions. Table 15. People who Received Antiretroviral Treatment by Institution, Institution SSA ND 2,386 3,460 6,502 8,304 12,338 14,808 17,978 PEMEX ND SEDENA ND IMSS 5,111 6,278 7,867 9,214 13,303 12,339 13,640 17,623 ISSSTE 540 1,242 1,844 2,152 2,388 2,651 3,000 3,170 Totals 5,651 10,189 13,450 18,168 24,320 27,790 31,951 39,295 Source: CONASIDA. Comité de Monitoreo y Evaluación. Boletín del Grupo de Información Sectorial en VIH/SIDA Número 4. Health Ministry: CONASIDA, The first thing that one should highlight is that the amount of people under ARV treatment in the SSA branch offices has substantially increased, from 17,978 by the end of 2006 to 25,881 to September 2008 (see Table 16). That is, in less than two years the number has risen 44%. Patient distribution throughout the national territory is uneven and concentrated in six states that put together amount to 52.4% of all treatment: Distrito Federal (16.4%), Veracruz (10.8%), Jalisco (9.4%), Estado de México (8.0%), Chiapas (4.0%), and Puebla (3.8%).The institutes, clinics, and hospitals listed receive AIDS patients from all the country, and deal with patients who require special treatment. It is clear that for each woman who gets treatment there are three men. However, a disparity is also observed in the percentage of women under treatment by state. Highly above average (24.7%) are (36.9%), Veracruz (34.4%) Baja California Sur (34%), Guerrero (32.8%), Baja California (31.6%), Tabasco (31%), and Campeche (31%) 78

80 El VIH y el SIDA en México al 2008 Table 16. Health Ministry Patients who Receive Antiretroviral Therapy by State and Sex, 2008 State Number % of the total of Patients Men (%) Women (%) Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas 1, Chihuahua Distrito Federal 4, Durango Guanajuato Guerrero Hidalgo Jalisco 2, México 2, Michoacán Morelos Nayarit Nuevo León Oaxaca Puebla Querétaro Quintana Roo San Luis Potosí Sinaloa Sonora Tabasco Tamaulipas Tlaxcala Veracruz 2, Yucatán Zacatecas Clín. Inmunodefec. UNAM Hospital Infantil de México Inst. Nac. de la Nutrición Inst. Nac. Pediatría Inst. Nac. Perinatología Totals 25, Source: CENSIDA. Operational Research Division, Sistema de Administración, Logística y Vigilancia de ARV (SALVAR). Boletín No. 2 SALVAR, information at september 30,

81 Magis, Bravo, Gayet, Rivera and De Luca This states correspond with two very clear profiles: the northern ones, given their special border situation (known for sexual work and injected drug use), and the poor and rural states many of which with a significant number of indigenous population of the middle-south part of the country (known for return migration, bisexuality, and gender inequality). In the opposite side, there is a predominance frame of men in ARV in Distrito Federal (86.4%), Jalisco (81.5%), and Chihuahua (81.3%) that corresponds to those being places with a high HIV prevalence in the gay population. Mortality and Impact of Antiretroviral Treatment Knowing the HIV/AIDS mortality rates and doing the adequate following and analysis has an enormous strategic value when evaluating achievements and failures in the war against the infection in Mexico. The mortality level associated to this illness expresses the quality and intensity of the measures that have been directed towards prevention, early detection, and adequate treatment. In other words, mortality diminishes as long as transmission levels diminish, HIV/AIDS is detected in its earliest stages, and more economical, effective, and simple treatments are applied. AIDS mortality rate was of 1.8 deaths for every hundred thousand inhabitants in 1990, and it reached its highest register in 1996 with 4.7 deaths. 26 From that year, the progressive ascent of a new group of antiretroviral drugs known as protease inhibitors (PI) radically changed HIV/AIDS patients outlook: it was proved that the combination of the existing medicines in what was called High Action Antiretroviral Treatment (HAART) was able to delay damage to the immunological system and substantially better the quality of life. 126 Therefore, from 1998 onwards general AIDS mortality has been kept between 4.3 and 4.6 deaths for every hundred thousand inhabitants (see Graph 3). A retrospective analysis done in the National Nutrition Institute about the first 93 admited patients concludes that 22 weeks after diagnosis the survival time was of 50% with an average of 47.7 hospitalization days, while the survival time observed was two times lower than that reported in other countries. 127 Another study established that the 80

82 El VIH y el SIDA en México al 2008 sobrevida time in patients that acquired HIV/AIDS through contaminated blood transfusion was of 9 months. 128 In Monterrey a median survival time of 11 months was found, although patients treated with AZT (Zidovudine) reported a median survival time of 32 months. 129 The first studies in patients who used PI were done in Mexico City and the results showed that hospital mortality decreased significantly 130 from 23.2% in 1996 to 12.2% and 6.4% in 1997 and Afterwards, analysis done with the AIDS cases database allowed to observe that the average survival time of AIDS patients diagnosed before 1996 was of 17 months, but that from that year it extends to 57 months thanks to ART. Women average survival time even reached 61 months, while men s reached Sadly, there have been about 62 thousand deaths associated with HIV/AIDS among the general population in Mexico in the period and almost 43 thousand in the years period, precisely the core of the economically active population. Without a doubt, the main achievement of the period is free universal ART access across the country, whose goal was achieved by the end of 2003 before it was expected (2006). The impact that this measure has had is not yet perceived, since in 2000 AIDS death rate in the general population was of 4.3 for every hundred thousand inhabitants, while in 2005 it was of 4.5, taking the 17 th place as national cause of death

83 Magis, Bravo, Gayet, Rivera and De Luca Graph 3. AIDS Mortality in General and in the years age group, Mexico RATES Reduction ( 9.6%) 10 Rates per hundred thousand No change (0.61%) General Population years age group DEATHS Increase (11%) Rates per hundred thousand Increase (7%) General Population years age group Note: Rates for every hundred thousand inhabitants. Do not include foreigners or nonspecified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA,

84 El VIH y el SIDA en México al 2008 If in the period there are no changes observed in the general AIDS mortality in Mexico (see Graph 3), since the rate remains around 4.5 yearly deaths for every hundred thousand inhabitants; however, mortality rates of the year age group do show a slight descending tendency, which indicates that the survival time period of infected people has dilated. The number of deaths caused by AIDS in the general population grew by 11% from 1997 to 2007, from 4,201 to 4,650 deaths. However, this result can be toned down observing that among the deceased are people of all ages and that, only in those nine years about 66,500 new cases were diagnosed, compared to 39,500 deaths, even removing the 6,448 cases diagnosed in 2005 it can be easily inferred that about 20,500 people were able to surpass the considered period thanks to ART, independent from the individual survival time attained. Furthermore, we have to add to this that during these six years there was not a universal ART access. Death rate in the age group most affected by HIV/AIDS (25 44 years) registered a 1.1 decrease for every hundred thousand inhabitants, which translates in a 9.6% reduction in relative terms compared to the population size; however, comparing 1997 to 2005, 198 more deaths were registered, which means a 7% increase in absolute numbers, 131 figure which does not take into account the population growth in that age group or the amount of new AIDS cases incorporated annually. Given that year after year more AIDS cases are registered and accumulated, the fact of observing constant if not decreasing mortality rates in the year age group, allows us to affirm that a growth in the amount of deaths is being hindered in relation to what would be expected had ART not been widely spread. Therefore, and even if a superficial reading of the absolute numbers in the deceases may distort the interpretation, it can be affirmed that thanks to ART AIDS mortality has not grown. However, neither was an appreciably large descent achieved that has indeed been seen in other Latin American countries (Brazil, Argentina, and Costa Rica) that had already universalized ART access some years before Mexico. It was calculated that in the period (before achieving universal access) thanks to ART about three thousand deaths have been avoided in the 25 to 34 year age group. Estimates done by CENSIDA 83

85 Magis, Bravo, Gayet, Rivera and De Luca consider that, under a setting composed by moderate achievements in the specific prevention, treatment, and institutional strengthening towards the infection actions, it would be feasible to attain an AIDS mortality rate in the general population of 3 for every hundred thousand inhabitants for 2014, a number similar to that presented in Even with a control to avoid an increase in the quantity of deaths and, possibly, the start of a slow but progressive descent in AIDS mortality, there are some questions: how effective is ART access in Mexico? is ART impact poor, moderate, or is it surpassing all expectations? Maybe the best answer to this questions comes from comparing the dynamics of AIDS mortality after ART universalization; such an exercise must be done with reference to countries that can be considered relatively similar to Mexico in socioeconomical and cultural indicators, as well as having implemented universal ART access. The comparison with developed countries, especially in Europe, is inadequate, since there they managed to lower high rates to very low numbers in very short periods of time, showing that the conditions reigning in that continent are beyond the actual possibilities of Latin American countries. Graph 4 allows us to appreciate very significant elements in order to evaluate ART evolution in Mexico constitutes itself as the year of highest mortality for three of the four countries that we are comparing (Mexico, Brazil, and Argentina), with a small rift in Costa Rica, which presents two consecutive peaks in mortality rates (4.8 deaths for every hundred thousand inhabitants) during 1996 and It is precisely in 1997 that Costa Rica universalizes ART access, which allowed obtaining a very steep descent that reflected in a 3.4 rate in In Brazil ART had been universalized in 1996 when there was a 9.6 mortality rate; the impact was not late in coming, and by 1997 it had dropped to 7.6 and kept descending to 6.0 in 2005, which is the most recently published figure. Argentina achieved universal ART access in 1998, however mortality rates had already started to descend beforehand, since in 1996 it was in 5.9 and dropped to 5.2, 4.7, and 4.1 in the following three years. The last figure we have from Argentina is 3.8 in Graph 4. General AIDS Mortality in some Latin American Countries at 84

86 El VIH y el SIDA en México al 2008 the Moment of Universal ART Access and Afterwards 12.0 Mortality rates per hundred thousand Argentina Brasil Costa Rica* México Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA, An important detail to be considered in the trajectories of mortality rates in Argentina, Brazil, and Costa Rica after Universal ART Access is that the following year the observed descents in mortality rates are very steep, even up to a 25%. During the second year the decrease continues, less steeply but still visible; however, after the third year the rates have remained stable, with small movements either ascending or descending. Otherwise, in the general mortality rate in Mexico a small decrease can be observed Turing 1997 and 1998, coinciding with the beginning of ART administering in IMSS affiliates in 1997, to then continue stable but growing up to in fact, the graph shows no movement of the positive effect that universal ART access in 2003 should have shown. In Mexico s case the mortality dynamic observed among IMSS beneficiaries, when ART was distributed by IMSS in 1997, has a lot of similarities with Argentina and Brazil. The highest rate observed by IMSS corresponds precisely to 1996 when it reached 6.4 deaths for every hundred thousand beneficiaries. The last figure that we have (2005) refers that in IMSS the death rate is of 3.2 for every hundred thousand, that is, exactly after 9 years of ART given out by this institution it has been reduced to half. 125 The numbers of the IMSS case 85

87 Magis, Bravo, Gayet, Rivera and De Luca in Mexico suggest that ART efficiency there is even better than that observed in Argentina, Brazil, or Costa Rica even when in those countries it is the general population in a similar time span, since none of them achieved a 50% reduction between 1996 and the last dates of available information. Sadly, the mortality descent among Mexico s general population did not acquire the size of the descents observed in IMSS or in the other analyzed countries. With the goal of refining observation and analysis of AIDS mortality in the general population and in the most affected age group (25 44 years) from 1998, the evolution graphs of the mortality rates together with the evolution of the number of deaths by sex, where there are patients of the insured population who receive ART since 1997 together with those who were gradually incorporated as the SSA expanded treatment access until 2003 when universalization is achieved are presented. Graph 5. AIDS Mortality in Male Population, General and in the Age Group, Mexico RATES 86

88 El VIH y el SIDA en México al Rates per hundred thousand Reduction ( 6.2%) Increase (3%) Male Population years age group DEATHS Deaths Increase (11%) Increase (7%) Male Population years age group Note: Rates for every hundred thousand inhabitants. Do not include foreigners or nonspecified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA, In the case of men from 25 to 44 years (see Graph 5), the slope made up by mortality rates between 1998 and 2005 descends irregularly. From a 18.4 mortality rate in 1998 a 17.3 one is achieved in 2005, which means that between the two points in time a modest 6.2% descent was achieved, or 1.1 less deceases for every hundred thousand 87

89 Magis, Bravo, Gayet, Rivera and De Luca men. In the decease quantity net figures 2,437 were observed in 1998, against 2,604 in 2005, which means a 7% relative increase during those 8 years that can be considered as a tendency that denotes stability through time. Mortality rates in the general men population show a 3% increase between 1998 and 2005, since they go from 7.3 to 7.5 deaths for every hundred thousand men. Here it should be mentioned that about a fourth of men who receive ART is more than 45 years old, which is why the probabilities of having other complications besides those provoked by AIDS are higher. In relation with this, mortality rates of a general woman population (see Graph 6) show an 18.2% increase during the considered period, going from 1.3 to 1.5 deaths for every hundred thousand women. As opposed to men, they show a soft but sustained increase of AIDS deaths. The mortality rates of the woman population between 25 and 44 years of age grow in a slow but evident way (10.7%). In absolute numbers, women AIDS deaths have grown 28% in this age group, that is 110 more deaths in the period (from 388 to 498), which seems to be associated with the progressive increase observed in the amount of AIDS cases in women and, possibly, a lesser effectiveness of ART because of late treatment beginning, lesser adherence, and/or due to reinfection presence. These casual associations come up when perceiving that AIDS deaths in the general women population show a 29% increase, which means 617 deceases in 1998 against 796 in 2005; that is, we are facing the presence of the same relative death increase in the general population than in the analyzed age groups. Graph 6. AIDS Mortality in female population, general and in the age group, Mexico RATES 88

90 El VIH y el SIDA en México al Rates per hundred thousand Increase (15%) Increase (11%) Female Population DEATHS years age group Increase (29%) Deaths Increase (28%) Female Population years age group Note: Rates for every hundred thousand inhabitants. Do not include foreigners or non-specified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA, This suggest that there is no differential factor in function of age, which could be signalling that new AIDS cases are in the rise among women younger than 45 besides problems with ART efficiency. The period that is being analyzed only contains two years of universal ART access. The disquieting aspect that manifests itself in the 89

91 Magis, Bravo, Gayet, Rivera and De Luca mortality dynamic observed is that the steep initial descent observedin Costa Rica, Brazil, and Argentina was not reproduced. With the object of better understanding the development of the illness in Mexico, its regional characteristics, and the priority areas for prevention and attention, it is useful to observe the advances and setbacks in relation to the five-year increase ( ) that has been produced in each state. Sadly, 16 states half of the total presented increases higher than 0.5 deaths for every hundred thousand inhabitants in general AIDS mortality rates in populations of all ages. Independently from the relative mortality growth observed in each of these states, absolute increases in mortality rates span increases from 3.2 to 0.6 deaths in Tabasco, Nayarit, Veracruz, Aguascalientes, Chiapas, Colima, Sonora, Sinaloa, Chihuahua, Tamaulipas, Baja California Sur, Durango, Guerrero, Oaxaca, Nuevo León, and San Luis Potosí (mentioned from higher to lower rate increase). The 16 remaining states have increased slightly, remained stable or decreased mortality in the period analyzed (see Graph 7). By observing the behavior of the rates of AIDS mortality in the general male population during , shows that states such as Campeche, Baja California, Mexico state, Puebla and Yucatanhave lowered by 19% or more the male mortality rate during said five-year period (see Graph 8). Graph 7. General AIDS Mortality by State: Decrease and Increase in General Population, Mexico, Rates Percent 90

92 El VIH y el SIDA en México al 2008 Baja California Distrito Federal Puebla México Morelos Jalisco Campeche Quintana Roo Querétaro Yucatán Hidalgo Guanajuato Michoacán Zacatecas Tlaxcala Coahuila San Luis Potosí Nuevo León Oaxaca Guerrero Durango Baja California Sur Tamaulipas Chihuahua Sinaloa Sonora Colima Chiapas Aguascalientes Veracruz Nayarit Tabasco Note: Rates for every hundred thousand inhabitants. Do not include foreigners or non-specified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA, Graph 8. General AIDS Mortality by State: Decrease and Increase in Male Population, Mexico, Rates Percent 91

93 Magis, Bravo, Gayet, Rivera and De Luca Baja California Campeche Distrito Federal Yucatán Morelos México Puebla Jalisco Hidalgo Quintana Roo Tlaxcala Coahuila Guanajuato Querétaro Zacatecas Michoacán Nuevo León Oaxaca San Luis Potosí Durango Guerrero Colima Chihuahua Tamaulipas Baja California Sur Sinaloa Sonora Chiapas Veracruz Aguascalientes Nayarit Tabasco Note: Rates for every hundred thousand inhabitants. Do not include foreigners or non-specified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA,

94 El VIH y el SIDA en México al 2008 However, there are also 16 states with increases in male death rates over 0.5 deaths for every hundred thousand inhabitants: Tabasco, Nayarit, Aguascalientes, Veracruz, Chiapas, Sonora, Sinaloa, Baja California Sur, Tamaulipas, Chihuahua, Colima, Guerrero, Durango, San Luis Potosí, Oaxaca, and Nueva León; mentioned by order from largest to smallest increase in their rates. The percentages of mortality increase in men observed in Aguascalientes (98%), Tabasco (71%), and Sinaloa (60%) should be pointed out. In general, few and of little important are the setbacks incurred in female mortality. The only states that can be mentioned for having attained a decrease equal or larger than 0.5 deaths for every hundred thousand women are Querétaro and Mexico City. The increases in female mortality observed in 16 states are equal or larger than 0.5 deaths in the 2005 rates when compared to 2000 (See Graph 9). The percentile growth registered in Campeche (729%), Yucatán (164%), Sonora (158%), Coahuila 155(%), and Nayarit (143%) is very high. What has happened to AIDS mortality in Mexico? During the period, general AIDS mortality has been stable among men, but among women it is on the rise. By a beneficiary condition, a significant decrease of mortality in the insured population and, therefore, an increase in non-beneficiary population. At the same time, AIDS mortality in the most affected group (25 44 years of age) has decreased in men but increased among women. The only explanations for this dissimilar behavior are the following: a more accelerated increase in the proportion of women cases and, hypothetically, problems in opportune HIV/AIDS detection and in ART adherence. This problems could well be related to the socioeconomical conditions and gender inequality more acutely presented in certain parts of the country. 93

95 Magis, Bravo, Gayet, Rivera and De Luca Table 9. General AIDS Mortality by State: Decrease and Increase in Female Population, Mexico Rates Percent Querétaro Distrito Federal Puebla Jalisco México Michoacán Baja California Sur Quintana Roo Morelos Zacatecas Guanajuato San Luis Potosí Tamaulipas Sinaloa Hidalgo Chihuahua Aguascalientes Durango Tlaxcala Nuevo León Guerrero Coahuila Sonora Nayarit Oaxaca Baja California Chiapas Tabasco Yucatán Colima Veracruz Campeche NA Note: Rates for every hundred thousand inhabitants. Do not include foreigners or nonspecified deaths. Source: Rivera P, Sánchez K. Mortalidad por SIDA en México. Informe técnico. Mexico: CENSIDA, Differences because of beneficiary condition can be related to the earliest universal ART access in the insured population as opposed to the uninsured one. However, it is also possible that the differences have a relation to the offer of other services, also of integral treatment, that social security gives to its population, such as access to laboratory tests that include a Viral Load (VL) and CD4, prophylaxis for opportunist infections (OI), medical infrastructures for the treatment 94

96 El VIH y el SIDA en México al 2008 of OI, among others, that the Health Ministry did not give extensively but that has started to incorporate. Finally, there exists the hypothesis that the Health Ministry is treating its ex IMSS users that are in bad health conditions, so that before dying they emigrate to the Health Ministry and their death is registered as non-insured population. The treatment quality (capacitating of attending physicians, as well as the implementation of effective patient adherence programs to ARV treatments together with late case detection), could be determinants that help to explain the differences found, both for social security beneficiary condition as well as observed differences among states. Successful massive incorporation to ART in Mexico has allowed the following benefits: increase in the lifequality of the afflicted, increase in patient survival time, decrease of opportunist infections associated to AIDS, reduction in the numbers of hospitalizations, and decrease in mortality. 126 However, current information systems do not allow the approach to each one of this variables contributions to AIDS mortality. Nevertheless, taking measures to narrow the bettering of integral attention of people in ARV treatment is key. In this sense, integral treatment monitoring, besides including impact indicators as AIDS mortality and survival time of ARV treatment must follow indicators of result and process, such as the continuity of ARV treatment and laboratory studies (VL and CD4) in shape and time, as well as these results, among other aspects. 95

97 Magis, Bravo, Gayet, Rivera and De Luca Conclusions Before analyzing the exposed information, it is necessary to highlight the limitations of measurements and available data. First, we worked based on AIDS cases, where various inconveniences lie in order to establish absolute certainties about some dimensions of the epidemic s behaviour in the recent past. An important percentage of diagnosed cases suffers a delay of up to five years in its register, and therefore the appreciations that can be elaborated since 2003 are based on incomplete figures. There is also an important number of cases where the mode of transmission is unknown (a third). However, this method allowed observing some aspects of the historical development of the epidemic, and therefore useful in order to retrospectively approach understanding how the epidemic started spreading from a longitudinal perspective, geographical distribution, and the changes in transmission routes and gender distribution. A great achievement of the response to the epidemic in Mexico is that for a great number of years cases related to blood manipulation have disappeared. The accumulated numbers at the moment and their accumulation rhythm suggest that the epidemic grows slowly, and therefore a 0.3% prevalence would be kept among the adult Mexican population. The traditional breach of six men with AIDS for every woman observed in the nineties has closed in recent years to 3.5 men per every woman case. Sexual transmission continues predominating, with 96% in men and 98% in women; as shown by figures declared during 2007, and there the breach starts to tighten among heterosexual males (46%) and MSM (49.5%), when in the story of the epidemic they represent 40% and 56.5% respectively. The proportion of IDU men has also grown: the history of the epidemic situates it in 1.6% but in

98 El VIH y el SIDA en México al 2008 they represented 4.3% of the case total when considering MSM with injected drug use. On the other hand, there have been very little empirical studies that allow directly appreciating HIV prevalence in the general population with a synchronic cut. We only have ENSE 1987, ENSA 2000, and ENSANUT 2006 with preliminary results. A bettering in epidemiological diagnostic alludes to the need of making surveys with national and probabilistic representation at least every five years, which would simplify précising various estimators. We have tried to solve this problem, in part by using models created with suppositions that are not always fulfilled outside this probabilistic systems, together with the danger that the possibility of feeding them with biased data represents. Recent estimates seem to approach the epidemic s incidence; however, non-measured changes in the behaviors of some variables could provoke false estimations. In this sense, to improve even more the quality of the data in all measurements that have been made is needed, and we know that there has been a lot of effort put towards that direction. The role played by migration has been determining at the beginning and in the first year s expansion of the epidemic. Recent studies are showing that in the last years its importance is directly linked to tother social phenomena. The result is that the vulnerability for a great sector of the population seems to have increased when combining conduct changes with various vulnerability conditions. The outlook that results of all that is that a greater complexity for dealing with behaviors, attributing transmission routes and even for allotting infected people exclusively to one key group. Thus, in this work some of the associations interwoven among poverty, youth, limited schooling, migration, drug use in general and injected drugs in particular, men who have sex with men, sexual work, from rural backgrounds or indigenous origin, and gender inequality are shown. The former can well be graphed with the special situation observed in Mexico s northern border, especially in Tijuana and Ciudad Juárez. There a subepidemic has been constituted where tendencies and particular dynamics in HIV prevalence in key groups with groups of other regions. The women sexual workers of the north border could have achieved a 6% HIV prevalence, which is very high considering what has been observed in other parts of the countries where it hardly 97

99 Magis, Bravo, Gayet, Rivera and De Luca ever goes beyond 2%. The same goes for IDU that live or wander through the north border, even though there are very few recent probabilistic control references in other parts of the country. It is possible that an incidence reduction is taking place, given that in the last years a series of steps is being taken in order to favour the use of sterilized injectable materials; in fact some of the most recent researches show a tendency in the decrease of the infected IDU proportion, and this in the midst of an expansion in thenumber of drug users in the US border. We hope that in some time the decrease can be confirmed in HIV transmissions as a consequence of the accurate measures that the Health Ministry, state governemts, and some social organizations have instrumented in order to reduce damage among IDU. Migratory movements are also related with the growing transmission to women, especially in the rural areas of the country. HIV/AIDS cases are very frequent in women who have contracted it through partners with a migratory history, besides the low condom use among married couples. AIDS cases in rural areas (around 5% of the total accumulated up to 2004) and in indigenous population (about 2%) have an unquestionable relationship with migratory movements. While the proportion of these cases is below the relative weight that said sectors of the population possess in the total population, there are signs of a faster growth than in the cities. Rural and indigenous populations can be considered as particularly vulnerable given the existing difficulties to achieve there effective prevention, early detection, and a more opportune treatment of the ill. An important characteristic of the cases registered in the rural locations and indigenous population is the dominance of heterosexual transmission, as well as women appearing sensibly more vulnerable than their urban counterparts. The great and recent increase in female mortality in the most rural and indigenous states allows to turn the suspicion into an investigation hypothesis. The facts we have about female AIDS mortality show, in function of maximizing the resources for investigation, to the need of priorizing the getting of samples in Campeche and Yucatán. The former takes us back to the importance that the second generation studies and recently those who measure stigma and discrimination have acquired. New methodological concepts, 98

100 El VIH y el SIDA en México al 2008 techniques developed in recent years (RDS and TLS), and the great quantity of variables adressed facilitate structured observation of a set of analytic dimensions that allow to extract information solidly founded. Comprehension of the epidemic results clearer when we can link prevention information referring to conducts and conduct changes, levels of prevention information, belonging networks, together with the serological status of the interviewed person in a quantitative or qualitative study. Up to now, there have been practiced transversally in order to study behaviors, perceptions, and serologies of groups considered as key, but have reached little points of the large Mexican geography. It is necessary to shake up these kinds of work because they truly orient inequivocally the production of steps that respond efficiently to stall/stop the epidemic. Here the three projects of recent second generation projects of largest scope in which CENSIDA has been involved have been considered. Together, these studies gave clues about the existence of some tendencies, facilitating the adoption of certain hypothesis that lead the future observations for the development of certain novelties that seem to be taking shape in the development of the epidemic in Mexico. The results of these studies coincide in that the prevalence of HIV in MSM is in a consistently limited range and is not being imcremented, in fact they allow to establish the hypothesis that a decrease in prevalence may have been produced. The opposite is visualized by MSW, a population that is extremely exposed to transmission. While among WSW, a key group that had shown low prevalences during the nineties, studies suggest that there could be an HIV increase among them, even if seropositive WSW is far from reaching the alarming numbers observed in Southeast Asia. It has also been shown that the combination of risk conducts (e.g. WSW+IDU) heightens the proportion of HIV cases to relatively high levels inside the Mexican context, all a worrying phenomenon. When combining all the available information it can be observed that MSM continue being a high HIV/AIDS prevalence group. However, hints have started to appear that allow maintaining the hypothesis of a possible recess in the epidemic in this group. MSM still possess the highest relative weight in the number of cases accumulated, but this seems to be slowly changing. A possible logic to explain this phenomena would be that it is already evinced a selection of the 99

101 Magis, Bravo, Gayet, Rivera and De Luca survivors among those that keep to a lower risk conduct, after assuming themselves as the group most affected by the epidemic and the center of various prevention campaigns. Historically, they have supported an HIV prevalence of 15.5%, while recent studies results suggest that it could have decreased, even to under 11%. The facts that refer to the protection degree assumed by MSM in occasional sexual encounters goes with the pertinence of formulating such a hypothesis. The realization of studies with MSW is difficulted by the degree of hiding and secrecy with which they perform this stigmatized commercial activity. Among MSW the frequency of transmission seems to have increased from a 14% prevalence a decade ago to levels that could be found around 20% today. The great quantity of sexual exchanges performed is constituted in the source of explanation most relevant to sustain such a preoccupation. The quantitative weight of this group key in relation to the general population is very low and its increment of HIV prevalence is not meaningful in relation to the total prevalence that it presentes in the adult population, but the problem there must be attended in a focalized manner in order to stop the incidence early. This warning implies the need of practicing an ad hoc following and not through general statistics where its visualization is hidden, extensive recommendation in the investigation in small populations in general. The size of HIV prevalence in WSW has always been a high line very much treated in the studies and actions that try to know and intervene in the infection development, since the situation is considered strategical to spread the infection among the general population, among other things because it is about a large group. In theory and also in the existence of worldwide examples we are dealing with a very vulnerable sector because of biological, socioeconomical, and gender reasons. Early developed situations among female sexual workers had obtained as a result low prevalences (even lower than 1%) in the epidemic history in Mexico. Sadly the registers obtained in the past year make us think that there has been an HIV case increase among them, although the numbers vary greatly from region to region. The WSW studies refer to a relatively elevated proportion in condom use during sexual work performance, there even seems to exist a lower degree of protection among young WSW recently incorprated to the activity in all kinds of sexual relation. This case will require a lot of 100

102 El VIH y el SIDA en México al 2008 imagination in order to be approached with studies that include the following of the youngest WSW. The IDU group is perceived by recent studies as the riskiest and least protected. The complexity that has configured out of this group by the high degree of overlapping (MSM, WSW, and migrants), together with scarce condom use in sexual relations, difficulties for providing sterilized syringes and needles, prosecution, discrimination, and stigma that they suffer has turned this into an especially vulnerable population. In fact, the complexities carried by the multiple interactions among risk factors has combined around IDU a difficulty establishing the transmission route. Furthermore, even when the proportional weight compared to the general population is low, the users of injected drugs are considered as the key group that tends to more rapidly grow parallel to the production and traffic of narcotics in Mexico. HIV/AIDS is mainly transmitted in children in the country perinatally (in infants) and sexually (in teenagers). The main challenges in perinatal prevention strategy would be to provide counselling and voluntary HIV detection to every pregnant woman being treated by health services, maintaining universal access to ARV treatment, as well as strict compliance of other perinatal prevention measures, not only regarding HIV/AIDS but also so that they can be protected from STDs and addictions. The Federal Governemtn has already started campaigns that cater to this need through divulgation of knowledge in schools; we hope that in a few years these are fruitful in adding an efficient response against HIV expansion. It is still necessary to consolidate a culture pro voluntary control through HIV test taking. The detection mechanism has been ostensibly modernized in the past years and it is now possible to have a result in only fifteen minutes, which does not require people returning for their results. It is very necessary that the general population and those belonging to key groups go to take these tests and to receive counselling: this action is key in order to stop the epidemic. To conclude, it is necessary to consider a factor of huge counter-weight to the epidemic expansion: growing condom use among the general population and especially among young people. It is true that there still are sectors lagging behind regarding protected sexual practices, but all indicates that AIDS and STDs information campaigns together 101

103 Magis, Bravo, Gayet, Rivera and De Luca with the growing opportunities for accessing condoms are contributing to a general will for taking precautions. A great part of this acheivment is due to the efforts that have been exerted by the health systems. 102

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116 The current situation of the information contained in this 9th volume of the Angulos del SIDA collection is strategic in order to observe how this terrible epidemic is acting in Mexico s population. The present edition represents a great effort in the integration of the different studies about AIDS s situation in our country Dr. Jorge Saavedra Center for the Prevention and Control of HIV (CENSIDA)