Land of Extremes: Prevention and Care Range From Bold to Bleak

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Science  28 Jul 2006:
Vol. 313, Issue 5786, pp. 477-479
DOI: 10.1126/science.313.5786.477b

With a population more than twice as large as all of Central America combined, the country has the most HIV/AIDS cases in the region yet a relatively low prevalence

MEXICO CITY AND TIJUANA, MEXICO—In 2003, when the Mexican government appointed Jorge Saavedra to head CENSIDA, its top AIDS agency, the messages were unmistakable. Saavedra, an articulate spokesperson, is an openly gay and HIV-infected clinician in a country where—as in much of Latin America—an abundance of machismo causes serious cases of homophobia. He's also a prime example of the power of modern anti-HIV drugs. “He was dying from AIDS,” says sociologist Mario Bronfman, a former top health official who hired Saavedra at the Ministry of Health years ago when no good anti-HIV drugs existed. “It's very symbolic that he's the head,” says Bronfman, who now works with the Ford Foundation in Mexico City. “And not just because he's HIV-positive and gay. No one can understand the problem from the inside the way that Jorge can.”

The choice of Saavedra was surprising even to those doing AIDS clinical care and research. “I could not believe that they chose him,” says Luis Soto-Ramírez, one of Mexico's leading HIV/AIDS researchers, who welcomed the move. “It was amazing.” But it's not the only unusual aspect of Mexico's epidemic—or the country's response to it.

In contrast to other countries in Latin America and the Caribbean, which tend to downplay the extent of the spread of HIV among men, Mexico candidly reports that the primary driver of its epidemic is men who have sex with men—many of whom do not consider themselves gay or bisexual. Since 2003, the government has also had a policy of universal access to antiretroviral drugs, and this year the government reported that everyone who has been identified with advanced disease is receiving treatment. In another sign of the country's progressiveness, activists, sex workers, and researchers have organized innovative efforts to combat the spread of HIV, as has Saavedra, who last year launched a provocative antihomophobia campaign.

Innovative approach.

As part of its HIV prevention efforts for sex workers, the NGO Aproase discreetly oversees the transactions on Sullivan Boulevard all night long.

Although Mexico has made big strides in tackling HIV/AIDS, there are still some glaring gaps, says Carlos del Rio of Emory University in Atlanta, Georgia, who headed AIDS policy for the Mexican government from 1992 to 1996. The epidemic has not grown as much as he and others once feared it would, but del Rio says the heterosexual spread in rural communities “is much more difficult to control.” Research is often “primitive,” he says—in particular, prevalence data are thin—and collaborations remain rare. And although antiretroviral drugs may be widely available, many people who need them do not know they are infected, and pharmacies often run out of drugs. The training of clinicians, and thus the quality of care, is also spotty, del Rio says: “The lofty goal of universal access is not being fully realized.”

Prevalence puzzles

If you believe the official figure—and many experts don't—only 0.3% of the adults in Mexico are infected with HIV. That's half the U.S. prevalence. “It's very difficult to say what's happening in Mexico,” says Soto-Ramírez, who runs an HIV/AIDS lab and clinic at the National Institute of Nutrition in Mexico City. “The numbers say very different things from what I think.” From his vantage point, the prevalence must be higher—and increasing. “I'm seeing many more women and many more rural cases,” he says.

Epidemiologist Carlos Magis-Rodríguez, CENSIDA's research director, has found a surprising degree of heterosexual spread in rural Mexican communities and disturbing new evidence that migration is a major factor. “We find a lot of at-risk behavior in these little towns,” says Magis-Rodríguez. In collaboration with the University of California's Universitywide AIDS Research Program (UARP), Magis-Rodríguez's team is comparing 1500 people from five Mexican states who in the past year migrated to California for seasonal work to some 1200 who did not. Preliminary data suggest that the migrants have more sexual partners, use drugs and alcohol more frequently, and hire sex workers more often.

A second study suggests that migrants are becoming infected in California and bringing the virus back to rural communities in Mexico at high rates. The researchers compared the prevalence of HIV in 800 Mexican migrants temporarily living in California (0.6%) to 1500 who migrated and then returned home to Mexico (1.1%). “Is it possible that a low-prevalence country like Mexico could take off like India and China?” asks epidemiologist George Lemp, who heads UARP in Oakland, California. “That's of great concern.”

A separate collaboration between clinicians at Tijuana General Hospital (TGH) and researchers at the University of California, San Diego (UCSD), published in the January Journal of Acquired Immune Deficiency Syndromes, suggests that the prevalence among pregnant women—generally considered an indicator of spread in the population at large—may also be significantly higher than official estimates. CENSIDA reported in 1997 that only 0.09% of pregnant women in Mexico were infected with HIV. In the new work, UCSD's Rolando Viani and co-workers tested more than 2500 pregnant women at TGH in 2003 who were either receiving prenatal care or who came to the hospital for the first time during labor. The group receiving prenatal care had a prevalence of 0.33%—nearly four times higher than earlier estimates. And in the group that only showed up in labor, which reported more frequent use of injecting drugs and more sexual partners, prevalence jumped to 1.12%.

Gynecologist Jorge Ruiz-Calderon, a co-author at TGH, says the initial reaction to the study from colleagues and officials alike was anger and denial. “They wanted to cut our heads off,” he says. “Most of my colleagues don't want to know anything about the problem.” Many critics also viewed TGH, which Ruiz-Calderon notes sees “the poorest of the poor” in a border town that attracts people from other locales, as an aberration. “They see these pregnant women as outcasts,” says Viani. And he says that's a serious mistake: “Eventually,” he predicts, “miniepidemics like this one will interchange with the general population.”

Quality of care

Although TGH may not represent Mexico at large, it does illustrate the serious limitations that exist even in middle-income countries that have universal-access policies. Anti-HIV drugs can dramatically lower a pregnant woman's risk of transmitting the virus to her baby. But at TGH—a well-equipped hospital in a large city that likely offers a higher standard of care than many other facilities in Mexico—screening of pregnant women is far from routine. Ruiz-Calderon says the residents and nurses are “not offering HIV tests to every pregnant woman, or they're doing it after delivery.”

Confronting homophobia.

CENSIDA head Jorge Saavedra launched a provocative campaign against discrimination against men who have sex with men.

Viani notes that UCSD has not had a case of mother-to-child transmission of HIV since 1994; TGH documented seven infected babies last year alone. TGH also routinely runs out of pediatric formulations of the anti-HIV drugs used to treat infected children. “We're 20 minutes away from San Diego, but things are so different,” says coauthor Patricia Hubbard, who coordinates the binational research program.

To Nuar Luna, a prominent AIDS activist, the biggest challenge Mexico faces is unequal access to quality care. “If you have influence and you have money, you have access,” says Luna, who has struggled to find competent care for his own HIV infection. “This is Mexico—and this is Latin America. It's a region with a lot of racism and classism and social issues. You can hear Jorge Saavedra say, ‘Here in Mexico, we have full access.’ But we have to analyze what kind of access we have. The good services are for the rich ones, and the bad services are for the poor.”

Reaching out

Despite the many concerns that people at the front have about Mexico's response to HIV/AIDS, nongovernmental organizations (NGOs) and the government itself have launched several innovative prevention efforts. One takes place each evening in a Mexico City “dark room,” a club where men meet to have sex. The HIV-prevention service offered by the NGO Ave de México gives new meaning to the word outreach.

Not only do workers from Ave de México pass out condoms and lubricants, but they also put their hands between men in flagrante delicto to make sure that they're using protection. Dentist Carlos García de León, who in his off hours runs the organization, says their studies found that nearly half of the men were not using condoms. “Most people accept it very well and are thankful,” says García de León. “They say, ‘I wasn't thinking.’” He notes that in a gay sex club in, say, the United States, this type of intervention wouldn't fly. “They'd kill you,” he laughs.

Late at night on the city's Sullivan Boulevard, Alejandra Gil and her group Aproase offer another uniquely Mexican approach to prevention. Gil, a former sex worker, provides a comprehensive program to protect the women who line the street and try to catch the eyes of men driving by. In addition to providing counseling and a clinic that offers testing for sexually transmitted infections such as HIV, Gil and her adult son sit in cars all night long and oversee each transaction, transporting the women to nearby hotels for their rendezvous—and even going to the room if they take longer than usual. “If the women don't have security, we can't help them with their health issues,” says Gil.

Another creative project has stepped up prevention efforts for injecting drug users in Tijuana, two-thirds of whom report never having been tested for HIV. A mobile health clinic travels around the city to areas that health care workers typically avoid, providing tests, clean syringes, and limited treatment. Delivering care at shooting galleries “takes away the stigma” that often prevents users from seeking help, says UCSD epidemiologist Steffanie Strathdee, who is running the project with Remedios Lozada, an AIDS clinician in Tijuana.

On the national front, Saavedra has spearheaded an antihomophobia campaign of radio and TV ads—so provocative that two Mexican states refused to run them—and posters, including one that shows a man and a woman both leaning their heads against the archetypical macho Mexican man dressed in revolutionary garb. “The antihomophobia campaign really has opened a lot of discussion on this issue,” Saavedra says.

Saavedra agrees that the country has a long way to go in its prevention efforts. And he also concedes that the government's quick launch of a universal access program meant that many health care workers and clinics were not as well trained in using the drugs as he would have liked. “We needed to do that first step in order to stop a lot of people from dying,” says Saavedra. “But I understand the way people feel and what they need. I'm part of them.”

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