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Mexico City´s experience: The Sanctuary Clinic Program
The 2018 National Latino HIV and Hepatitis C Conference
Mexico City’s Center for HIV Prevention and Comprehensive CareCondesa Specialized Clinic
Nathalie Gras AllainDeputy Director of Care for Key Populations
and Specific Programs
Andrea González, Florentino Badial, Ubaldo Ramos, Steven Diego Díaz, Luis Manuel Arellano, Israel Macías,
Eduardo Rodríguez, Ricardo Niño, René Leyva, Alejandro Brito, María Paula Castañeda (UNHCR)
Worshop “Continuity of Care for Immigrants and the Repatriated”May 18th, 2018- The Omni Collonade, San Antonio, Texas
Presentation
Mexico City is a sanctuary city and the protection of the migrants and refugees´
health that live with HIV constitutes a human rights imperative, of no discrimination, as well as an essential measure for the control of an epidemic that does not recognize territorial
boundaries or border walls.
Alfonso Rodríguez Ogaz. https://www.flickr.com/photos/69781981@N00
Context
Mexico City
Population: 8,918,653 (2015)
Metropolitan Area
~25 million people
Divided in 16 political delegationsSource: INEGI http://cuentame.inegi.org.mx/monografias/informacion/df/poblacion/
Source: UNHCR
Source: UNHCR
In the regional context, the population from the North of Central America is
highly mobile even following arrival in Mexico, which is a barrier for persons of
concern to have information and access to services. In addition, SGBV (sex and
gender violence) is a main reason that refugees flee their countries of origin and
they continue to face serious risks of SGBV in transit. The creation of a network of
safe spaces is fundamental to address the specific needs of survivors of SGBV in
need of international protection. Safe Spaces provide a minimum package of
basic services to SGBV survivors in a place, or during outreach and awareness-
raising activities, which use a survivor-centered and best interests approach to
foster an atmosphere of non-discrimination and inclusivity. Safe Spaces support
coordination and strengthening of multi-sectoral services to improve a survivor’s
network of care.
Posters at Condesa Specialized Clinics
Sanctuary Clinic Program
The Sanctuary Clinic Program was created on February 2017,although since 2009 we have been providing care to themigrant population through other programs.
The Sanctuary Clinic Program provides services at CondesaSpecialized Clinic and at Condesa-Iztapalapa Specialized Clinic.
The purpose is to speed up the access to treatment formigrants with HIV from Central America and other countries aswell as returning Mexicans to the country.
Service integration is done quickly and personalized for allservices at both clinics.
Target Population
Migrant men, women, and transgender population(adolescents and adults) in conditions of social vulnerability,emphasizing persons from Central America, residents or intransit through Mexico City, independent of their migratorysituation, including asylum seekers, as well as Mexican thatreturn to the country with or without documentation.
Objective
Recognize the right to Health protection of migrant individualsthat is equivalent to the rest of the population.
Intervención Objetivo
Human Rights Module
“Francisco Galván Díaz”
Letra S, Sida, Cultura y Vida Cotidiana
A.C.
Counselling, follow-up services in the presentation and
follow-up of complaints, linkage to legal services for
discrimination or violation of human rights.
As-Par:
Peer navigators
CHECCOS A.C.
Counselling and support for the integration to care of
persons recently diagnosed with HIV. It is
complemented through phone contacts and social
networks, as well as workshops.
Counselling and DiagnosisHIV, Hepatitis B and C, Syphilis diagnosis. Linkage to
appropriate service.
Care for victims of sexual violenceProphylaxis treatment for HIV and STI transmission, as
well as pregnancy.
Sexual and Reproductive Health and STI
Syndromic management of Sexually Transmitted
Infections, prevention of perinatal HIV transmission and
prenatal care for women in high vulnerability situations,
as well as long lasting birth control methods.
Services offered at Condesa and Condesa-Iztapalapa Clinics for Migrants and Repatriated Mexicans
Services offered at Condesa and Condesa-Iztapalapa Clinics for Migrants and Repatriated Mexicans
Intervention Objective
Mental Health AssessmentDiagnosis and treatment of mental health conditions and
interventions to improve adherence to HIV treatment.
HIV Care
Ambulatory medical care for HIV that includes ARV
treatment following the national and international
guidelines.
Referrals to 2nd/3rd levels of careMedical referrals to services not available at the
Condesa clinics based on medical assessment.
Follow-up
Counselling and linkage to social programs offered by
non-governmental organizations, private , and public
agencies.
Punto SeguroPersonalized care for male sex workers with or without
HIV.
Harm reduction in non-injectable drugsFocused on mitigating risks and harm associated to
drug use by persons with HIV.
Ponte a PruebaDetection, Treatment and HIV Care in prisons in Mexico
City.
Transgender Clinic Hormone therapy for sex change transformation.
National HIV Foreigners Registry by countryMarch 2018
34% come from Central
America, gathering 909
people
Country Men Women Total Country Men Women TotalHonduras 238 149 387 Israel 3 0 3United States 315 56 371 Japan 2 1 3Venezuela 299 17 316 Nigeria 0 3 3Colombia 222 27 249 Netherlands 2 1 3Guatemala 126 88 214 Paraguay 3 0 3El Salvador 145 63 208 Austria 2 0 2Argentina 125 16 141 China 2 0 2Cuba 103 4 107 Congo 1 1 2Spain 64 15 79 Dominica 2 0 2Brazil 53 2 55 Egypt 2 0 2Peru 38 9 47 Greece 2 0 2France 41 3 44 Guinea 0 2 2Chile 36 2 38 Kenya 1 1 2Nicaragua 29 8 37 Lebanon 2 0 2Italy 30 3 33 Norway 1 1 2
Belize 17 15 32 Czech Republic 2 0 2
Canada 25 3 28 Senegal 2 0 2Germany 24 0 24 Ukraine 2 0 2Costa Rica 21 2 23 Uganda 1 1 2Haiti 11 9 20 Afghanistan 1 0 1
Dominican Republic 14 4 18 Antigua and Barbuda 1 0 1
Mexico 11 3 14 Ivory Coast 0 1 1Cameroon 5 8 13 Fiji 1 0 1Uruguay 10 2 12 Gabon 1 0 1Australia 8 1 9 Ghana 1 0 1Ecuador 9 0 9 Hong Kong 1 0 1United Kingdom 8 1 9 Hungría 1 0 1Panama 6 2 8 India 1 0 1Portugal 7 0 7 Ireland 1 0 1Puerto Rico 5 2 7 Islas Aland 1 0 1Russia 6 1 7 Lithuania 1 0 1Bolivia 6 0 6 Micronesia 1 0 1Denmark 4 2 6 Mozambique 1 0 1Switzerland 4 1 5 Romania 1 0 1Jamaica 4 0 4 Sierra Leone 1 0 1Poland 3 1 4 Thailand 1 0 1South Africa 3 1 4 Taiwan 1 0 1Sweden 4 0 4 Turkey 1 0 1Belgium 3 0 3 Vietnam 1 0 1South Korea 3 0 3 Zambia 0 1 1Philippines 2 1 3 Total 2,138 534 2,672
Source: National System (SALVAR)31st March, 2018
National HIV Foreigners Registry by stateMarch 2018
State Total registry Total foreigners Proportion Foreigner menForeigner
womenCiudad de México 21,417 881 4.1 776 105
Chiapas 6,022 347 5.8 196 151
Jalisco 9,083 253 2.8 226 27
Quintana Roo 3,937 190 4.8 145 45
Baja california 4,986 112 2.2 84 28
Nuevo León 5,247 104 2 95 9
Tamaulipas 4,269 67 1.6 52 15
Yucatán 3,322 60 1.8 54 6
Veracruz 12,135 57 0.5 35 22
Oaxaca 3,506 49 1.4 35 14
Guanajuato 2,978 48 1.6 34 14
Puebla 4,380 43 1 30 13
Chihuahua 3,290 39 1.2 29 10
Tabasco 5,185 36 0.7 22 14
México 9,982 32 0.3 24 8
Coahuila 1,653 30 1.8 24 6
Querétaro 1,502 29 1.9 23 6
Morelos 2,346 23 1 21 2
Michoacán 2,319 22 0.9 19 3
San Luis Potosí 1,505 20 1.3 18 2
Sonora 2,034 17 0.8 14 3
Baja California Sur 972 15 1.5 15 0
Nayarit 1763 14 0.8 14 0
Hidalgo 1,232 13 1.1 10 3
Sinaloa 1,784 12 0.7 11 1
Campeche 1,604 11 0.7 5 6
Durango 923 11 1.2 10 1
Aguascalientes 877 8 0.9 8 0
Colima 1,068 8 0.7 6 2
Guerrero 3,938 3 0.1 3 0
Tlaxcala 966 3 0.3 2 1
Zacatecas 670 3 0.4 3 0
Nayarit 1,311 0 0 0 0
Institutos y Hospitales 670 112 0.4 95 17
Total 128,876 2,672 2.1 2,138 534
Source: National System (SALVAR)31st March, 2018
National HIV Foreigners RegistryMarch 2018
Historically at the national level, 2% of the total of the patients areforeigners
The largest proportions take place in these cities:
▪ Chiapas with 5.8%
▪ Quintana Roo with 4.8%
▪ Mexico City with 4.1%
34% come from Central America, gathering 909 people
Source: National System (SALVAR)31st March, 2018
Foreigners women and men receiving HIV care at the Condesa Specialised Clinic VSChiapas HIV Program
March 2018
Chiapas347 foreigners
5.8%
State Total registry Foreigners registry Proportion
Mexico City 21,417 881 4.1%
Chiapas 6,022 347 5.8%
Mexico City881 foreigners 4.1%
Country Men Women Total Country Men Women Total
Venezuela 165 11 176 Portugal 3 0 3
Colombia 131 14 145 Austria 2 0 2
United States 60 7 67 Congo 1 1 2
Argentina 61 5 66 Dominica 2 0 2
Honduras 35 12 47 Guinea 0 2 2
Spain 30 14 44 Jamaica 2 0 2
Cuba 41 2 43 Japan 1 1 2
Brazil 32 0 32 Paraguay 2 0 2
El Salvador 27 3 30 Puerto Rico 2 0 2
Peru 19 7 26 Russia 1 1 2
Chile 23 1 24 South Africa 1 1 2
France 20 1 21 Sweden 2 0 2
Guatemala 13 3 16 Switzerland 2 0 2
Costa Rica 13 1 14 South Korea 1 0 1
Germany 9 0 9 Philippines 0 1 1
Italy 8 0 8 Fiji 1 0 1
Cameroon 2 5 7 Greece 1 0 1
Uruguay 6 1 7 Hong Kong 1 0 1
Ecuador 6 0 6 Ireland 1 0 1
Nicaragua 5 1 6 Israel 1 0 1
Great Britain 6 0 6 Kenya 1 0 1
Belize 3 2 5 Netherlands 0 1 1
Bolivia 5 0 5 Czech Republic 1 0 1
Denmark 3 2 5 Romania 1 0 1
Dominican Republic 5 0 5 Senegal 1 0 1
Australia 4 0 4 Taiwan 1 0 1
Canada 4 0 4 Turkey 1 0 1
Haiti 2 2 4 Vietnam 1 0 1
Panama 2 2 4Total 776 105 881Poland 2 1 3
Country Men Women Total
Honduras 62 57 119
Guatemala 51 54 105
El Salvador 57 35 92
Nicaragua 9 4 13
Cuba 6 0 6
Argentina 2 0 2
Chile 2 0 2
Colombia 1 1 2
Mexico 2 0 2
Costa Rica 1 0 1
Spain 1 0 1
Jamaica 1 0 1
Panama 1 0 1
Total 196 151 347
Source: National System (SALVAR)31st March, 2018
Foreigners Voluntary HIV Counselling and Testing (VCT) Datum from January 2017 to February 2018
The Counselling and Testing Service gathers
the largest number of foreigners (641 people)
attended at the Condesa Specialised Clinic (from January 2017 to February 2018)
The number of people from
Central America (81) and
Colombia (81) are equal
HIV Prevalence
15.3%98 HIV positives
from 641 foreigners
Country Frequency Total% of all the
patients
VENEZUELA 109 109 17
Central America
HONDURAS 33
GUATEMALA 17
EL SALVADOR 15
COSTA RICA 5
NICARAGUA 4
PANAMA 7 81 12.6
North America
UNITED STATES 66
CANADA 5 71 11.1
South America
COLOMBIA 81
ARGENTINA 36
BRAZIL 19
CHILE 16
PERU 10
BOLIVIA 4
ECUADOR 4
URUGUAY 4
PARAGUAY 3 177 27.6
Caribbean
CUBA 15
DOMINICAN REPUBLIC 5
PUERTO RICO 3 23 3.6
TOTAL 461 71.9
Country Frequency
Other countriesSPAIN 43
FRANCE 40
ITALY 16
GERMANY 12
ENGLAND 11
JAPAN 5
AUSTRALIA 3
CHINA 3
KOREA 3
CROATIA 3
DENMARK 3
HOLLAND 3
INDIA 3
SWITZERLAND 3
BULGARY 2
GREECE 2
NIGERIA 2
PORTUGAL 2
SWEDEN 2
CONGO 1
AUSTRIA 1
BANGLADESH 1
BELGIUM 1
CAMEROON 1
SOUTH KOREA 1
SCOTLAND 1
SLOVENIA 1
GRENADA 1
HONG KONG 1
INDONESIA 1
ISRAEL 1
MALAYSIA 1
NEW ZEALAND 1
PAKISTAN 1
MOLDAVIAN REPUBLIC 1
ROMANIA 1
TUNISIA 1
UKRAINE 1
Total from all the countries 641
Source: Condesa SpecializedClinic´s- Laboratory report
Voluntary HIV Counselling and Testing (VCT) Datum from January 2017 to February 2018
n= 641
HIV Positives
Age group Men Women Transgender Total %
18 to 25 16 0 2 18 18.4
26 to 40 55 2 5 62 63.3
More than 40 15 3 0 18 18.4
Total 86 5 7 98 100.0
HIV Negatives
Age group Men Women Transgender Total %
< 18 7 2 1 10 1.8
18 to 25 116 43 9 168 30.9
26 to 40 234 61 6 301 55.4
More than 40 51 13 0 64 11.8
Total 408 119 16 543 100.0
HIV Prevalence15.3%
98 HIV positive from 641 foreigners
Source: Condesa SpecializedClinic´s- Laboratory report
HIV prevalences by countryUNAIDS 2016
Central AmericaCountry Population group Prevalence
BelizeAdult prevalence
From 15 to 49 years1.8%
[1,5% - 2,3%]
Costa RicaAdult prevalence
From 15 to 49 years0.4%
[0.4% - 0.5%]
El SalvadorAdult prevalence
From 15 to 49 years0.6%
[0.5% - 0.7%]
GuatemalaAdult prevalence
15 a 49 años de edad0.5%
[0.3% - 0.7%]
HondurasAdult prevalence
From 15 to 49 years0.4%
[0.3% - 0.5%]
NicaraguaAdults prevalence
From 15 to 49 years0.2%
[0.2% - 0.3%]
Country Population group Prevalence
CameroonAdult prevalence
From 15 to 49 years3.8%
[3.1% - 4.5%]
VenezuelaAdult prevalence
From 15 to 49 years0.6%
[0,5% - 0,7%]
MexicoAdult prevalence
From 15 to 49 years0.3%
[0.2% - 0.3%]
Migration and HIV in Central America and Mexico
• Central American Migrants in Transit through Mexico have a 0.71% HIV general prevalence and a 3.45% HIV prevalenceamong transgender people.
– 23. 5% of transgender people and 5.8% of women reportedsexual violence.
– Only 46.6% of the survey respondents accepted the HIV test.
Source: Leyva-Flores et al 2016
Profile by RegionI. Central Americans:
▪ Men, women, Trans women, children and adolescents with low educational levels
▪ Fleeing gang violence (Discrimination towards the LGBT population)
▪ Travel by foot, by bus and raft: risks (sexual violence, muggings, kidnapping…)
▪ Referred by NMI, COMAR and NGO´s
▪ Mainly diagnosed in Mexico City
▪ Few support networks
II. South Americans:
▪ Middle class men: students and professionals
▪ Flight
▪ Referred by COMAR and NGO´s besides contacts thorugh the social networks
▪ Diagnosed and previously treated: come to continue with care
▪ Have support networks
II.1. Venezuela:
▪ Fleeing the political and economic crisis
▪ They face hostilities when they arrive
▪ Flight
▪ Referred by COMAR and NGO´s besides contacts through the social networks
▪ Diagnosed and previously treated: come to continue with care (shortage of medications)
▪ Have support networks
Profile by Region
III. Africans:
▪ Men, women and children: professionals
▪ Fleeing political conflict: repression and prison to sympathizers
▪ Flights (long travel times)
▪ Diagnosed and previously treated: come to continue their treatment
▪ Few support networks
IV. Europeans and North Americans:
▪ Middle class men and women: students and professionals
▪ The majority have regular residency
▪ Flights
▪ Diagnosed and previously treated: come to continue their treatment
▪ Have support networks
V. Mexican Repatriated from the USA
▪ Working class men
▪ Detention center (ICE)/prison
▪ Buses and flights
▪ Diagnosed and previously treated: come to continue their treatment
▪ Have support networks but CULTURAL SHOCK
Guidelines of “Seguro Popular” for foreigner people
Proof of residency.
Foreigners must prove their
residency on mexican
territory.
If foreigners are not able to
show the evidentiary
documentation nor their
legal residency in the
country, a temporary
incorporation will
proceed: only for 90 days.
Migration status of population served(transit, temporary and permanent)
Migration statusTreatment Access according to the
guidelines of “Seguro Popular”
Temporal or Permanent Residency
Turist
Humanitarian visa
Refugee Applicants
Refugees
Indocumented
Repatriated
Without country
?
✓
✓
Interagency contributions (good practices)
Currently, Clínica Condesa is co-chairing with UNHCR the safe spaces network in
Mexico City. UNHCR, the Mexican Refugee Agency (COMAR), Clínica Condesa and
partner NGOs including migrant shelters, regularly coordinate for cases with special
needs, such as pregnant woman, LGBTI persons, persons with STIs/HIV. A special
referral system was established for these cases. Awareness raising activities on sexual
and reproductive health to persons of concern are also implemented, for example,
Condesa Clinic along with partner NGOs and UNHCR organized a sexual and
reproductive health fair in the migrant shelter Cafemín offering free HIV/ITS detection
tests. In addition, UNHCR and COMAR gave a joint training to Condesa staff on
identification of persons with international protection needs and the asylum process.
In turn, Clínica Condesa offered a training to COMAR, UNHCR, and NGO partners on
sexual health and HIV/STIs.
Conclusions
Access to health services for the migrant population,specifically in HIV prevention and care, should be a HealthSystem objective and should be audited by internationalorganisms.
The diagnosis and treatment of immigrants with HIV is aneeded component of the strategy for epidemic control, forthe prevention of Aids cases as well as death and for virustransmission prevention which is achieved when treatment isoffered to persons with HIV (Treatment as Prevention).
The Condesa and Condesa-Iztapalapa Clinics are safe spaces forthe migrant population, repatriated, and refugees.
Health services Access is necessary to guarantee the right tolive, physical wellness, free transit, and evidently to health.
The Young population is the age group with the highest needfor HIV services, pregnancy care, and sexual violence, and atthe same time, a population group with great mobility insideand outside country borders.
– The refusal of such services due to migratory status is a discriminatory act of grave consequences for world youth.
Conclusions
UNHCR Information at the Condesa Clinic
Source: UNHCR
ReferenciesAdministrative Manual for the Sanctuary Clinic Program (February 2017)
Affiliation and Operation Manual for the Seguro Popular (2013): https://transparencia.info.jalisco.gob.mx/sites/default/files/Manual%20de%20Organizacion%202013.pdf
Annual Activity Report 2017:http://www.condesadf.mx/pdf/DiaMundialCDMX2017_vFINAL_.pdf
Antiretrovirals Administration, Logistics and Surveillance System (SALVAR): https://www.salvar.salud.gob.mx/ (March 2018)
Condesa Specialized Clinics Laboratory report (February 2018)
Leyva, René et al. Chapter VI. “Migrants in transit through Mexico: Health status and access to health services” in: Migration and Health. Perspectives on the immigrant population. Secretariat of Government/National Population Council, Health Initiative of the Americas, School of Public Health, University of California, Berkeley. Mexico, 2016.
National Institute of Statistics and Geography (INEGI) Report 2016: http://cuentame.inegi.org.mx/monografias/informacion/df/poblacion/
The Joint United Nations Programme on HIV/AIDS (UNAIDS): http://www.unaids.org/en(October 2017)
United Nations High Commissioner for Refugees (UNHCR): http://www.unhcr.org/(October 2017)
www.condesadf.mxnathalie.gras81@gmail.com
condesasantuario@gmail.com+52 55 26 14 29 58 and +52 55 50 38 17 00 ext. 6446
Clínica Especializada Condesa Clínica Especializada Condesa Iztapalapa
“Dr. Jaime Sepúlveda Amor”
THANK YOU
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