Behaviors of Mexican Migrants Related to HIV
We know little about the impact of migration on the development of the HIV/AIDS epidemic in Mexico. Sufficient data are lacking to measure the role of migration in the spread of the epidemic accurately. The lack of serologic surveys of Mexican migrant populations, which would allow establishment of relations between sexual and cultural practices and infection, has led to use of indirect inferences of individual risk based on estimations of differences in sexual practices between migrants and nonmigrants.
Progress has been made in identifying certain sexual practices of the mobile populations to reveal paths of transmission. The qualitative study undertaken by Bronfman and Minello7 illustrated that changes in sexual habits are produced during the migratory process: numbers of sexual partners increase among men, and as a consequence of the loneliness, isolation, lack of women, and insertion in a “more open” society as well as the decline in social and family control, relations increase with male partners and/or with prostitutes who are often intravenous drug users. Learning of new practices was also noted among both men and women, especially different positions for vaginal coitus, oral sex, and anal sex.
Within the framework of the HIV-Related Behaviors Surveillance System,14 between August and December 2001, a survey was carried out in 2 states with high migration rates toward the United States (Morelos and Puebla), with the objective of reaching a population with high spatial mobility for labor reasons toward other countries or other localities within Mexico. Men and boys (n = 789) and women and girls (n = 367) older than the age of 14 years were interviewed. The results partially confirm the findings of the previous qualitative research. Of total interviewees, 5% had no migratory experience, 15% had worked outside their locality at some time but not within the past year, and 80% had done so in the past year. Among the last of these, 15% traveled to another country and the rest traveled to another national locality. The group, composed of 125 persons who had left their locality to work in another country during the year before the survey, was considered to represent international migrants for the purposes of this study. All were sexually active, and 75% were men or boys.
The results indicate that the international migrants had more sexual partners in the previous year than those who had not migrated to another country (for practical purposes, those who did not leave their locality and those who traveled to other locations within Mexico are referred to as nonmigrants). On average, the nonmigrant men and boys had 1.8 partners over the past year, whereas the international migrants had 3.3 sexual partners (P < 0.00). Among these partners, a greater proportion of male international migrants than nonmigrant men and boys reported having had sexual relations in the previous year with sex workers (commercial partners) and nonregular partners (Table 6). Among the women and girls who had sexual relations in the previous year, the study noted that the international migrants had a greater number of partners than nonmigrants. On average, the nonmigrant women and girls had 1.2 partners, whereas the female international migrants had 1.5 sexual partners (P < 0.05). The reduced number of cases of migrant women and girls interviewed did not permit comparison of other behaviors such as condom use and types of partners.
As opposed to the qualitative results, no significant results were found between the proportion of migrant men and boys who had declared having ever had sexual relations with another man compared with nonmigrants (3% and 2.6%, respectively).
In reference to condom use in the most recent sexual relation, the migrant men and boys tended to use condoms in a higher proportion with all partner types than nonmigrants. Among both groups (migrant and nonmigrant men and boys), there was greater use with commercial partners and with partners they had outside their locality or country than with a wife or habitual partner (Table 7). The figures show that an important number of sexual relations went unprotected.
Another indicator of greater exposure to HIV/AIDS risk among the international migrants compared with the nonmigrants is greater use of injected drugs for nonmedical purposes. Affirmative responses were received from 9.8% of the 122 migrants of both sexes, compared with 1.2% of nonmigrants (P < 0.00), to the question of whether they had used injected drugs that were not medicines in the past year. Interviewees were also asked whether they had ever tried cocaine, and 13.4% of migrants versus 1.7% of nonmigrants (P < 0.00) responded affirmatively. Even though no significant difference was found between international migrants and nonmigrants in the use of injected B complex, consumption was high (14.1% and 12.1%, respectively). Thus, it seems that injected use of vitamin B represents a risk for migrants if this practice is carried out in the United States, given that migrants may have greater difficulties in obtaining access to clean syringes, because of their migrant status and because clean syringes are more readily available without prescription in Mexico than in the United States. Lafferty20 has highlighted the importance of the use of injected medicines in a convenience sample of Latino immigrants, in which he found a high frequency of injection of vitamins and antibiotics (20.3%) and 3.5% reporting sharing the syringe.
Prevention Policies and Actions on Migration and AIDS
This section outlines binational agreements in health established in the past 2 decades and their possible use in the framework of HIV/AIDS prevention in Mexico and the United States. Given the escalating vulnerability of the mobile transborder populations, there is an urgent and emerging need to establish international collaboration mechanisms. The Binational Commission was formalized in 1981 with the participation of Mexico and the United States; its aim is to allow for exchange experiences between governmental institutions in both countries. In May 1996, the Nuclear Group on Migrant Health was established as part of the Health Group of the Mexico–United States Binational Commission to investigate the needs and common problems related to health of migrant workers and their families. The Nuclear Group on Migrant Health aims to advance research in the following areas: women’s health, AIDS/ HIV, sexually transmitted diseases (STDs), environmental health, and tuberculosis. Among its priority actions, it promotes development of a portable binational health registry, increased electronic communication, and exchange of information and bilingual material. In addition, it evaluates public health regulations that affect Mexican migrants.
In 1999, the Mexican and United States Health Ministries signed a Bilateral Agreement on Collaboration for Border Health. The Mexico–United States Binational Commission on Border Health was established in July 2000 to address health problems along the common border between the United States and Mexico. The Commission constituted 2 sections with 13 members each. The 2 countries’ Health Ministers serve as Presidents of their respective sections.21 On September 22 of that year, the Health Ministers of both nations initialed the Joint Declaration on Migrant Health, which constituted a historic recognition of the social and economic importance of Mexican workers in the United States.
In this context of binational agreements on migrant health care, there emerged a Mexican governmental program focused on the migrant population in the United States and on internal migrants in Mexico. The program, developed in 2001, is called “Go Healthy, Return Healthy” (Vete Sano, Regresa Sano [VSRS]). This program recognizes the situation of inequality of the undocumented workers living in the United States and of the national agricultural workers laboring far from their families and communities of origin. The VSRS program’s mission is to guarantee a favorable state of health during the 3 moments of the migratory phenomena: origin, travel, and destination.21a
The VSRS program was developed within the Model of Integrated Attention to Migrant Health (Modelo de Atención Integrada a la Salud del Migrante [MAIS]), which determines international coordination strategies to avoid duplicated efforts.21a The MAIS highlights the responsibility of the governments, federal and state, in migrant health and works to make health services accessible for all migrants in national territory, regardless of their migratory condition. Within the Mexican Ministry of Health structure, the VSRS program is coordinated by the National Center for Infant and Adolescent Health.
The VSRS has 2 stages of action. The first implements the component to address the internally migrating population. Actions to respond to the international migratory population are developed in the second stage.
One of the proposals is to establish a personal identification scheme, such as a migrant health card, to allow the migrant to use National Health System services throughout his or her travel and temporary stays. Another proposal is to call for intensive health promotion campaigns to foster self-care.
The program directs its execution based on 4 areas: information to the population (eg, identifying social networks, developing information guides on disease prevention, first aid, personal hygiene, community training); preventative care in the place of origin, travel, and destination (eg, prevention and control of illnesses preventable by vaccination, nutritional surveillance, sexual and reproductive health counseling); medical attention in origin, travel, and destination (eg, migrant health card, sensitizing health service providers, incorporation of migrants within care modules regardless of nonresidence in the area); and simplified epidemiologic surveillance (eg, outbreak studies, opportune notification of mobile populations of more than 100 persons). Given their great importance, the strategies focus on the most vulnerable population, such as children and reproductive age and pregnant women, offering them simple and clear information in a sensitive manner, even translated into their own language (Náhuatl, Zapoteco, and Mixteco).
The VSRS goals for 2001 to 2006 in high-mobility states and municipalities in the area of migrant health information are to develop a migrant health guide; promote self-care in health, especially in prevention and damage protection; identify migrant networks, especially in the 10 states with the highest migration rates; and disseminate and promote the self-care health guide through community leaders or municipal health committees.
The program contemplates guaranteeing prevention and control of diseases preventable by vaccination, tuberculosis treatment supply, nutrition orientation and intervention, family planning and sexual and reproductive health counseling (attending to all pregnancies and births), opportune detection of chronic-degenerative diseases, and intervention in areas such as mental and dental health.
Increasingly, mobility seems to be an element that may favor HIV/AIDS vulnerability in socially disadvantaged groups, which, in this case, correspond to undocumented migrants along the Mexico–US border. The VSRS program incorporates surveillance and attention to 100% of STD and HIV/AIDS cases detected.
It is important to note that in the first phase of the VSRS program, actions in the places of origin were initially begun in the 10 states with highest mobility: Baja California, Colima, Guanajuato, Guerrero, Jalisco, Michoacán, Oaxaca, Puebla, San Luis Potosí, and Zacatecas. Actions during migratory travel focus on active surveillance of bus stations, airports, and highways points so that health service providers, identifying mobilizations, may promote foreseen strategies. Actions in the destinations are proposed systematically in close coordination with the states of origin for the sanitary control of the population. The United States intends to strengthen coordination with migrant attention centers by promoting already existing health services and promoting their use.
Other efforts to consider the migrant health situation from a regional perspective are the Mexico–California Health Initiative (Iniciativa de Salud México–California [ISMECAL]) and the Mexico–Texas Health Initiative (Iniciativa de Salud México–Texas). On October 12, 2001, the ISMECAL was presented with the participation of the Mexican Ministry of Health, the Ministry of Health Services of the State of California, and the University of California, working in coordination with the VSRS and outlining a series of objectives such as coordination of efforts, improvement of the quality of life of the migrant and his family, promotion of binational health, education on health and disease prevention, facilitation of binational training of health professionals, broadening access to health services in California and in the 7 most important states of origin of the Mexican workers, exchange of information among sanitary authorities, and an annual binational public health week. In the most recent Binational Health Week in 2002, a focus was STDs and HIV/AIDS, with 1 day of the week dedicated to the issue.
Given that the epidemiologic registry and the surveillance system are unable to keep pace with population mobility between the 2 countries, the ISMECAL developed an agreement with the Universitywide AIDS Research Program (UARP), the California Department of Health Services (DHS), the Mexican Epidemiological General Office, and CENSIDA to develop a pilot project for epidemiologic surveillance in California and Mexico. The plan is for said population to have a specific system that offers reliable information on diseases such as HIV/AIDS or tuberculosis and development of STDs.21b
On November 11, 2002, the Mexican Ministry of Health and the Texas A&M University System22 signed the Mexico-Texas Health Initiative as part of the binational cooperation effort toward migrant welfare. This coordinated collaboration has the objectives of improving the health and quality of life of the Mexican population in Texas, promoting education in health, and developing research in applied health among several other objectives. Unfortunately, this initiative did not include any section on HIV/AIDS or sexuality, nor does it have any article that bars future incorporation of said theme.
Despite the effort proposed by diverse authorities and governments, national and international, the high risk and vulnerability in which migratory flows are immersed have not been reduced in real terms. The media report almost daily on migrant deaths as a result of diverse circumstances, including abuse by local authorities, scarce respect for human rights, exploitation, denial of medical services,12,23 and an infinite number of tragedies in relation to migrants’ search to improve their quality of life. The daily human rights violations increase this group’s vulnerability in relation to various diseases, including HIV transmission.
Future research is required to evaluate the impact of these policies on HIV transmission prevention among internal and international mobile populations. Incorporation of not only the health sector but the migration authorities, Ministries of Education, and Human Rights Commissions from both sides of the border seems necessary, given that HIV prevention in mobile populations requires holistic interventions and policies that take into account all the aspects that make migrants vulnerable to STDs and HIV.
HIV/AIDS Prevention Actions in Migrants
In addition to national policies, specific actions have been implemented to address the HIV infection problem in distinct mobile populations in Mexico.
Based on results of qualitative research on sexual habits of Mexican migrants carried out between May 1, 1991 and January 1, 1992,7 a made-for-television movie was filmed within a format that facilitates presentation of the information in a colloquial and socially accepted manner. A script for 5 actors was developed, combining frequent situations, humor, and testimonies. The movie was televised in Mexico on December 1, 1992 and in the United States on December 6, 11, and 13, 1992 through different cable channels, with a potential audience of 22 million viewers.24
Another project with the specific objective of HIV prevention among Mexican migrants to the United States was the videotape “La vida sigue“ (Life goes on)25 and the adult comic book “Más vale prevenir ...“ (A little prevention is worth more...). To disseminate information on migration and AIDS, the videotape was originally designed in 1995, transmitted on March 8, 1996 on national television in Mexico, and later redesigned as an adult comic book by Mexican National Council for HIV/AIDS Prevention and Control (CONASIDA) in 1997. The comic book is based on the return of migrants from the United States to their places of origin. In 32 pages, it narrates the changes in interactions between the migrants and residents, provides information on HIV/AIDS transmission and prevention, and, above all, promotes the use of condoms. On the back cover, it synthesizes how AIDS is transmitted and prevented as well as providing elements to reduce myths and misconceptions on transmission and to discourage rejection of persons who live with AIDS. The TELSIDA hotline and a Web page (http://www.ssa.gob.mx) are highlighted for more information. An evaluation of these 2 materials was undertaken with focus groups, which concluded that the videotape was remembered better than the comic book, although the latter could be sent by mail from Mexico to the United States.26 The comic book also reported positive acceptance, although to a lesser degree than the videotape. Forty thousand copies of the comic book were printed and have been distributed by state AIDS programs, Mexican consulates in the United States, and State of California health services since 2001.
Another noteworthy project is Prevención del VIH/ SIDA en la frontera Sur de México: Los traileros en Cd. Hidalgo, Chiapas (HIV/AIDS prevention in the southern Mexican border: truckers in Ciudad Hidalgo, Chiapas). This work was undertaken between 1998 and 1999 by the National Institute of Public Health (INSP) and CONASIDA, with the purpose of evaluating the impact of STDs and HIV/AIDS information on intervention and condom use promotion. An ethnographic study that included truck drivers and key community informants (physicians, nurses, health registrars, sex workers, and informal small-load pedal-powered transporters known as “tricyclers”) was carried out. A questionnaire was applied to 307 truckers encountered in cafeterias and boarding houses in Ciudad Hidalgo between June and July 1998, with the purpose of identifying what information they had on STDs and HIV/AIDS and on condom use. This group was considered a reference group to evaluate intervention impact. The intervention was evaluated 6 months later on 311 truckers. Of these, only 23% had participated in the intervention and the remaining 77% had not. The intervention consisted of developing and using materials that contained information on prevention and promotion of condom use. The truckers were also given pamphlets, key chains, and bumper stickers for their trailers, and informative posters were distributed in bars. The project evaluation identified that the forms used were effective and that it was appropriate to disseminate the information to specific groups. Border points are considered strategic locations in which to design and develop prevention actions with high potential for multiplication to increase information coverage within this specific group.
The educational television project “Los caminos de la vida“ (The ways of life), for HIV/AIDS prevention among rural adolescents in Mexico, was undertaken between 1998 and 2000 by the civil society organization AFLUENTES. The objective was to train educators and health service providers from rural areas on sexuality and HIV/AIDS prevention. The project hoped to generate experience with which to launch a campaign directed to tele-secundarias (secondary schools in poor regions, which rely on televised instruction) throughout the country and to develop an educational manual on sexuality and STDs directed to rural educators. For that purpose, ethnographic studies were undertaken with youth in rural communities, educators, and community promoters. The studies considered elements such as migration and transformations in local world visions on sexuality as a result of contact with other cities in the country and abroad and included focus groups with local community members. Elements and concepts related to solidarity, responsibility, tolerance, love, acceptance, equity, and justice were also explored. The elaboration and production of the educational videotape “Los caminos de la vida“ was undertaken in 2002 and 2003 following the previously mentioned focus groups, but its impact evaluation is not yet available. The goal is that the educational videotape be disseminated in rural communities in 17 states in collaboration with the Mexican Institute of Social Security (IMSS) OPORTUNIDADES program.
In speaking about clinical care settings in Mexico, it is important to point out that the country has a segmented health system that includes social security institutions (IMSS), Mexican Institute of Social Security for bureacrat (ISSSTE), Mexican Government Oil Company (PEMEX), Ministry of Army (SEDENA), and Ministry of Navy (SEMAR), private institutions, and public institutions of the Ministry of Health. The social security institutions provide free access to integral care for all illnesses and maternity for governmental and private sector employees, including antiviral medications and all care requirements for HIV/AIDS. An important percentage of the population does not have this social benefit, however, including the informal sector, which includes field hands or day workers and independent and non–wage-earning workers. This situation leads to unfair financial distribution and great inequities in the system.
At the beginning of the epidemic, it was estimated that 52% of the infected population had access to social security. The latest National Health Survey undertaken in 2000 found that 31.8% of the population had access to the IMSS, 5.7% to the ISSSTE, 2.1% to other social security institutions, and 1% to private services, and that 60% had no social security and relied on Ministry of Health public services.
Because of this finding and the high costs of antiviral medications, which represent 86% of the total cost of HIV/AIDS care, 27 the Mexican Ministry of Health established a program in 1998 to support the HIV/AIDS-infected population without social security with free medication, initiating with coverage of all those younger than the age of 18 years and pregnant women.28 Starting in 1999, coverage was gradually increased to adults, and the goal was established within the 2001 to 2006 action program to reach free coverage for 100% of the total registered living population with AIDS.29 In 2002, 93% coverage of living registered AIDS sufferers had already been reached, and in a joint effort with civil society organizations, an additional budget allocation was obtained from the Legislative Congress, allowing free antiviral medication coverage of 100% of the population needing it in 2003, encompassing 28,068 AIDS patients. As part of the health system reform, 9 funds were created for catastrophic* expense protection, and in 2004, the fund related to HIV/AIDS will have been integrated, based on the already assigned funds for antiviral medications.
Parallel to this effort, and as a consequence of decentralization of the Ministry of Health, beginning in 1997, specialized services known as Servicios Especializados para la Atención de las personas que viven con VIH/SIDA (SEAS) have been established for attention to persons living with HIV/AIDS in all federal entities throughout the country, in accordance with a model established by national experts. A total of 77 SEAs currently exist in the country, most of them located within specialized hospitals and integrated by health teams selected in accordance with their positive attitude toward persons with HIV/AIDS and their technical abilities. To support the medical care, periodically updated guides are available on medical, psychologic, nursing, and ambulatory care.
As a result of constant advances in attention to persons with HIV/AIDS, permanent training of the health teams is indispensable as well as supervision mechanisms that ensure compliance with guidelines and criteria established for attention to persons with HIV/AIDS. Tutorial courses have been developed for the physicians as well as courses and symposiums to update and ensure the technical quality of the SEA health teams. To ensure the quality of treatment, the General Office on Quality of the Ministry of Health has collaborated in the construction of indicators to measure the quality of services offered and joint commissions have been established with participation of civil organization representatives and persons who live with HIV/AIDS.
Despite all these efforts, the quality of services provided is still mixed. For that reason, according to changes in the General Health Law made in May 2003,30 services offered to persons with HIV/AIDS have to be accredited and criteria are to be established to ensure the quality of services offered.
Most specialized services are located in the main cities, given that most patients are concentrated in urban areas. This represents difficulties in access for persons living in rural areas, especially in those areas in which infrastructure and communication services are limited, implying hours of transport to the city in which the specialized service is located in some cases.
In addition to this, there is the problem of the lack of flexibility of medical services to attend to mobile populations, given that the norm limits persons to access to the service module in their place of residence. To date, there are no administrative policies for service payment between different institutions and federative entities. This situation may be resolved, however, with recent modifications to the General Health Law (Article 77 bis 5, Section B, fraction VII and Article 77 bis 18), which entered into effect on January 1, 2004. These changes establish mechanisms for service payments between institutions and federative entities. This is an important advance that should facilitate access to services for mobile populations, regardless of their place of residence or rights-holder institution.
One problem that requires careful evaluation relates to exchange of clinical files among institutions, given that, to date, the official Mexican norm on handling of medical files establishes that this information is confidential and does not allow its exchange between medical institutions. Only a summary of the file is disclosed at the patient’s direct request, delivered to the respective institution. In addition, it is important to consider that it is necessary to establish mechanisms to promote adherence to therapeutic regimens and to provide integral attention linked to diverse services, including nutritional, social, psychological, and legal support, as well as care at home.
DISCUSSION AND CONCLUSIONS
There was early concern in Mexico about the relation between international migration and the course of the AIDS epidemic. Existing data have not allowed decisive conclusions to be reached on the impact that migration has had on development of the epidemic. Territorial distribution of cases in Mexico seems to indicate a relation between rural cases and migration to the United States. Conversely, previous research and new evidence seem to indicate a link between migration of Mexicans to the United States and behavioral changes that place them at risk for HIV infection. In reference to sexual practices, we have determined that the Mexican migrants have had a greater number of partners, especially nonstable partners, than nonmigrants. Information is not conclusive enough to evaluate risk of infection, however. Greater condom use has also been found in migrants. In reference to illegal intravenous drug use, migrants have been found to demonstrate greater use than nonmigrants. A limiting factor in the establishment of conclusions in regard to infection risk is the lack of data on shared needles. To estimate the future direction of the AIDS epidemic in Mexico, it is necessary to undertake studies that allow evaluation of the impact of international migration on the distribution of infected persons. Establishment of a territorial pattern of infection, without waiting for infected persons to develop AIDS, will be indispensable to establish prevention and attention priorities.
Given the characteristics and social vulnerability conditions of migrant groups, the Mexican government has relocated political responses for migrants within its priority policy projects. In the area of health, there is increasing recognition of population mobility as an element that may favor HIV/AIDS vulnerability in socially disadvantaged groups, which, in this case, correspond to undocumented migrants along the Mexico–US and Mexico–Guatemala borders.
The VSRS program is a Mexican government program focused on the migrant population in the United States. This program recognizes the situation of inequality in which undocumented workers live in the United States, where they are generally marginalized from actions of organizations with the potential to defend their rights. According to the Mexican Ministry of Health, the guarantee of efficient and dignified medical attention for Mexicans in the United States is a responsibility borne primarily by the government and society of that country, although it also points out the potential importance of actions by the 45 consulates, the presence of national radio and television channels in Spanish, and relations with corporations doing business in that country.31 Knowing the reach of said projects in terms of their population coverage, attention capacity, available resources, and supply of services are central aspects in understanding their potential impact on a socially sensitive problem like HIV/AIDS infection. The formulation of the VSRS program may possibly be based on the premise that migrants leave their communities of origin healthy and that the greatest risk is found in the destinations. There is no scientific evidence available to support this statement, however. Strategically, it allows focus of resources in the destinations, where the undocumented migrants are socially disadvantaged because of their unauthorized status compared with the citizens of the location. The development of binational health policies may contribute to address the HIV/AIDS problem as part of an integrated social response to the needs of these vulnerable groups.
The HIV/AIDS prevention actions analyzed are based on attempts to sensitize and alter behaviors by providing more and better information on HIV/AIDS. The search for innovative messages aiming to respond to the different insertion forms and experiences of migrants in the United States constitutes the central focus of the development of information strategies. The reach of these projects is evaluated in terms of coverage, in other words, number of readers, dissemination and demand for videotapes, and television audience ratings. In general, we may consider that the different information projects have been well received by the migrant community in their places of origin and destinations. It can thus be concluded that the projects analyzed and others have contributed to the fact that migrants and their families now have appropriate information on forms of HIV/AIDS prevention and transmission. Nevertheless, it must be recalled that information availability does not automatically lead to change in sexual behavior. In addition, lack of continuity and complementary coordination of the information projects constitutes the main limitation to their development and adaptation to changing contexts of the migratory phenomenon. In this sense, it is important to consider the development and strengthening of different forms of binational collaboration with the participation of civil society organizations to provide sustainability to these projects.
With the broadening of coverage in attention to HIV patients, which is estimated to reach 100% in 2003, the gap in coverage that exists between Mexico and the United States will be reduced, although the quality gap will remain. Quality of attention will be put to the test for patients living in rural communities, for whom the SEAs are far away. In addition, Mexican and US legislation should be harmonized to allow adequate exchange of medical files. Population mobility should also be taken into account in the design of services currently received by the population and in future services. New forms of organization and service delivery must be found that offer services to the migrant population, regardless of its place of origin or rights-holder institution. The recent reform of the General Health Law and ongoing reorganization of health services may contribute to improve this situation.
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30. Gobierno Constitucional de los Estados Unidos Mexicanos. DECRETO por el que se reforma y adiciona la Ley General de Salud, Diario Oficial de la Federación, Mexico
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*Catastrophic expense is understood as that which represents more than 30% of family income.
Keywords:© 2004 Lippincott Williams & Wilkins, Inc.
migration; sexual behavior; Mexico; epidemiology; surveillance; AIDS