One size doesn’t fit all in Hispanic population

Funding changes may cut off some programs

Organizations successfully targeting Latino populations for HIV services and prevention have developed strategies specific to very different groups, including young men who have sex with men (MSM); rural, low-income Hispanics, and Latino migrants or Mexican border town residents.

The problem with finding a one-size-fits-all approach to Latino prevention and care is Hispanics are not homogenous, experts say.

"Previous studies have compared Hispanics to African Americans, and my concern has been that Hispanics are a very heterogeneous group," says Leo S. Morales, MD, PhD, assistant professor of medicine at the University of California, Los Angeles (UCLA) School of Medicine. Morales studies sociodemographic differences among Hispanic patients in the United States.

"One Hispanic is not the same as another, and there’s a lot of evidence and historical reasons for a large variation among Hispanics," he explains. "One message is that Hispanics should not be looked at as a monolithic group."

Morales and co-investigators analyzed data collected on HIV-positive patients to see if there were differences in access to care among various Hispanic subgroups, focusing on whether language or culture played a difference in treatment access. The study did not find large variations in access to care.1

"In a sense, that is a negative finding; but on the other hand, it suggests that people are doing a good job of providing care — or at least the people in care are getting good care whether or not they are acculturated or whether they are citizens or whether their primary language is English or Spanish," Morales says. The study also showed Hispanic females tend to have better access to care than Hispanic males, contrary to most research of general populations, he notes.

"We thought it might be something to do with the fact that among Hispanic women, there’s a large amount of childbearing, and because of that, they may be accessing care for other reasons already," Morales says. "As a result, when they discover they are infected with HIV, they are already plugged into the health care system."

Generally, the HIV prevention interventions available for Latinos are revamped from strategies already used in other populations, and while this is an efficient way to provide HIV education, it may not be as effective as interventions designed specifically for a certain Latino population, say experts.

"It’s almost like when you’re in college and you take 101 courses before you move onto advanced courses," says Ronald Gonzalez, technical assistance specialist with Rural Opportunities Inc. in Rochester, NY. "All of these organizations that take on HIV prevention work with migrants need sensitivity training before they do prevention work because they don’t have the capacity."

Rural Opportunities is one of four capacity-building assistance providers, funded by the Centers for Disease Control and Prevention (CDC). The organization serves migrant farm workers and has received additional funding to target young MSM, including Latinos, Gonzalez adds.

The organization developed an intervention called Impacto Positivo, which focuses exclusively on young Latino MSM. The prevention intervention speaks to the culture of young Latino MSM and their issues with sexual identity within migrant farm labor camps, he says.

Counselors trained specifically for this population soon learn that it’s difficult to obtain access to the migrant camps and that selecting bars to target for prevention work can be complicated, Gonzalez explains.

"A colleague and I went to a Northern California county and went to a bar, which you would consider to be a heterosexual bar, but it had performances by drag queens or transvestites, and the men would socialize and mix with transgender folks," he explains.

Impacto Positivo worked with AIDS service organizations to provide outreach workers with sensitivity training and strategies for targeting the specific subgroup of young MSM who are Latino and probably migrant workers, Gonzalez says.

The project eventually fell victim to CDC budget cuts and the shift to science-based interventions. The program had never been fully studied for outcomes, and so it is not one of the grocer’s dozen of interventions that the CDC is requiring organizations to use, he adds.

"There isn’t anything like this . . . ," Gonzalez notes. "Probably, the closest thing is the SISTA program, which calls for ethnic and gender pride." The trouble is that SISTA was developed for young black women, who mostly are college-bound or upwardly mobile.

"The CDC says you can take that and adapt it and tailor it, and that’s the conundrum that community-based organizations (CBOs) are faced with: How do you adapt it and keep the key elements and make it work for a young Latino MSM population?" he adds.

PROCEED Inc. of Elizabeth, NJ, is another organization that has received CDC funding to develop interventions for Latinos, specifically focused on HIV-positive Latinos, says Deanna McPherson, MPH, CHES, a capacity building coordinator for PROCEED.

The organization interviewed Latinos and New Jersey program directors and eventually formed the Prevention with Positives National Resource Network, she says.

PROCEED then formed a focus group, held in Spanish with HIV-positive Latino men and women. The group met for about two hours to discuss their issues of concern, and included on that list these items: housing, transportation, treatment, adherence, sexuality, disclosure, and stigma, McPherson explains.

Then the organization held a conference, attended mostly by Latinos, to discuss HIV and AIDS issues and to provide workshops on the issues of most concern, she adds.

"Our goal was to develop an intervention, and all along we were collecting this information, which came from the key interviews, the focus group, and the conference," McPherson explains.

With the help of a psychiatrist researcher, the organization developed an intervention that incorporated the elements HIV-positive Latinos and others identified as important to this population, she adds. "There was a small amount of people bringing individual expertise to this team, and they created modules that they’d bring back to a work group for improvement and suggestions, starting in January 2003."

Using the theoretical model of motivational interviewing, the intervention that was developed from these efforts has four sessions, including one individual session. Although the intervention’s outcomes have not yet been published, PROCEED would like it to be included in the CDC’s list of effective interventions, McPherson says. "We saw behavior change at the end of sessions, and that’s one of the things we’re looking at now with data analysis. In January, we were turned down from that request because their interventions were proved with scientific rigor, and they didn’t want to use the ones that the four of us had created, although they had funded it. All of the organizations have mailed me their pre- and post-tests from the intervention, and we sent out an implementation questionnaire that people are filling out about how they felt about the project as a whole."

She plans to write a final report and resubmit the intervention to the CDC.

Although HIV treatment programs tend to be similar for all populations, there are important advantages to having a clinic that treats a specific population, such as border-town Latinos, says John Wiebe, PhD, assistant professor of psychology at the University of Texas at El Paso.

The Centro de Salud Familiar La Fe CARE Center in El Paso serves HIV-positive Latinos who may live in Mexico or the United States, but who also frequently move back and forth between the two countries, he says.

"It’s imperative to have prevention here for so many reasons, but partly because the resources are so poor in Mexico, and the border is extremely fluid," Wiebe notes.

Wiebe was a co-author on a study about how a nurse-based HIV disease state management model at the border provides a feasible method of disease state management for a resource-poor community.2 "The HIV problem that occurs on the Mexican side of the border due to lack of resources and treatment and screening abilities affects folks on both sides," he explains.

The border population treatment model was developed over the past five years to answer the problem of a shortage of HIV specialists in the area, Wiebe says. The town has no medical school, and there is a shortage of general practitioners, as well, he notes.

"At the time we started the program, we had 300 patients, and we had the part-time services of one infectious disease doctor who had a full-time job at an academic institution," he says. "We also have a nursing school here, and when we started the model, we had a fair number of fluently bilingual nurses in the area, so we chose to hire nurses and train them extensively in HIV service."

Nurses, who are tested in HIV treatment, became the point people for care teams that included social workers and HIV-positive peer advocates, Wiebe says.

The nurses provide the wellness care, and the peer advocates provide support, while the social workers assist patients with resource issues and coordinating care, he explains. "The nurses triage to physicians as needed, and we have a nurse practitioner who works full time at the clinic."

Bilingual services are essential to the clinic, since about 60% of the patients speak only Spanish, Wiebe explains. Also the use of peer advocates builds trust and rapport with patients, and the coordinated team approach is another feature that works well with this particular population, he says. "The more traditional, physician-based model isn’t practical in our area."

Since the program was formed, the clinic has seen improvements in patient’s care, including increases in adherence and no decline on average in CD4 cell counts, he points out.

"We’ve seen a very slight increase in mental health across the group as a whole, although not all patients are receiving mental health services," Wiebe says. "We’ve seen a substantial increase in appointment attendance, which is a nice thing to see with this model."

The model easily could be adapted to other resource poor areas, although one obstacle would be the recent national nursing shortage, he adds.

References

1. Morales LS, Cunningham WE, Galvan FH, et al. Socio-demographic differences in access to care among Hispanic patients who are HIV infected in the United States. Am J Pub Health 2004; 94(7):1,119-1,121.

2. Jones A, Wiebe JS. A nurse-based HIV disease state management model on the U.S.-Mexico border. eJIAS 2004; 1(1):B12528.