RESEARCH ARTICLE
Identifying Opportunities to Increase HIV Testing among Mexican Migrants: A Call to Step Up Efforts in Health Care and Detention Settings Ana P. Martínez-Donate1*, Maria Gudelia Rangel2, Natalie Rhoads1, Xiao Zhang1, Melbourne Hovell3, Carlos Magis-Rodriguez4, Eduardo González-Fagoaga2 1 Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, United States of America, 2 El Colegio de la Frontera Norte, Tijuana, Mexico, 3 Graduate School of Public Health, San Diego State University, San Diego, CA, United States of America, 4 Centro de Investigaciones en Infecciones de Transmision Sexual, Programa de VIH y SIDA de la Ciudad de Mexico, la Ciudad de Mexico, Mexico * [email protected]
OPEN ACCESS Citation: Martínez-Donate AP, Rangel MG, Rhoads N, Zhang X, Hovell M, Magis-Rodriguez C, et al. (2015) Identifying Opportunities to Increase HIV Testing among Mexican Migrants: A Call to Step Up Efforts in Health Care and Detention Settings. PLoS ONE 10(4): e0123631. doi:10.1371/journal. pone.0123631 Academic Editor: Sandro Mancinelli, Universita degli Studi di Roma Tor Vergata, ITALY Received: November 12, 2014 Accepted: March 2, 2015 Published: April 10, 2015 Copyright: © 2015 Martínez-Donate et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This study was supported by Grant 1 R01HD046886-01A2 (PI: AMD) from the National Institutes of Health/ National Institute of Child Health and Human Development (https://www.nichd.nih.gov/ Pages/index.aspx). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Abstract HIV testing and counseling is a critical component of HIV prevention efforts and core element of current “treatment as prevention” strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities.
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Stepping Up Efforts to Promote HIV Testing among Migrants
Competing Interests: The authors have declared that no competing interests exist.
Introduction Highly mobile populations are more vulnerable to HIV and other infectious diseases and can play an important role in the relocation and spread of disease between home and host countries. In 2013, over 320,000 Mexican migrants traveled to the Mexican border to go to the U.S. and close to 703,000 Mexicans returned to Mexico from the U.S.[1,2] A survey of migrant flows in the Mexico-U.S. border found HIV rates are above those of adults in the U.S. and Mexico.[3] In Mexico, a large proportion of HIV infection has been associated with migration to the U.S.[4–6] In the U.S., approximately 20% of people infected with HIV are unaware of their infection and this group is estimated to be responsible for nearly half of new transmissions.[7] Undiagnosed HIV infected individuals are more likely to engage in riskier behavior and transmit the infection to others compared to those who are aware of their positive status. The former may not achieve the same quality-of-life adjusted years benefit as those who know they are infected and start treatment earlier.[8] Previous studies have documented barriers to HIV testing for Latino immigrants in the U.S., including undocumented immigrant status, lack of knowledge regarding HIV risk, limited access to health care,[9] and social stigma.[10] Late HIV testing is a prevalent problem for foreign-born Latinos in the U.S., with about 43% of HIV-infected cases progressing to AIDS within a year of diagnosis.[11] In Mexico, it is estimated that 52% of HIV cases are undiagnosed[12] and previous research has documented high levels of late HIV testing (approximately 61% of new HIV cases), which contribute to a lack of reduction in AIDS deaths.[13] Every year approximately 400,000 Mexican migrants return to their home country from the U.S.[1] and an additional 250,000 are forcedly removed or deported to Mexico.[14] Circular migration, defined as repeated migration experiences between communities of origin and destination involving more than one migration and return,[15] may increase the risk for HIV infection, as well as create barriers for HIV testing and engagement in care. Mexican migrants who repeatedly travel back and forth between sending and receiving communities either voluntarily or by force represent a highly mobile population at risk for HIV infection. A survey of returning Mexican migrants found that 89% of migrants who tested positive for HIV were unaware of their HIV status.[3] Identifying and seizing opportunities to promote HIV testing among circular Mexican migrants could help protect their health, as well as lower HIV incidence and improve rates of engagement into HIV care in both the U.S. and Mexico. Routine, voluntary, opt-out HIV testing in health care settings is an important strategy for identifying infected individuals and decreasing the spread of the disease[16,17] but the potential of this approach to increase HIV testing among circular Mexican migrants needs to be evaluated. Although Mexican migrants represent a medically underserved population, a substantial proportion interacts with the U.S. health care system. A recent survey of Mexican migrants returning from the U.S. estimated that 42% of them received healthcare services during the previous 12 months.[9] The Centers for Disease Control and Prevention (CDC) recommend that health care providers test everyone between the ages of 13 and 64 at least once as part of routine health care.[16] A recent study estimated that optimal, cost-effective HIV testing would be testing every 2.4 years for low-risk individuals, every 9 months for individuals at moderate risk and every 3 months for high-risk individuals.[18] Given their mobility, poor socioeconomic status, and limited access to health care, migrants should be considered a moderate to high-risk group and be routinely offered HIV testing by health care providers. However, the extent to which Mexican migrants accessing health care services are being offered and receiving HIV testing in health care settings in the U.S. is unknown. Prisons, jails, and immigration detention centers also offer a unique opportunity to provide prevention services to individuals at high risk for disease who may not otherwise interact with
PLOS ONE | DOI:10.1371/journal.pone.0123631 April 10, 2015
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Stepping Up Efforts to Promote HIV Testing among Migrants
the health care system or be identified and treated in the general community.[19] Mainly because of their unauthorized immigration status, a large number of Mexican migrants are arrested and detained in immigration centers, jails, or prisons and ultimately deported back to Mexico every year.[20] According to Mexico’s National Institute of Migration, 330,000 migrants were deported from the U.S. to Mexico in the year 2013 alone.[21] Data from a survey on the Mexico-U.S. border indicate that over a third of Mexican migrants returning to Mexico voluntarily or via deportation have been detained in a detention center or prison in the U.S. during the last 12 months.[3] These numbers suggest opportunities to promote HIV testing among Mexican migrants in health care settings, correctional systems, and detention centers. The National Commission on Correctional Health Care (NCCHC)[19](National Commission on Correctional Health Care 2002)(National Commission on Correctional Health Care)[19] recommends that correctional systems incorporate easy, convenient, and voluntary HIV testing into the intake procedure for all inmates not known to have HIV.[19] The CDC also recommends HIV testing upon entry into prisons and before release, with voluntary testing offered periodically during incarceration.[22] In practice, HIV testing in correctional facilities varies by state and more than 50% of state prisons do not require HIV testing at any point, although testing is reportedly available to prisoners who request it.[23] Similarly, U.S. Immigration and Customs Enforcement (ICE) standards require detainees to receive a medical screening within 12 hours of arrival at a facility and a comprehensive health assessment within 14 days.[24] However, this assessment does not necessarily include the provision of voluntary HIV counseling and testing. A detainee may request an HIV test at anytime, but testing is not routinely offered or encouraged.[25] International guidelines also establish that prisoners should have a right to health care that is equivalent to the surrounding community, including access to HIV voluntary testing, means of prevention, treatment and confidentiality.[26,27] Little research has examined HIV testing of immigrants in correctional or ICE detention centers in the U.S. Since ICE does not have a mandate to provide statistics on HIV, limited data are available on HIV testing and medical care for immigrant detainees. However, limited evidence suggests inadequate initial screening for HIV and lack of effective efforts to maintain a confidential, free from harassment environment for HIV-positive detainees.[28] In this study, we estimate last 12-months rates of HIV testing among circular, mostly undocumented Mexican migrants returning from the U.S. to Mexico voluntarily or via deportation. We also analyze the role of health care, correctional, or ICE detention systems in promoting HIV testing and missed opportunities to increase testing rates in these settings among this vulnerable and medically underserved population.
Methods From April to December 2013, we conducted a cross-sectional, probability health care survey (N = 1161) of mostly Mexican migrants that were returning from the U.S. either voluntarily (a.k.a Southbound flow, N = 695) or via deportation (a.k.a. Deported flow, N = 466). The survey was conducted in Tijuana, Mexico. In 2013, the Tijuana-San Diego border region concentrated about 30% of the Southbound migration flow between Mexico and the U.S.[2] and the highest number of repatriation events in the U.S.-Mexico border, accounting for 14% of them. [21] Samples size was calculated for the main objective of the survey, namely to estimate with relative precision levels of health care access and utilization among Mexican migrants. Estimates were obtained based on a previous pilot health care survey conducted in Tijuana with the same population.[9] Once the overall sample size was determined, the target sample sizes for each migrant flow were calculated to be proportional to the volume of each migration flow observed on previous survey waves.[3]
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Stepping Up Efforts to Promote HIV Testing among Migrants
The sampling methodology was designed after the Mexican government-funded Migration Survey on the North Border of Mexico (EMIF, its Spanish acronym, www.colef.mx/emif). Survey venues included the largest bus station, airport and deportation facility in Tijuana. Survey time units included the day of the week and survey shit. Every quarter a random sample of “venue-time” pairs was selected to determine where and when the survey was to be conducted over the following 3 months. The selection of sites and time units was done proportionally to the volume of the migrant flow traveling through each venue and time period. During each survey shift, individuals crossing through the sampling points were consecutively approached and screened for eligibility by a Mexico-native, trained research assistant. Eligible individuals were defined as those 18 years or older, born in Mexico or other Latin American countries, fluent in Spanish, not a resident of Tijuana (except for deported migrants), and not have participated in the survey before. An interviewer-administered, computer-assisted questionnaire was used to collect information on last 12-month HIV testing, socio-demographics (i.e. age, gender, marital status, education, and health insurance status), migration history (i.e. time spent in the U.S. overall and in the last 12 months, migration trips, illegal crossing, and intentions to return to the U.S. within the next year), and contextual factors from eligible, consenting individuals. Additional questions assessed whether respondents had received other health care services (different from HIV testing) or had been detained in an immigration or correctional setting for at least 30 days in the U.S. during the 12 months prior to the survey. Oral informed consent was obtained from each survey participant to reduce the risk of exposing personal identification. The oral consent was documented both by the interviewers and in the electronic questionnaire. All study procedures were approved by the Social and Behavioral Sciences Institutional Review Board at University of Wisconsin, Madison, and Ethics Committee of the Mexico-U.S. Border Health Commission. The sampling strategy, eligibility criteria, recruitment, and data collection procedures have been described in more detail elsewhere.[29] We calculated descriptive statistics of the rates of HIV testing, other healthcare receipt, and detention/imprisonment during the past 12 months. Logistic regression models were run to identify the association of last 12-months receipt of other health care services and incarceration or detention for at least 30 days in the U.S. with HIV testing. We estimated a model with all migrants included and two separate models for each migration flow (southbound vis a vis deported). Models included sociodemographics (gender, age, education, and marital status). The overall model further included migration flow (southbound or deported) and two interaction terms between migration flow and healthcare receipt and migration flow and incarceration or detention as control variables. Survey weights were computed and used to account for the complex sampling design and refusals. Survey weighting procedures have been described elsewhere.[30] Consistent with previous recommendations, survey weights were used to produce populationlevel descriptive estimates, while regression models were estimated with unweighted data to obtain smaller standard errors and produce more efficient parameter estimates.[31] All analyses were performed with the software STATA/MP 13.1 (StataCorp LP, College Station, TX).
Results Among 2,372 eligible individuals, 1,161 (695 southbound and 466 deported migrants) agreed to participate in the survey and provided complete data for this study, yielding a final response rate of 67.3% (55.8% for the Southbound and 97.0% for the Deported). Table 1 shows that overall Mexican migrants were generally young (mean age = 43.1 years, SD = 13.9), primarily male (77.1%), and low educated (only 33.3% completed high school). On average, migrants had spent 17.2 years (SD = 12.4) in the U.S. and had migrated to the U.S. three times in their lifetime to work or to find a job (Median = 1, Interquartile range = 1–2). Approximately, 68.2%
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Stepping Up Efforts to Promote HIV Testing among Migrants
Table 1. Socio-demographic, migration characteristics of Mexican migrants returning from the U.S. via Tijuana, Mexico. Overall (Sample N = 1,161; Weighted N = 227,888)
Southbound (Sample N = 695; Weighted N = 194,343)
Deported (Sample N = 466; Weighted N = 33,544)
P*
Male, %
77.1
75.1
88.1
Identifying Opportunities to Increase HIV Testing among Mexican Migrants: A Call to Step Up Efforts in Health Care and Detention Settings Ana P. Martínez-Donate1*, Maria Gudelia Rangel2, Natalie Rhoads1, Xiao Zhang1, Melbourne Hovell3, Carlos Magis-Rodriguez4, Eduardo González-Fagoaga2 1 Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, United States of America, 2 El Colegio de la Frontera Norte, Tijuana, Mexico, 3 Graduate School of Public Health, San Diego State University, San Diego, CA, United States of America, 4 Centro de Investigaciones en Infecciones de Transmision Sexual, Programa de VIH y SIDA de la Ciudad de Mexico, la Ciudad de Mexico, Mexico * [email protected]
OPEN ACCESS Citation: Martínez-Donate AP, Rangel MG, Rhoads N, Zhang X, Hovell M, Magis-Rodriguez C, et al. (2015) Identifying Opportunities to Increase HIV Testing among Mexican Migrants: A Call to Step Up Efforts in Health Care and Detention Settings. PLoS ONE 10(4): e0123631. doi:10.1371/journal. pone.0123631 Academic Editor: Sandro Mancinelli, Universita degli Studi di Roma Tor Vergata, ITALY Received: November 12, 2014 Accepted: March 2, 2015 Published: April 10, 2015 Copyright: © 2015 Martínez-Donate et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: This study was supported by Grant 1 R01HD046886-01A2 (PI: AMD) from the National Institutes of Health/ National Institute of Child Health and Human Development (https://www.nichd.nih.gov/ Pages/index.aspx). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Abstract HIV testing and counseling is a critical component of HIV prevention efforts and core element of current “treatment as prevention” strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities.
PLOS ONE | DOI:10.1371/journal.pone.0123631 April 10, 2015
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Stepping Up Efforts to Promote HIV Testing among Migrants
Competing Interests: The authors have declared that no competing interests exist.
Introduction Highly mobile populations are more vulnerable to HIV and other infectious diseases and can play an important role in the relocation and spread of disease between home and host countries. In 2013, over 320,000 Mexican migrants traveled to the Mexican border to go to the U.S. and close to 703,000 Mexicans returned to Mexico from the U.S.[1,2] A survey of migrant flows in the Mexico-U.S. border found HIV rates are above those of adults in the U.S. and Mexico.[3] In Mexico, a large proportion of HIV infection has been associated with migration to the U.S.[4–6] In the U.S., approximately 20% of people infected with HIV are unaware of their infection and this group is estimated to be responsible for nearly half of new transmissions.[7] Undiagnosed HIV infected individuals are more likely to engage in riskier behavior and transmit the infection to others compared to those who are aware of their positive status. The former may not achieve the same quality-of-life adjusted years benefit as those who know they are infected and start treatment earlier.[8] Previous studies have documented barriers to HIV testing for Latino immigrants in the U.S., including undocumented immigrant status, lack of knowledge regarding HIV risk, limited access to health care,[9] and social stigma.[10] Late HIV testing is a prevalent problem for foreign-born Latinos in the U.S., with about 43% of HIV-infected cases progressing to AIDS within a year of diagnosis.[11] In Mexico, it is estimated that 52% of HIV cases are undiagnosed[12] and previous research has documented high levels of late HIV testing (approximately 61% of new HIV cases), which contribute to a lack of reduction in AIDS deaths.[13] Every year approximately 400,000 Mexican migrants return to their home country from the U.S.[1] and an additional 250,000 are forcedly removed or deported to Mexico.[14] Circular migration, defined as repeated migration experiences between communities of origin and destination involving more than one migration and return,[15] may increase the risk for HIV infection, as well as create barriers for HIV testing and engagement in care. Mexican migrants who repeatedly travel back and forth between sending and receiving communities either voluntarily or by force represent a highly mobile population at risk for HIV infection. A survey of returning Mexican migrants found that 89% of migrants who tested positive for HIV were unaware of their HIV status.[3] Identifying and seizing opportunities to promote HIV testing among circular Mexican migrants could help protect their health, as well as lower HIV incidence and improve rates of engagement into HIV care in both the U.S. and Mexico. Routine, voluntary, opt-out HIV testing in health care settings is an important strategy for identifying infected individuals and decreasing the spread of the disease[16,17] but the potential of this approach to increase HIV testing among circular Mexican migrants needs to be evaluated. Although Mexican migrants represent a medically underserved population, a substantial proportion interacts with the U.S. health care system. A recent survey of Mexican migrants returning from the U.S. estimated that 42% of them received healthcare services during the previous 12 months.[9] The Centers for Disease Control and Prevention (CDC) recommend that health care providers test everyone between the ages of 13 and 64 at least once as part of routine health care.[16] A recent study estimated that optimal, cost-effective HIV testing would be testing every 2.4 years for low-risk individuals, every 9 months for individuals at moderate risk and every 3 months for high-risk individuals.[18] Given their mobility, poor socioeconomic status, and limited access to health care, migrants should be considered a moderate to high-risk group and be routinely offered HIV testing by health care providers. However, the extent to which Mexican migrants accessing health care services are being offered and receiving HIV testing in health care settings in the U.S. is unknown. Prisons, jails, and immigration detention centers also offer a unique opportunity to provide prevention services to individuals at high risk for disease who may not otherwise interact with
PLOS ONE | DOI:10.1371/journal.pone.0123631 April 10, 2015
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Stepping Up Efforts to Promote HIV Testing among Migrants
the health care system or be identified and treated in the general community.[19] Mainly because of their unauthorized immigration status, a large number of Mexican migrants are arrested and detained in immigration centers, jails, or prisons and ultimately deported back to Mexico every year.[20] According to Mexico’s National Institute of Migration, 330,000 migrants were deported from the U.S. to Mexico in the year 2013 alone.[21] Data from a survey on the Mexico-U.S. border indicate that over a third of Mexican migrants returning to Mexico voluntarily or via deportation have been detained in a detention center or prison in the U.S. during the last 12 months.[3] These numbers suggest opportunities to promote HIV testing among Mexican migrants in health care settings, correctional systems, and detention centers. The National Commission on Correctional Health Care (NCCHC)[19](National Commission on Correctional Health Care 2002)(National Commission on Correctional Health Care)[19] recommends that correctional systems incorporate easy, convenient, and voluntary HIV testing into the intake procedure for all inmates not known to have HIV.[19] The CDC also recommends HIV testing upon entry into prisons and before release, with voluntary testing offered periodically during incarceration.[22] In practice, HIV testing in correctional facilities varies by state and more than 50% of state prisons do not require HIV testing at any point, although testing is reportedly available to prisoners who request it.[23] Similarly, U.S. Immigration and Customs Enforcement (ICE) standards require detainees to receive a medical screening within 12 hours of arrival at a facility and a comprehensive health assessment within 14 days.[24] However, this assessment does not necessarily include the provision of voluntary HIV counseling and testing. A detainee may request an HIV test at anytime, but testing is not routinely offered or encouraged.[25] International guidelines also establish that prisoners should have a right to health care that is equivalent to the surrounding community, including access to HIV voluntary testing, means of prevention, treatment and confidentiality.[26,27] Little research has examined HIV testing of immigrants in correctional or ICE detention centers in the U.S. Since ICE does not have a mandate to provide statistics on HIV, limited data are available on HIV testing and medical care for immigrant detainees. However, limited evidence suggests inadequate initial screening for HIV and lack of effective efforts to maintain a confidential, free from harassment environment for HIV-positive detainees.[28] In this study, we estimate last 12-months rates of HIV testing among circular, mostly undocumented Mexican migrants returning from the U.S. to Mexico voluntarily or via deportation. We also analyze the role of health care, correctional, or ICE detention systems in promoting HIV testing and missed opportunities to increase testing rates in these settings among this vulnerable and medically underserved population.
Methods From April to December 2013, we conducted a cross-sectional, probability health care survey (N = 1161) of mostly Mexican migrants that were returning from the U.S. either voluntarily (a.k.a Southbound flow, N = 695) or via deportation (a.k.a. Deported flow, N = 466). The survey was conducted in Tijuana, Mexico. In 2013, the Tijuana-San Diego border region concentrated about 30% of the Southbound migration flow between Mexico and the U.S.[2] and the highest number of repatriation events in the U.S.-Mexico border, accounting for 14% of them. [21] Samples size was calculated for the main objective of the survey, namely to estimate with relative precision levels of health care access and utilization among Mexican migrants. Estimates were obtained based on a previous pilot health care survey conducted in Tijuana with the same population.[9] Once the overall sample size was determined, the target sample sizes for each migrant flow were calculated to be proportional to the volume of each migration flow observed on previous survey waves.[3]
PLOS ONE | DOI:10.1371/journal.pone.0123631 April 10, 2015
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Stepping Up Efforts to Promote HIV Testing among Migrants
The sampling methodology was designed after the Mexican government-funded Migration Survey on the North Border of Mexico (EMIF, its Spanish acronym, www.colef.mx/emif). Survey venues included the largest bus station, airport and deportation facility in Tijuana. Survey time units included the day of the week and survey shit. Every quarter a random sample of “venue-time” pairs was selected to determine where and when the survey was to be conducted over the following 3 months. The selection of sites and time units was done proportionally to the volume of the migrant flow traveling through each venue and time period. During each survey shift, individuals crossing through the sampling points were consecutively approached and screened for eligibility by a Mexico-native, trained research assistant. Eligible individuals were defined as those 18 years or older, born in Mexico or other Latin American countries, fluent in Spanish, not a resident of Tijuana (except for deported migrants), and not have participated in the survey before. An interviewer-administered, computer-assisted questionnaire was used to collect information on last 12-month HIV testing, socio-demographics (i.e. age, gender, marital status, education, and health insurance status), migration history (i.e. time spent in the U.S. overall and in the last 12 months, migration trips, illegal crossing, and intentions to return to the U.S. within the next year), and contextual factors from eligible, consenting individuals. Additional questions assessed whether respondents had received other health care services (different from HIV testing) or had been detained in an immigration or correctional setting for at least 30 days in the U.S. during the 12 months prior to the survey. Oral informed consent was obtained from each survey participant to reduce the risk of exposing personal identification. The oral consent was documented both by the interviewers and in the electronic questionnaire. All study procedures were approved by the Social and Behavioral Sciences Institutional Review Board at University of Wisconsin, Madison, and Ethics Committee of the Mexico-U.S. Border Health Commission. The sampling strategy, eligibility criteria, recruitment, and data collection procedures have been described in more detail elsewhere.[29] We calculated descriptive statistics of the rates of HIV testing, other healthcare receipt, and detention/imprisonment during the past 12 months. Logistic regression models were run to identify the association of last 12-months receipt of other health care services and incarceration or detention for at least 30 days in the U.S. with HIV testing. We estimated a model with all migrants included and two separate models for each migration flow (southbound vis a vis deported). Models included sociodemographics (gender, age, education, and marital status). The overall model further included migration flow (southbound or deported) and two interaction terms between migration flow and healthcare receipt and migration flow and incarceration or detention as control variables. Survey weights were computed and used to account for the complex sampling design and refusals. Survey weighting procedures have been described elsewhere.[30] Consistent with previous recommendations, survey weights were used to produce populationlevel descriptive estimates, while regression models were estimated with unweighted data to obtain smaller standard errors and produce more efficient parameter estimates.[31] All analyses were performed with the software STATA/MP 13.1 (StataCorp LP, College Station, TX).
Results Among 2,372 eligible individuals, 1,161 (695 southbound and 466 deported migrants) agreed to participate in the survey and provided complete data for this study, yielding a final response rate of 67.3% (55.8% for the Southbound and 97.0% for the Deported). Table 1 shows that overall Mexican migrants were generally young (mean age = 43.1 years, SD = 13.9), primarily male (77.1%), and low educated (only 33.3% completed high school). On average, migrants had spent 17.2 years (SD = 12.4) in the U.S. and had migrated to the U.S. three times in their lifetime to work or to find a job (Median = 1, Interquartile range = 1–2). Approximately, 68.2%
PLOS ONE | DOI:10.1371/journal.pone.0123631 April 10, 2015
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Stepping Up Efforts to Promote HIV Testing among Migrants
Table 1. Socio-demographic, migration characteristics of Mexican migrants returning from the U.S. via Tijuana, Mexico. Overall (Sample N = 1,161; Weighted N = 227,888)
Southbound (Sample N = 695; Weighted N = 194,343)
Deported (Sample N = 466; Weighted N = 33,544)
P*
Male, %
77.1
75.1
88.1
