MEXICO

Monitoting and Evaluation of HIV/AIDS programs

Adriana Arzac

The first case of AIDS in Mexico was diagnosed in 1983. Men who have sex with men, blood transfusion recipients were the most affected groups in the earlier years of the epidemic. In recent years, MSM, intravenous drug users and increasingly women are infected with HIV. HIV prevalence in the general population is low and Mexico currently has a concentrated epidemic with prevalence exceeding 5% in men who have sex with men. The current male-female ratio for AIDS cases is 6 to 1.

National response

During the incipient phase of the epidemic (1982-88) the response was slow. In 1986, the government established the national AIDS committee (CONASIDA) within the Ministry of Health, but only limited resources were given to the AIDS programme. An inform ation and attnetion centre was created in Mexico city and in later years replicated in some other states of Mexico. During 1988-94 the programme was seen more as an NGO than as part of the health sector. The first mid term plan was formulated in 1989. In 1994, health sector decentralization became more important and HIV/AIDS was declared as one of the 11 national health priority issues. Currently, Mexico's AIDS programme is implementing the 1996-2000 plan and federal funding has increased. In 1997 the nat ional and state AIDS programmes began to participate in the national programme to modernize public administration and the Ministry of Health's integral supervision plan. The programme developed a plan to strengthen HIV prevention and STD control. Importan t interventions included national education campaigns, special efforts aimed at youth and mass media programmes.

The national STD programme has been in existence since the 1940s, but became much more active because of the threat of AIDS. In 1994, the syndromic approach to STD treatment was adopted. The STD programme was incorporated in CONASIDA in 1997.

Monitoring and evaluation

The initial efforts were made by epidemiologists who focused on AIDS cases. In 1986, monitoring of the spread of HIV commenced through sentinel survey sites among risk groups and the establishment of screening of blood for transfusion. A national sero- prevalence survey was completed in 1987. Subsequently, a national system of HIV/AIDS cases registration was established at the national directorate of epidemiology and a national network of screening laboratories was set up. For 1990-94 sentinel surveillance sites were set up in 18 cities.

The evaluation of the end of the mid term plan in 1994 was extensive and considerable preparatory work led to useful reviews of programme efforts. In 1997, a set of 8 mostly impact indicators with specific was developed within the context of strengthe ning HIV/STD prevention and control, although not all indicators have been implemented. Goals include elimination of congenital syphilis, decreased AIDS case incidence by 30%, and increase condom use by 30%.

There is a fairly large data base on programme inputs and outputs. Such data are compiled in specific reviews. There is a range of research studies that have looked at knowledge and sexual behaviour, but no standardized set of indicators (such as the W HO prevention indicators has been used). In addition, several evaluation of specific interventions have been conducted. Most of these efforts have been funded by external donors.

Input, output and context

Several evaluations following specific IEC interventions (such as introdcution of a brochure for teenagers, a TV spot, a video, campaigns, telephone hotline) have been carried out to assess coverage and impact on knowledge. Often the evaluations used q ualitative methods, such as focus groups and in-depth interviews.

Condom distribution is monitored. In the last 12 months 43 million condoms were available for distribution by the health sector, and 35 million were sold during the same period. It has been estimated that 760 million condoms would be required to cover all acts at risk of HIV/STD prevention.

Proximate determinants

Most research studies among men (homosexual, bisexual, heterosexual), women and adolescents suggest that condom use has gone up considerably during the 1990s, although most studies have focused on Mexico City. There is very little information on sexual behaviour and sexuality of women, with the exception of commercial sex workers. There are also relatively few studies or pulbications on adolescent sexuality.

HIV and STD

HIV prevalence data are available for a range of populations: antenatal women, blood donors, female and male CSW, MSM and bi-sexual men , prisoners and TB patients. Among antenatal women prevalence has increased from 0.04% to 0.09%; among blood donors prevelance is also 0.09%, while the highest prevalence is reported for MSM and bisexual men.

The proportion of AIDS cases associated with blood transfusions has decreased from 17% of all AIDS cases in 1989 to 2.7% in 1998.

With regard to STDs underreporting affects the analysis of trends. It appears STD incidence for syphilis and gonorrhoea have declined considerably between 1970 and 1996, while herpes and other discharge causing STDs have increased during the same perio d.

AIDS impact mitigation

The number of legal and human rights violation complaints in 1994 was 2,551, of which about half was about health sector personnel. The effectiveness and level of use of antiretroviral treatment is not immediately clear from national data.

Conclusion

The overall efforts of the national AIDS programme during the past 15 years have been epidemic-driven with responses to urgent, immediate needs and with insufficient resources for the porgramme. The monitoring and evaluation component of the programme has similar features, and has been driven by research efforts and ad hoc evaluation of specific interventions. There has been much pre-occupation with high risk groups and much less so with the general population, especially women and youth.