CHAPTER 2

The Southern California Border HIV/AIDS Project: An Innovative Approach to HIV Outreach, Primary Care, and Cross-Border Linkages at the California–Baja California Border

San Ysidro Health Center (SYHC) was founded in 1969 by a local women’s organization concerned with the community’s lack of access to medical, behavioral, and dental services. At that time, the northern side of the San Ysidro–Tijuana U.S.–Mexico border had no significant health infrastructure, and many local residents did without health care until medical conditions made it necessary to seek care at the nearest emergency room. Because of their low income and lack of health insurance, most local residents were unable to access primary care services.

Guided by its grassroots beginnings and longstanding commitment to community service, SYHC has pursued public and private funding opportunities to provide health care for members of its surrounding communities. In the early 1970s, SYHC received a grant from the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care (BPHC), to provide primary care and limited behavioral health and dental services. Funding has been renewed over the years on the basis of SYHC’s ability to demonstrate improved care delivery and a positive impact on community health.

Since 1969, SYHC has been a leader in the provision of low-cost, high-quality, comprehensive primary health care services to residents of the South Bay region of San Diego County, California. Over the past 35 years, the health center’s growth has been driven by the community’s need for essential health care and social services. As of 2005, SYHC has satellite community health centers (CHCs) in San Ysidro, Otay Mesa, Chula Vista, and National City, all of which were strategically located to provide comprehensive health care (medical, dental, and mental health) to the entire South Bay region.

To effectively carry out its mission, SYHC provides a continuum of health care services through fixed and mobile clinic sites, and it conducts intensive community outreach programs to bring people into care. SYHC’s major stationary-site services include the following:

• Primary medical care: adult medicine, pediatrics, geriatrics, and obstetric and gynecological services
• Mental health and substance abuse services
• Dental services, including pediatric dental services
• HIV/AIDS services (Title II and Title III)
• Pharmacy prescriptions
• Laboratory services
• Radiology services
• Optometry
• Specialty medicine: podiatry, cardiology, pediatric pulmonology, and rheumatology
• Women, Infants and Children (WIC) nutrition services
• Enabling social services, such as case management, patient education, nutritional counseling, and community preventive education.

Area Demographics

SYHC is in California’s 51st Congressional District. Its service area is south suburban San Diego County, California. This geographic area, referred to as the South Bay, is a subregional area of San Diego County and as of January 2006 had a population of 138,259. SYHC’s service area comprises 82 census tracts. Eleven census tracts in the San Ysidro/Imperial Beach area along the California–Mexico border are designated as primary care health professional shortage areas (HPSAs), and four census tracts in SYHC’s National City service area are designated as medically underserved areas (MUAs) by the BPHC.

SYHC’s service area encompasses the southwestern region of San Diego County and the continental United States. Its service boundaries are the Pacific Ocean in the west; the international border between California and Baja California, Mexico, to the south; the city of San Diego in the north; and the Otay Mesa border to the east.

Target Population

SYHC’s target population consists of low-income, uninsured, minority people living in the South Bay region. Historically, most of SYHC’s patients have been people of Mexican ancestry with low incomes. In 2004, SYHC served 50,675 patients; 88 percent were of Latino4 or Mexican ancestry (44,793). Significant socioeconomic disparities exist within the population in SYHC’s service area, as demonstrated by the following indicators:

• Age. The San Diego Association of Governments (SANDAG) regional planning agency showed that the median age of the South Bay’s 138,259 residents is about 30 years. Adults age 25 to 44 account for 31 percent of the population; children and adolescents from birth to age 14, 24 percent; young adults age 15 to 24, 17 percent; and adults age 45 to 64, 20 percent. Seniors—those age 65 and older—account for only about 9 percent of the service area population (SANDAG, 2006).
• Insurance. A major portion of SYHC’s service area has the State’s 14th highest rate of uninsured residents from birth to age 64 (approximately 110,000 uninsured people). Uninsured residents compose 30 percent of the district’s total population; statewide, the average is 21 percent (UCLA Center for Health Policy Research, 2002).
• Poverty. According to SANDAG (2000), 17 percent of people living in the South Bay region live below the Federal Poverty Level (FPL). Two factors related to low income among area residents are limited English proficiency and limited educational attainment. Two service areas, National City and Imperial Beach, have the highest percentages of low-income households in the South Bay region. In 2000, 25 percent of San Ysidro families (1,597 families) had incomes below the FPL, compared with San Diego’s poverty rate of 8.9 percent. San Ysidro’s median household income was only $25,078 (SANDAG, 2000).
• Ethnicity/Culture. According to 2000 Census data (Ramirez & de la Cruz, 2003), communities geographically closer to the California–Mexico border have significantly higher percentages of people of Mexican or Latino heritage. This pattern is especially true in SYHC’s service area. Although Latinos account for only 26.7 percent of the county’s total population, they comprise 89 percent of San Ysidro’s population (SANDAG, 2003), 59 percent of National City’s population, and 50 percent of Chula Vista’s population (SANDAG, 2006).
• Education. Except in Chula Vista, educational attainment for the population age 25 and older in SYHC’s service area is low. Nearly 43 percent of National City’s population and 57 percent of San Ysidro’s population age 25 and older did not graduate from high school (SANDAG, 2000). High dropout rates are attributed in part to language and cultural barriers.

Other Federal, State, and Local Funding

SYHC funding comes from Federal, State, local and private foundations. SYHC aggressively seeks funding opportunities to secure the community’s growing need for health care services.

SYHC’s experience providing culturally and linguistically appropriate HIV services to Latinos in the San Diego–Tijuana border region enabled the health center to become the lead agency for the HRSA Special Projects of National Significance (SPNS) U.S.–Mexico Border Health Initiative. Moreover, it provided the framework for the development of the SPNS service delivery model used by the partner sites to develop or enhance their HIV programs and services under the SPNS initiative.

Before receiving the SPNS grant in 2001, the funding level for HIV/AIDS services at SYHC was $450,000; funds came primarily from Part B of the Ryan White HIV/AIDS Program through a grant administered by the San Diego Department of Health Services (DHS). In 2005, SYHC’s HIV/AIDS department had an annual budget of $1.8 million and administered 13 local, State, and Federal initiatives.

Development of HIV Services

SYHC is committed to providing care to HIV-positive patients, but prior to 2000, HIV services were limited. SYHC initially contracted with an HIV specialist for 4 hours of primary care services per week. In addition, SYHC provided rudimentary case management and social services at the fledgling HIV service center. Staff for this project—a case manager/project director, case worker, outreach worker, and food services coordinator—were funded through a Part B grant from the county of San Diego DHS. In 2000, a Ryan White HIV/AIDS Program Part C Early Intervention Services (EIS) grant enabled SYHC to increase primary medical care from 4 hours per week in 1999 to 40 hours per week by early 2002. Since 2000, additional funding has enabled expansion of other services, such as case management, HIV prevention education, and outreach, as well as the implementation of HIV counseling and testing services.

Service Mission and Commitment to Serving People Living With HIV/AIDS

SYHC’s mission—“to protect, promote and improve the health and well-being of the community’s traditionally underserved and culturally diverse people”—is woven into the fabric of all the health center’s programs. This mission guides all aspects of SYHC operations, from decisions made by the health center’s board of directors, to SYHC administration, to care provided by clinical staff, and to resource development to expand patient access to care. SYHC administration is committed to providing a continuum of high-quality, culturally competent services to HIV-positive patients. A full-time-equivalent HIV medical specialist provides primary care services. Other patient services include case management, nutritional counseling, dental care, and mental health and substance abuse counseling and support groups as well as linkages to more than 15 HIV social service agencies in the community. To receive HIV health care services, HIV/AIDS clinic patients must demonstrate proof of residency in the United States, have proof of diagnosis, and have valid identification.

Local HIV/AIDS Epidemiologic Data

Data from the County of San Diego (2007) show that between 1987 and 2005, a total of 13,015 people were diagnosed with AIDS in San Diego County; 23 percent, or 3,000 cases, were among Latinos. Since the mid-1990s, Latinos have been second to African Americans in the highest rate of AIDS in San Diego County among minority racial and ethnic groups. Of the total reported cases since 1987, approximately 91 percent have been among men; 90 percent of the cases among Latinos are among men as well. Of cumulative AIDS cases reported in Latinos, 58 percent of cases in men are among those who are foreign born and 64 percent of cases in women are among those who are foreign born (i.e., born outside the United States in a U.S. dependency or foreign country; County of San Diego, 2007).

Overview of the Southern California SPNS Initiative

The HRSA HIV/AIDS Bureau (HAB) established the Ryan White HIV/AIDS Program SPNS U.S.–Mexico Border Health Initiative in an effort to “diminish health disparities among individuals living with HIV disease along the U.S./Mexico border” (HRSA HAB, 2003).

HRSA was expecting a collaborative proposal. Senior staff at the San Diego County Office of AIDS Coordination (OAC) had a long history of working with other county and community agencies to develop programs; OAC agreed to facilitate the process with the help of staff from the San Diego County Office of Border Health (OBH).

OAC and OBH organized and facilitated a series of planning meetings. Participants included representatives from grantees of Ryan White HIV/AIDS Program Parts A through D; the Pacific AIDS Education and Training Center (AETC); the County Early HIV Intervention Program; county offices of epidemiology and tuberculosis control; and staff from county and State offices of border health. The SPNS working group consisted of 33 San Diego agency representatives and 2 from Imperial County. Once the SPNS request for proposals was issued, a grant writer hired by the San Diego County Office of Public Health, the parent entity for OAC and OBH, worked with the SPNS working group on the response to the RFP. The working group named its proposed project, “Borderland HIV/AIDS Care Innovations: New Approaches to Outreach, Primary Care and Cross-Border Linkages at the California/Baja California Border.”

SYHC was selected as the lead agency for the proposed project. Collaborating partners initially included five CHCs (four in San Diego County and one in Imperial County), and the University of California, San Diego (UCSD) served as the program evaluator. Family Health Centers of San Diego (FHCSD) represented the central region of San Diego County, Vista Community Clinic (VCC) represented the north region, East County Community Clinic (ECCC) represented the east region, and Clinicas de Salud del Pueblo (CSP) represented Imperial County. SYHC, the lead agency, represented the South Bay region. Comprehensive Health Centers served as technical advisors for treatment adherence services.

Early in the development of the collaboration, the ECCC was unable to participate; however, the remaining four partner sites and the evaluation team were active participants throughout the 5-year project and beyond. In June 2000, SYHC was awarded the SPNS grant. In the first year, the project was renamed the “Southern California Border HIV/AIDS Project.”

FIGURE 2.1. Southern California Border HIV/AIDS Project service delivery model.

D

 

The Southern California Border HIV/AIDS Project proposed to use innovative approaches to increase HIV/AIDS outreach, primary care services, and cross-border linkages for people who live or work in the San Diego or Imperial County border region. The project targeted underserved, hard-to-reach, minority populations, particularly Latinos. To address the diverse nature of Latino populations, each partner site was asked to designate its target population based on its organization’s geographical area and unique service population. Target populations collectively included:

• Newly immigrated Latinos
• Migrant and permanent farmworkers
• Latinas
• Transborder Latinos
• Latina sex workers
• Latino men who have sex with men (MSM).

The categories were not mutually exclusive, although they represented distinct populations for each region. Initially, one target population was male Latino youth sex workers; however, because of an inability to identify that population in a consistent manner, the youth sex worker population was integrated into the Latino MSM category.

Project Goals and Model

The Southern California Border HIV/AIDS Project had three main goals:

1. To increase early detection among the underserved HIV-positive Latino population
2. To increase access to comprehensive HIV/AIDS primary care services
3. To enhance the capacity of CHCs to provide culturally sensitive care.

The service delivery model implemented at each partner site was based on the service model developed at SYHC (Figure 2.1). The SYHC model identified five categories of primary HIV services (i.e., core services) that are necessary to reach and adequately serve Latinos:

1. HIV primary care services
2. Case management
3. AIDS Drug Assistance Program (ADAP) enrollment
4. Treatment adherence counseling
5. Culturally sensitive services in both Spanish and English, including onsite translation and interpretation services.

Three partner sites agreed to implement the SYHC HIV service delivery model, given demonstrated success observed at SYHC. The fourth site, Comprehensive Health Centers, was contracted to provide technical assistance to other partner sites for the development of culturally and linguistically appropriate treatment adherence counseling. Figure 2.2 depicts the patient flow at SYHC.

Providing HIV primary medical care was considered a basic service for meeting the needs of HIV-positive Latinos, but the case management component was essential to the success of SYHC’s service delivery model. All partner sites were required to have bilingual case management services. The case manager became the primary access point for helping HIV-positive Latinos access and stay in care.

Logic Model

The initial logic model for the Southern California Border HIV/AIDS Project was found to not accurately reflect the planned intervention or realistically capture the evaluation measures proposed to assess the intervention. Minor changes in model language and target population contact estimates were made through partner consensus and approved by HRSA. The logic model is shown in Appendix 2.A.

SYHC’s initial target population was transborder Latino MSM; the target population was modified to include all transborder Latinos because of the lack of MSM outreach sites in the South Bay region. As indicated earlier, a partner site, FHCSD, had to expand its initial target population of Latino youth sex workers to encompass Latino MSM as a result of similar participant recruitment problems. The proposed project plan remained essentially the same throughout the 5-year SPNS initiative. The evaluation plan for the Southern California Border HIV/AIDS Project used both process and outcome evaluation measures.

Implementation and Collaboration

Implementation of a new service delivery structure at partner sites was challenging. Most sites had established HIV services to various degrees. The longer the history of HIV services at a site, the harder it was to implement a new service delivery model and train staff in using that model.

A key to the success of the Southern California Border HIV/AIDS Project was the collaboration among the four partner sites and the local UCSD evaluation team from the outset. The successful collaboration was attributable to excellent communication established during the planning phase. Regular monthly meetings were forums to discuss project progress and problems. The monthly meetings also served as a support system for project staff and contributed to staff buy-in. Each site submitted monthly reports that provided the lead agency with regular updates on progress toward the project objectives. In addition to reports and meetings, the lead agency and evaluation team made annual site visits to provide consultation and assess progress.

Relationships With the Centro de Evaluación and the Pacific AETC

The Centro de Evaluación (see Chapter 1) provided technical support on various aspects of program evaluation. For example, it helped create TeleForm versions of two local HIV measurement instruments. TeleForm versions made it possible for local data to be entered online through the University of Oklahoma server and integrated with other multisite data using unique record numbers (URNs).

FIGURE 2.2. Patient flow diagram for San Ysidro Health Center (SYHC) HIV testing and case management department.

D

 

During annual site visits, the leadership of the Centro de Evaluación provided support and guidance when needed on evaluation-related activities. The visits proved useful for the project evaluation activities in general. The UCSD evaluation team met with the Pacific AETC director during the first project months. Her participation in monthly meetings helped identify individual site training needs and provide a source of additional funding to support staff development and education.

CASE STUDY “José” was an at-risk, Spanish-language-dominant, Latino MSM contacted by a female outreach worker at a local trolley station. He was given a test location card with information on where to go for an HIV test. José presented for HIV testing at the clinic the following week, where he received an incentive to return for results. The incentive was a $10 gift certificate to a local grocery store. On the day of his test, he was invited to become a participant in the SPNS study. The HIV test counselor explained the purpose and conditions of the study, read the voluntary consent statement, enrolled him in the study, and administered two data collection instruments: a demographic survey and an HIV risk assessment survey. The HIV test was performed, and José was asked to return in 5 days for his HIV test results. When José returned for his test results, he learned that he was HIV positive. He was immediately assigned a bilingual case manager. José’s first appointment with the case manager took place within 48 hours of learning his HIV status. During that first meeting, the case manager asked questions to assess José’s psychosocial needs and described the HIV medical care services. The data collection instruments used for program evaluation were completed during the initial assessment meeting. The surveys (i.e., the multisite modules) became part of José’s case management record. José agreed to enroll in medical care and was given information on other clinic services. José continues to seek medical care and case management services at the clinic. He also sees the bilingual mental health counselor and participates in the weekly support group.

Role of Consumers in Determining Agency Policy

Two consumer focus groups were used to obtain feedback on barriers to accessing HIV services. From those groups, it was learned that both men and women wanted improved access to clinical trials. This information was used for a pilot study funded by the National Institutes of Health, Center on Minority Health and Health Disparities, to explore barriers to HIV clinical trials for Latinas living with HIV.

Based on data from the study, UCSD sought to continue collaborating with SYHC to expand the study to include Latinos and HIV service providers and has since been awarded a 5-year grant5 from the National Institutes of Mental Health to improve understanding of barriers to HIV clinical trials and issues related to access to care.

Overview of SPNS Initiative Evaluation

Training and Staffing

The evaluation coordinator trained personnel at each site during first year of the project. The SYHC project coordinator met monthly with partner site representatives to discuss implementation challenges. Staff understanding of the project was critical to their buy-in, and it contributed to program stability at the sites throughout the grant period. Significant staff turnover occurred at only one partner site.

Outreach to populations at risk for HIV varied by the type of population served. For example, at VCC and CSP, promotores (bilingual lay health workers) conducted outreach activities with farmworkers. Initially, CSP promotores were inexperienced in the field of HIV/AIDS and were hesitant to ask personal questions involving sexual practices and orientation. The evaluation team provided peer-based training for new rural promotores in which experienced urban outreach workers taught effective HIV/AIDS outreach strategies. In addition, the AETC arranged for a promotor specialist from Arizona to train the CSP promotores. Training improved their HIV/AIDS outreach activities and services.

Community outreach workers trained specifically to conduct HIV/AIDS outreach performed outreach activities at SYHC and FHCSD. The enhanced HIV/AIDS outreach training helped in the data collection process for the project.

Development of Local Data Collection Instruments

Four local evaluation measures were used in this project (Table 2.1). The HIV Test Demographic Survey developed in Year 2 used items from the multisite demographic and risk factor instruments (Modules A and D, respectively; see Chapter 1 in this volume for additional information). The Treatment Adherence Counseling Form was developed in Year 3 to study the relationship of psychosocial factors to HIV medication adherence. The instrument was developed collaboratively by the UCSD Evaluation Unit and the treatment education staff at Comprehensive Health Centers. Quality of care was measured using Module G (see Chapter 1), a multisite instrument designed to measure patient satisfaction with the care services provided. In addition, two focus groups were created in 2002 to explore patient perceptions about access to care and related issues.

Patient Participation

Patients were read an informed consent form that outlined the risks and benefits of project participation. Participants received an incentive (a $10 grocery store voucher) when they returned for HIV test results. Clinic staff administered local modules at testing, so HIV-negative participants were enrolled in the study as well.

Working With Institutional Review Boards

The UCSD Human Research Protections Program (HRPP), the university’s institutional review board, oversees protection of study participants, adherence to university and Federal standards of research ethics (e.g., Health Insurance Portability and Accountability Act of 1996), and reviews all research-related projects at UCSD. Participant consent forms, protocols, and project activities were reviewed and approved by the UCSD HRPP. Each participant was read a voluntary consent form in his or her preferred language.

TABLE 2.1. Local Evaluation Instrument Overview

Description of Measure	Purpose
1. Outreach (group and individual)	Examine relationship between outreach contacts and HIV testing
2. Demographics of persons tested for HIV	Provide a profile of people reached for HIV testing
3. HIV test and return results	Compare clients who returned for HIV test results with those who did not return
4. Treatment adherence counseling	Explore psychosocial factors related to HIV medication adherence

 

Challenges in Collecting and Processing Data

The Southern California Border HIV/AIDS Project required extensive data collection from each participant. Data collection was carried out primarily by clinic staff. The process consumed considerable staff time, particularly that of case managers.

From the project’s inception, the evaluation team worked closely with SYHC and clinic partner sites to address staff concerns and questions regarding data collection activities.

Data processing presented a set of unique challenges, such as tracking missing or incomplete data from forms, ensuring that consent forms were received for each study participant, and monitoring the ways clinic staff were documenting information. On a bimonthly basis, the data manager generated lists of missing or incomplete participant data for staff follow-up. Toward the end of the project, it became increasingly difficult to retrieve missing information from clinic sites. Close attention to missing data throughout the project, however, minimized the total amount of missing information.

One initial challenge for all grantees involved in the Southern California Border HIV/AIDS Project was achieving consensus on the wording and English–Spanish translations of data collection instruments. A professional translator translated the documents, and project leadership reviewed the materials carefully prior to approval. Some regional differences in local word meanings presented challenges, but consensus was reached by including the various meanings in a codebook for personnel administering the instruments. Local instruments also were translated by a professional translator.

Value of Partnership With the Evaluation Center

For most clinic staff, the Southern California Border HIV/AIDS Project was their first research experience. Training and technical support provided many new learning opportunities. Clinic-specific databases were developed to track patients in case management. In addition, a treatment adherence form was created on the basis of feedback from clinic sites with support from Comprehensive Health Centers’ treatment adherence program. SYHC chose to adopt this form for use in its system beyond the study.

Data Collection Mechanisms

All hard copies of evaluation instruments were maintained in a locked file. Participant data were entered online through the evaluation center server, and local databases used a secure, firewall-protected server. Databases used a URN linked to the participant’s name in a separate database that was password protected and available only to key staff. Individual data were identified using only the URN. Local evaluation instruments captured information described in Table 2.2.

Status of Local Evaluation Activities

Data collection for local instruments ended June 30, 2004. Multisite data collection ended September 30, 2004. Efforts to locate missing data continued until December 30, 2004. During the last months of Year 5, the evaluation team generated information for a report to HRSA, which included findings to be used for dissemination at professional meetings and for peer-reviewed publications. Project dissemination activities are listed in Appendix 2.B.

Lessons Learned

The collaboration between the lead agency and partner CHCs in the Southern California Border HIV/AIDS Project strengthened the ties between CHCs in San Diego and Imperial County. The SPNS initiative built trust among staff across partner sites and increased interest in continuing to work together, a result that should benefit the California–Baja California border region as a whole.

TABLE 2.2. Local Measurement Instruments by Select Variables and Count

Description of Measure	Select Major Variables	Total Collected at All Four Partner Sites (7/1/01–4/04)
Case management referrals	Referrals at first contact Common referrals at first contact Successful referrals by verification	229
Client service knowledge	Knowledge of core services at first contact Knowledge of core services prior to first contact	192
Treatment adherence counseling	Client support available Number of missed medication doses in past 30 days Patient education	217 (includes repeat measures)
Outreach by individual contacts	Number of persons contacted by gender Risk behavior by types	7,672
Outreach by group contacts	Estimated size of group Risk behavior by types	398
Select demographics of clients tested	Gender and socioeconomic status Number of border crossings	3,771
HIV tests and return numbers	Number of persons tested Number of persons who returned for results	3,000

 

At the national level, the SPNS initiative enabled lead agency staff to learn about other CHCs providing services along the U.S.–Mexico border as well as about similarities and differences across SPNS sites, particularly with regard to populations served. It became evident that differences needed to be considered in planning HIV/AIDS services to meet the needs of the diverse Latino population living along the U.S.–Mexico border.

Additional lessons from the 5-year project are as follows:

• Flexibility is needed to allow for integration of changes when new instruments are introduced or revised to meet the needs of the project.
• A realistic time period must be allocated for document translation, pilot testing, protocol development, and staff training.
• Training of promotores in HIV outreach must include issues of social stigma associated with HIV and how to build trust in order to ask sensitive risk assessment questions. Using experienced promotores or outreach workers to teach outreach strategies was found to be effective.
• Development and implementation of interagency agreements and contracts consumed a great deal of administrative time, and planning in advance is necessary.
• High staff turnover affects evaluation and requires additional staff time for training and oversight.
• Buy-in by clinic managers overseeing the project was critical. Leadership needs to be actively involved because staff enthusiasm and support for a project wanes over time. When staff have competing demands on their time for data collection, projects with less funding tend to receive less attention.
• Reaching the target population is critical to planning project outcomes. At one site, the target population was modified when sufficient numbers of youth sex workers were not found.
• Risk behaviors, not sexual orientation, must be targeted in planning prevention outreach strategies.
• The relationship between lead agency staff, the evaluation team, and clinic staff partners must be based on a foundation of mutual respect and trust. This foundation sets the stage for a productive relationship.
• Client profiles, such as risk behavior exposure, varied by site and geographic area.
• To ensure consistent quality of data, staff roles and lines of authority must be clear.
• Clinics engage in a variety of internal and external outreach activities to increase community awareness; those efforts may have effects other than increased rates of HIV testing.
• It was difficult to standardize incentive types (all worth $10) and to determine whether incentives motivated people to return for HIV test results.
• Collaboration between lead agency administration and evaluation staff facilitated data collection monitoring.

Summary

A factor vital to the success of the Southern California Border HIV/AIDS Project was leadership participation in development of project goals at all levels. Both the project coordinator and evaluation team had strong community ties and an understanding of the cultural background of the target population. In addition, SYHC administration supported the goals of the project and the work involved in collaboration with other sites to achieve the goals of the SPNS initiative.

References

County of San Diego, Health and Human Services Agency, Public Health Services. (2007). HIV/AIDS epidemiology report 2007. San Diego, CA: County of San Diego. Retrieved June 15, 2007, from www2.sdcounty.ca.gov/hhsa/documents/AnnualReport2007final.pdf

Health Resources and Services Administration, HIV/AIDS Bureau. (2003). Advancing HIV/AIDS care along the U.S./Mexico border: A report on the Border Health Initiative. Rockville, MD: U.S. Department of Health and Human Services. Available at: www.ask.hrsa.gov/detail.cfm?PubID=HAB00326

Ramirez, R., & de la Cruz, G. P. (2003, June). The Hispanic population in the United States: March 2002. Current Population Reports (U.S. Census Bureau Pub. No. P20-545). Washington, DC: U.S. Department of Commerce. Retrieved July 2007 from www.census.gov/prod/2003pubs/p20-545.pdf

Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. L. 109–415.

San Diego Association of Governments. (2000). Data warehouse. Retrieved August 8, 2007, from http://datawarehouse.sandag.org/default.asp?g=2&gs=35&t20=%2B&o=d&l=1.

San Diego Association of Governments. (2003). Census 2000 profile: San Ysidro Community Planning Area, City of San Diego. Retrieved June 15, 2007, from http://profilewarehouse.sandag.org/profiles/cen00/sdcpa1433cen00.pdf

San Diego Association of Governments. (2006). Population and housing estimates, Subregional Area 22: South Bay. Fast facts. Retrieved August 8, 2007, from http://profilewarehouse.sandag.org/profiles/est/sra22est.pdf

UCLA Center for Health Policy Research. (2002). The state of health insurance in California: Findings from the 2001 California Health Interview Survey. Retrieved August 8, 2007, from www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=28

U.S. Census Bureau. (2001). Census 2000 demographic profile highlights. Retrieved July 30, 2007, from http://factfinder.census.gov/home/saff/main.html?_lang=en

APPENDIX 2.A. Logic Model: Southern California Border HIV/AIDS Project (San Diego, CA, and Imperial County, CA)

				Outcomes**
	Inputs*	Activities	Outputs*	Initial	Intermediate	Long-Term
	Program Goal I: Increase early detection of Latino/a population infected with HIV
1a	Clinicas de Salud del Pueblo Imperial County Community health center (CHC) promotora CHC case manager Comprehensive Health Center (technical assistance [TA]; treatment education and advocacy)	HIV education and testing outreach	Est. number of contacts per year: 2,500 farm workers (1,500 male, 1,000 female) Est. number of HIV+ clients from all points of entry into system: 10 per year	Increase number of persons tested 1. Local testing form	Increase HIV+ access to primary care referral Case management referral for follow-up	Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease
1b	San Ysidro Health Center Outreach worker CHC case manager Comprehensive Health Centers (TA; treatment education and advocacy)	HIV education and testing outreach	Est. number of contacts per year: 180 transborder Latinos, 300 Latinas 2. Est. number of HIV+ clients from all points of entry into system: 44 per year	Increase number of persons tested 1. Local testing form	Increase HIV+ access to primary care referral Case management referral for follow-up	Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease
1c	Family Health Centers Outreach worker Data entry person CHC case manager Comprehensive Health Centers (TA; treatment education and advocacy)	HIV education and testing outreach	Est. number of contacts per year through outreach and testing: 250 Latino men who have sex with men (MSM) 2. Est. number of HIV+ Latino MSM clients from contacts from all points of entry into case management: 20 per year	Increase number of persons tested 1. Local testing form	Increase HIV+ access to primary care referral	Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease
1d	Vista Community Clinic Outreach worker Bilingual case manager Comprehensive Health Centers (TA; treatment education and advocacy)	HIV education and testing outreach	Est. number of contacts: 100 Latina sex workers, 500 Latino farm workers, 200 newly immigrated Latino MSM. 2. Est. number of HIV+ clients from contacts from all points of entry into system: 8 per year	Increase number of persons tested 1. Local testing form	Case management referral for follow-up Increase HIV+ access to primary care referral Case management referral for follow-up	Early identification of clients at risk for HIV infection and enrollment into primary care systems at earlier stage of disease
2	SPNS coordinator CHC site coordinator CHC promotores (Imperial Co.) CHC health workers	Implement referral program (access to testing)	Approximately 5,000 referral cards distributed (tracked in monthly report)	Number of clients who come for testing and indicate receipt of a referral card	—	Improved client access to and use of services
3	Project coordinator CHC site coordinator	Social marketing plan for four individual sites	Culturally appropriate marketing tools developed to reach at least 2,000 of target population	Number of clients indicating knowledge of marketing effort	—	Improved client access to and use of services
	Program Goal II: Increase access to comprehensive HIV primary care for individuals diagnosed with HIV/AIDS
4	SPNS coordinator CHC site coordinator University of California, San Diego (UCSD) evaluation field coordinator	Strengthen referral network (includes referring clients for services in Mexico as well as United States)	Develop supplement to existing resource guide	Resource guide to be distributed to four CHC sites and a minimum of 20 county agencies	—	Improve system response by increasing access to primary care
	Program Goal III: Enhance capacity of ambulatory care/primary clinics to provide culturally effective care for individuals with HIV/AIDS
5	SPNS coordinator CHC site coordinator UCSD AIDS Education and Training Center (AETC)	AETC miniresidency	Clinic providers receive AETC training as needed	Provider needs and self-perceived confidence assessed	—	Increase quality of medical care
6	CHC site coordinator	Promote adoption of coordinated services (use South Bay Region model to promote clientcentered services)	Client-centered service model implemented in Clinicas de Salud del Pueblo (CSP)	Increase number of San Ysidro Health Center model core services at CSP	—	Increase quality of medical care and social services at CSP
7	SPNS coordinator CHC site coordinator UCSD evaluation unit	Develop “Aspects of Culturally Effective Care” training curriculum Hold in-service training on delivery of culturally effective care	“Aspects of Culturally Effective Care” curriculum developed Five to 10 providers or staff per site receive training (implement Year 3)	Increase in provider knowledge of delivering culturally effective care	—	Enhance quality of HIV primary care services and social services

* Year 1 activities: obtain baseline measures (e.g., number tested in target population, current number of referrals, knowledge of services) and
needs assessments.
** Process evaluation will be carried out throughout the initiative. It will include clinic provider and staff feedback on the initiative and client
assessment of quality of services. Qualitative measures will include community-based focus groups and context evaluation measures.

Special Projects of National Significance (SPNS) coordinator and evaluation field coordinator will be involved with sites as needed to facilitate programmatic
and evaluation activities, respectively. Estimated number of contacts will include number of contacts made in individual and group settings
as well as repeated contacts with the same individual in the target population.

Appendix 2.B. Dissemination Activities

Many dissemination activities were conducted through-out the project period. Project dissemination included the following activities:

• Presentation to Association of Community Health Outreach Workers (ACHOW), July 2002
• Presentation at U.S. Conference on AIDS, September 2002 and September 2003
• Interview, HIV/AIDS documentary, San Diego’s KGTV 10, October 2002
• Presentation to National Alliance of State and Territorial AIDS Directors, October 2002
• Presentation at Binational HIV/STD Conference, November 2002
• Radio interview on Radio Bilingüe, December 2002
• Presentation at Binational HIV Roundtable II, December 2002
• Poster presentation at American Public Health Association, November 2003
• Presentations at U.S.–Mexico Border Health Association Meetings, April 2003, May 2004, and June 2005
• Participation in Binational AIDS Research Forum at Universidad de Baja California at Tijuana (University of Baja California), March 2004
• Poster presentation at Ryan White CARE Act Grantee Conference, Washington, DC, August 2004
• Presentation at HIV Binational Conference, San Diego, CA, October 2004
• Presentation at Coalition of Latino AIDS Service Providers (CLASP), November 2004

Appendix 2.C. Additional Resources

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Besser, R. E., Pakiz, B., Schulte, J. M., Alvarado, S., Zell, E. R., Kenyon, T. A., et al. (2001). Risk factors for positive Mantou tuberculin skin tests in children in San Diego, California: Evidence for boosting and possible foodborne transmission. Pediatrics, 108(2), 305–310.

Centers for Disease Control and Prevention. (2001). HIV testing among racial/ethnic minorities—United States, 1999. MMWR: Morbidity and Mortality Weekly Report, 50(47):1054–1058. Retrieved January 26, 2003, from www.cdc.gov/mmwr/preview/mmwrhtml/mm5047a3.htm

Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention. (2002). HIV/AIDS among Hispanics in the United States. Retrieved March 11, 2002, from www.cdc.gov/hiv/hispanics/resources/factsheets/hispanic.htm

Denzin, N. K., & Lincoln, Y. S. (Eds.). (1994). Handbook of qualitative research. Thousand Oaks, CA: Sage.

Doyle, T. J., & Bryan, R. T. (2000). Infectious disease morbidity in the U.S. region bordering Mexico, 1990–1998. Journal of Infectious Diseases, 182, 1503–1510.

Guendelman, S., & Jasis, M. (1992). Giving birth across the border: The San Diego–Tijuana connection. Social Science and Medicine, 34(4), 419–425.

Guendelman, S., & Jasis, M. (1990). Measuring Tijuana residents’ choice of Mexican or U.S. health care services. Public Health Reports, 105(6), 575–583.

Guzman, B. (2001). The Hispanic population (Census 2000 Brief). Washington, DC: U.S. Census Bureau. Retrieved June 15, 2007, from www.census.gov/prod/2001pubs/c2kbr01-3.pdf

Kaiser Family Foundation. (2004). State health facts online. Retrieved January 26, 2003, from www.statehealthfacts.org

Land, H., & Hudson, S. (2002). HIV serostatus and factors related to physical and mental well-being
in Latina family AIDS caregivers. Social Science Medicine, 54, 157–159.

Notzon, S. (2004). Healthy Gente 2010: History and health measures. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved July 2007 from http://www.borderhealth.net/notzon.ppt

Organista, K. C., Balls Organista, P., Garcia de Alba, G. J. E., Castillo Moran, M. A., & Ureta Carrillo, M. E. (1997). Survey of condom-related beliefs, behaviors, and perceived social norms in Mexican migrant laborers. Journal of Community Health, 22(3), 185–198.

Qualitative Solutions and Research. (1997). Non-Numerical Unstructured Data Indexing, Searching and Theorizing user guide. Thousand Oaks, CA: Sage.

Ruiz, J. D. (2002, March). HIV prevalence, risk behaviors and access to care among young Latino MSM in San Diego, California and Tijuana, Mexico (data presentation). Sacramento: California Department of Health Services, Epidemiology Branch, Office of AIDS.

Salgado de Snyder, V. N., Diaz Perez, M. J., & Maldonado, M. (1996). AIDS: Risk behaviors among rural Mexican women married to migrant workers in the United States. AIDS Education and Prevention, 8(2), 134–142.

San Diego County Office of AIDS Coordination and San Diego HIV Health Services Planning Council. (2002). Comprehensive plan for services 2004–2006 for people living with HIV/AIDS in San Diego County. San Diego, CA: Author.

San Diego County Office of AIDS Coordination. (2002). San Diego County AIDS cases: Regional proportion of cases by five year cohort, reported through March 31, 2002. San Diego, CA: Author.

Secretaría de Salud de México, Centro Nacional Para la Prevención y Control del VIH/SIDA. (2003). Epidemiología del VIH/SIDA en México en el año 2003. Retrieved January 26, 2003, from www.salud.gob.mx/conasida

Southern California Border HIV/AIDS Project. (2002). Unpublished data. University of California, San Diego.

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Van der Veer Martens, B. (2001) Research techniques for information management [Science and Technology Center Course: IST 501]. Syracuse, NY: Syracuse University. Retrieved June 10, 2004, from http://www.theorywatch.com/ist501/syllabus.html

Webb, C., & Kevern, J. (2000). Focus groups as a research method: A critique of some aspects of their use in nursing research. Journal of Advanced Nursing, 33(6), 798–805.

4 In this chapter, Latino refers to both men and women of Hispanic heritage, unless otherwise specified.