The SPNS Border Health Initiative has developed a wide range of approaches for conducting outreach to migrant farm workers and other transborder populations in the U.S./Mexico border region. The goal of the SPNS initiative is to identify people who are HIVinfected and refer them to HIV primary care in the early stages of the disease. The objectives of the outreach efforts are to raise awareness about HIV, make HIV testing more accessible, and bring people living with HIV into care.

The SPNS Border Health Initiative uses both personal one-to-one contact and social marketing to target the transient, largely Latino population in the border region. The approaches reflect the unique nature of the border area, where people are generally hard to reach and language is a barrier for Spanish-speakers attempting to access healthcare and HIV services.

One-to-one outreach interventions include use of street outreach workers and lay community health workers such as promotores, outreach to migrant farm workers
in the workplace, outreach at truck stops and border crossings where commuters wait in lines of traffic for periods of time, and outreach to Latina women at events such as house parties.

The social marketing campaigns use public media such as radio and TV to convey messages to Hispanic communities, particularly rural and migrant communities. SPNS border outreach interventions are sensitive to the needs of people in the Latino culture, which values trust and relationship-building.

The outreach approaches developed by the SPNS projects can be used by other organizations along the U.S./Mexico border to improve HIV/AIDS education and services as well as to serve similar Hispanic populations throughout the United States and abroad. The models can be further expanded to reach underserved, hard-to-reach, at-risk individuals of any ethnicity and in any geographic location. They can be adapted to other resource-poor settings internationally where issues related to refugees, borders, racial and ethnic minorities, and language barriers exist.

The purpose of the Special Projects of National Significance (SPNS) program is to advance knowledge and skills in the delivery of health and social services to people with HIV infection who are financially disadvantaged and medically underserved. The SPNS program, which is administered by the Health Resources and Services
Administration (HRSA) HIV/AIDS Bureau (HAB), is funded by the Ryan White Comprehensive AIDS Resources Emergency Act, also known as the CARE Act.
when necessary.

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Lay community health workers are people from the targeted community who have been trained to provide basic health education, amplifying the work of professional health workers. The use of community health workers can help to overcome the challenges facing Hispanic people along the border, which include language differences, cultural barriers, issues of immigration status, and frequent border
crossings. In addition, community health workers supplement the inadequate number of health professionals in the region, particularly ones who are culturally sensitive,
Spanish-speaking, and experts in HIV/AIDS.

Promotores, community health workers who are volunteers or “lay leaders,” are trained to provide health education and prevention services to community members. They are often described as “natural helpers” who are members of informal community support
systems. In the past many AIDS agencies have not used promotores for HIV education and prevention because of concerns such as: the need for confidentiality and for counseling before and after HIV testing; cultural barriers related to asking about high risk behaviors and sexual practices; and, the highly technical nature of information regarding HIV treatment, including antiretroviral therapies. However, the SPNS Border Health Initiative demonstrates that promotores can be a valuable part of
the health care team who provide vital links with the targeted communities.

Key point: Use trusted people from within the community to conduct the outreach, in Spanish when necessary.

LAY COMMUNITY HEALTH WORKERS IN ARIZONA

The Arizona Border HIV/AIDS Care Project (ABHAC) uses promotores in several of the counties it serves. The targeted populations are men who have sex with men (MSM), injecting drug users (IDUs), sex partners of migrant farm workers, and Latina women. Promotores from the collaborating agencies Puentes de Amistad and Campesinos Sin Frontera work with Health Department staff to conduct
the outreach.

LAY COMMUNITY HEALTH WORKERS IN NEW MEXICO

The New Mexico Border Health Initiative uses health outreach workers (HOWs) to reach out to MSM, IDUs, and women. The HOWs are personally familiar with the
populations they are engaging, which increases their effectiveness as outreach workers. The HOW who targets injecting drug users is an ex-drug-user and the HOWs who target men who have sex with men are MSMs themselves — they know the local places to go to reach their audiences and how to discuss risk behaviors and risk reduction with them.

To reach rural communities, the initiative partners with local promotores projects that lack the capacity to conduct HIV testing and counseling. These include Mujeres Unidas en Acción contra el SIDA (MUACES, or Women United in Action Against AIDS) and at the Ben Archer Health Center (a maternal and child health center). HOWs organize house parties and make door-to-door contacts, accept referrals
from promotores, and conduct weekly testing at MUACES.

The HOWs work with individuals to identify their risk behaviors, teach them about safer behaviors, develop risk reduction plans, and make referrals when needed. They
conduct on-site oral HIV testing (OraSure). Outreach is conducted both door-to-door and in groups called platicas, which are talks in the home with up to eight participants.

Outreach in the city also includes visits to the halfway house, homeless shelter, and domestic violence shelter, and to areas where drug use and sex work occur.

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Truck drivers are considered at high risk for HIV infection because they are away from home for long periods of time, which often leads them to engage in casual sex or to seek the services of sex workers. Truck stops provide critical opportunities for identifying drivers as they cross back and forth between the U.S. and Mexico. SPNS border projects conduct outreach to truck drivers and other travelers who commute across the border, taking advantage of their rest stops as well as the long waiting times in lines of traffic at border crossings. The outreach staff hand out HIV
prevention information and condoms, and in some projects, they conduct in-field HIV counseling and testing.

Key point: Reach people who are in transit by approaching them at truck stops and border crossings. Go to locations where people are waiting for long periods, which provides opportunities to talk at length.

OUTREACH AT TRUCK STOPS AND BORDER CROSSINGS IN ARIZONA

The Arizona Border HIV/AIDS Care Project (ABHAC) conducts outreach at truck stops and at border crossings along the Mexico/Arizona border. On the Arizona side in Nogales, outreach staff from Platicamos Salud (Let’s talk about health) have talked to truck drivers at the truck stop and beside their trucks while they waited to cross the
border. Outreach staff supplies the truck stops with prevention kits containing condoms and educational and testing information. On the Sonora, Mexico side of the
border, staff from the collaborating agency Centro de Información para la Salud (CISAL) walk the line of trucks waiting to cross the border into the U.S., talking with
drivers and providing them with HIV information.

OUTREACH AT TRUCK STOPS AND BORDER CROSSINGS IN CALIFORNIA

The Southern California Border HIV/AIDS Project reaches out to transborder Latinos at the San Ysidro/Tijuana border-crossing area. Outreach is conducted around the
San Ysidro border entrance in bus stops, restaurants, and other businesses where people are waiting for rides or going back and forth to work. People frequent fast-food
restaurants and other businesses to eat, wait for rides, wait for incoming family members, or conduct business among other travelers. The waiting factor allows outreach workers more time to share information and, when possible, to test individuals for HIV.

Outreach workers also target the small buses that run along San Ysidro Boulevard from the border, displaying brochures and talking with commuters. Outreach is
productive here because the small buses have a 20- to 30- minute wait time. The bus drivers, who have become familiar with the outreach workers, refer people to the
workers and even allow time for HIV tests.

Although people who are commuting are in transit, they come through at the same time every day, making followup possible. Staff return to a given location for at least 2
weeks in a row, enabling them to find people who were tested and give them their test results.

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Several SPNS Border Initiative projects conduct outreach to migrant farm workers, which involves careful planning: obtaining cooperation of the farm foremen, adapting to
the schedules of the workers’ long days, and traveling to many different sites to meet with them. Staff conduct outreach at campsites, nurseries, corner stops, transit
stations and apartment complexes. They work in the early morning and also during the lunch hour, providing large and small group presentations as well as one-to-one testing, support, and referrals.

Key point: Go to transit and meeting locations at the times when workers gather to go to and from the fields.

OUTREACH TO MIGRANT FARM WORKERS IN ARIZONA

The Arizona Border HIV/AIDS Care Project (ABHAC) conducts outreach to migrant farm workers during the harvest season (October through February). Outreach staff and promotores talk with the workers beginning at 4 a.m. as they gather at corners, gas stations, or in the park waiting to be picked up by the buses that transport them
to the fields. Contact is also made during the workers’ lunch breaks if the mayordomo (foreman) gives permission, and outreach staff have encountered little resistance from the farm foremen. Finally, staff approach workers at the end of the workday when they are returned to the pick-up locations. Outreach staff give them information packets including HIV/AIDS and STD information, two condoms, and a card with HIV testing
site information.

OUTREACH TO MIGRANT FARM WORKERS IN CALIFORNIA

The Southern California Border HIV/AIDS Project targets migrant workers in many areas where they congregate — at bus stops, houses, packing sheds, fields, unemployment offices, markets, and directly along the U.S./Mexico border. Materials for outreach include Spanish-language brochures and novelitas on HIV. For the first contact, promotores go alone. Later, the promotores return with the person conducting HIV testing, who provides oral testing on-location and then gives results during a later
visit. HIV testing is also conducted at recovery homes, construction sites, and adult education centers.

The staff arrange their schedules around the most convenient times for the farm workers, beginning their day at the bus stops at 3 am, when farm workers are waiting for the bus to arrive. Promotores also obtain permission from packing shed supervisors to talk to the employees about HIV during their 15-minute breaks. The promotores themselves have worked in the fields and packing sheds before, and therefore they relate well to the target population.

The sex workers based near the migrant camps are women who are at especially high risk for HIV. They are contacted through a trusted promotora who has worked in community health for decades. She has arrangements with the owners of brothels to provide condoms and HIV counseling and testing to the sex workers.

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Latina women living in border areas are at risk for HIV infection because their husbands may engage in high risk behaviors while working away from home. For instance, many migrant farm workers leave home for long periods of time during crop-picking season while their wives stay at home. House parties provide culturally-appropriate, safe surroundings for reaching out to Latinas residing along the border. The party hostesses are often identified by promotoras, who are responsible for health education on many topics in the community. The parties are presented as an opportunity to participate in their community’s wellness and are not linked to the topic of HIV. The parties usually include 5-10 women who are friends invited by the hostess. Difficult topics such as sex and risk behaviors can be discussed, and education and HIV testing can occur in this confidential environment. They are staffed informally by a person from the Health Department and a promotora, who are responsible for providing prevention information as well as for conducting HIV counseling and testing.

Key point: Provide a confidential setting in which a trusted group of friends can discuss sensitive issues with a health care provider.

HOUSE PARTIES FOR LATINA WOMEN IN ARIZONA

The Arizona Border HIV/AIDS Care Project (ABHAC) uses house parties to educate Latina women about HIV testing. An increase in the number of women with HIV infection, most of whom had no risk factors other than their husbands having sex outside the marriage, prompted an aggressive outreach to increase HIV testing among Latinas.

House parties provide an opportunity for the Yuma County Health Department to educate women on multiple topics including overall health, diabetes, STDs, and HIV
prevention and testing. The participants have been receptive to talking about sensitive issues regarding sex and infidelity because they are with friends and knowledgeable, caring health professionals.

Oral HIV testing is conducted, and women retrieve their test results at the Health Department a few days after the party, where results are given in person by the Health
Department staff. The promotora only provides support if the woman chooses to disclose the result to her.

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SPNS Border Health Initiative projects have launched extensive social marketing campaigns to educate Latino communities along the border about the risk of HIV/AIDS and to encourage people to get tested for HIV and, if needed, to enter into HIV care services. Social marketing campaigns utilize Spanish language media, including radio, TV, and printed materials, to convey culturally appropriate messages to large numbers of people in the targeted communities. The goal of these campaigns is not only to provide information to large numbers of people but to change perceptions about HIV in the community.

Key point: Convey bold HIV messages in public media campaigns to normalize the idea that HIV is a community problem and to identify testing and clinical resources for people.

SOCIAL MARKETING TO BORDER COMMUNITIES IN CALIFORNIA

The Southern California Border HIV/AIDS Project conducted the Tu No Me Conoces (You Don’t Know Me) campaign targeting Latinas, MSMs, and farm workers. The campaign ran a radio commercial on four Spanish language radio stations popular with Latinos. The campaign wording was bold and direct to catch Latinos’ attention—even though it was not in line with most Latino efforts to keep illnesses like HIV/AIDS private and attuned to cultural norms. The “shock value” of the campaign was critical to normalizing the presence of HIV in the Latino community and encouraging Latinos to recognize HIV as a community problem. The ads provided a 1-800 phone number and a Web site with counseling/testing site locations.

Although two ads were originally developed, focus groups consisting of Latinas, MSMs, and farm workers selected one commercial targeting a mix of these populations.

Followup calls demonstrated that the commercial was broad enough to reach all of the target groups. Project staff believe that the campaign has brought attention to
HIV and has identified service locations for potential clients.

SOCIAL MARKETING TO BORDER COMMUNITIES IN TEXAS

Proyecto Juntos of the Valley AIDS Council in Harlingen, Texas implemented a social marketing campaign targeting Latina women in the lower Rio Grande Valley.

The aim was to educate Latinas who speak limited English about possible risks and signs of HIV disease and to motivate them to seek HIV counseling and testing. The
campaign was conducted over a 6-month period and included spots on Spanish language TV and radio. The spots were aired in the morning as well as in the afternoon during programming popular with Latina women such as “telenovelas,” or Mexican soap operas. Well-known local media personalities volunteered their time for the TV spots.

During the media campaign, Spanish/English posters and brochures were distributed to places where Latinas congregate, including “washaterias” and beauty shops.
The ads provided a phone number to call, where social marketing staff gave callers basic HIV information, screened them for HIV risks, and referred them to counseling and testing sites when appropriate. The largest source of calls received was in response to the ads on Spanish TV. The nature of the responses indicated that
there is much need among Latina women for continued education about HIV and risk.
Typical comments included:

• Nosotros como hispanas necesitamos perder el miedo y la verguenza y debemos hacernos la prueba para saber si tenemos VIH o SIDA.” (“We Hispanics need to lose our fear and shame and get tested so that we know whether we have HIV or AIDS.”)
• Es mejor prevenir que tener que lamentar.” (“It’s better to prevent than have to be sorry.”)
• Estoy muy agradecida que ustedes estan haciendo este proyecto para que nosotras nos podamos hacer la prueba gratis.” (“I am so very grateful that you
  are doing this project so that we can take the test free of cost.”)
  

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The outreach approaches developed by the SPNS Border Health Initiative include innovative ways to make personal, one-to-one contact in Spanish as well as culturally specific social marketing campaigns in Spanish language media. Using these approaches, staff and community health outreach workers such as promotores have conducted successful outreach in places where people work (eg, nurseries, farms, and truckstops along the highway), where they commute (eg, border crossings), and where they live (eg, house parties). Social marketing campaigns involve blanketing the community with messages that work to reverse the cultural norm that topics related to sexuality, including HIV, are not discussed in public.

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