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Team Puerto Rico, Western Region
(Team Puerto Rico Website)
The island of Puerto Rico continues to be one of the epicenters of the AIDS epidemic in the Western Hemisphere. ECI serves the western region of Puerto Rico which includes the fifteen municipalities of Aguadilla, Aguada, Isabela, Moca, San Sebastián, Lajas, Sabana Grande, San Germán, Añasco, Cabo Rojo, Hormigueros, Las Marias, Maricao, Mayagüez, and Rincón. The main office of ECI PR is located at Estancia Corazón, Inc, in Mayaqüez, Puerto Rico
The purpose of ECI Puerto Rico is to support the assessment of HIV/AIDS care in the western region of Puerto Rico by developing a systematic approach and a structural mechanism to facilitate and promote collaboration between multiple service organizations. This collaboration is designed to result in concrete improvements in the care of PLWHA, their families, and caregivers. Partner organizations include health care, drug, and mental treatment centers, central and local or municipal governments, health professionals, residential treatment facilities, soup kitchens, emergency shelters, academic institutions, non-government organizations and PLWHA associations. Overall, ECI Puerto Rico’s multisectoral partnership includes a team of 27 members. This team has succeeded in bringing together a multisectoral collaboration combining their academic, research, municipal, personal, and agency resources to identify and meet the needs of the local situation.
Managed Care in the Western Region
According to the 1993 Puerto Rico Health Act, the island’s government-owned traditional health care system would be replaced by private insurance carriers that contract with provider organizations for managed care services. In June 1998, the Western Region was the last region integrated into the new policy of managed care. Managed care, a "holistic system of clinical and financial organizations partnering to provide health care in a cost efficient way", was expected to achieve better health outcomes by anticipating patient needs and quickly linking patients with appropriate services. In the Western Region however, the effectiveness of managed care in addressing and providing physical and mental health care for vulnerable populations such as drug users, who are at high risk for HIV infection can be readily questioned. Under the former system of health care, indigent and uninsured individuals were able to access services with little or no cost. The region’s relatively short history with managed care, however, has not yet revealed whether these highly vulnerable groups will be able to receive sufficient care under the new system.
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Comprised of over 300,000 residents, the western region of Puerto Rico with its mountainous topography and shortage of mass transportation lacks access to many health services. Health service providers possess limited capability, health care agencies rarely work together to provide services. According to the Puerto Rico Labor Department, 22% of people living in the region are unemployed, 85% are below the federal poverty level, 85% are Medicaid (a US government funded medical program) eligible, and 80% of the population is considered medically indigent. High rates of teen pregnancy and births are comparable other Latin American countries immersed in extreme poverty, such as Brazil and Haiti.
Phase I & II -- Situation Analysis and Research
Western Region Demographics
(Surveillance Report January 2004)
• AIDS cases in Puerto Rico – 28,227
• AIDS cases in Western Region – 2,285
• Adult/adolescent cases – 98.9%; Pediatric – 1.1%
Estimated 10 HIV cases per identified AIDS cases
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Prior to ECI, there was no research on the needs of PLWHA or the services available to them in the western region of Puerto Rico. The Puerto Rico ECI Team conducted a needs assessment and situation analysis by gathering information from physicians, caregivers, and PLWHA from six agencies that provide services in the western region. Data collection included qualitative interviews, focus group discussions, and the administration of a Social Support Questionnaire, and an AIDS Knowledge Questionnaire, adapted from a questionnaire designed by the students of the Medical Sciences School of the University of Puerto Rico. The questionnaires examined attitudes toward availability and quality of health care facilities and health workers. Issues of personal health status were also examined, including perceived benefit from services received and the negative effects of illness, such as depression, loss of income and social isolation. Responses were evaluated based on the Center for Epidemiological Studies Depression Scale, Life Styles and Sexual Practices Scale, Evaluation of Services Scale, Needs Checklist, and AIDS-Related Symptoms Checklist in order to identify the PLWHA profile and assess the comprehensiveness and accessibility of HIV/AIDS services in the region.
Preliminary results of the Puerto Rico Team’s situation analysis have not yet been analyzed. These new insights into transmission and PLWHA needs, once analyzed, will help the team develop interventions that are relevant to local contexts.
Principal transmission modes:
• injecting drug use (45.5% males, 35.6% females)
• heterosexual contact (19% males, 64% females)
• men who have sex with men (25.3%).
PLWHA needs:
• economic support (70.8%)
• short and long-term housing (50%)
• psychological services (40.1%)
• medication (34%)
• medical treatment (37.7%).
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The Team’s survey revealed that symptoms of depression are present in 98.1% of PLWHAs. Data analysis revealed that depression is significantly correlated with the amount of social support, with satisfaction of social support, with the number of needs and with the number of AIDS-related symptoms. Coordination of inter-agency appointments, mental and psychological services, and economic support were identified as gaps or areas where services need to be improved. The Team was greatly concerned by the high level of depression, and identified mental health services as an area of particular focus for future ECI activities.
Phase III- Implementation
All team activities are guided by a set of core principles that were collectively developed and agreed upon by team members. First, open communication regarding project guidelines, objectives, activities, and roles and responsibilities is and will continue to be the foundation of all Team work. Second, continued identification and coordination of members’ strengths, resources or connections, priorities, and interests will enable the Team to best utilize its resources despite changes in membership. Commitment is the third element of the Team’s core principles, such that member involvement will be based on their individual strengths, resources, and interests. Finally, collaboration in resolving difficulties and developing workplans, research design and data collection tools will continue to be part of regular Team meetings. In anticipation of successful implementation, the Team has developed a protocol for self-monitoring and evaluation based on these core prinicples.
Impact of ECI in the Western Region of Puerto Rico
Even prior to the actual implementation of interventions, the ECI Team’s collaboration has had significant impact on the western region. Several Team members are also part of CBOs in the region. These individuals drew on the relationships they built as ECI partners to encourage collaboration among CBOs that once had competed. For example, based on the ECI model of multisectoral partnership, the Coalition for the Homeless in the Western Region has been re-activated and was incorporated in December of 2003. A Center for Studies for Professionals has been established for continuing education for health professionals working with HIV/AIDS.
ECI’s example of multisectoral collaboration is not the only aspect of the initiative that has gained attention and achieved results. Central and local government organizations have contacted the team to request the results of the situation analysis for use in their grant applications. In response to the team’s assessment of underserved areas, the region’s Migrant Health Clinic now has a mobile unit that complements existing medical services by helping to identify and serve HIV positive persons in hard to reach areas.
Benefits of membership in ECI PR
In October 2003, the ECI PR team met for a three-day monitoring and evaluation workshop. Along with developing a strategy for evaluating future interventions and research, the Team participated in a Focus Group Discussion of the non-monetary benefits of being part of the ECI PR Team. The following benefits were identified:
• Student involvement in meaningful research benefiting the western region of Puerto Rico
• Professional relationship building with professionals with similar interests
• Personal and professional growth opportunities
• Materials and resource availability
• Research translating into practice making a positive impact in the community
• Feeling of hopelessness transformed into hope by being part of a group filled with energy, resources, and commitment
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The Future of ECI Puerto Rico
A primary goal of the ECI PR Team is to continue to foster coordination of care through inter-agency collaboration. Two specific events that will support this goal are the design & implementation of a Caregivers Workshop for health care providers in the western region and the participation of the Team in the Puerto Rican Homelessness Summit.. In addition, preliminary meetings have been held with senior administration at local universities regarding the initiation of an inter-university collaboration to form an AIDS care research institute. The goal of all these activities would be to foster an environment in which individuals and organizations join their experience, influence, and resources to improve HIV/AIDS care in western Puerto Rico.
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