Fernando Macías-González

HIV prevention efforts in Mexico often overlook heterosexual-identified men who have sex with men (H-MSM), a subgroup at elevated risk for HIV. Using data from the 2021-2022 National Survey on Sexual and Gender Diversity (ENDISEG), we examined condomless sex among cisgender MSM, categorizing participants by sexual identity (heterosexual vs. gay, bisexual, or other non-heterosexual), sexual behavior (only male partners vs. both male and female), and their combinations: H-MSM, H-MSMW, GB+MSM, and GB+MSMW. Among cisgender men, 3.9% (n = 775) reported a male sexual partner in the past year, and 41% of them identified as heterosexual. Condomless sex was reported by 63.8% of MSM overall and was most common among H-MSM (74.4%). Probit regression analysis showed significantly lower probabilities of condomless sex among H-MSMW (-19.8%), GB+MSM (-14.8%), and GB+MSMW (-15.9%) compared to H-MSM. Additional risk factors included older age, lower education, and depression. These findings underscore the limitations of considering MSM as one group and reveal a sizable, high-risk subgroup that may be missed by current HIV programs. Effective prevention strategies must integrate sexual identity and behavior and be adapted to Mexico's sociocultural context. Identity-sensitive approaches, particularly for H-MSM and H-MSMW, are essential to reduce HIV transmission in this population.

PURPOSE: Cost containment and efficiency in the provision of health care are primary concerns for health systems that aim to provide affordable, high-quality care. Between 2005 and 2015, Seguro Poplar's Fund against Catastrophic Expenditures (FPGC) funded ALL treatment in Mexico. Before January 1, 2011, FPGC reimbursed a fixed amount per patient according to risk. In 2011, the per capita reimbursement method changed to fee for service. We used this natural experiment to estimate the impact of the reimbursement policy change on average expenditure and quality of care for ALL treatment in Mexico. METHODS: We used nationwide reimbursement data from the Seguro Poplar's FPGC from 2005 to 2015. We created a patient cohort to assess 3-year survival and estimate the average reimbursement before and after the fee-for-service policy. We examined survival and expenditure impacts, controlling for patients' and providers' characteristics, including sex, risk (standard and high), the volume of patients served, type of institution (federally funded v other), and level of care. To quantify the impact, we used a regression discontinuity approach. RESULTS: The average reimbursement for standard-risk patients in the 3-year survival cohort was $16,512 US dollars (USD; 95% CI, 16,042 to 17,032) before 2011 and $10,205 USD (95% CI, 4,659 to 12,541) under the fee-for-service reimbursement scheme after 2011. The average annual reimbursement per patient decreased by 136% among high-risk patients. The reduction was also significant for the standard-risk cohort, although the magnitude was substantially smaller (34%). CONCLUSION: As Mexico's government is currently restructuring the health system, our study provides evidence of the efficiency and effectiveness of the funding mechanism in the Mexican context. It also serves as a proof of concept for using administrative data to evaluate economic performance and quality of care of publicly funded health programs.