The effect of public health-oriented drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico: an epidemic modelling study

Background As countries embark on public health-oriented drug law reform, health impact evaluations are needed. In 2012, Mexico mandated the narcomenudeo reform, which depenalised the possession of small amounts of drugs and instituted drug treatment instead of incarceration. We investigated the past and future effect of this drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico. Methods In this epidemic modelling study, we used data from the El Cuete IV cohort study to develop a deterministic model of injecting and sexual HIV transmission in people who inject drugs in Tijuana between 2012 and 2030. The population was stratified by sex, incarceration status, syringe confiscation by the police, HIV stage, and exposure to drug treatment or rehabilitation (either opioid agonist treatment or compulsory drug abstinence programmes). We modelled the effect of these exposures on HIV risk in people who inject drugs, estimating the effect of observed and potential future reform enforcement levels. Findings In 2011, prior to the narcomenudeo reform, 547 (75%) of 733 people who inject drugs in the El Cuete cohort reported having ever been incarcerated, on average five times since starting injecting. Modelling estimated the limited reform implementation averted 2% (95% CI 0·2–3·0) of new HIV infections in people who inject drugs between 2012 and 2017. If implementation reduced incarceration in people who inject drugs by 80% from 2018 onward, 9% (95% CI 4–16) of new HIV infections between 2018 and 2030 could be averted, with 21% (10–33) averted if people who inject drugs were referred to opioid agonist treatment instead of being incarcerated. Referral to compulsory drug abstinence programmes instead of prison could have a lower or potentially negative impact with −2% (95% CI −23 to 9) infections averted. Interpretation Mexican drug law reform has had a negligible effect on the HIV epidemic among people who inject drugs in Tijuana. However, appropriate implementation could markedly reduce HIV incidence if linked to opioid agonist treatment. Unfortunately, compulsory drug abstinence programmes are the main type of drug rehabilitation available and their expansion could potentially increase HIV transmission

The effectiveness of compulsory drug treatment: A systematic review.

BackgroundDespite widespread implementation of compulsory treatment modalities for drug dependence, there has been no systematic evaluation of the scientific evidence on the effectiveness of compulsory drug treatment.MethodsWe conducted a systematic review of studies assessing the outcomes of compulsory treatment. We conducted a search in duplicate of all relevant peer-reviewed scientific literature evaluating compulsory treatment modalities. The following academic databases were searched: PubMed, PAIS International, Proquest, PsycINFO, Web of Science, Soc Abstracts, JSTOR, EBSCO/Academic Search Complete, REDALYC, SciELO Brazil. We also searched the Internet, and article reference lists, from database inception to July 15th, 2015. Eligibility criteria are as follows: peer-reviewed scientific studies presenting original data. Primary outcome of interest was post-treatment drug use. Secondary outcome of interest was post-treatment criminal recidivism.ResultsOf an initial 430 potential studies identified, nine quantitative studies met the inclusion criteria. Studies evaluated compulsory treatment options including drug detention facilities, short (i.e., 21-day) and long-term (i.e., 6 months) inpatient treatment, community-based treatment, group-based outpatient treatment, and prison-based treatment. Three studies (33%) reported no significant impacts of compulsory treatment compared with control interventions. Two studies (22%) found equivocal results but did not compare against a control condition. Two studies (22%) observed negative impacts of compulsory treatment on criminal recidivism. Two studies (22%) observed positive impacts of compulsory inpatient treatment on criminal recidivism and drug use.ConclusionThere is limited scientific literature evaluating compulsory drug treatment. Evidence does not, on the whole, suggest improved outcomes related to compulsory treatment approaches, with some studies suggesting potential harms. Given the potential for human rights abuses within compulsory treatment settings, non-compulsory treatment modalities should be prioritized by policymakers seeking to reduce drug-related harms

¿Cómo son las mujeres que pasan la barrera social? Un análisis de mujeres usuarias de drogas y alcohol en México. Resultados de la Encuesta Nacional de Adicciones 2008. En: Mujeres y Adicciones. Secretaría de Salud, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Instituto Nacional de las Mujeres. D.F. pp 73-129. ISBN: 978-607-460-177-0

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Risk of non‐fatal overdose and polysubstance use in a longitudinal study with people who inject drugs in Tijuana, Mexico

IntroductionAmong people who inject drugs (PWID), polysubstance use has been associated with fatal and non-fatal overdose (NFOD). However, the risk of overdose due to the cumulative number of various recently used drug types remains unexplored. We estimated the risk of NFOD for different polysubstance use categories among PWID in Tijuana, Mexico.MethodsData came from 661 participants followed for 2 years in Proyecto El Cuete-IV, an ongoing prospective cohort of PWID. A multivariable Cox model was used to assess the cumulative impact of polysubstance use on the time to NFOD. We used the Cochran-Armitage test to evaluate a dose-response relationship between number of polysubstance use categories and NFOD.ResultsWe observed 115 NFOD among 1029.2 person-years of follow-up (incidence rate: 11.2 per 100 person-years; 95% confidence interval [CI] 9.3-13.3). Relative to those who used one drug class, the adjusted hazard ratio of NFOD for individuals reporting using two drug classes was 1.11 (95% CI 0.69-1.79), three drug classes was 2.00 (95% CI 1.16-3.44) and for those reporting three compared to two was 1.79 (95% CI 1.09-2.97). A significant Cochran-Armitage trend test (P < 0.001) suggested a dose-response relationship.Discussion and conclusionsPolysubstance use was associated with increased risk of NFOD with a dose-response relationship over 2 years. We identified a subgroup of PWID at high risk of NFOD who reported concurrent use of opioids, stimulants and benzodiazepines. Prioritising tailored harm reduction and overdose prevention interventions for PWID who use multiple substances in Tijuana is needed

Evaluating the impact of public health oriented drug law reform on HIV incidence among people who inject drugs in Tijuana, Mexico: an epidemic modelling analysis

Background: As countries embark on public health-­oriented drug law reform, health impact evaluations are needed. In 2012, Mexico mandated the ‘Narcomenudeo reform’, depenalising possession of small amounts of drugs and instituting drug treatment instead of incarceration. We investigated its impact on HIV incidence among people who iinject drugs (PWID) in Tijuana, Mexico. Methods: We developed a deterministic model of injecting and sexual HIV transmission among PWID in Tijuana disaggregated by sex, incarceration status, syringe confiscation by the police, and exposure to drug treatment/”rehabilitation” (either opioid agonist therapy (OAT) or compulsory drug abstinence programmes (CAP)). We modelled the effect of these exposures on HIV risk among PWID, estimating the impact of observed and potential future reform enforcement levels. Findings: Modelling estimated the limited reform implementation averted 2% [95% Confidence Interval (CI): 0.2-­15 3%] of new HIV infections among PWID between 2012-­2017. If implementation reduced incarceration among PWID by 80% from 2018 onward, 9% [95% CI: 4-­16%] of new HIV infections between 2018-­2030 could be averted, with 21% [95% CI: 10­‐33%] averted if PWID were referred to OAT instead of incarcerated. However, referral to CAP instead of prison could have a lower or potentially negative impact with -­2% [95% CI: 23­‐9%] infections averted. Interpretation Mexican drug law reform has had negligible impact on the HIV epidemic among PWID in Tijuana. Appropriate implementation could markedly reduce HIV incidence if linked to OAT. Unfortunately, CAP are the predominant type of drug “rehabilitation” available and their expansion could potentially increase HIV transmission

Examining the gender composition of drug injecting initiation events: A mixed methods investigation of three North American contexts

BackgroundGender influences the health and social risks faced by individuals initiating drug injecting. Using mixed methods across three settings in North America, we investigated the gender composition of injection initiation events and the gendered risk environments in which they occurred.MethodsThe PReventing Injecting by Modifying Existing Responses (PRIMER) study pooled data from three prospective community-recruited cohorts of people who inject drugs (PWID) in San Diego, USA, Vancouver, Canada, and Tijuana, Mexico. A qualitative subsample provided narrative data on their experiences of, and the contexts for, injection initiation events. Guided by Rhodes' risk environment framework, we examined the gender composition of initiation events stratified by city, and analyzed qualitative data using abductive thematic analyses.ResultsAmong 2,622 PWID (Tijuana: n = 531; San Diego: n = 352; Vancouver: n = 1,739), 112 (4.3%) reported providing initiation assistance to injection-naïve individuals in the previous six months. The proportion of gender concordant (e.g., male-male) initiation pairs varied, (χ2 = 10.32, p <0.001) with greater than expected concordance among pairs in Tijuana compared with those in Vancouver or San Diego. Sixty-one interviews provided context for the discrepancy across sites by highlighting the gendered injection initiation risk environments of prison/jail detention in Tijuana, intimate partnerships in San Diego, and overdose risk in Vancouver.ConclusionsThese results highlight how gender influences injection initiation events within spatial, social, and economic risk environments, and how this influence varies across settings. These findings can inform interventions to reduce the risk of injection initiation and related harms