Poverty and Place: Structural Determinants of Infectious Disease Risk in Mexico and Central America

Background: Structural determinants of health are gaining recognition as being a prominent force in influencing risk of infectious diseases. Both HIV and Chagas disease are strongly influenced by structural inequities and represent significant burdens of communicable disease in terms of disability-adjusted life years in Latin America. Objective: Using the risk environment framework as a guide, the primary objective of this dissertation is to explore physical, social, and individual factors associated with increased risk for two diseases of interest: HIV and Chagas disease. Specific aims of each manuscript chapter are: To test structural factors associated with smoking methamphetamine among a cohort of female sex workers (FSWs) in Tijuana, Baja California, Mexico (Chapter 2); To determine the prevalence of sexual risk behaviors, HIV, and syphilis and to analyze variables associated with inconsistent condom use among casual partners among a sample of substance using migrants residing at the Mexico/Guatemala border (Chapter 3); To determine the seroprevalence of Chagas disease in regional and international migrant populations at the Mexico/Guatemala border and assess correlates of infection including migration path, sociodemographic, and socioeconomic variables (Chapter 4). Methods: Chapter 2 uses data from a longitudinal cohort study of FSWs in Tijuana (Mapa de Salud). Chapters 3 and 4 use data from a cross-sectional study among international and regional migrants at the Mexico/Guatemala border (Cruzando Fronteras). Chapter 4 also uses data from a UC MEXUS dissertation grant on Chagas disease. Results: We found that FSWs and migrants who used substances were at heightened risk for HIV via their substance use and sexual risk behaviors. The key social and physical structural factors associated with those risk behaviors were neighborhood, housing, and access to condoms. For Chagas disease, key physical structural factors were impoverished housing and being born in a rural area. Conclusions: The risk environment framework was a useful way to conceptualize the hypothesized relationships between structural factors and individual risk behaviors. This dissertation highlights multiple areas of structural vulnerability in order to suggest potential intervention points and shed greater light on the spaces in which our participants live

Structural factors associated with methamphetamine smoking among female sex workers in Tijuana, Mexico.

INTRODUCTION AND AIMS: Smoking methamphetamine is associated with increased risk of HIV among female sex workers (FSW). The structural context of substance use is an important shaper of individual behaviour; however, structural determinants of methamphetamine use among FSWs are largely unknown. We identified individual, structural and neighbourhood factors associated with smoking methamphetamine among FSWs in the border city of Tijuana, Baja California, Mexico. DESIGN AND METHODS: A prospective cohort of 301 FSWs sampled from indoor and outdoor sex work venues throughout Tijuana participated in quantitative surveys on behaviours and mapping of home and work neighbourhoods across three visits. Multinomial logistic regression using generalised estimating equations identified individual, structural and neighbourhood variables associated with smoking methamphetamine. RESULTS: Methamphetamine use, particularly smoking, was highly prevalent among FSWs. Over half (61%) of FSWs had ever used methamphetamine in their lifetime and at baseline, 38% currently smoked methamphetamine. Smoking methamphetamine daily was associated with living in the red light district [adjusted odds ratio (AOR) = 2.72, 95% confidence interval (CI) = 1.23-6.02] and with perceived homelessness, but only among women in a good financial situation (AOR = 4.08, 95% CI = 1.58-10.50). Smoking methamphetamine less than daily was associated with older age (AOR = 1.06, 95% CI = 1.02-1.10). DISCUSSION AND CONCLUSIONS: Our findings point to the important dynamic between the residential environment and more severe methamphetamine use. FSWs may prioritise the purchase of methamphetamine over stable housing if they have the financial means. Given the high prevalence of smoking methamphetamine among FSWs in Tijuana, drug treatment options, especially for women living in the red light district, are needed

A global systematic review of Chagas disease prevalence among migrants.

Human migration has been identified as a potential factor for increased Chagas disease risk and has transformed the disease from a Latin American problem to a global one. We conducted a systematic review of the scientific literature between 2004-2014 in order to: summarize recent seroprevalence estimates of Chagas disease among Latin American migrants, in both endemic and non-endemic settings; compare seroprevalence estimates in migrants to countrywide prevalence estimates; and identify risk factors for Chagas disease among migrants. A total of 320 studies were screened and 23 studies were included. We found evidence that the prevalence of Chagas disease is higher than expected in some migrant groups and that reliance on blood donor screening prevalence estimates underestimates the burden of disease. Overall there is a dearth of high quality epidemiologic studies on the prevalence of Chagas disease in migrants, especially among intra-regional migrants within Latin America. Given that this zoonotic disease cannot likely be eradicated, improved surveillance and reporting is vital to continuing control efforts. More accurate health surveillance of both Latin American migrants and the Chagas disease burden will help countries appropriately scale up their response to this chronic disease. Overall, improved estimates of Chagas disease among migrants would likely serve to highlight the real need for better screening, diagnostics, and treatment of individuals living with the disease

Structural factors associated with methamphetamine smoking among female sex workers in Tijuana, Mexico.

Introduction and aimsSmoking methamphetamine is associated with increased risk of HIV among female sex workers (FSW). The structural context of substance use is an important shaper of individual behaviour; however, structural determinants of methamphetamine use among FSWs are largely unknown. We identified individual, structural and neighbourhood factors associated with smoking methamphetamine among FSWs in the border city of Tijuana, Baja California, Mexico.Design and methodsA prospective cohort of 301 FSWs sampled from indoor and outdoor sex work venues throughout Tijuana participated in quantitative surveys on behaviours and mapping of home and work neighbourhoods across three visits. Multinomial logistic regression using generalised estimating equations identified individual, structural and neighbourhood variables associated with smoking methamphetamine.ResultsMethamphetamine use, particularly smoking, was highly prevalent among FSWs. Over half (61%) of FSWs had ever used methamphetamine in their lifetime and at baseline, 38% currently smoked methamphetamine. Smoking methamphetamine daily was associated with living in the red light district [adjusted odds ratio (AOR) = 2.72, 95% confidence interval (CI) = 1.23-6.02] and with perceived homelessness, but only among women in a good financial situation (AOR = 4.08, 95% CI = 1.58-10.50). Smoking methamphetamine less than daily was associated with older age (AOR = 1.06, 95% CI = 1.02-1.10).Discussion and conclusionsOur findings point to the important dynamic between the residential environment and more severe methamphetamine use. FSWs may prioritise the purchase of methamphetamine over stable housing if they have the financial means. Given the high prevalence of smoking methamphetamine among FSWs in Tijuana, drug treatment options, especially for women living in the red light district, are needed

Structural factors associated with methamphetamine smoking among female sex workers in Tijuana, Mexico.

Introduction and aimsSmoking methamphetamine is associated with increased risk of HIV among female sex workers (FSW). The structural context of substance use is an important shaper of individual behaviour; however, structural determinants of methamphetamine use among FSWs are largely unknown. We identified individual, structural and neighbourhood factors associated with smoking methamphetamine among FSWs in the border city of Tijuana, Baja California, Mexico.Design and methodsA prospective cohort of 301 FSWs sampled from indoor and outdoor sex work venues throughout Tijuana participated in quantitative surveys on behaviours and mapping of home and work neighbourhoods across three visits. Multinomial logistic regression using generalised estimating equations identified individual, structural and neighbourhood variables associated with smoking methamphetamine.ResultsMethamphetamine use, particularly smoking, was highly prevalent among FSWs. Over half (61%) of FSWs had ever used methamphetamine in their lifetime and at baseline, 38% currently smoked methamphetamine. Smoking methamphetamine daily was associated with living in the red light district [adjusted odds ratio (AOR) = 2.72, 95% confidence interval (CI) = 1.23-6.02] and with perceived homelessness, but only among women in a good financial situation (AOR = 4.08, 95% CI = 1.58-10.50). Smoking methamphetamine less than daily was associated with older age (AOR = 1.06, 95% CI = 1.02-1.10).Discussion and conclusionsOur findings point to the important dynamic between the residential environment and more severe methamphetamine use. FSWs may prioritise the purchase of methamphetamine over stable housing if they have the financial means. Given the high prevalence of smoking methamphetamine among FSWs in Tijuana, drug treatment options, especially for women living in the red light district, are needed

Cultivable Bacterial Diversity in the Gut of the Chagas Disease Vector Triatoma dimidiata: Identification of Possible Bacterial Candidates for a Paratransgenesis Approach

Since bacterial symbionts play a vital role in the metabolism of hematophagous insect vectors the method known as paratrangenesis, which consists of the use of cultivable insect symbionts to interfere with the transmission of vector-transmitted pathogens has been shown to be effective in certain vector control oriented studies. In Chagas disease research a recent study introduced transgenes through a parastransgenic approach and prevented the development of a vector species for this disease. However this approach requires a previous characterization of the bacterial symbionts present in the species vector of interest, since a selection of the cultivable bacterial symbiont used is mandatory. In this study, we describe the gut bacterial diversity of Triatoma dimidiata specimens from Southern Mexico. Bacteria from both wild and laboratory-reared specimens were cultured, and resulting colonies were grown individually, harvested, and subsequently identified by 16S ribosomal loci sequencing. A total of five and three genera and a total of nine and six bacterial species were identified from field captured and laboratory reared Triatoma dimidiata specimens respectively. A majority of Gram positive bacteria were identified, which included the genera Staphylococcus, Bacillus, Brevibacterium, Micrococcus, and Delftia. Given previous studies we propose the use of Staphylococcus saprophyticus, Micrococcus luteus, and Bacillus megaterium as potential candidates for future paratransgenic efforts done with Triatoma dimidiata, which is one of the most important vectors of Chagas disease, in Central and South America. Given the vital association bacterial symbionts play in the metabolism of routes of hematophagous insect vectors Paratransgenesis consists of the use of cultivable insect symbionts to interfere with the transmission of vector-transmitted pathogens