Karibu na sirenji (Near the Syringe): Applying mixed methods to characterize the HIV risk environment and gender differences among persons who inject drugs in Nairobi, Kenya

Thesis (Ph.D.)--University of Washington, 2021In Kenya, people who inject drugs (PWID) are considered a key population that are disproportionately affected by the HIV and hepatitis C (HCV) epidemics, with prevalence estimates reaching upwards of 19-25% and 11-36%, respectively. Kenya’s national HIV program scale-up for key populations has resulted in significant reductions in HIV incidence among PWID, but service gaps remain with only 43% of PWID aware of their HIV status, 68% of PWID living with HIV (PWID-LH) taking antiretroviral treatment (ART), and 64% of those on ART are virally suppressed. HIV care outcomes improved with the introduction of opioid agonist therapy (OAT) clinics that provide integrated methadone and HIV treatment services; however, OAT service access among PWID remains low (26%). Ecological frameworks, like the Modified Social Ecological Model and HIV risk environment frameworks, provide a holistic approach to understanding HIV, HCV and drug-related outcomes by looking beyond individual-level factors to examine the surrounding structural factors (e.g., political, economic, community, social) that are largely outside of an individual’s control, but often influence individual-level risk behaviors (e.g., syringe sharing, sexual risks, engagement in care). While ecological frameworks have been applied in other PWID-LH settings, their application has been limited in Kenya, yet, may be beneficial to current HIV strategies. To better understand environmental influences that affect HIV risk and service uptake, we applied a mixed methods design to (1) qualitatively characterize HIV and HCV barriers and facilitators to care among PWID through the lens of peer educators, including resource recommendations to improve service uptake; (2) qualitatively describe the Nairobi-specific HIV risk environment surrounding PWID-LH; and (3a) quantitatively identify distinct subgroups of PWID-LH based on demographic and risk environment factors using cluster analysis techniques in order to (3b) assess whether empirically derived clusters are associated with suboptimal care (i.e., discontinued care or treatment, virally unsuppressed) among PWID-LH

Live to tell: Narratives of methamphetamine-using women taken hostage by their intimate partners in San Diego, CA

BackgroundHostage-taking, an overlooked phenomenon in public health, constitutes a severe form of intimate partner violence and may be a precursor to female homicide within relationships characterized by substance use. Criminal justice studies indicate that most hostage incidents are male-driven events with more than half of all cases associated with a prior history of violence and substance use. Methamphetamine use increases a woman's risk of partner violence, with methamphetamine-using individuals being up to nine times more likely to commit homicide. As homicide is the most lethal outcome of partner violence and methamphetamine use, this study aims to characterize the potential role of hostage-taking within these intersecting epidemics.MethodsMethamphetamine-using women enrolled in an HIV behavioural intervention trial (FASTLANE-II) who reported experiences of partner violence were purposively selected to participate in qualitative sub-studies (Women's Study I & II). Twenty-nine women, ages 26-57, participated in semi-structured interviews that discussed relationship dynamics, partner violence, drug use and sexual practices.ResultsFindings indicated four cases of women being held hostage by a partner, with two women describing two separate hostage experiences. Women discussed partner jealousy, drug withdrawal symptoms, heightened emotional states from methamphetamine use, and escalating violent incidents as factors leading up to hostage-taking. Factors influencing lack of reporting incidents to law enforcement included having a criminal record, fear of partner retaliation, and intentions to terminate the relationship when the partner is incarcerated.ConclusionEducating women on the warning signs of hostage-taking within the context of methamphetamine use and promoting behaviour change among male perpetrators can contribute to reducing the risk of homicide. Furthermore, bridging the gap between health services and law enforcement agencies and providing comprehensive services that address the needs of methamphetamine-using women in violent relationships can prevent or minimize potential harm to vulnerable women

“Come on Baby. You Know I Love You”: African American Women’s Experiences of Communication with Male Partners and Disclosure in the Context of Unwanted Sex

We examined African American women's experiences of communication with their male intimate partners a couple of hours before and after an incident of unwanted sex. We also examined women's experiences of disclosure following an incident of unwanted sex. Semi-structured qualitative interviews were conducted with a community-based sample of sexually active African American women (n = 19) reporting at least one incident of sexual coercion (i.e., being pressured into unwanted sex without consent) by an intimate male partner since the age of 18. Our analysis was guided by "the sexual division of power" from Connell's (1987) theory of gender and power. Data were analyzed inductively by examining the interviews for common themes in the following domains: communication before the unwanted sex, communication after the unwanted sex, and disclosure to others. Men pressured partners for unwanted sex through verbal and non-verbal tactics, ranging from pestering and blunt requests for sex to verbal bullying and violence. Many women responded by clearly saying no. However, many women also described eventually ceasing to resist their partners and engaging in unwanted sex. After the unwanted sex, men actively and passively avoided discussing the incident. Although many women discussed the unwanted sex with family and friends, less women disclosed to trained professionals. In some cases, women did not discuss the incident with anyone at all. These findings indicate that, when addressing sexual violence against women, there is a need to target men as well as the norms of masculinity that underpin physical and sexual violence against women

Women's Perspectives on Female-Initiated Barrier Methods for the Prevention of HIV in the Context of Methamphetamine Use and Partner Violence

BackgroundFemale-initiated barrier methods for the prevention of HIV may be an effective alternative for drug-using women who are unable to negotiate safe sex, often as a result of physical and/or sexual partner violence.MethodsUtilizing a SAVA (substance abuse, violence, and AIDS) syndemic framework, we qualitatively examined perspectives on female condoms and vaginal microbicides among 18 women with histories of methamphetamine abuse and partner violence in San Diego, California.FindingsMost women were not interested in female condoms owing to perceived discomfort, difficulty of insertion, time-intensive effort, and unappealing appearance. Alternatively, most women viewed vaginal microbicides as a useful method. Positive aspects included convenience, ability to disguise as a lubricant, and a sense of control and empowerment. Concerns included possible side effects, timing of application, and unfavorable characteristics of the gel. Acceptability of female-initiated barrier methods was context dependent (i.e., partner type, level of drug use and violence that characterized the sexual relationship).ConclusionsFindings indicate that efforts are needed to address barriers identified for vaginal microbicides to increase its uptake in future HIV prevention trials and marketing of future Food and Drug Administration-approved products. Strategies should address gender-based inequalities (e.g., partner violence) experienced by drug-using women and promote female empowerment. Education on female-initiated barrier methods is also needed for women who use drugs, as well as health care providers and other professionals providing sexual health care and contraception to women with histories of drug use and partner violence

Implementing Mexico’s “Narcomenudeo” Drug Law Reform

In 2009, Mexico decriminalized small-scale drug possession, instituting drug treatment diversion in lieu of incarceration. To assess initial reform impact, our mixed methods study integrated a structured questionnaire with in-depth interviews assessing legal knowledge, police encounters, and risk behaviors among people who inject drugs (PWID) in Tijuana. Between 2010 and 2013, we recruited 737 adults; 32 participated in qualitative interviews. Only 11% reported being aware of the reform; virtually none experienced its operational components. Narratives underscored the law’s irrelevance to PWID; 699 (98%) saw police practice as generally inconsistent with formal law. Instead of treatment diversion, police encounters were associated with risk behaviors, including syringe sharing (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.09-1.46) and polydrug use (OR = 2.11; 95% CI = 1.38-3.22). As drug policy reforms gain global momentum, ancillary structural interventions are needed to improve their public health benefit

Implementing Mexico's "Narcomenudeo" Drug Law Reform: A Mixed Methods Assessment of Early Experiences Among People Who Inject Drugs

In 2009, Mexico decriminalized small-scale drug possession, instituting drug treatment diversion in lieu of incarceration. To assess initial reform impact, our mixed methods study integrated a structured questionnaire with in-depth interviews assessing legal knowledge, police encounters, and risk behaviors among people who inject drugs (PWID) in Tijuana. Between 2010 and 2013, we recruited 737 adults; 32 participated in qualitative interviews. Only 11% reported being aware of the reform; virtually none experienced its operational components. Narratives underscored the law’s irrelevance to PWID; 699 (98%) saw police practice as generally inconsistent with formal law. Instead of treatment diversion, police encounters were associated with risk behaviors, including syringe sharing (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.09-1.46) and polydrug use (OR = 2.11; 95% CI = 1.38-3.22). As drug policy reforms gain global momentum, ancillary structural interventions are needed to improve their public health benefit

"When you get old like this … you don't run those risks anymore": influence of age on sexual risk behaviors and condom use attitudes among methamphetamine-using heterosexual women with a history of partner violence.

BackgroundDrug use and partner violence affect older women, yet few studies highlight age-specific HIV risks and prevention strategies. This study compares sexual risk behaviors, condom use attitudes, and HIV knowledge between midlife/older women (ages 45+) and younger women (ages 18-44) reporting methamphetamine use and partner violence in San Diego, California.MethodsOur mixed methods study used themes from a qualitative substudy (n = 18) to inform logistic regression analysis of baseline data from an HIV behavioral intervention trial (n = 154).FindingsAge-related qualitative themes included physiologic determinants, HIV knowledge, and "dodging the bullet," referring to a lifetime of uncertainty surrounding HIV serostatus after engaging in unsafe drug and sex practices. Midlife/older age was associated with never being married (24.2% vs. 51.2; p = .03), having less than a high school education/GED (12.1% vs. 34.7%; p = .04), lower condom use self-efficacy (2.87 vs. 3.19; p = .03), lower positive outcome expectancies (1.9 vs. 2.1; p = .04), and lower HIV knowledge (85.3% vs. 89.7%; p = .04); however, sexual risk behaviors were not associated with age group. In the multivariate analysis, midlife/older age remained independently associated with lower condom use self-efficacy (adjusted odds ratio, 0.49; 95% CI, 0.27-0.87) and lower HIV knowledge (adjusted odds ratio, 0.96; 95% CI, 0.93-0.99).ConclusionsMidlife/older methamphetamine-using women with experiences of partner violence present similar sexual risk profiles, but possess different HIV-related knowledge and attitudes toward prevention methods compared with their younger counterparts. Clinicians and public health practitioners can have a positive impact on this overlooked population by assessing HIV risks during routine screenings, encouraging HIV testing, and providing age-appropriate HIV prevention education

Social and environmental determinants influencing injection drug use and HIV risk among two sister cities on the US–Mexico border: a comparative cross-sectional study, 2016–2018

Abstract The economic, social, cultural and political milieus that influence injection drug-related HIV risk behaviors along the US–Mexico border in the previous decade have been studied comparing cities on an East–West axis. In an effort to inform interventions targeting factors beyond the individual level, we used a cross-sectional study design comparing people who inject drugs during 2016–2018, living on a North–South axis, in two cities—Ciudad Juárez, Chihuahua, Mexico and El Paso, Texas, USA—situated at the midpoint of the 2000 US–Mexico borderland stretch. We conceptualize injection drug use and its antecedents and consequences as influenced by factors operating at various levels of influence. Results of analysis comparing samples recruited from each border city indicated significant differences in demographic, socioeconomic, micro- and macro-level factors that affect risk. Similarities emerged in individual-level risk behaviors and some dynamics of risk at the drug use site most frequented to use drugs. In addition, analyses testing associations across samples indicated that different contextual factors such as characteristics of the drug use sites influenced syringe sharing. In this article, we reflect on the potential tailored interventions needed to target the context of HIV transmission risk among people who use drugs and reside in binational environment