Factors associated with drug-related harms related to policing in Tijuana, Mexico

<p>Abstract</p> <p>Objective</p> <p>To assess factors associated with drug-related harms related to policing among injection drug users (IDUs) in Tijuana, Mexico.</p> <p>Methods</p> <p>IDUs who were over 18 years old and had injected drugs within the last six months were recruited via respondent-driven sampling and underwent questionnaires and testing for HIV (human immunodeficiency virus), syphilis and TB (tuberculosis). Random effects logistic regression was used to simultaneously model factors associated with five drug-related harms related to policing practices in the prior six months (i.e., police led them to rush injections; affected where they bought drugs; affected locations where they used drugs; feared that police will interfere with their drug use; receptive syringe sharing).</p> <p>Results</p> <p>Of 727 IDUs, 85% were male; median age was 38 years. Within the last 6 months, 231 (32%) of IDUs reported that police had led them to rush injections, affected where they bought or used drugs or were very afraid police would interfere with their drug use, or shared syringes. Factors independently associated with drug-related harms related to policing within the last six months included: recent arrest, homelessness, higher frequencies of drug injection, use of methamphetamine, using the local needle exchange program and perceiving a decrease in the purity of at least one drug.</p> <p>Conclusions</p> <p>IDUs who experienced drug-related harms related to policing were those who were most affected by other micro and macro influences in the physical risk environment. Police education programs are needed to ensure that policing practices do not exacerbate risky behaviors or discourage protective behaviors such as needle exchange program use, which undermines the right to health for people who inject drugs.</p

A qualitative assessment of stakeholder perceptions and socio-cultural influences on the acceptability of harm reduction programs in Tijuana, Mexico

<p>Abstract</p> <p>Background</p> <p>The Mexico-U.S. border region is experiencing rising rates of blood-borne infections among injection drug users (IDUs), emphasizing the need for harm reduction interventions.</p> <p>Methods</p> <p>We assessed the religious and cultural factors affecting the acceptability and feasibility of three harm reduction interventions – Needle exchange programs (NEPs), syringe vending machines, and safer injection facilities (SIFs) – in Tijuana, Mexico. In-depth qualitative interviews were conducted with 40 community stakeholders to explore cultural and societal-related themes.</p> <p>Results</p> <p>Themes that emerged included Tijuana's location as a border city, family values, and culture as a mediator of social stigma and empathy towards IDUs. Perception of low levels of both awareness and socio-cultural readiness for harm reduction interventions was noted. Religious culture emerged as a theme, highlighting the important role religious leaders play in determining community responses to harm reduction and rehabilitation strategies for IDUs. The influence of religious culture on stakeholders' opinions concerning harm reduction interventions was evidenced by discussions of family and social values, stigma, and resulting policies.</p> <p>Conclusion</p> <p>Religion and politics were described as both a perceived benefit and deterrent, highlighting the need to further explore the overall influences of culture on the acceptability and implementation of harm reduction programs for drug users.</p

Reducing harm from HIV/AIDS misconceptions among female sex workers in Tijuana and Ciudad Juarez, Mexico: A cross sectional analysis

Abstract Background HIV prevalence is increasing among female sex workers (FSWs) in Mexico’s Northern border region, who experience multiple occupational risks. Improving vulnerable populations’ education, empowerment, and access to preventive services are important components of harm reduction strategies. Given the increasing interest in adapting harm reduction principles from drug use to sex work and other public health responses to the HIV epidemic, we used a sex work harm reduction framework to guide our investigation of FSWs’ HIV knowledge. Methods From 2004–2006, FSWs aged ≥18 years in Tijuana and Ciudad Juarez participated in a behavioral intervention study and completed structured interviews. Measures included HIV knowledge assessment and factors within each domain of our theoretical framework for sex work harms: (1) socio-demographic factors that may lead to sex work, (2) sex work characteristics and behaviors that may lead to harm, and (3) mutually reinforcing harms that lead to sex work and result from it (e.g., drug abuse). Negative binomial regression identified factors independently associated with suboptimal HIV knowledge (i.e., incorrect responses during the HIV knowledge assessment). Results Among 924 FSWs, the median proportion of incorrect responses was nearly one third (28% incorrect). Examination of item responses revealed misconceptions regarding specific transmission and prevention mechanisms, including prevention of mother to child transmission. Suboptimal HIV knowledge was independently associated with older age, lower education, living in Tijuana (vs. Ciudad Juarez), inconsistent condom use for vaginal sex with male clients, and lacking prior HIV testing. Conclusions Our application of a sex work harm reduction framework to the study of FSWs’ HIV knowledge is an important first step in enhancing HIV prevention efforts in Northern Mexican border cities. Our findings imply that interventions should identify and discredit local HIV misconceptions to improve knowledge of specific HIV transmission routes and self-protective strategies (e.g., condom negotiation). Interventions will require materials appropriate for women from diverse socio-economic backgrounds and may benefit from innovative harm reduction approaches such as peer education and outreach

Pandemic (H1N1) 2009 Surveillance in Marginalized Populations, Tijuana, Mexico

To detect early cases of pandemic (H1N1) 2009 infection, in 2009 we surveyed 303 persons from marginalized populations of drug users, sex workers, and homeless persons in Tijuana, Mexico. Six confirmed cases of pandemic (H1N1) 2009 were detected, and the use of rapid, mobile influenza testing was demonstrated

Cost-Effectiveness of an Intervention to Reduce HIV/STI Incidence and Promote Condom Use among Female Sex Workers in the Mexico–US Border Region

Previous research demonstrated efficacy of a brief behavioral intervention to reduce incidence of HIV and sexually transmitted infections (STIs) among female sex workers (FSWs) in Tijuana and Ciudad Juarez, Mexico, cities on Mexico's border with the US. We assessed this intervention's cost-effectiveness.A life-time Markov model was developed to estimate HIV cases prevented, changes in quality-adjusted life expectancy (QALE), and costs per additional quality-adjusted life year gained (QALY), comparing (in US$2,009) no intervention to a once-only and annual intervention. Future costs and health benefits were discounted annually at 3$183. For FSWs receiving the intervention annually, there were 29 additional HIV cases prevented and 4.5 additional months of QALE compared to the once-only intervention. The additional cost per QALY was US$1,075. When highly active antiretroviral therapy (HAART) was included in the model, the annual intervention strategy resulted in net savings and dominated both once-only and no intervention strategies, and remained robust across extensive sensitivity analyses. Even when considering clinical benefits from HAART, ignoring added costs, the cost per QALY gained remained below three times the Mexican GDP per capita, and below established cost-effectiveness thresholds.This brief intervention was shown to be cost-effective among FSWs in two Mexico-US border cities and may have application for FSWs in other resource-limited settings.ClinicalTrials.gov NCT00338845

Injection Drug Use as a Mediator Between Client-perpetrated Abuse and HIV Status Among Female Sex Workers in Two Mexico-US Border Cities

We examined relationships between client-perpetrated emotional, physical, and sexual abuse, injection drug use, and HIV-serostatus among 924 female sex workers (FSWs) in Tijuana and Ciudad Juarez, two large Mexico-US border cities. We hypothesized that FSWs’ injection drug use would mediate the relationship between client-perpetrated abuse and HIV-seropositivity. The prevalence of client-perpetrated emotional, physical, and sexual abuse in the past 6 months was 26, 18, and 10% respectively; prevalence of current injection drug use and HIV was 12 and 6%, respectively. Logistic regression analyses revealed that client-perpetrated sexual abuse was significantly associated with HIV-seropositivity and injection drug use, and that injection drug use was positively associated with HIV-seropositivity. Injection drug use partially mediated the relationship between client-perpetrated sexual abuse and HIV-seropositivity. Results suggest the need to address client-perpetrated violence and injection drug use when assessing HIV risk among FSWs

A Qualitative View of Drug Use Behaviors of Mexican Male Injection Drug Users Deported from the United States

Deportees are a hidden yet highly vulnerable and numerous population. Significantly, little data exists about the substance use and deportation experiences of Mexicans deported from the United States. This pilot qualitative study describes illicit drug use behaviors among 24 Mexico-born male injection drug users (IDUs), ≥18 years old, residing in Tijuana, Mexico who self-identified as deportees from the United States. In-person interviews were conducted in Tijuana, Mexico in 2008. Content analysis of interview transcripts identified major themes in participants’ experiences. Few participants had personal or family exposures to illicit drugs prior to their first U.S. migration. Participants reported numerous deportations. Social (i.e., friends/family, post-migration stressors) and environmental factors (e.g., drug availability) were perceived to contribute to substance use initiation in the U.S. Drugs consumed in the United States included marijuana, heroin, cocaine, methamphetamine, and crack. More than half of men were IDUs prior to deportation. Addiction and justice system experiences reportedly contributed to deportation. After deportation, several men injected new drugs, primarily heroin or methamphetamine, or a combination of both drugs. Many men perceived an increase in their substance use after deportation and reported shame and loss of familial social and economic support. Early intervention is needed to stem illicit drug use in Mexican migrant youths. Binational cooperation around migrant health issues is warranted. Migrant-oriented programs may expand components that address mental health and drug use behaviors in an effort to reduce transmission of blood-borne infections. Special considerations are merited for substance users in correctional systems in the United States and Mexico, as well as substance users in United States immigration detention centers. The health status and health behaviors of deportees are likely to impact receiving Mexican communities. Programs that address health, social, and economic issues may aid deportees in resettling in Mexico

Respondent-Driven Sampling of Injection Drug Users in Two U.S.–Mexico Border Cities: Recruitment Dynamics and Impact on Estimates of HIV and Syphilis Prevalence

Respondent-driven sampling (RDS), a chain referral sampling approach, is increasingly used to recruit participants from hard-to-reach populations, such as injection drug users (IDUs). Using RDS, we recruited IDUs in Tijuana and Ciudad (Cd.) Juárez, two Mexican cities bordering San Diego, CA and El Paso, TX, respectively, and compared recruitment dynamics, reported network size, and estimates of HIV and syphilis prevalence. Between February and April 2005, we used RDS to recruit IDUs in Tijuana (15 seeds, 207 recruits) and Cd. Juárez (9 seeds, 197 recruits), Mexico for a cross-sectional study of behavioral and contextual factors associated with HIV, HCV and syphilis infections. All subjects provided informed consent, an anonymous interview, and a venous blood sample for serologic testing of HIV, HCV, HBV (Cd. Juárez only) and syphilis antibody. Log-linear models were used to analyze the association between the state of the recruiter and that of the recruitee in the referral chains, and population estimates of the presence of syphilis antibody were obtained, correcting for biased sampling using RDS-based estimators. Sampling of the targeted 200 recruits per city was achieved rapidly (2 months in Tijuana, 2 weeks in Cd. Juárez). After excluding seeds and missing data, the sample prevalence of HCV, HIV and syphilis were 96.6, 1.9 and 13.5% respectively in Tijuana, and 95.3, 4.1, and 2.7% respectively in Cd. Juárez (where HBV prevalence was 84.7%). Syphilis cases were clustered in recruitment trees. RDS-corrected estimates of syphilis antibody prevalence ranged from 12.8 to 26.8% in Tijuana and from 2.9 to 15.6% in Ciudad Juárez, depending on how recruitment patterns were modeled, and assumptions about how network size affected an individual’s probability of being included in the sample. RDS was an effective method to rapidly recruit IDUs in these cities. Although the frequency of HIV was low, syphilis prevalence was high, particularly in Tijuana. RDS-corrected estimates of syphilis prevalence were sensitive to model assumptions, suggesting that further validation of RDS is necessary

Social and Structural Factors Associated with HIV Infection among Female Sex Workers Who Inject Drugs in the Mexico-US Border Region

BACKGROUND: FSWs who inject drugs (FSW-IDUs) can acquire HIV through high risk sexual and injection behaviors. We studied correlates of HIV infection among FSW-IDUs in northern Mexico, where sex work is quasi-legal and syringes can be legally obtained without a prescription. METHODS: FSW-IDUs>18 years old who reported injecting drugs and recent unprotected sex with clients in Tijuana and Ciudad Juarez underwent surveys and HIV/STI testing. Logistic regression identified correlates of HIV infection. RESULTS: Of 620 FSW-IDUs, prevalence of HIV, gonorrhea, Chlamydia, trichomonas, syphilis titers ≥1:8, or any of these infections was 5.3%, 4%, 13%, 35%, 10% and 72%, respectively. Compared to other FSW-IDUs, HIV-positive women were more likely to: have syphilis titers ≥1:8 (36% vs. 9%, p<0.001), often/always inject drugs with clients (55% vs. 32%, p = 0.01), and experience confiscation of syringes by police (49% vs. 28%, p = 0.02). Factors independently associated with HIV infection were syphilis titers ≥1:8, often/always injecting with clients and police confiscation of syringes. Women who obtained syringes from NEPs (needle exchange programs) within the last month had lower odds of HIV infection associated with active syphilis, but among non-NEP attenders, the odds of HIV infection associated with active syphilis was significantly elevated. CONCLUSIONS: Factors operating in both the micro-social environment (i.e., injecting drugs with clients) and policy environment (i.e., having syringes confiscated by police, attending NEPs) predominated as factors associated with risk of HIV infection, rather than individual-level risk behaviors. Interventions should target unjustified policing practices, clients' risk behaviors and HIV/STI prevention through NEPs

Polydrug Use among IDUs in Tijuana, Mexico: Correlates of Methamphetamine Use and Route of Administration by Gender

Tijuana is situated on the Mexico–USA border adjacent to San Diego, CA, on a major drug trafficking route. Increased methamphetamine trafficking in recent years has created a local consumption market. We examined factors associated with methamphetamine use and routes of administration by gender among injection drug users (IDUs). From 2006–2007, IDUs ≥18 years old in Tijuana were recruited using respondent-driven sampling, interviewed, and tested for HIV, syphilis, and TB. Logistic regression was used to assess associations with methamphetamine use (past 6 months), stratified by gender. Among 1,056 participants, methamphetamine use was more commonly reported among females compared to males (80% vs. 68%, p < 0.01), particularly, methamphetamine smoking (57% vs. 34%; p < 0.01). Among females (N = 158), being aged >35 years (AOR, 0.2; 95% CI, 0.1–0.6) was associated with methamphetamine use. Among males (N = 898), being aged >35 years (AOR, 0.5; 95% CI, 0.3–0.6), homeless (AOR, 1.4 (0.9–2.2)), and ever reporting sex with another male (MSM; AOR, 1.9; 95% CI, 1.4–2.7) were associated with methamphetamine use. Among males, a history of MSM was associated with injection, while sex trade and >2 casual sex partners were associated with multiple routes of administration. HIV was higher among both males and females reporting injection as the only route of methamphetamine administration. Methamphetamine use is highly prevalent among IDUs in Tijuana, especially among females. Routes of administration differed by gender and subgroup which has important implications for tailoring harm reduction interventions and drug abuse treatment