Publications by authors named "Daniela Abramovitz"

39 Publications

Overlapping Key Populations and HIV Transmission in Tijuana, Mexico: A Modelling Analysis of Epidemic Drivers.

AIDS Behav 2021 Jul 3. Epub 2021 Jul 3.

Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK.

Tijuana, Mexico, has a concentrated HIV epidemic among overlapping key populations (KPs) including people who inject drugs (PWID), female sex workers (FSW), their male clients, and men who have sex with men (MSM). We developed a dynamic HIV transmission model among these KPs to determine the extent to which their unmet prevention and treatment needs is driving HIV transmission. Over 2020-2029 we estimated the proportion of new infections acquired in each KP, and the proportion due to their unprotected risk behaviours. We estimate that 43.7% and 55.3% of new infections are among MSM and PWID, respectively, with FSW and their clients making-up < 10% of new infections. Projections suggest 93.8% of new infections over 2020-2029 will be due to unprotected sex between MSM or unsafe injecting drug use. Prioritizing interventions addressing sexual and injecting risks among MSM and PWID are critical to controlling HIV in Tijuana.
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http://dx.doi.org/10.1007/s10461-021-03361-2DOI Listing
July 2021

Identifying counties at risk of high overdose mortality burden during the emerging fentanyl epidemic in the USA: a predictive statistical modelling study.

Lancet Public Health 2021 Jun 9. Epub 2021 Jun 9.

Department of Medicine, University of California, San Diego, CA, USA.

Background: The emergence of fentanyl around 2013 represented a new, deadly stage of the opioid epidemic in the USA. We aimed to develop a statistical regression approach to identify counties at the highest risk of high overdose mortality in the subsequent years by predicting annual county-level overdose death rates across the contiguous USA and to validate our approach against observed overdose mortality data collected between 2013 and 2018.

Methods: We fit mixed-effects negative binomial regression models to predict overdose death rates in the subsequent year for 2013-18 for all contiguous state counties in the USA (ie, excluding Alaska and Hawaii). We used publicly available county-level data related to health-care access, drug markets, socio-demographics, and the geographical spread of opioid overdose as model predictors. The crude number of county-level overdose deaths was extracted from restricted US Centers for Disease Control and Prevention mortality records. To predict county-level overdose rates for the year 201X: (1) a model was trained on county-level predictor data for the years 2010-201(X-2) paired with county-level overdose deaths for the year 2011-201(X-1); (2) county-level predictor data for the year 201(X-1) was fed into the model to predict the 201X county-level crude number of overdose deaths; and (3) the latter were converted to a population-adjusted rate. For comparison, we generated a benchmark set of predictions by applying the observed slope of change in overdose death rates in the previous year to 201(X-1) rates. To assess the predictive performance of the model, we compared predicted values (of both the model and benchmark) to observed values by (1) calculating the mean average error, root mean squared error, and Spearman's correlation coefficient and (2) assessing the proportion of counties in the top decile (10%) of overdose death rates that were correctly predicted as such. Finally, in a post-hoc analysis, we sought to identify variables with greatest predictive utility.

Findings: Between 2013 and 2018, among the 3106 US counties included, our modelling approach outperformed the benchmark strategy across all metrics. The observed average county-level overdose death rate rose from 11·8 per 100 000 people in 2013 to 15·4 in 2017 before falling to 14·6 in 2018. Our negative binomal modelling approach similarly identified an increasing trend, predicting an average 11·8 deaths per 100 000 in 2013, up to 15·1 in 2017, and increasing further to 16·4 in 2018. The benchmark model over-predicted average death rates each year, ranging from 13·0 per 100 000 in 2013 to 18·3 in 2018. Our modelling approach successfully ranked counties by overdose death rate identifying between 42% and 57% of counties in the top decile of overdose mortality (compared with 29% and 43% using the benchmark) each year and identified 194 of the 808 counties with emergent overdose outbreaks (ie, newly entered the top decile) across the study period, versus 31 using the benchmark. In the post-hoc analysis, we identified geospatial proximity of overdose in nearby counties, opioid prescription rate, presence of an urgent care facility, and several economic indicators as the variables with the greatest predictive utility.

Interpretation: Our model shows that a regression approach can effectively predict county-level overdose death rates and serve as a risk assessment tool to identify future high mortality counties throughout an emerging drug use epidemic.

Funding: National Institute on Drug Abuse.
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http://dx.doi.org/10.1016/S2468-2667(21)00080-3DOI Listing
June 2021

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

Drug Alcohol Rev 2021 May 27. Epub 2021 May 27.

Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA.

Introduction: Among 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.

Methods: Data 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.

Results: We 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 Conclusions: Polysubstance 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.
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http://dx.doi.org/10.1111/dar.13305DOI Listing
May 2021

Correlates of trichomoniasis among female sex workers who inject drugs in two Mexico-US border cities.

Int J STD AIDS 2020 08 5;31(9):866-875. Epub 2020 Jul 5.

Department of Medicine, Division of Global Public Health, University of California San Diego, La Jolla, CA, USA.

This paper evaluates correlates of trichomoniasis among female sex workers who inject drugs (FSWIDs) in two Mexico-US border cities. HIV-negative FSWIDs aged 18 years or older were enrolled in a study between 2008 and 2010 in Tijuana and Ciudad Juarez (Cd.), Mexico. All participants underwent a baseline interviewer-administered survey and did a rapid test for trichomoniasis. Using regression to estimate prevalence ratios, we examined sociodemographics, sex work characteristics, sexual health and behavior, substance use, and police and violence exposures as potential correlates of trichomoniasis. Of 584 women (284 in Tijuana, 300 in Cd. Juarez), prevalence of trichomoniasis was 33.6%. Factors associated with trichomoniasis in multivariable analysis were having money stolen by police in the past six months (adjusted prevalence ratio [aPR] =1.448, 95% confidence interval [CI] = 1.152-1.821), recent methamphetamine use (aPR = 1.432, CI = 1.055-1.944), lifetime syphilis infection (aPR = 1.360, CI = 1.061-1.743), ever use of a home remedy to treat vaginal symptoms (aPR = 1.301, CI = 1.027-1.649), and number of regular clients in the past month (aPR = 1.006 per client, CI = 1.004-1.009), while controlling for age and city of interview. Alongside the need for trichomoniasis surveillance and treatment programs, findings indicate that both structural and behavioral factors serve as primary correlates of trichomoniasis among FSWIDs in these cities.
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http://dx.doi.org/10.1177/0956462420929463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226424PMC
August 2020

Sex Work as a Mediator Between Female Gender and Incident HIV Infection Among People Who Inject Drugs in Tijuana, Mexico.

AIDS Behav 2020 Sep;24(9):2720-2731

School of Medicine, University of California, San Diego, La Jolla, USA.

We studied mechanisms driving gender differences in HIV incidence among 651 women and men who inject drugs (PWID) in Tijuana, Mexico, hypothesizing that sex work will mediate the association between female gender and HIV incidence. Of 43 HIV seroconversions occurring between 2011 and 2018, 8.8% were among females and 5.2% among males. HIV incidence density was significantly higher among females versus males (1.75 per 100 person years [PY], 95% CI 1.16-2.66, vs. 0.95 per 100 PY, 95% CI 0.62-1.47). Factors significantly associated with HIV seroconversion were: sex work (adjusted hazard ratio [aHR] = 2.25, 95% CI 1.05-4.80); methamphetamine injection (aHR = 2.30, 95% CI 1.12-4.73); and methamphetamine and heroin co-injection in the past six months (aHR = 2.26, 95% CI 1.23-4.15). In mediation analyses, sex work mediated a substantial proportion (84.3%) of the association between female gender and HIV incidence. Interventions should target female PWID who engage in sex work to reduce gender-related disparities in HIV incidence.
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http://dx.doi.org/10.1007/s10461-020-02828-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453791PMC
September 2020

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011-2018.

Int J Drug Policy 2020 01 24;75:102601. Epub 2019 Nov 24.

Division of Infectious Diseases and Global Public Health in the Department of Medicine, University of California San Diego, San Diego, CA, United States.

Background: People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.

Methods: Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.

Results: Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.

Conclusion: In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.
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http://dx.doi.org/10.1016/j.drugpo.2019.11.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957706PMC
January 2020

Addressing Police Occupational Safety During an Opioid Crisis: The Syringe Threat and Injury Correlates (STIC) Score.

J Occup Environ Med 2020 01;62(1):46-51

Division of Infectious Diseases and Global Public Health, School of Medicine, University of California (Mr Beletsky, Ms Abramovitz, Dr Arredondo, Mr Baker, Ms Artamonova, Dr Mittal, Dr Rocha-Jimenez, Dr Cepeda, Mr Morales, Ms Clairgue, Dr Patterson, Dr Strathdee); School of Law & Bouvé College of Health Sciences, Northeastern University, Massachusetts (Mr Beletsky); British Columbia Centre on Substance Use, Vancouver, Canada; Programa de Politica de Drogas, Centro de Investigacion y Docencia Economica, Aguascalientes, Mexico (Dr Arredondo); School of Public Health, San Diego State University (Mr Baker, Dr Rocha-Jimenez), San Diego, California; School of Social Work, Columbia University, New York, New York; Department of Pyschiatry, Yale University School of Medicine, New Haven, Connecticut (Dr Marotta); School of Medicine, Universidad Xochicalco, Chapultepec Alamar, Tijuana, Baja California, Mexico (Dr Mittal); Society and Health Research Center, Facultad de Humanidades, Universidad Mayor, Santiago, Chile (Dr Rocha-Jimenez); School of Government and Public Policy, University of Arizona, Tucson, Arizona (Mr Morales).

Objective: To develop and validate syringe threat and injury correlates (STIC) score to measure police vulnerability to needlestick injury (NSI).

Methods: Tijuana police officers (N = 1788) received NSI training (2015 to 2016). STIC score incorporates five self-reported behaviors: syringe confiscation, transportation, breaking, discarding, and arrest for syringe possession. Multivariable logistic regression was used to evaluate the association between STIC score and recent NSI.

Results: Twenty-three (1.5%) officers reported NSI; higher among women than men (3.8% vs 1.2%; P = 0.007). STIC variables had high internal consistency, a distribution of 4.0, a mode of 1.0, a mean (sd) of 2.0 (0.8), and a median (interquartile range [IQR]) of 2.0 (1.2 to 2.6). STIC was associated with recent NSI; odds of NSI being 2.4 times higher for each point increase (P-value <0.0001).

Conclusions: STIC score is a novel tool for assessing NSI risk and prevention program success among police.
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http://dx.doi.org/10.1097/JOM.0000000000001754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6933083PMC
January 2020

The Role of Gender in the Health and Human Rights Practices of Police: The SHIELD Study in Tijuana, Mexico.

Health Hum Rights 2019 Jun;21(1):227-238

Professor at the School of Law and Bouvé College of�Health Sciences, Northeastern University, and an associate adjunct professor at the University of California San Diego, USA.

Globally, punitive drug law enforcement drives human rights violations. Drug control tactics, such as syringe confiscation and drug-related arrests, also cascade into health harms among people who use drugs. The role of police officer characteristics in shaping such enforcement and measures to reform police practices remains underexamined. We evaluated gender differences in syringe confiscation and syringe-related arrest behaviors among municipal police officers in Tijuana, Mexico, where syringe possession is legal. In the context of the SHIELD Study focusing on aligning policing with harm reduction measures, our baseline sample covered municipal police officers who reported having occupational contact with syringes. We used multivariable logistic regression with robust variance estimation via a generalized estimating equation to identify correlates of syringe-related policing behaviors. Among respondent officers (n=1,555), 12% were female. After considering possible confounding variables, such as district of service and work experience, female officers were significantly less likely to report confiscating syringes or arresting individuals for syringe possession. Consideration of officer gender is important in the design of interventions to improve the health and human rights of people who inject drugs and other highly policed groups, as well as measures to safeguard officer occupational safety. The feminization of law enforcement deserves special consideration as an imperative in reducing the public health harms of policing.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586956PMC
June 2019

Interactive Versus Video-Based Training of Police to Communicate Syringe Legality to People Who Inject Drugs: The SHIELD Study, Mexico, 2015-2016.

Am J Public Health 2019 06 18;109(6):921-926. Epub 2019 Apr 18.

Jaime Arredondo, Leo Beletsky, Pieter Baker, Daniela Abramovitz, Irina Artamonova, Erika Clairgue, Mario Morales, Maria Luisa Mittal, Teresita Rocha-Jimenez, Steffanie A. Strathdee, and Javier A. Cepeda are with the Division of Infectious Diseases and Global Public Health, School of Medicine, University of California, San Diego. Thomas Kerr is with the Department of Medicine, University of British Columbia, Vancouver, Canada. Arnulfo Banuelos is with the Department of Planning and Special Projects, Secretaría de Seguridad Pública Municipal, Tijuana, Mexico.

To assess how instructional techniques affect officers' intent to communicate syringe legality during searches in Tijuana, Mexico, where pervasive syringe confiscation potentiates risk of HIV and HCV among people who inject drugs (PWID) and of occupational needle-stick injury among police. Using the SHIELD (Safety and Health Integration in the Enforcement of Laws on Drugs) model, Tijuana police underwent training to encourage communication of syringe possession legality to PWID. Trainees received either passive video or interactive role-play exercise on safer search techniques. We used logistic regression to assess the training's impact on self-reported intent to communicate syringe legality by training type and gender. Officers (n = 1749) were mostly men (86%) assigned to patrol (84%). After the training, intent to communicate the law improved markedly: from 20% to 39% (video group) and 20% to 58% (interactive group). Gender and training type significantly predicted intent to communicate syringe legality. Male and female officers' adjusted odds ratios in the interactive group were 5.37 (95% confidence interval [CI] = 4.56, 6.33) and 9.16 (95% CI = 5.88, 14.28), respectively, after the training. To more effectively persuade police to endorse harm reduction and occupational safety practices, police trainings should include interactive elements.
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http://dx.doi.org/10.2105/AJPH.2019.305030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507990PMC
June 2019

Prevalence of HIV/STIs and correlates with municipal characteristics among female sex workers in 13 Mexican cities.

Salud Publica Mex 2019 Mar-Apr;61(2):116-124

Departamento de Cuidado Integral, Centro Nacional para la Prevención y el Control del VIH y el Sida, Secretaría de Salud. Mexico City, Mexico.

Objective: To identify correlates of HIV/STI prevalence among 13 cities with varying sizes of female sex worker (FSW) populations and municipal characteristics in Mexico.

Materials And Methods: FSWs underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia. Logistic regression explored variations in HIV/STI prevalence.

Results: Among FSWs (n=1 092), prevalence across 13 sites was: HIV: 0.4% (range: 0%-1.4%): syphilis: 7.8% (range: 0%-17.2%); chlamydia: 15.3% (range: 5.7%-32.2%); gonorrhea:2.9% (range 0%-13.8%), and any HIV/STI: 23% (range: 9.9%- 46%). Municipalities with high human development scores and a lower municipal marginalization index had higher odds of combined HIV/STI prevalence. After controlling for sitespecific variability in municipal characteristics, greater risk of HIV/STIs was associated with lower education, having a spouse diagnosed or treated for an STI, unaffordability of condoms, and having non-Mexican clients.

Conclusions: Prevalence of HIV/STIs varies across Mexican municipalities indicating the need for surveillance to identify hotspots for targeted resource allocation.
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http://dx.doi.org/10.21149/8863DOI Listing
December 2019

Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis.

BMJ Open 2019 01 29;9(1):e026298. Epub 2019 Jan 29.

Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA.

Objective: From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision.

Design: Costing study and longitudinal cohort study.

Setting: Tijuana, Mexico.

Participants: Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study.

Primary Outcome Measures: Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal.

Results: During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02).

Conclusions: Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.
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http://dx.doi.org/10.1136/bmjopen-2018-026298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352756PMC
January 2019

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis.

Lancet Infect Dis 2018 12 29;18(12):1397-1409. Epub 2018 Oct 29.

International Charitable Foundation Alliance for Public Health, Kiev, Ukraine.

Background: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I statistic and the P-value for heterogeneity.

Findings: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

Interpretation: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

Funding: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.
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http://dx.doi.org/10.1016/S1473-3099(18)30469-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280039PMC
December 2018

Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico.

BMC Int Health Hum Rights 2018 09 15;18(1):36. Epub 2018 Sep 15.

Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA.

Background: Mexican law permits syringe purchase and possession without prescription. Nonetheless, people who inject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights, but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID and police personnel. To better understand how police practices contribute to the PWID risk environment, prior research has primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs) in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession.

Methods: Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire on knowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies. Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest.

Results: Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession (previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio [AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04-2.52; working in a district along Tijuana River Canal (where PWID congregate) (AOR = 2.85; 95%CI = 2.16-3.77); having recently experienced a physical altercation with PWID (AOR = 2.83; 95% CI = 2.15-3.74); and having recently referred PWID to social and health services (AOR = 1.97; 95% CI = 1.48-2.61). Conversely, odds were significantly lower among officers reporting knowing that syringe possession is legal (AOR = 0.61; 95% CI = 0.46-0.82).

Conclusions: Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role in shaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicial syringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at various governmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of drug laws, and facilitate harm reduction strategies that promote human rights and community health.
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http://dx.doi.org/10.1186/s12914-018-0175-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139125PMC
September 2018

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

Lancet Public Health 2018 09 17;3(9):e429-e437. Epub 2018 Aug 17.

Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; Population Health Sciences, University of Bristol, Bristol, UK.

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.

Funding: National Institute on Drug Abuse, UC San Diego Center for AIDS Research.
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http://dx.doi.org/10.1016/S2468-2667(18)30097-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211569PMC
September 2018

Impact of time perspectives on texting intervention to reduce HIV/STI transmission among female sex workers in Tijuana and Ciudad Juarez, Mexico.

J Behav Med 2019 02 9;42(1):111-127. Epub 2018 Jul 9.

Division of Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.

Text messages may sustain post-counseling gains in behavioral improvements and reduce HIV/STI incidence. However, their effectiveness may depend on the messages' time perspective and characteristics of the individual. We evaluated the impact of time perspective on a text messaging intervention designed to maintain improvements in safer sex practices among drug-using and non-drug-using female sex workers (FSWs) in Tijuana (n = 141) and Cd. Juarez (n = 129), Mexico. FSWs received the efficacious Mujer Segura intervention, and were randomized to receive safer sex maintenance text messages with either a short-term or future-oriented time perspective. The outcome was HIV/STI incidence rate over 6-month follow-up. In Tijuana, combined HIV/STI incidence density was lower among FSWs in the FUTURE group (31.67 per 100 py) compared to women in the SHORT-TERM group (62.40 per 100 py). Conversely, in Cd. Juarez, HIV/STI incidence density was lower (although non-significant) among FSWs in the SHORT-TERM group (19.80 per 100 py) compared to those in the FUTURE group (35.05 per 100 py). These findings suggest that future-oriented text messages may sustain post-counseling improvements in sexual risk behavior among FSWs, but findings may vary by FSWs' characteristics (e.g., drug use), and by region and context.
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http://dx.doi.org/10.1007/s10865-018-9948-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326895PMC
February 2019

Assessing police officers' attitudes and legal knowledge on behaviors that impact HIV transmission among people who inject drugs.

Int J Drug Policy 2017 12;50:56-63

University of California, San Diego, Department of Medicine, Division of Global Public Health, La Jolla, CA, United States; School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, MA, United States.

Background: Policing practices such as syringe confiscation and arrest can act as important social-structural drivers of HIV risk among people who inject drugs (PWID). However, police referral to treatment and other services may improve the health of PWID. Little is known about the role of modifiable attitudinal and knowledge factors in shaping officer behavior. Using baseline findings from a police education program (PEP), we assessed relationships between drug policy knowledge and attitudes towards public health interventions with self-reported syringe confiscation, drug arrest, and service referral among street-level police in Tijuana, Mexico.

Methods: Between February, 2015 and May, 2016 we surveyed 1319 police officers who reported syringe contact. The self-administered survey focused on attitudes, knowledge, and behaviors related to drug policy, public health, and occupational safety. We used ordinal logistic regression to model the odds of syringe confiscation, arrest for heroin possession, and referring PWID to health/social programs.

Results: The sample was mostly male (87%) and had at least a high school education (80%). In the last six months, a minority reported always/sometimes confiscating syringes (49%), arresting someone for heroin possession (43%), and referring PWID to health and social programs (37%). Those reporting needlestick injuries (NSI) had 1.38 (95% CI: 1.02-1.87) higher odds of reporting syringe confiscation. Officers who had favorable views on laws that treat addiction as a public health issue had lower odds (aOR=0.78; 95% CI: 0.59-1.03) of arresting PWID. Those agreeing that it was their role to refer PWID to health and social programs had higher odds of reporting such referrals (aOR: 3.32, 95% CI: 2.52-4.37). Legal knowledge was not associated with these practices.

Conclusion: Changing drug policy and knowledge may be insufficient in shifting police behavior. Modifying officers' occupational risks and attitudes towards harm reduction interventions can facilitate efforts to align police practices with PWID health.
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http://dx.doi.org/10.1016/j.drugpo.2017.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705567PMC
December 2017

Utilization of Google enterprise tools to georeference survey data among hard-to-reach groups: strategic application in international settings.

Int J Health Geogr 2016 07 28;15(1):24. Epub 2016 Jul 28.

Division of Global Public Health, University of California, San Diego, School of Medicine, La Jolla, CA, USA.

Background: As geospatial data have become increasingly integral to health and human rights research, their collection using formal address designations or paper maps has been complicated by numerous factors, including poor cartographic literacy, nomenclature imprecision, and human error. As part of a longitudinal study of people who inject drugs in Tijuana, Mexico, respondents were prompted to georeference specific experiences.

Results: At baseline, only about one third of the 737 participants were native to Tijuana, underscoring prevalence of migration/deportation experience. Areas frequented typically represented locations with no street address (e.g. informal encampments). Through web-based cartographic technology and participatory mapping, this study was able to overcome the use of vernacular names and difficulties mapping liminal spaces in generating georeferenced data points that were subsequently analyzed in other research.

Conclusion: Integrating low-threshold virtual navigation as part of data collection can enhance investigations of mobile populations, informal settlements, and other locations in research into structural production of health at low- or no cost. However, further research into user experience is warranted.
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http://dx.doi.org/10.1186/s12942-016-0053-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964042PMC
July 2016

Prevalence and correlates of needle-stick injuries among active duty police officers in Tijuana, Mexico.

J Int AIDS Soc 2016 18;19(4 Suppl 3):20874. Epub 2016 Jul 18.

Division of Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA;

Introduction: Police officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection. We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational safety and simultaneously reduce HIV risks among police and PWID.

Methods: Tijuana's Department of Municipal Public Safety (SSPM) is among Mexico's largest. Our binational, multi-sectoral team analyzed de-identified data from SSPM's 2014 anonymous self-administered occupational health survey. The prevalence of NSI and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating equations identified factors associated with ever having an occupational NSI.

Results: Approximately one-quarter of the Tijuana police force was given the occupational health survey (N=503). Respondents were predominantly male (86.5%) and ≤35 years old (42.6%). Nearly one in six officers reported ever having a NSI while working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering needles/syringes while on duty (n=473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56-5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29-3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22-0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19-0.91).

Conclusions: Tijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe confiscation) - factors that also impact HIV transmission among PWID and other members of the community.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951532PMC
http://dx.doi.org/10.7448/IAS.19.4.20874DOI Listing
October 2017

Intravaginal practices among HIV-negative female sex workers along the US-Mexico border and their implications for emerging HIV prevention interventions.

Int J Gynaecol Obstet 2016 May 28;133(2):212-6. Epub 2016 Jan 28.

Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA. Electronic address:

Objective: To describe intravaginal practices (IVPs) among female sex workers (FSWs) who inject drugs in two cities-Tijuana and Ciudad Juarez-on the border between the USA and Mexico.

Methods: Data for a secondary analysis were obtained from interviews conducted as part of a randomized controlled trial in FSWs who injected drugs between October 28, 2008, and May 31, 2010. Eligible individuals were aged at least 18years and reported sharing injection equipment and having unprotected sex with clients in the previous month. Descriptive statistics were used to assess frequency and type of IVPs. Logistic regression was used to assess correlates of IVPs.

Results: Among 529 FSWs who completed both surveys, 229 (43.3%) had performed IVPs in the previous 6months. Factors independently associated with IVPs were reporting any sexually transmitted infection in the previous 6months (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1-3.1; P=0.03), three or more pregnancies (aOR 1.9, 95% CI 1.1-3.2; P=0.02), and having clients who became violent when proposing condom use (aOR 5.8, 95% CI 1.0-34.3; P=0.05), which are all factors related to inconsistent condom use.

Conclusion: Screening for IVPs could help to identify FSW at increased risk of HIV, and facilitate conversations about specific risk-reduction methods.
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http://dx.doi.org/10.1016/j.ijgo.2015.09.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842145PMC
May 2016

Predictors of needle exchange program utilization during its implementation and expansion in Tijuana, Mexico.

Am J Addict 2016 Mar 14;25(2):118-24. Epub 2016 Jan 14.

Division of Global Public Health, Department of Medicine, University of California, San Diego.

Objective: Until the early 2000s, there was only one needle exchange program (NEP) offered in Mexico. In 2004, the second Mexican NEP opened in Tijuana, but its utilization has not been studied. We studied predictors of initiating NEP during its early expansion in Tijuana, Mexico.

Methods: From April 2006 to April 2007, people who inject drugs (PWID) residing in Tijuana who had injected within the last month were recruited using respondent-driven sampling. Weighted Poisson regression incorporating generalized estimating equations was used to identify predictors of initiating NEP, while accounting for correlation between recruiter and recruits.

Results: NEP uptake increased from 20% at baseline to 59% after 6 months. Among a subsample of PWID not accessing NEP at baseline (n = 480), 83% were male and median age was 37 years (Interquartile Range: 32-43). At baseline, 4.4% were HIV-infected and 5.9% had syphilis titers >1:8. In multivariate models, factors associated with NEP initiation (p < .05) were attending shooting galleries (Adjusted Relative Risk [ARR]: 1.54); arrest for track-marks (ARR: 1.38); having a family member that ever used drugs (ARR: 1.37); and having a larger PWID network (ARR: 1.01 per 10 persons). NEP initiation was inversely associated with obtaining syringes at pharmacies (ARR: .56); earning >2500 pesos/month (ARR: .66); and reporting needle sharing (ARR: .71).

Conclusions: Uptake of NEP expansion in Tijuana was vigorous among PWID. We identified a range of factors that influenced the likelihood of NEP initiation, including police interaction. These findings have important implications for the scale-up of NEP in Mexico.
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http://dx.doi.org/10.1111/ajad.12326DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470727PMC
March 2016

Predictors of Injection Cessation and Relapse among Female Sex Workers who Inject Drugs in Two Mexican-US Border Cities.

J Urban Health 2016 Feb;93(1):141-54

Division of Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive 0507, La Jolla, CA, 92093-0507, USA.

We know little about predictors of injection drug cessation and relapse among female sex workers who inject drugs (FSW-PWID) at the US-Mexico border. Among HIV-negative FSW-PWID taking part in a behavioral intervention study in Tijuana and Ciudad Juárez, Cox regression was used to identify predictors of time to first cessation of injection, which was defined as reporting not having injected drugs for a period of 4 months or longer, and among that subset, we examined predictors of time to injection relapse. Among 440 women, 84 (19%) reported ceasing injection during follow-up (median time to cessation = 9.3 months); of these, 30 (35%) reported relapse to injection (median time to relapse = 3.5 months). The rate of injection cessation was lower for women reporting trading sex prior to age 18 (adj. hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.41-1.01), ever being sexually abused (adj. HR = 0.44, 95% CI = 0.27-0.71), and a higher number of vaginal sex acts with casual clients (adj. HR = 0.99 per transaction, 95% CI = 0.98-1.00). The rate of cessation was higher for women who spent more hours on the streets on a typical day (adj. HR = 1.04/h, 95% CI = 1.01-1.08) and who lived in Tijuana vs. Ciudad Juárez (adj. HR = 2.15, 95% CI = 1.14-4.07). The rate of relapse was higher among women reporting regular drug use with clients (adj. HR = 2.17, 95% CI = 0.96-4.89) and those scoring higher on a risk injection index (adj. HR = 2.04, 95% CI = 1.15-3.61). The rate of relapse was lower for FSW-PWID with higher than average incomes (adj. HR = 0.40, 95% CI = 0.18-0.89). These findings have important implications for the scale-up of methadone maintenance treatment programs (MMTPs) in Mexico and indicate a need for gender-specific programs that address sexual abuse experiences and economic vulnerabilities faced by FSW-PWID.
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http://dx.doi.org/10.1007/s11524-015-9995-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4794460PMC
February 2016

Correlates of perceived risk of HIV infection among persons who inject drugs in Tijuana, Baja California, Mexico.

Salud Publica Mex 2015 ;57 Suppl 2:s107-12

Division of Global Public Health, Department of Medicine, University of California, San Diego, California, Estados Unidos de América.

Objective: We identified correlates of perceived risk of HIV infection among persons who inject drugs (PWID) in Tijuana.

Materials And Methods: PWID ≥18 years of age who injected drugs in the past month were recruited between 2006-2007 and completed risk assessment interviews and serologic testing for HIV, syphilis, and tuberculosis. Logistic regression was used to determine factors associated with high-perceived risk of HIV infection.

Results: Among 974 PWID, HIV prevalence was 4.4%; 45.0% of participants perceived themselves to be more likely to become HIV infected relative to other PWID in Tijuana. Participants who reported high-perceived risk of HIV infection participated in high-risk behaviors such as injecting with used syringes, transactional sex, and were less likely to have had an HIV test.

Conclusions: Recognition of HIV infection risk was associated with high risk behaviors and markers of vulnerability. Findings support efforts to encourage HIV testing and access to health care for this vulnerable population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5659113PMC
http://dx.doi.org/10.21149/spm.v57s2.7597DOI Listing
July 2017

A police education programme to integrate occupational safety and HIV prevention: protocol for a modified stepped-wedge study design with parallel prospective cohorts to assess behavioural outcomes.

BMJ Open 2015 Aug 10;5(8):e008958. Epub 2015 Aug 10.

Department of Medicine, University of California San Diego, La Jolla, California, USA School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA.

Introduction: Policing practices are key drivers of HIV among people who inject drugs (PWID). This paper describes the protocol for the first study to prospectively examine the impact of a police education programme (PEP) to align law enforcement and HIV prevention. PEPs incorporating HIV prevention (including harm reduction programmes like syringe exchange) have been successfully piloted in several countries but were limited to brief pre-post assessments; the impact of PEPs on policing behaviours and occupational safety is unknown.

Objectives: Proyecto ESCUDO (SHIELD) aims to evaluate the efficacy of the PEP on uptake of occupational safety procedures, as assessed through the incidence of needle stick injuries (NSIs) (primary outcome) and changes in knowledge of transmission, prevention and treatment of HIV and viral hepatitis; attitudes towards PWID, adverse behaviours that interfere with HIV prevention and protective behaviours (secondary outcomes).

Methods/analysis: ESCUDO is a hybrid type I design that simultaneously tests an intervention and an implementation strategy. Using a modified stepped-wedge design involving all active duty street-level police officers in Tijuana (N = ∼ 1200), we will administer one 3 h PEP course to groups of 20-50 officers until the entire force is trained. NSI incidence and geocoded arrest data will be assessed from department-wide de-identified data. Of the consenting police officers, a subcohort (N=500) will be randomly sampled from each class to undergo pre-PEP and post-PEP surveys with a semiannual follow-up for 2 years to assess self-reported NSIs, attitudes and behaviour changes. The impact on PWIDs will be externally validated through a parallel cohort of Tijuana PWIDs.

Ethics/dissemination: Research ethics approval was obtained from the USA and Mexico. Findings will be disseminated through open access to protocol materials through the Law Enforcement and HIV Network.

Trial Registration Number: NCT02444403.
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http://dx.doi.org/10.1136/bmjopen-2015-008958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4538275PMC
August 2015

Policing behaviors, safe injection self-efficacy, and intervening on injection risks: Moderated mediation results from a randomized trial.

Health Psychol 2016 Jan 29;35(1):87-91. Epub 2015 Jun 29.

Division of Global Public Health, Department of Medicine, University of California, San Diego.

Objective: We aim to use conditional or moderated mediation to simultaneously test how and for whom an injection risk intervention was efficacious at reducing receptive needle sharing among female sex workers who inject drugs (FSWs-IDUs) in Mexico.

Methods: Secondary analysis of data from a randomized trial. A total of 300 FSW-IDUs participated in Mujer Mas Segura in Ciudad Juarez, Mexico, and were randomized to an interactive injection risk intervention or a didactic injection risk intervention. We measured safe injection self-efficacy as the hypothesized mediator and policing behaviors (being arrested and syringe confiscation) as hypothesized moderators. In total, 213 women provided complete data for the current analyses.

Results: Conditional (moderated) mediation showed that the intervention affected receptive needle sharing through safe injection self-efficacy among women who experienced syringe confiscation. On average, police syringe confiscation was associated with lower safe injection self-efficacy (p = .04). Among those who experienced syringe confiscation, those who received the interactive (vs. didactic) intervention reported higher self-efficacy, which in turn predicted lower receptive needle sharing (p = .04).

Conclusions: Whereas syringe confiscation by the police negatively affected safe injection self-efficacy and ultimately injection risk behavior, our interactive intervention helped to "buffer" this negative impact of police behavior on risky injection practices. The theory-based, active skills building elements included in the interactive condition, which were absent from the didactic condition, helped participants' self-efficacy for safer injection in the face of syringe confiscation.
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http://dx.doi.org/10.1037/hea0000241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695282PMC
January 2016

Prevalence and correlates of HIV among men who have sex with men in Tijuana, Mexico.

J Int AIDS Soc 2015 9;18:19304. Epub 2015 Feb 9.

Department of Psychiatry, University of California, San Diego, CA, USA;

Introduction: Men who have sex with men (MSM) in developing countries such as Mexico have received relatively little research attention. In Tijuana, Mexico, a border city experiencing a dynamic HIV epidemic, data on MSM are over a decade old. Our aims were to estimate the prevalence and examine correlates of HIV infection among MSM in this city.

Methods: We conducted a cross-sectional study of 191 MSM recruited through respondent-driven sampling (RDS) in 2012. Biological males over the age of 18 who resided in Tijuana and reported sex with a male in the past year were included. Participants underwent interviewer-administered surveys and rapid tests for HIV and syphilis with confirmation.

Results: A total of 33 MSM tested positive for HIV, yielding an RDS-adjusted estimated 20% prevalence. Of those who tested positive, 89% were previously unaware of their HIV status. An estimated 36% (95% CI: 26.4-46.5) had been tested for HIV in the past year, and 30% (95% CI: 19.0-40.0) were estimated to have ever used methamphetamine. Independent correlates of being infected with HIV were methamphetamine use (odds ratio [OR] = 2.24, p = 0.045, 95% CI: 1.02, 4.92) and active syphilis infection (OR = 4.33, p = 0.01, 95% CI: 1.42, 13.19).

Conclusions: Our data indicate that MSM are a key sub-population in Tijuana at higher risk for HIV. Tijuana would also appear to have the highest proportion among upper-middle-income countries of HIV-positive MSM who are unknowingly infected. More HIV prevention research on MSM is urgently needed in Tijuana.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323407PMC
http://dx.doi.org/10.7448/IAS.18.1.19304DOI Listing
May 2016

Randomized controlled trial to test the RHANI Wives HIV intervention for women in India at risk for HIV from husbands.

AIDS Behav 2013 Nov;17(9):3066-80

Division of Global Public Health, Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA,

This study involved evaluation of the short-term impact of the RHANI Wives HIV intervention among wives at risk for HIV from husbands in Mumbai, India. A two-armed cluster RCT was conducted with 220 women surveyed on marital sex at baseline and 4-5 month follow-up. RHANI Wives was a multisession intervention focused on safer sex, marital communication, gender inequities and violence; control participants received basic HIV prevention education. Generalized linear mixed models were conducted to assess program impact, with cluster as a random effect and with time, treatment group, and the time by treatment interaction as fixed effects. A significant time by treatment effect on proportion of unprotected sex with husband (p = 0.01) was observed, and the rate of unprotected sex for intervention participants was lower than that of control participants at follow-up (RR = 0.83, 95 % CI = 0.75, 0.93). RHANI Wives is a promising model for women at risk for HIV from husbands.
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http://dx.doi.org/10.1007/s10461-013-0586-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058338PMC
November 2013

Reductions in HIV/STI incidence and sharing of injection equipment among female sex workers who inject drugs: results from a randomized controlled trial.

PLoS One 2013 13;8(6):e65812. Epub 2013 Jun 13.

University of California San Diego, Department of Medicine, La Jolla, California, United States of America.

Background: We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico during 2008-2010, when harm reduction coverage was expanding rapidly in Tijuana, but less so in Juarez.

Methods: FSW-IDUs ≥18 years reporting sharing injection equipment and unprotected sex with clients within the last month participated in a randomized factorial trial comparing four brief, single-session conditions combining either an interactive or didactic version of a sexual risk intervention to promote safer sex in the context of drug use, and an injection risk intervention to reduce sharing of needles/injection paraphernalia. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and Trichomonas, blinding interviewers and assessors to assignment. Poisson regression with robust variance estimation and repeated measures ordinal logistic regression examined effects on combined HIV/STI incidence and receptive needle sharing frequency.

Findings: Of 584 initially HIV-negative FSW-IDUs, retention was ≥90%. After 12 months, HIV/STI incidence decreased >50% in the interactive vs. didactic sex intervention (Tijuana:AdjRR:0.38,95% CI:0.16-0.89; Juarez: AdjRR:0.44,95% CI:0.19-0.99). In Juarez, women receiving interactive vs. didactic injection risk interventions decreased receptive needle-sharing by 85% vs. 71%, respectively (p = 0.04); in Tijuana, receptive needle sharing declined by 95%, but was similar in active versus didactic groups. Tijuana women reported significant increases in access to syringes and condoms, but Juarez women did not.

Interpretation: After 12 months in both cities, the interactive sexual risk intervention significantly reduced HIV/STI incidence. Expanding free access to sterile syringes coupled with brief, didactic education on safer injection was necessary and sufficient for achieving robust, sustained injection risk reductions in Tijuana. In the absence of expanding syringe access in Juarez, the injection risk intervention achieved significant, albeit more modest reductions, suggesting that community-level interventions incorporating harm reduction are more powerful than individual-level interventions.

Trial Registration: clinicaltrials.gov NCT00840658.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0065812PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681783PMC
January 2014

Cigarette-Smoking Intensity and Interferon-Gamma Release Assay Conversion among Persons Who Inject Drugs: A Cohort Study.

Pulm Med 2012 10;2012:828106. Epub 2012 Dec 10.

San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4162, USA ; Division of Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC-0507, San Diego, CA 92093-0507, USA.

We analyzed data from a longitudinal cohort study of persons who inject drugs (PWID) in Tijuana, Mexico, to explore whether cigarette smoking increases the risk of interferon gamma release assay (IGRA) conversion. PWID were recruited using respondent driven sampling (RDS). QuantiFERON-TB Gold In-Tube (QFT) assay conversion was defined as interferon-gamma concentrations <0.35 IU/mL at baseline and ≥0.7 IU/mL at 18 months. We used multivariable Poisson regression adjusted for RDS weights to estimate risk ratios (RRs). Of 129 eligible participants, 125 (96.9%) smoked at least one cigarette during followup with a median of 11 cigarettes smoked daily, and 52 (40.3%) had QFT conversion. In bivariate analysis, QFT conversion was not associated with the number of cigarettes smoked daily (P = 0.716). Controlling for age, gender, education, and alcohol use, the RRs of QFT conversion for smoking 6-10, 11-15, and ≥16 cigarettes daily compared to smoking 0-5 cigarettes daily were 0.9 (95% confidence interval (CI), 0.5-1.6), 0.5 (95% CI, 0.3-1.2), and 0.7 (95% CI, 0.3-1.6), respectively. Although this study did not find an association between self-reported smoking intensity and QFT conversion, it was not powered sufficiently to negate such an association. Larger longitudinal studies are needed to fully explore this relationship.
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http://dx.doi.org/10.1155/2012/828106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3529865PMC
January 2013

Mujer Mas Segura (Safer Women): a combination prevention intervention to reduce sexual and injection risks among female sex workers who inject drugs.

BMC Public Health 2012 Aug 14;12:653. Epub 2012 Aug 14.

Department of Medicine, University of California, San Diego, 9500 Gilman Drive # 0507, La Jolla, CA 92093-0507, USA.

Background: Female sex workers who inject drugs (FSW-IDUs) are at risk of acquiring HIV, sexually transmitted infections (STI) and blood-borne infections through unprotected sex and sharing injection equipment. We conducted a 2×2 factorial randomized controlled trial to evaluate combination interventions to simultaneously reduce sexual and injection risks among FSW-IDUs in Tijuana and Ciudad Juarez, Mexico.

Methods/design: FSW-IDUs ≥18 years reporting sharing injection equipment and unprotected sex with clients within the last month were randomized to one of four conditions based on an a priori randomization schedule, blinding interviewer/counselors to assignment. Due to the extreme vulnerability of this population, we did not include a control group that would deny some women access to preventive information. All women received similar information regardless of group allocation; the difference was in the way the information was delivered and the extent to which women had an interactive role. Each condition was a single 60-minute session, including either an interactive or didactic version of an injection risk intervention and sexual risk intervention. Women underwent interviewer-administered surveys and testing for HIV, syphilis, gonorrhea, Chlamydia, and Trichomonas at baseline and quarterly for 12 months. Combined HIV/STI incidence will be the primary outcome. Secondary outcomes are proportionate reductions in sharing of injection equipment and unprotected sex with clients.

Discussion: Of 1,132 women, 548 (48.4%) were excluded (88.9% were ineligible; 11.1% refused to participate or did not return); 584 eligible women enrolled (284 in Tijuana; 300 in Ciudad Juarez). All 584 participants completed the baseline interview, provided biological samples and were randomized to one of the four groups. During follow-up, 17 participants (2.9%) were lost to follow-up, of whom 10 (58.8%) had died, leaving 567 participants for analysis. This study appears to be the first intervention to attempt to simultaneously reduce injection and sexual risk behaviors among FSW-IDUs. The factorial design will permit analysis to determine whether the combination of the two interactive interventions and/or its respective components are effective in reducing injection and/or sexual risks, which will have direct, tangible policy implications for Mexico and potentially other resource-poor countries.

Trial Registration: NCT00840658.
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http://dx.doi.org/10.1186/1471-2458-12-653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490986PMC
August 2012
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