International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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N. Kori et al. / International Journal of Drug Policy 25 (2014) 525–532 529 of services in them they were not included in the multivariate model. As depicted in Table 1, the characteristics of IDUs who injected inside versus outside the HIV incidence hotspot in Tijuana sug- gested differences by sex. Thus, bivariate analyses were performed separately for males and females (see Table 2). Compared with men injecting outside of the hotspot, men injecting inside the HIV incidence hotspot were 1.89 and 1.75 times as likely to be home- less or a deportee, respectively (P < 0.001). They also had increased odds of having syphilis (P < 0.001), having higher perceived risk of acquiring HIV (P = 0.001), and injecting outdoors (P = 0.04), with marginally higher odds of having rushed injection due to police presence (P = 0.06). Compared to female IDUs injecting outside the hotspot, those who injected within the hotspot had 6.43 times the odds of reporting prostitution as their principal income in the past year (P < 0.001), were 2.48 times as likely to have lifetime exposure to syphilis (P = 0.02), 2.16 times more likely to have been tested for HIV before this study (P = 0.03), and 2.43 times more likely to ever have been asked for sexual favors by police (P = 0.02); 3.53 times more likely to inject inside home (P = 0.01); and 4.23 times more likely to have engaged in casual sex with no condom use in the past six months (P = 0.06). Correlates of injecting in the HIV incidence hotspot Separate multivariate models were constructed for men and women. In the final multivariate model for men (Table 3), indepen- dent correlates of injecting in the HIV incidence hotspot included 3.03 times greater odds of having an active syphilis infection and 1.72 and 1.58 times greater odds of being homeless or ever being deported from the U.S., respectively. Men who injected in the hotspot also had 3.26 times the odds of having traveled farther between their residence and their regular injection location (95%CI 1.67–6.38) and were 1.52 times more likely to have high perceived risk of HIV infection (95%CI 1.13–2.03). Police interaction variables were also significant correlates of injection in the hotspot. Interest- ingly, men who injected inside the HIV hotspot had decreased odds of engaging in receptive needle/syringe sharing than those outside of the hotspot (P < 0.001) and were also less likely to have had health insurance in past six months compared to injectors outside of the hotspot (P = 0.01). In the final multivariable model for women (Table 3), female IDUs who injected in the HIV incidence hotspot were 8.2 times more likely to report prostitution as main source of income in the past year (P = 0.001), 5.26 times more likely to regularly inject drugs indoors (P = 0.008) and 4.87 times more likely to have ever been arrested for carrying unused needles/syringes (P = 0.006). They also had nearly 2.73 times greater odds of testing positive for syphilis antibodies (P = 0.03) and 2.45 times more likely to have been tested for HIV in the past (P = 0.04). Similar to male IDUs, female IDUs in the hotspot were much less likely to have had health insurance in past six months (P = 0.008). Discussion In this study of an area of high HIV incidence in Tijuana, we found that there were significant differences among IDUs who reg- ularly inject in the HIV hotspot compared to those who primarily inject outside of the hotspot. We also found different correlates of injecting in this HIV hotspot between male and female injectors. These findings provide insight into potentially modifiable factors that may be associated with increased HIV transmission in this area. As hypothesized, mobility was statistically significantly asso- ciated with injecting in the HIV hotspot, although this was only true for male, not female IDUs. Among male study participants, those in the hotspot had higher odds of reporting ever being deported from the U.S. and traveling a sizeable distance (>5 km) between where they live and regularly inject. This finding may have important implications for disease transmission. Studies else- where have shown how mobility can potentially increase risk of HIV transmission through such factors as the social changes associated with migration, bridging of social networks, disconnec- tion with health services, and increased exposure to authorities – which might lead to risky injection practices, such as rushed injec- tions or needle sharing (Atlani, Carael, Brunet, Frasca, & Chaika, 2000; Deren, Kang, & Colon, 2003; Elliot, Mijch, Street, & Crofts, 2003; Rachlis et al., 2007). Maas et al. (2007) found that mobility was a significant factor in HIV infection among IDUs in Vancou- ver's Downtown Eastside. They observed IDUs' movements both into and out of the Downtown Eastside due to drug availabil- ity, affordable housing, and sex trade work. Tijuana is a major repatriation point for Mexicans who are deported from the U.S.; 39% of our total sample and 44% of men primarily injecting in the HIV hotspot had ever been deported. Deportation may pre- dispose IDUs to HIV risk behaviors by separating them from their social networks and employment, and triggering a cycle of homelessness (Strathdee, Lozada, et al., 2008; Strathdee, Philbin, et al., 2008). A previous study by our group found that individu- als who had been deported were less knowledgeable about HIV risks and less likely to have been tested for HIV compared to non-deportees (Brouwer et al., 2009). Deportation has increased steadily over the past decade (US Department of Homeland Security, 2013), which may have unintended consequences for pub- lic health in Tijuana and other repatriation sites, especially among groups vulnerable to HIV and other infectious diseases, such as IDUs. Male IDUs primarily injecting in the hotspot were also more likely to report having been beaten, arrested for carrying unused syringes, or otherwise affected by police presence. Even though possession of sterile syringes without a prescription is legal in Mexico, police enforcement does not always reflect laws on the books and instead may be having a negative impact on IDUs' ability to perform safe injection practices. Studies have shown that fear of arrest discourages IDUs from purchasing and carrying sterile syringes, and may lead to rushed injection practices that include sharing syringes/other injection paraphernalia, even in settings where over-the-counter syringe sales and possession are legal (Miller et al., 2008; Pollini et al., 2008). A study in Vancouver's Downtown Eastside found that IDUs who reported public injec- tion and who were affected by police presence more often engaged in high-risk injection practices, such as rushed injection (Rachlis et al., 2010). Furthermore, aggressive policing practices and legal repressiveness have been associated with shooting gallery utiliza- tion (Cooper et al., 2011) and HIV prevalence among IDUs in a variety of settings (Friedman et al., 2006). Female IDUs in the hotspot were more likely to report inject- ing indoors compared to women primarily injecting outside of the hotspot. An indoor setting might reflect drug use associated with sex work; in our bivariate analysis, for women there was a strong association between injecting in the hotspot and drug use before or during sex. Further, while assessing collinearity between vari- ables before constructing the multivariate model, we found there was a high correlation between sex work and drug use before or during sex (data not shown). As we hypothesized, sex work was highly associated with injecting in the HIV hotspot for female IDUs, which suggests that the combination of both drug use and sex- ual risks, associated with sex work, may be driving HIV incidence among females in our sample. This conclusion is substantiated by several studies documenting higher rates of HIV among injection drug using female sex workers (FSWs) compared to non-injecting

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