International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 30 of 153

N. Kori et al. / International Journal of Drug Policy 25 (2014) 525–532 531 exchange programs (SEPs) compared to those who inject outside the hotspot, reported knowing more people with HIV or who have died of AIDS, and had higher perceived risk of acquiring HIV. Thus, it could be that participating in harm reduction services, which are more available within than outside the hotspot, is having a benefi- cial impact by increasing awareness about transmission of HIV and reducing needle sharing. We also found that fewer male and female IDUs in the hotspot had health insurance in the past six months compared to injectors outside the hotspot. Depending on a person's job status, medical care in Mexico is either subsidized fully or in part by the federal government. Mexico aspires to universal health coverage for all its citizens; therefore, even the poorest can obtain insurance through Seguro Popular, a government funded healthcare program. How- ever, to sign up for this insurance, proper identification showing citizenship must be presented–posing a barrier to some migrants and especially to deportees–which were over-represented in the HIV transmission hotspot. There are several limitations to this study. Because we were not exploring predictors of HIV infection, but rather correlates of injecting in a high transmission area, we cannot conclude that the specific variables found to be associated with injection in the hotspot were directly related to HIV transmission; we can only speak about a geographical association with a high transmission area. Also, this analysis focused on the locations where a partici- pant "most often" injected drugs in the past three months. Thus, our data fails to capture activities of participants who often move injection sites or inject in a variety of locations. Despite using respondent-driven sampling to try to obtain a less biased sam- ple, some social networks may have been overrepresented while others underrepresented. Participants were given a small mone- tary reimbursement for their participation in the study and, for some social groups (e.g. those with high income, those with higher social status that may not want to be linked to the study), the reim- bursement may not have been enough of an incentive to spend the time needed for full participation in the study. Also, as mentioned earlier, self-presentation bias may have led some participants to over- or underestimate health/risk behaviors in order to provide more socially desirable responses. In regards to analysis, because we investigated a large number of variables, it is possible that some of the associations found were due to chance alone (type I error). However, multivariate modeling likely removed spurious associa- tions, especially considering that most of the variables in the final model were strongly associated with injection in the hotspot (P- value < 0.01) and supported prior literature related to HIV infection or HIV risk behaviors. Finally, our analysis may have been limited by not measuring other factors that could have given better insight into injection in the hotspot. At the local level, our findings have important implications for organizations working in HIV prevention and harm reduction for individuals who inject drugs in Tijuana and more specifically within this HIV incidence area that abuts the 'Zona Roja.' For women, injecting in the hotspot was predicted by injecting indoors, life- time syphilis infection, being arrested for carrying paraphernalia, ever being tested for HIV and sex work. Women injecting primarily in the hotspot were over 4-fold more likely to report prostitu- tion as their main source of income. This risk factor may underlie predictors for these female IDU as (1) sex workers are dispro- portionately vulnerable to STI because of the increased likelihood they will engage in multiple concurrent sexual relationships and may have limited agency to consistently use condoms, and (2) and may be injecting with their clients within their work environment. With over 50% of FSWs in Tijuana working without a work per- mit, both the limitations and benefits of the permit system might warrant further examination, considering that the routine med- ical examinations of permits are currently not occurring for the majority of FSWs. For men, intra-urban travel, deportation, nega- tive experiences with the police, and perceived risk for acquiring HIV were predictive of injecting within the hot spot. However, receptive needle sharing was inversely associated, such that men who reported sharing were less likely to inject within the hot spot. As we described before, harm reduction and HIV prevention ser- vices are concentrated in this known 'high-risk' area. While this finding may evidence social desirable responses to this question, it may also indicate that men are changing behavior in light of rec- ommendations to not share syringes as their ability to access clean injection equipment increases. Therefore, policies and funding to expand syringe exchange programs to further reduce HIV trans- mission among injectors in the HIV incidence hotspot should be considered. Also, outreach programs targeting the homeless and mobile populations should be expanded given that these popu- lations may not be readily connected to more traditional service delivery mechanisms. Finally, because certain policing practices have been associated with especially risky substance use behav- iors and were also associated with injection in the HIV hotspot, a dialogue with police in the area should be started to discuss the public health implications of enforcement activities. More broadly, this work contributes to the growing body of liter- ature that documents the dynamic role of 'place' in shaping health behaviors. Mexico enacted drug policy reform in the summer of 2010 that decriminalized possession of a small amount of cocaine, heroin, methamphetamine and cannabis for personal use drugs for personal use and mandated drug treatment (or jail time) for indi- viduals caught by police possessing sub-threshold amounts of these drugs upon a 3 rd strike (Moreno, Licea, & Ajenjo, 2010). Although the extent to which the new law will positively influence polic- ing practices and lead to fewer of the negative police encounters we found associated with the HIV hotspot is not yet known, this policy may have an important bearing on both HIV risk and pro- tective behaviors and is of great interest to Mexico, the U.S, and internationally. Acknowledgments Proyecto El Cuete and this analysis were made possible through funding by the National Institutes of Health, National Institute on Drug Abuse (NIDA) (grants R01DA019829, R37DA019829, and K01DA020364). The funders had no role in the design of this study; collection, analysis and interpretation of data; the writing of the report; nor in the decision to submit this article for publication. Special thanks to the study participants who gave of their time; to Drs. Richard Shaffer and John Weeks, who served on the disserta- tion committee of N. Kori; and to Dr. Steffanie Strathdee who is the Principal Investigator of the Proyecto El Cuete cohort. Conflict of interest statement There are no conflicts of interest to declare. References Atlani, L., Carael, M., Brunet, J. B., Frasca, T., & Chaika, N. (2000). Social change and HIV in the former USSR: The making of a new epidemic. Social Science and Medicine, 2000, 1547–1556. Brouwer, K. C., Lozada, R., Cornelius, W. A., Cruz, M. F., Magis-Rodriguez, C., de Nun- cio, M. L. Z., et al. (2009). Deportation along the US–Mexico border: Its relation to drug use patterns and accessing care. Journal of Immigrant and Minority Health, 11(1.). Brouwer, K. C., Lozada, R., Weeks, J. R., Magis-Rodriguez, C., Firestone, M., & Strathdee, S. A. (2012). Intraurban mobility and its potential impact on the spread of blood-borne infections among drug injectors in Tijuana, Mexico. Substance Use & Misuse, 47(3), 244–253. Brouwer, K. C., Rusch, M. L., Weeks, J. R., Lozada, R., Vera, A., Magis-Rodriguez, C., et al. (2012). Spatial epidemiology of HIV among injection drug users in Tijuana, Mexico. Annals of the Association of American Geographers, 102(5), 1190–1199.

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