Circular migration by Mexican female sex workers who are injection drug users: implications for HIV in Mexican sending communities

"You know that we travel a lot": Mobility narratives among female sex workers living with HIV in Tanzania and the Dominican Republic

Female sex workers (FSW) are highly mobile, which may result in reduced access to and use of health services and increased risk for poor health outcomes, particularly for those living with HIV. Mobility includes spatial, temporal, and social elements that are not fully captured by quantitative measures. We conducted two rounds of in-depth interviews with FSW living with HIV in Iringa, Tanzania (n = 20), and Santo Domingo, Dominican Republic (n = 20), to describe mobility experiences and compare mobility narratives across settings. We integrated a thematic analysis of all interviews with a narrative analysis of a subset of 10 information-rich interviews (five in each country) with women who had recently traveled, for sex work or another reason, outside of their hometown. Across narratives, FSW living with HIV traveled locally or to seasonal destinations, for short and long periods. Social factors influencing mobility included economic drivers; risk of arrest, harassment, or violence; anonymity and/or familiarity; social relationships; and clients' mobility. Spatial, temporal, and social factors intersected in unique ways in FSW's mobility experiences, yet distinct mobility typologies were evident across settings and destinations. Together, mobility narratives of FSW living with HIV can inform quantitative research on mobility typologies in Tanzania, the Dominican Republic, and elsewhere. With the potential for economic circumstances, climate change, and other emergencies to increase people's mobility around the world, researchers and practitioners can learn from the lived experiences of FSW to inform whether and how to tailor and improve the accessibility of HIV care and treatment interventions based on spatial, temporal, and social characteristics of mobility.

The paradox of choice in the sexual and reproductive health and rights challenges of south-south migrant girls and women in Central America and Mexico: A scoping review of the literature

The last decade has seen high levels of displacement in Central America and Mexico, with women and girls representing a growing share of this flow. Women and girls face a unique set of sexual and reproductive health risks, both as a direct result of the migration process, and as a consequence of violence, conflict and oppressive gender norms in the region. This scoping review adopts a five-stage process to search for, identify, and review selected literature to answer two questions: (1) what sexual and reproductive health and rights risks, challenges, and needs do women and girls face before and during displacement; and (2) how do issues of sexual and reproductive health and rights influence women and girls' coping mechanisms and decisions in displacement in the region? Extracted data from intersecting literature on migration, gender, and health in the corridors of migration in Central America and Mexico are mapped and analyzed against a framework adapted from the Guttmacher-Lancet Commission on components of sexual and reproductive health and rights. Many Central American and Mexican women and girls flee conditions of gang-related conflict, gender-based violence, poverty, and other situations of extreme disadvantage. Findings from this study demonstrate they face further deprivation and suffering from the denial of health and rights throughout the migratory cycle. This review finds that migrant women and girls encounter considerable barriers to accessing services of sexual and reproductive health, are vulnerable to sexually transmitted infections, and face many violations of sexual and reproductive rights. Young migrants and sex workers, who are often connected with irregular migration in border areas, appear to be particularly vulnerable. Findings also reveal that the literature tends to focus on sexual health and rights, with a relative paucity of evidence on wider reproductive health issues. Of critical importance is how women and girls must constantly balance risk and opportunity in situations of constrained choice, and how their coping strategies and decisions define and influence their migration trajectories and broader wellbeing. This review identifies a gap in the literature around comprehensive studies that define sexual and reproductive health and rights beyond the confines of disease and sexual behavior, as well as a need for greater focus on under-represented migrant groups such as adolescent girls.

Enhancing the Ethical Conduct of HIV Research with Migrant Sex Workers: Human Rights, Policy, and Social Contextual Influences

BACKGROUND

Migrant sex workers are often highly marginalized and disproportionately experience health and social inequities, including high prevalence of HIV, sexually transmitted infections, and human rights violations. In recent years, research involving migrant sex workers has increased, yet many knowledge gaps remain regarding how best to protect research participant rights and welfare. Our objective was to identify key challenges and opportunities related to the responsible conduct of HIV research with migrant sex workers.

METHODS

Focus groups and interviews conducted with 33 female sex workers ≥18 years old at the Guatemala-Mexico border from June 2013-February 2014 were analyzed. Participants were recruited through community outreach by a local HIV prevention organization to sex work establishments such as bars, hotels, street corners, and truck stops.

RESULTS

Key themes influencing research engagement for migrant sex workers included researcher mistrust and fear related to research participation, rooted in the social isolation frequently faced by recent migrants; intersecting concerns related to immigration status, fear of criminalization, and compliance with sex work regulations; and perceived benefits and risks of HIV/STI testing for migrants (e.g., immigration implications, stigma) represent potential barriers and opportunities for the responsible conduct of research involving migrant sex workers.

CONCLUSIONS

Results highlight the intersection between the human rights vulnerabilities of migrant sex workers and barriers to research participation, including social isolation of migrants and policy/legal barriers related to immigration and sex work. Findings illustrate the need for researchers to develop population-tailored procedures to address fears related to immigration and criminalization, and to reinforce positive and non-stigmatizing relationships with migrant sex workers. Community-led efforts to reduce stigma and foster community organization and supports for migrant sex workers are recommended, as are broader policy shifts that move away from punitive legal approaches towards approaches that safeguard and prioritize the human rights of migrant sex workers.

In-Country Migration and Risk Factors for HIV Acquisition among Pregnant Women in Tijuana, Mexico

OBJECTIVE

To compare HIV prevalence and HIV acquisition risk behaviors between pregnant women residents and migrants.

DESIGN

A cross-sectional study of pregnant women of unknown HIV status seeking care at Tijuana General Hospital, Mexico.

METHODS

Pregnant women attending the labor and delivery unit or the prenatal clinic had a rapid HIV test drawn, with positive results confirmed by Western blot. Migrants were defined as women who had resided in Tijuana for less than 5 years.

RESULTS

Between 2007 and 2008, a total of 3331 pregnant women consented to participate. The HIV seroprevalence did not differ between Tijuana residents (18 of 2502, 0.72%) and migrants (3 of 829, 0.36%, P = .32). In multivariate regression analyses, HIV acquisition risk behaviors included methamphetamine use (adjusted odds ratio [OR]: 6.03, 95% confidence interval [CI]: 2.3-15.8, P < .001) and first presentation at labor (adjusted OR: 5.0, 95% CI: 1.6-15.3, P = .005), adjusted for migrant status, age, and history of sexually transmitted infections.

CONCLUSION

The overall HIV seroprevalence was 0.63% and did not differ between Tijuana residents and migrants.

An ethnographic exploration of drug markets in Kisumu, Kenya

BACKGROUND

Illegal drug markets are shaped by multiple forces, including local actors and broader economic, political, social, and criminal justice systems that intertwine to impact health and social wellbeing. Ethnographic analyses that interrogate multiple dimensions of drug markets may offer both applied and theoretical insights into drug use, particularly in developing nations where new markets and local patterns of use traditionally have not been well understood. This paper explores the emergent drug market in Kisumu, western Kenya, where our research team recently documented evidence of injection drug use.

METHODS

Our exploratory study of injection drug use was conducted in Kisumu from 2013 to 2014. We draw on 151 surveys, 29 in-depth interviews, and 8 months of ethnographic fieldwork to describe the drug market from the perspective of injectors, focusing on their perceptions of the market and reports of drug use therein.

RESULTS

Injectors described a dynamic market in which the availability of drugs and proliferation of injection drug use have taken on growing importance in Kisumu. In addition to reports of white and brown forms of heroin and concerns about drug adulteration in the market, we unexpectedly documented widespread perceptions of cocaine availability and injection in Kisumu. Examining price data and socio-pharmacological experiences of cocaine injection left us with unconfirmed evidence of its existence, but opened further possibilities about how the chaos of new drug markets and diffusion of injection-related beliefs and practices may lend insight into the sociopolitical context of western Kenya.

CONCLUSIONS

We suggest a need for expanded drug surveillance, education and programming responsive to local conditions, and further ethnographic inquiry into the social meanings of emergent drug markets in Kenya and across sub-Saharan Africa.

Short-term cessation of sex work and injection drug use: evidence from a recurrent event survival analysis

OBJECTIVE

This study quantitatively examined the prevalence and correlates of short-term sex work cessation among female sex workers who inject drugs (FSW-IDUs) and determined whether injection drug use was independently associated with cessation.

METHODS

We used data from FSW-IDUs (n=467) enrolled into an intervention designed to increase condom use and decrease sharing of injection equipment but was not designed to promote sex work cessation. We applied a survival analysis that accounted for quit-re-entry patterns of sex work over 1-year stratified by city, Tijuana and Ciudad Juarez, Mexico.

RESULTS

Overall, 55% of participants stopped sex work at least once during follow-up. Controlling for other characteristics and intervention assignment, injection drug use was inversely associated with short-term sex work cessation in both cities. In Ciudad Juarez, women receiving drug treatment during follow-up had a 2-fold increase in the hazard of stopping sex work. In both cities, income from sources other than sex work, police interactions and healthcare access were independently and significantly associated with shorter-term cessation.

CONCLUSIONS

Short-term sex work cessation was significantly affected by injection drug use. Expanded drug treatment and counseling coupled with supportive services such as relapse prevention, job training, and provision of alternate employment opportunities may promote longer-term cessation among women motivated to leave the sex industry.

Migrants in transit: the importance of monitoring HIV risk among migrant flows at the Mexico-US border

We conducted a probability-based survey of migrant flows traveling across the Mexico-US border, and we estimated HIV infection rates, risk behaviors, and contextual factors for migrants representing 5 distinct migration phases. Our results suggest that the influence of migration is not uniform across genders or risk factors. By considering the predeparture, transit, and interception phases of the migration process, our findings complement previous studies on HIV among Mexican migrants conducted at the destination and return phases. Monitoring HIV risk among this vulnerable transnational population is critical for better understanding patterns of risk at different points of the migration process and for informing the development of protection policies and programs.

The longitudinal association of venue stability with consistent condom use among female sex workers in two Mexico-USA border cities

We examined the relationship between venue stability and consistent condom use (CCU) among female sex workers who inject drugs (FSW-IDUs; n = 584) and were enrolled in a behavioural intervention in two Mexico-USA border cities. Using a generalized estimating equation approach stratified by client type and city, we found venue stability affected CCU. In Tijuana, operating primarily indoors was significantly associated with a four-fold increase in the odds of CCU among regular clients (odds ratio [OR]: 3.77, 95% confidence interval [CI]: 1.44, 9.89), and a seven-fold increase among casual clients (OR: 7.18, 95% CI: 2.32, 22.21), relative to FSW-IDUs spending equal time between indoor and outdoor sex work venues. In Ciudad Juarez, the trajectory of CCU increased over time and was highest among those operating primarily indoors. Results from this analysis highlight the importance of considering local mobility, including venue type and venue stability, as these characteristics jointly influence HIV risk behaviours.