Deportation experiences of women who inject drugs in Tijuana, Mexico

Intersections between syndemic conditions and stages along the continuum of overdose risk among women who inject drugs in Mexicali, Mexico

BACKGROUND

Research on women who inject drugs is scarce in low- and middle-income countries. Women experience unique harms such as sexism and sexual violence which translate into negative health outcomes. The present work aims to provide insight into the experiences of women who inject drugs at the US-Mexico border to identify social and health-related risk factors for overdose to guide harm reduction interventions across the Global South.

METHODS

We recruited 25 women ≥ 18 years of age accessing harm reduction and sexual health services at a non-governmental harm reduction organization, "Verter", in Mexicali, Mexico. We employed purposeful sampling to recruit women who inject drugs who met eligibility criteria. We collected quantitative survey data and in-depth interview data. Analyses of both data sources involved the examination of descriptive statistics and thematic analysis, respectively, and were guided by the syndemic and continuum of overdose risk frameworks.

RESULTS

Survey data demonstrated reports of initiating injection drug use at a young age, experiencing homelessness, engaging in sex work, being rejected by family members, experiencing physical violence, injecting in public spaces, and experiencing repeated overdose events. Interview data provided evidence of stigma and discrimination toward women, a lack of safe spaces and support systems, risk of overdose-related harms, sexual violence, and the overall need for harm reduction services.

CONCLUSION

Women who inject drugs in Mexicali describe experiences of violence, overdose, and public injecting. Women are particularly vulnerable in the Mexicali context, as this area faces a noticeable lack of health and social services. Evidenced-based harm reduction strategies such as safe consumption sites and overdose prevention strategies (e.g., naloxone distribution and training) may benefit this population. Evidence from local organizations could help close the gap in service provision in low-resource settings like Mexico, where government action is almost nonexistent.

Tattoo Removal as a Resettlement Service to Reduce Incarceration Among Mexican Migrants

In Mexico, tattooed migrants face discrimination and are at high-risk of incarceration, thus, we assessed whether receiving laser tattoo removal affected the likelihood of incarceration. In 2015-2016, 89 adults ages ≥ 18 years with visible tattoos were recruited at a free-clinic to receive laser tattoo removal or assigned to the wait-list; all completed baseline and 6-month questionnaires. Overall, 97.8% of participants ever migrated to the USA. In multivariate analyses restricted to migrants (n = 87), those receiving laser tattoo removal [Adjusted Odds Ratio (AOR) 0.27, 95% CI 0.07-0.89] and possessing a Mexican Voting card (AOR 0.14; 95% CI 0.03-0.58) were significantly less likely than wait-list participants to be incarcerated at 6-months. Previously incarcerated participants were significantly more likely to be incarcerated at follow-up. Tattoo removal may reduce incarceration among Mexican migrants. Future studies can assess other health and social benefits of tattoo removal for migrants/deportees returning to Mexico.

Deportation and mental health among migrants who inject drugs along the US-Mexico border

This study describes the prevalence and factors of depressive symptoms among a sample of persons who inject drugs (PWID) with a history of deportation from the US in Tijuana, Mexico. In 2014, 132 deported PWID completed a structured questionnaire. Depressive symptoms were measured using the Center for Epidemiologic Studies Short Depression Scale (CESD-10) screening instrument. Eligible participants were ≥18 years old, injected drugs in the past month, spoke English or Spanish, and resided in Tijuana. Multivariate analyses identified factors associated with depressive symptoms. Among deported PWID, 45% reported current symptoms of depression. Deported PWID who were initially detained in the US for a crime-related reason before being deported (adjusted odds ratio (AOR): 5.27; 95% CI: 1.79-15.52) and who perceived needing help with their drug use (AOR: 2.15; 95% 1.01-4.61) had higher odds of reporting depressive symptoms. Our findings highlight the need for effective strategies targeting deported migrants who inject drugs to treat mental health and drug abuse in Tijuana. Investing in the mental health of deported PWID may also be a viable HIV prevention strategy.

The Relationship Between Social Support, HIV Serostatus, and Perceived Likelihood of Being HIV Positive Among Self-Settled Female, Foreign Migrants in Cape Town, South Africa

Female cross-border migrants experience elevated risks for HIV, and migrants in South Africa may face additional risks due to the country's underlying HIV prevalence. These risks may be mitigated by the receipt of social support. A behavioral risk-factor survey was administered using respondent-driven sampling. Multivariable regression models assessed the relationships between social support and two HIV outcomes: HIV serostatus and perceived HIV status. Low social support was not significantly associated with HIV status (aOR = 1.03, 95 % CI 0.43-2.46), but was significantly related to a perception of being HIV positive (aPR = 1.36, 95 % CI 1.04-1.78). Age, marital status, and education level were significantly associated with HIV serostatus. Illegal border-crossing, length of time in South Africa, anal sex, and transactional sex were significantly associated with aperception of being HIV positive. Future research should investigate how HIV risks and the receipt of social support change throughout the migration process.

Health-damaging policing practices among persons who inject drugs in Mexico: Are deported migrants at greater risk?

BACKGROUND

Evidence-based public health and criminal justice policies aimed at addressing the structurally vulnerable population of persons who inject drugs (PWID) and who are involved in the immigrant enforcement and deportation system are lacking. Policing practices are critical structural determinants of HIV among PWID. PWID in Mexico who have been deported from the US are at elevated risk of HIV.

METHODS

From 2011 to 2013, 733 PWID were recruited to complete structured questionnaires, including past 6-month experiences with police. Eligible PWID were 18 years or older, had injected in the past month, and resided in Tijuana, Mexico with no intentions of moving. To determine if deportation status was associated with experiences of arrests and problematic policing practices, we conducted separate multivariate logistic regression models for independent policing variables.

RESULTS

In multivariate analyses, deportation status was independently associated with higher odds of being arrested (Adjusted Odds Ratio (AOR): 1.45; 95% Confidence Interval (CI): 1.02-2.05), being asked for a bribe (AOR: 1.39; 95% CI: 1.05-2.04), and being forced to leave a place of residence (AOR: 2.00; 95% CI: 1.08-3.70) in the past 6 months.

CONCLUSION

Results highlight a previously poorly understood elements of the US-deportation experience: migrants' experiences with law enforcement post-deportation and the role of deportation policies and practices as structural drivers of public health risk in destination countries. We provide policy recommendations for Mexico and the US based on our findings, which have potential application in other countries seeking to improve enforcement and related policing practices from a public health perspective.

Respiratory Health in Migrant Populations: A Crisis Overlooked

The crisis in the Middle East has raised awareness about the challenges encountered by migrant populations, in particular, health-care access and delivery. Similar challenges are encountered by migrant populations around the world, including those entering the United States as refugees and/or survivors of torture as well as Mexicans and other Latin Americans crossing the border. During the 2016 International American Thoracic Society Meeting held in San Francisco, California, a group of researchers and health-care providers discussed these challenges at a minisymposium devoted to the respiratory health of migrants. The discussion focused on the increased incidence of airway diseases among individuals migrating to more developed countries, the problems created by sleep disorders and their implications for cardiovascular and mental health, the challenges inherent in the control of infections in refugee populations, and the problems resulting from deportation. The group also discussed the potential impact of novel strategies made available by Internet-based technologies and how these strategies could be deployed to support worldwide efforts in assisting migrants and refugees, even in countries that find themselves in the direst circumstances. These presentations are summarized in this document, which is not meant to be exhaustive, but to improve awareness about the challenges confronted by migrants and their host nations regarding respiratory health-care access and delivery, and about the need for adequate investment of resources to better define these challenges through research and for the development of efficient strategies for intervention.

Deportation history among HIV-positive Latinos in two US-Mexico border communities

Health-related vulnerabilities associated with deportation are understudied. We conducted a cross-sectional study to identify factors associated with history of deportation from the US to Mexico among HIV-positive Latinos. From 2009 to 2010, we recruited a convenience sample from HIV clinics in San Diego, US and Tijuana, Mexico. Of 283 participants, 25% reported a prior deportation. Factors independently associated with increased odds of deportation history were being male [adjusted odds ratio (AOR) 2.77; 95% CI 1.18-6.48], having ≤high-school education (AOR 3.87; 95% CI 1.84-8.14), ever using cocaine (AOR 2.46; 95% CI 1.33-4.57), and reporting personalized HIV-stigma: "some have told me HIV is what I deserve for how I lived" (AOR 2.23; 95% CI 1.14-4.37). Lower self-reported antiretroviral medication adherence (AOR 0.35; 95% CI 0.12-0.96) and perceiving HIV-stigma: "most people believe a person who has HIV is dirty" (AOR 0.49; 95% CI 0.25-0.94) were associated with decreased odds of deportation history. Deportation is associated with specific socioeconomic indicators that are known to impact the health of individuals living with HIV.

Epidemiology of Substance Use among Forced Migrants: A Global Systematic Review

INTRODUCTION

Forced migration is occurring at unprecedented levels. Forced migrants may be at risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality. This paper aimed to systematically review the literature examining substance use among forced migrants, and identify priority areas for intervention and future research.

METHODS

Seven medical, allied health and social science databases were searched from inception to September 2015 in accordance with PRISMA guidelines to identify original peer-reviewed articles describing any findings relating to alcohol and/or illicit drug use among refugees, internally displaced people (IDPs), asylum seekers, people displaced by disasters and deportees. A descriptive synthesis of evidence from quantitative studies was conducted, focusing primarily on studies which used validated measures of substance use. Synthesis of evidence from qualitative studies focused on identifying prominent themes relating to the contexts and consequences of substance use. Critical Appraisal Skills Programme (CASP) checklists were used to assess methodological quality of included studies.

RESULTS

Forty-four quantitative (82% cross-sectional), 16 qualitative and three mixed-methods studies were included. Ten studies were rated as high methodological quality (16%), 39 as moderate quality (62%) and 14 as low quality (22%). The majority of research was conducted among refugees, IDPs and asylum seekers (n = 55, 87%), predominantly in high-income settings. The highest-quality prevalence estimates of hazardous/harmful alcohol use ranged from 17%-36% in camp settings and 4%-7% in community settings. Few studies collected validated measures of illicit drug use. Seven studies compared substance use among forced migrants to other migrant or native-born samples. Among eight studies which conducted multivariable analysis, male sex, trauma exposure and symptoms of mental illness were commonly identified correlates of substance use.

CONCLUSION

Our understanding of substance use among forced migrants remains limited, particularly regarding persons displaced due to disasters, development and deportation. Despite a growing body of work among refugee-background populations, few studies include refugees in low and middle-income countries, where over 80% of the global refugee population resides. Findings suggest a need to integrate substance use prevention and treatment into services offered to forced migrants, particularly in camp settings. Efforts to develop and evaluate interventions to reduce substance use and related harms are needed.

Spatial patterns of arrests, police assault and addiction treatment center locations in Tijuana, Mexico

AIMS

In the context of a public health-oriented drug policy reform in Mexico, we assessed the spatial distribution of police encounters among people who inject drugs (PWID) in Tijuana, determined the association between these encounters and the location of addiction treatment centers and explored the association between police encounters and treatment access.

DESIGN

Geographically weighted regression (GWR) and logistic regression analysis using prospective spatial data from a community-recruited cohort of PWID in Tijuana and official geographical arrest data from the Tijuana Municipal Police Department.

SETTING

Tijuana, Mexico.

PARTICIPANTS

A total of 608 participants (median age 37; 28.4% female) in the prospective Proyecto El Cuete cohort study recruited between January and December 2011.

MEASUREMENTS

We compared the mean distance of police encounters and a randomly distributed set of events to treatment centers. GWR was undertaken to model the spatial relationship between police interactions and treatment centers. Logistic regression analysis was used to investigate factors associated with reporting police interactions.

FINDINGS

During the study period, 27.5% of police encounters occurred within 500 m of treatment centers. The GWR model suggested spatial correlation between encounters and treatment centers (global R(2)  = 0.53). Reporting a need for addiction treatment was associated with reporting arrest and police assault [adjusted odds ratio = 2.74, 95% confidence interval (CI) = 1.25-6.02, P = 0.012].

CONCLUSIONS

A geospatial analysis suggests that, in Mexico, people who inject drugs are at greater risk of being a victim of police violence if they consider themselves in need of addiction treatment, and their interactions with police appear to be more frequent around treatment centers.

Depressive symptoms among patients at a clinic in the Red Light District of Tijuana, Mexico

Little is known about depression among structurally vulnerable groups living in Tijuana (e.g., migrants, deportees, substance users, sex workers, homeless) who may be at high risk for poor mental health. This study investigates the prevalence and correlates of depressive symptoms among vulnerable patients receiving services at a free clinic in Tijuana, Mexico. A convenience sample of 584 adult Mexican patients completed an interviewer-administered questionnaire in English or Spanish that included the 8-item NIH PROMIS depression short form and measures of individual, social, and structural factors affecting health. The prevalence of clinically significant depressive symptoms in our sample was 55%. In the multivariate analysis, female gender, poor/fair self-rated health, recent illicit drug use (past six months), feeling rejected (past six months), history of forced sex, and history of violence were independently associated with increased odds of experiencing depressive symptoms. When stratified by gender, we found important differences in significant factors, including recent illicit drug use in men and deportation in women. Among study participants, prevalence of depressive symptoms exceeds prevalence rates reported elsewhere in the U.S.-Mexico border region. These findings suggest that public health efforts to support mental health services in the border region are needed.

Establishing a binational student-run free-clinic in Tijuana, Mexico: a model for US-Mexico border states

In 2011, a bi-national student-run free clinic for the underserved, known as "Health Frontiers in Tijuana" (HFiT), was created in Tijuana, Mexico. Students and faculty from one Mexican and one US medical school staff the clinic and attend patients on Saturdays. Students from both medical schools enroll in a didactic course during the quarter/semester that they attend the free clinic. The course addresses clinical, ethical, cultural, population-specific issues and the structure, financing and delivery of medical care in Mexico. The clinic implements an electronic medical record and is developing telemedicine for consulting on complex cases. Despite challenges related to sustaining adequate funding, this program may be replicated in other border communities.

High dead-space syringe use among people who inject drugs in Tijuana, Mexico

BACKGROUND

High dead-space syringes (HDSS) are believed to confer an elevated risk of acquiring HIV and other blood-borne infections.

OBJECTIVES

We identified prevalence and correlates of HDSS use among injection drug users (IDU) in Tijuana, Mexico, where syringe purchase and possession is legal without a prescription.

METHODS

Beginning in 2011, IDU who reported being 18 years or older and injected drugs within the last month were recruited into a prospective study. At baseline and semi-annually, 557 IDU underwent HIV-testing and interviewer-administered surveys. Logistic regression was used to identify correlates of using HDSS.

RESULTS

Of 557 IDU, 40% had ever used HDSS, mostly because no other syringe type was available (72%), or because they were easier to get (20%). Controlling for sex and age at first injection, use of HDSS was associated with cocaine as the first drug injected (Adjusted Odds Ratio [AOR]: 2.68; Confidence Interval 95% [CI]: 1.15-6.22), having been stopped or arrested by police (AOR: 1.84; 95% CI: 1.11-3.07), being deported from the US (AOR: 1.64; 95% CI:1.06-2.53), and believing it is illegal to carry syringes (AOR:1.78; 95% CI: 1.01-3.15).

CONCLUSION

Use of HDSS is surprisingly common among IDU in Tijuana. Efforts are needed to expand coverage of low-dead space syringes through existing syringe exchange programs. Education is required to increase awareness of the harms associated with HDSS, and to inform IDU that syringe possession is legal across Mexico.

The role of visual markers in police victimization among structurally vulnerable persons in Tijuana, Mexico

BACKGROUND

Law enforcement can shape HIV risk behaviours and undermine strategies aimed at curbing HIV infection. Little is known about factors that increase vulnerability to police victimization in Mexico. This study identifies correlates of police or army victimization (i.e., harassment or assault) in the past 6 months among patients seeking care at a free clinic in Tijuana, Mexico.

METHODS

From January to May 2013, 601 patients attending a binational student-run free clinic completed an interviewer-administered questionnaire. Eligible participants were: (1) ≥18 years old; (2) seeking care at the clinic; and (3) spoke Spanish or English. Multivariate logistic regression analyses identified factors associated with police/army victimization in the past 6 months.

RESULTS

More than one-third (38%) of participants reported victimization by police/army officials in the past 6 months in Tijuana. In multivariate logistic regression analyses, males (adjusted odds ratio (AOR): 3.68; 95% CI: 2.19-6.19), tattooed persons (AOR: 1.56; 95% CI: 1.04-2.33) and those who injected drugs in the past 6 months (AOR: 2.11; 95% CI: 1.29-3.43) were significantly more likely to report past 6-month police/army victimization. Recent feelings of rejection (AOR: 3.80; 95% CI: 2.47-5.85) and being denied employment (AOR: 2.23; 95% CI: 1.50-3.32) were also independently associated with police/army victimization.

CONCLUSION

Structural interventions aimed at reducing stigma against vulnerable populations and increasing social incorporation may aid in reducing victimization events by police/army in Tijuana. Police education and training to reduce abusive policing practices may be warranted.

Perceived risk of HIV infection among deported male injection drug users in Tijuana, Mexico

Deported injection drug users (IDUs) in Mexico may be vulnerable to HIV infection following expulsion from the USA. We examined factors associated with HIV risk perception among a sample of deportees in Tijuana. From January to April 2010, 313 male IDUs who reported ever being deported from the USA completed a questionnaire. Overall, 35% (N=110) of deportees perceived HIV risk. In multivariate logistic regression analyses, factors independently associated with HIV risk perception included ever having a steady female partner in Tijuana post-deportation (adjusted odds ratio [AOR]: 2.26; 95% confidence interval [CI]: 1.01-5.07) and years spent in a US prison (AOR: 1.29 per year; 95% CI: 1.13-1.48). Conversely, years of drug injection use (AOR: 0.95 per year; 95% CI: 0.91-0.99), ever witnessing family members use drugs prior to first migration trip (AOR: 0.24; 95% CI: 0.09-0.65), years of residence in the USA (AOR: 0.91 per year; 95% CI: 0.84-0.98) and being a Tijuana native (AOR: 0.40; 95% CI: 0.16-0.99) were negatively associated with HIV risk perception. US-Mexico border cities that receive deported migrants should target HIV prevention interventions to specific subgroups, including drug-using male deportees. Interventions should consider migrant's time in the USA, the role of their social networks, and reducing missed opportunities for HIV testing/education.

A critical review of social and structural conditions that influence HIV risk among Mexican deportees

Mexican migrants who are deported from the US may be at elevated risk for HIV infection. Deportations of Mexican migrants by the US have reached record numbers. We critically reviewed existing literature to assess how social and structural conditions in post-deportation settings can influence Mexican deported migrants' HIV risk. We also identify critical research gaps and make research recommendations.

Rethinking risk: gender and injection drug-related HIV risk among female sex workers and their non-commercial partners along the Mexico-U.S. border

BACKGROUND

Studies of injection drug-using couples suggest a gendered performance of risk in which men exert greater control over drug use and render their female partners vulnerable to HIV infection and other negative health outcomes. This study assesses gender roles in injection drug use as practiced among female sex workers and their intimate male partners within a risk environment marked by rapid socioeconomic changes.

METHODS

We draw on quantitative surveys, semi-structured interviews, and ethnographic fieldwork conducted as part of cohort study of HIV/STI risk among female sex workers and their intimate, non-commercial partners along the Mexico-U.S. border. This study employed descriptive statistics and inductive analyses of transcripts and field notes to examine practices related to drug procurement, syringe sharing, and injection assistance among couples in which both partners reported injecting drugs in the past 6 months.

RESULTS

Among 156 couples in which both partners injected drugs (n=312), our analyses revealed that women's roles in drug use were active and multidimensional, and both partners' injection risk practices represented embodied forms of cooperation and compassion. Women often earned money to purchase drugs and procured drugs to protect their partners from the police. Sharing drugs and syringes and seeking injection assistance were common among couples due to drug market characteristics (e.g., the use of "black tar" heroin that clogs syringes and damages veins). Both women and men provided and received injection assistance, which was typically framed as caring for the partner in need of help.

CONCLUSION

Our mixed methods study suggests that in certain risk environments, women are more active participants in injection-related practices than has often been revealed. This participation is shaped by dynamic relationship and structural factors. Our suggestion to consider gendered injection risk as a nuanced and relational process has direct implications for future research and interventions.