Estimating the impact of a police education program on hepatitis C virus transmission and disease burden among people who inject drugs in Tijuana, Mexico: A dynamic modeling analysis

BACKGROUND AND AIMS

Criminalization of drug use and punitive policing are key structural drivers of hepatitis C virus (HCV) risk among people who inject drugs (PWID). A police education program (Proyecto Escudo) delivering training on occupational safety together with drug law content was implemented between 2015 and 2016 in Tijuana, Mexico, to underpin drug law reform implementation. We used data from a longitudinal cohort of PWID in Tijuana to inform epidemic modeling and assess the long-term impact of Escudo on HCV transmission and burden among PWID in Tijuana.

METHODS

We developed a dynamic, compartmental model of HCV transmission and incarceration among PWID and tracked liver disease progression among current and former PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence. We used segmented regression analysis to estimate impact of Escudo on recent incarceration among an observational cohort of PWID. By simulating the observed incarceration trends, we estimated the potential impact of the implemented (2-year reduction in incarceration) and an extended (10-year reduction in incarceration) police education program over a 50-year follow-up (2016-2066) on HCV outcomes (incidence, cirrhosis, HCV-related deaths and disability adjusted life-years averted) compared with no intervention.

RESULTS

Over the 2-year follow-up, Proyecto Escudo reduced HCV incidence among PWID from 21.5 per 100 person years (/100py) (95% uncertainty interval [UI] = 15.3-29.7/100py) in 2016 to 21.1/100py (UI = 15.0-29.1/100py) in 2018. If continued for 10 years, Escudo could reduce HCV incidence to 20.0/100py (14.0-27.8/100py) by 2026 and avert 186 (32-389) new infections, 76 (UI = 12-160) cases of cirrhosis and 32 (5-73) deaths per 10 000 PWID compared with no intervention over a 50-year time horizon.

CONCLUSIONS

In Tijuana, Mexico, implementation of a police education program delivering training on occupational safety and drug law content appears to have reduced hepatitis C virus incidence among people who inject drugs.

Modelling the contribution of incarceration and public health oriented drug law reform to HCV transmission and elimination among PWID in Tijuana, Mexico

BACKGROUND

Incarceration is associated with increased risk of hepatitis C virus (HCV) among people who inject drugs (PWID). Mexico's previous attempt in implementing a public health-oriented drug law reform resulted in minimal impact on incarceration among PWID. However, implementation of reforms alongside Mexico's HCV elimination program has the potential to reshape the HCV epidemic among PWID in the next decade. We use data from a cohort of PWID in Tijuana, Mexico, to inform epidemic modeling to assess the contribution of incarceration and fully implemented drug reform on HCV transmission and elimination among PWID.

METHODS

We developed a dynamic, deterministic model of incarceration, HCV transmission and disease progression among PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence among 10,000 PWID. We estimated the 10-year population attributable fraction (PAF) of incarceration to HCV incidence among PWID and simulated, from 2022, the potential impact of the following scenarios: 1) decriminalization (80% reduction in incarceration rates); 2) fully implemented drug law reform (decriminalization and diversion to opiate agonist therapy [OAT]); 3) fully implemented drug law reform with HCV treatment (direct-acting antivirals [DAA]). We also assessed the number DAA needed to reach the 80% incidence reduction target by 2030 under these scenarios.

RESULTS

Projections suggest a PAF of incarceration to HCV incidence of 5.4% (95% uncertainty interval [UI]:0.6-11.9%) among PWID in Tijuana between 2022-2032. Fully implemented drug reforms could reduce HCV incidence rate by 10.6% (95%UI:3.1-19.2%) across 10 years and reduce the number of DAA required to achieve Mexico's HCV incidence reduction goal by 14.3% (95%UI:5.3-17.1%).

CONCLUSIONS

Among PWID in Tijuana, Mexico, incarceration remains an important contributor to HCV transmission. Full implementation of public health-oriented drug law reform could play an important role in reducing HCV incidence and improve the feasibility of reaching the HCV incidence elimination target by 2030.

Impact of cumulative incarceration and the post-release period on syringe-sharing among people who inject drugs in Tijuana, Mexico: a longitudinal analysis

BACKGROUND AND AIMS

Syringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing.

DESIGN

Ongoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups.

SETTING

Tijuana, Mexico.

PARTICIPANTS

Sample of 185 participants (median age 35 years; 67% female) with no history of incarceration at study entry, followed to 2017.

MEASUREMENTS

Cumulative incarceration and post-release period were constructed from incarceration events reported in the past 6 months for each study visit. Receptive syringe-sharing in the past 6 months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation.

FINDINGS

At baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6 months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median = 2, interquartile range (IQR) = 1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) = 0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI = 1.02-1.99) and more than three incarcerations, 2.10 (95% CI = 1.15-3.85). Participants released within the past 6 months had 1.53 (95% CI = 1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5 years post-incarceration (adjusted odds ratio = 1.41, 95% CI = 1.04-1.91), but then waned.

CONCLUSIONS

A longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.

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

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.