Correlates of recent overdose among people who inject drugs in the San Diego/Tijuana border region

BACKGROUND

Along the Mexico-US border, illicitly manufactured fentanyls (fentanyl) have been detected in other illicit drugs, including street opioid formulations known as 'china white.' We studied correlates of recent overdose among people who inject drugs (PWID), focusing on the risk of knowlingly or unknowingly using fentanyl in china white.

METHODS

From October 2020 - September, 2021 we surveyed participants in San Diego, California and Tijuana, Mexico and employed Poisson regression to identify correlates of recent overdose.

RESULTS

Of 612 PWID, most were male (74.0 %), Latinx (71.9 %), US residents (67.0 %). Mean age was 43 years. In the last six months, 15.8 % experienced overdose, 31.0 % knowingly used fentanyl and 11.1 % used china white, of whom 77.9 % did not think it contained fentanyl. After controlling for sex and race, factors independently associated with risk of overdose included knowingly using fentanyl, using china white and not believing it contained fentanyl, recent drug rehabilitation, being stopped/arrested by police, and homelessness. Further, PWID who believed china white contained fentanyl were less likely to use it.

CONCLUSIONS

Both intentional fentanyl use and unintentional exposure to fentanyl via china white were associated with overdose risk; however, PWID who believed china white contained fentanyl were less likely to use it. These data suggest that advanced drug checking systems should be implemented to empower PWID to avoid dangerous street formulations or to plan their drug use knowing its contents. Other overdose risk factors such as decreased tolerance following drug treatment, police interactions, and homelessness also require urgent intervention.

COVID-19 vaccine uptake among people who inject drugs in Tijuana Mexico

Background

SARS-CoV-2 prevalence is elevated among people who inject drugs (PWID). In Tijuana, Mexico, COVID-19 vaccines became available to the general population in June 2021, but uptake among PWID was <10%. We studied COVID-19 vaccine uptake among PWID in Tijuana following implementation of a pop-up vaccination clinic.

Methods

Beginning in October, 2020, PWID in Tijuana aged ≥18 years were enrolled into a longitudinal cohort study. At baseline and semi-annually, participants underwent interviewer-administered interviews on health behaviors and COVID-19 exposures through April 5, 2022. From June 21-September 20, 2021, staff referred PWID to a temporary COVID-19 vaccine pop-up clinic that was coincidentally established near the study office. Participants attending the clinic completed a short interview on barriers to vaccination and were offered facilitated access to free Janssen® COVID-19 vaccine. All participants were reimbursed $5 for this interview, regardless of whether or not they chose to be vaccinated. Poisson regression was used to evaluate the effect of the pop-up clinic on COVID-19 vaccination uptake, controlling forpotential confounders.

Results

Of 344 participants, 136 (39.5%) reported having received at least one COVID-19 vaccine dose during the 10 months follow-up period, of whom 113 (83.1%) received vaccine at the pop-up clinic and 23 (16.9%) elsewhere. One third of those receiving COVID-19 vaccine during the pop-up clinic were previously vaccine hesitant. Attending the pop-up clinic was independently associated with higher rates of COVID-19 vaccination Adjusted Rate Ratio (AdjRR: 9.15; 95% CI: 5.68-14.74).

Conclusions

We observed a significant increase in COVID-19 vaccine uptake associated with attending a temporary pop-up vaccine clinic in Tijuana suggesting that efforts to improve vaccination in this vulnerable population should include convenient locations and staff who have experience working with substance using populations. Since COVID-19 vaccination rates remain sub-optimal, sustained interventions to increase uptake are needed.

They just took him: Impacts of immigration enforcement on U.S. citizen Latino adolsecents’ well-being

Background

Escalating interior immigration enforcement by the Trump administration threatens U.S. Latino immigrant families, yet systematic evidence is limited regarding the impacts of immigration enforcement in this community. Our study explored lived experiences of U.S.-citizen adolescents affected by various levels of immigration enforcement, including parental deportation.

Methods

In-depth interviews were conducted with adolescents (13-17 years old, N = 7) who experienced-or were at risk of-parental deportation as part of a larger, on-going longitudinal study. Interviews queried after their health, family life, perceived discrimination, conceptualization of today's anti-immigrant climate and, if applicable, the circumstances and impact of their parent's deportation. A preliminary qualitative analysis of the interviews was conducted. Interview summaries were created and reviewed systematically. Major themes and qualitative assertions were derived and discussed by the analytical team.

Results

Parental detainment/deportation was inherently violent and traumatic and had profound mental/emotional, physical, socio-cultural and economic consequences for separated adolescents as they assumed adult roles and responsibilities. The threat of deportation negatively affected the well-being of adolescents with deportable parents, resulting in increased vigilance and stress. Participants were ambivalent regarding their desire to talk about the risk of deportation or their experiences with it, as well as their own identities as Latinx citizens. They also reported feelings of isolation, discrimination and victimization related to immigration enforcement.

Conclusions

Anticipated and experienced parental deportation negatively affects health and well-being among U.S.-citizen adolescents. Family-friendly immigration policies, community-based interventions, and family counseling are critical to protect this vulnerable population.

Key messages

Following deportation, the deportee’s family—especially their U.S.-citizen adolescents—are profoundly and negatively affected. Even the threat of deportation stresses adolescents and their families and results in negative psychosocial outcomes.

Impacting Binational Health through Leadership Development: A Program Evaluation of the Leaders across Borders Program, 2010-2014

Background

Workforce and leadership development is imperative for the advancement of public health along the U.S./Mexico border. The Leaders across borders (LaB) program aims to train the public health and health-care workforce of the border region. The LaB is a 6-month intensive leadership development program, which offers training in various areas of public health. Program curriculum topics include: leadership, border health epidemiology, health diplomacy, border public policies, and conflict resolution.

Methods

This article describes the LaB program evaluation outcomes across four LaB cohort graduates between 2010 and 2014. LaB graduates received an invitation to participate via email in an online questionnaire. Eighty-five percent (n = 34) of evaluation participants indicated an improvement in the level of binationality since participating in the LaB program. Identified themes in the evaluation results included increased binational collaborations and partnerships across multidisciplinary organizations that work towards improving the health status of border communities. Approximately 93% (n = 37) of the LaB samples were interested in participating in future binational projects while 80% (n = 32) indicated interest in the proposal of other binational initiatives. Participants expressed feelings of gratitude from employers who supported their participation and successful completion of LaB.

Discussion

Programs such as LaB are important in providing professional development and education to a health-care workforce along the U.S./Mexico border that is dedicated to positively impacting the health outcomes of vulnerable populations residing in this region.

Understanding the Impact of Migration on HIV Risk: An Analysis of Mexican Migrants' Sexual Practices, Partners, and Contexts by Migration Phase

HIV risk among Mexican migrants varies across migration phases (pre-departure, transit, destination, interception, and return), but there is limited knowledge about specific sexual behaviors, characteristics of sexual partners, and sexual contexts at different migration stages. To fill the gap, we used data from a cross-sectional population-based survey conducted in Tijuana, Mexico. Information on migration phase and last sexual encounter was collected from 1219 male migrants. Our findings suggest that compared to pre-departure migrants, repeat migrants returning from communities of origin were more likely to have sex with male partners, use substances before sex, and not use condoms; migrants in the transit phase in the Mexican border were more likely to have sex with casual partners and sex workers; and migrants in the interception phase were more likely to engage in anal sex and use substances before sex. Sexual behaviors, partners, and contexts vary significantly among migrants at different migration phases. Tailored HIV prevention programs targeting Mexican migrants need to be developed and implemented at all migration phases.

Substance Use Across Different Phases of the Migration Process: A Survey of Mexican Migrants Flows

This study examined the levels of substance use and changes across different migration stages, including pre-departure, travel, destination, and return, among Mexican migrants converging on the US-Mexico border. A cross-sectional survey was conducted in Tijuana, Mexico, between 2009 and 2010 among Mexican migrants returning from the US and those travelling from other Mexican regions. The overall prevalence of last 12-month at-risk drinking, illicit drug use, and current smoking, was 42.3, 17.7 and 31.4%, respectively. Compared to pre-departure migrants, males were at increased risk for illicit drug use at the destination and return stages. In contrast, females' alcohol consumption at the destination stage was lower than at pre-departure (p < 0.05). The level of smoking was stable across all stages for both genders. In the destination stage, undocumented migrants were more likely to use illicit drugs relative to their documented peers (p < 0.05). Binational interventions promoting substance use reduction are needed among this mobile population.

Risk behaviours for HIV infection among travelling Mexican migrants: The Mexico-US border as a contextual risk factor

The Mexico-US border region is a transit point in the trajectory of Mexican migrants travelling to and from the USA and a final destination for domestic migrants from other regions in Mexico. This region also represents a high-risk environment that may increase risk for HIV among migrants and the communities they connect. We conducted a cross-sectional, population-based survey, in Tijuana, Mexico, and compared Mexican migrants with a recent stay on the Mexico-US border region (Border, n = 553) with migrants arriving at the border from Mexican sending communities (Northbound, n = 1077). After controlling for demographics and migration history, border migrants were more likely to perceive their risk for HIV infection as high in this region and regard this area as a liberal place for sexual behaviours compared to Northbound migrants reporting on their perceptions of the sending communities (p < .05). Male border migrants were more likely to engage in sex, and have unprotected sex, with female sex workers during their recent stay on the border compared to other contexts (rate ratio = 3.0 and 6.6, respectively, p < .05). Binational and intensified interventions targeting Mexican migrants should be deployed in the Mexican border region to address migration related HIV transmission in Mexico and the USA.

A police education programme to integrate occupational safety and HIV prevention: protocol for a modified stepped-wedge study design with parallel prospective cohorts to assess behavioural outcomes

INTRODUCTION

Policing practices are key drivers of HIV among people who inject drugs (PWID). This paper describes the protocol for the first study to prospectively examine the impact of a police education programme (PEP) to align law enforcement and HIV prevention. PEPs incorporating HIV prevention (including harm reduction programmes like syringe exchange) have been successfully piloted in several countries but were limited to brief pre-post assessments; the impact of PEPs on policing behaviours and occupational safety is unknown.

OBJECTIVES

Proyecto ESCUDO (SHIELD) aims to evaluate the efficacy of the PEP on uptake of occupational safety procedures, as assessed through the incidence of needle stick injuries (NSIs) (primary outcome) and changes in knowledge of transmission, prevention and treatment of HIV and viral hepatitis; attitudes towards PWID, adverse behaviours that interfere with HIV prevention and protective behaviours (secondary outcomes).

METHODS/ANALYSIS

ESCUDO is a hybrid type I design that simultaneously tests an intervention and an implementation strategy. Using a modified stepped-wedge design involving all active duty street-level police officers in Tijuana (N = ∼ 1200), we will administer one 3 h PEP course to groups of 20-50 officers until the entire force is trained. NSI incidence and geocoded arrest data will be assessed from department-wide de-identified data. Of the consenting police officers, a subcohort (N=500) will be randomly sampled from each class to undergo pre-PEP and post-PEP surveys with a semiannual follow-up for 2 years to assess self-reported NSIs, attitudes and behaviour changes. The impact on PWIDs will be externally validated through a parallel cohort of Tijuana PWIDs.

ETHICS/DISSEMINATION

Research ethics approval was obtained from the USA and Mexico. Findings will be disseminated through open access to protocol materials through the Law Enforcement and HIV Network.

TRIAL REGISTRATION NUMBER

NCT02444403.

Identifying opportunities to increase HIV testing among mexican migrants: a call to step up efforts in health care and detention settings

HIV testing and counseling is a critical component of HIV prevention efforts and core element of current “treatment as prevention” strategies. Mobility, low education and income, and limited access to health care put Latino migrants at higher risk for HIV and represent barriers for adequate levels of HIV testing in this population. We examined correlates of, and missed opportunities to increase, HIV testing for circular Mexican migrants in the U.S. We used data from a probability-based survey of returning Mexican migrants (N=1161) conducted in the border city of Tijuana, Mexico. We estimated last 12-months rates of HIV testing and the percentage of migrants who received other health care services or were detained in an immigration center, jail, or prison for 30 or more days in the U.S., but were not tested for HIV. Twenty-two percent of migrants received HIV testing in the last 12 months. In general, utilization of other health care services or detention for 30 or more days in the U.S. was a significant predictor of last 12-months HIV testing. Despite this association, we found evidence of missed opportunities to promote testing in healthcare and/or correctional or immigration detention centers. About 27.6% of migrants received other health care and/or were detained at least 30 days but not tested for HIV. Health care systems, jails and detention centers play an important role in increasing access to HIV testing among circular migrants, but there is room for improvement. Policies to offer opt-out, confidential HIV testing and counseling to Mexican migrants in these settings on a routine and ethical manner need to be designed and pilot tested. These policies could increase knowledge of HIV status, facilitate engagement in HIV treatment among a highly mobile population, and contribute to decrease incidence of HIV in the host and receiving communities.

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.

Correlates of STI symptoms among female sex workers with truck driver clients in two Mexican border towns

Background

Female sex workers (FSW) are at increased risk for HIV and other STI due to occupation-related risks and exposures. Long-distance truck drivers have been implicated in the spread of HIV, but less is known about HIV/STI risks of FSW servicing truck drivers, especially in North America. As part of an international collaborative pilot study, we interviewed FSWs servicing truck driver clients along two major transportation corridors to explore factors associated with recent STI symptoms.

Methods

A cross-sectional study of 200 FSW was conducted in Mexico: 100 from Nuevo Laredo (U.S. border); 100 from Ciudad Hidalgo (Guatemalan border). Eligibility criteria included age ≥18 years, speaking English or Spanish, and having ≥1 truck driver client in the past month. The main outcome was reporting any recent STI symptoms, defined as experiencing genital/anal warts, genital ulcers/sores, genital itching, or abnormal vaginal discharge in the past 6 months. Logistic regression was used to identify correlates of recent STI symptoms.

Results

Median age of FSW was 29 years, 74% were single, 87% had <9^th grade education, and median income was 4000 pesos/month ($300 USD). Sex work occurred at a bar/cantina for 70%. One-quarter had never been tested for HIV, 53% reported lifetime drug use, 22% reported drinking alcohol before/during transactional sex and 17% reported recent STI symptoms. After controlling for age and study site, factors associated with STI symptoms were lifetime drug use (AOR 2.9, 95% CI 1.2-6.9), drug use before/during sex (AOR 2.8, 95% CI 1.1-7.1), alcohol use before/during sex (AOR 5.2, 95% CI 2.2, 12.6), forced sex ever (AOR 2.6, 95% CI 1.1-6.1), lifetime history of arrest (AOR 2.3, 95% CI 1.0-5.0), and being surveyed in Nuevo Laredo rather than Ciudad Hidalgo (AOR 4.8, 95% CI 2.0-10.0).

Conclusions

The associations we observed between recent STI symptoms and drug and alcohol use suggest that interventions are needed that promote consistent and effective safer sex practices, especially while under the influence of alcohol or other substances.