1,721,638 research outputs found
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Access to and utilization of harm reduction practices and services among people who use drugs in San Diego, California and Tijuana, Mexico
No full textBackground: Overdose and infectious disease are major causes of morbidity and mortality among people who use drugs (PWUD). Harm reduction is a public health approach to reducing the negative consequences of criminalized substance use. This dissertation explored access to and utilization of harm reduction practices and services among PWUD in Tijuana, Baja California, Mexico and San Diego, California, United States (U.S.).Methods: This dissertation utilized survey data from the La Frontera binational cohort study. Chapter 1 compared overdose prevention strategies utilized by PWUD in Tijuana (n=343) and San Diego (n=143) between May 2022–March 2023. Latent class analysis (LCA) identified underlying groups of PWUD based on their probabilities of utilizing these strategies. Chapter 2 compared Tijuana (n=345) and San Diego (n=129) participant scores on a safe injection self-efficacy (SISE) scale between October 2020–September 2021 and assessed correlates of SISE score levels using ordinal logistic regression. Chapter 3 assessed naloxone accessibility among PWUD in San Diego between December 2021–December 2022 using qualitative interviews (N=20) and survey data (N=194).
Results: Chapter 1 revealed that participants’ primary overdose prevention strategies were trying to avoid fentanyl among Tijuana residents (84%) and trying to stop/reduce injecting among San Diego residents (52%). LCA revealed four latent classes among Tijuana participants characterized by unique overdose prevention strategies. Chapter 2 demonstrated that Tijuana residents had lower mean SISE scores than San Diego residents (1.93 vs. 3.46 out of 4). Among Tijuana participants, White race and previous San Diego residence were positively associated with greater SISE scores, whereas HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were negatively associated. Chapter 3 showed that among PWUD in San Diego, 24% reported never having accessible naloxone, 52% sometimes did, and 24% always did. Qualitative findings revealed PWUD generally felt naloxone was easy to obtain in San Diego due to community distribution from harm reduction providers and satellite distribution among peers, but experienced some barriers. In quantitative analyses, greater naloxone accessibility was positively associated with female sex, witnessing an overdose, and knowing where to get free naloxone, while monthly income ≤USD$500 was negatively associated.
Conclusions: These findings highlight multi-level opportunities to improve access to harm reduction services in Tijuana and San Diego, including drug checking, naloxone distribution and overdose response education, and medications for opioid use disorder (MOUD). Additionally, PWID in Tijuana could benefit from syringe service program (SSPs) expansion and safe injection self-efficacy education
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Prevalence and Correlates of Methicillin-Resistant Staphylococcus aureus Colonization Among People Who Inject Drugs in San Diego and Tijuana
Full text linkThe opioid epidemic in the United States has contributed to a rise in drug injection-related disease transmission and infection. People who inject drugs (PWID) are at an increased risk of developing bacterial infections such as Methicillin-resistant Staphylococcus aureus (MRSA). This study examines the prevalence and correlates of MRSA infections and related abscesses amongst PWID in San Diego, California, and Tijuana, Mexico, to better inform harm reduction practices. This is a cross-sectional study conducted from June 2022 until November 2022 in which PWID (N = 187) participating in an ongoing cohort study completed interviewer-administered questionnaires and MRSA swabs nasally and at abscess sites (if present). Chi-Square Tests of Independence, Fisher’s Exact Tests, and Wilcoxon Rank Sum Tests were used to identify potential risk factors. Analysis revealed significant associations between injection practices, structural factors (e.g. homelessness), and prevalent MRSA infections. These positive associations between arm injections, homelessness, and MRSA infections emphasize the need for structural interventions that reduce the barriers PWID face when accessing resources that would improve their health outcomes
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Early substance use experiences and trajectories leading to injection drug use among male and female current injection drug users in the Mexico-US Border Region
Full text linkBackground: The research proposed herein investigates factors associated with substance use trajectories leading to injection drug use (injection) and the circumstances surrounding injection within two different populations of injection drug users (IDUs). This study aims to identify factors associated with: (1) initiation of substance use through injection, (2) lifetime and current agua celeste use (an inhalant unique to Northern Mexico), and (3) time to initiation of sex work, and initiation of injection.Methods: Three manuscripts form the basis of this dissertation using existing data from two datasets. Manuscript 1 uses data from IDU from the Proyecto El Cuete phase III dataset, and Manuscript 2 and 3 use data from female sex workers who inject drugs (FSW-IDU) in the Mujer Mas Segura dataset.Results: Manuscript 1 identified a sub-group of IDUs who initiated illicit drug use by injecting the drug (`injection first'). `Injection first' IDUs were more likely to first inject heroin and inject alone, but were not significantly riskier in their current drug use or sexual behaviors compared to IDUs who used illicit drugs prior to injection. Manuscript 2 found that only FSW-IDUs in Ciudad Juarez reported agua celeste use and prevalence overall (53%) and within the past 6 months (47%) was high. Manuscript 3 identified that early abuse and illicit drug use was associated an accelerated time to initiation of both sex work and injection. Low education and a perceived need to enter sex work to support family were associated with a shorter time to sex work initiation, and geographical migration was found to decelerate time to injection initiation. Having an intimate partner suggest sex work and injecting to deal with feelings of depression accelerated time to both sex work and injection initiation when they occurred at the same age. Conclusions: The unique populations of IDUs studied and novel research questions make the findings within this dissertation valuable to the larger field of research on substance use careers. These findings build on previous literature showing that inhalant use is an important risk factor for subsequent injection and may help identify possible avenues for intervention that can delay or prevent onset of initiation of injection drug use and/or sex work
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Drugs, Germs & Justice: Examining Police Practices and the HIV Risk Environment for People who Inject Drugs
Full text linkBackground: Interactions with police shape the HIV risk environment for people who inject drugs (PWID) by driving risky injection behaviors and harm reduction service avoidance. The SHIELD (Safety and Health Integration in the Enforcement of Laws on Drugs) police training in Tijuana, Mexico, is an intervention to improve PWID health by modifying police behavior. This dissertation 1) explores the global body of peer-reviewed literature on police practices and HIV risk among PWID and 2) examines police knowledge, attitudes, and behaviors relevant to PWID health in the context of the SHIELD training.Methods: Chapter 2 constitutes a systematic review of published research with quantitative associations between police practices and HIV and/or risky injection behaviors among PWID (n=8,201 abstracts, 175 manuscripts). Chapter 2 applies longitudinal logistic regression to examine the association between police knowledge of syringe possession law and extrajudicial arrests for syringe possession over 24 months following the SHIELD training in Tijuana (n=693). Chapter 3 uses log-binomial regression to identify police attitudes associated with support for officer-led referrals to drug treatment and syringe service programs (n=305).
Results: Chapter 2 identified 27 studies with data on police practices and risk of HIV infection among PWID (n=5), risky injection behaviors (n=21) and harm reduction service avoidance (n=9) from diverse global settings. Chapter 3 establishes that training with the SHIELD model can police improve knowledge of syringe law and reduce self-reported extrajudicial arrests for syringe possession up to 24 months following the training (adjusted odds ratio [AOR]:0.87,95% confidence interval [CI]:0.85,0.90). Officers with correct knowledge of syringe possession law were 37% less likely to arrest PWID for syringe possession (AOR:0.63,CI:0.44,0.89), after controlling for sex and patrol assignment location. Chapter 4 showed that officer-held beliefs that MMT programs reduce criminal activity and SSPs increase the risk of NSI among police were significantly associated with support for officer-led referrals to drug treatment (Adjusted Prevalence Ratio [APR]=4.66,CI=2.05,9.18) and SSPs (APR=0.44,CI=0.27,0.71), respectively.
Conclusions: Together, these findings highlight the deleterious role that drug law enforcement practices have on the HIV risk environment for PWID and sheds light on interventions to align police behavior with public health priorities
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Evaluating the Implementation of Drug Decriminalization in Tijuana Mexico: Police and Public Health
Full text linkThis research seeks to evaluate the impact of drug policy reform in Mexico within the larger Latin American context. Through theoretical and statistical analyses, I use the case study of the municipal Police Department in Tijuana to understand the implementation of Mexico’s 2009 “narcomenudeo” drug policy reform that decriminalized drug possession for personal consumption. Using internal unpublished police data, I demonstrate that the policy shift did not appear to impact the policing of drug arrests over the five years following the implementation of the reform. Police education efforts designed to improve officer understanding of the reform and its street-level implementation found low baseline knowledge of the decriminalization policy, shedding light into the mechanisms impeding its application. Training evaluation suggested that officers increased their legal knowledge, but that training uptake was shaped by level of educational attainment. Ultimately, these findings add to the emerging implementation science literature on the importance of structural interventions to better align public health-oriented drug policy reforms with their intended impact in Latin America and elsewhere
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Water, Sanitation and Hygiene Access, Insecurity, Inequalities, Including Menstrual Health, and Their Association with Abscess Incidence Among People Who Inject Drugs in the Tijuana and San Diego Metropolitan Area
No full textBackground: Access to water, sanitation and hygiene (WASH) are human rights often violated among marginalized populations. WASH is also a major dimension required for menstrual health (MH). People who inject drugs (PWID) have particular water needs, such as for preparing drugs for injection and for cleaning wounds. Insecurity accessing WASH services is associated with infectious-related diseases, including abscesses. Little research has explored WASH, MH, and WASH-related health conditions among PWID, especially on the United States (US) – Mexico border. The objective of this research was to provide the first comprehensive assessment of WASH access, insecurity and inequalities, including MH, among PWID in the Tijuana – San Diego metropolitan area and its association with abscess incidence. Methods: This dissertation included cross-sectional and longitudinal analyses using existing data from the binational cohort study La Frontera among PWID in the Tijuana – San Diego metropolitan area in 2020-2023. The first chapter is a descriptive analysis of WASH access, insecurity and inequalities (N=586). The second chapter includes the development and validation of a scale to measure the WASH dimension of MH among PWID who menstruate (N=125). Thirdly, through a longitudinal analysis, WASH insecurity variables are examined as predictors of abscess incidence in a 24-month follow up period in 2020-2023 (N=647).
Results: Basic access to drinking water, hand hygiene, sanitation and bathing were low (89%, 38% and 28% respectively) and open defecation was common (38%). WASH insecurity variables were higher among participants experiencing unsheltered homelessness. Among PWID who menstruate, our brief ‘WASH Domain Scale-12’ was found to be reliable and valid. Over 24-months of follow-up, the incidence of abscesses was high (24 per 100 person-years). After adjusting for covariates, the hazard of developing an abscess was independently associated with the use of non-improved water sources for preparing drugs, bathing insecurity and open defecation.
Conclusions: The three chapters presented here highlight low levels of WASH access among vulnerable PWID living on the US-Mexico border, and describe critical implications for health inequalities, including for MH and infectious disease risk. Accessible WASH infrastructure should be systematically ensured among PWID communities and championed as a key component of harm reduction
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The impact of involuntary drug treatment on overdose, subsequent drug use and drug use treatment-seeking among people who inject drugs in Tijuana, Mexico
Full text linkBackground: The treatment of substance use disorders, as any other form of medical care, is a human right and must comply with quality standards of health care, including the right to refuse use of services. Involuntary drug treatment has been reported ineffective in decreasing drug use but its effects on health and subsequent treatment-seeking have not been longitudinally assessed.Aims: (1) To examine the dynamics of involuntary drug treatment from the perspectives of people who inject drugs (PWID); (2) to assess the effect of involuntary drug treatment on non-fatal overdose; and (3) to determine whether past experiences of involuntary drug treatment influence subsequent voluntary treatment-seeking behavior in Tijuana, Baja California, Mexico.Methods: PWID who were at least 18-years old and reported injecting drugs in the prior month were enrolled in a prospective study. Participants completed interviewer-administered surveys at baseline and every six months (2011-2017). For Chapters 2 and 4, a subsample of PWID reporting involuntary drug treatment in the context of a federally-funded policing program was interviewed and thematic analysis was performed. In Chapter 3, generalized estimating equation analyses were conducted on recent (i.e., past 6 months) non-fatal overdose event and its relationship to involuntary drug treatment. In Chapter 4, Cox regression was also conducted to identify factors related to voluntary drug treatment subsequent to involuntary drug treatment experience among those with no prior drug treatment history.Results: In Chapter 2, 25 PWID described punitive characteristics of a local policing program and lack of State oversight and healthcare at drug centers. In Chapter 3, among 670 PWID, 31.5% reported a recent non-fatal overdose, which was independently associated with recent involuntary drug treatment. In Chapter 4, among 359 PWID, a possible pathway through which involuntary drug treatment limits future treatment-seeking was identified through mistreatment, stigmatization and discrimination at drug centers.Conclusions: Findings highlight the use of involuntary treatment as a mechanism of control that may have life-threatening risks as well as a complexity of factors that drive drug treatment-seeking among PWID in Tijuana. Policy implications include the need to protect PWIDs’ right to choose the circumstances of treatment, for adequate professionalization and training of drug treatment staff, and for treatment centers’ oversight
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Behavioral and contextual factors shaping HIV risk environments among people who inject drugs in Tijuana, Mexico: implications for prevention and treatment
Full text linkABSTRACT OF THE DISSERTATIONBehavioral and contextual factors shaping HIV risk environments among people who inject drugs in Tijuana, Mexico: implications for prevention and treatmentby Jennifer P. JainDoctor of Philosophy in Interdisciplinary Research on Substance Use University of California San Diego, 2019San Diego State University, 2019Professor Steffanie A. Strathdee, Chair Professor Eileen V. Pitpitan, Co-Chair Background: HIV prevalence among people who inject drugs (PWID) in Tijuana, Mexico is 22 times higher than that among the general population. Among PWID, HIV transmission is shaped by factors in the physical, social, economic and policy risk environments. This dissertation explored factors associated with incident HIV infections sex differences in HIV-related risk factors and their potential underlying mechanisms among PWID in Tijuana, Mexico. Methods: Data were drawn from a prospective cohort study of PWID in Tijuana, (N=651) chapters 2 and 3, and (N=734) chapter 4. Chapter 2 assesses sex work as a mediator in the association between female sex and elevated HIV incidence using modern mediational analyses. Chapter 3 identifies factors associated with time to HIV seroconversion using Cox regression and assesses the robustness of these associations using novel sensitivity analyses. Chapter 4 explores sex differences in the environmental and psychological correlates of injection risk, using generalized linear regression. Results: Chapter 2 demonstrates that HIV incidence is significantly higher among female PWID (1.75 per 100 person years [PY], 95% confidence interval [CI] 1.2- 2.7, vs. 0.95 per 100 PY, 95% CI=0.6-1.4), and that sex work mediates the association between female sex and HIV incidence (proportion mediated=86.0%, p=0.01). Chapter 3 highlights sex work (adjusted hazard ratio [aHR]=2.20, 95% CI=1.03-4.68); methamphetamine injection (aHR=2.13, 95% CI=1.04-4.35); and methamphetamine and heroin co-injection (aHR=2.09, 95% CI=1.13-3.85) as drivers of HIV seroconversion, and shows that these associations are relatively robust to unmeasured confounding. In chapter 4 among both sexes, using syringes from a safe source, and safe injection self-efficacy were associated with lower injection risk (b=0.87, 95% CI=0.82-0.94, and b=0.80, 95% CI=0.76-0.84, respectively). Among females, incarceration (b=1.22, 95% CI=1.09-1.36) and syringe confiscation (b=1.16, 95% CI=1.01-1.33) were associated with elevated injection risk, whereas, among males sex work (b=1.16, 95% CI=1.04-1.30), and polysubstance use (b=1.22, 95% CI=1.13-1.31) were associated with elevated injection risk. Conclusions: Interventions should be sex-specific, incorporate sexual risk reduction, consider drug use behaviors, and address environmental influences of HIV risk among PWID in Tijuana
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Polydrug use and risk of HIV and overdose among people who inject drugs in San Diego, California, and Tijuana, Baja California, Mexico
Full text linkBackground: Patterns of polydrug use among people who inject drugs (PWID) may be differentially associated with overdose as well as with unique risk factors for HIV transmission. Objective: Examine patterns of polydrug use among PWID in Tijuana, Baja California, Mexico, and San Diego, California and the relationship of these patterns to HIV risk behavior and overdose.Methods: These analyses use data from two prospective cohort studies of PWID in San Diego (N=576) (Chapter 2) and Tijuana (N=735) (Chapters 2-4). Chapter 2 assesses prevalence and correlates of methamphetamine and heroin co-injection in a binational sample of PWID from both San Diego and Tijuana using logistic regression. Chapter 3 applies latent class analysis to identify classes of polydrug use and multinomial logistic regression to determine associations with HIV risk behaviors and overdose among PWID in Tijuana. Chapter 4 applies latent transition analysis to describe dynamic statuses of polydrug use at baseline and 6 month follow up, determine probabilities of transitioning between statuses, and examine whether these probabilities are modified by self-report needed for help for drug use. Results: Chapter 2 findings show that prevalence of heroin and methamphetamine co-injection in the past 6 months was 39.9% overall, was higher in Tijuana (55.8%) than in San Diego (19.8%), and was significantly associated with HIV injection risk behavior in both locations and associated with overdose only in San Diego. Chapter 3 findings show that PWID in Tijuana exhibited 5 distinct patterns of substance use behaviors. Compared to primarily heroin injectors, polydrug and polyroute class membership was associated with HIV injection and sexual risk behaviors. Chapter 4 findings showed that over a third (39.1%) of PWID in Tijuana transitioned to a different subgroup of heroin and methamphetamine polydrug use over 6 months. Those who reported greater need for help for drug use were more likely to transition to subgroups characterized by greater polydrug and polyroute use 6 months later.Conclusions: Findings highlight the heterogeneity in substance use patterns among PWID in Tijuana and San Diego and demonstrate that polydrug and polyroute users are a high-risk subgroup who may require more tailored prevention and treatment interventions
Women, drugs and HIV
Full text linkAbstractBackgroundWomen who use drugs, irrespective of whether these are injected or not, are faced with multiple issues which enhance their vulnerability to HIV.MethodsIn this commentary, we explore the HIV risks and vulnerabilities of women who use drugs as well as the interventions that have been shown to reduce their susceptibility to HIV infection.ResultsWomen who inject drugs are among the most vulnerable to HIV through both unsafe injections and unprotected sex. They are also among the most hidden affected populations, as they are more stigmatized than their male counterparts. Many sell sex to finance their own and their partner's drug habit and often their partner exerts a significant amount of control over their sex work, condom use and injection practices. Women who use drugs all over the world face many different barriers to HIV service access including police harassment, judgmental health personnel and a fear of losing their children.ConclusionIn order to enable these women to access life-saving services including needle-syringe and condom programs, opioid substitution therapy and HIV testing and treatment, it is essential to create a conducive environment and provide tailor-made services that are adapted to their specific needs
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