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Background Police constitute a structural determinant of health and HIV risk of people who inject drugs (PWID), and negative encounters with law enforcement present significant barriers to PWID access to harm reduction services. Conversely, police may facilitate access via officer-led referrals, potentiating prevention of HIV, overdose, and drug-related harms. We aimed to identify police characteristics associated with support for officer-led referrals to addiction treatment services and syringe service programs (SSP). We hypothesized that officers who believe harm reduction services are contradictory to policing priorities in terms of safety and crime reduction will be less likely to support police referrals. Methods Between January and June 2018, police officers (n = 305) in Tijuana, Mexico, completed self-administered surveys about referrals to harm reduction services during the 24-month follow-up visit as part of the SHIELD police training and longitudinal cohort study. Log-binomial regression was used to estimate adjusted prevalence ratios and model policing characteristics and attitudes related to officers’ support for including addiction treatment and SSP in referrals. Results Respondents were primarily male (89%), patrol officers (86%) with a median age of 38 years (IQR 33–43). Overall, 89% endorsed referral to addiction services, whereas 53% endorsed SSP as acceptable targets of referrals. Officers endorsing addiction services were less likely to be assigned to high drug use districts (adjusted prevalence ratio [APR] = 0.50, 95% CI 0.24, 1.08) and more likely to agree that methadone programs reduce crime (APR = 4.66, 95% CI 2.05, 9.18) than officers who did not support addiction services. Officers endorsing SSPs were younger (adjusted prevalence ratio [APR] = 0.96 95% CI 0.93, 0.98), less likely to be assigned to high drug use districts (APR = 0.50, 95% CI 0.29, 0.87), more likely to believe that methadone programs reduce crime (APR = 2.43, 95% CI 1.30, 4.55), and less likely to believe that SSPs increase risk of needlestick injury for police (APR = 0.44, 0.27, 0.71). Conclusions Beliefs related to the occupational impact of harm reduction services in terms of officer safety and crime reduction are associated with support for referral to related harm reduction services. Efforts to deflect PWID from carceral systems toward harm reduction by frontline police should include measures to improve officer knowledge and attitudes about harm reduction services as they relate to occupational safety and law enforcement priorities. Trial Registration: NCT02444403.

BACKGROUND: Asynchronous video directly observed therapy (VDOT) may reduce tuberculosis (TB) program costs and the burden on patients. We compared VDOT performance across three cities in the United States, each of which have TB incidence rates above the national average.METHODS: Patients aged ≥18 years who are currently receiving directly observed anti-TB treatment were invited to use VDOT for monitoring treatment. Pre- and post-treatment interviews and medical records were used to assess site differences in treatment adherence and patient characteristics and perceptions.RESULTS: Participants were enrolled in New York City, NY (n = 48), San Diego, CA (n = 52) and San Francisco, CA, USA (n = 49). Overall, the mean age was 41 years (range 18–87); 59% were male; most were Asian (45%) or Hispanic/Latino (30%); and 77% were foreign-born. The median fraction of expected doses observed (FEDO) was 88% (IQR 76–96). At follow-up, 97% thought VDOT was “very or somewhat easy to use” and 95% would recommend VDOT to other TB patients. Age, race/ethnicity, annual income, and country of birth differed by city (P < 0.05), but FEDO and VDOT perceptions did not.CONCLUSIONS: TB programs in three large US cities observed a high FEDO using VDOT while minimizing staff time and travel. Similar findings across sites support VDOT adoption by other large, urban TB programs.

Abscess is a common source of morbidity for people who inject drugs. We used data from the Study to Assess Hepatitis C Risk to measure prevalence of abscess and identify factors associated with the history of abscess. Of 541 participants, 388 (72%) were male and 149 (28%) were female. Almost half (n = 258, 48%) reported ever having an abscess. Persons who inject drugs with an abscess history were significantly more likely to have more injection partners (p = .01), inject heroin daily (p < .05), and share cookers (p = .001) and less likely to report using new syringes with each injection (p = .02). Most reported self-treating their last abscess and increasing drug use when having an abscess. High-risk injection-related activity was associated not only with infections such as HIV and hepatitis C virus but also with abscess. Nurses should screen patients presenting with abscess for high-risk practices and provide prevention education.

Author(s): Rafful, Claudia; Jain, Sonia; Sun, Xiaoying; Strathdee, Steffanie A; Garfein, Richard S; Cuevas-Mota, Jazmine; Magis-Rodriguez, Carlos; Smith, Laramie R; Werb, Dan | Abstract: BackgroundEfforts to prevent injection drug use (IDU) are increasingly focused on the role that people who inject drugs (PWID) play in the assistance with injection initiation. We studied the association between recent (ie, past 6 months) injection-related HIV risk behaviors and injection initiation assistance into IDU among PWID in the US-Mexico border region.SettingPreventing Injecting by Modifying Existing Responses (PRIMER) is a multicohort study assessing social and structural factors related to injection initiation assistance. This analysis included data collected since 2014 from 2 participating cohorts in San Diego and Tijuana.MethodsParticipants were 18 years and older and reported IDU within the month before study enrollment. Logistic regression analyses were conducted to assess the association between recent injection-related HIV risk behaviors (eg, distributive/receptive syringe sharing, dividing drugs in a syringe, and paraphernalia sharing) and recent injection initiation assistance.ResultsAmong 892 participants, 41 (4.6%) reported recently providing injection initiation assistance. In multivariable analysis adjusting for potential confounders, reporting a higher number of injection-related risk behaviors was associated with an increased odds of recently assisting others with injection initiation (adjusted odds ratio per risk behavior: 1.3; 95% confidence interval: 1.0 to 1.6, P = 0.04).ConclusionsPWID who recently engaged in one or more injection-related HIV risk behavior were more likely to assist others in injection initiation. These results stress the syndemic of injection initiation and risk behaviors, which indicates that prevention of injection-related HIV risk behaviors might also reduce the incidence of injection initiation.

Author(s): Bloom, Brittnie E; Jain, Sonia; Sun, Xiaoying; Garfein, Richard S; Strathdee, Steffanie A; Milloy, M-J; Hayashi, Kanna; DeBeck, Kora; Bluthenthal, Ricky; Werb, Dan; Rafful, Claudia | Abstract: Introduction and aimsPeople who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance.Design and methodsData from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation.ResultsHaving provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors.Discussion and conclusionsRelationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.

IntroductionMigrants, especially those in temporary accommodations like camps and shelters, might be a vulnerable population during the COVID-19 pandemic, but little is known about the impact of the pandemic in these settings in low-income and middle-income countries. We assessed SARS-CoV-2 seropositivity and RNA prevalence, the correlates of seropositivity (emphasising socially determined conditions), and the socioeconomic impacts of the pandemic among migrants living in shelters in Tijuana, a city on the Mexico-US border.MethodsWe conducted a cross-sectional, non-probability survey of migrants living in shelters in Tijuana in November–December 2020 and February–April 2021. Participants completed a questionnaire and provided anterior nasal swab and blood samples for detection of SARS-CoV-2 RNA and antibodies (IgG and IgM), respectively. We explored whether SARS-CoV-2 infection was associated with sociodemographic and migration-related variables, access to sanitation, protective behaviours and health-related factors.ResultsOverall, 481 participants were enrolled, 67.7% from Northern Central America, 55.3% women, mean age 33.2 years. Seven (1.5%) participants had nasal swabs positive for SARS-CoV-2 RNA and 53.0% were SARS-CoV-2 seropositive. Avoiding public transportation (OR 0.59, 95% CI 0.39 to 0.90) and months living in Tijuana (OR 1.06, 95% CI 1.02 to 1.10) were associated with seropositivity. Sleeping on the streets or other risky places and having diabetes were marginally associated with seropositivity. Most participants (90.2%) had experienced some socioeconomic impact of the pandemic (eg, diminished income, job loss).ConclusionCompared with results from other studies conducted in the general population in Mexico at a similar time, migrants living in shelters were at increased risk of acquiring SARS-CoV-2, and they suffered considerable adverse socioeconomic impacts as a consequence of the pandemic. Expanded public health and other social support systems are needed to protect migrants from COVID-19 and reduce health inequities.

Background Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership. Methods Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership. Results Of the 151 participants enrolled, mean age was 41 years (range: 18–87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05–1.12), males (AOR = 2.86, 95% CI: 1.04–7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57–12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone. Conclusions Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

© 2018, Centers for Disease Control and Prevention (CDC). All rights reserved. We assessed video directly observed therapy (VDOT) for monitoring tuberculosis treatment in 5 health districts in California, USA, to compare adherence between 174 patients using VDOT and 159 patients using in-person directly observed therapy (DOT). Multivariable linear regression analyses identified participant-reported sociodemographics, risk behaviors, and treatment experience associated with adherence. Median participant age was 44 (range 18–87) years; 61% of participants were male. Median fraction of expected doses observed (FEDO) among VDOT participants was higher (93.0% [interquartile range (IQR) 83.4%–97.1%]) than among patients receiving DOT (66.4% [IQR 55.1%– 89.3%]). Most participants (96%) would recommend VDOT to others; 90% preferred VDOT over DOT. Lower FEDO was independently associated with US or Mexico birth, shorter VDOT duration, finding VDOT difficult, frequently taking medications while away from home, and having video-recording problems (p

Background The prevention of drug injecting is often cited as a justification for the deployment of law enforcement and for the continuation of drug criminalization policies. We sought to characterize the impact of law enforcement interactions on the risk that people who inject drugs (PWID) report assisting others with injection initiation in three North American countries. Methods Cross-sectional data from PWID participating in cohort studies in three cities (San Diego, USA; Tijuana, Mexico; Vancouver, Canada) were pooled (August 2014–December 2016). The dependent variable was defined as recently (i.e., past six months) providing injection initiation assistance; the primary independent variable was the frequency of recent law enforcement interactions, defined categorically (0 vs. 1 vs. 2–5 vs. ≥6). We employed multivariable logistic regression analyses to assess this relationship while controlling for potential confounders. Results Among 2122 participants, 87 (4.1%) reported recently providing injection initiation assistance, and 802 (37.8%) reported recent law enforcement interactions. Reporting either one or more than five recent interactions with law enforcement was not significantly associated with injection initiation assistance. Reporting 2–5 law enforcement interactions was associated with initiation assistance (Adjusted Odds Ratio = 1.74, 95% Confidence Interval: 1.01–3.02). Conclusions Reporting interactions with law enforcement was not associated with a reduced likelihood that PWID reported initiating others into injection drug use. Instead, we identified a positive association between reporting law enforcement interactions and injection initiation assistance among PWID in multiple settings. These findings raise concerns regarding the effectiveness of drug law enforcement to deter injection drug use initiation.

Author(s): Seifert, Marva; Georghiou, Sophia B; Garfein, Richard S; Catanzaro, Donald; Rodwell, Timothy C | Abstract: BackgroundPrevious retrospective and in vitro studies suggest that use of later-generation fluoroquinolones may reduce mortality risk and improve treatment outcomes for drug-resistant tuberculosis (TB) patients, including individuals resistant to a fluoroquinolone. Meta-analysis results are mixed and few studies have examined this relationship prospectively.MethodsAs part of a comparative diagnostic study, we conducted a prospective cohort study with 834 Mycobacterium tuberculosis-infected patients from selected hospitals and clinics with high prevalence of drug-resistant TB in India, Moldova, and South Africa. We used Cox proportional hazards regression models to assess the association between later-generation fluoroquinolone (moxifloxacin or levofloxacin) use and patient mortality, adjusting for risk factors typically associated with poor treatment outcomes.ResultsAfter adjusting for phenotypic resistance profile, low body mass index (l18.5 kg/m2), human immunodeficiency virus status, and study site, participants treated with a later-generation fluoroquinolone had half the risk of mortality compared with participants either not treated with any fluoroquinolone or treated only with an earlier-generation fluoroquinolone (adjusted hazard ratio, 0.46 [95% confidence interval, .26-.80]) during follow-up.ConclusionsUse of later-generation fluoroquinolones significantly reduced patient mortality risk in our cohort, suggesting that removal of a later-generation fluoroquinolone from a treatment regimen because of demonstrated resistance to an earlier-generation fluoroquinolone might increase mortality risk. Further studies should evaluate the effectiveness of later-generation fluoroquinolones among patients with and without resistance to early-generation fluoroquinolones.Clinical trials registrationNCT02170441.

Author(s): Armenta, RF; Collins, KM; Strathdee, SA; Bulterys, MA; Munoz, F; Cuevas-Mota, J; Chiles, P; Garfein, RS | Abstract: BackgroundPersons who inject drugs (PWID) might be at increased risk for Mycobacterium tuberculosis infection and reactivation of latent tuberculous infection (LTBI) due to their injection drug use.ObjectivesTo determine prevalence and correlates of M. tuberculosis infection among PWID in San Diego, California, USA.MethodsPWID aged 18 years underwent standardized interviews and serologic testing using an interferon-gamma release assay (IGRA) for LTBI and rapid point-of-care assays for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections. Independent correlates of M. tuberculosis infection were identified using multivariable log-binomial regression.ResultsA total of 500 participants met the eligibility criteria. The mean age was 43.2 years (standard deviation 11.6); most subjects were White (52%) or Hispanic (30.8%), and male (75%). Overall, 86.7% reported having ever traveled to Mexico. Prevalence of M. tuberculosis infection was 23.6%; 0.8% were co-infected with HIV and 81.7% were co-infected with HCV. Almost all participants (95%) had been previously tested for M. tuberculosis; 7.6% had been previously told they were infected. M. tuberculosis infection was independently associated with being Hispanic, having longer injection histories, testing HCV-positive, and correctly reporting that people with 'sleeping' TB cannot infect others.ConclusionsStrategies are needed to increase awareness about and treatment for M. tuberculosis infection among PWID in the US/Mexico border region.

BACKGROUND: Ecological momentary assessment (EMA)—which often involves brief surveys delivered via mobile technology—has transformed our understanding of the individual and contextual micro-processes associated with legal and illicit drug use. However, little empirical research has focused on participant’s perspective on the probability and magnitude of potential risks in EMA studies. OBJECTIVES: To garner participant perspectives on potential risks common to EMA studies of illicit drug use. METHODS: We interviewed 38 persons who inject drugs living in San Diego (CA) and Philadelphia (PA), United States. They completed simulations of an EMA tool and then underwent a semi-structured interview that systematically explored domains of risk considered within the proposed revisions to the Federal Policy for the Protection of Human Subjects or the “Common Rule.”Interviews were transcribed verbatim and coded systematically to explore psychological, physical, social, legal, and informational risks from participation. RESULTS: Participants perceived most risks to be minimal. Some indicated that repetitive questioning about mood or drug use could cause psychological (i.e., anxiety) or behavioral risks (i.e., drug use relapse). Ironically, the questions that were viewed as risky were considered motivational to engage in healthy behaviors. The most cited risks were legal and social risks stemming from participant concerns about data collection and security. IMPORTANCE: Improving our understanding of these issues is an essential first step to protect human participants in future EMA research. We provide a brief set of recommendations that can aid in the design and ethics review of the future EMA protocol with substance using populations.

Author(s): Conners, E; Garfein, RS; Rodwell, TC; Udwadia, ZF; Catanzaro, DG | Abstract: SettingTuberculosis (TB) hospital in Mumbai, India.ObjectiveTo describe the mobility patterns of persons with suspected drug-resistant tuberculosis (DR-TB) and to assess whether there were significant differences in demographic or risk characteristics based on mobility.DesignObservational cohort study of TB clinic patients at risk for DR-TB.ResultsAmong 602 participants, 37% had ever moved from their place of birth; 14% were local movers (within state), and 23% were distant movers, between states or countries. Univariate multinomial logistic regression models showed that distant movers were more likely than non-movers to have lower income, less education, a greater number of previous TB episodes, and to have ever smoked. Compared to non-movers, local movers were more likely to have lower income and were more likely to have seen a doctor in the past 2 years. Clinical outcomes, including DR-TB, diabetes, and human immunodeficiency virus (HIV), did not differ between the three mobility groups.ConclusionMobility was common among patients at risk for DR-TB in Mumbai. TB programs should consider the implications of mobility on the protracted treatment for DR-TB in India.

Background Injection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation. Methods and findings We employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36–0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%–97.5% interval [95% I 490–2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406–1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4–21.7), 17.3% (95% I 5.6–29.4), and 22.8% (95% I 8.1–36.8) and reduce the PWID population size by 5.4% (95% I 0.1–12.0), 8.2% (95% I 2.2–16.9), and 10.9% (95% I 3.2–21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study’s main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation. Conclusions In addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size., In a modelling study, Natasha Martin and co-workers estimate the impact of increased use of opioid agonist therapy on initiation of injection drug use., Author summary Why was this study done? The majority of injection drug use (IDU) initiations are assisted by people who inject drugs (PWID). Evidence from North America indicates that PWID receiving opioid agonist treatment (OAT; such as methadone or buprenorphine) are less likely to have provided assistance with IDU initiation. We used dynamic modeling to assess the impact of scaling up OAT coverage among PWID on IDU initiations in the next decade in a generic North American setting. What did the researchers do and find? We used cohort data among PWID from Vancouver, Canada; San Diego, United States; and Tijuana, Mexico, to assess the relationship between recent OAT enrollment and recent provision of assistance with IDU initiation, finding that past–6-month enrollment in OAT was associated with nearly half the likelihood of past–6-month provision of assistance with IDU initiation. Using these associations, we parameterized a dynamic model of IDU initiation and assessed the population-level impact of scaling up OAT coverage on IDU initiations over the next decade in a generic North American setting. We estimate that if OAT coverage is scaled up from approximately 21% to 60% among PWID, the number of people who initiate IDU each year will decrease by 23% after a decade. What do these findings mean? In addition to its known benefits of preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our findings suggest that increasing OAT coverage among PWID can have an important impact on reducing IDU initiations.

Women’s initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation, and sub-themes were identified drawing on three concepts within the theory of gender and power. Building on the sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. Regarding the structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in how the intersection of risk, gender, and harm reduction is understood within injection initiation events across socio-cultural contexts.

Cross-border infectious disease transmission is a concern related to drug tourism from the U.S. to Mexico. We assessed this risk among people who inject drugs (PWID) in Tijuana, Mexico. We measured the prevalence and identified correlates of injecting with PWID visiting from the U.S. among PWID in Tijuana using univariable and multivariable logistic regression. Of 727 participants, 18.5% injected during the past 6 months in Mexico with U.S. PWID described mostly as friends (63%) or acquaintances (26%). Injecting with U.S. PWID was independently associated with higher education [adjusted odds ratio (aOR) = 1.13/year], deportation from the U.S. (aOR = 1.70), younger age at first injection (aOR = 0.96/year), more lifetime overdoses (aOR = 1.08), and, in the past 6 months, backloading (aOR = 4.00), syringe confiscation by the police (aOR = 3.02) and paying for sex (aOR = 2.98; all p-values

BACKGROUND:Diabetes is a leading cause of morbidity and mortality in Mexico and understudied among indigenous populations. This study aimed to determine the prevalence and identify correlates of Type 2 diabetes mellitus (Type 2 DM) and metabolic syndrome (MetS) in a rural, indigenous community in Northwestern Mexico. METHODS:A cross-sectional study was conducted in the community of San Quintin, Baja California, Mexico, among a sample of households. A total of 275 participants (≥18 years old) underwent a questionnaire, physical examination, and serologic test. Prevalence and adjusted odds ratio (AOR), using logistic regression modeling, were estimated with 95%25 confidence intervals (95%25 CI). RESULTS:The prevalence of Type 2 DM and MetS was 21.8 and 53.1%25, respectively. Mean ± standard deviation (SD) age and body mass index of study participants was 35.8 ± 13.0 years and 28.7 ± 5.6 kg/m2, respectively. Participants were 75%25 female and 60.7%25 self-identified as indigenous. Thirty-seven percent of adults had high blood pressure. After controlling for age, higher educational attainment had a protective effect on Type 2 DM (AOR = 0.39; 95%25 CI 0.20, 0.77). Additionally, the presence of MetS was associated with being female (AOR = 2.27; 95%25 CI 1.23, 4.14) and having lower educational attainment (AOR = 0.62; 95%25 CI 0.37, 0.94). CONCLUSIONS:The prevalence of Type 2 DM and MetS was high in this rural and indigenous population, and education was shown to play a critical role. These findings support the need for community-inclusive health-promoting interventions in rural communities.

Objective Our purpose was to assess whether participation in needle exchange programs (NEPs) influenced incident hepatitis C virus (HCV) infection through effects on injection risk behaviors among young injection drug users (IDUs) in the United States. Methods Data were drawn from three multi-site studies carried out in four major cities that enrolled IDUs over the period 1994–2004. Bivariate and multivariate analyses were conducted to assess relationships among sociodemographic characteristics, NEP use, injection risk behaviors, and prevalent or incident HCV infection. Results Of the total participants ( n = 4663), HCV seroprevalence was 37%; among those who initially tested negative and completed follow-up at three, six, or 12 months ( n = 1288), 12% seroconverted. Nearly half of participants reported NEP (46%) use at baseline. Multivariate results showed no significant relationship between NEP use and HCV seroconversion. Controlling for sociodemographic characteristics, IDUs reporting NEP use were significantly less likely to share needles (aOR = 0.77, 95% CI = 0.67–0.88). Additionally, controlling for sociodemographic characteristics and program use, sharing needles, sharing other injection paraphernalia, longer injection duration, and injecting daily were all positively related to prevalent infection. Conclusions Our results suggest an indirect protective effect of NEP use on HCV infection by reducing risk behavior.

Disclosure of HIV status to potential and current sex partners by HIV-positive people (HIVPP) is a complex issue that has received a significant amount of attention. Research has found that disclosure depends upon the evaluation by HIVPP of potential benefits and risks, especially of the risks stemming from the profound social stigma of HIV and AIDS. Drawing on concepts from Goffman's classic stigma theory and Anderson's more recently developed cultural-identity theory of drug abuse, we analyzed data from in-depth, post-intervention qualitative interviews with 116 heterosexually active, HIV-positive injection drug users enrolled in a randomized trial of a behavioral intervention to prevent HIV transmission. We explored how disclosure experiences lead to "identity impacts" defined as: (1) identity challenges (i.e. interactions that challenge an individual's self-concept as a "normal" or non-deviant individual); and (2) identity transformations (i.e. processes whereby an individual comes to embrace a new identity and reject behaviors and values of an old one, resulting in the conscious adoption of a social and/or public identity as an HIV-positive individual). Participants engaged in several strategies to manage the identity impacts associated with disclosure. Implications of these findings for research and prevention programming are discussed.

Summary Background People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I 2 statistic and the P-value for heterogeneity. Findings We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40–2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies ( I 2 =63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28–2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies ( I 2 =57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94–1·65) and a 21% increase in HCV (1·21, 1·02–1·43) acquisition risk. Interpretation Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID. Funding Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

OBJECTIVE:Although persons who inject drugs (PWID) in the western United States-Mexico border region are known to inject both heroin and methamphetamine, little is known about the prevalence and risks associated with co-injection of this depressant-stimulant combination (also known as "goofball" and "Mexican speedball"). METHOD:Baseline data from parallel cohort studies of PWID conducted concurrently in San Diego, CA, and Tijuana, Mexico, were used to estimate the prevalence and identify correlates of heroin-methamphetamine co-injection. PWID older than 18 years of age who reported injecting illicit drugs in the past month (N = 1,311; 32.7% female) were recruited in San Diego (n = 576) and Tijuana (n = 735) and completed interviewer-administered questionnaires. Bivariate and multivariable logistic regression analyses were used to identify correlates of heroin-meth-amphetamine co-injection. RESULTS:The prevalence of co-injection in the past 6 months was 39.9% overall and was higher in Tijuana (55.8%) than in San Diego (19.8%). In multivariable analyses adjusting for study cohort, distributive syringe sharing, purchasing syringes prefilled with drugs, finding it hard to get new syringes, reporting great or urgent need for treatment, and younger age were independently associated with co-injection. Past-6-month overdose was significantly associated with higher odds of co-injection in San Diego than in Tijuana. CONCLUSIONS:These findings indicate that heroin-methamphetamine co-injection is more common in Tijuana than in San Diego, yet this practice was only associated with overdose in San Diego. Heroin-methamphetamine coinjection was also independently associated with HIV-associated injection risk behaviors. Overdose-prevention interventions should address co-injection of depressants and stimulants.

Anemia is a public health problem in Mexico. This study sought to determine the prevalence and correlates of anemia among women and children residing in a rural farming region of Baja California, Mexico. An existing partnership between universities, non-governmental organizations, and an underserved Mexican community was utilized to perform cross-sectional data collection in 2004-2005 (Wave 1) and in 2011-2012 (Wave 2) among women (15-49 years) and their children (6-59 months). All participants completed a survey and underwent anemia testing. Blood smears were obtained to identify etiology. Nutrition education interventions and clinical health evaluations were offered between waves. Participants included 201 women and 99 children in Wave 1, and 146 women and 77 children in Wave 2. Prevalence of anemia significantly decreased from 42.3 to 23.3 % between Waves 1 and 2 in women (p

Directly observed therapy (DOT) is a cornerstone of tuberculosis control. DOT has been criticized as paternalistic, but it has also been argued that the interaction with health workers can be a source of support for patients. We explored the experience of patients in antituberculosis treatment, with the aim of understanding the balance between surveillance and support from the recipient’s point of view. We interviewed 27 patients in Tijuana, Mexico, employing narrative analysis to understand how participants made sense of their illness and their experience of DOT. We found a core narrative of biographic disruption and self-reconstruction, in which health care workers helped participants to attribute a less negative meaning to tuberculosis. Interviewees accepted DOT’s as necessary for other people to avoid treatment abandonment, but felt that in their case it was unnecessary. Only a few felt that DOT represented mistrust on the part of the health workers. We conclude that DOT can be a source of support when it is enacted in a patient-centered way. We discuss whether participants’ lack of criticism of DOT is a case of adaptive preference, in the context of a power differential between patient and health system.

Aim: Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of “initiator” gender in the provision of injection initiation assistance across multiple settings. Methods: We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable. Results: Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22–3.84). Gender was not significantly associated with providing injection initiation assistance in other sites. Conclusion: We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.

Background: HIV sequence data can be used to reconstruct local transmission networks. Along international borders, like the San Diego–Tijuana region, understanding the dynamics of HIV transmission across reported risks, racial/ethnic groups, and geography can help direct effective prevention efforts on both sides of the border. Methods: We gathered sociodemographic, geographic, clinical, and viral sequence data from HIV infected individuals participating in ten studies in the San Diego–Tijuana border region. Phylogenetic and network analysis was performed to infer putative relationships between HIV sequences. Correlates of identified clusters were evaluated and spatiotemporal relationships were explored using Bayesian phylogeographic analysis. Findings: After quality filtering, 843 HIV sequences with associated demographic data and 263 background sequences from the region were analyzed, and 138 clusters were inferred (2–23 individuals). Overall, the rate of clustering did not differ by ethnicity, residence, or sex, but bisexuals were less likely to cluster than heterosexuals or men who have sex with men (p = 0.043), and individuals identifying as white (p ≤ 0.01) were more likely to cluster than other races. Clustering individuals were also 3.5 years younger than non-clustering individuals (p

Author(s): Moor, Molly A; Fraga, Miguel A; Garfein, Richard S; Rashidi, Hooman H; Alcaraz, John; Kritz-Silverstein, Donna; Elder, John P; Brodine, Stephanie K | Abstract: IntroductionAnemia is a public health concern among women in rural Baja California, Mexico. The purpose of this study was to identify the individual and community factors contributing to the disproportionately high prevalence of anemia among women in this region.MethodsA cross-sectional study of 118 women (15-49 years) was performed in a rural colonia (small settlement) in Baja California, Mexico in 2012. Participants completed a survey comprised of demographic, socioeconomic, health, and dietary questions and provided a capillary blood sample. A portable HemoCue was used to measure hemoglobin and diagnose anemia. Anemic participants provided a venous blood sample for laboratory testing to elucidate the etiology of anemia. Anemic participants received vitamin supplements and nutritional counseling. Assessments of six local tiendas (community grocery stores) were performed to ascertain the types of food available for purchase within the community.ResultsPrevalence of anemia was 22% among women; laboratory tests revealed iron deficiency was the primary etiology in 80.8% of anemia cases. Other causes of anemia in women included vitamin B-12 deficiency (11.5%) and combined iron and vitamin B-12 deficiency (7.7%). Women from low SES households and women enrolled in the government assistance program Prospera were significantly more likely to be anemic (OR = 3.48, 95% CI 1.35-8.98 and OR = 2.49, 95% CI 1.02-6.09, respectively). Vitamin supplementation was significantly more common among non-anemic women (OR = 0.12, 95% CI 0.02-0.94). Dietary assessments showed limited consumption of iron absorption enhancing foods such as fruits and vegetables. Assessments of local tiendas revealed at least one type of meat and citrus fruit available for purchase at each store; however, leafy green vegetables were only available for purchase at one store.ConclusionAll cases of anemia were due to nutritional deficiencies. While vitamin supplementation is a temporary solution, improved individual nutrition knowledge and community access to iron absorption enhancing foods, particularly produce, is needed. Promoting government assistance programs like Prospera and implementing additional programs designed to improve nutrition and health literacy, in conjunction with ensuring access to nutritious foods, might reduce the high prevalence nutritional anemia within the community.

Background The prevalence of HIV and Hepatitis C Virus (HCV) are significantly lower among people who inject drugs (PWID) in San Diego, CA, USA compared with PWID in Tijuana, Mexico, located directly across the border. We investigated associations between cross-border injection drug use (IDU), HIV and HCV seroprevalence and engagement in injecting risk behaviours while on each side of the border. Methods Using baseline interviews and serologic testing data from STAHR II , a longitudinal cohort study of PWID in San Diego, bivariate and multivariable logistic regression analyses examined associations between recent (past six months) cross-border IDU and HIV and HCV antibody seropositivity, socio-demographics, drug use characteristics, and participants' connections to, and perceptions about Mexico. Chi-squared tests and McNemar tests examined associations between cross-border IDU and injecting risk behaviours. Results Of the 567 participants (93% U.S.-born, 73% male, median age 45 years), 86 (15%) reported recent cross-border IDU. Cross-border IDU was not associated with HIV (OR: 0.85, 95% CI: 0.37–1.95) or HCV seropositivity (OR: 1.01, 95% CI: 0.62–1.65). Age, identifying as Hispanic or Latino/a, and being concerned about risk of violence when travelling to Mexico were independently associated with decreased odds of recent cross-border IDU. Injecting cocaine at least weekly, having ever lived in Mexico and knowing PWID who reside in Mexico were associated with increased odds of recent cross-border IDU. PWID who reported cross-border IDU were significantly less likely to engage in receptive needle sharing, equipment sharing, and public injection while in Mexico compared with in San Diego (all p Conclusion Prevalence of HIV and HCV infection was similar among PWID who had and had not injected in Mexico, possibly due to practising safer injecting while in Mexico. Research is needed to elucidate contextual factors enabling U.S. PWID to inject safely while in Mexico.

Persons who inject drugs (PWID) are at risk for adverse health outcomes as a result of their drug use, and the resulting social stigma makes this a difficult population to reach for interventions aimed at reducing morbidity and mortality. During our study of adult PWID aged ≤40 years living in San Diego during 2009 and 2010, we compared three different sampling methods: respondent-driven sampling (RDS), venue-based sampling at one syringe exchange program (SEP), and street-based outreach. We compared demographic, socioeconomic, health, and behavioral factors and tested participants for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) and compared across the three methods. Overall, 561 (74.8%) of the targeted 750 PWID were enrolled. Venue-based convenience sampling enrolled 96% (242/250) of the targeted participants, followed closely by street-based outreach with 92% (232/250) recruited. While RDS yielded the fewest recruits, producing only 35% (87/250) of the expected participants, those recruited through RDS were more likely to be female, more racially diverse, and younger.

BackgroundBlack tar heroin is typically prepared for injection with heat which decreases the risk of HIV transmission by inactivating the virus. We received reports that persons who inject drugs (PWID) in Tijuana, Baja California, Mexico, a black tar heroin market, were using only water to dissolve heroin.ObjectivesBecause Tijuana abuts San Diego County, CA, United States, we undertook the present analyses to determine the prevalence of this practice among PWID in San Diego, California.MethodsPWID completed quarterly behavioral assessments and serological testing for blood-borne viruses. Bivariate and multivariable logistic regression models were constructed to assess for individual, social, and structural correlates of preparing heroin without heat within the preceding 6months.ResultsNearly half of black tar heroin users (149/305) reported they had prepared heroin without heat within 6months. In multivariable analysis, cold preparation was independently associated with younger age (10year decrease; AOR = 1.25; 95% CI 1.03, 1.53), more drug injecting acquaintances (per 5 acquaintance increase; AOR = 1.05; 95% CI 1.01, 1.09) and prefilled syringe use (injecting drugs from syringes that are already filled with drugs before purchase; AOR = 1.86; 95% CI 1.14, 3.02). Conclusions/Importance: To our knowledge, this is the first paper to report that PWID living in a black tar heroin market are preparing heroin without heat. Additional research is needed to determine whether this is an endemic practice or PWID are engaging in new forms of drug preparation in response to changes in the environment.

Background Injection drug use initiation is shaped by social networks and structural contexts, with people who inject drugs often assisting in this process. We sought to explore the norms and contexts linked to assisting others to initiate injection drug use in San Diego, USA, to inform the development of structural interventions to prevent this phenomenon. Methods We undertook qualitative interviews with a purposive sample of people who inject drugs and had reported assisting others to initiate injection (n = 17) and a sub-sample of people who inject drugs (n = 4) who had not reported initiating others to triangulate accounts. We analyzed data thematically and abductively. Results Respondents' accounts of providing initiation assistance were consistent with themes and motives reported in other contexts: of seeking to reduce harm to the ‘initiate', responding to requests for help, fostering pleasure, accessing resources, and claims that initiation assistance was unintentional. We developed analysis of these themes to explore initiation assistance as governed by a ‘moral code'. We delineate a fragmented moral code which includes a range of meanings and social contexts that shape initiation assistance. We also show how assistance is happening within a structural context that limits discussion of injection drug use, reflecting a prevailing silence on drug use linked to stigma and criminalization. Conclusions In San Diego, the assistance of others to initiate injection drug use is governed by a fragmented moral code situated within particular social norms and contexts. Interventions that address the social and structural conditions shaped by and shaping this code may be beneficial, in tandem with efforts to support safe injection and the reduction of injection-related harms.

Rapid molecular diagnostics have great potential to limit the spread of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) (M/XDR-TB). These technologies detect mutations in the Mycobacterium tuberculosis genome that confer phenotypic drug resistance. However, there have been few data published regarding the relationships between the detected M. tuberculosis resistance mutations and M/XDR-TB treatment outcomes, limiting our current ability to exploit the full potential of molecular diagnostics. We analyzed clinical, microbiological, and sequencing data for 451 patients and their clinical isolates collected in a multinational, observational cohort study to determine if there was an association between M. tuberculosis resistance mutations and patient mortality. The presence of an rrs 1401G mutation was associated with significantly higher odds of patient mortality (adjusted odds ratio [OR] = 5.72; 95% confidence interval [CI], 1.65 to 19.84]) after adjusting for relevant patient clinical characteristics and all other resistance mutations. Further analysis of mutations, categorized by the associated resistance level, indicated that the detection of mutations associated with high-level fluoroquinolone (OR, 3.99 [95% CI, 1.10 to 14.40]) and kanamycin (OR, 5.47 [95% CI, 1.64 to 18.24]) resistance was also significantly associated with higher odds of patient mortality, even after accounting for clinical site, patient age, reported smoking history, body mass index (BMI), diabetes, HIV, and all other resistance mutations. Specific gyrA and rrs resistance mutations, associated with high-level resistance, were associated with patient mortality as identified in clinical M. tuberculosis isolates from a diverse M/XDR-TB patient population at three high-burden clinical sites. These results have important implications for the interpretation of molecular diagnostics, including identifying patients at increased risk for mortality during treatment. (This study has been registered at ClinicalTrials.gov under registration no. NCT02170441.)

Background Research among people who inject drugs (PWIDs) in the USA and Mexico has identified a range of adverse health impacts associated with policing of PWIDs. We employed a mixed methods design to investigate how PWIDs from San Diego and Mexico experienced policing in Tijuana, and how these interactions affect PWIDs behavior, stratifying by country of origin. Methods In 2012–2014, 575 PWIDs in San Diego, 102 of whom had used drugs in Mexico in the past six months, were enrolled in the STAHR-II study, with qualitative interviews conducted with a subsample of 20 who had recently injected drugs in Mexico. During this period, 735 PWIDs in Tijuana were also enrolled in the El Cuete-IV study, with qualitative interviews conducted with a subsample of 20 recently stopped by police. We calculated descriptive statistics for quantitative variables and conducted thematic analysis of qualitative transcripts. Integration of these data involved comparing frequencies across cohorts and using qualitative themes to explain and explore findings. Results Sixty-one percent of San Diego-based participants had been recently stopped by law enforcement officers (LEOs) in Mexico; 53% reported it was somewhat or very likely that they would be arrested while in Mexico because they look like a drug user. Ninety percent of Tijuana-based participants had been recently stopped by LEOs; 84% reported it was somewhat or very likely they could get arrested because they look like a drug user. Participants in both cohorts described bribery and targeting by LEOs in Mexico. However, most San Diego-based participants described compliance with bribery as a safeguard against arrest and detention, with mistreatment being rare. Tijuana-based participants described being routinely targeted by LEOs, were frequently detained, and reported instances of sexual and physical violence. Tijuana-based participants described modifying how, where, and with whom they injected drugs in response; and experienced feelings of stress, anxiety, and powerlessness. This was less common among San Diego-based participants, who mostly attempted to avoid contact with LEOs in Mexico while engaging in risky injection behavior. Conclusion Experiences of discrimination and stigma were reported by a larger proportion of PWIDs living in Mexico, suggesting that they may be subject to greater health harms related to policing practices compared with those residing in the USA. Our findings reinforce the importance of efforts to curb abuse and align policing practices with public health goals in both the US and Mexico.

BackgroundUse of synthetic cathinones (SC) and cannabimimetics (i.e., "THC homologues" [TH]) is associated with adverse health effects. We investigated the epidemiology of synthetic drug use among a cohort of injection drug users (IDUs) in San Diego, California.MethodsWe used logistic regression analysis to identify correlates of SC and TH use among 485 IDUs enrolled from June 2012 to September 2013.ResultsSeven percent of participants reported ever using SC and 30% reported ever using TH. In multivariate logistic regression, age and recent hospitalization were significantly associated with odds of SC use (Adjusted Odds Ratio [AOR] 0.93, 95% Confidence Interval [C.I.] 0.90, 0.97; and AOR 2.34 95% C.I. 1.00, 5.49, respectively) and TH use (AOR 0.96, 95% C.I. 0.94, 0.98; and AOR 2.62, 95% C.I. 1.47, 4.68, respectively). Use of methamphetamine (AOR 9.35, 95% C.I. 1.20, 72.79) and club drugs in the past six months (AOR 3.38, 95% C.I. 1.17, 9.76) were significantly associated with SC use. Being on probation/parole (AOR 2.42, 95% C.I. 1.44, 4.07), initiating injection drug use with stimulants (AOR 1.89 95% C.I. 1.13, 3.16), and past six-month marijuana (AOR 9.22, 95% C.I. 4.49, 18.96) and prescription drug use (AOR 1.98, 95% C.I. 1.20, 3.27) were significantly associated with TH use.ConclusionsA considerable proportion of IDU use synthetic drugs and may experience harms associated with their use. Findings have implications for criminal justice system management. Prevention efforts should emphasize the risks associated with rapidly changing synthetic formulations, and the potential harms associated with polydrug use.

Unsafe injection practices significantly increase the risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection among injection drug users (IDUs). We examined individual and socio-environmental factors associated with unsafe injection practices in young adult IDUs in San Diego, California. Of 494 IDUs, 46.9 % reported receptive syringe sharing and 68.8 % sharing drug preparation paraphernalia in the last 3 months. Unsafe injection practices were associated with increased odds of having friends who injected drugs with used syringes, injecting with friends or sexual partners, and injecting heroin. Perceived high susceptibility to HIV and perceived barriers to obtaining sterile syringes were associated with increased odds of receptive syringe sharing, but not with sharing injection paraphernalia. Over half the IDUs reported unsafe injection practices. Our results suggest that personal relationships might influence IDUs' perceptions that dictate behavior. Integrated interventions addressing individual and socio-environmental factors are needed to promote safe injection practices in this population.

Objectives. We sought to compare prevalence and determinants of multidrug-resistant tuberculosis (MDR-TB) between tuberculosis patients in Baja California, Mexico, and Hispanic patients in California. Methods. Using data from Mexico’s National TB Drug Resistance Survey (2008–2009) and California Department of Public Health TB case registry (2004–2009), we assessed differences in MDR-TB prevalence comparing (1) Mexicans in Baja California, (2) Mexico-born Hispanics in California, (3) US-born Hispanics in California, and (4) California Hispanics born elsewhere. Results. MDR-TB prevalence was 2.1% in Baja California patients, 1.6% in Mexico-born California patients, 0.4% in US-born California patients, and 2.7% in Hispanic California patients born elsewhere. In multivariate analysis, previous antituberculosis treatment was associated with MDR-TB (odds ratio [OR] = 6.57; 95% confidence interval [CI] = 3.34, 12.96); Mexico-born TB patients in California (OR = 5.08; 95% CI = 1.19, 21.75) and those born elsewhere (OR = 7.69; 95% CI = 1.71, 34.67) had greater odds of MDR-TB compared with US-born patients (reference category). Conclusions. Hispanic patients born outside the US or Mexico were more likely to have MDR-TB than were those born within these countries. Possible explanations include different levels of exposure to resistant strains and inadequate treatment.

ObjectiveSexual partner concurrency is common among MSM and may increase the probability of HIV transmission during recent (acute or early) infection. We examined the relationship between concurrency and HIV transmission network characteristics (proxies for HIV transmission) among MSM with recent HIV infection.DesignObservational study integrating behavioral, clinical, and molecular epidemiology.MethodsWe inferred a partial HIV transmission network using 986 HIV-1 pol sequences obtained from HIV-infected individuals in San Diego, California (1996-2015). We further analyzed data from 285 recently HIV-infected MSM in the network who provided information on up to three sexual partners in the past 3 months, including the timing of intercourse with each partner. Concurrency was defined as sexual partners overlapping in time. Logistic and negative binomial regressions were used to investigate the link between concurrency and HIV transmission network characteristics (i.e. clustering and degree or number of connections to others in the network) among these MSM.ResultsOf recently HIV-infected MSM (n = 285), 54% reported concurrent partnerships and 54% were connected by at least one putative transmission link to others (i.e. clustered) in the network (median degree = 1.0; interquartile range: 0.0-3.0). Concurrency was positively associated with HIV transmission network clustering (adjusted odds ratio = 1.83, 95% confidence interval: 1.08, 3.10) and degree (adjusted incidence rate ratio = 1.48, 95% confidence interval: 1.02, 2.15).ConclusionOur findings provide empirical evidence consistent with the hypothesis that concurrency facilitates HIV transmission during recent infection. Interventions to mitigate the impact of concurrency on HIV transmission may help curb the HIV epidemic among MSM.

© 2016 Taylor & Francis Group, LLC. Background: New and innovative methods of delivering interventions are needed to further reduce risky behaviors and increase overall health among persons who inject drugs (PWID). Mobile health (mHealth) interventions have potential for reaching PWID; however, little is known about mobile technology use (MTU) in this population. In this study, the authors identify patterns of MTU and identified factors associated with MTU among a cohort of PWID. Methods: Data were collected through a longitudinal cohort study examining drug use, risk behaviors, and health status among PWID in San Diego, California. Latent class analysis (LCA) was used to define patterns of MTU (i.e., making voice calls, text messaging, and mobile Internet access). Multinomial logistic regression was then used to identify demographic characteristics, risk behaviors, and health indicators associated with mobile technology use class. Results: In LCA, a 4-class solution fit the data best. Class 1 was defined by low MTU (22%, n = 100); class 2, by PWID who accessed the Internet using a mobile device but did not use voice or text messaging (20%, n = 95); class 3, by primarily voice, text, and connected Internet use (17%, n = 91); and class 4, by high MTU (41%, n = 175). Compared with low MTU, high MTU class members were more likely to be younger, have higher socioeconomic status, sell drugs, and inject methamphetamine daily. Conclusion: The majority of PWID in San Diego use mobile technology for voice, text, and/or Internet access, indicating that rapid uptake of mHealth interventions may be possible in this population. However, low ownership and use of mobile technology among older and/or homeless individuals will need to be considered when implementing mHealth interventions among PWID.

We analyzed data from a large randomized HIV/HCV prevention intervention trial with young injection drug users (IDUs) conducted in five U.S. cities. The trial compared a peer education intervention (PEI) with a time-matched, attention control group. Applying categorical latent variable analysis (mixture modeling) to baseline injection risk behavior data, we identified four distinct classes of injection-related HIV/HCV risk: low risk, non-syringe equipment-sharing, moderate-risk syringe-sharing, and high-risk syringe-sharing. The trial participation rate did not vary across classes. We conducted a latent transition analysis using trial baseline and 6-month follow-up data, to test the effect of the intervention on transitions to the low-risk class at follow-up. Adjusting for gender, age, and race/ethnicity, a significant intervention effect was found only for the high-risk class. Young IDU who exhibited high-risk behavior at baseline were 90 % more likely to be in the low-risk class at follow-up after the PEI intervention, compared to the control group.

We examined drug-scene familiarity and exposure to gang violence among residents of a migrant farming community in rural Baja California, Mexico. In October 2010, 164 members of a single colonia (community) underwent an interviewer-administered survey to assess 'exposure to gang violence' and 'drug-scene familiarity', as well as other health indicators. Logistic regression was used to identify correlates of exposure to gang violence. Overall, 20% of participants were male, the median age was 27 years, 24% spoke an indigenous language, 42% reported exposure to gang violence and 39% reported drug-scene familiarity. Factors independently associated with exposure to gang violence included being younger (adjusted odds ratio [AOR] =0.80 per 5-year increase, 95% confidence interval [CI]=0.67-0.96), living in the community longer (AOR=1.47 per 5-year increase, 95% CI=1.11-1.72), higher educational attainment (AOR=1.70 per 5-year increase, 95% CI=1.07-1.12) and drug-scene familiarity (AOR=5.10, 95% CI=2.39-10.89). Exposure to gang violence was very common in this community and was associated with drug-scene familiarity, suggesting a close relationship between drugs and gang violence in this rural community. In a region characterised by mass migration from poorer parts of Mexico, where drugs and gangs have not been previously reported, emerging social harms may affect these communities unless interventions are implemented.

San Diego, California shares the world’s busiest land border crossing with Tijuana, Mexico—a city where 95 % of injection drug users (IDUs) test hepatitis C virus (HCV) antibody-positive. Yet, little is known about the prevalence and risk behaviors for HCV among IDUs in San Diego. In 2009–2010, 18–40-year-old IDUs in San Diego County completed a risk assessment interview and serologic testing for HCV and HIV infection. Recruitment involved respondent-driven sampling, venue-based sampling at a syringe exchange program, and convenience sampling. Correlates of HCV infection were identified by multivariable logistic regression. Among 510 current IDUs, 26.9 % (95 % CI 23.0–30.7 %) and 4.2 % (95 % CI 2.4–5.9 %) had been infected with HCV and HIV, respectively. Overall, median age was 28 years; 74 % were male; 60 % white and 29 % Hispanic; and 96 % were born in the U.S. Median years of injecting was 6; 41 % injected daily; 60 % injected heroin most often; 49 % receptively shared syringes and 68 % shared other injection paraphernalia; and only 22 % reported always using new syringes in the past 3 months. Two thirds had ever traveled to Mexico and 19 % injected in Mexico. HCV infection was independently associated with sharing injection paraphernalia (adjusted odds ratio [AOR] = 1.69) and SEP use (AOR = 2.17) in the previous 3 months, lifetime history of drug overdose (AOR = 2.66), and increased years of injecting (AOR = 2.82, all P values

Background Approximately 4.1 million Americans are estimated to have been infected with hepatitis C virus (HCV), 45–85% of whom are unaware of their infection. Persons who inject drugs (PWID) account for 55.8% of all persons with HCV antibody (anti-HCV) in the U.S. PWID have limited access to healthcare and are infrequently tested for anti-HCV using conventional laboratory assays. Objective To evaluate performance characteristics (sensitivity and specificity) of three, pre-market rapid point-of-care tests (one oral fluid and two finger-stick assays) from two manufacturers (Chembio and MedMira) in settings providing services to young adult PWID in San Diego, CA. Study design Behavioral risk assessment surveys and testing for HCV were conducted among persons who reported injection drug use (IDU) within the past 6 months as part of the Study to Assess Hepatitis C Risk (STAHR) among PWID aged 18–40 years in 2009–2010. Sensitivity and specificity of the rapid anti-HCV assays were evaluated among STAHR participants, using two commonly used testing algorithms. Results Variability in sensitivity (76.6–97.1%) and specificity (99.0–100.0%) was found across assays. The highest sensitivity achieved for the Chembio finger-stick blood, Chembio oral fluid and MedMira finger-stick blood tests was 97.1%, 85.4% and 80.0% respectively; the highest specificity was 99.0%, 100.0% and 100.0%, respectively. In multivariate analysis false negative anti-HCV results were associated with female sex for the MedMira blood assay. Conclusions Sensitive anti-HCV rapid assays are appropriate and feasible for high-prevalence, high-risk populations such as young PWID.

Prior studies estimate HIV prevalence of 4% among injection drug users (IDUs), compared with 0.8% in the general population of Tijuana, Mexico. However, data on HIV prevalence and correlates among non-injecting drug users (NIDUs) are sparse. Individuals were recruited through street outreach for HIV testing and behavioural risk assessment interviews to estimate HIV prevalence and identify associated sexual risk behaviours among NIDUs in Tijuana. Descriptive statistics were used to characterise 'low-risk' NIDUs (drug users who were not commercial sex workers or men who have sex with men). Results showed that HIV prevalence was 3.7% among low-risk NIDUs. During the prior six months, 52% of NIDUs reported having1 casual partner; 35% reported always using condoms with a casual partner; and 13% and 15%, respectively, reported giving or receiving something in exchange for sex. Women were significantly more likely than men to have unprotected sex with an IDU (p0.01).The finding that HIV prevalence among NIDUs was similar to that of IDUs suggests that HIV transmission has occurred outside of traditional core groups in Tijuana. Broad interventions including HIV testing, condom promotion and sexual risk reduction should be offered to all drug users in Tijuana.

Tuberculosis (TB) remains a common and deadly disease globally. Approximately two billion people are latently infected with TB, and there are almost two million deaths annually due to active disease. In 2009, there were 9.4 million new TB cases, of which 3.3 million (35%) occurred in the South-East Asia region.1 Of all reportable infectious diseases in Taiwan, TB has for decades been the most prevalent and significant.2 From 1990 to 2005, TB incidence in Taiwan almost doubled, from 40 cases per 100 000 population to 72/100 000,2 and over 60% of TB treatment ‘failures’ were shown to be caused by death during treatment rather than defaulting on treatment.2 After the World Health Organization (WHO) introduced the ‘Plan to Stop TB’ in 2006,3 with proposals to halve TB incidence by 2015, the Taiwan Centers for Disease Control (CDC) adopted an aggressive strategy for TB control centred firmly on the implementation of directly observed treatment short course (DOTS) in the hope that increased monitoring would reduce both transmission of new cases and TB mortality.2 Directly observed treatment (DOT) was not previously a component of TB control policy in Taiwan, and when the DOTS strategy was implemented by the Taiwan CDC, TB patients at greatest risk for transmitting TB and with the most severe disease (e.g., those with positive acid-fast bacilli [AFB] smear or TB culture) were initially preferentially assigned to DOT.2 While the WHO endorses DOT, which stipulates that every dose of TB medication be observed by a health professional or designee to increase adherence, it has had variable effectiveness on TB treatment outcomes when put into practice.4–12 A Cochrane review of DOT in 2009 concluded that there were no statistically significant differences in treatment outcomes between TB patients on DOT and those using self-administered therapy (SAT).13 While the studies reviewed controlled for potential confounders, some null findings could have resulted from selection bias and residual confounding. To determine whether patients receiving DOT had lower all-cause mortality than those treated with SAT, we compared all-cause mortality rates among TB patients receiving TB treatment via DOT vs. SAT between 2006 and 2008 in Taipei City, the second largest city in Taiwan. We hypothesised that after accounting for confounding variables, patients on DOT would have lower all-cause mortality than those on SAT.

We examined correlates of ever injecting drugs in Mexico among residents of San Diego, California. From 2007 to 2010, injecting drug users (IDUs) in San Diego underwent an interviewer-administered survey. Logistic regression identified correlates of injection drug use in Mexico. Of 302 IDUs, 38% were Hispanic, 72% male and median age was 37; 27% ever injected in Mexico; 43% reported distributive syringe sharing there. Factors independently associated with ever injecting drugs in Mexico included being younger at first injection, injecting heroin, distributive syringe sharing at least half of the time, and transporting drugs over the last 6 months. One-quarter of IDUs reported ever injecting drugs in Mexico, among whom syringe sharing was common, suggesting possible mixing between IDUs in the Mexico-US border region. Prospective studies should monitor trends in cross-border drug use in light of recent Mexican drug policy reforms partially decriminalizing drug possession. © Springer Science+Business Media, LLC 2011.

Objectives To compare genotypes of Mycobacterium bovis strains from humans in Southern California with genotypes of M. bovis strains in cattle in Mexico and the USA to explore the possible origins of human infections. Methods We conducted a descriptive analysis of M. bovis genotypes from a binational population of humans and cattle using spacer oligonucleotide typing (spoligotyping). Results One hundred six human M. bovis spoligotypes were compared to spoligotypes from 496 Mexican cattle and 219 US cattle. Twelve spoligotype patterns were identified among human cases and 126 spoligotype patterns were detected in cattle. Over 91% (97/106) of the human M. bovis isolates had spoligotypes that were identical to those found in Mexican cattle. Four human cases had spoligotypes that matched both cattle born in Mexico and in the USA. Nine human cases had spoligotypes that did not match cattle born in Mexico or the USA. Conclusions Our data indicate that the population of M. bovis strains causing human TB disease in Southern California is closely related to the M. bovis strain population found in Mexican cattle and supports existing epidemiological evidence that human M. bovis disease in San Diego likely originated from Mexican cattle.

The objectives were to estimate the prevalence and identify correlates of latent tuberculosis infection (LTBI) among residents of a migrant agricultural community in San Quintín, Baja-California, Mexico. Residents completed a questionnaire and had their blood tested for LTBI using the QuantiFERON(®)-TB Gold In-Tube (QFT) assay. Among 133 participants, 39.8% (95% CI 31.5-48.7%) tested QFT-positive. Having crossed the U.S.-Mexican border since living in San Quintin (P=0.03), consuming unpasteurized milk (P=0.02) and receiving health care at IMSS-Oportunidades in the last 6months (P=0.03) were independently associated with QFT-positivity. High LTBI prevalence in this community emphasizes the need for TB education and LTBI treatment for its residents. Association with travel to the U.S. suggests the potential for TB transmission across borders. Higher QFT-positivity among those consuming unpasteurized milk could indicate M. bovis infection, previously reported among Mexican migrants living in U.S. border cities.

Increased options for syringe acquisition and disposal have been associated with reductions in high-risk behaviors. This study determined the extent of pharmacy uptake in accessing syringes among injection drug users (IDUs) and estimated associations between pharmacy uptake and safer injection/disposal practices. Two years after the implementation of California’s Disease Prevention Demonstration Project, which removed restrictions to non-prescription syringe sales through pharmacies with local authorization, IDUs were recruited through street outreach in San Francisco and interviewed regarding recent syringe acquisition, use, and disposal. The sample of 105 persons included a high proportion of men (67%), people of color (49%), and homeless persons (71%). The most common syringe source was a syringe exchange program (SEP) (80%), with pharmacies being accessed by 39% of respondents. The most commonly cited source of disposal was a SEP (65%), with very few reports of pharmacy disposal (2%). Adjusted analysis showed that unsuccessful attempts to purchase syringes at a pharmacy increased the odds of both injecting with a used syringe and giving away a used syringe. Using a SEP decreased the odds of unsafe injection and disposal practices. Thus, 2 years after the initiation of the California Disease Prevention Demonstration Project, results from this small study suggest that SEPs still provide the majority of syringe distribution and disposal services to San Francisco IDUs; however, pharmacies now augment syringe access. In addition, unsafe injection behavior is reported more often among those who do not use these syringe sources. These results are consistent with prior studies in suggesting that increasing the availability of syringes through SEPs and pharmacies, and developing bridges between them, may further reduce syringe-related risk.

Interventions that prevent HIV transmission and TB reactivation are needed., Because there is little routine tuberculosis (TB) screening in Mexico, the prevalence of latent TB infection (LTBI) is unknown. In the context of an increasing HIV epidemic in Tijuana, Mexico, understanding prevalence of LTBI to anticipate emergence of increased LTBI reactivation is critical. Therefore, we recruited injection drug users, noninjection drug users, female sex workers, and homeless persons for a study involving risk assessment, rapid HIV testing, and TB screening. Of 503 participants, the overall prevalences of TB infection, HIV infection, and TB/HIV co-infection were 57%, 4.2%, and 2.2%, respectively; no significant differences by risk group (p>0.05) were observed. Two participants had TB (prevalence 398/100,000). Incarceration in Mexico (odds ratio [OR] 2.28), age (OR 1.03 per year), and years lived in Tijuana (OR 1.02 per year) were independently associated with TB infection (p

This study identified sociodemographic factors, drug using practices, sexual behaviors, and motivational factors associated with binge (a period of uninterrupted) methamphetamine (MA) use among heterosexual MA users.The FASTLANE study provided cross-sectional data collected by audio computer-assisted self-interview (ACASI) between June 2001 and August 2004 from 451 HIV-negative MA users in San Diego, California, USA who had engaged in unprotected sex and used MA in the previous two months.The study sample was 67.8% male, 49.4% Caucasian, 26.8% African-American, and 12.8% Hispanic with a mean age of 36.6 years; 183 (40.5%) reported binge use in the past 2 months. Compared with non-binge users, binge users of MA were more likely to report risky drug use and sex behaviors and differed in motivations to initiate and currently use MA. The final logistic regression model for binge use included more days of MA use in the last month, ever treated for MA use, injection drug use, higher Beck Depression Inventory score, "experimentation" as a motivation for initiating MA use, and engaging in sex marathons while high on MA. HIV prevention efforts should differentiate and address these differences in motivations for MA use and the associated HIV-risk sex and drug use behaviors as key targets for effective intervention.

Objectives. We sought to identify correlates of reported lifetime diagnoses of TB among injection drug users in the border city of Tijuana, Mexico. Methods. Injection drug users in Tijuana were recruited into a prospective cohort study during 2006 and 2007. We used weighted multivariate logistic regression to identify correlates of TB diagnoses. Results. Of the 1056 participants, 103 (9.8%) reported a history of TB, among whom 93% received anti-TB medication and 80% were diagnosed in the United States. Treatment was prematurely halted among 8% of patients; deportation from the United States was the cause of half of these treatment interruptions. History of travel to (odds ratio [OR] = 6.44; 95% confidence interval [CI] = 1.53, 27.20) or deportation from (OR = 1.83; 95% CI = 1.07, 3.12) the United States and incarceration (OR = 2.20; 95% CI = 1.06, 4.58) were independently associated with a reported lifetime diagnosis of TB. Conclusions. Mobility and migration are important factors in identifying and treating TB patients diagnosed in the US–Mexico border region. Strengthening capacity on both sides of the border to identify, monitor, and treat TB is a priority.