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BackgroundPeople who inject drugs (PWID) face increased risk of SARS-CoV-2 acquisition and severe disease, yet COVID-19 vaccine uptake has been suboptimal. To inform vaccination interventions tailored for the needs of this population, we explored COVID-19 vaccination acceptability and experiences among PWID in San Diego County, USA.MethodsFrom September-November 2021, we conducted qualitative interviews with PWID aged ≥18years who were participating in a prospective study of infectious disease risks in San Diego. Thematic analysis of coded interview transcripts focused on identifying barriers and facilitators to COVID-19 vaccination.ResultsOf 28 participants, 15 reported having had ≥1 dose of COVID-19 vaccine, primarily received through community health centers, pharmacies, jails, and homeless shelters. We identified three key barriers to COVID-19 vaccination: (1) low perceived risk of COVID-19 (or belief in natural immunity), (2) institutional distrust (e.g., of pharmaceutical companies and government agencies that "rushed" vaccine development, approval, and distribution), and (3) conflicting information from news, social media, and peers. We also identified three key facilitators of vaccination, including (1) heightened personal and interpersonal safety concerns, (2) health service outreach efforts to make vaccines more accessible, and (3) tailored information delivered by trusted sources (e.g., outreach or community health workers).ConclusionsTailored intervention strategies to increase acceptability and uptake of COVID-19 vaccination among PWID should involve efforts to increase vaccine literacy and motivation while decreasing institutional distrust and structural barriers to access.

Background Craving has been implicated as a central feature of addiction and a predictor of relapse. However, a complete understanding of how craving varies across patient populations is lacking. This study aimed to better inform the effective and accurate use of craving as a clinical prognostic tool for patients with substance use disorders (SUD). Methods This cross-sectional study utilized information gathered on patients (n = 112) entering specialty treatment for a SUD. Craving in the prior 30 days was assessed with a single item with other intake questionnaires. Results Patients who reported Hispanic/Latinx ethnicity were less likely to report craving compared to patients who did not report Hispanic/Latinx ethnicity (AOR = 0.28 [95% CI, 0.08–0.95], p-value = 0.04). Patients who reported substance use in the last 30 days were more likely to report craving compared to patients who did not report substance use in the last 30 days (AOR = 6.86 [95% CI, 2.17–21.7], p-value = 0.001). There was no association between craving and Adverse Childhood Events (OR = 1.03 [95% CI, 0.84–1.25], p-value = 0.81). Conclusion The association between recent substance use and craving supports previous findings. The observed variation in craving among patients who report Hispanic/Latinx ethnicity is novel and suggests socio-cultural influences and genetic factors may influence reported craving amongst patients. Additional research is needed to further understand the underlying factors leading to this finding, in order for better utilization of craving as a clinical indicator across patient populations.

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 and aim Experience of stigma towards methadone maintenance treatment (MMT) may be a barrier to the use of this treatment by people with opioid use disorder. We evaluated the factor structure, internal reliability, construct and criterion validity of a theory-based stigma measure, the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS) and compared this with the Substance Use Stigma Mechanism Scale (SU-SMS). Design Surveys at the beginning and end of a prospective study together with records of drug use and treatment attendance during that study. Setting Community methadone clinic in the Northeastern USA. Participants Ninety-three participants who were receiving MMT; the average daily methadone dose was 84.8 mg/day (standard deviation = 28.39 mg/day). Measurements The MMT-SMS uses a self-report questionnaire to assess three dimensions reflecting experiences of anticipated (nine items), enacted (nine items) and internalized stigma (seven items) specifically related to receiving MMT. Anticipated and enacted scales include three stigma source subscales (family, employers, health care workers; three items each). Responses are recorded on a five-point Likert-type scale, then averaged to produce the MMT-SMS scale/subscale scores. The SU-SMS is a self-report questionnaire to assess experiences of anticipated, enacted and internalized stigma regarding substance use history. Both scales were administered at the final parent study visit. Other measures included were assessed in the parent study and used to assess life-time and recent MMT (e.g. current MMT dose) and drug use experiences (e.g. past 30-day heroin injection). Findings The MMT-SMS demonstrated good internal reliability (α = 0.806-0.952 for components). Confirmatory factor analysis supported the seven-factor scale structure, distinguishing between experiences of anticipated, enacted and internalized stigma, and anticipated and enacted stigma source subscales (family, employers, health care workers) [root mean square error of approximation (RMSEA) = 0.076, 90% confidence interval (CI) = 0.061-0.090, P-close = 0.003; confirmatory fit index (CFI) = 0.974; Tucker-Lewis index (TLI) = 0.971]. Construct validity helped to distinguish the MMT-SMS from established substance use stigma constructs. Criterion validity observed associations with substance use experiences while on MMT, likely to predict future MMT success. Internalized MMT stigma was uniquely associated with daily MMT dose. Regarding criterion validity: anticipated MMT and enacted substance use stigma were associated with past 30-day heroin injection, MMT stigma uniquely associated with opioid use behaviors while receiving MMT, and substance use stigma broadly associated with injection-related behaviors. Conclusions The Methadone Maintenance Treatment Stigma Mechanisms Scale appears to be a reliable measure of methadone maintenance treatment stigma with robust validity in a sample of people with opioid use disorders receiving methadone maintenance treatment.

Uptake of pre-exposure prophylaxis (PrEP) has dramatically increased but remains well below the estimated number of individuals who could benefit from PrEP in the United States, and uptake remains limited among young men who have sex with men (YMSM) and MSM of color. Reasons for not adopting PrEP as a prevention strategy among those at elevated risk for HIV is an important area of inquiry that could advise efforts to better position PrEP as an active part of prevention programs. As part of a mixed methods study investigating experiences with repeat HIV testing, we identified main themes emerging from in-depth interview data pertaining to reasons why YMSM report not using PrEP, among YMSM with frequent access to HIV testing services. Themes from 14 in-depth interviews with predominantly Latino MSM for not using PrEP included perceived burden of daily dosing, feeling that risk was not high enough to warrant PrEP, and beliefs that PrEP would have severe adverse events affecting the kidneys and bones. Less prominent but noteworthy themes included stigma as a PrEP user, social or provider influence on decisions not to use PrEP, and preference for current prevention strategy. No differences in PrEP discourse were noted across those at different levels of HIV risk. Results suggest that efforts are needed to engage communities and individuals around PrEP-related education, facilitate risk evaluation, and reduce PrEP stigma. New formulations and nondaily regimens may also be of particular interest to YMSM who may perceive daily PrEP regimens as highly burdensome.

Background Opioid agonist treatment (OAT) is an effective biomedical intervention to manage opioid use disorder among persons who inject drugs (PWID). Preliminary evidence suggests that OAT may also disrupt the social communicability of injection drug use (IDU) practices by established PWID. We therefore aim to investigate the association between OAT enrollment and initiating others into IDU among PWID in Vancouver, Canada. Methods Preventing Injecting by Modifying Existing Responses (PRIMER; NIDA DP2-DA040256-01) is a prospective multi-cohort study seeking to identify structural interventions that reduce the risk that PWID initiate others into IDU. The present analysis was conducted using data from a participating cohort of PWID in Vancouver, Canada, between December 2014 and May 2017. Multivariable logistic regression models were built to assess the association between reporting active (i.e., within the past six months) OAT enrollment and assisting others in injection initiation. A final model was determined using a manual stepwise approach whereby covariates were excluded if their removal altered the coefficient of interest by Results Participants (n = 1740) were predominantly male (62.3%); 35.1% reported daily injecting (n = 611); 860 (49.4%) reported active OAT enrollment, and 80 (4.6%) reported recently providing injection initiation assistance. In a multivariable model, participants who reported active OAT enrollment had significantly lower odds of recently providing injection initiation assistance (Adjusted Odds Ratio = 0.52, 95% Confidence Interval: 0.31-0.87, P = 0.01). Conclusion Results suggest a protective association between OAT and the expansion of IDU practices among vulnerable populations, suggesting its potential use as ‘addiction treatment as prevention.’

Author(s): Mittal, Maria L; Artamonova, Irina; Baker, Pieter; Strathdee, Steffanie A; Cepeda, Javier; Banuelos, Arnulfo; Morales, Mario; Arredondo, Jaime; Rocha-Jimenez, Teresita; Clairgue, Erika; Bustamante, Elaine; Patino, Efrain; Gaines, Tommi; Beletsky, Leo | Abstract: Background and objectivesPolicing practices do not reflect recent decriminalization of drug possession in Mexico. We assessed knowledge of cannabis law as part of a police education program (PEP) post-drug law reform in Tijuana.MethodsOfficers took pre-/post-PEP surveys; random subsample (n = 759) received follow-up assessments. Longitudinal logistic regression (pre-, post-, 3-months post-PEP) measured knowledge of cannabis law.ResultsPEP increased conceptual knowledge of cannabis law from baseline to post-training (AOR = 56.1, CI: 41.0-76.8) and 3 months post-PEP (AOR = 11.3, CI: 9.0-14.2).Conclusion and scientific significancePEPs improve police knowledge of cannabis law. Reforms should be bundled with PEPs to improve policy implementation. (Am J Addict 2018;XX:XX-XX).

ObjectiveAt a time of unprecedented attention to the public health impact of policing, it is imperative to understand the role of occupational safety in shaping officer behaviours. We assessed the longitudinal impact of police training in a quasi-experimental hybrid type-1 trial to reduce syringe-related occupational risk, while realigning police practices with public health prevention among people who inject drugs (PWID).SettingTijuana, Mexico.ParticipantsOf 1806 Tijuana municipal police trainees, 771 reporting previous exposure to syringes were randomly selected for follow-up. All participants completed at least one follow-up visit; attrition at 24 months was 8%.InterventionBetween 2015 and 2016, officers received a training intervention (Safety and Health Integration in the Enforcement of Laws on Drugs, SHIELD) bundling occupational needle stick injury (NSI) prevention with health promotion among PWID.Outcome measuresLongitudinal analysis with generalised linear mixed models to evaluate training impact on occupational NSI risk via NSI incidence and prevalidated Syringe Threat and Injury Correlates (STIC) score. This composite indicator integrates five self-reported risky syringe-handling practices (eg, syringe confiscation, breaking) and was used as a proxy for NSI risk due to reporting bias and concerns about reliability of NSI incidence reports.ResultsNo change in self-reported NSI incidence was observed, but significant reductions in risk (16.2% decrease in STIC score) occurred at 3 months, with a sustained decrease of 17.8% through 24 months, compared with pretraining (pConclusionsSHIELD is the first intervention to be associated with significant sustained changes in police practices that pose risk for both occupational and the public’s health. Integrating occupational safety and public health education should inform other interventions to mitigate the community health detriments of policing behaviours.Trial registration numberNCT02444403.

Author(s): Felner, Jennifer K; Mittal, Maria L; Hoenigl, Martin; Amico, K Rivet; Grelotti, David J; Eanes, Alex; Hess, Kristen; Crawford, Jessica; Smith, Laramie R | Abstract: IntroductionTo end the HIV epidemic, HIV prevention and pre-exposure prophylaxis (PrEP) promotion efforts must reach young men who have sex with men (YMSM) at greatest risk for HIV. This study qualitatively explored whether common metrics used by clinicians, scientists, and public health officials to objectively assess HIV risk align with how YMSM conceptualize their risk for HIV and the factors that shape YMSM's risk perceptions.MethodsInterviews with a racially/ethnically diverse sample of HIV-negative YMSM (ages 19-24 years, 60% Latinx; n = 20) examined conceptualizations of HIV risk within the context of repeat HIV testing. Iterative, applied thematic analysis examined how participants conceptualized and constructed their HIV risk, and compared participants' descriptions of their risk with a validated quantitative assessment of HIV risk that reliably predicts HIV seroconversion in this group.ResultsObjective quantitative assessments of HIV risk poorly aligned with participants' perceived HIV risk. Participants described their current risk in relative terms (relative to past risk and relative to friends'/peers' risk) and described age/developmental stage and changes in knowledge about HIV prevention as key factors in risk changes over time. Other factors included substance use and trust/mistrust in sexual partners and scientific advances in HIV prevention (eg, U = U and PrEP). Factors that influenced participants' perceived HIV risk were similar regardless of objective risk assessment.ConclusionsQuantitative assessments of risk may poorly align with risk perception among YMSM. Although objective metrics can effectively target YMSM at greatest risk for HIV transmission, interventions to improve prevention behaviors and PrEP uptake may be more effective when tailored to bridge the disconnection between objective HIV risk assessments and YMSM's constructions of risk.

Background 12-step programs aim to address drug-related harms, like opioid overdose, via abstinence. However, abstaining from opioids can diminish tolerance, which increases risk for overdose death upon resumption. A recent study found that desire to abstain from drugs inhibited willingness to participate in take-home naloxone programming, which was linked to perceptions of harm reduction strategies being tied to drug use. In the present study, we uncovered a similar phenomenon occurring among newly-abstinent participants who were refusing to carry naloxone. Methods This study is an analysis of broader qualitative data collected throughout Southern California among persons who use opioids, including those recently abstinent. Preliminary analysis revealed that those newly abstinent refused to accept naloxone at the end of interviews, and so we began probing about this (N=44). We used thematic analysis and author positionality to explicate the emergent phenomenon and applied social identity theory to conceptualize findings. Results Mechanisms underlying naloxone refusal included its tie to a drug-using identity that newly-abstinent participants were attempting to retire. Carrying naloxone was also viewed as pointless due to doubt of witnessing an overdose again. Furthermore, the thought of being equipped with naloxone was not believed to be congruent with an abstinent identity, e.g. “me carrying it [naloxone] is making me feel like I'm going to be hanging out with people that are doing it [using drugs].” Conclusion Recent detoxification heightens vulnerability to overdose, which other newly-abstinent peers might be positioned to respond to as bonds are formed through 12-step identity formation. However, naloxone is often refused by this group due to perceived 12-step identity clash. While some treatment spaces distribute naloxone, 12-step identity associated behavioral expectations appear to conflict with this strategy. Reframing these disconnects is essential for expanding the lifesaving naloxone community safety net.

Background Homeless people who use drugs (PWUD) are often displaced, detained, and/or forced into drug treatment during police crackdowns. Such operations follow a zero-tolerance approach to law enforcement and have a deleterious impact on the health of PWUD. In Mexico, municipal police officers (MPOs) conducted the largest crackdown documented at the Tijuana River Canal (Tijuana Mejora) to dismantle an open drug market. We analyzed active-duty MPOs’ attitudes on the rationale, implementation, and outcomes of the crackdown. We also included the involvement of non-governmental allies in the disguised imprisonment as drug treatment referral and potential legal consequences of having illegally detained PWUD. Methods Between February–June 2016, 20 semi-structured interviews were conducted with MPOs in Tijuana. Interviews were transcribed, translated and coded using a consensus-based approach. Emergent themes, trends and frameworks were analyzed through a hermeneutic grounded theory protocol. Results Participants recognized the limitations of Tijuana Mejora in effectively controlling crime and addressing drug treatment solutions. MPOs perceived that the intent of the operation was to displace and detain homeless PWUD, not to assist or rehabilitate them. The police operation was largely justified as a public safety measure to reduce the risk of injury due to flooding, decrease drug consumption among PWUD and protect local tourism from PWUD. Some participants perceived the crackdown as a successful public health and safety measure while others highlighted occupational risks to MPOs and potential human rights violations of PWUD. Conclusions Tijuana Mejora illustrated why public and private actors align in enforcing zero-tolerance drug policy. Perceptions of care are often based on captivity of the diseased, not in health and well-being of PWUD. Officer perceptions shed light on the many limitations of this punitive policing tool in this context. A shift towards evidence-based municipal strategies to address drug use, wherein police are perceived as partners in harm reduction rather than antagonists, is warranted.

Introduction: Prior work found Methods: We held a community forum and measured perspectives of key stakeholders in local organizations that serve KPLWH using online surveys, and in-depth interviews (with select key informants). Results: Univariate descriptive statistics and emergent thematic analysis illustrated that there was general consensus that the program could improve ART coverage for KPLWH by helping to overcome geographic, transportation, and sociostructural barriers to HIV care. Police harassment, mobility, and non-HIV comorbidities were identified as challenges the program would need to navigate. Conclusions: Community stakeholders expressed perceived need and acceptability of a program to improve HIV care outcomes among KPLWH in Tijuana. The program should address the challenges identified by community stakeholders.

Background and AimsDrug policy reforms typically seek to improve health among people who use drugs (PWUD), but flawed implementation impedes potential benefits. Mexico’s 2009 drug policy reform emphasized public health-oriented measures to address addiction. Implementation has been deficient, however. We explored the role of municipal police officers’ (MPOs) enforcement decision-making and local systems as barriers to reform operationalization.MethodsBetween February-June 2016, 20 semi-structured interviews were conducted with MPOs in Tijuana. Interviews were transcribed, translated and coded using a consensus-based approach. Emergent themes, trends and frameworks were analyzed through a hermeneutic grounded theory protocol.ResultsIn conceptualizing their orientation towards municipal (not state) law, MPOs reported prioritizing enforcement of nebulous anti-vice ordinances to control PWUD activity. Local laws were seen as conflicting with drug policy reforms. Incentives within the police organization were aligned with ordinance enforcement, generating pressure through quotas and reinforced by judges. Driven by discretion, fuzzy understanding of procedures, and incentives to sanitize space, detention of PWUD for minor infractions was systematic.ConclusionsFailure to harmonize policies and priorities at different levels of government undermine effective operationalization of health-oriented drug policy. Implementation must address local priorities and administrative pressures shaping MPO decision-making and enforcement practice.

Study objective Postoverdose interventions that deploy peer recovery support specialists to emergency departments (EDs) are a promising response to opioid overdoses among patients presenting in EDs. The objective of this study was to elicit patients’ perspectives regarding the feasibility and acceptability of such an intervention and to ensure that their perspectives are represented in intervention design, implementation, and evaluation. Method In 2019 the study investigators conducted focus groups with people who use opioids to elicit perspectives about a postoverdose intervention delivered in the ED by using a semistructured interview guide that asked about feasibility, acceptability, perceived benefits, and concerns. Focus groups were digitally recorded, transcribed, and analyzed for emerging themes. Results Nine focus groups with 30 people who use opioids were conducted. Key findings that could improve feasibility and acceptability of the intervention include the following: the importance of balancing the urgency of seeing patients quickly with a need to accommodate the experience of precipitated withdrawal symptoms; the need to address privacy concerns; and the need to address concerns related to cost, insurance coverage, and sustainability. Perceived benefits of the intervention included the ability of the peer recovery support specialist to provide advocacy and support, serve as a model of hope and encouragement for behavior change, and fill key service gaps. Conclusion Postoverdose interventions in the ED provide the opportunity to integrate harm reduction–based interventions into traditional biomedical care facilities. These interventions can fill gaps in services and provide additional care and comfort for people who use opioids, but design, implementation, and evaluation should be informed by a patient-centered care perspective.

Sensationalistic media coverage has fueled stereotypes of the Mexican border city of Tijuana as a violent battleground of the global drug war. While the drug war shapes health and social harms in profoundly public ways, less visible are the experiences and practices of hope that forge communities of care and represent more private responses to this crisis. In this article, we draw on ethnographic fieldwork and photo elicitation with female sex workers who inject drugs and their intimate, non-commercial partners in Tijuana to examine the personal effects of the drug war. Drawing on a critical phenomenology framework, which links political economy with phenomenological concern for subjective experience, we explore the ways in which couples try to find hope amidst the horrors of the drug war. Critical visual scholarship may provide a powerful alternative to dominant media depictions of violence, and ultimately clarify why this drug war must end.

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.

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.

BACKGROUND: Gender influences the health and social risks faced by individuals initiating drug injecting. Using mixed methods across three settings in North American, we investigated the gender composition of injection initiation events and the gendered risk environments in which they occurred. METHODS: The PReventing Injecting by Modifying Existing Responses (PRIMER) study pooled data from three prospective community-recruited cohorts of people who inject drugs (PWID) in San Diego, USA, Vancouver, Canada, and Tijuana, Mexico. A qualitative subsample provided narrative data on their experiences of, and the contexts for, injection initiation events. Guided by Rhodes’ risk environment framework, we examined the gender composition of initiation events stratified by city, and analyzed qualitative data using abductive thematic analyses. RESULTS: Among 2,622 PWID (Tijuana: n = 531; San Diego: n = 352; Vancouver: n = 1,739), 112 (4.3%) reported providing initiation assistance to injection-naïve individuals in the previous six months. The proportion of gender concordant (e.g., male-male) initiation pairs varied, (χ(2) = 10.32, p

Background: Mexican law permits syringe purchase and possession without prescription. Nonetheless, people who inject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights, but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID and police personnel. To better understand how police practices contribute to the PWID risk environment, prior research has primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs) in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession. Methods: Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire on knowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies. Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest. Results: Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession (previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio [AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04–2.52; working in a district along Tijuana River Canal (where PWID congregate) (AOR = 2.85; 95%CI = 2.16–3.77); having recently experienced a physical altercation with PWID (AOR = 2.83; 95% CI = 2.15–3.74); and having recently referred PWID to social and health services (AOR = 1.97; 95% CI = 1.48–2.61). Conversely, odds were significantly lower among officers reporting knowing that syringe possession is legal (AOR = 0.61; 95% CI = 0.46–0.82). Conclusions: Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role in shaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicial syringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at various governmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of drug laws, and facilitate harm reduction strategies that promote human rights and community health.

BACKGROUND:Dual epidemics of injection drug use and blood-borne disease, characterized as "syndemics," are present in a range of settings. Behaviors that drive such syndemics are particularly prevalent among mobile drug-using populations, for whom cross-border migration may pose additional risks. OBJECTIVES:This narrative review aims to characterize the risk factors for injection drug use initiation associated with migration, employing a risk environment framework and focusing on the San Diego-Tijuana border region as the most dynamic example of these phenomena. METHODS:Based on previous literature, we divide migration streams into three classes: intra-urban, internal, and international. We synthesized existing literature on migration and drug use to characterize how mobility and migration drive the initiation of injection drug use, as well as the transmission of hepatitis and HIV, and to delineate how these might be addressed through public health intervention. RESULTS:Population mixing between migrants and receiving communities and the consequent transmission of social norms about injection drug use create risk environments for injection drug use initiation. These risk environments have been characterized as a result of local policy environments, injection drug use norms in receiving communities, migration-related stressors, social dislocation, and infringement on the rights of undocumented migrants. CONCLUSION:Policies that exacerbate risk environments for migrants may inadvertently contribute to the expansion of epidemics of injection-driven blood-borne disease. Successful interventions that address emerging syndemics in border regions may therefore need to be tailored to migrant populations and distinguish between the vulnerabilities experienced by different migration classes and border settings.

BackgroundMexico recently enacted drug policy reform to decriminalize possession of small amounts of illicit drugs and mandated that police refer identified substance users to drug treatment. However, the economic implications of drug treatment expansion are uncertain. We estimated the costs of opioid substitution therapy (OST) provision in Tijuana, Mexico, where opioid use and HIV are major public health concerns.MethodsWe adopted an economic health care provider perspective and applied an ingredients-based micro-costing approach to quantify the average monthly cost of OST (methadone maintenance) provision at two providers (one private and one public) in Tijuana, Mexico. Costs were divided by type of input (capital, recurrent personnel and non-personnel). We defined “delivery cost” as all costs except for the methadone and compared total cost by type of methadone (powdered form or capsule). Cost data were obtained from interviews with senior staff and review of expenditure reports. Service provision data were obtained from activity logs and senior staff interviews. Outcomes were cost per OST contact and cost per person month of OST. We additionally collected information on patient charges for OST provision from published rates.ResultsThe total cost per OST contact at the private and public sites was $3.12 and $5.90, respectively, corresponding to $95 and $179 per person month of OST. The costs of methadone delivery per OST contact were similar at both sites ($2.78 private and $3.46 public). However, cost of the methadone itself varied substantially ($0.34 per 80 mg dose [powder] at the private site and $2.44 per dose [capsule] at the public site). Patients were charged $1.93–$2.66 per methadone dose.ConclusionsThe cost of OST provision in Mexico is consistent with other upper-middle income settings. However, evidenced-based (OST) drug treatment facilities in Mexico are still unaffordable to most people who inject drugs.

Background Policing practices such as syringe confiscation and arrest can act as important social-structural drivers of HIV risk among people who inject drugs (PWID). However, police referral to treatment and other services may improve the health of PWID. Little is known about the role of modifiable attitudinal and knowledge factors in shaping officer behavior. Using baseline findings from a police education program (PEP), we assessed relationships between drug policy knowledge and attitudes towards public health interventions with self-reported syringe confiscation, drug arrest, and service referral among street-level police in Tijuana, Mexico. Methods Between February, 2015 and May, 2016 we surveyed 1319 police officers who reported syringe contact. The self-administered survey focused on attitudes, knowledge, and behaviors related to drug policy, public health, and occupational safety. We used ordinal logistic regression to model the odds of syringe confiscation, arrest for heroin possession, and referring PWID to health/social programs. Results The sample was mostly male (87%) and had at least a high school education (80%). In the last six months, a minority reported always/sometimes confiscating syringes (49%), arresting someone for heroin possession (43%), and referring PWID to health and social programs (37%). Those reporting needlestick injuries (NSI) had 1.38 (95% CI: 1.02–1.87) higher odds of reporting syringe confiscation. Officers who had favorable views on laws that treat addiction as a public health issue had lower odds (aOR=0.78; 95% CI: 0.59–1.03) of arresting PWID. Those agreeing that it was their role to refer PWID to health and social programs had higher odds of reporting such referrals (aOR: 3.32, 95% CI: 2.52–4.37). Legal knowledge was not associated with these practices. Conclusion Changing drug policy and knowledge may be insufficient in shifting police behavior. Modifying officers' occupational risks and attitudes towards harm reduction interventions can facilitate efforts to align police practices with PWID health.

Female sex work is often perceived as women being controlled by men. We used surveys and qualitative interviews with female sex workers and their intimate partners in two Northern Mexico cities to examine couples' own perceptions of their relationships and male partners' involvement in sex work. Among 214 couples, the median age was 34 and relationship duration was approximately 3 years. Only 10 women in the survey reported having a pimp, and the majority reported sole control over sex work decisions. Qualitative analyses revealed that while most men avoided direct involvement in sex work, they offered advice that was largely driven by concern for their partner's well-being. Our discussion of these results considers the broader socio-political context surrounding these relationships and how changing gender roles, economic insecurity and stigma shape couples' everyday social interactions. Assumptions that all sex workers' relationships are coercive and commercial marginalises these couples while leaving their health concerns unaddressed.

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.

Introduction: Police officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection. We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational safety and simultaneously reduce HIV risks among police and PWID. Methods: Tijuana’s Department of Municipal Public Safety (SSPM) is among Mexico’s largest. Our binational, multi-sectoral team analyzed de-identified data from SSPM’s 2014 anonymous self-administered occupational health survey. The prevalence of NSI and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating equations identified factors associated with ever having an occupational NSI. Results: Approximately one-quarter of the Tijuana police force was given the occupational health survey ( N =503). Respondents were predominantly male (86.5%) and ≤35 years old (42.6%). Nearly one in six officers reported ever having a NSI while working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering needles/syringes while on duty ( n =473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56–5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29–3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22–0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19–0.91). Conclusions: Tijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe confiscation) – factors that also impact HIV transmission among PWID and other members of the community. Keywords: occupational accidents; HIV; viral hepatitis; syringe disposal; syringe confiscation; policing; law enforcement; harm reduction. (Published: 18 July 2016) Citation: Mittal ML et al. Journal of the International AIDS Society 2016, 19(Suppl 3) :20874 http://www.jiasociety.org/index.php/jias/article/view/20874 | http://dx.doi.org/10.7448/IAS.19.4.20874