Steffanie Strathdee: “called” to HIV prevention

Abstract

For Steffanie Strathdee, Associate Dean of Global Health Sciences at the University of California San Diego (UCSD) and one of the leaders of a Lancet Series on HIV prevention in sex workers, being drawn into the world of HIV/AIDS was no accident. “When I was an undergraduate in microbiology at the University of Toronto, one of my teachers didn't show up one week. He had died of AIDS”, she recalls. “Later I lost my PhD supervisor and my best friend to the disease as well, so for me, coming to work in the HIV/AIDS field was a calling, something I just had to do.”Much of Strathdee's work over the past decade has focused on HIV research and prevention programmes in Tijuana, a frontier city on the USA–Mexico border. A magnet for migrants on a drug-trafficking route, sex work and injecting drug use is common. Inspired by the work of her husband, Tom Patterson, who saw the potential for HIV prevention programmes there, she developed an intervention that reduced HIV and sexually transmitted infections among sex workers who also inject drugs, a particularly vulnerable group. Her work in Tijuana led to awards for binational collaboration, given by the US National Institute on Drug Abuse. And Strathdee is also involved in Health Frontiers in Tijuana, a remarkable cross-border project run by medical students that offers free clinical care to Tijuana's poor and is a binational partnership between the University of California, San Diego School of Medicine and Tijuana's Autonomous University of Baja California School of Medicine.Today, she sees the targeting of upstream drivers of the HIV epidemic—such as structural violence and decriminalisation of drug use and sex work—as more of a priority than trying to change behaviour at the individual level. “Our team is designing a harm reduction programme for the police department in Tijuana”, she explains. “If we can teach the police how to protect themselves from needle-sticks while promoting HIV prevention instead of interfering with it, we can exert a much greater effect downstream.”Strathdee is well equipped to take on the challenges inherent in such research. Catherine Hankins, Deputy Director of Science at the Amsterdam Institute for Global Health and Development, has known Strathdee since she was a graduate student and speaks of her “fearless attitude and a powerful drive to make a difference”, noting that “she is equally at ease conducting research among sex workers and people who use drugs in dangerous areas along the Mexico–USA border, as she is presenting the scientific evidence on harm reduction to a hostile Commission on Narcotic Drugs in Vienna”.Back in the late 1980s, while studying for a masters in infectious diseases epidemiology at the University of Toronto, Strathdee volunteered at the city's Casey House HIV/AIDS hospice, and earned money to help pay her tuition by recruiting sex workers and drug users to a WHO research programme. “I was struck by how many sex workers and people who injected drugs confided to me that they had experienced sexual abuse in childhood and adolescence, even though it wasn't included in the survey”, she says. “This was an under-researched area of HIV epidemiology at that time, which I found compelling, not least because I had experienced sexual abuse myself in adolescence.” This became a focus of postdoctoral research for her after a move to the University of British Columbia in Vancouver.Vancouver was also the host of the 1996 International AIDS Society conference, a milestone in Strathdee's career. She was selected to present her work on the independent association between sexual abuse and increased HIV risk, winning a young investigator's award. Her appointment to the position of Assistant Professor in Epidemiology at the University of British Columbia soon followed. Later, she was recruited to an Associate Professorship at Johns Hopkins University Bloomberg School of Public Health, and became a leading figure for research in the HIV epidemic in people who inject drugs. “My time in Baltimore, the heroin capital of North America, was fascinating”, she recalls. “But I naively thought that I could repeat our success in Vancouver, where our work had convinced the government to expand needle-exchange programmes and methadone facilities. What I found in Baltimore was a complex pattern of HIV epidemiology in a population that was deeply segregated, and low political will to support harm reduction at the federal level”, she says.She was offered an endowed Chair at UCSD a decade ago, and so began her work on the USA–Mexico border “where all the conditions for an HIV epidemic existed, but no-one was studying it”, she says. Carlos Magis-Rodríguez, Director of Integrated Programmes at CENSIDA, Mexico's leading HIV prevention agency, recognises her pioneering work in the region. “Her work has had great influence in Mexico, where she developed her work in two of the most violent cities of the country, when Mexico had started a ‘war on drugs’. She is widely considered to have given very important evidence to public policy makers, and has worked successfully with federal authorities, local police authorities, and NGOs.”A prolific author, Strathdee remains grounded about the role of research. “I always emphasise to students the importance of research having impact in the real world, away from the ivory tower”, she says. “As for myself, I just want to continue this amazing life where I actually get paid for doing work that I am passionate about. If I can one day make myself redundant because we have made a serious dent in halting HIV/AIDS, I'll be a very happy woman”, she says.For Health Frontiers in Tijuana see http://meded.ucsd.edu/index.cfm/groups/hfit/about/ For Steffanie Strathdee, Associate Dean of Global Health Sciences at the University of California San Diego (UCSD) and one of the leaders of a Lancet Series on HIV prevention in sex workers, being drawn into the world of HIV/AIDS was no accident. “When I was an undergraduate in microbiology at the University of Toronto, one of my teachers didn't show up one week. He had died of AIDS”, she recalls. “Later I lost my PhD supervisor and my best friend to the disease as well, so for me, coming to work in the HIV/AIDS field was a calling, something I just had to do.” Much of Strathdee's work over the past decade has focused on HIV research and prevention programmes in Tijuana, a frontier city on the USA–Mexico border. A magnet for migrants on a drug-trafficking route, sex work and injecting drug use is common. Inspired by the work of her husband, Tom Patterson, who saw the potential for HIV prevention programmes there, she developed an intervention that reduced HIV and sexually transmitted infections among sex workers who also inject drugs, a particularly vulnerable group. Her work in Tijuana led to awards for binational collaboration, given by the US National Institute on Drug Abuse. And Strathdee is also involved in Health Frontiers in Tijuana, a remarkable cross-border project run by medical students that offers free clinical care to Tijuana's poor and is a binational partnership between the University of California, San Diego School of Medicine and Tijuana's Autonomous University of Baja California School of Medicine. Today, she sees the targeting of upstream drivers of the HIV epidemic—such as structural violence and decriminalisation of drug use and sex work—as more of a priority than trying to change behaviour at the individual level. “Our team is designing a harm reduction programme for the police department in Tijuana”, she explains. “If we can teach the police how to protect themselves from needle-sticks while promoting HIV prevention instead of interfering with it, we can exert a much greater effect downstream.” Strathdee is well equipped to take on the challenges inherent in such research. Catherine Hankins, Deputy Director of Science at the Amsterdam Institute for Global Health and Development, has known Strathdee since she was a graduate student and speaks of her “fearless attitude and a powerful drive to make a difference”, noting that “she is equally at ease conducting research among sex workers and people who use drugs in dangerous areas along the Mexico–USA border, as she is presenting the scientific evidence on harm reduction to a hostile Commission on Narcotic Drugs in Vienna”. Back in the late 1980s, while studying for a masters in infectious diseases epidemiology at the University of Toronto, Strathdee volunteered at the city's Casey House HIV/AIDS hospice, and earned money to help pay her tuition by recruiting sex workers and drug users to a WHO research programme. “I was struck by how many sex workers and people who injected drugs confided to me that they had experienced sexual abuse in childhood and adolescence, even though it wasn't included in the survey”, she says. “This was an under-researched area of HIV epidemiology at that time, which I found compelling, not least because I had experienced sexual abuse myself in adolescence.” This became a focus of postdoctoral research for her after a move to the University of British Columbia in Vancouver. Vancouver was also the host of the 1996 International AIDS Society conference, a milestone in Strathdee's career. She was selected to present her work on the independent association between sexual abuse and increased HIV risk, winning a young investigator's award. Her appointment to the position of Assistant Professor in Epidemiology at the University of British Columbia soon followed. Later, she was recruited to an Associate Professorship at Johns Hopkins University Bloomberg School of Public Health, and became a leading figure for research in the HIV epidemic in people who inject drugs. “My time in Baltimore, the heroin capital of North America, was fascinating”, she recalls. “But I naively thought that I could repeat our success in Vancouver, where our work had convinced the government to expand needle-exchange programmes and methadone facilities. What I found in Baltimore was a complex pattern of HIV epidemiology in a population that was deeply segregated, and low political will to support harm reduction at the federal level”, she says. She was offered an endowed Chair at UCSD a decade ago, and so began her work on the USA–Mexico border “where all the conditions for an HIV epidemic existed, but no-one was studying it”, she says. Carlos Magis-Rodríguez, Director of Integrated Programmes at CENSIDA, Mexico's leading HIV prevention agency, recognises her pioneering work in the region. “Her work has had great influence in Mexico, where she developed her work in two of the most violent cities of the country, when Mexico had started a ‘war on drugs’. She is widely considered to have given very important evidence to public policy makers, and has worked successfully with federal authorities, local police authorities, and NGOs.” A prolific author, Strathdee remains grounded about the role of research. “I always emphasise to students the importance of research having impact in the real world, away from the ivory tower”, she says. “As for myself, I just want to continue this amazing life where I actually get paid for doing work that I am passionate about. If I can one day make myself redundant because we have made a serious dent in halting HIV/AIDS, I'll be a very happy woman”, she says. For Health Frontiers in Tijuana see http://meded.ucsd.edu/index.cfm/groups/hfit/about/ For Health Frontiers in Tijuana see http://meded.ucsd.edu/index.cfm/groups/hfit/about/ For Health Frontiers in Tijuana see http://meded.ucsd.edu/index.cfm/groups/hfit/about/ Dispelling myths about sex workers and HIVSex work might or might not be the oldest profession, but it has existed for millennia across all continents and cultures. Nevertheless, myths about sex work and sex workers persist (panel). These myths can denigrate, devalue, and marginalise sex workers. Some widely held and unsupported views hinder HIV responses, driving sex workers away from already scarce HIV prevention and treatment services. Here, we aim to dispel the most harmful of these myths with evidence-based literature. Full-Text PDF Why are sex workers who use substances at risk for HIV?Sex workers who use drugs are particularly vulnerable to HIV and other bloodborne and sexually transmitted infections for several reasons. Sex workers who inject drugs can acquire HIV through unprotected sex or syringe sharing, with the latter conferring higher HIV transmission risk. Sex workers who are alcohol or drug dependent are more likely to engage in transactions while under the influence of substances and might earn less per transaction; when experiencing withdrawal symptoms they can feel more pressure to acquiesce to clients' demands for unprotected sex, especially if offered more money or drugs. Full-Text PDF Global epidemiology of HIV among female sex workers: influence of structural determinantsFemale sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Full-Text PDF An action agenda for HIV and sex workersThe women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. Full-Text PDF