Drugs In Tijuana Research Articles

Illicit Fentanyl Use and Hepatitis C Virus Seroconversion Among People Who Inject Drugs in Tijuana and San Diego: Results From a Binational Cohort Study.

Illicitly manufactured fentanyl (IMF) increases overdose mortality, but its role in infectious disease transmission is unknown. We examined whether IMF use predicts hepatitis C virus (HCV) and human immunodeficiency virus (HIV) incidence among a cohort of people who inject drugs (PWID) in San Diego, California and Tijuana, Mexico. PWID were recruited during 2020-2022, undergoing semi-annual interviewer-administered surveys and HIV and HCV serological rapid tests through 2024. Cox regression was conducted to examine predictors of seroconversion considering self-reported IMF use as a 6-month lagged, time-dependent covariate. Of 398 PWID at baseline, 67% resided in San Diego, 70% were male, median age was 43 years, 42% reported receptive needle sharing, and 25% reported using IMF. HCV incidence was 14.26 per 100 person-years (95% confidence interval [CI]: 11.49-17.02), and HIV incidence was 1.29 (95% CI: .49-2.10). IMF was associated with HCV seroconversion, with a univariable hazard ratio (HR) of 1.64 (95% CI: 1.09-2.40), and multivariable HR of 1.57 (95% CI: 1.03-2.40). The direction of the relationship with HIV was similar, albeit not significant (HR 2.39; 95% CI: .66-8.64). We document a novel association between IMF and HCV seroconversion among PWID in Tijuana-San Diego. Few HIV seroconversions (n = 10) precluded our ability to assess if a similar relationship held for HIV. IMF's short half-life may destabilize PWID-increasing the need for repeat dosing and sharing smoking materials and syringes. New preventive care approaches may reduce HCV transmission in the fentanyl era.

Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020–2021: a cross-sectional study

BackgroundWater, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area.MethodsIn this cross-sectional binational study, we interviewed PWID (age 18+) in 2020–2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates.ResultsOf 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02–2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28–1.64), and bathing (aRR: 1.21, 95%CI: 1.06–1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07–3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52–2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55–6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36–4.89) than participants living in permanent housing.ConclusionWASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID—especially those who are unsheltered.

Estimating the impact of a police education program on hepatitis C virus transmission and disease burden among people who inject drugs in Tijuana, Mexico: A dynamic modeling analysis.

Criminalization of drug use and punitive policing are key structural drivers of hepatitis C virus (HCV) risk among people who inject drugs (PWID). A police education program (Proyecto Escudo) delivering training on occupational safety together with drug law content was implemented between 2015 and 2016 in Tijuana, Mexico, to underpin drug law reform implementation. We used data from a longitudinal cohort of PWID in Tijuana to inform epidemic modeling and assess the long-term impact of Escudo on HCV transmission and burden among PWID in Tijuana. We developed a dynamic, compartmental model of HCV transmission and incarceration among PWID and tracked liver disease progression among current and former PWID. The model was calibrated to data from Tijuana, Mexico, with 90% HCV seroprevalence. We used segmented regression analysis to estimate impact of Escudo on recent incarceration among an observational cohort of PWID. By simulating the observed incarceration trends, we estimated the potential impact of the implemented (2-year reduction in incarceration) and an extended (10-year reduction in incarceration) police education program over a 50-year follow-up (2016-2066) on HCV outcomes (incidence, cirrhosis, HCV-related deaths and disability adjusted life-years averted) compared with no intervention. Over the 2-year follow-up, Proyecto Escudo reduced HCV incidence among PWID from 21.5 per 100 person years (/100py) (95% uncertainty interval [UI] = 15.3-29.7/100py) in 2016 to 21.1/100py (UI = 15.0-29.1/100py) in 2018. If continued for 10years, Escudo could reduce HCV incidence to 20.0/100py (14.0-27.8/100py) by 2026 and avert 186 (32-389) new infections, 76 (UI = 12-160) cases of cirrhosis and 32 (5-73) deaths per 10 000 PWID compared with no intervention over a 50-year time horizon. In Tijuana, Mexico, implementation of a police education program delivering training on occupational safety and drug law content appears to have reduced hepatitis C virus incidence among people who inject drugs.

An Ethnographic Assessment of COVID-19‒Related Changes to the Risk Environment for People Who Use Drugs in Tijuana, Mexico.

Objectives. To characterize the effects of the onset of the COVID-19 pandemic on the risk environment of people who use drugs (PWUD) in Tijuana, Mexico. Methods. We used intensive participant-observation ethnography among street-based PWUD and key informants, such as frontline physicians and harm reductionists. Results. PWUD described an unprecedented cessation of police violence and extortion during the initial pandemic-related lockdown, though this quickly reversed and police violence worsened. Government-provided housing and medical treatment with methadone were temporarily provided to PWUD in a dedicated clinic, yet only for PWUD with COVID-19 symptoms. Concurrently, non‒COVID-19‒related hospital care became virtually inaccessible, and many PWUD died of untreated, chronic illnesses, such as hepatitis C, and soft-tissue infections. Border closures, decreases in social interaction, and reduced drug and sex tourism resulted in worsening food, income, and housing insecurity for many PWUD. By contrast, potent illicit drugs remained easily accessible in open-air drug markets. Conclusions. The pandemic exacerbated health risks for PWUD but also offered profound glimpses of beneficial structural changes. Efforts are needed in Tijuana and elsewhere to institutionalize positive pandemic-related shifts and ameliorate novel harms for PWUD. (Am J Public Health. 2022;112(S2):S199-S202. https://doi.org/10.2105/AJPH.2022.306796).

\u201cI would rather do it myself\u201d: injection initiation and current injection patterns among women who inject drugs in Tijuana, Mexico

BackgroundWomen who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico.MethodsSemistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants.ResultsThe interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to.ConclusionsThe narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico.

Municipal police support for harm reduction services in officer-led referrals of people who inject drugs in Tijuana, Mexico

BackgroundPolice 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.MethodsBetween 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.ResultsRespondents 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).ConclusionsBeliefs 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.

The impact of recent homelessness on the provision of injection drug use initiation assistance among persons who inject drugs in Tijuana, Mexico and Vancouver, Canada

ObjectiveTo assess the relationship between experiencing homelessness and assisting injection drug use (IDU) initiation among people who inject drugs (PWID) in Tijuana, Mexico and Vancouver, Canada. MethodsWe used self-reported questionnaire data collected semi-annually on PWID from Tijuana (n = 703) and Vancouver (n = 1551) between 2014 and 2017. Within each setting, the effect of recent (i.e., past six months) homelessness on recent provision of injection initiation assistance (i.e., helping anybody inject for the first time in the past six months) was estimated using inverse-probability-of-treatment (IPT)-weighted estimation of a marginal structural model. ResultsAcross follow-up, the prevalence of recent homelessness at a given visit ranged from 11.6%–16.5% among Tijuana-based participants and 9.4%–18.9% among Vancouver-based participants; the prevalence of recent provision of injection initiation at a given follow-up visit was lower, ranging from 3.3%–5.4% in Tijuana and 2.5%–4.1% in Vancouver. Based on the IPT-weighted estimates, recent homelessness was associated with 66% greater odds among Tijuana-based PWID (Adjusted Odds Ratio [AOR] = 1.66; 95% CI: 1.01–2.73) and 47% greater odds among Vancouver-based PWID (AOR = 1.47, 95% CI: 1.02–2.13) of providing injection initiation assistance over the same six-month period. ConclusionWe found that recently experiencing homelessness was associated with an increased likelihood of PWID reporting IDU initiation assistance over time in both Tijuana and Vancouver. Addressing homelessness may decrease the initiation of IDU via multiple pathways.

Risk of non-fatal overdose and polysubstance use in a longitudinal study with people who inject drugs in Tijuana, Mexico.

Among people who inject drugs (PWID), polysubstance use has been associated with fatal and non-fatal overdose (NFOD). However, the risk of overdose due to the cumulative number of various recently used drug types remains unexplored. We estimated the risk of NFOD for different polysubstance use categories among PWID in Tijuana, Mexico. Data came from 661 participants followed for 2 years in Proyecto El Cuete-IV, an ongoing prospective cohort of PWID. A multivariable Cox model was used to assess the cumulative impact of polysubstance use on the time to NFOD. We used the Cochran-Armitage test to evaluate a dose-response relationship between number of polysubstance use categories and NFOD. We observed 115 NFOD among 1029.2 person-years of follow-up (incidence rate: 11.2 per 100 person-years; 95% confidence interval [CI] 9.3-13.3). Relative to those who used one drug class, the adjusted hazard ratio of NFOD for individuals reporting using two drug classes was 1.11 (95% CI 0.69-1.79), three drug classes was 2.00 (95% CI 1.16-3.44) and for those reporting three compared to two was 1.79 (95% CI 1.09-2.97). A significant Cochran-Armitage trend test (P< 0.001) suggested a dose-response relationship. Polysubstance use was associated with increased risk of NFOD with a dose-response relationship over 2 years. We identified a subgroup of PWID at high risk of NFOD who reported concurrent use of opioids, stimulants and benzodiazepines. Prioritising tailored harm reduction and overdose prevention interventions for PWID who use multiple substances in Tijuana is needed.

Impact of cumulative incarceration and the post-release period on syringe-sharing among people who inject drugs in Tijuana, Mexico: a longitudinal analysis.

Syringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing. Ongoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups. Tijuana, Mexico. Sample of 185 participants (median age 35years; 67% female) with no history of incarceration at study entry, followed to 2017. Cumulative incarceration and post-release period were constructed from incarceration events reported in the past 6months for each study visit. Receptive syringe-sharing in the past 6months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation. At baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median= 2, interquartile range(IQR)=1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) =0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI=1.02-1.99) and more than three incarcerations, 2.10 (95% CI=1.15-3.85). Participants released within the past 6months had 1.53 (95% CI=1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5years post-incarceration (adjusted odds ratio=1.41, 95% CI=1.04-1.91), but then waned. A longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.

Sex differences in the multilevel determinants of injection risk behaviours among people who inject drugs in Tijuana, Mexico.

HIV and hepatitis C virus transmission among people who inject drugs (PWID) is fuelled by personal and environmental factors that vary by sex. We studied PWID in Mexico to identify sex differences in multilevel determinants of injection risk. From 2011 to 2013, 734 PWID (female: 277, male: 457) were enrolled into an observational cohort study in Tijuana. Participants completed interviews on injection and sexual risks. Utilising baseline data, we conducted multiple generalised linear models stratified by sex to identify factors associated with injection risk scores (e.g. frequency of injection risk behaviours). For both sexes, difficult access to sterile syringes was associated with elevated injection risk (b = 1.24, 95% confidence interval [CI] 1.16-1.33), using syringes from a safe source (e.g. needle exchange programs) was associated with lower injection risk (b = 0.87, 95% CI 0.82-0.94), and for every one-unit increase in safe injection self-efficacy we observed a 20% decrease in injection risk (b = 0.80, 95% CI 0.76-0.84). Females had a higher safe injection self-efficacy score compared to males (median 2.83, interquartile range 2.2-3 vs. median 2.83, interquartile range 2-3; P = 0.01). Among females, incarceration (b = 1.22, 95% CI 1.09-1.36) and police confiscation of syringes in the past 6 months (b = 1.16, 95% CI 1.01-1.33) were associated with elevated injection risk. Among males, sex work (b = 1.16, 95% CI 1.04-1.30) and polysubstance use in the past 6 months (b = 1.22, 95% CI 1.13-1.31) were associated with elevated injection risk. Interventions to reduce HIV and hepatitis C virus transmission among PWID in Tijuana should be sex-specific and consider multilevel determinants of injection risk to create safer drug use environments.

Modelling integrated antiretroviral treatment and harm reduction services on HIV and overdose among people who inject drugs in Tijuana, Mexico.

IntroductionThe HIV epidemic in Tijuana, Mexico is concentrated in key populations, including people who inject drugs (PWID). However, HIV interventions among PWID are minimal, and federal funding was provided for compulsory abstinence programmes associated with HIV and overdose. Alternatively, opioid agonist therapy reduces overdose, reincarceration, HIV, while improving antiretroviral therapy (ART) outcomes. We assessed potential impact and synergies of scaled‐up integrated ART and opioid agonist therapy, compared to scale‐up of each separately, and potential harms of compulsory abstinence programmes on HIV and fatal overdose among PWID in Tijuana.MethodsWe developed a dynamic model of HIV transmission and overdose among PWID in Tijuana. We simulated scale‐up of opioid agonist therapy from zero to 40% coverage among PWID. We evaluated synergistic benefits of an integrated harm reduction and ART scale‐up strategy (40% opioid agonist therapy coverage and 10‐fold ART recruitment), compared to scale‐up of each intervention alone or no scale‐up of low coverage ART and no harm reduction). We additionally simulated compulsory abstinence programmes (associated with 14% higher risk of receptive syringe sharing and 76% higher odds of overdose) among PWID.ResultsWithout intervention, HIV incidence among PWID could increase from 0.72 per 100 person‐years (PY) in 2020 to 0.92 per 100 PY in 2030. Over ten years, opioid agonist therapy scale‐up could avert 31% (95% uncertainty interval (UI): 18%, 46%) and 22% (95% UI: 10%, 28%) new HIV infections and fatal overdoses, respectively, with the majority of HIV impact from the direct effect on HIV transmission due to low ART coverage. Integrating opioid agonist therapy and ART scale‐up provided synergistic benefits, with opioid agonist therapy effects on ART recruitment/retention averting 9% more new infections compared to ART scale‐up alone. The intervention strategy could avert 48% (95% UI: 26%, 68%) of new HIV infections and one‐fifth of fatal overdoses over ten years. Conversely, compulsory abstinence programmes could increase HIV and overdoses.ConclusionsIntegrating ART with opioid agonist therapy could provide synergistic benefits and prevent HIV and overdoses among PWID in Tijuana, whereas compulsory abstinence programmes could cause harm. Policymakers should consider the benefits of integrating harm reduction and HIV services for PWID.

\u201cPick up anything that moves\u201d: a qualitative analysis of a police crackdown against people who use drugs in Tijuana, Mexico

BackgroundHomeless 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.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.ResultsParticipants 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.ConclusionsTijuana 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.

Sex Work as a Mediator Between Female Gender and Incident HIV Infection Among People Who Inject Drugs in Tijuana, Mexico.

We studied mechanisms driving gender differences in HIV incidence among 651 women and men who inject drugs (PWID) in Tijuana, Mexico, hypothesizing that sex workwill mediate the association between female gender and HIV incidence. Of 43 HIV seroconversions occurring between 2011 and 2018, 8.8% were among females and 5.2% among males. HIV incidence density was significantly higher among females versus males (1.75 per 100 person years [PY], 95% CI 1.16-2.66, vs. 0.95 per 100 PY, 95% CI 0.62-1.47). Factors significantly associated with HIV seroconversion were: sex work (adjusted hazard ratio [aHR] = 2.25, 95% CI 1.05-4.80); methamphetamine injection (aHR = 2.30, 95% CI 1.12-4.73); and methamphetamine and heroin co-injection in the past six months (aHR = 2.26, 95% CI 1.23-4.15). In mediation analyses, sex work mediated a substantial proportion (84.3%) of the association between female gender and HIV incidence. Interventions should target female PWID who engage in sex work to reduce gender-related disparities in HIV incidence.

Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis

BackgroundIn 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana. MethodsWe constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions. ResultsModeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770–21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640–970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions. ConclusionsElimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.

Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, 2011–2018

BackgroundPeople who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID. MethodsData come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011–2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age. ResultsAmong 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective. ConclusionIn addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction.

Syringe sharing among people who inject drugs in Tijuana: before and after the Global Fund

Introduction. Needle and syringe programs (NSP) reduce syringe sharing and HIV transmission among people who inject drugs (PWID). However, their effectiveness relies on sufficient individual and population level coverage. In Tijuana, Mexico, the Global Fund (GF) supported NSP during 10/2011-12/2013, but withdrew funds at the end of 2013 following Mexico’s re-classification as an upper-middle income country. Objective. We tested the hypothesis of higher NSP access and lower receptive syringe sharing among PWID in Tijuana during the GF support period compared to pre-GF initiation and post-GF withdrawal. Method. We used data from an ongoing cohort study of PWID in Tijuana (03/2011-10/2015) to implement a segmented regression analysis investigating changes in the self-reported probability of NSP access, reported difficulty in finding sterile syringes and receptive syringe sharing before GF initiation and after GF discontinuation. Results. We found a large significant increase in the probability of NSP access (+.07) and decrease in receptive syringe sharing (-.23) right after GF initiation, which continued over the GF period. Subsequently, we found a significant decline in NSP access (-.05) and an increase in receptive syringe sharing (+.02) right after post-GF withdrawal, which continued thereafter. Discussion and conclusion. We demonstrated significant temporal changes in NSP access and receptive syringe sharing among PWID in Tijuana after GF initiation and withdrawal consistent with our hypothesis. Coordinated efforts with local authorities are needed to sustain major coverage NSP in settings receiving GF or external aid to guarantee continuity of harm reduction services and prevent reinside in risk behaviors associated with HIV transmission.

Prevalence and Correlates of Injecting with Visitors from the United States Among People Who Inject Drugs in Tijuana, Mexico.

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 6months 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 6months, backloading (aOR = 4.00), syringe confiscation by the police (aOR = 3.02) and paying for sex (aOR = 2.98; all p-values < 0.05). Nearly one-fifth of PWID in Tijuana recently injected with U.S. PWID, and their reported risk behaviors could facilitate cross-border disease transmission.

Violence, urban space and everyday life in the Mexican War on Drugs: Tijuana as a case Study

The following paper explores the spatiality of Mexico’s war on drugs by developing an analytical frame to examine urban space in Tijuana, a Mexican northern border city. Tijuana has been signified and construed as an unsafe and violent place within the context of the Mexican antinarcotics strategy. Its construction as a dangerous space coincides with its urban and demographic expansion, as well as its connection with the global circuits of drug distribution and the implementation of the war on drugs within the city. By representing it as an unsafe space, it has been authorized the exertion of unlimited violence upon its users and inhabitants by both state and private agents producing forms of extreme citizen vulnerability. As a consequence, both the political life of the city and its citizens´ rights have been reduced to their bare minimum. Building on the analysis of Tijuana´s symbolic, demographic and urban configuration, the consequences these processes have had upon the production of the city´s residents’ political identities are explored. By delving into the microphysics of the geographical imaginations on criminality and drugs in Tijuana, this paper contributes to the analysis on the ways in which the exertion of violence within the war on drugs is linked to the variegated forms urban space is interpreted by both citizens and authorities.

Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis

ObjectiveFrom 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF...

The effect of public health-oriented drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico: an epidemic modelling study

As countries embark on public health-oriented drug law reform, health impact evaluations are needed. In 2012, Mexico mandated the narcomenudeo reform, which depenalised the possession of small amounts of drugs and instituted drug treatment instead of incarceration. We investigated the past and future effect of this drug law reform on HIV incidence in people who inject drugs in Tijuana, Mexico. In this epidemic modelling study, we used data from the El Cuete IV cohort study to develop a deterministic model of injecting and sexual HIV transmission in people who inject drugs in Tijuana between 2012 and 2030. The population was stratified by sex, incarceration status, syringe confiscation by the police, HIV stage, and exposure to drug treatment or rehabilitation (either opioid agonist treatment or compulsory drug abstinence programmes). We modelled the effect of these exposures on HIV risk in people who inject drugs, estimating the effect of observed and potential future reform enforcement levels. In 2011, prior to the narcomenudeo reform, 547 (75%) of 733 people who inject drugs in the El Cuete cohort reported having ever been incarcerated, on average five times since starting injecting. Modelling estimated the limited reform implementation averted 2% (95% CI 0·2-3·0) of new HIV infections in people who inject drugs between 2012 and 2017. If implementation reduced incarceration in people who inject drugs by 80% from 2018 onward, 9% (95% CI 4-16) of new HIV infections between 2018 and 2030 could be averted, with 21% (10-33) averted if people who inject drugs were referred to opioid agonist treatment instead of being incarcerated. Referral to compulsory drug abstinence programmes instead of prison could have a lower or potentially negative impact with -2% (95% CI -23 to 9) infections averted. Mexican drug law reform has had a negligible effect on the HIV epidemic among people who inject drugs in Tijuana. However, appropriate implementation could markedly reduce HIV incidence if linked to opioid agonist treatment. Unfortunately, compulsory drug abstinence programmes are the main type of drug rehabilitation available and their expansion could potentially increase HIV transmission. National Institute on Drug Abuse, UC San Diego Center for AIDS Research.