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Greer A, Xavier J, Loewen OK, Kinniburgh B, Crabtree A. Awareness and knowledge of drug decriminalization among people who use drugs in British Columbia: a multi-method pre-implementation study. BMC Public Health 2024; 24:407. [PMID: 38331771 PMCID: PMC10851533 DOI: 10.1186/s12889-024-17845-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/22/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND In January 2023, British Columbia implemented a three-year exemption to Controlled Drugs and Substances Act, as granted by the federal government of Canada, to decriminalize the personal possession of small amounts of certain illegal drugs. This decriminalization policy, the first in Canada, was announced in response to the overdose emergency in British Columbia as a public health intervention that could help curb overdose deaths by reducing the impact of criminalization and increasing access to health and social services through stigma reduction. METHODS The current multi-method study examines people who use drugs' awareness and knowledge of British Columbia's decriminalization model through cross-sectional quantitative surveys and qualitative interviews among people who use drugs from September-November 2022, immediately prior to the implementation of decriminalization. RESULTS Quantitative findings show that two-thirds (63%) of people who use drugs were aware of the policy, but substantial knowledge gaps existed about the legal protections afforded (threshold amount, substances included, drug trafficking, confiscation). The qualitative findings suggest that people who use drugs misunderstood the details of the provincial decriminalization model and often conflated it with regulation. Results suggest that information sharing about decriminalization were minimal pre-implementation, highlighting areas for knowledge dissemination about people who use drugs' rights under this policy. CONCLUSIONS Given that decriminalization in British Columbia is a new and landmark reform, and that the success of decriminalization and its benefits may be undermined by poor awareness and knowledge of it, efforts to share information, increase understanding, and empower the community, may be required to promote its implementation and benefits for the community.
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Affiliation(s)
- Alissa Greer
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A1S6, Canada.
| | - Jessica Xavier
- School of Criminology, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A1S6, Canada
- British Columbia Center for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Olivia K Loewen
- Public Health Agency of Canada, Sinclair Centre Federal Building, 218-757 Hastings St. West, Vancouver, BC, V6C 1A1, Canada
| | - Brooke Kinniburgh
- British Columbia Center for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
| | - Alexis Crabtree
- British Columbia Center for Disease Control, 655 W 12th Ave, Vancouver, BC, V5Z 4R4, Canada
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Lechuga J, Ramos R, Dickson-Gomez J, Beachy S, Perez G, Nevola O, Varela A, Ramos ME, Sauceda J, Ludwig-Barrron N, Salazar J. Institutional violence from police militarization and drug cartel wars as a 'Big Event' and its influence on drug use harms and HIV risk in people who inject drugs on the U.S.-Mexico border. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104125. [PMID: 37499305 DOI: 10.1016/j.drugpo.2023.104125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Globally, the US-Mexico Border is one of the largest drug trafficking regions, with Ciudad Juarez (CJ) and El Paso (EP) making up the second-largest border crossing in the world. Border communities are places where the risk of drug use harm and infectious diseases such as HIV are augmented due to the confluence of factors operating across the physical, social, economic and policy environment. Although the two cities are economically, culturally, and socially intertwined, each has distinct criminal justice systems and policy practices aimed at curtailing substance use. Between 2008 and 2011, the CJ/EP region experienced an unprecedented level of violence that stemmed from the intersection of police militarization and drug cartel wars, which profoundly shaped every aspect of life. Little research has documented the impact of drug cartel wars on the drug use and health harms of people who inject drugs (PWID) living in CJ and EP. The purpose of the study is to understand the effect that the drug cartel war had on the drug use harms and HIV risk of PWID. METHODS We conducted 40 in-depth interviews with people who inject drugs who resided in CJ or EP and had used heroin or crack cocaine in the last 30 days, and asked how police militarization and drug cartel war affected their daily lives. The risk environment framework informed the analysis and interpretation of findings. RESULTS Findings indicated that the risk environment was profoundly altered as PWID residing in CJ experienced profound changes in their daily lives that promoted engagement in behaviors that increased drug use and health harms including HIV risk, exacerbated trauma, and prevented use of substance use treatment and harm reduction services. The risk environment was also altered in EP, where PWID experienced drug supply shortages, violent policing practices, and reduced availability of harm reduction services. Findings underscore the permeability of risk environments across geographical borders. CONCLUSION The intersection of law enforcement militarization and drug cartel wars can be conceptualized as a 'big event' because it disrupts the drug market economy, leads to drug shortages, promotes entrance into the drug market economy by people who use drugs, reshapes drug use sites, and constrains the provision of harm reduction services. The stability of the harm reduction system in CJ was negatively impacted and limited the ability of individuals to reduce harm. Our findings show that drug cartel wars render the CJ/EP region extremely susceptible to drug use and health harms, while also creating vulnerability by severely restricting its ability to respond. Traditional recommendations to intervene to limit the impact of risk environments on the drug use harms of PWID need to be reconsidered in the context of drug cartel wars.
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Affiliation(s)
- Julia Lechuga
- Department of Public Health Sciences, The University of Texas at El Paso, El Paso, TX, United States.
| | - Rebeca Ramos
- Department of Public Health Sciences, The University of Texas at El Paso, El Paso, TX, United States
| | | | - Sara Beachy
- Lehigh University, Bethlehem PA, United States
| | - Gilberto Perez
- Texas State Health Department, Houston, TX, United States
| | | | - Alan Varela
- Department of Public Health Sciences, The University of Texas at El Paso, El Paso, TX, United States
| | | | - John Sauceda
- The University of California San Francisco, San Francisco, CA, United States
| | | | - Jorge Salazar
- The University of California San Francisco, San Francisco, CA, United States
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Lechuga J, Ramos R, Ludwig-Barron N, Perez G, Ramos ME, Ferreira-Pinto JB, Cordero JI, Sauceda J, Salazar J. Social and environmental determinants influencing injection drug use and HIV risk among two sister cities on the US-Mexico border: a comparative cross-sectional study, 2016-2018. Harm Reduct J 2023; 20:84. [PMID: 37400843 PMCID: PMC10318714 DOI: 10.1186/s12954-023-00802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/06/2023] [Indexed: 07/05/2023] Open
Abstract
The economic, social, cultural and political milieus that influence injection drug-related HIV risk behaviors along the US-Mexico border in the previous decade have been studied comparing cities on an East-West axis. In an effort to inform interventions targeting factors beyond the individual level, we used a cross-sectional study design comparing people who inject drugs during 2016-2018, living on a North-South axis, in two cities-Ciudad Juárez, Chihuahua, Mexico and El Paso, Texas, USA-situated at the midpoint of the 2000 US-Mexico borderland stretch. We conceptualize injection drug use and its antecedents and consequences as influenced by factors operating at various levels of influence. Results of analysis comparing samples recruited from each border city indicated significant differences in demographic, socioeconomic, micro- and macro-level factors that affect risk. Similarities emerged in individual-level risk behaviors and some dynamics of risk at the drug use site most frequented to use drugs. In addition, analyses testing associations across samples indicated that different contextual factors such as characteristics of the drug use sites influenced syringe sharing. In this article, we reflect on the potential tailored interventions needed to target the context of HIV transmission risk among people who use drugs and reside in binational environment.
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Affiliation(s)
- Julia Lechuga
- College of Health Sciences, The University of Texas at El Paso, El Paso, USA.
| | - Rebeca Ramos
- College of Health Sciences, The University of Texas at El Paso, El Paso, USA
| | | | | | | | | | - Jacquelin I Cordero
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, USA
| | - John Sauceda
- Texas State Health Department in Houston, Houston, USA
| | - Jorge Salazar
- Texas State Health Department in Houston, Houston, USA
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Bardwell G, Mansoor M, Van Zwietering A, Cleveland E, Snell D, Kerr T. The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting. Harm Reduct J 2022; 19:136. [PMID: 36476225 PMCID: PMC9730691 DOI: 10.1186/s12954-022-00725-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD. METHODS Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team. RESULTS Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking. CONCLUSIONS Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.
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Affiliation(s)
- Geoff Bardwell
- grid.46078.3d0000 0000 8644 1405School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada ,grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9 Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Manal Mansoor
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9 Canada
| | - Ashley Van Zwietering
- qathet Community Action Team, 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada
| | - Ellery Cleveland
- qathet Community Action Team, 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada ,Lift Community Services of qathet Society, 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada
| | - Dan Snell
- qathet Community Action Team, 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada ,Lift Community Services of qathet Society, 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada ,Substance Users Society Teaching Advocacy Instead of Neglect (SUSTAIN), 218-6975 Alberni Street, Powell River, BC V8A 2B8 Canada
| | - Thomas Kerr
- grid.511486.f0000 0004 8021 645XBritish Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9 Canada ,grid.416553.00000 0000 8589 2327Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
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Urbanik MM, Maier K, Greene C. A qualitative comparison of how people who use drugs’ perceptions and experiences of policing affect supervised consumption services access in two cities. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103671. [DOI: 10.1016/j.drugpo.2022.103671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
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West BS, Henry BF, Agah N, Vera A, Beletsky L, Rangel MG, Staines H, Patterson TL, Strathdee SA. Typologies and Correlates of Police Violence Against Female Sex Workers Who Inject Drugs at the México-United States Border: Limits of De Jure Decriminalization in Advancing Health and Human Rights. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP8297-NP8324. [PMID: 33261533 PMCID: PMC8166925 DOI: 10.1177/0886260520975820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Decriminalization of sex work is increasingly promoted as a structural measure to improve the health of vulnerable groups. In México, sex work is not illegal, but knowledge of policies' street-level impact is limited. This study describes typologies of police violence against female sex workers who inject drugs (FSWID), identifying risk and protective factors for violence exposure to inform policy responses. Survey data were collected during 2008-2010 among HIV-negative FSWID in a behavioral intervention in Tijuana and Ciudad Juarez (N = 584). Latent class analysis identified typologies of police violence in the past 6 months: asked for money, money taken, syringes taken, asked for sex, and sexually assaulted. Structural equation modeling (SEM) predicted latent class membership using sociodemographic, behavioral and risk environment factors, controlling for age, education, marital status, and city. Recent police violence was reported by 68% of FSWID, with three typologies emerging: Low (36.6%); Material (47.8%): having money/syringes taken or being asked for money; and Material/Sexual (15.7%): material violence and being asked for sex or sexually assaulted. In multivariable SEM, Material Violence was associated with: being jailed [adjusted Odds Ratio (aOR) = 4.34], HIV testing (aOR = 2.18), and trading sex indoors (aOR = 1.66). Factors associated with Material/Sexual Violence included: being jailed (aOR = 41.18), injecting with clients (aOR = 3.12), earning more money for sex without a condom (aOR = 2.88), being raped by a client (aOR = 2.13), drinking with clients (aOR = 2.03), receiving substance use treatment (aOR = 1.95), being <18 when first trading sex (aOR = .43), trading sex outdoors (aOR = .53), and poor working conditions (aOR = .56). Despite de jure decriminalization of sex work, police violence against FSWID at the México-United States border is pervasive with implications for sex- and drug-related harms. Closing gaps in policy implementation and mitigating material/sexual violence from police is imperative to decreasing economic vulnerability, risk of overdose and HIV, and improving engagement in HIV and harm reduction services.
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Affiliation(s)
| | | | - Niloufar Agah
- University of California San Diego, La Jolla, CA, USA
| | - Alicia Vera
- University of California San Diego, La Jolla, CA, USA
| | - Leo Beletsky
- University of California San Diego, La Jolla, CA, USA
| | | | - Hugo Staines
- Universidad Autónoma de Ciudad Juárez, Chihuahua, México
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Greer A, Selfridge M, Watson TM, Macdonald S, Pauly B. Young People Who Use Drugs Views Toward the Power and Authority of Police Officers. CONTEMPORARY DRUG PROBLEMS 2022; 49:170-191. [PMID: 35465248 PMCID: PMC9021434 DOI: 10.1177/00914509211058989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/22/2021] [Indexed: 11/28/2022]
Abstract
Many young people who use drugs are structurally vulnerable to policing powers given the ongoing criminalization of drug possession. Police authority limits and the expression of that authority may play a significant role in police encounters among young people who use drugs. This qualitative study explores the views of young people who use drugs toward police power and authority in their recent encounters with police officers. Interviews were conducted with 38 young people who recently used illegal drugs in British Columbia, Canada. We found five interrelated themes related to perceptions of police authority: (1) skepticism and distrust toward authority; (2) paternalism and authority over drug use; (3) officer use of force; (4) police as power-hungry; and (5) officers above the law. Participants described police authority as limitless, unpredictable, untethered, easily abused, and lacking accountability. Participants feared holding police officers accountable to power abuses in a criminal justice system that they saw as stacked against them. Moving forward, institutional reforms may consider and account for the expression, limits, and use of police authority among young people who use drugs and other structurally vulnerable communities.
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Affiliation(s)
- Alissa Greer
- School of Criminology, Simon Fraser University, British Columbia, Canada.,Canadian Institute for Substance Use Research, University of Victoria, British Columbia, Canada
| | - Marion Selfridge
- Canadian Institute for Substance Use Research, University of Victoria, British Columbia, Canada
| | - Tara Marie Watson
- Provincial System Support Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Scott Macdonald
- Canadian Institute for Substance Use Research, University of Victoria, British Columbia, Canada.,Health and Information Sciences, University of Victoria, British Columbia, Canada
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, British Columbia, Canada.,School of Nursing, University of Victoria, British Columbia, Canada
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Shrestha S, Bauer CX, Hendricks B, Stopka TJ. Spatial epidemiology: An empirical framework for syndemics research. Soc Sci Med 2022; 295:113352. [PMID: 32950331 PMCID: PMC7962030 DOI: 10.1016/j.socscimed.2020.113352] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 02/03/2023]
Abstract
Syndemics framework describes two or more co-occurring epidemics that synergistically interact with each other and the complex structural social forces that sustain them leading to excess disease burden. The term syndemic was first used to describe the interaction between substance abuse, violence, and AIDS by Merrill Singer. A broader range of syndemic studies has since emerged describing the framework's applicability to other public health scenarios. With syndemic theory garnering significant attention, the focus is shifting towards developing robust empirical analytical approaches. Unfortunately, the complex nature of the disease-disease interactions nested within several social contexts complicates empirical analyses. In answering the call to analyze syndemics at the population level, we propose the use of spatial epidemiology as an empirical framework for syndemics research. Spatial epidemiology, which typically relies on geographic information systems (GIS) and statistics, is a discipline that studies spatial variations to understand the geographic landscape and the risk environment within which disease epidemics occur. GIS maps provide visualization aids to investigate the spatial distribution of disease outcomes, the associated social factors, and environmental exposures. Analytical inference, such as estimation of disease risks and identification of spatial disease clusters, can provide a detailed statistical view of spatial distributions of diseases. Spatial and spatiotemporal models can help us to understand, measure, and analyze disease syndemics as well as the social, biological, and structural factors associated with them in space and time. In this paper, we present a background on syndemics and spatial epidemiological theory and practice. We then present a case study focused on the HIV and HCV syndemic in West Virginia to provide an example of the use of GIS and spatial analytical methods. The concepts described in this paper can be considered to enhance understanding and analysis of other syndemics for which space-time data are available.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, USA
| | - Cici X.C. Bauer
- Department of Biostatistics and Data Science, University of Texas, Health Sciences Center at Houston, USA
| | - Brian Hendricks
- Department of Epidemiology, School of Public Health, West Virginia University, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, USA,Corresponding author. Department of Public Health and Community Medicine, Clinical and Translational Science Institute, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA. , (T.J. Stopka)
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Fraser H, Borquez A, Stone J, Abramovitz D, Brouwer KC, Goodman-Meza D, Hickman M, Patterson TL, Silverman J, Smith L, Strathdee SA, Martin NK, Vickerman P. Overlapping Key Populations and HIV Transmission in Tijuana, Mexico: A Modelling Analysis of Epidemic Drivers. AIDS Behav 2021; 25:3814-3827. [PMID: 34216285 PMCID: PMC8560668 DOI: 10.1007/s10461-021-03361-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2021] [Indexed: 12/18/2022]
Abstract
Tijuana, Mexico, has a concentrated HIV epidemic among overlapping key populations (KPs) including people who inject drugs (PWID), female sex workers (FSW), their male clients, and men who have sex with men (MSM). We developed a dynamic HIV transmission model among these KPs to determine the extent to which their unmet prevention and treatment needs is driving HIV transmission. Over 2020-2029 we estimated the proportion of new infections acquired in each KP, and the proportion due to their unprotected risk behaviours. We estimate that 43.7% and 55.3% of new infections are among MSM and PWID, respectively, with FSW and their clients making-up < 10% of new infections. Projections suggest 93.8% of new infections over 2020-2029 will be due to unprotected sex between MSM or unsafe injecting drug use. Prioritizing interventions addressing sexual and injecting risks among MSM and PWID are critical to controlling HIV in Tijuana.
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Affiliation(s)
- Hannah Fraser
- Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK.
| | - Annick Borquez
- School of Medicine, University of California San Diego, San Diego, USA
| | - Jack Stone
- Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | | | | | - David Goodman-Meza
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew Hickman
- Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
| | | | - Jay Silverman
- School of Medicine, University of California San Diego, San Diego, USA
| | - Laramie Smith
- School of Medicine, University of California San Diego, San Diego, USA
| | | | - Natasha K Martin
- Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK
- School of Medicine, University of California San Diego, San Diego, USA
| | - Peter Vickerman
- Oakfield House, Population Health Sciences - Bristol Medical School, University of Bristol, Bristol, BS8 2BN, UK.
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Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103297. [PMID: 34077825 PMCID: PMC9844096 DOI: 10.1016/j.drugpo.2021.103297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID). METHODS We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces. RESULTS In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin. CONCLUSION Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.
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Intersectional structural vulnerability to abusive policing among people who inject drugs: A mixed methods assessment in California's central valley. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102981. [PMID: 33129133 DOI: 10.1016/j.drugpo.2020.102981] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abusive and violent policing is an important determinant of health for people who inject drugs (PWID), which has been linked to structural vulnerability. However, further exploration of the intersectional nature of this vulnerability is warranted. California's Central Valley is a largely rural/suburban and politically conservative area, with high rates of injection drug use and overdose mortality, where rates of abusive policing of PWID have not been characterized. METHODS We assessed self-reported experiences of abusive policing using a sequential mixed-methods approach, consisting of n = 54 in-depth qualitative interviews followed by a respondent driven survey of n = 494 PWID. Qualitative conclusions were used to guide the development a novel quantitative framework to explore intersectional structural vulnerability, drawing on UpSet visualization and multivariable logistic regression. RESULTS Qualitative analysis suggests that abusive policing is not random or isolated; instead it can be understood in the context of routinized police harassment of PWID, which can escalate into physical or other forms of violence. These cycles are mediated by various forms of social disadvantage-often articulated through the frame of "looking like a drug user"-with deep connections to markers of race, class, gender, occupation and other elements of personal identity. Quantitative results confirm high frequency of abusive encounters with police, including physical violence (42%), verbal abuse (62%), sexual violence (9%), and the confiscation of new/unused syringes (39%). Females report higher rates of sexual violence and exploitation (aOR= 4.2; 95% CI: 2.1-9.0) and males report higher rates of physical violence (aOR=3.6; 95% CI: 2.4-5.6) and all other outcomes. Experiencing homelessness, having traded sex, and living in a rural zip code, are independently associated with numerous forms of police abuse. Intersectional analysis reveals clusters of individuals with highly elevated vulnerability, and in general, having a greater number of vulnerability factors was associated with increased odds of police abuse. CONCLUSIONS We find that structural vulnerability is linked-in a highly intersectional manner-with experiencing abusive police encounters among PWID in California's Central Valley. Monitoring, prevention, and response to deleterious law enforcement practices must be integrated into structural interventions to protect vulnerable groups. Reform is especially urgent in rural/suburban areas that are increasingly important focal points to reduce social and health harms associated with injection drug use.
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Pitpitan EV, Rocha-Jimenez T, Salazar M, Chavarin C, Magis-Rodriguez C. A Mixed Methods Analysis of the Venue-Related Social and Structural Context of Drug Use During Sex Among Male Clients of Female Sex Workers in Tijuana, Mexico. AIDS Behav 2020; 24:724-737. [PMID: 31093819 DOI: 10.1007/s10461-019-02519-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Drug use during sex increases risks for HIV acquisition. Male clients of female sex workers (FSW) represent both a key population at risk for HIV as well as a transmission bridge population. In Tijuana, Mexico, drug use is prevalent and there is a need to understand male clients' drug use during sex with FSW. Characteristics of sex work venues may confer higher risks for drug use, risky sex, and HIV/STI. It is essential to understand the venue-related social and structural factors associated with drug use during sex in order to inform HIV prevention interventions with male clients in this region. We used a Mixed-Methods Sequential Explanatory Design to conduct an enriched examination of drug use during sex among male clients of FSW in Tijuana. Findings from logistic regression analysis showed that drug use during sex was significantly correlated with police harassment (AOR = 4.06, p < .001) and methamphetamine use (AOR = 33.77, p < .001). In-depth interview data provided rich meaning behind and context around the quantitative associations. Social and structural interventions to reduce police harassment, methamphetamine use, and promote condom availability are needed to reduce risks for HIV among male clients of FSW in Tijuana.
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Bardwell G, Strike C, Mitra S, Scheim A, Barnaby L, Altenberg J, Kerr T. "That's a double-edged sword": Exploring the integration of supervised consumption services within community health centres in Toronto, Canada. Health Place 2019; 61:102245. [PMID: 31740126 DOI: 10.1016/j.healthplace.2019.102245] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/29/2019] [Accepted: 11/08/2019] [Indexed: 01/04/2023]
Abstract
Supervised consumption services (SCS) have been integrated into community health centres in Toronto. We draw on qualitative interviews and ethnographic observations to examine the implementation contexts of these SCS. Participants' perspectives on the integration of SCS within CHCs were mixed. Some participants identified the benefits of integrated SCS such as convenience and access to other health and social services. However, others identified negative consequences of integration, including building design, lack of privacy and anonymity, and limited hours of operation. These perspectives highlight the ways in which contextual factors affect the experiences of clients in accessing SCS, and suggest that various factors need to be considered in order to improve service uptake.
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Affiliation(s)
- Geoff Bardwell
- British Columbia Centre for Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Carol Strike
- Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Sanjana Mitra
- British Columbia Centre for Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Ayden Scheim
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 50 Bond Street, Toronto, ON, M5B 1W8, Canada; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Lorraine Barnaby
- Parkdale Queen West Community Health Centre, 168 Bathurst Street, Toronto, ON, M5V 2R4, Canada
| | - Jason Altenberg
- South Riverdale Community Health Centre, 955 Queen Street East, Toronto, ON, M4M 3P3, Canada
| | - Thomas Kerr
- British Columbia Centre for Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
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Nelson EUE, Brown AS. Extra-legal policing strategies and HIV risk environment: accounts of people who inject drugs in Nigeria. DRUGS: EDUCATION, PREVENTION AND POLICY 2019. [DOI: 10.1080/09687637.2019.1684446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Rocha-Jiménez T, Mittal ML, Artamonova I, Baker P, Cepeda J, Morales M, Abramovitz D, Clairgue E, Bañuelos A, Patterson T, Strathdee S, Beletsky L. The Role of Gender in the Health and Human Rights Practices of Police: The SHIELD Study in Tijuana, Mexico. Health Hum Rights 2019; 21:227-238. [PMID: 31239629 PMCID: PMC6586956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Globally, punitive drug law enforcement drives human rights violations. Drug control tactics, such as syringe confiscation and drug-related arrests, also cascade into health harms among people who use drugs. The role of police officer characteristics in shaping such enforcement and measures to reform police practices remains underexamined. We evaluated gender differences in syringe confiscation and syringe-related arrest behaviors among municipal police officers in Tijuana, Mexico, where syringe possession is legal. In the context of the SHIELD Study focusing on aligning policing with harm reduction measures, our baseline sample covered municipal police officers who reported having occupational contact with syringes. We used multivariable logistic regression with robust variance estimation via a generalized estimating equation to identify correlates of syringe-related policing behaviors. Among respondent officers (n=1,555), 12% were female. After considering possible confounding variables, such as district of service and work experience, female officers were significantly less likely to report confiscating syringes or arresting individuals for syringe possession. Consideration of officer gender is important in the design of interventions to improve the health and human rights of people who inject drugs and other highly policed groups, as well as measures to safeguard officer occupational safety. The feminization of law enforcement deserves special consideration as an imperative in reducing the public health harms of policing.
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Affiliation(s)
- Teresita Rocha-Jiménez
- Research associate at the University of California San Diego’s Division of Infectious Diseases and Global Public Health and a fellow at the Center for U.S.-Mexican Studies, University of California San Diego, USA
| | - Maria Luisa Mittal
- Project scientist at the Division of Infectious Diseases and Global Public Health, University of California San Diego, USA
| | | | - Pieter Baker
- PhD student and research associate at the University of California San Diego and San Diego State University, USA
| | - Javier Cepeda
- Assistant professor at the Division of Infectious Diseases and Global Public Health, University of California San Diego, USA
| | - Mario Morales
- Research assistant at the Division of Infectious Diseases and Global Public Health, University of California San Diego, USA
| | - Daniela Abramovitz
- Principal statistician at the Division of Infectious Diseases and Global Public Health, University of California San Diego, USA
| | - Erika Clairgue
- Research program manager at the University of California San Diego, USA
| | - Arnulfo Bañuelos
- Research liaison at the Secretaría de Seguridad Pública Municipal, department of special planning and projects, Tijuana, Mexico
| | - Thomas Patterson
- Distinguished professor of psychiatry at the University of California San Diego, USA
| | - Steffanie Strathdee
- Associate dean of global health sciences, Harold Simon Professor at the University of California San Diego Department of Medicine, and principal investigator at Project ESCUDO
| | - Leo Beletsky
- Professor at the School of Law and Bouvé College of�Health Sciences, Northeastern University, and an associate adjunct professor at the University of California San Diego, USA
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Davis CS. Bias Against People Who Inject Drugs Undermines Police Training on Needlestick Injury. Am J Public Health 2019; 109:839-840. [DOI: 10.2105/ajph.2019.305096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Corey S. Davis
- The author is with the Network for Public Health Law, Los Angeles, CA, and the Brody School of Medicine, East Carolina University, Greenville, NC
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Rafful C, Medina-Mora ME, González-Zúñiga P, Jenkins JH, Rangel MG, Strathdee SA, Davidson PJ. "Somebody Is Gonna Be Hurt": Involuntary Drug Treatment in Mexico. Med Anthropol 2019; 39:139-152. [PMID: 31099592 DOI: 10.1080/01459740.2019.1609470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Involuntary drug treatment (IDT) is ineffective in decreasing drug use, yet it is a common practice. In Mexico, there are not enough professional residential drug treatment programs, and both voluntary and involuntary drug treatment is often provided by non-evidence based, non-professional programs. We studied the experiences of people who inject drugs (PWID) in Tijuana who were taken involuntarily to drug centers under the auspices of a federally funded police operation. We provide insight into how the health, wellbeing, human rights, dignity, and security of PWID ought to be at the center of international drug policies included in universal health care systems.
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Affiliation(s)
- Claudia Rafful
- Faculty of Psychology, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | | | - Patricia González-Zúñiga
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, California, USA
| | - Janis H Jenkins
- Department of Anthropology, Department of Psychiatry, University of California, San Diego, California, USA
| | - M Gudelia Rangel
- US-Mexico Border Health Commission, El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, California, USA
| | - Peter J Davidson
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, California, USA
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Bardwell G, Strike C, Altenberg J, Barnaby L, Kerr T. Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis. Harm Reduct J 2019; 16:30. [PMID: 31046759 PMCID: PMC6498561 DOI: 10.1186/s12954-019-0302-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/17/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Supervised consumption services (SCS) are being implemented across Canada in response to a variety of drug-related harms. We explored the implementation context of newly established SCS in Toronto and the role of policing in shaping program access by people who inject drugs (PWID). METHODS We conducted one-to-one qualitative semi-structured interviews with 24 PWID. Participants were purposively recruited. Ethnographic observations were conducted at each of the study sites as well as in their respective neighbourhoods. Relevant policy documents were also reviewed. RESULTS Policing was overwhelmingly discussed by participants from both SCS sites. However, participant responses varied depending on the site in question. Subthemes from participant responses on policing at site #1 described neighbourhood police presence and fears of police harassment and drug arrests before, during, or after accessing SCS. Conversely, subthemes from participant responses on policing at site #2 described immunity and protection from police while using the SCS, as well as a lack of police presence or fears of police harassment and arrests. These differences in implementation contexts were largely shaped by differences in local neighbourhoods and drug scenes. Police policies highlighted federal laws protecting PWID within SCS, but also the exercise of discretion when applying the rule of law outside of these settings. CONCLUSIONS Participants' perspectives on, and experiences with, policing as they relate to accessing SCS were shaped by the implementation contexts of each SCS site and how neighbourhoods, drug scenes, and differences in policing practices affected service use. Our findings also demonstrate the disconnect between the goals of policing and those of SCS. Until larger structural barriers are addressed (e.g. criminalization), future SCS programming should consider the impact of policing on the SCS implementation context to improve client experience with, and access to, SCS.
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Affiliation(s)
- Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada. .,Department of Medicine, University of British Columbia, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Carol Strike
- Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3 M7, Canada
| | - Jason Altenberg
- South Riverdale Community Health Centre, 955 Queen Street East, Toronto, ON, M4M 3P3, Canada
| | - Lorraine Barnaby
- Parkdale Queen West Community Health Centre, 168 Bathurst Street, Toronto, ON, M5V 2R4, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
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Dombrowski JC, Dorabjee J, Strathdee SA. Editorial: Atrocity in the Philippines: How Rodrigo Duterte's War on Drug Users May Exacerbate the Burgeoning HIV Epidemic. J Acquir Immune Defic Syndr 2018; 76:23-25. [PMID: 28797018 DOI: 10.1097/qai.0000000000001464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Julia C Dombrowski
- Departments of *Medicine; and†Epidemiology, University of Washington, Seattle, WA;‡Asian Network of People who Use Drugs, Bangkok, Thailand; and§Global Health Institute, University of California San Diego, San Diego, CA
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Morales M, Rafful C, Gaines TL, Cepeda JA, Abramovitz D, Artamonova I, Baker P, Clairgue E, Mittal ML, Rocha-Jimenez T, Arredondo J, Kerr T, Bañuelos A, Strathdee SA, Beletsky L. Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2018; 18:36. [PMID: 30219105 PMCID: PMC6139125 DOI: 10.1186/s12914-018-0175-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/29/2018] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Mario Morales
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Claudia Rafful
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada
| | - Tommi L Gaines
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Javier A Cepeda
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Daniela Abramovitz
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Irina Artamonova
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Pieter Baker
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Erika Clairgue
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Maria Luisa Mittal
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA.,School of Medicine, Universidad Xochicalco, 4850 Calle Rampa Yumalinda, Chapultepec Alamar, 22110, Tijuana, Baja California, Mexico
| | - Teresita Rocha-Jimenez
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA.,School of Public Health, San Diego State University, 5500 Campanile Dr, San Diego, California, 92182, USA
| | - Jaime Arredondo
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA.,School of Public Health, San Diego State University, 5500 Campanile Dr, San Diego, California, 92182, USA
| | - Thomas Kerr
- Center of Excellence in HIV/AIDS, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Arnulfo Bañuelos
- Department of Planning and Special Projects, Secretaría de Seguridad Pública Municipal, 2141 Blvd Cuauhtémoc Sur y Río Suchiate, 22015, Tijuana, Mexico
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA
| | - Leo Beletsky
- Division of Infectious Diseases and Global Public Health, School of Medicine, University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego, California, 92093, USA. .,Health in Justice Action Lab, School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, 02115, USA.
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The Mexican consensus on the treatment of hepatitis C. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2017.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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Aiza-Haddad I, Ballesteros-Amozurrutia A, Borjas-Almaguer OD, Castillo-Barradas M, Castro-Narro G, Chávez-Tapia N, Chirino-Sprung RA, Cisneros-Garza L, Dehesa-Violante M, Flores-Calderón J, Flores-Gaxiola A, García-Juárez I, González-Huezo MS, González-Moreno EI, Higuera-de la Tijera F, Kershenobich-Stalnikowitz D, López-Méndez E, Malé-Velázquez R, Marín-López E, Mata-Marín JA, Méndez-Sánchez N, Monreal-Robles R, Moreno-Alcántar R, Muñoz-Espinosa L, Navarro-Alvarez S, Pavia-Ruz N, Pérez-Ríos AM, Poo-Ramírez JL, Rizo-Robles MT, Sánchez-Ávila JF, Sandoval-Salas R, Torre A, Torres-Ibarra R, Trejo-Estrada R, Velarde-Ruiz Velasco JA, Wolpert-Barraza E, Bosques-Padilla F. The Mexican consensus on the treatment of hepatitis C. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:275-324. [PMID: 29803325 DOI: 10.1016/j.rgmx.2017.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/17/2017] [Accepted: 11/02/2017] [Indexed: 12/12/2022]
Abstract
The aim of the Mexican Consensus on the Treatment of HepatitisC was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitisC treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.
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Affiliation(s)
| | | | - O D Borjas-Almaguer
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - G Castro-Narro
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | | | - L Cisneros-Garza
- Centro de Enfermedades Hepáticas del Hospital San José, Monterrey, Nuevo León, México
| | | | - J Flores-Calderón
- Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Ciudad de México, México
| | | | - I García-Juárez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - E I González-Moreno
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | | | - E López-Méndez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - R Malé-Velázquez
- Instituto de Salud Digestiva y Hepática, Guadalajara, Jalisco, México
| | | | - J A Mata-Marín
- Hospital de Infectología del Centro Médico Nacional «La Raza», Ciudad de México, México
| | | | - R Monreal-Robles
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - L Muñoz-Espinosa
- Hospital Universitario «Dr. José Eleuterio González», Monterrey, Nuevo León, México
| | | | - N Pavia-Ruz
- Hospital Infantil de México «Federico Gómez», Ciudad de México, México
| | - A M Pérez-Ríos
- Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, México
| | - J L Poo-Ramírez
- Clínica San Jerónimo de Salud Hepática y Digestiva, Ciudad de México, México
| | | | - J F Sánchez-Ávila
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | - A Torre
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
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Ospina-Escobar A, Magis-Rodríguez C, Juárez F, Werb D, Bautista Arredondo S, Carreón R, Ramos ME, Strathdee S. Comparing risk environments for HIV among people who inject drugs from three cities in Northern Mexico. Harm Reduct J 2018; 15:27. [PMID: 29776368 PMCID: PMC5960140 DOI: 10.1186/s12954-018-0225-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/22/2018] [Indexed: 12/03/2022] Open
Abstract
Background A large body of research has investigated the rise of injection drug use and HIV transmission in Tijuana and Ciudad Juarez (CJ). However, little is known about the dynamics of injecting in Hermosillo. This study compares drug-related behaviors and risk environment for HIV of people who inject drugs (PWID) across Tijuana, CJ, and Hermosillo to identify factors that could explain differences in HIV prevalence. Methods Data from Tijuana belong to a prospective study (El Cuete IV). Data from Hermosillo and Ciudad Juarez belong to a cross-sectional study. Both studies collected data in places where PWID spend time. All participants completed quantitative behavioral and serological testing for HIV. Datasets were merged using only comparable variables. Descriptive statistics tests were used to compare sociodemographic and behavioral characteristics of people who inject drugs PWID sampled in each city. A logistic regression model was built to identify factors independently associated with the likelihood of reporting receptive syringe sharing in the past 6 months. Results A total of 1494 PWID provided data between March 2011 and May 2012. HIV prevalence differed significantly between participants in Tijuana (4.2%), CJ (7.7%), and Hermosillo (5.2%; p < 0.05). PWID from Hermosillo reported better living conditions, less frequency of drug injection, and lower prevalence of syringe sharing (p < 0.01). PWID from CJ reported a higher prevalence of syringe sharing and confiscation by police (p < 0.01). In a multivariable logistic regression model, living in Hermosillo compared to Tijuana (adjusted odds ratio [AOR] = 0.42, 95% confidence interval [CI] 0.29–0.61) and being female (AOR = 0.61, 95% CI 0.45–0.83) were protective against syringe sharing. Having used crystal meth (AOR = 1.62, 95% CI 1.24–2.13, p = 0.001), having experienced syringe confiscation by police in the last 6 months (AOR = 1.78, 95% CI 1.34–2.40), and lower perception of syringe availability (AOR = 2.15, 95% CI 1.59–2.91) were significantly associated with syringe sharing (p < 0.05). Conclusions Differences in HIV prevalence across cities reflect mainly differences in risk environments experienced by PWID, shaped by police practices, access to injection equipment, and dynamics of drug markets. Findings highlight the importance of ensuring sterile syringe availability through harm reduction services and a human rights approach to drug harms in northern Mexico and to generate better understanding of local dynamics and contexts of drug use for designing proper harm reduction programs.
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Affiliation(s)
| | | | | | - Dan Werb
- Division of Global Public Health, University of California, San Diego, USA.
| | | | - Rubén Carreón
- Instituto Nacional de Salud Pública, Cuernavaca, Mexico
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Hughes CE, Barratt MJ, Ferris JA, Maier LJ, Winstock AR. Drug-related police encounters across the globe: How do they compare? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 56:197-207. [PMID: 29699837 DOI: 10.1016/j.drugpo.2018.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/01/2018] [Accepted: 03/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Drug law enforcement subsumes the majority of drug policy expenditure across the globe. Fuelled by knowledge that much of this investment is ineffective or counter-productive there have been increasing calls for cross-national comparisons to identify where policing approaches differ and what types of approaches may be more effective. Yet, to date cross-national comparison of drug law enforcement has proven a methodologically hazardous affair. Using a new drug policing module added to the 2017 Global Drug Survey, this study seeks to provide the first cross-national comparison of the incidence, nature and intensity of illicit drug-related police encounters amongst people who use drugs. METHODS The Global Drug Survey was administered in late 2016. Across 26 countries including Australia, Germany, Italy, Mexico, Switzerland, the UK and the USA a total of 45,942 people who had recently used drugs completed the drug policing module. Key variables assessed included the incidence and frequency of drug-related police encounters in the last 12 months that involved: a) being stopped and searched; b) encountering a drug detection dog; c) being given a caution or warning; d) being charged and arrested; and e) paying a bribe. Multi-level models were used to control for pre-existing national differences in drug use prevalence and non-drug specific policing (including the total number of police personnel in each country). RESULTS Drug-related police encounters were most commonly reported in Italy and Scotland. Conversely, police encounters were most likely to lead to arrest in Norway, Finland and Sweden. The type and locations of encounters further differed across countries, with for example stop and search most reported in Greece and Colombia, and encounters with drug detection dogs most reported in Scotland, Italy, UK and Australia. Multi-level models showed that the incidence of reported policing encounters continued to differ significantly across countries after controlling for pre-existing national differences in drug use prevalence and policing, and that drug policing encounters were 4 to 14 times more common in some nations than others. CONCLUSION The findings unearth significant cross-national differences in the incidence and nature of drug-related policing of people who use drugs. This suggests that there may be opportunities for countries to learn from each other about how and why they differ, and the potential benefits of switching to lower intensity modes of drug policing.
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Affiliation(s)
- Caitlin E Hughes
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, UNSW, Sydney, NSW, Australia.
| | - Monica J Barratt
- Drug Policy Modelling Program, National Drug and Alcohol Research Centre, UNSW, Sydney, NSW, Australia; National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, WA, Australia; Behaviours and Health Risks Program, Burnet Institute, Melbourne, VIC, Australia
| | - Jason A Ferris
- Institute for Social Science Research, The University of Queensland, St Lucia, QLD, Australia
| | | | - Adam R Winstock
- Institute of Epidemiology & Health Care, Faculty of Population Health Sciences, University College London, UK; Global Drug Survey Ltd, London, UK
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Experiences of police contact among young adult recreational drug users: A qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 56:64-72. [PMID: 29609152 DOI: 10.1016/j.drugpo.2018.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 02/19/2018] [Accepted: 03/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND While young adults who engage in recreational drug use are at increased risk of contact with police, their experiences of police contact have been largely overlooked. METHOD In-depth qualitative interviews were conducted with 70 young adult amphetamine-type stimulant (ATS; i.e., ecstasy [MDMA] and methamphetamine) users who had experienced intensive alcohol and other drug-related police contact (e.g., being arrested, charged, or raided by police). These interviews focused on perceptions of personal experiences of alcohol and other drug-related police contact and general perceptions of police and policing and were conducted as part of a larger longitudinal study of drug use among a population-based sample of young adults from South-East Queensland, Australia. RESULTS ATS users' perceptions of their personal interactions with police and general perceptions of police and policing were influenced by a number of factors, including police behaviour, prior contact with police, friends and family members' contact with police, and perceptions of their own behaviour leading to their contact with police. While a majority of ATS users reported that their contact with police had either a neutral or negative impact on their general perceptions of police and policing, some ATS users reported that police contact had a positive impact. For 70% of ATS users, police contact was reported to have had an impact on their substance use behaviours, resulting in either modification of their substance use behaviours to avoid further police contact or reduction in their substance use. CONCLUSIONS These findings suggest that police contact among young adult ATS users can impact on both perceptions of police and policing and substance use behaviours, emphasising the importance of the quality and nature of police contact and its potential role in harm reduction.
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Abstract
Although most people who inject drugs (PWID) report receiving assistance during injection initiation events, little research has focused on risk factors among PWID for providing injection initiation assistance. We therefore sought to determine the influence of non-injection drug use among PWID on their risk to initiate others. We used generalized estimating equation (GEE) models on longitudinal data among a prospective cohort of PWID in Tijuana, Mexico (Proyecto El Cuete IV), while controlling for potential confounders. At baseline, 534 participants provided data on injection initiation assistance. Overall, 14% reported ever initiating others, with 4% reporting this behavior recently (i.e., in the past 6 months). In a multivariable GEE model, recent non-injection drug use was independently associated with providing injection initiation assistance (adjusted odds ratio [AOR] = 2.42, 95% confidence interval [CI] = 1.39-4.20). Further, in subanalyses examining specific drug types, recent non-injection use of cocaine (AOR = 9.31, 95% CI = 3.98-21.78), heroin (AOR = 4.00, 95% CI = 1.88-8.54), and methamphetamine (AOR = 2.03, 95% CI = 1.16-3.55) were all significantly associated with reporting providing injection initiation assistance. Our findings may have important implications for the development of interventional approaches to reduce injection initiation and related harms. Further research is needed to validate findings and inform future approaches to preventing entry into drug injecting.
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DeBeck K, Cheng T, Montaner JS, Beyrer C, Elliott R, Sherman S, Wood E, Baral S. HIV and the criminalisation of drug use among people who inject drugs: a systematic review. Lancet HIV 2017; 4:e357-e374. [PMID: 28515014 PMCID: PMC6005363 DOI: 10.1016/s2352-3018(17)30073-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/22/2017] [Accepted: 03/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Mounting evidence suggests that laws and policies prohibiting illegal drug use could have a central role in shaping health outcomes among people who inject drugs (PWID). To date, no systematic review has characterised the influence of laws and legal frameworks prohibiting drug use on HIV prevention and treatment. METHODS Consistent with PRISMA guidelines, we did a systematic review of peer-reviewed scientific evidence describing the association between criminalisation of drug use and HIV prevention and treatment-related outcomes among PWID. We searched MEDLINE, Embase, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and other sources. To be included in our review, a study had to meet the following eligibility criteria: be published in a peer-reviewed journal or presented as a peer-reviewed abstract at a scientific conference; examine, through any study design, the association between an a-priori set of indicators related to the criminalisation of drugs and HIV prevention or treatment among PWID; provide sufficient details on the methods followed to allow critical assessment of quality; be published or presented between Jan 1, 2006, and Dec 31, 2014; and be published in the English language. FINDINGS We identified 106 eligible studies comprising 29 longitudinal, 49 cross-sectional, 22 qualitative, two mixed methods, four mathematical modelling studies, and no randomised controlled trials. 120 criminalisation indicators were identified (range 1-3 per study) and 150 HIV indicators were identified (1-5 per study). The most common criminalisation indicators were incarceration (n=38) and street-level policing (n=39), while the most frequent HIV prevention and treatment indicators were syringe sharing (n=35) and prevalence of HIV infection among PWID (n=28). Among the 106 studies included in this review, 85 (80%) suggested that drug criminalisation has a negative effect on HIV prevention and treatment, 10 (9%) suggested no association, five (5%) suggested a beneficial effect, one (1%) suggested both beneficial and negative effects, and five (5%) suggested both null and negative effects. INTERPRETATION These data confirm that criminalisation of drug use has a negative effect on HIV prevention and treatment. Our results provide an objective evidence base to support numerous international policy initiatives to reform legal and policy frameworks criminalising drug use. FUNDING Canadian Institutes of Health Research and US National Institutes of Health.
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Affiliation(s)
- Kora DeBeck
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Policy, Simon Fraser University, Vancouver, BC, Canada
| | - Tessa Cheng
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Julio S Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chris Beyrer
- Centre for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Susan Sherman
- Centre for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stefan Baral
- Centre for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA.
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Roth AM, Armenta RF, Wagner KD, Strathdee SA, Goldshear JL, Cuevas-Mota J, Garfein RS. Cold Preparation of Heroin in a Black Tar Market. Subst Use Misuse 2017; 52:1202-1206. [PMID: 28605301 PMCID: PMC6125133 DOI: 10.1080/10826084.2017.1302956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Black tar heroin is typically prepared for injection with heat which decreases the risk of HIV transmission by inactivating the virus. We received reports that persons who inject drugs (PWID) in Tijuana, Baja California, Mexico, a black tar heroin market, were using only water to dissolve heroin. OBJECTIVES Because Tijuana abuts San Diego County, CA, United States, we undertook the present analyses to determine the prevalence of this practice among PWID in San Diego, California. METHODS PWID completed quarterly behavioral assessments and serological testing for blood-borne viruses. Bivariate and multivariable logistic regression models were constructed to assess for individual, social, and structural correlates of preparing heroin without heat within the preceding 6 months. RESULTS Nearly half of black tar heroin users (149/305) reported they had prepared heroin without heat within 6 months. In multivariable analysis, cold preparation was independently associated with younger age (10 year decrease; AOR = 1.25; 95% CI 1.03, 1.53), more drug injecting acquaintances (per 5 acquaintance increase; AOR = 1.05; 95% CI 1.01, 1.09) and prefilled syringe use (injecting drugs from syringes that are already filled with drugs before purchase; AOR = 1.86; 95% CI 1.14, 3.02). Conclusions/Importance: To our knowledge, this is the first paper to report that PWID living in a black tar heroin market are preparing heroin without heat. Additional research is needed to determine whether this is an endemic practice or PWID are engaging in new forms of drug preparation in response to changes in the environment.
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Affiliation(s)
- Alexis M Roth
- a Department of Community Health & Prevention , Drexel University , Philadelphia , Pennsylvania , USA
| | - Richard F Armenta
- b Family Medicine and Public Health , University of California San Diego , San Diego , California , USA
| | - Karla D Wagner
- c School of Community Health Sciences , University of Nevada, Reno, Reno , Nevada , USA
| | - Steffanie A Strathdee
- d Division of Global Public Health , University of California San Diego , San Diego , California , USA
| | - Jesse L Goldshear
- a Department of Community Health & Prevention , Drexel University , Philadelphia , Pennsylvania , USA
| | - Jazmine Cuevas-Mota
- d Division of Global Public Health , University of California San Diego , San Diego , California , USA
| | - Richard S Garfein
- d Division of Global Public Health , University of California San Diego , San Diego , California , USA
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Flath N, Tobin K, King K, Lee A, Latkin C. Enduring Consequences From the War on Drugs: How Policing Practices Impact HIV Risk Among People Who Inject Drugs in Baltimore City. Subst Use Misuse 2017; 52:1003-1010. [PMID: 28318343 PMCID: PMC5600621 DOI: 10.1080/10826084.2016.1268630] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Neighborhood-level characteristics, including police activity, are associated with HIV and Hepatitis C injection risk-behaviors among people who inject drugs (PWID). However, the pathways through which these neighborhood perceptions shape individual-level HIV risk behaviors are unclear. This study helps to explain perceived behaviors between perceived neighborhood police activity and HIV injection risk behavior (i.e., injection syringe/tool sharing in the previous 6 months). METHODS A sample of (n = 366) PWIDs who self-reported recent use were recruited using community-based outreach methods in Baltimore, Maryland. Neighborhood police perceptions were assessed by asking participants whether they would (1) be more likely to ask others to share injection tools in the context of heightened police activity and (2) be less likely to carry syringes with them due to fear of arrest. Poisson regression with robust variance was used to identify statistical relationships. Recent police encounters, frequency of heroin injection, and sociodemographic characteristics were controlled for in the model. RESULTS Neighborhood police perceptions shaped injection-risk behavior. Half of the sample (49%) reported an aversion of carrying personal syringes, due to fear of arrest. Those who agreed they would be more likely to ask others to share injection equipment in the context of heightened police activity were more likely to share syringes (21% vs. 3%, p <.01). Adjusted models showed that syringe sharing was independently associated with asking to borrow equipment in neighborhoods with perceived heightened police activity (aPR: 2.22, 95% confidence interval (CI): 1.7, 3.0). CONCLUSION This study sheds light on how police perceptions may influence injection risk behavior. While these relationships require further elucidation, this study suggests that public health interventions aiming to reduce HIV risk would benefit from improving community-police relationships.
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Affiliation(s)
- Natalie Flath
- a Department of Health , Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Karin Tobin
- a Department of Health , Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Kelly King
- a Department of Health , Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Alexandra Lee
- a Department of Health , Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Carl Latkin
- a Department of Health , Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
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Health-damaging policing practices among persons who inject drugs in Mexico: Are deported migrants at greater risk? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:41-46. [PMID: 28601020 DOI: 10.1016/j.drugpo.2017.05.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/12/2017] [Accepted: 05/05/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Evidence-based public health and criminal justice policies aimed at addressing the structurally vulnerable population of persons who inject drugs (PWID) and who are involved in the immigrant enforcement and deportation system are lacking. Policing practices are critical structural determinants of HIV among PWID. PWID in Mexico who have been deported from the US are at elevated risk of HIV. METHODS From 2011 to 2013, 733 PWID were recruited to complete structured questionnaires, including past 6-month experiences with police. Eligible PWID were 18 years or older, had injected in the past month, and resided in Tijuana, Mexico with no intentions of moving. To determine if deportation status was associated with experiences of arrests and problematic policing practices, we conducted separate multivariate logistic regression models for independent policing variables. RESULTS In multivariate analyses, deportation status was independently associated with higher odds of being arrested (Adjusted Odds Ratio (AOR): 1.45; 95% Confidence Interval (CI): 1.02-2.05), being asked for a bribe (AOR: 1.39; 95% CI: 1.05-2.04), and being forced to leave a place of residence (AOR: 2.00; 95% CI: 1.08-3.70) in the past 6 months. CONCLUSION Results highlight a previously poorly understood elements of the US-deportation experience: migrants' experiences with law enforcement post-deportation and the role of deportation policies and practices as structural drivers of public health risk in destination countries. We provide policy recommendations for Mexico and the US based on our findings, which have potential application in other countries seeking to improve enforcement and related policing practices from a public health perspective.
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Wood EF, Werb D, Beletsky L, Rangel G, Cuevas Mota J, Garfein RS, Strathdee SA, Wagner KD. Differential experiences of Mexican policing by people who inject drugs residing in Tijuana and San Diego. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 41:132-139. [PMID: 28111221 DOI: 10.1016/j.drugpo.2016.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/29/2016] [Accepted: 12/16/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Research among people who inject drugs (PWIDs) in the USA and Mexico has identified a range of adverse health impacts associated with policing of PWIDs. We employed a mixed methods design to investigate how PWIDs from San Diego and Mexico experienced policing in Tijuana, and how these interactions affect PWIDs behavior, stratifying by country of origin. METHODS In 2012-2014, 575 PWIDs in San Diego, 102 of whom had used drugs in Mexico in the past six months, were enrolled in the STAHR-II study, with qualitative interviews conducted with a subsample of 20 who had recently injected drugs in Mexico. During this period, 735 PWIDs in Tijuana were also enrolled in the El Cuete-IV study, with qualitative interviews conducted with a subsample of 20 recently stopped by police. We calculated descriptive statistics for quantitative variables and conducted thematic analysis of qualitative transcripts. Integration of these data involved comparing frequencies across cohorts and using qualitative themes to explain and explore findings. RESULTS Sixty-one percent of San Diego-based participants had been recently stopped by law enforcement officers (LEOs) in Mexico; 53% reported it was somewhat or very likely that they would be arrested while in Mexico because they look like a drug user. Ninety percent of Tijuana-based participants had been recently stopped by LEOs; 84% reported it was somewhat or very likely they could get arrested because they look like a drug user. Participants in both cohorts described bribery and targeting by LEOs in Mexico. However, most San Diego-based participants described compliance with bribery as a safeguard against arrest and detention, with mistreatment being rare. Tijuana-based participants described being routinely targeted by LEOs, were frequently detained, and reported instances of sexual and physical violence. Tijuana-based participants described modifying how, where, and with whom they injected drugs in response; and experienced feelings of stress, anxiety, and powerlessness. This was less common among San Diego-based participants, who mostly attempted to avoid contact with LEOs in Mexico while engaging in risky injection behavior. CONCLUSION Experiences of discrimination and stigma were reported by a larger proportion of PWIDs living in Mexico, suggesting that they may be subject to greater health harms related to policing practices compared with those residing in the USA. Our findings reinforce the importance of efforts to curb abuse and align policing practices with public health goals in both the US and Mexico.
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Affiliation(s)
- Emily F Wood
- Interdisciplinary Social Psychology Ph.D. Program, University of Nevada, Reno, United States
| | - Dan Werb
- Division of Global Public Health, University of California, San Diego, United States
| | - Leo Beletsky
- Northeastern University School of Law & Bouve College of Health Sciences, Division of Global Public Health, University of California, San Diego, United States
| | - Gudelia Rangel
- Comisión de Salud Fronteriza México-EEUU, Sección México, Tijuana, Mexico; Department of Migrant Health, Secretaría de Salud, México DF, Mexico
| | - Jazmine Cuevas Mota
- Division of Global Public Health, University of California, San Diego, United States
| | - Richard S Garfein
- Division of Global Public Health, University of California, San Diego, United States
| | - Steffanie A Strathdee
- Division of Global Public Health, University of California, San Diego, United States
| | - Karla D Wagner
- School of Community Health Sciences, University of Nevada, Reno, United States.
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Prevalence and correlates of needle-stick injuries among active duty police officers in Tijuana, Mexico. J Int AIDS Soc 2016; 19:20874. [PMID: 27435711 PMCID: PMC4951532 DOI: 10.7448/ias.19.4.20874] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 04/25/2016] [Accepted: 05/02/2016] [Indexed: 01/23/2023] Open
Abstract
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.
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Police, Law Enforcement and HIV. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.4.21260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Michalopoulos LM, Jiwatram-Negrón T, Choo MKK, Kamarulzaman A, El-Bassel N. The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: A cross-sectional study. BMC Public Health 2016; 16:464. [PMID: 27250497 PMCID: PMC4890521 DOI: 10.1186/s12889-016-3125-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 05/13/2016] [Indexed: 11/24/2022] Open
Abstract
Background Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen. Methods The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container). Results Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02). Conclusions Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3125-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lynn Murphy Michalopoulos
- Social Intervention Group, Global Health and Mental Health Unit of the Social Intervention Group, Global Health Research Center of Central Asia, Columbia University, School of Social Work, New York, NY, USA.
| | - Tina Jiwatram-Negrón
- Social Intervention Group, Global Health Research Center of Central Asia, Columbia University, School of Social Work, New York, NY, USA
| | - Martin K K Choo
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nabila El-Bassel
- Social Intervention Group, Global Health Research Center of Central Asia, Columbia University, School of Social Work, New York, NY, USA
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Pinedo M, Burgos JL, Zuniga ML, Perez R, Macera CA, Ojeda VD. Police Victimization Among Persons Who Inject Drugs Along the U.S.-Mexico Border. J Stud Alcohol Drugs 2016; 76:758-63. [PMID: 26402356 DOI: 10.15288/jsad.2015.76.758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Problematic policing practices are an important driver of HIV infection among persons who inject drugs (PWID) in the U.S.-Mexico border region. This study identifies factors associated with recent (i.e., past 6 months) police victimization (e.g., extortion, physical and sexual violence) in the border city of Tijuana, Mexico. METHOD From 2011 to 2013, 733 PWID (62% male) were recruited in Tijuana and completed a structured questionnaire. Eligible participants were age 18 years or older, injected illicit drugs within the past month, and spoke Spanish or English. Multivariable logistic regression analyses identified correlates of recent experiences of police victimization (e.g., bribes, unlawful confiscation, physical and sexual violence). RESULTS Overall, 56% of PWID reported a recent police victimization experience in Tijuana. In multivariable logistic regression analyses, factors independently associated with recent police victimization included recent injection of methamphetamine (adjusted odds ratio [AOR] = 1.62; 95% CI [1.18, 2.21]) and recently received injection assistance by a "hit doctor" (AOR = 1.56; 95% CI [1.03, 2.36]). Increased years lived in Tijuana (AOR = 0.98 per year; 95% CI [0.97, 0.99]) and initiating drug use at a later age (AOR = 0.96 per year; 95% CI [0.92, 0.99]) were inversely associated with recent police victimization. CONCLUSIONS Physical drugusing markers may increase PWID susceptibility to police targeting and contribute to experiences of victimization. Interventions aimed at reducing police victimization events in the U.S.-Mexico border region should consider PWID's drug-using behaviors. Reducing problematic policing practices may be a crucial public health strategy to reduce HIV risk among PWID in this region.
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Affiliation(s)
- Miguel Pinedo
- Alcohol Research Group, University of California, Berkeley, California
| | - Jose Luis Burgos
- Division of Global Public Health, Department of Medicine, University of California, San Diego, California
| | - Maria Luisa Zuniga
- School of Social Work, San Diego State University, San Diego, California
| | - Ramona Perez
- Department of Anthropology, San Diego State University, San Diego, California
| | - Caroline A Macera
- School of Public Health, San Diego State University, San Diego, California
| | - Victoria D Ojeda
- Division of Global Public Health, Department of Medicine, University of California, San Diego, California
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Loza O, Ramos R, Ferreira-Pinto J, Hernandez MT, Villalobos SA. A qualitative exploration of perceived gender differences in methamphetamine use among women who use methamphetamine on the Mexico–U.S. border. J Ethn Subst Abuse 2015; 15:405-424. [DOI: 10.1080/15332640.2015.1070392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Oralia Loza
- College of Health Sciences, University of Texas at El Paso, El Paso, TX
| | - Rebeca Ramos
- Alliance of Border Collaboratives (ABC), El Paso, TX
| | | | | | - Susana A. Villalobos
- Department of Emergency Medicine, Texas Tech Health Sciences of El Paso, Paul Foster School of Medicine, El Paso, TX
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Lunze K, Lunze FI, Raj A, Samet JH. Stigma and Human Rights Abuses against People Who Inject Drugs in Russia--A Qualitative Investigation to Inform Policy and Public Health Strategies. PLoS One 2015; 10:e0136030. [PMID: 26305697 PMCID: PMC4549320 DOI: 10.1371/journal.pone.0136030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 07/29/2015] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Drug policing practices in the Russian Federation (Russia) are often punitive and have been shown to be associated with HIV risk behaviors among people who inject drugs (PWID). Less is known about strategies to address the problem in that setting, where substance use stigma is highly persistent. A better understanding of forms, causes and consequences of drug policing in Russia could inform drug policy in a context of substantial policy resistance. This qualitative study's goal is to characterize the phenomenon of police involvement with Russian PWID and to explore strategies for drug policing in the Russian country context. METHODS Using a semi-structured interview guide, we collected data from a purposive sample of 23 key informants including PWID, police officers, and experts from civil society and international organizations in Russia. We used a thematic analysis approach to inductively generate new insight into the phenomenon of police involvement and potential strategies to address it. RESULTS Policing practices involving PWID include unjustified arrests, planting of false evidence and extrajudicial syringe confiscations, and often constitute human rights violations. Russian PWID personally experienced police violence as ubiquitous, taking on various forms such as beating, unjustified arrests, verbal harassment, and coercion. The persistent societal stigma dehumanizes PWID, and such stigmatization facilitates police abuse. To address stigma and overcome the PWID-police adversity, study participants suggested fostering a mutual understanding between the police and public health sectors. CONCLUSIONS Participants describe substantial human rights violations as part of policing illicit drug use in Russia. Police should include principles of effective prevention of substance use and HIV risk reduction in their trainings. Alignment of public safety and public health goals could address drug use-related risks and HIV prevention among key populations in Russia.
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Affiliation(s)
- Karsten Lunze
- Boston University School of Medicine, Boston, MA, United States of America
- * E-mail:
| | - Fatima I. Lunze
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Anita Raj
- Division of Global Public Health, Department of Medicine, University of California at San Diego School of Medicine, San Diego, CA, United States of America
| | - Jeffrey H. Samet
- Boston University School of Medicine, Boston, MA, United States of America
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Strathdee SA, Arredondo J, Rocha T, Abramovitz D, Rolon ML, Patiño Mandujano E, Rangel MG, Olivarria HO, Gaines T, Patterson TL, Beletsky L. A police education programme to integrate occupational safety and HIV prevention: protocol for a modified stepped-wedge study design with parallel prospective cohorts to assess behavioural outcomes. BMJ Open 2015; 5:e008958. [PMID: 26260350 PMCID: PMC4538275 DOI: 10.1136/bmjopen-2015-008958] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/25/2015] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Policing practices are key drivers of HIV among people who inject drugs (PWID). This paper describes the protocol for the first study to prospectively examine the impact of a police education programme (PEP) to align law enforcement and HIV prevention. PEPs incorporating HIV prevention (including harm reduction programmes like syringe exchange) have been successfully piloted in several countries but were limited to brief pre-post assessments; the impact of PEPs on policing behaviours and occupational safety is unknown. OBJECTIVES Proyecto ESCUDO (SHIELD) aims to evaluate the efficacy of the PEP on uptake of occupational safety procedures, as assessed through the incidence of needle stick injuries (NSIs) (primary outcome) and changes in knowledge of transmission, prevention and treatment of HIV and viral hepatitis; attitudes towards PWID, adverse behaviours that interfere with HIV prevention and protective behaviours (secondary outcomes). METHODS/ANALYSIS ESCUDO is a hybrid type I design that simultaneously tests an intervention and an implementation strategy. Using a modified stepped-wedge design involving all active duty street-level police officers in Tijuana (N = ∼ 1200), we will administer one 3 h PEP course to groups of 20-50 officers until the entire force is trained. NSI incidence and geocoded arrest data will be assessed from department-wide de-identified data. Of the consenting police officers, a subcohort (N=500) will be randomly sampled from each class to undergo pre-PEP and post-PEP surveys with a semiannual follow-up for 2 years to assess self-reported NSIs, attitudes and behaviour changes. The impact on PWIDs will be externally validated through a parallel cohort of Tijuana PWIDs. ETHICS/DISSEMINATION Research ethics approval was obtained from the USA and Mexico. Findings will be disseminated through open access to protocol materials through the Law Enforcement and HIV Network. TRIAL REGISTRATION NUMBER NCT02444403.
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Affiliation(s)
- Steffanie A Strathdee
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jaime Arredondo
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Teresita Rocha
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Daniela Abramovitz
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Maria Luisa Rolon
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Xochicalco University, Tijuana, Baja California, Mexico
| | | | - Maria Gudelia Rangel
- U.S.-Mexico Border Health Commission, Mexico Section, Tijuana, Baja California, Mexico
| | | | - Tommi Gaines
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Thomas L Patterson
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Leo Beletsky
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
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Gaines TL, Beletsky L, Arredondo J, Werb D, Rangel G, Vera A, Brouwer K. Examining the spatial distribution of law enforcement encounters among people who inject drugs after implementation of Mexico's drug policy reform. J Urban Health 2015; 92:338-51. [PMID: 25300503 PMCID: PMC4411320 DOI: 10.1007/s11524-014-9907-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 2009, Mexico decriminalized the possession of small amounts of illicit drugs for personal use in order to refocus law enforcement resources on drug dealers and traffickers. This study examines the spatial distribution of law enforcement encounters reported by people who inject drugs (PWID) in Tijuana, Mexico to identify concentrated areas of policing activity after implementation of the new drug policy. Mapping the physical location of law enforcement encounters provided by PWID (n = 461) recruited through targeted sampling, we identified hotspots of extra-judicial encounters (e.g., physical/sexual abuse, syringe confiscation, and money extortion by law enforcement) and routine authorized encounters (e.g., being arrested or stopped but not arrested) using point density maps and the Getis-Ord Gi* statistic calculated at the neighborhood-level. Approximately half of the participants encountered law enforcement more than once in a calendar year and nearly one third of these encounters did not result in arrest but involved harassment or abuse by law enforcement. Statistically significant hotspots of law enforcement encounters were identified in a limited number of neighborhoods located in areas with known drug markets. At the local-level, law enforcement activities continue to target drug users despite a national drug policy that emphasizes drug treatment diversion rather than punitive enforcement. There is a need for law enforcement training and improved monitoring of policing tactics to better align policing with public health goals.
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Affiliation(s)
- Tommi L Gaines
- Division of Global Public Health, School of Medicine, University of California at San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA,
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Werb D, Wagner KD, Beletsky L, Gonzalez-Zuniga P, Rangel G, Strathdee SA. Police bribery and access to methadone maintenance therapy within the context of drug policy reform in Tijuana, Mexico. Drug Alcohol Depend 2015; 148:221-5. [PMID: 25655577 PMCID: PMC4330115 DOI: 10.1016/j.drugalcdep.2015.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 12/29/2022]
Abstract
AIMS In 2009, Mexico passed legislation to decriminalize drug possession and improve access to addiction treatment. We undertook research to assess the implementation of the reform among a cohort of people who inject drugs (PWID) in Tijuana. This study specifically sought to determine whether discretionary policing practices like extortion impact access to methadone maintenance therapy (MMT) in Tijuana, a city characterized by high levels of drug-related harms. METHODS Generalized estimating equation analyses were used to construct longitudinal confounding models to determine the association between paying a police bribe and MMT enrolment among PWID in Tijuana enrolled in a prospective cohort study. Outcome of interest was MMT enrolment in the past six months. Data on police interactions and MMT enrolment were also obtained. RESULTS Between October, 2011 and September, 2013, 637 participants provided 1825 observations, with 143 (7.8%) reports of MMT enrolment during the study period. In a final confounding model, recently reporting being forced to pay a bribe to police was significantly associated with an increased likelihood of accessing MMT (adjusted odds ratio=1.69, 95% confidence interval: 1.02-2.81, p=0.043). However, in 56 (39.2%) cases, MMT enrolment ceased within six months. The majority of participant responses cited the fact that MMT was too expensive (69.1%). DISCUSSION Levels of MMT access were low. PWID who experienced police extortion were more likely to access MMT at baseline, though this association decreased during the study period. Coupled with the costs of MMT, this may compromise MMT retention among PWID.
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Affiliation(s)
- D Werb
- Division of Global Public Health, Department of Medicine, University of California, San Diego, United States; BC Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - K D Wagner
- Division of Global Public Health, Department of Medicine, University of California, San Diego, United States
| | - L Beletsky
- Division of Global Public Health, Department of Medicine, University of California, San Diego, United States; Northeastern University School of Law, Bouvé College of Health Sciences, Boston, United States
| | - Patricia Gonzalez-Zuniga
- Division of Global Public Health, Department of Medicine, University of California, San Diego, United States
| | | | - S A Strathdee
- Division of Global Public Health, Department of Medicine, University of California, San Diego, United States.
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The role of visual markers in police victimization among structurally vulnerable persons in Tijuana, Mexico. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 26:501-8. [PMID: 25281235 DOI: 10.1016/j.drugpo.2014.08.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/04/2014] [Accepted: 08/10/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Law enforcement can shape HIV risk behaviours and undermine strategies aimed at curbing HIV infection. Little is known about factors that increase vulnerability to police victimization in Mexico. This study identifies correlates of police or army victimization (i.e., harassment or assault) in the past 6 months among patients seeking care at a free clinic in Tijuana, Mexico. METHODS From January to May 2013, 601 patients attending a binational student-run free clinic completed an interviewer-administered questionnaire. Eligible participants were: (1) ≥18 years old; (2) seeking care at the clinic; and (3) spoke Spanish or English. Multivariate logistic regression analyses identified factors associated with police/army victimization in the past 6 months. RESULTS More than one-third (38%) of participants reported victimization by police/army officials in the past 6 months in Tijuana. In multivariate logistic regression analyses, males (adjusted odds ratio (AOR): 3.68; 95% CI: 2.19-6.19), tattooed persons (AOR: 1.56; 95% CI: 1.04-2.33) and those who injected drugs in the past 6 months (AOR: 2.11; 95% CI: 1.29-3.43) were significantly more likely to report past 6-month police/army victimization. Recent feelings of rejection (AOR: 3.80; 95% CI: 2.47-5.85) and being denied employment (AOR: 2.23; 95% CI: 1.50-3.32) were also independently associated with police/army victimization. CONCLUSION Structural interventions aimed at reducing stigma against vulnerable populations and increasing social incorporation may aid in reducing victimization events by police/army in Tijuana. Police education and training to reduce abusive policing practices may be warranted.
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Yen YF, Yen MY, Lin T, Li LH, Jiang XR, Chou P, Deng CY. Prevalence and factors associated with HIV infection among injection drug users at methadone clinics in Taipei, Taiwan. BMC Public Health 2014; 14:682. [PMID: 24996558 PMCID: PMC4098925 DOI: 10.1186/1471-2458-14-682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 06/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methadone treatment was introduced in Taiwan in 2006 as a harm-reduction program for injection drug users (IDUs), among whom HIV was endemic. We examined the association of HIV serostatus with demographic characteristics, substance use, and sexual behaviors among IDUs at methadone clinics in Taipei, Taiwan. METHODS During 2012-2013, IDUs at methadone clinics in Taipei were recruited to complete a risk assessment interview and undergo serologic testing for HIV infection. Correlates of HIV infection were identified by multivariate logistic regression. RESULTS Of the 827 eligible participants, 85.9% were male, median age was 45 years, and mean years of injecting was 18.0 (range 1-56). The prevalence of HIV infection was 17.7%. In multivariate analysis, HIV infection was significantly associated with age ≤ 45 years (adjusted odds ratio [AOR] = 1.62, 95% confidence interval [CI] 1.01-2.62), being divorced (AOR = 1.67, 95% CI 1.06-2.62), deriving the majority of income during the previous 6 months from temporary jobs or other noncriminal sources (AOR = 1.53, 95% CI 1.02-2.30), unstable housing during the previous 6 months (AOR = 1.47, 95% CI 1.003-2.15), higher number of incarcerations (AOR = 1.14, 95% CI 1.03-1.26), and a history of overdose (AOR = 1.51, 95% CI 1.01-2.28). CONCLUSIONS Taiwanese IDUs at methadone clinics have a relatively high HIV prevalence, which was associated with younger age and history of overdose. It is imperative to educate IDUs' about HIV transmission, particularly for the younger and overdosed IDUs.
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Affiliation(s)
- Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital, Taipei City Government, 145, Zhengzhou Rd., Datong Dist., Taipei 10341, Taiwan
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, 155, Section 2, Ni-Long Street, Taipei 11221, Taiwan
| | - Muh-Yong Yen
- Department of Disease Control and Prevention, Taipei City Hospital, Taipei City Government, 145, Zhengzhou Rd., Datong Dist., Taipei 10341, Taiwan
| | - Ting Lin
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, 155, Section 2, Ni-Long Street, Taipei 11221, Taiwan
| | - Lan-Huei Li
- Department of Disease Control and Prevention, Taipei City Hospital, Taipei City Government, 145, Zhengzhou Rd., Datong Dist., Taipei 10341, Taiwan
| | - Xiao-Ru Jiang
- Department of Disease Control and Prevention, Taipei City Hospital, Taipei City Government, 145, Zhengzhou Rd., Datong Dist., Taipei 10341, Taiwan
| | - Pesus Chou
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, 155, Section 2, Ni-Long Street, Taipei 11221, Taiwan
| | - Chung-Yeh Deng
- Institute of Hospital and Health Care Administration, National Yang-Ming University, 155, Section 2, Ni-Long Street, Taipei 11221, Taiwan
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Robertson AM, Garfein RS, Wagner KD, Mehta SR, Magis-Rodriguez C, Cuevas-Mota J, Moreno-Zuniga PG, Strathdee SA. Evaluating the impact of Mexico's drug policy reforms on people who inject drugs in Tijuana, B.C., Mexico, and San Diego, CA, United States: a binational mixed methods research agenda. Harm Reduct J 2014; 11:4. [PMID: 24520885 PMCID: PMC3944401 DOI: 10.1186/1477-7517-11-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 01/10/2014] [Indexed: 11/23/2022] Open
Abstract
Background Policymakers and researchers seek answers to how liberalized drug policies affect people who inject drugs (PWID). In response to concerns about the failing “war on drugs,” Mexico recently implemented drug policy reforms that partially decriminalized possession of small amounts of drugs for personal use while promoting drug treatment. Recognizing important epidemiologic, policy, and socioeconomic differences between the United States—where possession of any psychoactive drugs without a prescription remains illegal—and Mexico—where possession of small quantities for personal use was partially decriminalized, we sought to assess changes over time in knowledge, attitudes, behaviors, and infectious disease profiles among PWID in the adjacent border cities of San Diego, CA, USA, and Tijuana, Baja California, Mexico. Methods Based on extensive binational experience and collaboration, from 2012–2014 we initiated two parallel, prospective, mixed methods studies: Proyecto El Cuete IV in Tijuana (n = 785) and the STAHR II Study in San Diego (n = 575). Methods for sampling, recruitment, and data collection were designed to be compatible in both studies. All participants completed quantitative behavioral and geographic assessments and serological testing (HIV in both studies; hepatitis C virus and tuberculosis in STAHR II) at baseline and four semi-annual follow-up visits. Between follow-up assessment visits, subsets of participants completed qualitative interviews to explore contextual factors relating to study aims and other emergent phenomena. Planned analyses include descriptive and inferential statistics for quantitative data, content analysis and other mixed-methods approaches for qualitative data, and phylogenetic analysis of HIV-positive samples to understand cross-border transmission dynamics. Results Investigators and research staff shared preliminary findings across studies to provide feedback on instruments and insights regarding local phenomena. As a result, recruitment and data collection procedures have been implemented successfully, demonstrating the importance of binational collaboration in evaluating the impact of structural-level drug policy reforms on the behaviors, health, and wellbeing of PWID across an international border. Conclusions Our prospective, mixed methods approach allows each study to be responsive to emerging phenomena within local contexts while regular collaboration promotes sharing insights across studies. The strengths and limitations of this approach may serve as a guide for other evaluations of harm reduction policies internationally.
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Affiliation(s)
| | | | | | | | | | | | | | - Steffanie A Strathdee
- Division of Global Public Health, School of Medicine, University of California at San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0507, USA.
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Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, Kerr T. Groin injecting among a community-recruited sample of people who inject drugs in Thailand. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2014; 9:4. [PMID: 24433435 PMCID: PMC3904698 DOI: 10.1186/1747-597x-9-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 01/15/2014] [Indexed: 11/23/2022]
Abstract
Background Use of the femoral vein for the injection of illicit drugs (i.e. groin injecting) has been linked to various health-related harms, including deep vein thrombosis. However, little is known about the prevalence of groin injecting and factors that predict this practice among people who inject drugs (PWID) in Thailand. We sought to investigate the prevalence and factors associated with groin injecting in Bangkok, Thailand. Methods Data were derived from the Mitsampan Community Research Project in Bangkok between July and October 2011. Multivariate logistic regression was used to identify factors associated with groin injecting in the last six months. Results Among 437 participants, 34.3% reported groin injecting in the last six months. In multivariate analyses, factors positively associated with groin injecting included: having higher than secondary education (adjusted odds ratio [AOR] = 1.59; 95% confidence interval [CI]: 1.00 – 2.56), weekly midazolam injection (AOR = 8.26; 95% CI: 5.04 – 14.06), and reports of having had drugs planted on oneself by police (AOR = 2.14; 95% CI: 1.37 – 3.36). Conclusions Over one-third of our sample of Thai PWID reported recent groin injecting. Frequent midazolam injection and higher education were found to be associated with groin injecting. That high intensity PWID were more likely to inject in the groin is concerning given the known negative consequences associated with the groin as a site of injection. Additionally, PWID who reported drug planting by police were more likely to inject in the groin, suggesting that reliance on law enforcement approaches may undermine safe injection practices in this setting. These findings highlight the need for evidence-based interventions to address the harms associated with groin injecting, including efforts to alert PWID to risks of groin injecting, the distribution of appropriate injecting equipment, and efforts to encourage use of other injecting sites.
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Affiliation(s)
| | | | | | | | | | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St, Paul's Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Kori N, Roth AM, Lozada R, Vera A, Brouwer KC. Correlates of injecting in an HIV incidence hotspot among substance users in Tijuana, Mexico. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 25:525-32. [PMID: 24418632 DOI: 10.1016/j.drugpo.2013.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 10/08/2013] [Accepted: 12/06/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Substance use and HIV are growing problems in the Mexico-U.S. border city of Tijuana, a sex tourism destination situated on a northbound drug trafficking route. In a previous longitudinal study of injection drug users (IDUs), we found that >90% of incident HIV cases occurred within an 'HIV incidence hotspot,' consisting of 2.5-blocks. This study examines behavioral, social, and environmental correlates associated with injecting in this HIV hotspot. METHODS From 4/06 to 6/07, IDUs aged ≥18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and interviewer-administered surveys eliciting information on demographics, drug use, sexual behaviors, and socio-environmental influences. Participants were defined as injecting in the hotspot if they most frequently injected within a 3 standard deviational ellipse of the cohort's incident HIV cases. Logistic regression was used to identify individual and structural factors associated with the HIV 'hotspot'. RESULTS Of 1031 IDUs, the median age was 36 years; 85% were male; HIV prevalence was 4%. As bivariate analysis indicated different correlates for males and females, models were stratified by sex. Factors independently associated with injecting in the HIV hotspot for male IDUs included homelessness (AOR 1.72; 95%CI 1.14-2.6), greater intra-urban mobility (AOR 3.26; 95%CI 1.67-6.38), deportation (AOR 1.58; 95%CI 1.18-2.12), active syphilis (AOR 3.03; 95%CI 1.63-5.62), needle sharing (AOR 0.57; 95%CI 0.42-0.78), various police interactions, perceived HIV infection risk (AOR 1.52; 95%CI 1.13-2.03), and health insurance status (AOR 0.53; 95%CI 0.33-0.87). For female IDUs, significant factors included sex work (AOR 8.2; 95%CI 2.2-30.59), lifetime syphilis exposure (AOR 2.73; 95%CI 1.08-6.93), injecting inside (AOR 5.26; 95%CI 1.54-17.92), arrests for sterile syringe possession (AOR 4.87; 95%I 1.56-15.15), prior HIV testing (AOR 2.45; 95%CI 1.04-5.81), and health insurance status (AOR 0.12; 95%CI 0.03-0.59). CONCLUSION While drug and sex risks were common among IDUs overall, policing practices, STIs, mobility, and lack of healthcare access were correlated with injecting in this HIV transmission hotspot. Although participants in the hotspot were more aware of HIV risks and less likely to report needle sharing, interventions addressing STIs and structural vulnerabilities may be needed to effectively address HIV risk.
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Affiliation(s)
- Nana Kori
- Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, USA; Graduate School of Public Health, San Diego State University, Hardy Tower 119, 5500 Campanile Drive, San Diego, CA 92182-4162, USA
| | - Alexis M Roth
- Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, USA
| | - Remedios Lozada
- Pro-COMUSIDA, Niños héroes 697, Oficina 1 y 6, Zona Norte, Tijuana 22000, Baja California, Mexico
| | - Alicia Vera
- Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, USA
| | - Kimberly C Brouwer
- Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA 92093-0507, USA.
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Abstract
In an accompanying Perspective, Scott Burris and Stephen Koester discuss the association between punitive policies and health inequalities and argue for more research focusing on policing and health. Please see later in the article for the Editors' Summary
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Experiences with policing among people who inject drugs in Bangkok, Thailand: a qualitative study. PLoS Med 2013; 10:e1001570; discussion e1001570. [PMID: 24339753 PMCID: PMC3858231 DOI: 10.1371/journal.pmed.1001570] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/30/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite Thailand's commitment to treating people who use drugs as "patients" not "criminals," Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012. METHODS AND FINDINGS Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample. CONCLUSIONS This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
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Meng J, Burris S. The role of the Chinese police in methadone maintenance therapy: A literature review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 24:e25-34. [DOI: 10.1016/j.drugpo.2013.03.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 03/01/2013] [Accepted: 03/18/2013] [Indexed: 11/29/2022]
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The association between law enforcement encounters and syringe sharing among IDUs on skid row: a mixed methods analysis. AIDS Behav 2013; 17:2637-43. [PMID: 23620243 DOI: 10.1007/s10461-013-0488-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The legal environment is one factor that influences injection drug users' (IDUs) risk for HIV and other bloodborne pathogens such as hepatitis C virus (HCV). We examined the association between law enforcement encounters (i.e., arrests and citations) and receptive syringe sharing among IDUs in the context of an intensified policing effort. We conducted a mixed methods analysis of 30 qualitative and 187 quantitative interviews with IDUs accessing services at a Los Angeles, CA syringe exchange program from 2008 to 2009. Qualitative findings illustrate concerns related to visibility, drug withdrawal, and previous history of arrest/incarceration. In quantitative analysis, the number of citations received, current homelessness, and perceiving that being arrested would be a "big problem" were independently associated with recent syringe sharing. Findings illustrate some of the unintended public health consequences associated with intensified street-level policing, including risk for HIV and HCV transmission.
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Odinokova V, Rusakova M, Urada LA, Silverman JG, Raj A. Police sexual coercion and its association with risky sex work and substance use behaviors among female sex workers in St. Petersburg and Orenburg, Russia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2013; 25:96-104. [PMID: 23916802 PMCID: PMC4211608 DOI: 10.1016/j.drugpo.2013.06.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 05/31/2013] [Accepted: 06/24/2013] [Indexed: 11/29/2022]
Abstract
Background Extensive research documents that female sex workers (FSWs) in Russia are very vulnerable to abuses from police, including police sexual coercion. However, despite qualitative data suggesting abusive policing practices are more likely for FSWs contending with substance abuse issues and risky sex work contexts, there is a paucity of quantitative study evaluating these associations specifically in terms of police sexual coercion. Such research is needed to guide structural interventions to improve health and safety for FSWs in Russia and globally. Objective The purpose of this study is to assess the prevalence of police sexual coercion among FSWs from two Russian cities, St. Petersburg and Orenburg, and to determine whether riskier sex work behaviors and contexts and substance use behaviors, including both IDU and risky alcohol use, are associated with increased risk for sexual coercion from police Method FSWs in St. Petersburg and Orenburg were recruited via time-location and convenience sampling and completed structured surveys on demographics (age, education), sex work risks (e.g., violence during sex work) and substance use. Logistic regression analyses assessed associations of substance use and risky sex work with police sexual coercion, adjusting for demographics. Results Participants (N=896) were aged 15 and older (94% were 20+ years). Most (69%) reported past year binge alcohol use, and 48% reported IDU the day before. Half (56%) reported 4+ clients per day. Rape during sex work ever was reported by 64%. Police sexual coercion in the past 12 months was reported by 38%. In the multivariate model, both current IDU (AOR=2.09, CI=1.45–3.02) and past year binge alcohol use (AOR=1.46, CI=1.03–2.07) were associated with police sexual coercion, as was selling sex on the street (not in venues) (AOR=7.81, CI=4.53–13.48) and rape during sex work (AOR=2.04, CI=1.43–2.92). Conclusion Current findings document the substantial role police sexual violence plays in the lives of FSWs in Russia. These findings also highlight heightened vulnerability to such violence among self-managed and substance abusing FSWs in this context. Structural interventions addressing police violence against FSWs may be useful to improve the health and safety of this population.
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Affiliation(s)
| | - Maia Rusakova
- NGO Stellit, 197101 St. Petersburg, Russian Federation; Deviance and Social Control, The Sociological Institute of the Russian Academy of Sciences, 198005 St. Petersburg, Russian Federation
| | - Lianne A Urada
- Division of Global Public Health, School of Medicine, University of California at San Diego, 92093-0507 La Jolla, CA, USA
| | - Jay G Silverman
- Division of Global Public Health, School of Medicine, University of California at San Diego, 92093-0507 La Jolla, CA, USA; Center on Global Justice, University of California at San Diego, 92093-0507 La Jolla, CA, USA
| | - Anita Raj
- Division of Global Public Health, School of Medicine, University of California at San Diego, 92093-0507 La Jolla, CA, USA; Boston University, School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education, 02118 Boston, MA, USA; Center on Global Justice, University of California at San Diego, 92093-0507 La Jolla, CA, USA
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