Social and structural factors associated with HIV infection among female sex workers who inject drugs in the Mexico-US border region

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review

BACKGROUND

Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups.

AIM

To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations.

METHODS

A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively.

RESULTS

A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations.

CONCLUSION

Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.

Substance use, economic vulnerability, and HIV/STI risk among female sex workers in Mexico

BACKGROUND

Economic hardship (e.g., difficulty to pay for basic needs) has been associated with increased HIV/STI risk among female sex workers (FSW), and may be exacerbated by high levels of substance use. Few studies have assessed the intersection of economic hardship, substance use, and HIV/STI risk among FSW.

METHODS

Quantitative data were collected via questionnaires among 469 FSW residing in Tijuana and Ciudad Juarez, Mexico. Using logistic regression, we assessed the role of economic hardship on the association between substance use (past 30-days alcohol use, drug use, or injection drugs use with clients, and past 6-months drug use) and testing positive for an STI (also an indicator of HIV risk).

RESULTS

Drug use in the preceding six months was significantly associated with testing positive for an STI (AOR = 1.8, CI: 1.1 = 2.9, p = .02); no difference in this association was found by whether women reported economic hardship. Past 30-day drug use with clients was associated with STI infection, but only among those who did not report economic hardship (AOR = 1.5, 95% CI: 1.1-1.9, p < .01).

CONCLUSIONS

Findings suggest that economic hardship influences the association between substance use and increased risk for HIV/STI among FSW; however, these associations may be more complex than previously hypothesized.

The unwritten rules and HIV: a qualitative study of informal institutions and HIV vulnerability among workers at social venues in Uganda

Introduction

There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. The unwritten rules, also known as informal institutions or social norms, are increasingly recognized as important determinants of HIV transmission. Unfortunately, these informal institutions, especially among high-risk environments for HIV, such as social venues like bars, lodges, remain poorly understood. This study explored the informal institutions at social venues, and how these institutions influenced vulnerability for HIV for venue workers in Uganda.

Methods

We conducted a qualitative study in two districts of Kyotera and Rakai in Central Uganda. We purposively selected and interviewed 44 workers including, cleaners, waiters, and waitresses and 22 venue managers at 22 social venues to explore the informal institutions at these establishments and how the institutions shaped HIV vulnerabilities among the workers. 31.8% (14) of the participants were males, and 68.2% (30) females. Data were analyzed using thematic content analysis.

Results

We found that the informal institutions at the venues were both officially and socially created, communicated, and sanctioned. The most common institutions operated through; selective hiring, rigid reporting structures, and informal job contracting procedures. Meager salaries, varying and delayed payments as well as attractive benefits and bonuses from customers were also important forms of informal institutions at the venues. Drinking alcohol, and offering sexual services at the venues were acceptable, although excessive drinking, and committed sexual relationships with customers were disapproved. These informal institutions shaped a risk environment at the venues by creating risk exposure opportunities that influenced workers' engagement into sexual risk behaviors.

Conclusion

The risk environment at social venues is shaped by the informal institutions at these venues. Thus, the need for venue-based HIV programs that integrate social norms interventions to better address the contextual determinants of HIV risk behaviors at the venues.

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

Burden of Disease of Gonorrhoea in Latin America: Systematic Review and Meta-analysis

INTRODUCTION

Neisseria gonorrhoeae causes gonorrhoea, a globally neglected but increasing disease. This systematic review and meta-analysis reviewed the epidemiology and economic burden of gonorrhoea in Latin America and the Caribbean (LAC).

METHODS

We searched PubMed, EMBase, Cochrane Library, EconLIT, CINAHL, CRD, LILACS, Global Health, Global Dissertations and Theses, SciELO, Web of Science databases, countries' ministries of health, and the IHME's Global Burden of Disease databases. Studies published in the last 10 years (20 years for economic studies) were included if conducted in any LAC country, without language restrictions. The main outcome measures were incidence/prevalence, proportion of co-infections, case fatality rates, specific mortality/hospitalisation rates, direct/indirect costs, and impact of gonorrhoea on quality of life. To assess evidence quality, we used a checklist developed by the US National Heart, Lung, and Blood Institute for observational studies and trial control arms, the Cochrane Effective Practice Organization of Care Group tool for randomised controlled trials, and the CICERO checklist for economic studies.

RESULTS

We identified 1290 articles; 115 included epidemiological studies and one included an economic study. Ministry of health data from Argentina, Brazil, Chile, Colombia, Mexico, and Uruguay were identified. Gonorrhoea prevalence was 1.46% (95% confidence interval [CI] 1.00-2.00%) from 48 studies and 5.68% (95% CI 4.23-7.32%) from 58 studies for non-high-risk and high-risk populations, respectively. Cumulative incidence for the high-risk population was 2.05 cases per 100 persons/year. Few published studies were rated as "good" in the risk of bias assessments. Variations in the methodology of the sources and limited information found in the countries' surveillance systems hinder the comparison of data.

CONCLUSION

The burden of gonorrhoea in LAC is not negligible. Our results provide public health and clinical decision support to assess potential interventions to prevent gonorrhoea.

TRIAL REGISTRATION

The protocol is registered on PROSPERO (CRD42021253342). The study was funded by GlaxoSmithKline Biologicals SA (GSK study identifier VEO-000025).

Exploring the dynamics of the quality of HIV care experienced by female sex workers living in the Dominican Republic

Despite increased attention and efforts to improve HIV care among female sex workers (FSWs), they continue to have suboptimal HIV outcomes. Exploring the socio-structural dynamics related to the quality of HIV care received by FSWs is critical to further strengthen interventions to improve their HIV care continuum outcomes. In this study, we conducted two rounds of qualitative in-depth interviews with 20 FSWs living with HIV in the Dominican Republic to explore how healthcare experiences contributed to their quality of HIV care. Data was analyzed using a thematic analytic approach exploring diverse structural and relational aspects of the quality of HIV care affecting FSWs as they navigate the clinic environment. Results indicated that quality of HIV care was influenced by both structural and relational factors within clinics. At the structural level, insufficient stock of antiretroviral therapy and the financial burden created by HIV care related costs hindered FSWs' satisfaction with their current HIV care and presented a barrier in FSWs' ability to access HIV care services. Quality of care was also closely linked to relational aspects of the HIV care environment, including FSWs' relationship and communication with their clinical providers, as FSWs often expressed their satisfaction with HIV care experiences based on these interpersonal factors. Lastly, personal agency emerged as an important factor contributing to the quality of HIV care, specifically as FSWs' treatment literacy resulted in greater advocacy and demands for quality care. Programmatic efforts should be directed to improving the quality of HIV care experiences of FSWs in the clinic environment. These include addressing resource shortages, promoting positive and effective patient-provider relationships, and facilitating HIV treatment education opportunities for FSWs.

Syndemic Profiles for HIV, Hepatitis C, and Sextually Transmitted Infections Among Mexican American Women Formerly Affiliated with Youth Street Gangs

We examine syndemic profiles of intimate partner violence, mental health, drug use, incarceration, and infectious diseases (HIV, HCV, and STIs) among a sample of adult Mexican American women who were affiliated with youth street gangs during adolescence through their relationships to boys and men. Latent class analysis included multiple factors along the following dimensions: intimate partner violence, drug use, mental illness, and incarceration. Five unique syndemic profiles were found with varying associations to HIV, HCV, and STI: (1) no syndemic, (2) intimate partner violence, no syndemic, (3) drug use, mental health, and incarceration syndemic, (4) intimate partner violence, drug use (without injection drug use), and mental health syndemic, and (5) intimate partner violence, drug use with injection drug use, mental health, and incarceration syndemic. To successfully prevent HIV, HCV, and STI among gang-involved girls and women, it is necessary to address syndemic factors.

Economic vulnerability, violence, and sexual risk factors for HIV among female sex workers in Tijuana, Mexico

Economic vulnerability is often reported to underlie involvement in sex work among female sex workers (FSW), but may also create urgency in women's work, limiting women's negotiating power with clients and in turn, increasing their vulnerability for violence and HIV. This study assessed economic vulnerability in relation to violence and sexual risk behaviors for HIV among a sample of FSW in Tijuana, Mexico. FSW at least 18 years of age were recruited through venue-based sampling for a survey (n = 228) and in-depth interviews (n = 50) to investigate HIV risk factors in this region. Using crude and adjusted logistic regression models, we assessed lack of financial support from others as well as reports of financial hardship separately in relation to experiencing sexual violence (e.g. by clients, police, relationship partners, in the past 6 months), physical violence (past 6 months), STI diagnosis, and inconsistent condom use (past 30 days). Qualitative interviews (n = 50), conducted with a subsample of the survey participants, were also examined for related themes. FSW who reported no financial support were more likely to report sexual violence (OR = 2.1; 95% CI:1.1-4.2). FSW who reported financial hardship were more likely to experience sexual violence (OR = 1.9; 95% CI:1.1-3.6) and physical violence (OR = 1.9; 95% CI:1.1-3.6), as well as to report past 30-day inconsistent condom use (OR = 2.4; 95%CI: 1.3-4.6) and to test positive for an STI (OR = 1.9; 95% CI:1.1-3.4). Qualitative data substantiated these findings. Findings suggest that interventions to improve economic well-being may be useful to prevent the intersecting concerns of violence and HIV among FSW.

Factors Associated with the Involvement of Women Drug Users in Risky Sexual Behaviors: A Narrative Review

BACKGROUND

Drug use is known as an important underlying factor in the occurrence of risky sexual behaviors. The present study was conducted to identify the factors associated with the involvement of women drug users in risky sexual behaviors.

MATERIALS AND METHODS

This review was conducted by searching databases of ISI Web of Science, Scopus, Science Direct, Cochrane, PubMed, Scientific Information Database (SID), the Iranian Magazine Database (Magiran), the Iranian Research Institute for Information Science and Technology (IranDoc), and the Iranian Medical Articles Database (IranMedex) and searching through the Google Scholar engine. All the articles published in English and Persian using the keywords including substance use, drug users, addiction, substance use disorders, substance-related disorders, sexual risks, high-risk sexual behavior, HIV risk behavior, unsafe sex, unprotected sex, and risky sex were searched from January 2000 to December 2020. After reviewing the articles, out of 110 articles, 21 articles were selected for final evaluation.

RESULTS

Factors related to the involvement of women drug users in risky sexual behaviors were divided into five categories: individual factors, factors related to drug use, inter-personal relationships, gender discrimination, and socio-economic factors.

CONCLUSIONS

The results can be used in the field of women's social harms in finding strategies and designing the necessary interventions to prevent risky sexual behaviors in women drug users in different societies and cultural contexts. Also, the results can be used by all researchers who want to study the relationship between these factors and the involvement of women drug users in risky sexual behaviors.

Social and structural determinants of health associated with police violence victimization: A latent class analysis of female sex workers who use drugs in Kazakhstan

INTRODUCTION

Punitive legal environments remain a challenge to HIV prevention efforts in Central Asia, and female sex workers who use drugs are vulnerable to police violence. Little is known about the heterogeneity of police violence against female sex workers who use drugs and factors associated with HIV risk in Central Asia, despite the growing HIV epidemic.

METHODS

We recruited a community-based sample of 255 female sex workers who use drugs in Almaty, Kazakhstan between February 2015 and May 2017. We used latent class analysis to differentiate women into distinct classes of police violence victimization, and multinomial logistic regression to identify individual-level health outcomes, HIV risk behaviors, and social and structural factors within the risk environment associated with class membership.

RESULTS

A three-class model emerged: Low Victimization (51%), Discrimination and Extortion (15%), and Poly-Victimization (34%). Relative to Low Victimization, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR: 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (2.73 (1.15, 6.50)), injection drug use (IDU) (2.00 (1.12, 3.58)), greater number of unsafe IDU behaviors (1.21 (1.08, 1.35)), homelessness (1.92 (1.06, 3.48)), greater drug use (1.22 (1.07, 1.39)) and sex work stigma (1.23 (1.06, 1.43)), greater number of sex work clients (2.40 (1.33, 4.31)), working for a boss/pimp (2.74 (1.16, 6.50)), client violence (2.99 (1.65, 5.42)), economic incentives for condomless sex (2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (3.47 (1.42, 8.50)), recent arrest (2.99 (1.36, 6.55)) and detention (2.93 (1.62, 5.30)), and negative police perceptions (8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics.

CONCLUSION

Police violence against female sex workers who use drugs is pervasive in Kazakhstan. Patterns of police violence vary, with greater HIV susceptibility associated with a higher probability of experiencing multiple forms of police violence. Police sensitization workshops that integrate policing and harm reduction, and drug policy reforms that decriminalize drug use may help mitigate the HIV epidemic in Kazakhstan.

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

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.

Recent sex work and associations with psychosocial outcomes among women living with HIV: findings from a longitudinal Canadian cohort study

INTRODUCTION

Sex workers are disproportionately impacted by the HIV pandemic across global contexts, in part due to social and structural contexts of stigma and criminalization. Among women living with HIV, there is a dearth of longitudinal information regarding dynamics of sex work engagement and associated social and health outcomes. In order to better understand the social contexts and health needs of sex working women living with HIV, this study aimed to understand recent sex work prevalence and its longitudinal associations with stigma, psychosocial and clinical HIV outcomes among women living with HIV in Canada.

METHODS

We conducted a three-wave prospective cohort survey at 18-month intervals with women living with HIV aged 16 and older in three Canadian provinces between 2013 and 2018. We used generalized estimating equations to examine longitudinal associations between recent (past 6-month) sex work with three types of outcomes: psychosocial (recent violence, recent injection drug use, hazardous alcohol use, clinical depression and post-traumatic stress disorder), clinical HIV (CD4 count and viral load) and stigma (HIV-related stigma, racial discrimination and gender discrimination). Equations were adjusted for socio-demographic factors associated with sex work across all three waves: province, age, income, gender identity, sexual orientation, education level, ethnicity and housing security.

RESULTS AND DISCUSSION

Of 1422 participants, 129 (9.1%) reported recent sex work during at least one wave (82 at baseline, 73 at first follow-up and 32 at second follow-up). In adjusted analyses, recent sex work was associated with psychosocial outcomes, including: past 3-month violence (adjusted odds ratio [AOR] = 2.47, 95% CI = 1.70, 3.60), past 6-month injection drug use (AOR = 3.49, 95% CI = 2.21-5.52), hazardous alcohol use (AOR = 2.00, 95% CI = 1.04-3.89) and depression (AOR = 1.51, 95% CI = 1.06-2.15). In unadjusted analyses, sex work was also associated with clinical HIV outcomes and gender discrimination, but not racial discrimination/HIV-related stigma.

CONCLUSIONS

Among women living with HIV in Canada, sex work engagement is dynamic, and sex workers are more likely to report recent violence, recent injection drug use, problematic alcohol use and clinical depression. Violence prevention and support, harm reduction, mental health promotion and sex work-affirming programs could be employed to optimize health and rights for sex working women living with HIV.

Assessing the Relationship Between HIV Quality of Care and Treatment Literacy on ART Adherence and Viral Suppression Among Female Sex Workers Living in the Dominican Republic

This study assessed the relationship between the quality of HIV care and treatment literacy on antiretroviral therapy (ART) adherence and viral suppression among female sex workers (FSWs) living with HIV (n = 211) in Santo Domingo, Dominican Republic. Multivariable logistic regression results indicate better patient-provider communication (AOR 1.04; 95% CI 1.01-1.07) and respectful treatment (AOR 2.17; 95% CI 1.09-4.32) increase the odds of viral suppression, while higher costs reduce both the odds of ART adherence (AOR 0.57, 95% CI 0.34- 0.95) and being virally suppressed (AOR 0.59, 95% CI 0.41-0.85). Greater treatment literacy was associated with an increased odds of ART adherence (AOR 4.15 for understanding of viral load; 95% CI 1.50-11.52) and viral suppression (AOR 2.75 for understanding of CD4 count; 95% CI 1.31-5.80). Findings support investments in treatment education, effective and respectful patient-provider communication, dignified care, and cost-support for associated HIV care costs to facilitate FSWs' pathway towards viral suppression.

Magnitude of HIV Infection and Associated Factors among Female Sex Workers at Hawassa, Ethiopia

Background

HIV is among one of the most serious public health problems. Low-income countries are highly affected by Human Immuno-deficiency Virus (HIV). The burden of HIV varies across various segments of the population. The aim of this study was to determine the magnitude of HIV infection and associated factors among female sex workers (FSWs).

Methods

A cross-sectional study was conducted among 381 FSWs at Integrated Service on Health and Development Organization (ISHDO) located in Hawassa city from July to November 2018. Socio-demographic and related data were collected using a structured questionnaire. About 5 ml of venous blood was collected from study participants; serum was prepared and tested for HIV using the 4^th generation Microlisa HIV assay. Data were analyzed by using SPSS version 21; binary and multivariable logistic regressions were used to determine factors associated with HIV infection among FSWs. A p-value of less than 0.05 was considered statistically significant.

Results

The prevalence of HIV among FSWs at ISHDO, Hawassa was 19.9% [95% CI: 16, 24.4].

Conclusion

The prevalence of HIV among FSWs at ISHDO, Hawassa was relatively high compared to national and regional reports. In this study, none of the factors assessed were significantly associated with HIV infection.

Evaluation of an Experimental Web-based Educational Module on Opioid-related Occupational Safety Among Police Officers: Protocol for a Randomized Pragmatic Trial to Minimize Barriers to Overdose Response

BACKGROUND

As drug-related morbidity and mortality continue to surge, police officers are on the front lines of the North American overdose (OD) crisis. Drug law enforcement shapes health risks among people who use drugs (PWUD), while also impacting the occupational health and wellness of officers. Effective interventions to align law enforcement practices with public health and occupational safety goals remain underresearched.

OBJECTIVE

The Opioids and Police Safety Study (OPS) aims to shift police practices relating to PWUD. It adapts and evaluates the relative effectiveness of a curriculum that bundles content on public health promotion with occupational risk reduction (ORR) to supplement a web-based OD response and naloxone training platform (GetNaloxoneNow.org, or GNN). This novel approach has the potential to improve public health and occupational safety practices, including using naloxone to reverse ODs, referring PWUD to treatment and other supportive services, and avoiding syringe confiscation.

METHODS

This longitudinal study uses a randomized pragmatic trial design. A sample of 300 active-duty police officers from select counties in Pennsylvania, Vermont, and New Hampshire with high OD fatality rates will be randomized (n=150 each) to either the experimental arm (GNN + OPS) or the control arm (GNN + COVID-19 ORR). A pre- and posttraining survey will be administered to all 300 officers, after which they will be administered quarterly surveys for 12 months. A subsample of police officers will also be qualitatively followed in a simultaneous embedded mixed-methods approach. Research ethics approval was obtained from the New York University Institutional Review Board.

RESULTS

Results will provide an understanding of the experiences, knowledge, and perceptions of this sample of law enforcement personnel. Generalized linear models will be used to analyze differences in key behavioral outcomes between the participants in each of the 2 study arms and across multiple time points (anticipated minimum effect size to be detected, d=0.50). Findings will be disseminated widely, and the training products will be available nationally once the study is completed.

CONCLUSIONS

The OPS is the first study to longitudinally assess the impact of a web-based opioid-related ORR intervention for law enforcement in the U.S. Our randomized pragmatic clinical trial aims to remove barriers to life-saving police engagement with PWUD/people who inject drugs by focusing both on the safety of law enforcement and evidence-based and best practices for working with persons at risk of an opioid OD. Our simultaneous embedded mixed-methods approach will provide empirical evaluation of the diffusion of the naloxone-based response among law enforcement.

TRIAL REGISTRATION

ClinicalTrail.gov NCT05008523; https://clinicaltrials.gov/show/NCT05008523.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33451.

Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in the San Diego-Tijuana border region

BACKGROUND

People who inject drugs may be at elevated SARS-CoV-2 risk due to their living conditions and/or exposures when seeking or using drugs. No study to date has reported upon risk factors for SARS-CoV-2 infection among people who inject drugs.

METHODS AND FINDINGS

Between October, 2020 and June, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month underwent interviews and testing for SARS-CoV-2 RNA and antibodies. Binomial regressions identified correlates of SARS-CoV-2 seropositivity.

RESULTS

Of 386 participants, SARS-CoV-2 seroprevalence was 36.3% (95% CI: 31.5%-41.1%); 92.1% had detectable IgM antibodies. Only 37.5% had previously been tested. Seroprevalence did not differ by country of residence. None tested RNA-positive. Most (89.5%) reported engaging in ≥1 protective behavior [e.g., facemasks (73.5%), social distancing (46.5%), or increasing handwashing/sanitizers (22.8%)]. In a multivariate model controlling for sex, older age, and Hispanic/Latinx/Mexican ethnicity were independently associated with SARS-CoV-2 seropositivity, as was engaging in sex work (AdjRR: 1.63; 95% CI: 1.18-2.27) and having been incarcerated in the past six months (AdjRR: 1.49; 95% CI: 0.97-2.27). Comorbidities and substance using behaviors were not associated with SARS-CoV-2 seropositivity.

CONCLUSIONS

In this community-based study of people who inject drugs in the San Diego-Tijuana border region, over one third were SARS-CoV-2 seropositive, exceeding estimates from the general population in either city. We found no evidence that substance use behaviors were associated with an elevated risk of SARS-CoV-2 infection, but observed that circumstances in the risk environment, notably sex work and incarceration, were independently associated with higher SARS-CoV-2 seroprevalence. Our findings suggest that a binational policy response to COVID-19 mitigation is warranted beyond the closure of the U.S.-Mexico border. Furthermore, decriminalizing sex work and drug use could reduce the burden of COVID-19 among people who inject drugs.

Overlapping Key Populations and HIV Transmission in Tijuana, Mexico: A Modelling Analysis of Epidemic Drivers

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.

"He is the Same as Me": Key Populations' Acceptability and Experience of a Community-Based Peer Navigator Intervention to Support Engagement in HIV Care in Tijuana, Mexico

Engagement in the HIV care continuum among people living with HIV is essential to prevent ongoing transmission. Although there is evidence for the need for comprehensive approaches (e.g., peer navigation) to improve the HIV care continuum, there is limited knowledge of how the peer navigation model might work to improve the HIV care continuum in low resource settings among Latinx key populations (e.g., persons who inject drugs, female sex workers, men who have sex with men, and transgender women). Therefore, this article aims to qualitatively assess members of key populations' acceptability of Conexiones Saludables (Healthy Connections), a community-based peer navigation intervention implemented in Tijuana, Mexico. This analysis draws upon the postintervention survey data from 34 participants and data from qualitative interviews with 10 participants. Participants found the intervention to be acceptable and discussed the ways in which peer navigators were influential in educating participants about HIV, antiretroviral therapy (ART), linking participants to existing HIV care and ancillary services in Tijuana, and in providing emotional and instrumental support to facilitate engagement in HIV treatment and ART adherence. The intervention emphasized the use of peer navigators who had a deep understanding of the sociostructural barriers (e.g., substance use, homelessness) that HIV-positive key populations face in Tijuana. Findings from this study may inform programs with highly vulnerable populations in similar settings.

Sexually Transmitted Infections in Association With Area-Level Prostitution and Drug-Related Arrests

OBJECTIVES

This study aimed to examine the mediators and moderators of area-level prostitution arrests and sexually transmitted infections (STIs) using population-level data.

METHODS

Using justice and public health STI/HIV data in Marion County (Indianapolis), Indiana, during an 18-year period, we assessed the overall association of area-level prostitution and drug-related arrests and STI/HIV, and mediators and moderators of the relationship. Point-level arrests were geocoded and aggregated by a census block group.

RESULTS

Results indicate a positive relationship between numbers of prostitution arrests and area-level STI rates. There was a dose-response relationship between prostitution arrests and STI rates when accounting for drug-related arrests. The highest quintile block groups had significantly higher rates of reported chlamydia (incident rate ratio [IRR], 3.29; 95% confidence interval [CI], 2.82-3.84), gonorrhea (IRR, 4.73; 95% CI, 3.90-5.57), syphilis (IRR, 4.28; 95% CI, 3.47-5.29), and HIV (IRR, 2.76; 95% CI, 2.24-3.39) compared with the lowest quintile. When including drug arrests, the second (IRR, 1.19; 95% CI, 1.03-1.38) and the third (IRR, 1.20; 95% CI, 1.02-1.41) highest quintile block groups had lower IRR for reported rates of chlamydia, indicating that drug arrests mediated the prostitution arrest effect.

CONCLUSIONS

These findings inform public health agencies and community-based organizations that conduct outreach in these areas to expand their efforts to include harm reduction and HIV/STI testing for both sex workers and individuals experiencing substance use disorder. Another implication of these data is the importance of greater collaboration in public health and policing efforts to address overlapping epidemics that engage both health and legal interventions.

Negative illness feedbacks: High-frisk policing reduces civilian reliance on ED services

OBJECTIVE

This paper demonstrates that localized and chronic stop-question-and-frisk (SQF) practices are associated with community members' utilization of emergency department (ED) resources. To explain this relationship, we explore the empirical applicability of a legal epidemiological framework, or the study of legal institutional influences on the distribution of disease and injury.

DATA AND STUDY DESIGN

Analyses are derived from merging data from the Philadelphia Vehicle and Pedestrians Investigation, the National Historical Geographic Information System, and the Southeastern Philadelphia Community Health database to zip code identifiers common to all datasets. Weighted multilevel negative binomial regressions measure the influence that local SQF practices have on ED use for this population. Analytic methods incorporate patient demographic covariates including household size, health insurance status, and having a doctor as a usual source of care.

PRINCIPAL FINDINGS

Findings reveal that both tract-level frisking and poor health are linked to more frequent use of hospital EDs, per respondent report. Despite their health care needs, however, reporting poor/fair health status is associated with a substantial decrease in the rate of emergency department visits as neighborhood frisk concentration increases (IRR = 0.923; 95% CI: 0.891, 0.957). Moreover, more sickly people in high-frisk neighborhoods live in tracts that have greater racial disparities in frisking-a pattern that accounts for the moderating role of neighborhood frisking in sick people's usage of the emergency room.

CONCLUSIONS

Findings indicating the robust association reported above interrogate the chronic incompatibility of local health and human service system aims. The study also provides an interdisciplinary theoretical lens through which stakeholders can make sense of these challenges and their implications.

Reducing police occupational needle stick injury risk following an interactive training: the SHIELD cohort study in Mexico

Objective

At a time of unprecedented attention to the public health impact of policing, it is imperative to understand the role of occupational safety in shaping officer behaviours. We assessed the longitudinal impact of police training in a quasi-experimental hybrid type-1 trial to reduce syringe-related occupational risk, while realigning police practices with public health prevention among people who inject drugs (PWID).

Setting

Tijuana, Mexico.

Participants

Of 1806 Tijuana municipal police trainees, 771 reporting previous exposure to syringes were randomly selected for follow-up. All participants completed at least one follow-up visit; attrition at 24 months was 8%.

Intervention

Between 2015 and 2016, officers received a training intervention (Safety and Health Integration in the Enforcement of Laws on Drugs, SHIELD) bundling occupational needle stick injury (NSI) prevention with health promotion among PWID.

Outcome measures

Longitudinal analysis with generalised linear mixed models to evaluate training impact on occupational NSI risk via NSI incidence and prevalidated Syringe Threat and Injury Correlates (STIC) score. This composite indicator integrates five self-reported risky syringe-handling practices (eg, syringe confiscation, breaking) and was used as a proxy for NSI risk due to reporting bias and concerns about reliability of NSI incidence reports.

Results

No change in self-reported NSI incidence was observed, but significant reductions in risk (16.2% decrease in STIC score) occurred at 3 months, with a sustained decrease of 17.8% through 24 months, compared with pretraining (p<0.001). Police assignment (patrol vs administration) moderated the training effect (p=0.01). Younger age, male gender, lower rank and previous NSI were independently and significantly associated with higher NSI risk overtime, although all groups demonstrated significant reductions post-training.

Conclusions

SHIELD is the first intervention to be associated with significant sustained changes in police practices that pose risk for both occupational and the public’s health. Integrating occupational safety and public health education should inform other interventions to mitigate the community health detriments of policing behaviours.

Trial registration number

NCT02444403.

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade

This paper examines the prevalence of and potential for community mobilization (CM) and its association with HIV/STI risk, substance use, and violence victimization among women, particularly those using substances, in the sex trade in Tijuana, Mexico.

METHODS

195 women participated in Mujeres Unidas (K01DA036439 Urada) under a longitudinal survey study, "Proyecto Mapa de Salud" (R01DA028692, PI: Brouwer). Local health/social service providers (N = 16) were also interviewed.

RESULTS

39% of women who participated in community mobilization activities used substances. In adjusted analyses (n = 135), participation in CM activities (n = 26) was more likely among women who did not report substance use (AOR: 4.36, CI: 1.11-17.16), perceived a right to a life free from violence (AOR: 9.28, CI: 2.03-59.26), talked/worked with peers in the sex trade to change a situation (AOR: 7.87, CI: 2.03-30.57), witnessed violence where they worked (AOR: 4.45, CI: 1.24-15.96), and accessed free condoms (AOR: 1.54, CI: 1.01-2.35). Forty-five of the women using substances demonstrated their potential for engaging in asset-based community development (ABCD) with service providers in Mujeres Unidas meetings.

CONCLUSION

Women using substances, vs. those who did not, demonstrated their potential to engage in ABCD strategies. Women's empowerment, safety, and health could be enhanced by communities engaging in ABCD strategies that build and bridge social capital for marginalized women who otherwise have few exit and recovery options.

"Todo se trata de a quién conoces": Social Networks and Drug Use Among Female Sex Workers Living with HIV in the Dominican Republic

The purpose of this study was to characterize the social networks of female sex workers (FSWs) living with HIV in the Dominican Republic (DR) and to examine the association between daily drug use and network risk profile. The study employed a micro-longitudinal observational design using a 7-day mobile health (mHealth) daily diary to collect daily substance use behaviors and social network data was collected at study enrollment. A series of crude and adjusted modified log-Poisson repeated measures regression models with generalized estimating equations (GEE), clustering by individual with a compound symmetry working correlation structure were fit to estimate the relative risks and 95% confidence intervals. Controlling for individual level factors, findings revealed that FSWs with more network members who were drug users (≥ 3) and more network members who were sexual partners and also drugs users (≥ 2) were 8.89 (95% CI 2.62, 30.22) and 6.08 (95% CI 1.20, 30.92) times more likely to engage in daily drug use compared to women with small drug and sex and drug networks. Study findings demonstrate the role high risk networks have on risk behaviors. Results may be used to inform interventions that focus on modifying negative social ties, creating and/or improving existing positive support relationships, and integrating drug use harm reduction promotion within HIV treatment programs.

The Experience of Violence Against Women Who Use Injection Drugs: An Exploratory Qualitative Study

BACKGROUND

While literature exists about persons who use injection drugs, few studies explore the experience of women who use these substances. Furthermore, even less research specifically focuses on the lives and experiences of homeless women who use injection drugs. What literature does exist, moreover, is often dated and primarily addresses concerns about infectious disease transmission among these women; and some highlight that these women have lives fraught with violence.

PURPOSE

To update this knowledge and better understand the lives of women who use injection drugs in the Canadian context.

METHODS

We undertook an exploratory qualitative study and we engaged in semi-structured interviews with 31 homeless women who use injection drugs in downtown Ottawa, Canada. We analyzed the data using the principles of applied thematic analysis.

RESULTS

Our data identified that violence pervaded the lives of our participants and that these experiences of violence could be categorized into three main areas: early and lifelong experiences of violence; violence with authority figures (e.g., police, healthcare); and societal violence toward women who use injection drugs.

CONCLUSIONS

We take these findings to mean that, violence toward women is rampant in Canada (not just internationally) and that healthcare workers play a role in propagating and addressing this violence.

Prevalence of sexual violence in Ethiopian workplaces: systematic review and meta-analysis

BACKGROUND

Workplace sexual violence is a significant public health problem in low and middle-income countries, including Ethiopia. However, except for individual studies with varying prevalence rates in different occupations, there are no national prevalence studies conducted in workplace settings in Ethiopia. Appropriate estimation of the problem is essential to formulate health service plans most fitted for workplaces. Hence, this review and meta-analysis intended to estimate the national pooled prevalence of workplace sexual violence in Ethiopia.

METHODS

The databases used were; PubMed, Google Scholar, CINAHL, and African Journals Online. For a critical appraisal of the papers, we used the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument for cross-sectional studies. The meta-analysis was conducted using comprehensive meta-analysis and MetaXL software. Descriptive information of studies was presented in narrative form, and quantitative results were presented in forest plots. The Cochran Q test and I2 test statistics were employed to test heterogeneity across studies. A random-effect model computed the pooled estimate prevalence with 95% confidence intervals.

RESULTS

The pooled prevalence of workplace sexual violence was 22% (95% CI 17%, 28%). The pooled prevalence was 14.1% (95% CI 10.4%, 18.9%) for attempted rape, 8% (95% CI 5.7%, 11.1%) for rape, and 33.2% (95% CI 24.1%, 43.7%) for sexual harassment. The pooled prevalence was the highest among female university staffs 49% (95% CI 45%, 56%), and among commercial sex workers 28% (95% CI 3%, 59%).

CONCLUSIONS

This analysis revealed that the prevalence of sexual violence and sexual harassment in Ethiopian workplaces is high. It was also exceptionally high among female faculty staff, commercial sex workers, and workplaces in Tigray National regional state. Thus, concerned stakeholders must design and implement effective interventions to prevent workplace sexual violence in workplaces in Ethiopia and provide necessary support and care to the victims.

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

INTRODUCTION AND AIMS

HIV and hepatitis C virus transmission among people who inject drugs (PWID) is fuelled by personal and environmental factors that vary by sex. We studied PWID in Mexico to identify sex differences in multilevel determinants of injection risk.

DESIGN AND METHODS

From 2011 to 2013, 734 PWID (female: 277, male: 457) were enrolled into an observational cohort study in Tijuana. Participants completed interviews on injection and sexual risks. Utilising baseline data, we conducted multiple generalised linear models stratified by sex to identify factors associated with injection risk scores (e.g. frequency of injection risk behaviours).

RESULTS

For both sexes, difficult access to sterile syringes was associated with elevated injection risk (b = 1.24, 95% confidence interval [CI] 1.16-1.33), using syringes from a safe source (e.g. needle exchange programs) was associated with lower injection risk (b = 0.87, 95% CI 0.82-0.94), and for every one-unit increase in safe injection self-efficacy we observed a 20% decrease in injection risk (b = 0.80, 95% CI 0.76-0.84). Females had a higher safe injection self-efficacy score compared to males (median 2.83, interquartile range 2.2-3 vs. median 2.83, interquartile range 2-3; P = 0.01). Among females, incarceration (b = 1.22, 95% CI 1.09-1.36) and police confiscation of syringes in the past 6 months (b = 1.16, 95% CI 1.01-1.33) were associated with elevated injection risk. Among males, sex work (b = 1.16, 95% CI 1.04-1.30) and polysubstance use in the past 6 months (b = 1.22, 95% CI 1.13-1.31) were associated with elevated injection risk.

DISCUSSION AND CONCLUSIONS

Interventions to reduce HIV and hepatitis C virus transmission among PWID in Tijuana should be sex-specific and consider multilevel determinants of injection risk to create safer drug use environments.

Preferences and acceptability of law enforcement initiated referrals for people who inject drugs: a mixed methods analysis

BACKGROUND

Law enforcement officers (LEOs) come into frequent contact with people who inject drugs (PWID). Through service referrals, LEOs may facilitate PWID engagement in harm reduction, substance use treatment, and other health and supportive services. Little is known about PWID and LEO attitudes and concerns about service referrals, however. The objective of this mixed-methods study was to examine the alignment of service referral preferences and acceptability among PWID and LEOs in Tijuana, Mexico.

METHODS

We assessed service referral preferences and perceived likelihood of participation in health and social services, integrating data from structured questionnaires with 280 PWID and 306 LEOs, contextualized by semi-structured interviews and focus groups with 15 PWID and 17 LEOs enrolled in two parallel longitudinal cohorts in Tijuana, Mexico.

RESULTS

Among potential service referral options, both PWID (78%) and LEOs (88%) most frequently cited assistance with drug- and alcohol-use disorders. Over half of PWID and LEOs supported including harm reduction services such as syringe service programs, overdose prevention, and HIV testing. The majority of PWID supported LEO referrals to programs that addressed basic structural needs (e.g. personal care [62%], food assistance [61%], housing assistance [58%]). However, the proportion of LEOs (30-45%) who endorsed these service referrals was significantly lower (p <  0.01). Regarding referral acceptability, 71% of PWID reported they would be very likely or somewhat likely to make use of a referral compared to 94% of LEOs reporting that they thought PWID would always or sometimes utilize them. These results were echoed in the qualitative analysis, although practical barriers to referrals emerged, whereby PWID were less optimistic that they would utilize referrals compared to LEOs.

CONCLUSIONS

We identified strong support for LEO service referrals among both LEO and PWID respondents, with the highest preference for substance use treatment. LEO referral programs offer opportunities to deflect PWID contact with carceral systems while facilitating access to health and social services. However, appropriate investments and political will are needed to develop an evidence-based (integrated) service infrastructure.

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

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

Correlates of trichomoniasis among female sex workers who inject drugs in two Mexico-US border cities

This paper evaluates correlates of trichomoniasis among female sex workers who inject drugs (FSWIDs) in two Mexico-US border cities. HIV-negative FSWIDs aged 18 years or older were enrolled in a study between 2008 and 2010 in Tijuana and Ciudad Juarez (Cd.), Mexico. All participants underwent a baseline interviewer-administered survey and did a rapid test for trichomoniasis. Using regression to estimate prevalence ratios, we examined sociodemographics, sex work characteristics, sexual health and behavior, substance use, and police and violence exposures as potential correlates of trichomoniasis. Of 584 women (284 in Tijuana, 300 in Cd. Juarez), prevalence of trichomoniasis was 33.6%. Factors associated with trichomoniasis in multivariable analysis were having money stolen by police in the past six months (adjusted prevalence ratio [aPR] =1.448, 95% confidence interval [CI] = 1.152-1.821), recent methamphetamine use (aPR = 1.432, CI = 1.055-1.944), lifetime syphilis infection (aPR = 1.360, CI = 1.061-1.743), ever use of a home remedy to treat vaginal symptoms (aPR = 1.301, CI = 1.027-1.649), and number of regular clients in the past month (aPR = 1.006 per client, CI = 1.004-1.009), while controlling for age and city of interview. Alongside the need for trichomoniasis surveillance and treatment programs, findings indicate that both structural and behavioral factors serve as primary correlates of trichomoniasis among FSWIDs in these cities.

"An ethnographic exploration of factors that drive policing of street-based female sex workers in a U.S. setting - identifying opportunities for intervention"

Background

Building on a broader sociological discourse around policing approaches towards vulnerable populations, increasing public health and human rights evidence points to policing practices as a key health determinant, particularly among street-based sex workers. Despite the importance of policing as a structural health determinant, few studies have sought to understand the factors that underlie and shape harmful policing practices towards sex workers. This study therefore aimed to explore the drivers for policing attitudes and practices towards street-based cisgender female sex workers.

Methods

Drawing on ethnographic methods, 280 h of observations with police patrol and 10 stakeholder interviews with senior police leadership in Baltimore City, USA were carried out to better understand the drivers for policing strategies towards cisgender female sex workers. Analysis was data- and theory-driven, drawing on the concepts of police culture and complementary criminological and sociological literature that aided exploration of the influence of the ecological and structural environment on policing practices.

Results

Ecological factors at the structural (e.g., criminalization), organizational (e.g., violent crime control), community and individual level (e.g., stigmatizing attitudes) emerged as key to shaping individual police practices and attitudes towards cisgender female sex workers in this setting. Findings indicate senior police support for increased alignment with public health and human rights goals. However, the study highlights that interventions need to move beyond individual officer training and address the broader structural and organizational setting in which harmful police practices towards sex work operate.

Conclusions

A more in-depth understanding of the circumstances that drive law enforcement approaches to street-based sex work is critical to the collaborative design of interventions with police in different settings. In considering public health-police partnerships to address the rights and health of sex worker populations in the U.S. and elsewhere, this study supports existing calls for decriminalization of sex work, supported by institutional and policy reforms, neighborhood-level dialogues that shift the cultural landscape around sex work within both the police and larger community, and innovative individual-level police trainings.

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

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.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

Addressing Police Occupational Safety During an Opioid Crisis: The Syringe Threat and Injury Correlates (STIC) Score

OBJECTIVE

To develop and validate syringe threat and injury correlates (STIC) score to measure police vulnerability to needlestick injury (NSI).

METHODS

Tijuana police officers (N = 1788) received NSI training (2015 to 2016). STIC score incorporates five self-reported behaviors: syringe confiscation, transportation, breaking, discarding, and arrest for syringe possession. Multivariable logistic regression was used to evaluate the association between STIC score and recent NSI.

RESULTS

Twenty-three (1.5%) officers reported NSI; higher among women than men (3.8% vs 1.2%; P = 0.007). STIC variables had high internal consistency, a distribution of 4.0, a mode of 1.0, a mean (sd) of 2.0 (0.8), and a median (interquartile range [IQR]) of 2.0 (1.2 to 2.6). STIC was associated with recent NSI; odds of NSI being 2.4 times higher for each point increase (P-value <0.0001).

CONCLUSIONS

STIC score is a novel tool for assessing NSI risk and prevention program success among police.

Study of the possibility of introduction of Kazakhstan NGO-based rapid HIV testing procedures

Introduction

New initiatives presented by the World Health Organization (WHO) and the Joint United Nations Program on HIV and AIDS , such as 90-90-90, test and treat, preventive treatment, and best international practices related to the introduction of rapid human immunodeficiency virus (HIV) testing in clinics, and field conditions, including self-testing, predetermined the introduction of NGO-based rapid HIV testing in the Republic of Kazakhstan nongovernmental organizations (NGOs). This work presents the results of a comprehensive study conducted about the possible introduction of NGO-based rapid HIV testing in the country. It should be noted that 32,573 HIV infections have been diagnosed in Kazakhstan (prevalence of 117.7 per 100,000 people) from 1987 to 2018. Most of these new cases are diagnosed among "key" population groups, such as people who use injectable drugs, sex workers, men who have sex with men, those who rely mainly on NGOs, and those who prefer to deal with an organization such as an NGO, which makes it possible to introduce NGO-based rapid HIV testing in Kazakhstan.

Methods

In this work, we used the following rapid HIV tests: Alere DetermineTM HIV ½ Ag/Ab Combo, Hexagon HIV 1+2, Abon HIV ½, HIV 1,2 Han Medtest, and Geenius HIV1/2 Confirmatory.

Results

The study of the rapid tests, including their diagnostic patterns, conducted in Kazakhstan shows that five rapid HIV tests completely meet the WHO's requirements (sensitivity>99%; specificity>98%). These are Alere DetermineTM HIV ½ Ag/Ab Combo, Hexagon HIV 1+2, Abon HIV ½, HIV 1,2 Han Medtest, and Geenius HIV1/2 Confirmatory. The study of legal and social problems associated with rapid HIV testing in NGOs shows that HIV-related medical examination and counseling carried out in Kazakhstan, including those by rapid methods, are governed by corresponding laws and normative legal documents.

Conclusion

It has been established that there are social barriers that interfere with rapid HIV testing. In view of this, services associated with NGO-based rapid HIV testing shall be rendered with the use of a social and legal protection mechanism for those under examination.

Women in Sex Work and the Risk Environment: Agency, Risk Perception, and Management in the Sex Work Environments of Two Mexico-U.S. Border Cities

Sex work around the world takes place under conditions of structural violence and vulnerability. The México-U.S. border region is characterized by the presence of factors that increase the risk for health harms among female sex workers (FSW); located in this context, the risk environments of Tijuana and Ciudad Juárez have similar yet distinct characteristics that influence how risk is produced and experienced among FSWs. Exploring the ways in which FSWs enact agency in risk environments can illustrate how environmental characteristics shape perceived risks and the strategies that FSWs develop to manage them. This approach also identifies the limits that are placed by environmental characteristics over the capacity for harm reduction and prevention practices among FSWs. We analyzed the role of agency in the work environments of female sex workers and its relationship with risk perception and management in the cities of Tijuana and Cd. Juárez.

Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs

AIMS

To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW-IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition.

DESIGN

Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study.

SETTING

Baltimore, MD, USA PARTICIPANTS: One hundred and eighty FSW-IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married.

MEASUREMENTS

Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio-demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural-level factors included methods of syringe access.

FINDINGS

Nearly all FSW-IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW-IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi-level mixed-effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09-4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98-4.85), being injected by others (aOR = 4.95, 95% CI = 2.42-10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94-3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21-8.90).

CONCLUSIONS

Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs.

Investigation of HIV/AIDS prevalence and associated risk factors among female sex workers from 2010 to 2017: a meta-analysis study

Objectives: Female sex workers (FSW) are highly at risk of HIV, and can potentially transmit the human immunodeficiency virus (HIV) in different societies. Study design: The aims of the present study were to investigate the prevalence of HIV/AIDS and associated risk factors among FSW between 2010 and 2017 using a systematic literature review and meta-analysis approach. Methods: International databases were searched, including ISI Web of Science, Embase, PubMed, and Scopus. Using the appropriate keywords, relevant studies published on the HIV/AIDS prevalence among FSW between 2010 and 2017 were identified. Afterwards, the information was extracted and analyzed by STATA version 14. Results: Thirty-seven studies were found eligible for inclusion in this research, encompassing a total of 46,657 subjects. The results revealed that the global prevalence of HIV/AIDS among FSW was 2.17 (95% CI=1.37-3.14). Conclusion: These findings demonstrated the high prevalence of HIV/AIDS among FSWs worldwide. Accordingly, strict educational and interventional programs should be implemented globally to reduce HIV/AIDS prevalence among this group, as well as to prevent probable HIV transmission.

Factors Associated with Sexual Risks and Risk of STIs, HIV and Other Blood-Borne Viruses Among Women Using Heroin and Other Drugs: A Systematic Literature Review

This systematic literature review identified factors associated with sexual risks related to sexually transmitted infections (STI), HIV and other blood-borne viruses (BBV) among women using heroin and other drugs. The search strategy included five databases (PubMed, EMBASE, PsycNET, Web of Science, Scopus), and PsycEXTRA for grey literature. Out of the 12,135 publications screened, 30 peer-reviewed articles were included. Most publications were cross-sectional (n = 25), quantitative (n = 23) and included 11,305 women. Factors identified were: (1) socio-demographics; (2) gender roles and violence against women; (3) substance use; (4) transactional sex; (5) partner characteristics, partner's drug use, and context of sex; (6) preferences, negotiation and availability of condoms; (7) HIV status and STIs; (8) number of sexual partners; (9) love and trust; (10) reproductive health and motherhood; and (11) risk awareness and perception of control. Overall, this review highlights important implications for future research and practice, and provides evidence for developing STI/BBV preventive strategies.

Substance Use among Female Sex Workers in Two US-Mexico Border Cities: Associations with Age of Entry

BACKGROUND

Research has documented consistent associations between entry into sex work as a minor and sexual HIV risk. However, previous studies have not examined whether substance use and related HIV risk are elevated among those who enter sex work under age 18.

METHODS

Quantitative data were collected via time-location sampling of 603 female sex workers (FSWs) ages 18 years and older residing in two Mexico-US border cities. Age of entry into sex work (categorized as 15 years or younger, 16-17 years, or 18 years and older) was assessed as a predictor of substance use (forced and voluntary) within the first month post-entry and recent (past 30 days) substance use with clients.

RESULTS

Compared to those who entered as adults, participants who entered sex work at age 15 or younger were significantly more likely to report drug use (AOR = 5.2, CI = 2.9-8.9) and forced drug use within the first 30 days of entry (AOR= 6.0, CI = 1.9-18.9), as well as past month drug use with clients (AOR= 3.4, CI = 1.9-5.8). Similar results were found among participants who entered sex work at age 16-17.

CONCLUSIONS

Increased risk of recent substance use with clients indicates continuing elevated risk for those entering sex work at these early ages. Early and forced substance use at entry may underlie the elevated risk of HIV infection consistently observed among this population.

Optimizing HIV Interventions for Multiplex Social Networks via Partition-Based Random Search

There are multiple modes for human immunodeficiency virus (HIV) transmissions, each of which is usually associated with a certain key population (e.g., needle sharing among people who inject drugs). Recent field studies revealed the merging trend of multiple key populations, making HIV intervention difficult because of the existence of multiple transmission modes in such complex multiplex social networks. In this paper, we aim to address this challenge by developing a multiplex social network framework to capture the multimode transmission across two key populations. Based on the multiplex social network framework, we propose a new random search method, named partition-based random search with network and memory prioritization (PRS-NMP), to identify the optimal subset of high-value individuals in the social network for interventions. Numerical experiments demonstrated that the proposed PRS-NMP-based interventions could effectively reduce the scale of HIV transmissions. The performance of PRS-NMP-based interventions is consistently better than the benchmark nested partitions method and network-based metrics.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

'Pure' drug users, commercial sex workers and 'ordinary girls': gendered narratives of HIV risk and prevention in post-Soviet Ukraine

International best practices call for a gender-responsive approach to HIV prevention for women, including those who use drugs and those who engage in sex work. This paper draws on multiple qualitative data sources collected over five years in Ukraine to explore the notions of gender, women and family that buttress HIV-related programmes for women. Our analysis reveals that service providers often cast women as hapless victims of unfortunate family circumstances and troubled personal relationships that produce sudden poverty, or social strivers who seek access to wealth and privilege at the expense of their health. Women are portrayed as most vulnerable to HIV when they lack a male 'protector'. We argue that the programmes constituted around these stereotypes of women and their vulnerabilities reflect new forms of institutional power that deflect attention away from gendered socio-economic processes that contribute to women's HIV vulnerability, including job insecurity and unemployment, workplace discrimination, unreliable social benefits and power imbalances within their relationships. We explore how to transform HIV prevention efforts to better address the causes of women's increased vulnerability to HIV in Ukraine and in Eastern Europe more generally.

Interventions that Address Intimate Partner Violence and HIV Among Women: A Systematic Review

Recognizing the high prevalence of human immunodeficiency virus (HIV)-positive women and girls who are either at risk for or suffer from intimate partner violence (IPV) and the overlapping challenges posed by both public health issues, the White House established an Interagency Federal Working Group to address the intersection of both public health issues in 2012. We conducted this systematic review in response to the Working Group's charge to identify and describe interventions that address both IPV and HIV among women. We identified 14 studies that met our inclusion criteria, including seven studies (nine unique intervention arms) that significantly affected at least one outcome related to IPV and HIV. In this article, we examine the characteristics of these studies including core components, intervention populations, and effectiveness data. We highlight opportunities to improve the effectiveness of existing interventions, guide future research about IPV and HIV, and inform prevention programmatic delivery. This knowledge will improve the lives of populations at risk, reduce gender-related health disparities, and ultimately reduce the societal burden of both public health issues.

Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey of municipal police in Tijuana, Mexico

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.

Factors in the HIV risk environment associated with bacterial vaginosis among HIV-negative female sex workers who inject drugs in the Mexico-United States border region

Background

Bacterial vaginosis (BV) is the most common cause of vaginitis among women worldwide and is associated with increased susceptibility to sexually transmitted infections (STIs), including HIV. We aimed to determine the impact of the HIV risk environment on BV among female sex workers who inject drugs (FSW-PWIDs) in Tijuana and Ciudad Juarez, Mexico.

Methods

We performed a cross-sectional analysis utilizing baseline data from a randomized controlled trial evaluating a behavioral HIV prevention intervention. Participants underwent testing for BV using the OSOM BVBlue® Rapid Test (Genzyme Diagnostics, San Diego, CA) and completed a survey eliciting information on the HIV risk environment, sexual risk behaviors, and substance use. We applied logistic regression to identify correlates of BV in the physical, social, economic, and political HIV risk environments stratified by study site (Ciudad Juarez vs. Tijuana).

Results

In total, 584 HIV-negative FSW-PWIDs (300 Ciudad Juarez; 284 Tijuana) were enrolled. The prevalence of BV was 39% (n = 228), which was higher in Ciudad Juarez (56.7%) compared to Tijuana (20.4%). In both cities, micro-level components of the physical HIV risk environment were associated with BV. In Ciudad Juarez, BV was associated with past experiences or threats of physical violence in response to proposed condom use (adjusted odds ratio [aOR] = 3.66, 95% confidence interval [CI]: 1.74–7.69, p = 0.001) and lifetime residence in Ciudad Juarez (aOR = 1.74, 95% CI: 1.05–2.87, p = 0.031). In Tijuana, BV was associated with the number of hours spent on the street daily in the past six months looking for, using, or dealing drugs, engaging in other income generating activities, or sleeping (aOR = 1.05, 95% CI: 1.001–1.097, p = 0.045).

Conclusions

Our findings suggest that FSW-PWIDs’ risk of BV may be shaped by the microphysical HIV risk environment. Addressing components of the physical risk environment, including interventions to reduce gender-based violence, may alleviate the burden of BV and subsequent susceptibility to HIV/STIs among FSW-PWIDs in the Mexico/US border region.

Trial registration

National Institute of Health (NIH) Clinical Trials Identifier NCT00840658, and date of NIH trial registration February 7, 2009.

Sex Trade and Health Care Utilization Among People Living with HIV/AIDS

People living with HIV/AIDS (PLWH) are more likely to have a history of trading sex, but little research has examined whether trading sex is associated with lower health care utilization amongst PLWH. This study assesses this association with PLWH (N = 583) recruited and surveyed from seven community sites in six US cities participating in a multi-site community-based HIV test and treat initiative. Participants were 90.6% Black or Latino, 30.4% homeless, and 9.0% (1 in 11) sold sex (past 90 days). Most reported receiving HIV clinical care (63.9%, past 6 months) and HIV case management (68.9%, past year), but 35.7% reported a missed health care appointment (past 3 months). In adjusted regression models, trading sex was associated with a missed health care appointment (OR = 2.44) and receiving psychological assistance (OR = 2.31), past 90 days, but not receipt of HIV care or supportive HIV services. Trading sex may compromise consistent health care utilization among PLWH.

Risk Behaviors for HIV and HCV Infection Among People Who Inject Drugs in Hai Phong, Viet Nam, 2014

We examined the potential for HIV and hepatitis C (HCV) transmission across persons who inject drugs (PWID), men-who-have-sex-with-men (MSM) and female commercial sex workers (CSW) PWID and the potential for sexual transmission of HIV from PWID to the general population in Hai Phong, Viet Nam. Using respondent driven and convenience sampling we recruited 603 participants in 2014. All participants used heroin; 24% used non-injected methamphetamine. HIV prevalence was 25%; HCV prevalence was 67%. HIV infection was associated with HCV prevalence and both infections were associated with length of injecting career. Reported injecting risk behaviors were low; unsafe sexual behavior was high among MSM-PWID and CSW-PWID. There is strong possibility of sexual transmission to primary partners facilitated by methamphetamine use. We would suggest future HIV prevention programs utilize multiple interventions including "treatment as prevention" to potential sexual transmission of HIV among MSM and CSW-PWID and from PWID to the general population.

HIV infection, high-risk behaviors and substance use in homeless men sheltered in therapeutic communities in Central Brazil

Homeless men present high vulnerability to HIV infection, mainly due to sexual risk behaviors and substance use. The objective was to estimate the prevalence of HIV infection, risk behaviors and substance use in homeless men. A cross-sectional study was conducted in 481 homeless men recruited in four therapeutic communities in the Goiás State, Central Brazil. All were interviewed about sociodemographic characteristics, substance use, and risk behaviors. Furthermore, all were tested for HIV. Poisson regression was used to verify factors associated with HIV infection. HIV prevalence was 1.24% (95.0% CI: 0.57 to 2.69%). Previous HIV testing (adjusted prevalence ratio [APR]: 10.0; 95.0% CI: 1.86-55.8) and years of education (APR: 0.76; 95.0% CI: 0.60-0.97) were factors associated with HIV infection. Participants had high rates of hazardous alcohol use and illicit drug use. The prevalence of HIV infection among homeless men was higher than that found in the Brazilian male population and we identified a high rate of risk behaviors for HIV among the homeless men investigated. Thus, it is necessary to expand HIV prevention measures in Brazil, such as health education, condom availability, regular HIV testing and increased testing coverage in this population, and treatment for alcohol and/or illicit drug dependence/abuse.

Prevalence of Trichomonas vaginalis and Human papillomavirus in female sex workers in Central Veracruz, Mexico

Female sex workers (FSWs) have been considered a key population for sexually transmitted infections (STIs); therefore, they are periodically screened as a requirement to obtain a work card. However, there is insufficient epidemiological data on STIs among FSWs in Mexico. The detection of Trichomonas vaginalis is limited to microscopic studies and the molecular screening of Human papillomavirus (HPV) is only done to women 35 years of age and older. The objective of this study was to determine the prevalence of T. vaginalis and HPV infections in FSWs in the city of Orizaba, Veracruz, Mexico. Samples from 105 FSWs were obtained by cervical swab and analyzed. The identification of T. vaginalis and HPV was performed by molecular methods. HPV DNA was identified in 5.71% of the samples with the presence of HPV16, HPV18, and HPV58. A percentage of 25.7% samples were positive for T. vaginalis for optical microscopy and 23.8% for PCR. The results of the study indicate the need to incorporate more sensitive methods for the timely diagnosis of STIs as well as comprehensive health promotion programs directed to the most vulnerable groups among FSWs.