HIV co-infections with STIs among MSM in Tijuana, Mexico
Funding Source: University of California, San Diego Center for AIDS Research (CFAR)
Co-PIs: Gudelia Rangel and Heather Pines 

Globally, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and syphilis are among the most prevalent sexually transmitted infections (STIs). HIV co-infection with these STIs is common and may play an important role in driving HIV transmission. Men who have sex with men (MSM) are at substantial risk of HIV/STIs worldwide, including those in low- and middle-income countries (LMIC). In Tijuana, Mexico, the prevalence of HIV among MSM is high at ~20%. Elevated rates of sexual and substance use behaviors associated with HIV/STIs have also been documented within this population suggesting that STI control strategies could significantly reduce the spread of HIV among MSM in this setting. 
The overall goal of the co-infections among MSM project (CAMP) is to determine the potential impact of HIV co-infection with STIs on HIV transmission dynamics among MSM in Tijuana. CAMP is embedded in two ongoing studies among MSM in Tijuana (Enlaces or Links [R01DA037811; PI: Patterson] and Redes or Networks [K01DA040543; PI: Pines]). CAMP aims to enroll approximately 600 MSM (~300 newly diagnosed HIV-positive and ~300 HIV-negative) to determine: (1) the prevalence of CT, NG, and syphilis, as well as HIV co-infection with these STIs and (2) whether HIV co-infection with STIs is associated with HIV transmission network characteristics among MSM in Tijuana. Findings will inform future work evaluating the impact of STI control strategies designed to interrupt HIV transmission among MSM in Tijuana, which may be applicable to MSM populations in other similar LMIC.

Cultural Perceptions of Adolescent Mental Health and Patterns of Help-Seeking in Northern Mexico

Project Title:  “Cultural Perceptions of Adolescent Mental Health and Patterns of Help-Seeking in Northern Mexico,” 
PI: Janis H. Jenkins, Ph.D.

Project Description:  In this study, our interdisciplinary team is currently collecting data to identify cultural conceptions of mental health and patterns of help-seeking in the northern Mexico region.  The research seeks an empirical understanding of contemporary knowledge and practices surrounding emotional distress and behaviors regarded as problematic.  Working with parents, teachers, and service providers, we are investigating (1) the conceptualization of wellbeing and the identification of problems of emotional/mental health; (2) decision-making for seeking services; and (3) the social-emotional features that contribute to vulnerability and resilience in processes of recovery.  That empirical data obtained will serve as the basis for interactive, community-designed interventions for adolescent health that are effective and sustainable over time.  

Proyecto Redes

Proyecto Redes: Sexual Networks and HIV Transmission Clusters among Substance Using MSM 
Funding Source: NIDA K01 DA040543;
PI: Heather Pines  

Global disparities in resource allocation to HIV prevention services may limit the promise of recent breakthroughs in HIV prevention science, particularly among vulnerable substance using populations, such as men who have sex with men (MSM), in low- and middle-income countries (LMIC). Innovative research that integrates social network analysis and genetic sequence analysis methods to direct the delivery of biomedical HIV prevention strategies to individuals at greatest risk may help maximize their impact, control costs, and facilitate their implementation in the context of limited prevention resources.

Proyecto Redes (Networks Project) is a 5-year project funded by a Mentored Research Scientist Development Award (K01) from the National Institute on Drug Abuse (NIDA). It contains both a training and research component. The aims of the training component are to develop expertise in social network analysis and genetic sequence analysis methods to identify HIV transmission clusters (i.e., individuals with genetically related HIV infections). The overall goal of the research component is to characterize the sexual networks and sexual network-based drivers of HIV transmission among MSM in Tijuana, Mexico.  

More specifically, the research component aims to:

1) Examine the influence of mean degree (i.e., number of male anal intercourse partners), the degree distribution, and sexual mixing patterns on overall sexual network structure among MSM in Tijuana

2) Identify individual, sexual network compositional, and socio-contextual factors associated with degree by HIV status among MSM

3) Determine whether sexual mixing patterns are associated with HIV transmission cluster membership among HIV-positive MSM

To address these aims, Proyecto Redes will partner with a NIDA study (R01DA037811; PI: Patterson) examining the effectiveness of two HIV case identification methods (HIV testing in high-risk venues vs. partner contact tracing) among MSM in Tijuana. Proyecto Redes will utilize behavioral, psychosocial, egocentric sexual network, and HIV-1 pol sequence data collected from 200 newly diagnosed HIV-positive MSM identified via partner contact tracing as part of the parent study and collect additional data from 200 of their HIV-negative and previously diagnosed HIV-positive male sexual partners. Findings from this project will inform the development of comprehensive HIV prevention programs that leverage information on sexual network characteristics to interrupt HIV transmission among MSM in Mexico and other LMIC.

Proyecto Futura: Modeling Structural HIV Determinants in Substance Users and Related populations

Funded by NIDA grant R01 DA0 37773;
PIs: Natasha MartinSteffanie Strathdee, Peter Vickerman

We are conducting secondary data analyses to model potential effects of structural determinants and combination interventions and cost-effectiveness to optimize HIV prevention in Tijuana. Our team of prevention scientists and modelers from the U.S., Mexico and the U.K. will utilize data from 8 NIH-funded R01s and related sub-studies in Tijuana.

Our aims are:
  1. To model overlapping HIV and syphilis epidemics occurring among different high risk groups in Tijuana (PWID, MSM, MSM-IDU, FSW, FSW-IDU, and their clients) to ascertain the extent to which HIV transmission is driven by specific risk groups and sexual or injecting risk behaviors.
  2. To assess the impact and cost-effectiveness of scaling up coverage of existing and novel interventions (e.g. SEP, OST, ART, and two existing behavioral interventions), targeted at specific risk subgroups, to identify the most cost-effective combination intervention package to control HIV transmission.
  3. To model the potential importance of policing practices and incarceration on HIV transmission among PWID in Tijuana, and the subsequent impact of a PEP on changing policing practices and HIV transmission.
  4. To model the potential impact of reducing involuntary (i.e., forced/coerced) entry into sex trade as a minor or adult on HIV transmission in Tijuana.
Our project will advance efforts to model the potential impacts of structural determinants and combination prevention interventions on emerging HIV epidemics in lower and middle-income countries.

Economic Debt, Drug Use, and HIV Risk among Sex Workers in Tijuana, Mexico

Funding Source: Center for AIDS Research, University of California, San Diego 
PI: Elizabeth Reed, ScD, MPH

High rates of sex trade and drug use, and the intersection of these, exacerbate the spread of HIV in Tijuana, the largest Mexican city bordering the US. Poor socioeconomic conditions are the primary driver of sex work initiation in Tijuana, as well as elsewhere. Our previous research in South Asia has established that economic debt is not only significant in terms of women’s initiating sex trade, but is also associated with elevated HIV/STI risk among female sex workers (FSW). This work indicated that the vast majority of FSW have debt (80%) and that debt appears to reduce women’s condom negotiating power with clients and increases women’s experiences of gender-based violence, both increasing HIV risk. The prevalence, nature, and effects of debt in the US-Mexico border region likely differs significantly from that of South Asia, as a result of the intersecting influence of drug use and debt on HIV risk. Thus, this project aims 1) to describe the prevalence, nature, and magnitude of debt, 2) to examine the relation between debt and HIV risk among FSW in Tijuana, and 3) to assess the contribution of drug use to debt and how this translates to increased HIV risk.

Selected Publications
Reed, E., Gupta, J., Biradavolu, M., Devireddy, V., & Blankenship, K.M. The context of economic insecurity and relation to violence and risk factors for HIV among female sex workers in Andhra Pradesh, India. Public Health Reports. 2010;125(Suppl 4): 81–89.

Impact of Drug Policy Reform on the HIV Risk Environment Among IDUs in Tijuana (El Cuete, Phase IV)

Funding Source: NIDA grant R01 DA0 19829
PI:Steffanie Strathdee

El Bordo -- HIV/SIDA: The Epidemic in Tijuana - Episode 1
The overall objective of Proyecto El Cuete is to evaluate the impact of structural interventions in the legal environment that may influence drug use and HIV risk behaviors of people who inject drugs (PWID) in Tijuana, Mexico. Specifically, we will continue to monitor the impact of Mexico’s federal drug policy reform (narcomenudeo) which partially decriminalized possession of small, specified amounts of cocaine, heroin, methamphetamine and marijuana for personal use. We are also collecting data from an implementation science perspective to examine factors at the institutional, environmental and policy level that impede vs. promote operationalization of the narcomenudeo.

We will also use the El Cuete cohort to prospectively examine the impact of a police education program (PEP) newly designed to align law enforcement and HIV prevention programs in Tijuana. In Mexico and other countries, policing practices are directly and/or indirectly linked to behaviors that increase PWIDs’ vulnerability to HIV, viral hepatitis and STIs. These include syringe confiscation and police misconduct (e.g., physical and sexual abuse). PEPs have been successfully piloted in several locations, but to date, evaluations were limited to brief pre-post assessments of police knowledge, attitudes and/or intentions. Since the impact of PEPs on policing behaviors is unknown, the El Cuete cohort will be utilized to examine the impact of the PEP on PWIDs’ behaviors that influence their risk of acquiring HIV and other blood-borne infections. Our specific aims are:

  1. To continue to monitor the following impacts of the narcomenudeo in Tijuana with respect to: i) temporal trends in drug use behaviors; ii) PWIDs’ health risks and protective behaviors; iii) experiences with drug treatment; iv) interactions with law enforcement.
  2. To prospectively examine extent to which police detention and arrest behaviors adhere to narcomenudeo legislation that institutionalizes diversion of substance users to substance use treatment instead of incarceration.
  3. To study factors at the institutional, environmental and policy level that are impeding vs. promoting implementation of the narcomenudeo legislation.
  4. To evaluate the impact of a PEP on PWIDs’ outcomes with respect to i) temporal trends in high risk injection behaviors (e.g., rushed injections, needle sharing, injecting in shooting galleries); iii) protective behaviors (e.g., attendance at syringe exchange and drug treatment programs); iii) interactions with law enforcement (e.g., experience with police misconduct, syringe confiscation).
As the narcomenudeo reforms continue to be scaled up, our study will generate important findings that will inform drug policy reforms in Mexico and in other countries. In particular, since the next UN General Assembly Special Session on Drugs will be held in 2016, our study results will be particularly timely. Our study also would be the first to evaluate the impact of a PEP on PWIDs’ risk behaviors, which could serve as a model for other countries. We are also comparing HIV prevalence, incidence and risk behaviors among PWID in Tijuana to a parallel cohort of PWID in San Diego, STAHR II.

 Postcard From The Trenches: Tijuana’s Hidden HIV and Tuberculosis Epidemics

"Drug Decriminalization and Tijuana’s AIDS Epidemic with Sir Richard Branson" See More

Selected Publications:
  • Robertson AM, Garfein RS, Wagner KD, Mehta SR, Magis-Rodriguez C, Cuevas-Mota J, Moreno-Zuniga PG, Strathdee SA; Proyecto El Cuete IV and STAHR II. 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(1):4. doi: 10.1186/1477-7517-11-4. PMCID: PMC3944401
  • Mackey TK, Werb D, Beletsky L, Rangel G, Arredondo J, Strathdee SA. Mexico’s “ley de narcomenudeo” drug policy reform and the international drug control regime. Harm Reduct J. 2014 Nov 14; 11(1):31. doi: 10.1186/1477-7517-11-31.
  • Werb D, Medina-Mora EL, Arredondo J, Beletsky L, Patterson T, Strathdee SA. Mexico’s drug policy reform: cutting edge success or crisis in the making? Int J Drug Policy. 2014. pii: S0955-3959(14)00145-5. doi: 10.1016/j.drugpo.2014.05.014.
  • Werb D, Wagner KD, Beletsky L, Gonzalez-Zuniga P, Vera A, Strathdee SA. Police bribery and access to methadone maintenance therapy among injection drug users in Tijuana, Mexico. Drug Alc Depend (in press)
  • Meachem M, Rudolph AE, Strathdee SA, Brouwer KC, Rusch M, Roesch S. Polydrug use and HIV risk among people who inject heroin in Tijuana, Mexico: A latent class analysis. Substance Use and Misuse (in press)
  • Beletsky L, Arredondo J, Werb D, et al. Utilization of Google enterprise tools to georeference survey data among hard-to-reach groups: strategic application in international settings. Int. J. Health Geogr. 2016;15(24)e1-4 [link]
  • Beletsky L, Wagner KD, Arredondo J, et al. Implementing Mexico’s “Narcomenudeo” Drug Law Reform: A Mixed-Methods Assessment of Early Experiences among People Who Inject Drugs. Journal of Mixed Methods Research 2015; doi: 10.1177/1558689815575862