We evaluated brief combination interventions to
simultaneously reduce sexual and injection risks among female sex workers who
inject drugs (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico during 2008–2010,
when harm reduction coverage was expanding rapidly in Tijuana, but less so in
Juarez.
FSW-IDUs ≥18 years reporting sharing injection equipment and
unprotected sex with clients within the last month participated in a randomized
factorial trial comparing four brief, single-session conditions combining
either an interactive or didactic version of a sexual risk intervention to
promote safer sex in the context of drug use, and an injection risk
intervention to reduce sharing of needles/injection paraphernalia. Women
underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and Trichomonas,blinding
interviewers and assessors to assignment. Poisson regression with robust
variance estimation and repeated measures ordinal logistic regression examined
effects on combined HIV/STI incidence and receptive needle sharing frequency.
Of 584 initially HIV-negative FSW-IDUs, retention was ≥90%.
After 12 months, HIV/STI incidence decreased >50% in the interactive vs.
didactic sex intervention (Tijuana:AdjRR:0.38,95% CI:0.16–0.89; Juarez:
AdjRR:0.44,95% CI:0.19–0.99). In Juarez, women receiving interactive vs.
didactic injection risk interventions decreased receptive needle-sharing by 85%
vs. 71%, respectively (p = 0.04); in Tijuana, receptive needle sharing declined
by 95%, but was similar in active versus didactic groups. Tijuana women
reported significant increases in access to syringes and condoms, but Juarez
women did not.
After 12 months in both cities, the interactive sexual risk
intervention significantly reduced HIV/STI incidence. Expanding free access to
sterile syringes coupled with brief, didactic education on safer injection was
necessary and sufficient for achieving robust, sustained injection risk
reductions in Tijuana. In the absence of expanding syringe access in Juarez,
the injection risk intervention achieved significant, albeit more modest
reductions, suggesting that community-level interventions incorporating harm
reduction are more powerful than individual-level interventions.
Table 2
HIV/STI incidence density over 12 months: Overall, by intervention group and site.
| Group | Intervention group | #of incident cases* | # of peopleat risk | #of py at risk | Incidence densityper 100 py (95% CI) | |
| Entire Sample | ||||||
| A | Didactic injection and sex interventions (control) | 31 | 69 | 47.68 | 65.02 (42.13,87.91) | |
| B | Interactive injection/Didactic sex interventions | 31 | 63 | 45.82 | 67.66 (43.84, 91.47) | |
| C | Interactive sex/Didactic injection interventions | 18 | 63 | 51.32 | 35.08 (18.87,51.28) | |
| D | Interactive injection and sex interventions | 26 | 63 | 48.11 | 54.04 (33.27, 74.81) | |
| Tijuana | ||||||
| A | Didactic injection and sex interventions (control) | 18 | 41 | 28.01 | 64.26 (34.58, 93.95) | |
| B | Interactive injection/Didactic sex interventions | 11 | 31 | 23.88 | 46.067(18.84, 73.29) | |
| C | Interactive sex/Didactic injection interventions | 9 | 33 | 25.34 | 35.52 (12.31, 58.72) | |
| D | Interactive injection and sex interventions | 8 | 32 | 26.66 | 30.01 (9.21, 50.81) | |
| Cd. Juarez | ||||||
| A | Didactic injection and sex interventions (control) | 13 | 28 | 19.67 | 66.10 (30.17,102.02) | |
| B | Interactive injection/Didactic sex interventions | 20 | 32 | 21.94 | 91.15 (51.20, 131.09) | |
| C | Interactive sex/Didactic injection interventions | 9 | 30 | 25.98 | 34.65 (12.01, 57.29) | |
| D | Interactive injection and sex interventions | 18 | 31 | 21.45 | 83.90 (45.14,122.66) | |
*By STI: 1 HIV, 24 lifetime syphilis, 6 syphilis titers > = 1∶8, 23 Chlamydia, 3 gonorrhea, and 66 trichomoniasis. Fifteen participants presented with more than one STI at the same visit, so incident cases by STI do not add to the same number as the total number of incident HIV/STIs.
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1University of California San Diego, Department of Medicine, La Jolla, California, United States of America
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