Cost-Effectiveness of Combined Sexual and Injection Risk Reduction Interventions among Female Sex Workers Who Inject Drugs in Two Very Distinct Mexican Border Cities

Background

We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008–2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.

Methods

A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1,000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The costs for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$10,300).

Findings

For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4,360 ($310–$7,200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5,874 ($310–$7,200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5,921 ($104–$9,500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.

Interpretation

In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex-didactic safer injection intervention in Cd. Juarez

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex/Safer injection intervention for Ciudad Juarez

Below:  Cost-effectiveness acceptability curve for the combined interactive safer sex and didactic safer injection components of the Mujer Mas Segura intervention in Tijuana

Full article at:   http://goo.gl/RBQD6m

By:  

Jose L. Burgos, Steffanie A. Strathdee

University of California San Diego, Department of Medicine, Division of Global Public Health, La Jolla, California, United States of America

Jose L. Burgos

Universidad Autonoma de Baja California, Facultad de Medicina y Psicología, Tijuana, Baja California, México

Thomas L. Patterson

University of California San Diego, Department of Psychiatry, La Jolla, California, United States of America

Joshua S. Graff-Zivin

University of California San Diego, School of Global Policy and Strategy, La Jolla, California, United States of America

James G. Kahn

University of California San Francisco, Department of Epidemiology and Biostatistics, Philip R. Lee Institute for Health Policy Studies, Global Health Sciences, San Francisco, California, United States of America

M. Gudelia Rangel

Secretaria de Salud de México, Comision de Salud Fronteriza Mexico-Estados Unidos Sección México, Tijuana, Baja California, México

M. Remedios Lozada

Instituto de Servicios de Salud Pública del Estado de Baja California, Mexicali, Baja California, Mexico

Hugo Staines

Universidad Autonoma de Ciudad Juarez, Facultad de Medicina, Ciudad Juárez, Chihuahua, México

  

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Intravaginal Practices among HIV-Negative Female Sex Workers Along the US-Mexico Border & Their Implications for Emerging HIV Prevention Interventions

OBJECTIVE:

To describe intravaginal practices (IVPs) among female sex workers (FSWs) who inject drugs in two cities-Tijuana and Ciudad Juarez-on the border between the USA and Mexico.

METHODS:

Data for a secondary analysis were obtained from interviews conducted as part of a randomized controlled trial in FSWs who injected drugs between October 28, 2008, and May 31, 2010. Eligible individuals were aged at least 18 years and reported sharing injection equipment and having unprotected sex with clients in the previous month. Descriptive statistics were used to assess frequency and type of IVPs. Logistic regression was used to assess correlates of IVPs.

RESULTS:

Among 529 FSWs who completed both surveys, 229 (43.3%) had performed IVPs in the previous 6 months. Factors independently associated with IVPs were reporting any sexually transmitted infection in the previous 6 months, three or more pregnancies, and having clients who became violent when proposing condom use, which are all factors related to inconsistent condom use.

CONCLUSION:

Screening for IVPs could help to identify FSW at increased risk of HIV, and facilitate conversations about specific risk-reduction methods.

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By:  Seidman D1, Rusch M2, Abramovitz D3, Stockman JK3, Martinez G4, Rangel G5, Vera A3, Ulibarri MD6, Strathdee SA7.

• 1Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
• 2Population Health and Epidemiology, Island Health, Victoria, BC, Canada; School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada.
• 3Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA.
• 4Community Health and Development of Ciudad Juarez and the Mexican Federation of Private Associations, Ciudad Juarez, Mexico.
• 5El Colegio de la Frontera del Norte, Tijuana, Mexico.
• 6Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA.
• 7Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA. Electronic address: sstrathdee@ucsd.edu. 
• Int J Gynaecol Obstet. 2016 Jan 28. pii: S0020-7292(16)00037-0. doi: 10.1016/j.ijgo.2015.09.025.

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Substance Use and Treatment Seeking in Colonias and Urban Areas of the Texas-Mexico Border - Slides

Slides from:  http://goo.gl/8Qmguq

Via:  https://goo.gl/XcRHTN

A Qualitative Exploration of Perceived Gender Differences in Methamphetamine Use among Women Who Use Methamphetamine on the Mexico-U.S. Border

The purpose of this study is to extend the research on contextual factors that influence the initiation and continued use of methamphetamine (meth) by women on the U.S.-Mexico border. 

At present, a minimal body of literature exists that explores meth use on the Mexico-U.S. border. A purposeful sample of 20 women who were active meth users aged ≥18 years was recruited by trained outreach workers from a variety of meth-user networks in Ciudad Juárez, Mexico, the city bordering El Paso, Texas. 

Respondents participated in in-depth, semi-structured interviews including questions on users' perceived familial, social, and environmental influences of meth use. Gender-based themes emerged from the analysis: 

1. patterns of meth use; 
2. places where drugs were used; 
3. effects of relationship networks on meth use; 
4. differential access to drugs; 
5. trading sex for drugs; 
6. perceived class differences; and 
7. long-term drug use and its consequences. 

Respondents reported a preference for using meth as powder or pills as opposed to smoking or injecting the drug. They reported being introduced to meth by men they trust and relying on men for drug acquisition in spaces less accessible and more dangerous to women. 

They described how the drug changed their lifestyle and their behavior towards family members and friends, including instances of physical and psychological violence. Interventions for women on the Mexico-U.S. border should be developed based on users' social networks to target social processes to prevent initiation and to bring active meth users into treatment.

Purchase full article at:   http://goo.gl/0ZvM9Y

By:   Loza O¹, Ramos R², Ferreira-Pinto J¹, Hernandez MT³, Villalobos SA⁴.

¹a College of Health Sciences , University of Texas at El Paso (http://chs.utep.edu/) , El Paso , TX.

²b Alliance of Border Collaboratives (ABC) , El Paso , TX.

³c School of Public Health , University of California , Berkeley , CA.

⁴d Department of Emergency Medicine , Texas Tech Health Sciences of El Paso, Paul Foster School of Medicine , El Paso , TX.

J Ethn Subst Abuse. 2015 Dec 21:1-20. [Epub ahead of print]

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HIV/SIDA: Epidemic in Tijuana

Via: http://goo.gl/ZrlNsO  By: https://twitter.com/uctelevision

The Clinics at Prevencasa -- HIV/SIDA: The Epidemic in Tijuana Episode 2

Via: http://goo.gl/ZrlNsO  By: https://twitter.com/uctelevision

Ending AIDS -- HIV/SIDA: The Epidemic in Tijuana Episode 4

Via: http://goo.gl/ZrlNsO By: https://twitter.com/uctelevision

A Qualitative Exploration of Perceived Gender Differences in Methamphetamine Use among Women Who Use Methamphetamine on the Mexico–U.S. border

The purpose of this study is to extend the research on contextual factors that influence the initiation and continued use of methamphetamine (meth) by women on the U.S.-Mexico border. 

At present, a minimal body of literature exists that explores meth use on the Mexico-U.S. border. A purposeful sample of 20 women who were active meth users aged ≥18 years was recruited by trained outreach workers from a variety of meth-user networks in Ciudad Juárez, Mexico, the city bordering El Paso, Texas. Respondents participated in in-depth, semi-structured interviews including questions on users’ perceived familial, social, and environmental influences of meth use. 

Gender-based themes emerged from the analysis: 

1. patterns of meth use; 
2. places where drugs were used; 
3. effects of relationship networks on meth use; 
4. differential access to drugs; 
5. trading sex for drugs; 
6. perceived class differences; and 
7. long-term drug use and its consequences. 

Respondents reported a preference for using meth as powder or pills as opposed to smoking or injecting the drug. They reported being introduced to meth by men they trust and relying on men for drug acquisition in spaces less accessible and more dangerous to women. 

They described how the drug changed their lifestyle and their behavior towards family members and friends, including instances of physical and psychological violence. Interventions for women on the Mexico-U.S. border should be developed based on users’ social networks to target social processes to prevent initiation and to bring active meth users into treatment.

Purchase full article at:   http://goo.gl/3HQjNt

By:   Oralia Loza^a*, Rebeca Ramos^b, João Ferreira-Pinto^a, Maria Teresa Hernandez^c & Susana A. Villalobos^d

• ^a College of Health Sciences, University of Texas at El Paso, El Paso, TX
• ^b Alliance of Border Collaboratives (ABC), El Paso, TX
• ^c School of Public Health, University of California, Berkeley, CA
• ^d Department of Emergency Medicine, Texas Tech Health Sciences of El Paso, Paul Foster School of Medicine, El Paso, TX

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Substance Use and Cumulative Exposure to American Society: Findings from Both Sides of the US-Mexico Border Region

OBJECTIVES:

We investigated whether Mexican immigration to the United States exerts transnational effects on substance use in Mexico and the United States.

METHODS:

We performed a cross-sectional survey of 2336 Mexican Americans and 2460 Mexicans in 3 Texas border metropolitan areas and their sister cities in Mexico (the US-Mexico Study on Alcohol and Related Conditions, 2011-2013). We collected prevalence and risk factors for alcohol and drug use; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, alcohol-use disorders; and 2 symptoms (hazardous use and quit or control) of drug use disorder across a continuum of migration experiences in the Mexican and Mexican American populations.

RESULTS:

Compared with Mexicans with no migrant experience, the adjusted odds ratios for this continuum of migration experiences ranged from 1.10 to 8.85 for 12-month drug use, 1.09 to 5.07 for 12-month alcohol use disorder, and 1.13 to 9.95 for 12-month drug-use disorder. Odds ratios increased with longer exposure to US society. These findings are consistent with those of 3 previous studies.

CONCLUSIONS:

People of Mexican origin have increased prevalence of substance use and disorders with cumulative exposure to US society. 

Purchase full article at:  http://goo.gl/sIJLCG

By:  Borges G1, Cherpitel CJ1, Orozco R1, Zemore SE1, Wallisch L1, Medina-Mora ME1, Breslau J1.

• 1Guilherme Borges, Ricardo Orozco, and Maria Elena Medina-Mora are with Instituto Nacional de Psiquiatría, México DF, México. Guilherme Borges is also with the Universidad Autónoma Metropolitana, México DF. Cheryl J. Cherpitel and Sarah E. Zemore are with the National Alcohol Research Center, Public Health Institute, Emeryville, CA. Lynn Wallisch is with the University of Texas, Center for Social Work Research, Austin, TX. Joshua Breslau is with RAND Corporation, Pittsburgh, PA.

 

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Living with VIH/SIDA: Tijuana Stories -- HIV/SIDA: The Epidemic in Tijuana Episode 3

Via:  https://goo.gl/nTkLhz By: https://twitter.com/uctelevision/

El Bordo -- HIV/SIDA: The Epidemic in Tijuana - Episode 1

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Police Victimization among Persons Who Inject Drugs Along the U.S.-Mexico Border

Problematic policing practices are an important driver of HIV infection among persons who inject drugs (PWID) in the U.S.-Mexico border region. This study identifies factors associated with recent (i.e., past 6 months) police victimization (e.g., extortion, physical and sexual violence) in the border city of Tijuana, Mexico.

From 2011 to 2013, 733 PWID (62% male) were recruited in Tijuana and completed a structured questionnaire. Eligible participants were age 18 years or older, injected illicit drugs within the past month, and spoke Spanish or English. Multivariable logistic regression analyses identified correlates of recent experiences of police victimization (e.g., bribes, unlawful confiscation, physical and sexual violence).

Overall, 56% of PWID reported a recent police victimization experience in Tijuana. 

• In multivariable logistic regression analyses, factors independently associated with recent police victimization included 
• recent injection of methamphetamine 
• and recently received injection assistance by a "hit doctor". 

Increased years lived in Tijuana and initiating drug use at a later age were inversely associated with recent police victimization.

Physical drug using markers may increase PWID susceptibility to police targeting and contribute to experiences of victimization. Interventions aimed at reducing police victimization events in the U.S.-Mexico border region should consider PWID's drug-using behaviors. Reducing problematic policing practices may be a crucial public health strategy to reduce HIV risk among PWID in this region

Via:  http://ht.ly/SPrnU Purchase full article at:  http://ht.ly/SPrpO 

By: Pinedo M1, Burgos JL2, Zuniga ML3, Perez R4, Macera CA5, Ojeda VD2.

• 1Alcohol Research Group, University of California, Berkeley, California.
• 2Division of Global Public Health, Department of Medicine, University of California, San Diego, California.
• 3School of Social Work, San Diego State University, San Diego, California.
• 4Department of Anthropology, San Diego State University, San Diego, California.
• 5School of Public Health, San Diego State University, San Diego, California.

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"Amar Te Duele" ("Love Hurts"): Sexual Relationship Power, Intimate Partner Violence, Depression Symptoms & HIV Risk among Female Sex Workers Who Use Drugs & Their Non-Commercial, Steady Partners in Mexico

A significant body of research among female sex workers (FSWs) has focused on individual-level HIV risk factors. Comparatively little is known about their non-commercial, steady partners who may heavily influence their behavior and HIV risk. 

This cross-sectional study of 214 FSWs who use drugs and their male steady partners aged ≥18 in two Mexico-U.S. border cities utilized a path-analytic model for dyadic data based upon the Actor-Partner Interdependence Model to examine relationships between sexual relationship power, intimate partner violence (IPV), depression symptoms, and unprotected sex. 

• FSWs' relationship power, IPV perpetration and victimization were significantly associated with unprotected sex within the relationship. 
• Male partners' depression symptoms were significantly associated with unprotected sex within the relationship. 

Future HIV prevention interventions for FSWs and their male partners should address issues of sexual relationship power, IPV, and mental health both individually and in the context of their relationship.

Via: http://ht.ly/SOSmX  Purchase full article at: http://goo.gl/82GOji

By: Ulibarri MD1, Roesch S, Rangel MG, Staines H, Amaro H, Strathdee SA.

1Department of Psychiatry, University of California-San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0849, USA

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Situating HIV Risk in the Lives of Formerly Trafficked Female Sex Workers on the Mexico-US Border

Due to stigma and the psychosocial repercussions of past trauma and abuse, survivors of sex trafficking may experience increased susceptibility to violence, revictimization, and various harmful health outcomes, including HIV infection. Given the paucity of research characterizing the experiences of formerly trafficked female sex workers (FSWs), we set out to describe and contextualize perceptions of HIV risk among women who have experienced past episodes of sex trafficking and who are currently engaged in sex work in Tijuana, Mexico. 

Based on semi-structured interviews and ethnographic fieldwork, we describe the following interrelated themes as influencing formerly trafficked FSWs' perceptions and experiences of HIV risk: 

• economic vulnerability; 
• susceptibility to violence; 
• and psychological trauma. 

Our findings highlight the need for HIV prevention efforts to incorporate broader structural and social interventions aimed at reducing vulnerability to violence and human rights abuses among this population and improving their general economic, psychological, and social well-being.

Read more at: http://ht.ly/S78VQ 

By: Shane P. Collins, MS,a Shira M. Goldenberg, PhD,b,* Nancy J. Burke, PhD,c Ietza Bojorquez, MD, PhD,d Jay G. Silverman, PhD,b and Steffanie A. Strathdee, PhDb

^bDivision of Global Public Health, University of California, San Diego, USA

^cHelen Diller Family Comprehensive Cancer Center and Department of Anthropology, History, and Social Medicine, University of California, San Francisco, USA

^d

^bDivision of Global Public Health, University of California, San Diego, USA

^cHelen Diller Family Comprehensive Cancer Center and Department of Anthropology, History, and Social Medicine, University of California, San Francisco, USA

^d

^b

aGlobal Health Sciences, University of California, San Francisco, USA
bDivision of Global Public Health, University of California, San Diego, USA
cHelen Diller Family Comprehensive Cancer Center and Department of Anthropology, History, and Social Medicine, University of California, San Francisco, USA
dEl Colegio de la Frontera Norte, Tijuana, Mexico

aGlobal Health Sciences, University of California, San Francisco, USA

aGlobal Health Sciences, University of California, San Francisco, USA

aGlobal Health Sciences, University of California, San Francisco, USA