High prevalence of multiple syndemic conditions associated with sexual risk behavior and HIV infection among a large sample of Spanish- and Portuguese-speaking men who have sex with men in Latin America.

The HIV epidemic in Latin America is highly concentrated in men who have sex with men (MSM). In the United States, multiple co-occurring psychosocial conditions have been shown to act as intertwined epidemics to potentiate HIV transmission among MSM. To date, no study has examined the role of syndemics and condomless sex among MSM in Latin America. In 2012, an online survey was conducted among members of the largest social/sexual networking website for MSM in Latin America. Participants were asked about demographics, sexual behaviors, HIV/STI diagnoses, and psychosocial well-being, including depression, suicidal ideation, hazardous alcohol use, hard drug use during sex, history of childhood/adolescent sexual abuse, intimate partner violence, and sexual compulsivity. Multivariable logistic generalized estimation equations were used to assess the relationship of syndemic factors and (1) engagement in higher risk condomless anal sex and (2) self-report of prior HIV diagnosis. Among 24,274 survey respondents, 74.6 % of the sample had at least one syndemic factor. In an additive model, syndemics were associated with increased odds of higher risk condomless anal sex, ranging from adjusted odds ratio of 1.31 (95 % CI 1.20, 1.43) for one syndemic factor to 4.06 (95 % CI 3.25, 5.09) for 6/7 syndemic factors. Similarly, syndemics were associated with increased odds of HIV infection (p < .0001). This study provides initial evidence that intertwined syndemics increase HIV risk behavior and HIV infection among MSM in Latin America. In the Latin American context, comprehensive HIV prevention interventions for MSM should be developed and tested that simultaneously address co-occurring psychosocial conditions and HIV risk.

Client perspectives on design and implementation of a couples-based intervention to reduce sexual and drug risk behaviors among female sex workers and their noncommercial partners in Tijuana and Ciudad Juárez, México.

This mixed-methods study examined the acceptability of a hypothetical couples-based HIV prevention program for female sex workers and their intimate (non-commercial) male partners in Mexico. Among 320 participants, 67 % preferred couples-based over individual programs, particularly among men. Reasons cited for preferring couples-based programs included convenience and health benefits for both partners. Participants reported that they would benefit from general health information and services, HIV counseling and testing, job training (particularly for men) and other services. However, qualitative interviews revealed that barriers relating to the environment (i.e., poor access to services), providers (i.e., lack of a therapeutic alliance), and intimate relationships (i.e., mistrust or instability) would need to be addressed before such a program could be successfully implemented. Despite women's concerns about privacy and men's preferences for gender-specific services, couples-based HIV prevention programs were largely acceptable to female sex workers and their intimate male partners.

Epidemiology of sexual health in the virtual environment: a multinational online survey of Spanish- and Portuguese-speaking men who use an internet sexual networking site.

There is limited data on the sexual health of users of sexual networking websites for men who have sex with men (MSM) in Latin America. Members of a MSM-targeted social/sexual networking website in Latin America, Spain, and Portugal participated in an online sexual health survey. Among 36,063 respondents, nearly 90 % reported having anal or vaginal intercourse in the past 3 months. Among sexually active men, 53.2 % used condoms inconsistently. In the past year, 54 % of respondents reported undergoing sexually transmitted infections (STI) testing and 67 % reported testing yearly or more often for HIV. Self-reported HIV prevalence was 9.1 %. Differences were seen by geographic region. Unprotected intercourse with partners of different or unknown HIV status was associated with recent STI diagnosis (OR = 1.83, t = 13.15, d.f. = 21, p < .001) and HIV diagnosis (OR = 2.20, t = 14.00, d.f. = 21, p < .001). Online surveys are a promising tool for HIV/STI surveillance and prevention internationally to reach an important subset of MSM.

Prevalence and correlates of HIV and sexually transmitted infections among female sex workers and their non-commercial male partners in two Mexico-USA border cities.

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.

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.

BACKGROUND: Policymakers and researchers seek answers to how liberalized drug policies affect people who inject drugs (PWID). In response to concerns about the failing "war on drugs," Mexico recently implemented drug policy reforms that partially decriminalized possession of small amounts of drugs for personal use while promoting drug treatment. Recognizing important epidemiologic, policy, and socioeconomic differences between the United States-where possession of any psychoactive drugs without a prescription remains illegal-and Mexico-where possession of small quantities for personal use was partially decriminalized, we sought to assess changes over time in knowledge, attitudes, behaviors, and infectious disease profiles among PWID in the adjacent border cities of San Diego, CA, USA, and Tijuana, Baja California, Mexico. METHODS: Based on extensive binational experience and collaboration, from 2012-2014 we initiated two parallel, prospective, mixed methods studies: Proyecto El Cuete IV in Tijuana (n = 785) and the STAHR II Study in San Diego (n = 575). Methods for sampling, recruitment, and data collection were designed to be compatible in both studies. All participants completed quantitative behavioral and geographic assessments and serological testing (HIV in both studies; hepatitis C virus and tuberculosis in STAHR II) at baseline and four semi-annual follow-up visits. Between follow-up assessment visits, subsets of participants completed qualitative interviews to explore contextual factors relating to study aims and other emergent phenomena. Planned analyses include descriptive and inferential statistics for quantitative data, content analysis and other mixed-methods approaches for qualitative data, and phylogenetic analysis of HIV-positive samples to understand cross-border transmission dynamics. RESULTS: Investigators and research staff shared preliminary findings across studies to provide feedback on instruments and insights regarding local phenomena. As a result, recruitment and data collection procedures have been implemented successfully, demonstrating the importance of binational collaboration in evaluating the impact of structural-level drug policy reforms on the behaviors, health, and wellbeing of PWID across an international border. CONCLUSIONS: Our prospective, mixed methods approach allows each study to be responsive to emerging phenomena within local contexts while regular collaboration promotes sharing insights across studies. The strengths and limitations of this approach may serve as a guide for other evaluations of harm reduction policies internationally.

Sex workers' noncommercial male partners who inject drugs report higher-risk sexual behaviors.

Female sex workers are less likely to use condoms with noncommercial male partners than clients. We compare noncommercial male partners who do and do not inject drugs in Tijuana and Ciudad Juárez, Mexico. Sexual risk behaviors were more prevalent among injectors, who could promote HIV/sexually transmitted infection transmission in this region.

'Where sex ends and emotions begin': love and HIV risk among female sex workers and their intimate, non-commercial partners along the Mexico-US border.

This study explores the affective dimensions of female sex workers' relationships with their intimate, non-commercial partners and assesses how emotions shape each partner's sexual and drug-related risk within their relationship. We draw on qualitative data from a study of HIV, sexually transmitted infections and high-risk behaviours among female sex workers and their non-commercial partners in Tijuana and Ciudad Juárez, Mexico, to illustrate that these couples share relationships based on love, trust, respect and emotional and material support. These relationships range in emotional intensity, which shapes partners' decisions not to use condoms with each other. Drugs were important in most couples' relationships. Among injectors, syringe sharing was common and represented both a sign of care and a pragmatic reaction to conditions of material scarcity. Our findings suggest that couple-based HIV interventions to address dual sexual and drug-related risks should be tailored to the emotional dynamics of sex workers' intimate relationships.

The influence of having children on HIV-related risk behaviors of female sex workers and their intimate male partners in two Mexico-US border cities.

Among female sex workers who use drugs, the experience of having children and its effect on HIV risk behaviors remains underexplored. We draw from a study of 214 female sex workers and their intimate non-commercial partners in Tijuana and Ciudad Juárez, México (n = 428), approximately 30% of whom have children living with them. During qualitative interviews with 41 of these couples, having children emerged as an important topic. Children influenced partners' lives and HIV-related risk behaviors in positive and negative ways. Couples perceived that children strengthened their relationships. Concern for children's well-being motivated couples to contemplate healthier lifestyle changes. However, childrearing costs motivated sex work and structural constraints prevented couples from enacting lifestyle changes. Case studies illustrate these themes and highlight implications for couple- and family-based harm reduction interventions. Specifically, our results suggest a need for economic alternatives to sex work while working with families to develop risk reduction skills.

Muscle function during takeoff and landing flight in the pigeon (Columba livia).

This study explored the muscle strain and activation patterns of several key flight muscles of the pigeon (Columba livia) during takeoff and landing flight. Using electromyography (EMG) to measure muscle activation, and sonomicrometry to quantify muscle strain, we evaluated the muscle function patterns of the pectoralis, biceps, humerotriceps and scapulotriceps as pigeons flew between two perches. These recordings were analyzed in the context of three-dimensional wing kinematics. To understand the different requirements of takeoff, midflight and landing, we compared the activity and strain of these muscles among the three flight modes. The pectoralis and biceps exhibited greater fascicle strain rates during takeoff than during midflight or landing. However, the triceps muscles did not exhibit notable differences in strain among flight modes. All observed strain, activation and kinematics were consistent with hypothesized muscle functions. The biceps contracted to stabilize and flex the elbow during the downstroke. The humerotriceps contracted to extend the elbow at the upstroke-downstroke transition, followed by scapulotriceps contraction to maintain elbow extension during the downstroke. The scapulotriceps also appeared to contribute to humeral elevation. Greater muscle activation intensity was observed during takeoff, compared with mid-flight and landing, in all muscles except the scapulotriceps. The timing patterns of muscle activation and length change differed among flight modes, yet demonstrated that pigeons do not change the basic mechanical actions of key flight muscles as they shift from flight activities that demand energy production, such as takeoff and midflight, to maneuvers that require absorption of energy, such as landing. Similarly, joint kinematics were consistent among flight modes. The stereotypy of these neuromuscular and joint kinematic patterns is consistent with previously observed stereotypy of wing kinematics relative to the pigeon's body (in the local body frame) across these flight behaviors. Taken together, these observations suggest that the control of takeoff and landing flight primarily involves modulation of overall body pitch to effect changes in stroke plane angle and resulting wing aerodynamics.

Correlates and contexts of US injection drug initiation among undocumented Mexican migrant men who were deported from the United States.

Preventing the onset of injection drug use is important in controlling the spread of HIV and other blood borne infections. Undocumented migrants in the United States face social, economic, and legal stressors that may contribute to substance abuse. Little is known about undocumented migrants' drug abuse trajectories including injection initiation. To examine the correlates and contexts of US injection initiation among undocumented migrants, we administered quantitative surveys (N = 309) and qualitative interviews (N = 23) on migration and drug abuse experiences to deported male injection drug users in Tijuana, Mexico. US injection initiation was independently associated with ever using drugs in Mexico pre-migration, younger age at first US migration, and US incarceration. Participants' qualitative interviews contextualized quantitative findings and demonstrated the significance of social contexts surrounding US injection initiation experiences. HIV prevention programs may prevent/delay US injection initiation by addressing socio-economic and migration-related stressors experienced by undocumented migrants.

Study protocol for the recruitment of female sex workers and their non-commercial partners into couple-based HIV research.

BACKGROUND: Researchers are increasingly recognizing the importance of addressing sexual and drug-related HIV risk within the context of intimate relationships rather than solely focusing on individual behaviors. Practical and effective methods are needed to recruit, screen, and enroll the high risk and hard-to-reach couples who would most benefit from HIV interventions, such as drug-using female sex workers (FSWs) and their intimate, non-commercial partners. This paper outlines a bi-national, multidisciplinary effort to develop and implement a study protocol for research on the social context and epidemiology of HIV, sexually transmitted infections (STI), and high risk behaviors among FSWs and their non-commercial male partners in Tijuana and Ciudad Juarez, Mexico. We provide an overview of our study and specifically focus on the sampling, recruitment, screening, and successful enrollment of high risk couples into a public health study in this context. METHODS/DESIGN: We used targeted and snowball sampling to recruit couples through the female partner first and administered a primary screener to check her initial eligibility. Willing and eligible females then invited their primary male partners for couple-based screening using a couple verification screening (CVS) instrument adapted from previous studies. The CVS rechecked eligibility and separately asked each partner the same questions about their relationship to "test" if the couple was legitimate. We adapted the original protocol to consider issues of gender and power within the local cultural and socioeconomic context and expanded the question pool to create multiple versions of the CVS that were randomly administered to potential couples to determine eligibility and facilitate study enrollment. DISCUSSION: The protocol successfully enrolled 214 high risk couples into a multi-site public health study. This work suggests the importance of collaborating to construct a study protocol, understanding the local population and context, and drawing on multiple sources of input to determine eligibility and verify the legitimacy of relationships. We provide a practical set of tools that other researchers should find helpful in the study of high risk couples in international settings, with particular relevance to studies of FSWs and their intimate partners.

Reducing harm from HIV/AIDS misconceptions among female sex workers in Tijuana and Ciudad Juarez, Mexico: A cross sectional analysis.

BACKGROUND: HIV prevalence is increasing among female sex workers (FSWs) in Mexico's Northern border region, who experience multiple occupational risks. Improving vulnerable populations' education, empowerment, and access to preventive services are important components of harm reduction strategies. Given the increasing interest in adapting harm reduction principles from drug use to sex work and other public health responses to the HIV epidemic, we used a sex work harm reduction framework to guide our investigation of FSWs' HIV knowledge. METHODS: From 2004-2006, FSWs aged ≥18 years in Tijuana and Ciudad Juarez participated in a behavioral intervention study and completed structured interviews. Measures included HIV knowledge assessment and factors within each domain of our theoretical framework for sex work harms: (1) socio-demographic factors that may lead to sex work, (2) sex work characteristics and behaviors that may lead to harm, and (3) mutually reinforcing harms that lead to sex work and result from it (e.g., drug abuse). Negative binomial regression identified factors independently associated with suboptimal HIV knowledge (i.e., incorrect responses during the HIV knowledge assessment). RESULTS: Among 924 FSWs, the median proportion of incorrect responses was nearly one third (28% incorrect). Examination of item responses revealed misconceptions regarding specific transmission and prevention mechanisms, including prevention of mother to child transmission. Suboptimal HIV knowledge was independently associated with older age, lower education, living in Tijuana (vs. Ciudad Juarez), inconsistent condom use for vaginal sex with male clients, and lacking prior HIV testing. CONCLUSIONS: Our application of a sex work harm reduction framework to the study of FSWs' HIV knowledge is an important first step in enhancing HIV prevention efforts in Northern Mexican border cities. Our findings imply that interventions should identify and discredit local HIV misconceptions to improve knowledge of specific HIV transmission routes and self-protective strategies (e.g., condom negotiation). Interventions will require materials appropriate for women from diverse socio-economic backgrounds and may benefit from innovative harm reduction approaches such as peer education and outreach.

Deportation experiences of women who inject drugs in Tijuana, Mexico.

Deportation from the United States for drug offenses is common, yet the consequences of deportation for women drug users are poorly documented. In 2008, in Tijuana, Mexico, we conducted an exploratory qualitative study of migration, deportation, and drug abuse by interviewing 12 Mexican injection-drug-using women reporting U.S. deportation. Women reported heavy drug use before and after deportation, but greater financial instability and physical danger following deportation than when in the United States. We identified an unmet need for health and social services among deported drug-using women, including HIV prevention, drug treatment, physical and mental health services, and vocational training. Binational coordination is needed to help deported women resettle in Mexico.

A qualitative view of drug use behaviors of Mexican male injection drug users deported from the United States.

Deportees are a hidden yet highly vulnerable and numerous population. Significantly, little data exists about the substance use and deportation experiences of Mexicans deported from the United States. This pilot qualitative study describes illicit drug use behaviors among 24 Mexico-born male injection drug users (IDUs), ≥ 18 years old, residing in Tijuana, Mexico who self-identified as deportees from the United States. In-person interviews were conducted in Tijuana, Mexico in 2008. Content analysis of interview transcripts identified major themes in participants' experiences. Few participants had personal or family exposures to illicit drugs prior to their first U.S. migration. Participants reported numerous deportations. Social (i.e., friends/family, post-migration stressors) and environmental factors (e.g., drug availability) were perceived to contribute to substance use initiation in the U.S. Drugs consumed in the United States included marijuana, heroin, cocaine, methamphetamine, and crack. More than half of men were IDUs prior to deportation. Addiction and justice system experiences reportedly contributed to deportation. After deportation, several men injected new drugs, primarily heroin or methamphetamine, or a combination of both drugs. Many men perceived an increase in their substance use after deportation and reported shame and loss of familial social and economic support. Early intervention is needed to stem illicit drug use in Mexican migrant youths. Binational cooperation around migrant health issues is warranted. Migrant-oriented programs may expand components that address mental health and drug use behaviors in an effort to reduce transmission of blood-borne infections. Special considerations are merited for substance users in correctional systems in the United States and Mexico, as well as substance users in United States immigration detention centers. The health status and health behaviors of deportees are likely to impact receiving Mexican communities. Programs that address health, social, and economic issues may aid deportees in resettling in Mexico.

Prevention of HIV infection among injection drug users in resource-limited settings.

Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.

Pandemic (H1N1) 2009 Surveillance in Marginalized Populations, Tijuana, Mexico.

To detect early cases of pandemic (H1N1) 2009 infection, in 2009 we surveyed 303 persons from marginalized populations of drug users, sex workers, and homeless persons in Tijuana, Mexico. Six confirmed cases of pandemic (H1N1) 2009 were detected, and the use of rapid, mobile influenza testing was demonstrated.

Correlates of seeking injection assistance among injection drug users in Tijuana, Mexico.

Assisted injection among injection drug users (IDUs) remains understudied. We recruited 1,056 IDUs using respondent-driven sampling in Tijuana, Mexico. Participants underwent HIV and syphilis testing and structured interviews. One-quarter (25%) sought injection assistance in the past 6 months. Seeking injection assistance was independently associated with being female (adjusted odds ratio [AOR]= 2.59; 95% confidence interval [CI]= 1.73-3.90), being born outside Baja California (AOR = 1.75; CI = 1.26-2.42), having recent abscesses (AOR = 2.59; CI = 1.93-3.47), using syringes previously used by others in the past 6 months (AOR = 1.99; CI = 1.45-2.71), and ever being arrested for carrying sterile syringes (AOR = 1.55; CI = 1.15-2.09).

The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men.

BACKGROUND: Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial health problems may accelerate HIV transmission among men who have sex with men (MSM) in the United States. We aimed to assess how 5 syndemic conditions (depressive symptoms, heavy alcohol use, stimulant use, polydrug use, and childhood sexual abuse) affected HIV incidence and sexual risk behavior over time. METHODS: Eligible men in a large prospective cohort of sexually active HIV-uninfected MSM completed HIV testing and behavioral surveys at baseline and every 6 months for 48 months. We examined interrelationships between psychosocial problems and whether these interactions increased the odds of HIV risk behaviors and risk of seroconversion over study follow-up. RESULTS: Among 4295 men, prevalence of psychosocial conditions was substantial at baseline and was positively associated with each other. We identified a statistically significant positive dose-response relationship between numbers of syndemic conditions and HIV seroconversion for all comparisons (with the greatest hazard among those with 4-5 conditions, adjusted hazard ratio = 8.69; 95% confidence interval: 4.78 to 15.44). The number of syndemic conditions also predicted increased HIV-related risk behaviors over time, which mediated the syndemic-HIV seroconversion association. CONCLUSIONS: The accumulation of syndemic psychosocial problems predicted HIV-related sexual risk behaviors and seroconversion in a large sample of US MSM. Given the high prevalence of syndemic conditions among MSM and the moderate effect sizes attained by traditional brief behavioral interventions to date, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services.

Perceived risk of HIV infection among deported male injection drug users in Tijuana, Mexico.

Deported injection drug users (IDUs) in Mexico may be vulnerable to HIV infection following expulsion from the USA. We examined factors associated with HIV risk perception among a sample of deportees in Tijuana. From January to April 2010, 313 male IDUs who reported ever being deported from the USA completed a questionnaire. Overall, 35% (N=110) of deportees perceived HIV risk. In multivariate logistic regression analyses, factors independently associated with HIV risk perception included ever having a steady female partner in Tijuana post-deportation (adjusted odds ratio [AOR]: 2.26; 95% confidence interval [CI]: 1.01-5.07) and years spent in a US prison (AOR: 1.29 per year; 95% CI: 1.13-1.48). Conversely, years of drug injection use (AOR: 0.95 per year; 95% CI: 0.91-0.99), ever witnessing family members use drugs prior to first migration trip (AOR: 0.24; 95% CI: 0.09-0.65), years of residence in the USA (AOR: 0.91 per year; 95% CI: 0.84-0.98) and being a Tijuana native (AOR: 0.40; 95% CI: 0.16-0.99) were negatively associated with HIV risk perception. US-Mexico border cities that receive deported migrants should target HIV prevention interventions to specific subgroups, including drug-using male deportees. Interventions should consider migrant's time in the USA, the role of their social networks, and reducing missed opportunities for HIV testing/education.

Women's perspectives on female-initiated barrier methods for the prevention of HIV in the context of methamphetamine use and partner violence.

BACKGROUND: Female-initiated barrier methods for the prevention of HIV may be an effective alternative for drug-using women who are unable to negotiate safe sex, often as a result of physical and/or sexual partner violence. METHODS: Utilizing a SAVA (substance abuse, violence, and AIDS) syndemic framework, we qualitatively examined perspectives on female condoms and vaginal microbicides among 18 women with histories of methamphetamine abuse and partner violence in San Diego, California. FINDINGS: Most women were not interested in female condoms owing to perceived discomfort, difficulty of insertion, time-intensive effort, and unappealing appearance. Alternatively, most women viewed vaginal microbicides as a useful method. Positive aspects included convenience, ability to disguise as a lubricant, and a sense of control and empowerment. Concerns included possible side effects, timing of application, and unfavorable characteristics of the gel. Acceptability of female-initiated barrier methods was context dependent (i.e., partner type, level of drug use and violence that characterized the sexual relationship). CONCLUSIONS: Findings indicate that efforts are needed to address barriers identified for vaginal microbicides to increase its uptake in future HIV prevention trials and marketing of future Food and Drug Administration-approved products. Strategies should address gender-based inequalities (e.g., partner violence) experienced by drug-using women and promote female empowerment. Education on female-initiated barrier methods is also needed for women who use drugs, as well as health care providers and other professionals providing sexual health care and contraception to women with histories of drug use and partner violence.