Changes in injecting versus smoking heroin, fentanyl, and methamphetamine among people who inject drugs in San Diego, California, 2020-2023.

BACKGROUND: Amidst an increasingly toxic drug supply in North America, people who inject drugs may be transitioning to smoking them. We aimed to assess changes in injecting and smoking opioids and methamphetamine among a cohort of people who inject drugs from San Diego, California. METHODS: Over five six-month periods spanning October 2020-April 2023, we assessed prevalence of injecting and smoking opioids or methamphetamine and whether participants used these drugs more frequently by smoking than injecting. Multivariable Poisson regression via generalized estimating equations was used to examine time trends. RESULTS: Of 362 participants, median age was 40 years; a minority were female (29%), Hispanic/Latinx/Mexican (45%), and housed (33%). Among this cohort, of whom 100% injected (and 84% injected and smoked) in period one (October 2020-April 2021), by period five (November 2022-April 2023), 34% only smoked, 59% injected and smoked, and 7% only injected. By period five, the adjusted relative risk (aRR) of injecting opioids was 0.41 (95% Confidence Interval [CI]: 0.33, 0.51) and the aRR for injecting methamphetamine was 0.50 (95% CI: 0.39, 0.63) compared to period one. Risks for smoking fentanyl rose significantly during period three (aRR=1.44, 95% CI: 1.06, 1.94), four (aRR=1.65, 95% CI: 1.24, 2.20) and five (aRR=1.90, 95% CI: 1.43, 2.53) compared to period one. Risks for smoking heroin and methamphetamine more frequently than injecting these drugs increased across all periods. CONCLUSIONS: Opioid and methamphetamine injection declined precipitously, with notable increases in smoking these drugs. Research is needed to understand the health consequences of these trends.

Changes in injecting versus smoking heroin, fentanyl, and methamphetamine among people who inject drugs in San Diego, California, 2020 to 2023.

Background: Amidst a rapidly evolving drug supply in North America, people who inject drugs may be transitioning to smoking them. We aimed to assess changes in injecting and smoking heroin, fentanyl and methamphetamine among a cohort of people who injected drugs at baseline from San Diego, California. Methods: Over five six-month periods spanning October 2020-April 2023, we assessed prevalence of injecting and smoking opioids or methamphetamine and whether participants used these drugs more frequently by smoking than injecting. Multivariable Poisson regression via Generalized Estimating Equations was used to examine time trends. Results: Of 362 participants, median age was 40 years; most were male (72%), non-Hispanic (55%), and unhoused (67%). Among this cohort, of whom 100% injected (or injected and smoked) at baseline, by period five (two years later), 34% reported only smoking, while 59% injected and smoked, and 7% only injected. By period five, the adjusted relative risk (aRR) of injecting opioids was 0.41 (95% Confidence Interval [CI]: 0.33, 0.51) compared to period one, and the aRR for injecting methamphetamine was 0.50 (95% CI: 0.39, 0.63). Compared to period one, risks for smoking fentanyl rose significantly during period three (aRR=1.44, 95% CI: 1.06, 1.94), four (aRR=1.65, 95% CI: 1.24, 2.20) and five (aRR=1.90, 95% CI: 1.43, 2.53). Risks for smoking heroin and methamphetamine more frequently than injecting these drugs increased across all periods. Conclusions: Opioid and methamphetamine injection declined precipitously, with notable increases in smoking these drugs. Research is urgently needed to understand the health consequences of these trends.

"A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex.

Background: People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods: From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results: Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion: Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

Long-Acting Injectable Human Immunodeficiency Virus Pre-Exposure Prophylaxis Preferred Over Other Modalities Among People Who Inject Drugs: Findings from a Qualitative Study in California.

People who inject drugs (PWID) have extraordinarily low uptake of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) despite high levels of need. Long-acting PrEP modalities hold promise for HIV prevention among PWID, but product preferences remain poorly understood. From September to November 2021, we conducted qualitative interviews with 28 HIV-negative, adult (≥18 years) PWID in San Diego County, CA, to explore their perspectives on daily oral PrEP pills and long-acting PrEP modalities (i.e., injections, implants, intravaginal rings, and broadly neutralizing antibodies), which we explained using standard scripts. Thematic analysis identified variations in PrEP modality interest and acceptability. We identified three key factors across the 28 interviews that appeared to influence PrEP modality preferences: perceived convenience of use, invasiveness, and familiarity (based on past experience). Overall, most participants preferred injectable PrEP over other modalities because they viewed injectable medications as convenient, noninvasive, and familiar. While injectable PrEP was recently approved for use in the United States and was most the acceptable PrEP modality in this sample, our findings suggest that intervention and implementation research is urgently needed to improve our understanding of strategies that could support access, uptake, and sustained adherence to longer-acting PrEP for PWID.

Eliminación de la hepatitis C en usuarios de drogas inyectadas en México durante la pandemia de COVID-19 / Hepatitis C elimination among people who inject drugs in Mexico during the COVID-19 pandemic

Resumen En 2019, México fue uno de los primeros países en Latinoamérica en comprometer recursos para eliminar la hepatitis C antes de 2030. Un año después de este compromiso, la pandemia mundial de COVID-19 desvió la atención hacia las necesidades inmediatas de salud para combatir la propagación de esta última. Como resultado, los esfuerzos para implementar programas de prevención y manejo de la hepatitis C se suspendieron indefinidamente. Asimismo, las poblaciones con alto riesgo de contraer el virus de la hepatitis C y que representan el mayor peso de la epidemia nacional, como las personas que se inyectan drogas y las personas que viven con infección por el virus de la inmunodeficia humana, permanecen expuestas a disparidades de salud extremas que potencialmente se han exacerbado durante la pandemia de COVID-19. En este artículo discutimos el impacto potencial que la pandemia de COVID-19 ha tenido sobre los esfuerzos de eliminación de la hepatitis C en México y la necesidad urgente de reanudarlos, ya que sin ellos los objetivos de eliminación no se alcanzarán en el país en 2030.

Abstract In 2019, Mexico was one of the first countries in Latin America to commit resources to achieve hepatitis C elimination by 2030. One year after this commitment, the global COVID-19 pandemic diverted attention to address immediate health needs to combat the spread of the disease. As a result, efforts to implement hepatitis C prevention and management programs were indefinitely postponed. Furthermore, populations at high risk of contracting the hepatitis C virus (HCV) and who bear the greatest burden of HCV national epidemic, including people who inject drugs and people who live with human immunodeficiency virus infection, remain exposed to extreme health disparities, which have potentially been exacerbated during the COVID-19 pandemic. In this article, we discuss the potential impact the COVID-19 pandemic has had on HCV elimination efforts in Mexico and the urgent need to resume them, since without these efforts, HCV elimination goals are likely not be achieved in the country by 2030.

Human Immunodeficiency Virus transmission by HIV Risk Group and Along the HIV Care Continuum: A Contrast of 6 US Cities.

BACKGROUND: Understanding the sources of HIV transmission provides a basis for prioritizing HIV prevention resources in specific geographic regions and populations. This study estimated the number, proportion, and rate of HIV transmissions attributable to individuals along the HIV care continuum within different HIV transmission risk groups in 6 US cities. METHODS: We used a dynamic, compartmental HIV transmission model that draws on racial behavior-specific or ethnic behavior-specific and risk behavior-specific linkage to HIV care and use of HIV prevention services from local, state, and national surveillance sources. We estimated the rate and number of HIV transmissions attributable to individuals in the stage of acute undiagnosed HIV, nonacute undiagnosed HIV, HIV diagnosed but antiretroviral therapy (ART) naïve, off ART, and on ART, stratified by HIV transmission group for the 2019 calendar year. RESULTS: Individuals with undiagnosed nonacute HIV infection accounted for the highest proportion of total transmissions in every city, ranging from 36.8% (26.7%-44.9%) in New York City to 64.9% (47.0%-71.6%) in Baltimore. Individuals who had discontinued ART contributed to the second highest percentage of total infections in 4 of 6 cities. Individuals with acute HIV had the highest transmission rate per 100 person-years, ranging from 76.4 (58.9-135.9) in Miami to 160.2 (85.7-302.8) in Baltimore. CONCLUSION: These findings underline the importance of both early diagnosis and improved ART retention for ending the HIV epidemic in the United States. Differences in the sources of transmission across cities indicate that localized priority setting to effectively address diverse microepidemics at different stages of epidemic control is necessary.

A comparison of the effectiveness of respondent-driven and venue-based sampling for identifying undiagnosed HIV infection among cisgender men who have sex with men and transgender women in Tijuana, Mexico.

BACKGROUND: Efforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low- and middle-income countries (LMIC). We compared the effectiveness of respondent-driven sampling (RDS) and venue-based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico. METHODS: Between March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing. RESULTS: Of those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States. CONCLUSIONS: Despite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC.

Geographical and socioeconomic disparities in opioid access in Mexico, 2015-19: a retrospective analysis of surveillance data.

BACKGROUND: In 2015, Mexico implemented regulatory changes and an electronic system to improve access to prescription opioids. We aimed to investigate trends in opioid dispensing after the implementation of these changes and assess how opioid dispensing varied geographically and by socioeconomic status. METHODS: In this retrospective analysis of prescription medication surveillance data, we analysed dispensing data for group 1 medications (all opioids, including morphine, methadone, hydromorphone, oxycodone, tapentadol, fentanyl, sufentanil, and remifentanil) obtained from the Federal Commission for the Protection against Sanitary Risk database for 32 states and six large metropolitan areas in Mexico. We calculated crude annual opioid prescriptions per 10 000 people at the national, state, and municipal levels. Adapting methods from the report of the Lancet Commission on Palliative Care and Pain Relief, we calculated the need for palliative opioids by state, and then assessed the observed opioid dispensing rates as a percentage of expected need by geographical socioeconomic status. Within the six major metropolitan areas, we mapped the geocoded location of opioid prescriptions and assessed the association between opioid dispensing and socioeconomic status as well as the association between opioid dispensing and time to US border crossing for areas on the US-Mexico border. FINDINGS: Between June 25, 2015, and Oct 7, 2019, opioid dispensing rates increased by an average of 13% (95% CI 6·8-19·6) per quarter (3 months). The overall national opioid dispensing rate during the study period was 26·3 prescriptions per 10 000 inhabitants. States with a higher socioeconomic status had higher opioid dispensing rates than states with lower socioeconomic status (rate ratio [RR] 1·88, 95% CI 1·33-2·58, p=0·00016) after controlling for the estimated opioid requirement per state, the presence of methadone clinics, and the presence of tertiary hospitals and cancer centres. The same association between opioid dispensing and socioeconomic status was observed in the metropolitan areas, and in those metropolitan areas on the US-Mexico border a 20% decrease (RR 0·80, 95% CI 0·75-0·86) in opioid dispensation was observed per each SD increase (SD 17·1 min) in travel time to the border. INTERPRETATION: Measures introduced by the Mexican federal Government to increase opioid access for patients with palliative care needs were only marginally successful in raising opioid prescription rates. Opioid access should be improved for patients with palliative care needs who live in geographical areas of lower socioeconomic status. FUNDING: US National Institutes of Health.

Dynamics and Dispersal of Local Human Immunodeficiency Virus Epidemics Within San Diego and Across the San Diego-Tijuana Border.

BACKGROUND: Evolutionary analyses of well-annotated human immunodeficiency virus (HIV) sequence data can provide insights into viral transmission patterns and associated factors. Here, we explored the transmission dynamics of the HIV-1 subtype B epidemic across the San Diego (US) and Tijuana (Mexico) border region to identify factors that could help guide public health policy. METHODS: HIV pol sequences were collected from people with HIV in San Diego County and Tijuana between 1996-2018. A multistep phylogenetic approach was used to characterize the dynamics of spread. The contributions of geospatial factors and HIV risk group to the local dynamics were evaluated. RESULTS: Phylogeographic analyses of the 2034 sequences revealed an important contribution of local transmission in sustaining the epidemic, as well as a complex viral migration network across the region. Geospatial viral dispersal between San Diego communities occurred predominantly among men who have sex with men, with central San Diego being the main source (34.9%) and recipient (39.5%) of migration events. HIV migration was more frequent from San Diego county towards Tijuana than vice versa. Migrations were best explained by the driving time between locations. CONCLUSIONS: The US-Mexico border may not be a major barrier to the spread of HIV, which may stimulate coordinated transnational intervention approaches. Whereas a focus on central San Diego has the potential to avert most spread, the substantial viral migration independent of central San Diego shows that county-wide efforts will be more effective. Combined, this work shows that epidemiological information gleaned from pathogen genomes can uncover mechanisms that underlie sustained spread and, in turn, can be a building block of public health decision-making.

The Potential Epidemiological Impact of Coronavirus Disease 2019 (COVID-19) on the Human Immunodeficiency Virus (HIV) Epidemic and the Cost-effectiveness of Linked, Opt-out HIV Testing: A Modeling Study in 6 US Cities.

BACKGROUND: Widespread viral and serological testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may present a unique opportunity to also test for human immunodeficiency virus (HIV) infection. We estimated the potential impact of adding linked, opt-out HIV testing alongside SARS-CoV-2 testing on the HIV incidence and the cost-effectiveness of this strategy in 6 US cities. METHODS: Using a previously calibrated dynamic HIV transmission model, we constructed 3 sets of scenarios for each city: (1) sustained current levels of HIV-related treatment and prevention services (status quo); (2) temporary disruptions in health services and changes in sexual and injection risk behaviors at discrete levels between 0%-50%; and (3) linked HIV and SARS-CoV-2 testing offered to 10%-90% of the adult population in addition to Scenario 2. We estimated the cumulative number of HIV infections between 2020-2025 and the incremental cost-effectiveness ratios of linked HIV testing over 20 years. RESULTS: In the absence of linked, opt-out HIV testing, we estimated a total of a 16.5% decrease in HIV infections between 2020-2025 in the best-case scenario (50% reduction in risk behaviors and no service disruptions), and a 9.0% increase in the worst-case scenario (no behavioral change and 50% reduction in service access). We estimated that HIV testing (offered at 10%-90% levels) could avert a total of 576-7225 (1.6%-17.2%) new infections. The intervention would require an initial investment of $20.6M-$220.7M across cities; however, the intervention would ultimately result in savings in health-care costs in each city. CONCLUSIONS: A campaign in which HIV testing is linked with SARS-CoV-2 testing could substantially reduce the HIV incidence and reduce direct and indirect health care costs attributable to HIV.

Can the 'Ending the HIV Epidemic' initiative transition the USA towards HIV/AIDS epidemic control?

: Using a dynamic HIV transmission model calibrated for six USA cities, we projected HIV incidence from 2020 to 2040 and estimated whether an established UNAIDS HIV epidemic control target could be met under ideal implementation of optimal combination strategies previously defined for each city. Four of six cities (Atlanta, Baltimore, New York City and Seattle) were projected to achieve epidemic control by 2040 and we identified differences in reaching epidemic control across racial/ethnic groups.

"Ending the Epidemic" Will Not Happen Without Addressing Racial/Ethnic Disparities in the United States Human Immunodeficiency Virus Epidemic.

We estimated human immunodeficiency virus incidence and incidence rate ratios (IRRs) for black and Hispanic vs white populations in 6 cities in the United States (2020-2030). Large reductions in incidence are possible, but without elimination of disparities in healthcare access, we found that wide disparities persisted for black compared with white populations in particular (lowest IRR, 1.69 [95% credible interval, 1.19-2.30]).

Automated image analysis of instagram posts: Implications for risk perception and communication in public health using a case study of #HIV.

People's perceptions about health risks, including their risk of acquiring HIV, are impacted in part by who they see portrayed as at risk in the media. Viewers in these cases are asking themselves "do those portrayed as at risk look like me?" An accurate perception of risk is critical for high-risk populations, who already suffer from a range of health disparities. Yet, to date no study has evaluated the demographic representation of health-related content from social media. The objective of this case study was to apply automated image recognition software to examine the demographic profile of faces in Instagram posts containing the hashtag #HIV (obtained from January 2017 through July 2018) and compare this to the demographic breakdown of those most at risk of a new HIV diagnosis (estimates of incidence of new HIV diagnoses from the 2017 US Centers for Disease Control HIV Surveillance Report). We discovered 26,766 Instagram posts containing #HIV authored in American English with 10,036 (37.5%) containing a detectable human face with a total of 18,227 faces (mean = 1.8, standard deviation [SD] = 1.7). Faces skewed older (47% vs. 11% were 35-39 years old), more female (41% vs. 19%), more white (43% vs. 26%), less black (31% vs 44%), and less Hispanic (13% vs 25%) on Instagram than for new HIV diagnoses. The results were similarly skewed among the subset of #HIV posts mentioning pre-exposure prophylaxis (PrEP). This disparity might lead Instagram users to potentially misjudge their own HIV risk and delay prophylactic behaviors. Social media managers and organic advocates should be encouraged to share images that better reflect at-risk populations so as not to further marginalize these populations and to reduce disparity in risk perception. Replication of our methods for additional diseases, such as cancer, is warranted to discover and address other misrepresentations.

Responses to addiction help-seeking from Alexa, Siri, Google Assistant, Cortana, and Bixby intelligent virtual assistants.

We investigated how intelligent virtual assistants (IVA), including Amazon's Alexa, Apple's Siri, Google Assistant, Microsoft's Cortana, and Samsung's Bixby, responded to addiction help-seeking queries. We recorded if IVAs provided a singular response and if so, did they link users to treatment or treatment referral services. Only 4 of the 70 help-seeking queries presented to the five IVAs returned singular responses, with the remainder prompting confusion (e.g., "did I say something wrong?"). When asked "help me quit drugs" Alexa responded with a definition for the word drugs. "Help me quit…smoking" or "tobacco" on Google Assistant returned Dr. QuitNow (a cessation app), while on Siri "help me quit pot" promoted a marijuana retailer. IVAs should be revised to promote free, remote, federally sponsored addiction services, such as SAMSHA's 1-800-662-HELP helpline. This would benefit millions of IVA users now and more to come as IVAs displace existing information-seeking engines.

Ending the Epidemic in America Will Not Happen if the Status Quo Continues: Modeled Projections for Human Immunodeficiency Virus Incidence in 6 US Cities.

We estimated 10-year (2020-2030) trajectories for human immunodeficiency virus incidence in 6 US cities. Estimated incidence will only decrease in 2 of 6 cities, with the overall population-weighted incidence decreasing 3.1% (95% credible interval [CrI], -1.0% to 8.5%) by 2025, and 4.3% (95% CrI, -2.6% to 12.7%) by 2030 across cities. Targeted, context-specific combination implementation strategies will be necessary to meet the newly established national targets.

Syringe sharing among people who inject drugs in Tijuana: before and after the Global Fund / Uso compartido de jeringas entre las personas que se inyectan drogas en Tijuana: antes y después del Fondo Mundial

Abstract Introduction Needle and syringe programs (NSP) reduce syringe sharing and HIV transmission among people who inject drugs (PWID). However, their effectiveness relies on sufficient individual and population level coverage. In Tijuana, Mexico, the Global Fund (GF) supported NSP during 10/2011-12/2013, but withdrew funds at the end of 2013 following Mexico's re-classification as an upper-middle income country. Objective We tested the hypothesis of higher NSP access and lower receptive syringe sharing among PWID in Tijuana during the GF support period compared to pre-GF initiation and post-GF withdrawal. Method We used data from an ongoing cohort study of PWID in Tijuana (03/2011-10/2015) to implement a segmented regression analysis investigating changes in the self-reported probability of NSP access, reported difficulty in finding sterile syringes and receptive syringe sharing before GF initiation and after GF discontinuation. Results We found a large significant increase in the probability of NSP access (+.07) and decrease in receptive syringe sharing (-.23) right after GF initiation, which continued over the GF period. Subsequently, we found a significant decline in NSP access (-.05) and an increase in receptive syringe sharing (+.02) right after post-GF withdrawal, which continued thereafter. Discussion and conclusion We demonstrated significant temporal changes in NSP access and receptive syringe sharing among PWID in Tijuana after GF initiation and withdrawal consistent with our hypothesis. Coordinated efforts with local authorities are needed to sustain major coverage NSP in settings receiving GF or external aid to guarantee continuity of harm reduction services and prevent reinside in risk behaviors associated with HIV transmission.

Resumen Antecedentes Los programas de intercambio de jeringas (PIJ) reducen la transmisión del VIH entre las personas que se inyectan drogas (PID). Sin embargo, su efectividad depende de una cobertura suficiente a nivel individual y poblacional. En Tijuana, México, el Fondo Mundial (FM) apoyó los PIJ durante 10/2011-12/2013, pero retiró los fondos a fines de 2013. Objetivo Probamos la hipótesis de un mayor acceso a los PIJ y un menor uso receptivo de jeringas compartidas entre las PID en Tijuana durante el período de financiamiento del FM en comparación con el periodo anterior y posterior al FM. Método Usando datos de un estudio de cohorte de PID en Tijuana (03/2011-10/2015), implementamos un análisis de regresión segmentado para investigar cambios en la probabilidad de acceso a las PIJ, la dificultad para encontrar jeringas estériles y el uso receptivo de jeringas compartidas sobre los periodos pre-, durante y post-FM. Resultados Identificamos un aumento en la probabilidad de acceso a PIJ (+.07) y una disminución en el uso de jeringas compartidas (-.23) justo después del inicio del FM, ambos significativos, que se sostuvieron durante el período del FM. Después del retiro del FM, identificamos una disminución en el acceso a PIJ (-.05) y un aumento en el uso de jeringas compartidas (+.02), ambos también significativos. Discusión y conclusión Esfuerzos coordinados con las autoridades locales son necesarios para garantizar una mayor cobertura de los programas de reducción del daño, independientemente de financiamientos externos, para prevenir reincidir en las conductas de riesgo para el VIH en PID.

Developing a dynamic HIV transmission model for 6 U.S. cities: An evidence synthesis.

BACKGROUND: Dynamic HIV transmission models can provide evidence-based guidance on optimal combination implementation strategies to treat and prevent HIV/AIDS. However, these models can be extremely data intensive, and the availability of good-quality data characterizing regional microepidemics varies substantially within and across countries. We aim to provide a comprehensive and transparent description of an evidence synthesis process and reporting framework employed to populate and calibrate a dynamic, compartmental HIV transmission model for six US cities. METHODS: We executed a mixed-method evidence synthesis strategy to populate model parameters in six categories: (i) initial HIV-negative and HIV-infected populations; (ii) parameters used to calculate the probability of HIV transmission; (iii) screening, diagnosis, treatment and HIV disease progression; (iv) HIV prevention programs; (v) the costs of medical care; and (vi) health utility weights for each stage of HIV disease progression. We identified parameters that required city-specific data and stratification by gender, risk group and race/ethnicity a priori and sought out databases for primary analysis to augment our evidence synthesis. We ranked the quality of each parameter using context- and domain-specific criteria and verified sources and assumptions with our scientific advisory committee. FINDINGS: To inform the 1,667 parameters needed to populate our model, we synthesized evidence from 59 peer-reviewed publications and 24 public health and surveillance reports and executed primary analyses using 11 data sets. Of these 1,667 parameters, 1,517 (91%) were city-specific and 150 (9%) were common for all cities. Notably, 1,074 (64%), 201 (12%) and 312 (19%) parameters corresponded to categories (i), (ii) and (iii), respectively. Parameters ranked as best- to moderate-quality evidence comprised 39% of the common parameters and ranged from 56%-60% across cities for the city-specific parameters. We identified variation in parameter values across cities as well as within cities across risk and race/ethnic groups. CONCLUSIONS: Better integration of modelling in decision making can be achieved by systematically reporting on the evidence synthesis process that is used to populate models, and by explicitly assessing the quality of data entered into the model. The effective communication of this process can help prioritize data collection of the most informative components of local HIV prevention and care services in order to reduce decision uncertainty and strengthen model conclusions.

Prevalence of HIV/STIs and correlates with municipal characteristics among female sex workers in 13 Mexican cities / Prevalencia de VIH/ITS y correlaciones con carácterísticas municipales entre trabajadoras sexuales en 13 ciudades mexicanas

Abstract: Objective: To identify correlates of HIV/STI prevalence among 13 cities with varying sizes of female sex worker (FSW) populations and municipal characteristics in Mexico. Materials and methods: FSWs underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia. Logistic regression explored variations in HIV/STI prevalence. Results: Among FSWs (n=1 092), prevalence across 13 sites was: HIV: 0.4% (range: 0%-1.4%): syphilis: 7.8% (range: 0%-17.2%); chlamydia: 15.3% (range: 5.7%-32.2%); gonorrhea: 2.9% (range 0%-13.8%), and any HIV/STI: 23% (range: 9.9%-46%). Municipalities with high human development scores and a lower municipal marginalization index had higher odds of combined HIV/STI prevalence. After controlling for site-specific variability in municipal characteristics, greater risk of HIV/STIs was associated with lower education, having a spouse diagnosed or treated for an STI, unaffordability of condoms, and having non-Mexican clients. Conclusions: Prevalence of HIV/STIs varies across Mexican municipalities indicating the need for surveillance to identify hotspots for targeted resource allocation.

Resumen: Objetivo: Identificar correlaciones de la prevalencia de VIH / ITS entre 13 ciudades con diferentes tamaños de población de trabajadoras sexuales y características municipales en México. Material y métodos: Las trabajadoras sexuales fueron entrevistadas y recibieron pruebas de VIH, sífilis, gonorrea y clamidia. La regresión logística exploró las variaciones en la prevalencia del VIH/ITS. Resultados: Entre las trabajadoras sexuales (n = 1 092), la prevalencia en 13 sitios fue: VIH: 0.4% (rango: 0-1.4%): sífilis: 7.8% (rango: 0-17.2%); clamidia: 15.3% (rango: 5.7-32.2%); gonorrea: 2.9% (rango 0-13.8%) y cualquier VIH/ITS: 23% (rango: 9.9-46%). Los municipios con altos puntajes de desarrollo humano y menor índice de marginación municipal tuvieron una mayor probabilidad de prevalencia combinada de VIH/ITS. Después de controlar la variabilidad específica del sitio en las características municipales, el mayor riesgo de VIH / ITS se asoció con menor educación, tener un cónyuge diagnosticado o tratado para una ITS, imposibilidad de conseguir condones y tener clientes no mexicanos. Conclusiones: La prevalencia de VIH/ITS varía entre los municipios mexicanos, lo que indica la necesidad de una vigilancia para identificar hotspots para la asignación selectiva.

The global response and unmet actions for HIV and sex workers.

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5-11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights-a key recommendation in our Lancet Series-has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.