Examining the Interplay Between Preexposure Prophylaxis (PrEP) and Gender-Related Stigmas as Barriers for PrEP Uptake Among Transgender Women in Tijuana, Mexico: A Mixed-Methods Study.

HIV prevalence among transgender women (TW) in Tijuana, Mexico is estimated at 22%. Pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition by > 90%, though uptake in Tijuana has been low due to limited availability. The interplay between PrEP and gender stigmas may also serve as a barrier to PrEP uptake among TW in Tijuana. Experiences of gender- and PrEP- stigmas were assessed quantitatively (Quan) among 110 HIV-negative TW and qualitatively (Qual) among 17 TW through semi-structured interviews guide by the Health Stigma and Discrimination Framework. Qual findings were triangulated with Quant data to identify factors that may support gender affirmation and reduce PrEP stigma in an explanatory sequential Quan → Qual fashion. Most participants were < 40 years of age (80%), while approximately half had at least a high school education (48.2%) and were accessing gender-affirming hormone therapy (56.4%). Mean expectations of gender stigma were greatest for endorsing negative future expectations from others (M = 17.69; possible range 0-36). PrEP stigma was prominent among those who associated negative stereotypes with PrEP users, such as poor judgment (M = 45.91; possible range 14-70) and high personal risk attributes (M = 28.61; possible range 12-60). While PrEP knowledge was low among the qualitative sample, participants identified gender-, PrEP-, and intersectional- stigmas as potential barriers to PrEP uptake. Participants suggested that resilience strategies used to combat gender stigma could also mitigate PrEP stigma. Enhancing resilience skills at the intersection of gender and PrEP stigma may reduce these barriers, facilitating greater PrEP uptake as it becomes more available in Mexico.

Safe Injection Self-Efficacy is Associated with HCV and HIV Seropositivity Among People Who Inject Drugs in the San Diego-Tijuana Border Region.

Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. PWID were recruited via street outreach for a longitudinal cohort study from October 2020-September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE score levels (low, medium, high) using ordinal logistic regression. Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to change the risk environment.

RESUMEN: La autoeficacia de inyección segura (SISE, por sus siglas en inglés) se asocia negativamente con conductas de riesgo de inyección entre las personas que se inyectan drogas (PWID, por sus siglas en inglés), pero no se ha examinado en diferentes entornos de riesgo. Comparamos las respuestas a una escala validada de SISE entre PWID en San Diego, California, y Tijuana, México, y examinamos los correlatos de SISE entre PWID en Tijuana. Participantes fueron reclutados por medio de alcance callejero para un estudio de cohorte longitudinal entre octubre 2020 ­septiembre de 2021. Comparamos los ítems de la escala SISE por ciudad. Debido a la baja variabilidad en los puntajes SISE entre los residentes de San Diego, restringimos el análisis de factores asociados con SISE a los residentes de Tijuana e identificamos factores correlacionados con niveles de SISE (bajo, medio, alto) mediante regresión logística ordinal. De 474 participantes, la mayoría eran hombres (74%), latinx (78%) y residentes de Tijuana (73%). La edad promedio fue de 44 años. Los puntajes medios de SISE entre los residentes de San Diego fueron altos (3.46 de un máximo de 4) en comparación con los residentes de Tijuana (media: 1.93). Entre los residentes de Tijuana, la raza blanca y haber residido previamente en San Diego se asociaron con puntajes más altos de SISE. La seropositividad para HCV y VIH, la falta de vivienda, el uso de fentanilo, la co-inyección de múltiples sustancias y una mayor frecuencia de inyecciónes se asociaron con puntajes más bajos de SISE. Encontramos profundas desigualdades entre SISE en Tijuana y San Diego, probablemente atribuibles a diferentes entornos de riesgo. Las asociaciones con fentanilo y la co-inyección de múltiples sustancias, la frecuencia de inyección y la seropositividad tanto para VIH como para HCV sugieren que SISE contribuye a los riesgos de transmisión de infecciones transmitidas por la sangre en Tijuana. SISE refleja un objetivo de intervención accionable para reducir las conductas de riesgo de inyección, pero se requieren intervenciones estructurales para cambiar el entorno de riesgo.

Implications and Lessons Learned While Using Social Media Advertisements to Promote Longitudinal Social Network Study Participation in Latino Men Who Have Sex with Men (LMSM): A Brief Report.

We assess the effectiveness of paid ads on social media platforms as a research recruitment tool with Latino men who have sex with men (LMSM). We deployed four paid ad campaigns July-September 2022 in English and Spanish on Meta and Grindr featuring happy or risqué images of LMSM, documenting engagement and cost metrics. The four campaigns generated a total of 1,893,738 impressions and 1078 clicks (0.057 click-through rate) with a total cost of $7,989.39. Of the 58 people who accessed the study screener, 31 completed it (53.4%), 13 were eligible (22.4%), but none enrolled. Comparing platforms, Meta had higher engagement metrics than Grindr, while Grindr had higher proportions of those who completed the screener (57.9%) and were eligible (26.3%) than Meta (52.6% and 21.0%, respectively). Challenges to using paid ads as an LMSM recruitment tool included intersecting pandemics (Mpox, COVID-19), and limited connection between platforms and staff for study enrollment.

Depression mediates the relationship between adverse childhood experiences and risky drinking among Hispanic young adults.

BACKGROUND AND OBJECTIVES: Hispanic young adults in the United States have consistently high rates of risky drinking, adverse childhood experiences (ACEs), depression, and anxiety. There is a positive association between ACEs and alcohol use among Hispanic populations; it is unknown if mental health symptomatology mediates this relationship. The purpose of this study was to test whether depression and anxiety mediated the relationship between ACEs and risky drinking among Hispanic young adults who engage in risky drinking. METHODS: Data from 264 Hispanic young adults, ages 19 to 30, were collected via an online questionnaire. Participants were recruited via social media, emails/listservs across colleges, the community, and web-panels. The questionnaire assessed ACEs, risky drinking, depression, and anxiety. We conducted a mediational analysis to test whether depression and anxiety mediated the relationship between ACEs and risky drinking. RESULTS: Of the sample, 59.8% identified as female and 40.2% as male. The average age was 24.37 (SD = 3.069). Participants (61%) identified as Mexican, Mexican American, or Chicano, and 84.1% identified as second-generation. ACEs were positively associated with risky drinking, depression, and anxiety. Depression mediated the relationship between ACEs and risky drinking. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Depression explained the association between ACEs and risky drinking among Hispanic young adults, adding to our understanding of how mediators can illustrate pathways that lead from ACEs to risky drinking. Practitioners and interventionists should continue supporting Hispanic youth by integrating them into early prevention programs to mitigate the mental health consequences of ACEs that could lead to risky drinking.

Injection Drug Use and Sexual Risk Behaviors Among People who Inject Drugs in Ukraine: A Random-Intercept Latent Transition Analysis.

HIV transmission in Ukraine is driven in part by unsafe injection drug use and sexual risk behaviors among people who inject drugs. We performed a random-intercept latent transition analysis on responses to 9 binary injection drug use and sexual behavior items from 1195 people who inject drugs with negative HIV status enrolled in a clustered randomized clinical trial of a social network intervention in Odessa, Donetsk, and Nikolayev, Ukraine. We identified 5 baseline classes: "Social injection/equipment-sharing" (11.7%), "Social injection" (25.9%), "High-risk collective preparation/splitting" (17.0%), "Collective preparation/splitting" (11.3%), and "Dealer-facilitated injection" (34.1%). After 12 months, intervention participants were more likely to transition to the "Collective preparation/splitting" class, which featured the fewest risk behaviors. Transitioning from the "Collective preparation/splitting" to the "Social injection/equipment-sharing" class was associated with HIV acquisition for control participants. Research to illuminate the stability of these patterns and how they may benefit from uniquely tailored programming to reduce unsafe behaviors is needed.

In the era of universal test and treat in Uganda, recent intimate partner violence is not associated with subsequent ART use or viral suppression.

Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023.

BACKGROUND: Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum. METHODS: Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era. RESULTS: We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined. CONCLUSIONS: The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

Adolescent alcohol use: use of social network analysis and cross-classified multilevel modeling to examine peer group, school, and neighborhood-level influences.

Background: Neighborhood-, school-, and peer-contexts play an important role in adolescent alcohol use behaviors. Methodological advances permit simultaneous modeling of these contexts to understand their relative and joint importance. Few empirical studies include these contexts, and studies that do typically: examine each context separately; include contexts for the sole purpose of accounting for clustering in the data; or do not disaggregate by sex.Objectives: This study takes an eco-epidemiologic approach to examine the role of socio-contextual contributions to variance in adolescent alcohol use. The primary parameters of interest are therefore variance rather than beta parameters (i.e. random rather than fixed effects). Sex-stratified models are also used to understand how each context may matter differently for male and female adolescents.Method: Data come from the National Longitudinal Study of Adolescent to Adult Health (n = 8,534 females, n = 8,102 males). We conduct social network analysis and traditional and cross-classified multilevel models (CCMM) in the full and sex-disaggregated samples.Results: In final CCMM, peer groups, schools, and neighborhoods contributed 10.5%, 10.8%, and 0.4%, respectively, to total variation in adolescent alcohol use. Results do not differ widely by gender.Conclusions: Peer groups and schools emerge as more salient contributing contexts relative to neighborhoods in adolescent alcohol use for males and females. These findings have both methodological and practical implications. Multilevel modeling can model contexts simultaneously to prevent the overestimation of variance in youth alcohol use explained by each context. Primary prevention strategies addressing youth alcohol use should focus on schools and peer networks.

Effects of a social network intervention on HIV seroconversion among people who inject drugs in Ukraine: moderation by network gender composition.

BACKGROUND: Women who inject drugs in Ukraine are disproportionately burdened by HIV. To help address the needs of this population, a greater understanding of how interventions may uniquely benefit women who inject drugs is needed. METHODS: Data come from a randomized controlled trial of a social network intervention targeting people who inject drugs in Ukraine (N = 1195). Indexes, plus two of their injection network members, received HIV testing and counseling (control arm) or HIV testing and counseling plus a social network intervention (intervention arm), in which indexes were trained to influence network members' risk behaviors. We used Cox regressions with interaction terms to assess differences in time to HIV seroconversion between arms by network gender composition and gender of the index. For significant interaction terms, we calculated simple effects, generated survival functions using Kaplan-Meier methods, and compared survival curves using log-rank tests. RESULTS: At 12 months, there were 45 seroconversions among women (40.0 [28.3, 51.7] per 100 person years) and 111 among men (28.4 [23.1, 33.6] per 100 person years) in the control arm; there were 27 seroconversions among women (17.1 [10.7, 23.6] per 100 person years) and 77 among men (18.7 [14.5, 22.9] per 100 person years) in the intervention arm. Network gender composition (but not gender of the index) moderated the intervention effect on HIV incidence (p < 0.05). Specifically, the intervention appeared to be even more protective against HIV acquisition as female gender composition increased. In the intervention arm, the HIV seroconversion hazard rate was 44% lower with 1 network female; 61% lower with 2 network females; and 72% lower with 3 network females. CONCLUSIONS: A greater number of women in an injection network, coupled with the provision of risk-reduction strategies, is associated with HIV risk-mitigation, though the mechanisms through which this occurs remain unclear. Findings can support new research and practice directions that prioritize women who inject drugs and more thoughtfully support their health and wellbeing.

Intersections between syndemic conditions and stages along the continuum of overdose risk among women who inject drugs in Mexicali, Mexico.

BACKGROUND: Research on women who inject drugs is scarce in low- and middle-income countries. Women experience unique harms such as sexism and sexual violence which translate into negative health outcomes. The present work aims to provide insight into the experiences of women who inject drugs at the US-Mexico border to identify social and health-related risk factors for overdose to guide harm reduction interventions across the Global South. METHODS: We recruited 25 women ≥ 18 years of age accessing harm reduction and sexual health services at a non-governmental harm reduction organization, "Verter", in Mexicali, Mexico. We employed purposeful sampling to recruit women who inject drugs who met eligibility criteria. We collected quantitative survey data and in-depth interview data. Analyses of both data sources involved the examination of descriptive statistics and thematic analysis, respectively, and were guided by the syndemic and continuum of overdose risk frameworks. RESULTS: Survey data demonstrated reports of initiating injection drug use at a young age, experiencing homelessness, engaging in sex work, being rejected by family members, experiencing physical violence, injecting in public spaces, and experiencing repeated overdose events. Interview data provided evidence of stigma and discrimination toward women, a lack of safe spaces and support systems, risk of overdose-related harms, sexual violence, and the overall need for harm reduction services. CONCLUSION: Women who inject drugs in Mexicali describe experiences of violence, overdose, and public injecting. Women are particularly vulnerable in the Mexicali context, as this area faces a noticeable lack of health and social services. Evidenced-based harm reduction strategies such as safe consumption sites and overdose prevention strategies (e.g., naloxone distribution and training) may benefit this population. Evidence from local organizations could help close the gap in service provision in low-resource settings like Mexico, where government action is almost nonexistent.

Correlates of impulsivity among female sex workers in Mexico.

Impulsivity is a trait characteristic that is associated with sexual risk behavior. We examined correlates of impulsivity among 602 female sex workers (FSWs) enrolled in a sexual risk reduction intervention in Mexico (2016-2020). Impulsivity was positively associated with condomless sex with clients. Higher levels of impulsivity were associated with greater use of alcohol and heavy drugs, use of illicit drugs with clients, sexual/physical abuse history, and clinical depression. Global public health policy that supports free substance abuse treatment in combination with psychotherapeutic treatments (e.g. regulation management skills) and behavioral-focused therapy may help to reduce HIV/STI incidence in this vulnerable population.

Impact of SHIELD Police Training on Knowledge of Syringe Possession Laws and Related Arrests in Tijuana, Mexico.

Between 2015 and 2018, we provided training for 1806 municipal police officers in Tijuana, Mexico, in an effort to improve their knowledge and behaviors related to HIV and injection drug use. Correct knowledge of syringe possession laws improved from 56% before training to 94% after training and was sustained at 24 months (75%). Knowledge improvement was associated with decreases in arrests for syringe possession over time (adjusted odds ratio [AOR] = 0.87; 95% confidence interval [CI] = 0.85, 0.90). Officers with correct knowledge had significantly lower odds of reporting arrests (AOR = 0.63; 95% CI = 0.44, 0.89). Training was associated with sustained improvements in knowledge and practices that advance public health. (Am J Public Health. 2022;112(6):860-864. https://doi.org/10.2105/AJPH.2021.306702).

Assessing Potential Outcomes Mediation in HIV Interventions.

Knowledge of causal processes through mediation analysis can help improve the effectiveness and reduce costs of public health programs, like HIV prevention and treatment interventions. Advancements in mediation using the potential outcomes framework provide a method for estimating the causal effect of interventions on outcomes via a mediating variable. The purpose of this paper is to provide practical information about mediation and the potential outcomes framework that can enhance data analysis and causal inference for intervention studies. Causal mediation effects are defined and then estimated using data from an HIV intervention randomized trial among people who inject drugs (PWID) in Ukraine. Results from a potential outcomes mediation analysis show that the intervention had a total causal effect on incident HIV infection such that participants in the experimental group were 36% less likely to become infected during the 12-month study than those in the control arm, but that neither self-efficacy nor network communication mediated this effect. Because neither putative mediator was significant, measurement and confounding issues should be investigated to rule out these mediators. Other putative mediators, such as injection frequency, route of administration, or HIV knowledge can be considered. Future research is underway to examine additional, multiple mediators explaining efficacy of the current intervention and sensitivity to confounding effects.

Transactional Sex, Alcohol Use and Intimate Partner Violence Against Women in the Rakai Region of Uganda.

Transactional sex (TS) is prevalent in sub-Saharan Africa. Women's engagement in TS is linked with HIV infection; little is known about the relationship between TS, intimate partner violence (IPV) and alcohol use-established HIV risk behaviors. Using modified Poisson regression, we assessed associations between TS and physical, verbal and sexual IPV among 8248 women (15-49 years) who participated in the Rakai Community Cohort Study across forty communities in Uganda. An interaction term assessed moderation between alcohol use and TS and no significant interaction effects were found. In adjusted analysis, alcohol use and TS were significantly associated with all forms of IPV. In stratified analysis, TS was only associated with IPV in agrarian communities; alcohol use was not associated with physical IPV in trade communities or sexual IPV in trade and fishing communities. Identifying differences in IPV risk factors by community type is critical for the development of tailored interventions.

RESUMEN: El sexo transaccional (ST) es frecuente en África subsahariana. La participación de las mujeres en el ST está relacionada con la infección por VIH; Se sabe poco sobre la relación entre el ST, la violencia de pareja íntima (VPI) y el consumo de alcohol: conductas de riesgo establecidas para el VIH. Utilizando la regresión de Poisson modificada, evaluamos las asociaciones entre el ST y la VPI física, verbal y sexual entre 8,248 mujeres (15-49 años) que participaron en el Estudio de cohorte de la comunidad Rakai en cuarenta comunidades de Uganda. Un término de interacción evaluó la moderación entre el consumo de alcohol y el ST y no se encontraron efectos de interacción significativos. En el análisis ajustado, el consumo de alcohol y el ST se asociaron significativamente con todas las formas de VPI. En el análisis estratificado, el ST solo se asoció con la VPI en las comunidades agrarias; El consumo de alcohol no se asoció con la VPI física en las comunidades comerciales ni con la VPI sexual en las comunidades comerciales y pesqueras. Identificar las diferencias en los factores de riesgo de la violencia de género por tipo de comunidad es fundamental para el desarrollo de intervenciones personalizadas.

Municipal police support for harm reduction services in officer-led referrals of people who inject drugs in Tijuana, Mexico.

BACKGROUND: Police constitute a structural determinant of health and HIV risk of people who inject drugs (PWID), and negative encounters with law enforcement present significant barriers to PWID access to harm reduction services. Conversely, police may facilitate access via officer-led referrals, potentiating prevention of HIV, overdose, and drug-related harms. We aimed to identify police characteristics associated with support for officer-led referrals to addiction treatment services and syringe service programs (SSP). We hypothesized that officers who believe harm reduction services are contradictory to policing priorities in terms of safety and crime reduction will be less likely to support police referrals. METHODS: Between January and June 2018, police officers (n = 305) in Tijuana, Mexico, completed self-administered surveys about referrals to harm reduction services during the 24-month follow-up visit as part of the SHIELD police training and longitudinal cohort study. Log-binomial regression was used to estimate adjusted prevalence ratios and model policing characteristics and attitudes related to officers' support for including addiction treatment and SSP in referrals. RESULTS: Respondents were primarily male (89%), patrol officers (86%) with a median age of 38 years (IQR 33-43). Overall, 89% endorsed referral to addiction services, whereas 53% endorsed SSP as acceptable targets of referrals. Officers endorsing addiction services were less likely to be assigned to high drug use districts (adjusted prevalence ratio [APR] = 0.50, 95% CI 0.24, 1.08) and more likely to agree that methadone programs reduce crime (APR = 4.66, 95% CI 2.05, 9.18) than officers who did not support addiction services. Officers endorsing SSPs were younger (adjusted prevalence ratio [APR] = 0.96 95% CI 0.93, 0.98), less likely to be assigned to high drug use districts (APR = 0.50, 95% CI 0.29, 0.87), more likely to believe that methadone programs reduce crime (APR = 2.43, 95% CI 1.30, 4.55), and less likely to believe that SSPs increase risk of needlestick injury for police (APR = 0.44, 0.27, 0.71). CONCLUSIONS: Beliefs related to the occupational impact of harm reduction services in terms of officer safety and crime reduction are associated with support for referral to related harm reduction services. Efforts to deflect PWID from carceral systems toward harm reduction by frontline police should include measures to improve officer knowledge and attitudes about harm reduction services as they relate to occupational safety and law enforcement priorities. TRIAL REGISTRATION: NCT02444403.

A Mixed Methods Analysis of the Venue-Related Social and Structural Context of Drug Use During Sex Among Male Clients of Female Sex Workers in Tijuana, Mexico.

Drug use during sex increases risks for HIV acquisition. Male clients of female sex workers (FSW) represent both a key population at risk for HIV as well as a transmission bridge population. In Tijuana, Mexico, drug use is prevalent and there is a need to understand male clients' drug use during sex with FSW. Characteristics of sex work venues may confer higher risks for drug use, risky sex, and HIV/STI. It is essential to understand the venue-related social and structural factors associated with drug use during sex in order to inform HIV prevention interventions with male clients in this region. We used a Mixed-Methods Sequential Explanatory Design to conduct an enriched examination of drug use during sex among male clients of FSW in Tijuana. Findings from logistic regression analysis showed that drug use during sex was significantly correlated with police harassment (AOR = 4.06, p < .001) and methamphetamine use (AOR = 33.77, p < .001). In-depth interview data provided rich meaning behind and context around the quantitative associations. Social and structural interventions to reduce police harassment, methamphetamine use, and promote condom availability are needed to reduce risks for HIV among male clients of FSW in Tijuana.

Sex Work as a Mediator Between Female Gender and Incident HIV Infection Among People Who Inject Drugs in Tijuana, Mexico.

We studied mechanisms driving gender differences in HIV incidence among 651 women and men who inject drugs (PWID) in Tijuana, Mexico, hypothesizing that sex work will mediate the association between female gender and HIV incidence. Of 43 HIV seroconversions occurring between 2011 and 2018, 8.8% were among females and 5.2% among males. HIV incidence density was significantly higher among females versus males (1.75 per 100 person years [PY], 95% CI 1.16-2.66, vs. 0.95 per 100 PY, 95% CI 0.62-1.47). Factors significantly associated with HIV seroconversion were: sex work (adjusted hazard ratio [aHR] = 2.25, 95% CI 1.05-4.80); methamphetamine injection (aHR = 2.30, 95% CI 1.12-4.73); and methamphetamine and heroin co-injection in the past six months (aHR = 2.26, 95% CI 1.23-4.15). In mediation analyses, sex work mediated a substantial proportion (84.3%) of the association between female gender and HIV incidence. Interventions should target female PWID who engage in sex work to reduce gender-related disparities in HIV incidence.

A Randomized Controlled Trial of a Texting Intervention to Maintain Sexual Risk Reduction with Clients Among Female Sex Workers in Tijuana and Ciudad Juarez, Mexico.

Mobile phone technology may help sustain reductions in HIV/STI transmission risk behaviors among female sex workers (FSWs). We examined the efficacy of a text messaging intervention designed to maintain behavioral improvements in safer sex practices among 602 FSWs in Tijuana and Ciudad Juarez, Mexico. We hypothesized that FSWs who received brief risk reduction counseling and theory-based safer sex maintenance text messages over a 24-month period would have fewer incident HIV/STIs and report greater maintenance of safer sex practices compared to FSWs who received counseling and texts on maintaining general health. Theory-based texts did not change the odds of becoming infected with HIV/STIs in either study site. However, they did lead to significant, sustained protected sex in Tijuana. Theory-based text messaging interventions may help sustain reductions in sexual risk behavior among FSWs.Trial Registration Clinical Trials.gov. Identifier: NCT02447484.

Maternal role strain and depressive symptoms among female sex workers in Mexico: the moderating role of sex work venue.

Stressors that arise in parenting are likely to have an adverse impact on the psychological well-being of female sex workers (FSWs), particularly in low- to middle-income countries (LMIC). This study examined the association between maternal role strain and depressive symptoms among 426 FSW mothers with dependent-age children (aged < 18 years) in Tijuana and Cd. Juarez, Mexico (2016-2017). Four dimensions of maternal role strain (e.g., child emotional and behavioral problems) were examined in relation to maternal depressive symptoms. We also investigated whether the relationship between maternal role strain and depressive symptoms was modified by venue of sex work. Compared to indoor/establishment-based FSWs, street-based FSWs reported significantly more child-related financial strain. In multiple regression analysis, having more depressive symptoms was associated with identifying as a street-based FSW, greater use of drugs, lower emotional support, more child-related financial strain and more emotional and behavioral problems in children. A significant interaction was identified such that the association between maternal role strain and depressive symptoms was stronger for indoor/establishment-based compared to street-based FSWs. These findings suggest the need to address parenting strain and type of sex work venue in the development of counseling programs to improve the mental health of FSWs in LMIC.

Mood, Meth, Condom Use, and Gender: Latent Growth Curve Modeling Results from a Randomized Trial.

Methamphetamine use poses increased risk for HIV and other sexually transmitted infections. There is robust evidence that methamphetamine use increases sexual risk behavior, like condomless sex, primarily among men who have sex with men but also among heterosexual women and men. Gender differences have been found among women and men who use meth, and there is a high degree of interconnectedness between meth use, depression, and condomless sex. The aims of the current study are to evaluate the efficacy of a theory-based, tri-focal intervention designed to reduce depression, meth use, and condomless sex among women and men, and to examine gender as a moderator of efficacy. A total of 432 HIV-negative women and men who use meth participated in a two-arm randomized controlled trial and completed baseline and follow-up assessments at 4, 8, and 12 months. We used latent growth curve modeling techniques to analyze the data. Results showed that while all participants exhibited reductions in depression, meth use, and condomless sex, the intervention and comparison groups did not differ in changes over time. However, we did find a significant gender moderation effect, such that among men, those in the intervention arm reported greater reductions in meth use relative to those in the comparison group; reduced meth use was associated with reduced condomless sex, but not depression. In contrast, women in the intervention condition did not differ from women in the comparison condition in changes in any of the three outcome variables. Interventions targeting heterosexual women and men who use meth must be gender-specific, and take into account the unique vulnerabilities and experiences of women, including the perceived positive aspects of using meth, gendered power dynamics, higher depression, and violence.