"It's hard for everyone" systemic barriers to home confinement to prevent community spread of COVID-19.

Rapid identification and isolation/quarantine of COVID-19 cases or close contacts, respectively, is a vital tool to support safe, in-person learning. However, safe isolation or quarantine for a young child also necessitates home confinement for at least one adult caregiver, as well as rapid learning material development by the teacher to minimize learning loss. The purpose of this study is to better understand barriers and supports to student home confinement. We conducted a mixed-methods study using focus group discussions and a self-administered online survey with parents and staff members from 12 elementary schools and childcare sites across San Diego County serving low-income and socially vulnerable families. Focus group participants reported that mental distress and loneliness, learning loss, childcare, food, income loss, and overcrowded housing were major barriers related to home confinement. The experiences described by FGD participants were prevalent in a concurrent community survey: 25% of participants reported that isolation would be extremely difficult for a household member who tested positive or was exposed to COVID-19, and 20% were extremely concerned about learning loss while in isolation or quarantine. Our findings suggest that there are serious structural impediments to safely completing the entire recommended course of isolation or quarantine, and that the potential for isolation or quarantine may also lead to increased hesitancy to access diagnostic testing.

BACKGROUND: During the COVID-19 pandemic, home confinement (isolation and quarantine) are important public health tools to keep children learning in-person at schools. However, isolation or quarantine for young children also means that often their caregivers must also go into home confinement, as well as forcing teachers to adapt their lessons to online teaching. PURPOSE: The purpose of this study is to better understand what makes home confinement comfortable or difficult for students and their families. METHODS: We did focus group discussions and shared an online survey with parents and staff members from 12 elementary schools and childcare centers across San Diego County vulnerable families. RESULTS: Focus group participants said that mental distress and loneliness, learning loss, childcare, food, income loss, and overcrowded housing made home confinement hard to do. Also 25% of survey participants said that isolation would be difficult for a household member who tested positive or was exposed to COVID-19, and 20% were really concerned about their child's learning loss if the family had to isolate or do quarantine. CONCLUSIONS: Our study's results suggest that there are serious structural issues for school families to safely go into isolation or quarantine, and because of this may make families more hesitant to get tested for COVID-19.

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade.

This paper examines the prevalence of and potential for community mobilization (CM) and its association with HIV/STI risk, substance use, and violence victimization among women, particularly those using substances, in the sex trade in Tijuana, Mexico. METHODS: 195 women participated in Mujeres Unidas (K01DA036439 Urada) under a longitudinal survey study, "Proyecto Mapa de Salud" (R01DA028692, PI: Brouwer). Local health/social service providers (N = 16) were also interviewed. RESULTS: 39% of women who participated in community mobilization activities used substances. In adjusted analyses (n = 135), participation in CM activities (n = 26) was more likely among women who did not report substance use (AOR: 4.36, CI: 1.11-17.16), perceived a right to a life free from violence (AOR: 9.28, CI: 2.03-59.26), talked/worked with peers in the sex trade to change a situation (AOR: 7.87, CI: 2.03-30.57), witnessed violence where they worked (AOR: 4.45, CI: 1.24-15.96), and accessed free condoms (AOR: 1.54, CI: 1.01-2.35). Forty-five of the women using substances demonstrated their potential for engaging in asset-based community development (ABCD) with service providers in Mujeres Unidas meetings. CONCLUSION: Women using substances, vs. those who did not, demonstrated their potential to engage in ABCD strategies. Women's empowerment, safety, and health could be enhanced by communities engaging in ABCD strategies that build and bridge social capital for marginalized women who otherwise have few exit and recovery options.

Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis.

BACKGROUND: In 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana. METHODS: We constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions. RESULTS: Modeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770-21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640-970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions. CONCLUSIONS: Elimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.

Women Trading Sex in a U.S.-Mexico Border City: A Qualitative Study of the Barriers and Facilitators to Finding Community and Voice.

Poverty and income inequality can increase a woman's decision to engage in risky transactional sex, and may lead to unimaginable harms, such as violence, substance use, and human trafficking. This study examines the facilitators and barriers to finding community and voice among women trading sex in Tijuana, Mexico, and what factors, such as socio-structural support, violence, and substance use, may impact their potential to engage with others, including human service providers. Sixty qualitative in-depth interviews were conducted with women trading sex in Tijuana, Mexico. Researchers met with participants for in-depth-face-to-face structured interviews. Data were coded using ATLAS.ti. Participants were aged 19-73 (mean: 37), 98% were of Mexican nationality, 90% reported trading sex independent of the control of others, with 58% identified as independent and street-based. Thirty percent of women trading sex reported substance use (excluding marijuana) and 20% reported injection drug use within 30 days. The majority reported no involvement in mobilization activities, but 85% expressed interest. However, barriers included stigma, cultural gender norms, partner violence, and privacy in regards to disclosure of sex trade involvement, moral conflict (revealing one's involvement in sex trade), involvement in substance use, human trafficking, and feeling powerless. Facilitators were having a safe space to meet, peer support, self-esteem, feeling heard, knowledge of rights, economic need to support families, and staying healthy. Findings imply the potential to go beyond mobilizing limited groups of women in the sex trade and instead involve whole community mobilization; that is, to reach and include the more vulnerable women (substance use, trafficked) in supportive services (social services, exit strategies, better healthcare opportunities, and/or education for healthcare providers to help break societal stigmas regarding women in the sex trade) and to change the status of women in society in general.

Impact of Public Safety Policies on Human Immunodeficiency Virus Transmission Dynamics in Tijuana, Mexico.

Background: North Tijuana, Mexico is home to many individuals at high risk for transmitting and acquiring human immunodeficiency virus (HIV). Recently, policy shifts by local government impacted how these individuals were handled by authorities. Here we examined how this affected regional HIV transmission dynamics. Methods: HIV pol sequences and associated demographic information were collected from 8 research studies enrolling persons in Tijuana and were used to infer viral transmission patterns. To evaluate the impact of recent policy changes on HIV transmission dynamics, qualitative interviews were performed on a subset of recently infected individuals. Results: Between 2004 and 2016, 288 unique HIV pol sequences were obtained from individuals in Tijuana, including 46.4% from men who have sex with men, 42.1% from individuals reporting transactional sex, and 27.8% from persons who inject drugs (some individuals had >1 risk factor). Forty-two percent of sequences linked to at least 1 other sequence, forming 37 transmission clusters. Thirty-two individuals seroconverted during the observation period, including 8 between April and July 2016. Three of these individuals were putatively linked together. Qualitative interviews suggested changes in policing led individuals to shift locations of residence and injection drug use, leading to increased risk taking (eg, sharing needles). Conclusions: Near real-time molecular epidemiologic analyses identified a cluster of linked transmissions temporally associated with policy shifts. Interviews suggested these shifts may have led to increased risk taking among individuals at high risk for HIV acquisition. With all public policy shifts, downstream impacts need to be carefully considered, as even well-intentioned policies can have major public health consequences.

Prevalence and correlates of neck injection among people who inject drugs in Tijuana, Mexico.

INTRODUCTION AND AIMS: Injecting drugs in the neck has been related to adverse health conditions such as jugular vein thrombosis, deep neck infections, aneurysm, haematomas, airway obstruction, vocal cord paralysis and wound botulism, among others. We identified prevalence and correlates of neck injection among people who inject drugs (PWID) in Tijuana, Mexico. DESIGN AND METHODS: Beginning in 2011, PWID aged ≥18 years who injected drugs within the last month were recruited into a prospective cohort. At baseline and semi-annually, PWID completed interviewer-administered surveys soliciting data on drug-injecting practices. Logistic regression was used to identify predictors of injecting in the neck as the most frequent injection site at a single visit. RESULTS: Of 380 PWID, 35.3% injected in the neck at least once in the past 6 months, among whom 71.6% reported it as their most common injection site, the most common injecting site after the arms (47%). Controlling for age, years injecting and injecting frequency, injecting heroin and methamphetamine two or more times per day and having sought injection assistance were associated with injecting in the neck [adjusted odds ratios (AOR): 2.12; 95% confidence intervals (CI): 1.27-3.53 and AOR: 2.65; 95% CI: 1.52-4.53 respectively]. DISCUSSION AND CONCLUSIONS: Injecting in the neck was very common among PWID in Tijuana and was associated with polydrug use and seeking injection assistance. Tailoring harm reduction education interventions for individuals who provide injection assistance ('hit doctors') may allow for the dissemination of safe injecting knowledge to reduce injection-related morbidity and mortality.

High dead-space syringe use among people who inject drugs in Tijuana, Mexico.

BACKGROUND: High dead-space syringes (HDSS) are believed to confer an elevated risk of acquiring HIV and other blood-borne infections. OBJECTIVES: We identified prevalence and correlates of HDSS use among injection drug users (IDU) in Tijuana, Mexico, where syringe purchase and possession is legal without a prescription. METHODS: Beginning in 2011, IDU who reported being 18 years or older and injected drugs within the last month were recruited into a prospective study. At baseline and semi-annually, 557 IDU underwent HIV-testing and interviewer-administered surveys. Logistic regression was used to identify correlates of using HDSS. RESULTS: Of 557 IDU, 40% had ever used HDSS, mostly because no other syringe type was available (72%), or because they were easier to get (20%). Controlling for sex and age at first injection, use of HDSS was associated with cocaine as the first drug injected (Adjusted Odds Ratio [AOR]: 2.68; Confidence Interval 95% [CI]: 1.15-6.22), having been stopped or arrested by police (AOR: 1.84; 95% CI: 1.11-3.07), being deported from the US (AOR: 1.64; 95% CI:1.06-2.53), and believing it is illegal to carry syringes (AOR:1.78; 95% CI: 1.01-3.15). CONCLUSION: Use of HDSS is surprisingly common among IDU in Tijuana. Efforts are needed to expand coverage of low-dead space syringes through existing syringe exchange programs. Education is required to increase awareness of the harms associated with HDSS, and to inform IDU that syringe possession is legal across Mexico.