Ethics in Mental Health Research with Haitian Migrants: Lessons from a Community-Based Study in Santiago, Chile.

Migration research poses several unique challenges and opportunities. Conducting ethical global health practice, especially when studying migrant mental health, is of particular concern. This article explores seven challenges and lessons learned in our mixed-methods study conducted to assess the impact of the migration experience on Haitian migrants' mental health in Santiago, Chile. The primary challenges were recruiting in a highly mobile population, building trust and community participation, overcoming language barriers, safety considerations during the Covid-19 pandemic, mitigating potential negative impacts of research on the community, providing psychological support, and finding meaningful ways to benefit the community. We propose moving toward a better and more ethical migrant research practice by ensuring language accessibility, hiring community members for the study team, working with local institutions and nongovernmental organizations, and maintaining sustainable connections.

"Border closure only increased precariousness": a qualitative analysis of the effects of restrictive measures during the COVID-19 pandemic on Venezuelan's health and human rights in South America.

BACKGROUND: In 2010, a political and social crisis pushed thousands of Venezuelans out of their country; today, seven million Venezuelans live abroad. In addition, during the COVID-19 pandemic, border closure increased and affected specific vulnerable migration flows, such as Venezuelans trying to migrate to Chile through the Northern borders. In this context, there is little evidence of migrants' health status and needs, their access to health services, and other basic needs (e.g., housing) from a human rights perspective. Therefore, we qualitatively explored the effects of border closure due to the COVID-19 pandemic on Venezuelan migrants' health and human rights, focusing on access to healthcare in the Northern Chilean border that adjoins Peru and Bolivia. METHODS: Following a case-study qualitative design, we conducted an ethnography that included participatory observation of relevant sites (e.g., hospitals, main squares, migrant shelters) in Antofagasta, Iquique, and Arica and 30 in-depth interviews with actors in the health sector (n = 7), experts from the non-governmental sector (n = 16), and governmental actors (n = 7) in three large cities close to the Northern border. RESULTS: We found four main dimensions: (i) border and migration processes, (ii) specific groups and intersectionality, (iii) barriers to healthcare services, and (iv) regional and local responses to the crisis during the COVID-19 pandemic. Programs characterized by the presence of healthcare providers in the field were essential to attend to migrants' health needs at borders. CONCLUSIONS: Coordination between actors is crucial to implement regional protocols that respond to current migration phenomena and migrants' health needs. Health policies using a human rights approach are urgently required to respond to migrants' healthcare needs at borders in South America.

Traducción, validación, y adaptación del español al Kreyol-creole haitiano de la Escala de Depresión del Centro de Estudios Epidemiológicos (CESD-R-20)

Introducción. A pesar de la importante presencia de la población haitiana en países de América Latina, existen pocos estudios que evalúen la salud mental en esta población; una de las razones es la falta de instrumentos psicométricos en kreyol (creole haitiano). Objetivo. Adaptar la versión en español de la Escala de Depresión del Centro de Estudios Epidemiológicos (CESD-R-20) al kreyol. Métodos. Estudio transversal de muestreo bietápico con 207 migrantes haitianos viviendo en Santiago de Chile, se tradujo y retrotradujo la Escala CESD-R-20 del español al kreyol. Resultados. 132 participantes respondieron la encuesta en kreyol y 75 en español. Las técnicas de detección de la dimensionalidad recomiendan retener un único componente y tres factores, con pocas excepciones a través de las muestras. Las soluciones factoriales llevan a retener un único factor, que presenta un Alfa de Cronbach =0.92 (IC: 0.90-0.94) adecuado. Estos resultados indican que se necesita un único factor. Discusión y conclusión. La adaptación del instrumento CESD-R-20 de español al kreyol obtiene evidencias de validez favorables y puede servir para iniciar nuevos estudios en población migrante haitiana en su trayecto por América Latina, si bien es necesario seguir ampliando el proceso de validación.

Introduction. Although the Haitian migrant population has a significant presence in Latin American countries, a few studies assess this population's mental health; one of the reasons is the lack of psychometric instruments in kreyol (Haitian Creole). Objective. Adapt the Spanish version of the Depression Scale of the Center for Epidemiological Studies (CESD-R-20) into kreyol. Methods. Based on a cross-sectional two-stage cluster sampling with 207 Haitian migrants living in Santiago de Chile, we conducted translation and back translation of the CESD-R-20 Scale from Spanish to kreyol; additionally, we reached an adapted version in Spanish. Results. In total, 132 participants answered the survey in Kreyol and 75 in Spanish. Dimensionality detection techniques recommend retaining a single component and three factors, with few exceptions across samples. Exploration of factor solutions leads to the retention of a single factor, which has an adequate Cronbach's alpha=0.92 (IC: 0.90;0.94). These results indicate that only one factor is needed. Discussion and conclusion. The adaptation of the Spanish CESD-R-20 instrument to Kreyol has obtained favorable validity evidence and can be used to initiate new studies on the Haitian migrant population on their journey through Latin America, although the validation process needs to be further extended.

Does substance use disorder treatment completion reduce the risk of treatment readmission in Chile?

BACKGROUND: Recovery from substance use disorders (SUD) often entails multiple treatment episodes, which clashes with a context of a treatment system with limited resources and long waiting. Treatment retention and completion have been pointed out as key elements for sustainable achievement; however, most of the evidence generated focuses on opioids and injected substances, which is hardly transferable to the Latin American context. OBJECTIVES: This study aims to estimate the effect of SUD treatment completion on the risk of being readmitted to a SUD treatment in Chile. METHODS: We conducted a retrospective analysis on a database of 107,559 treatment episodes from 85,048 adult patients admitted to SUD treatment during 2010-2019 in Chile. We adjusted two separate Prentice Williams and Petersen Gap Time models, to explore the association between treatment completion (vs. non-completion) and up to the third treatment readmission among residential and ambulatory modalities while controlling for time-varying covariates. To examine whether the effect of treatment completion differs between events, we included an interaction term with the stratification variable. RESULTS: We found that completing the treatment cuts readmission risk for the first event by 17% (Average Hazard Ratio [95% CI] = 0.83 [0.78, 0.88]) and by 14% for the second entry (Average Hazard Ratio [95% CI] = 0.86 [0.78, 0.94]) in ambulatory treatments. We did not find evidence that completing a treatment reduces the readmission risk for residential treatments or third attempts in ambulatory ones. CONCLUSION: Treatment completion was associated with benefits in cutting readmission risk for the first and second episodes in ambulatory treatments among Chilean adults. It is important to explore different mechanisms than treatment retention for residential treatments.

The Epidemiology of Violent Deaths in Chile between 2001 and 2018: Prevalence, Trends, and Correlates.

BACKGROUND: Despite its enormous health and social burden, there are limited published studies describing the epidemiology of violent deaths in Chile. We described violent mortality rate trends in Chile between 2001 and 2018, its current spatial distribution and ecological level correlates. METHODS: A population-based study using publicly accessible data. We calculated age-adjusted mortality rates per 100,000 persons for sex, age, intention, and mechanism of death. Next, we used linear regression to estimate time trends for sex and intention. We then employed hierarchical Poisson analyses to model the spatial distribution across 345 municipalities and the influence of six ecological level variables. RESULTS: The average rate of violent death in Chile between 2001 and 2018 was 15.9 per 100,000 people, with the majority (70.3%) of these attributed to suicide. Suffocation was the most common mechanism of death for suicide (82.3%) and cut/pierce for homicide (43.1%), followed by firearm (33.2%). Violent deaths are trending downward in Chile across all categories except suicides by women, which have remained stable. Poverty rates and urban population were positively associated with violent mortality rates. CONCLUSIONS: Although violence-related deaths seem to be decreasing, disparities across gender, age group, and geographic location may have continuing effects on mortality rates.

Hoping for a Better Future during COVID-19: How Migration Plans Are Protective of Depressive Symptoms for Haitian Migrants Living in Chile.

This paper explores the migration experiences, perceived COVID-19 impacts, and depression symptoms among Haitian migrants living in Santiago, Chile. Ninety-five participants from eight neighborhoods with a high density of Haitian migrants were recruited. Descriptive statistics, univariate analysis, and logistic regression analysis were conducted. Chi-squared tests were used to confirm univariate results. We found that 22% of participants had major depressive symptoms based on the CESD-R-20 scale, 87% reported major life changes due to COVID-19, and 78% said their migration plans had changed due to the pandemic. Factors associated with more depressive symptoms were being in debt (OR = 3.43) and experiencing discrimination (ORs: 0.60 to 6.19). Factors associated with less odds of depressive symptoms were social support (ORs: 0.06 to 0.25), change in migration plans due to COVID-19 (OR = 0.30), and planning to leave Chile (OR = 0.20). After accounting for relevant factors, planning to leave Chile is significantly predictive of fewer symptoms of depression. Haitian migrants living in Chile had a high prevalence of depression. Planning to leave Chile was a significant protector against depressive symptoms. Future studies should explore how nuanced experiences of uncertainty play out in migrants' lives, mental well-being, and planning for their future.

Migration and Mobility: Correlates of Recent HIV Testing Among Substance Using Female Sex Workers at the Mexico-Guatemala Border.

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.

RESUMEN: El objetivo de este artículo es determinar la asociación entre viajar a otro país para ejercer el comercio sexual y el acceso a una prueba reciente de VIH, en una población de mujeres trabajadoras sexuales en la frontera de México con Guatemala. Entre el 2012 y 2015, utilizando un muestreo por conveniencia y por referencia de pares, se invitó a 255 mujeres trabajadoras sexuales en la frontera sur de México a participar en este proyecto de investigación. Las participantes completaron una encuesta que comprendió preguntas sociodemográficas así como experiencias de migración y movilidad, características del trabajo sexual, y patrones de uso de sustancia. Utilizamos un marco conceptual que se ilustra en una Gráfica Acíclica Dirigida (DAG) el cual sirvió para guiar nuestro análisis. Realizamos análisis de regresión logística cruda y ajustada para evaluar la asociación entre experiencias de movilidad y haber recibido una prueba de VIH en el último año. En general, el porcentaje de haber recibido una prueba de VIH en el último año fue bajo (41%); después de considerar covariables relevantes; (ej., interacción con organizaciones y servicios de salud, características del trabajo sexual) encontramos que viajar a otro país para ejercer el comercio sexual está asociado con haber recibido una prueba de VIH en el último año. Es importante que, en el futuro, se concentren esfuerzos en servicios de prevención del VIH que sean voluntarios, no estigmatizantes, y que se enfoquen en mujeres trabajadoras sexuales menos móviles.

Intercepted journeys: Associations between migration and mobility experiences and depressive symptoms among substance using migrants at the Mexico-Guatemala border.

Substance use and depressive psychiatric symptoms have been associated with migration and mobility. The Mexico-Guatemala border is a key transit point for internal, regional, and international migration flows. However, there is limited knowledge of the role of substance use, migration, and mobility on mental health among migrants at this border. Our paper explores the association of migration and mobility patterns with possible major depressive symptoms among migrants at this key geographic region. We recruited 392 substance-using migrants using modified time-location sampling. Crude and adjusted logistic regression models were developed. We found that 12% of the sample had possible major depressive symptoms. After adjusting for relevant covariates, including gender, income, and perceived homelessness, we found that recent rural-urban and short-term migrants had higher odds of possible major depressive symptoms, whereas international migrants had lower odds. Findings of this paper suggest that although migrants experience hardship and uncertainty, they may respond with complex and nuanced forms of coping and planning.

"At Least I Didn't Get Raped": A Qualitative Exploration of IPV and Reproductive Coercion among Adolescent Girls Seeking Family Planning in Mexico.

Adolescent girls who report intimate partner violence (IPV) are at an increased risk of experiencing reproductive coercion (RC); both these forms of gender-based violence (GBV) are associated with unintended pregnancy. Yet little is known about these experiences among adolescent girls in Mexico. Qualitative data were collected as part of formative research for the adaptation of an evidence-based intervention to address RC and IPV in community health centers in Tijuana, Mexico. From September, 2017 to January, 2018, adolescent girls aged 16 to 20 years old (n = 20) seeking voluntary family planning (FP) services were identified and recruited from two publicly funded community health centers. We conducted semi-structured, in-depth interviews and analyzed the transcripts using inductive and deductive techniques. Participants in this sample commonly described experiencing IPV and RC (including pregnancy coercion and contraceptive sabotage), which many girls reported resulted in unintended pregnancy. Further, participants' narratives and general lack of knowledge on how to cope with IPV or RC illuminated the acceptability of offering GBV prevention intervention within FP clinics serving this population. Findings highlight an urgent need to prevent IPV and RC, and reduce risk for unintended pregnancy among adolescent girls in this region and the potential of FP clinics to serve as a safe space for intervention delivery. Findings contribute to the limited qualitative evidence from Mexico, describing adolescent girl's experiences of IPV and RC, strategies for preventing pregnancy in the context of RC, and opportunities for support from FP providers.

"I would rather do it myself": injection initiation and current injection patterns among women who inject drugs in Tijuana, Mexico.

BACKGROUND: Women who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico. METHODS: Semistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants. RESULTS: The interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to. CONCLUSIONS: The narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico.

"He is the Same as Me": Key Populations' Acceptability and Experience of a Community-Based Peer Navigator Intervention to Support Engagement in HIV Care in Tijuana, Mexico.

Engagement in the HIV care continuum among people living with HIV is essential to prevent ongoing transmission. Although there is evidence for the need for comprehensive approaches (e.g., peer navigation) to improve the HIV care continuum, there is limited knowledge of how the peer navigation model might work to improve the HIV care continuum in low resource settings among Latinx key populations (e.g., persons who inject drugs, female sex workers, men who have sex with men, and transgender women). Therefore, this article aims to qualitatively assess members of key populations' acceptability of Conexiones Saludables (Healthy Connections), a community-based peer navigation intervention implemented in Tijuana, Mexico. This analysis draws upon the postintervention survey data from 34 participants and data from qualitative interviews with 10 participants. Participants found the intervention to be acceptable and discussed the ways in which peer navigators were influential in educating participants about HIV, antiretroviral therapy (ART), linking participants to existing HIV care and ancillary services in Tijuana, and in providing emotional and instrumental support to facilitate engagement in HIV treatment and ART adherence. The intervention emphasized the use of peer navigators who had a deep understanding of the sociostructural barriers (e.g., substance use, homelessness) that HIV-positive key populations face in Tijuana. Findings from this study may inform programs with highly vulnerable populations in similar settings.

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.

"Pick up anything that moves": a qualitative analysis of a police crackdown against people who use drugs in Tijuana, Mexico.

BACKGROUND: Homeless people who use drugs (PWUD) are often displaced, detained, and/or forced into drug treatment during police crackdowns. Such operations follow a zero-tolerance approach to law enforcement and have a deleterious impact on the health of PWUD. In Mexico, municipal police officers (MPOs) conducted the largest crackdown documented at the Tijuana River Canal (Tijuana Mejora) to dismantle an open drug market. We analyzed active-duty MPOs' attitudes on the rationale, implementation, and outcomes of the crackdown. We also included the involvement of non-governmental allies in the disguised imprisonment as drug treatment referral and potential legal consequences of having illegally detained PWUD. METHODS: Between February-June 2016, 20 semi-structured interviews were conducted with MPOs in Tijuana. Interviews were transcribed, translated and coded using a consensus-based approach. Emergent themes, trends and frameworks were analyzed through a hermeneutic grounded theory protocol. RESULTS: Participants recognized the limitations of Tijuana Mejora in effectively controlling crime and addressing drug treatment solutions. MPOs perceived that the intent of the operation was to displace and detain homeless PWUD, not to assist or rehabilitate them. The police operation was largely justified as a public safety measure to reduce the risk of injury due to flooding, decrease drug consumption among PWUD and protect local tourism from PWUD. Some participants perceived the crackdown as a successful public health and safety measure while others highlighted occupational risks to MPOs and potential human rights violations of PWUD. CONCLUSIONS: Tijuana Mejora illustrated why public and private actors align in enforcing zero-tolerance drug policy. Perceptions of care are often based on captivity of the diseased, not in health and well-being of PWUD. Officer perceptions shed light on the many limitations of this punitive policing tool in this context. A shift towards evidence-based municipal strategies to address drug use, wherein police are perceived as partners in harm reduction rather than antagonists, is warranted.

The influence of migration in substance use practices and HIV/STI-related risks of female sex workers at a dynamic border crossing.

We explored the association of international migration with substance use and HIV/STI risk factors among female sex workers (FSW). Using modified time-location sampling, we recruited 266 FSW at the Mexico-Guatemala border. Crude and adjusted logistic regression models were used to evaluate the relationships. HIV risks, such as frequent hard drug use and drug use in another country, were greater for migrant compared to nonmigrant FSW. However, more migrant versus nonmigrant FSW reported consistent condom use with clients and having a health card. Our study highlights regional patterns of substance use among FSW and risk or protective behaviors related to migration status.

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.

Addressing Police Occupational Safety During an Opioid Crisis: The Syringe Threat and Injury Correlates (STIC) Score.

OBJECTIVE: To develop and validate syringe threat and injury correlates (STIC) score to measure police vulnerability to needlestick injury (NSI). METHODS: Tijuana police officers (N = 1788) received NSI training (2015 to 2016). STIC score incorporates five self-reported behaviors: syringe confiscation, transportation, breaking, discarding, and arrest for syringe possession. Multivariable logistic regression was used to evaluate the association between STIC score and recent NSI. RESULTS: Twenty-three (1.5%) officers reported NSI; higher among women than men (3.8% vs 1.2%; P = 0.007). STIC variables had high internal consistency, a distribution of 4.0, a mode of 1.0, a mean (sd) of 2.0 (0.8), and a median (interquartile range [IQR]) of 2.0 (1.2 to 2.6). STIC was associated with recent NSI; odds of NSI being 2.4 times higher for each point increase (P-value <0.0001). CONCLUSIONS: STIC score is a novel tool for assessing NSI risk and prevention program success among police.

The Role of Gender in the Health and Human Rights Practices of Police: The SHIELD Study in Tijuana, Mexico.

Globally, punitive drug law enforcement drives human rights violations. Drug control tactics, such as syringe confiscation and drug-related arrests, also cascade into health harms among people who use drugs. The role of police officer characteristics in shaping such enforcement and measures to reform police practices remains underexamined. We evaluated gender differences in syringe confiscation and syringe-related arrest behaviors among municipal police officers in Tijuana, Mexico, where syringe possession is legal. In the context of the SHIELD Study focusing on aligning policing with harm reduction measures, our baseline sample covered municipal police officers who reported having occupational contact with syringes. We used multivariable logistic regression with robust variance estimation via a generalized estimating equation to identify correlates of syringe-related policing behaviors. Among respondent officers (n=1,555), 12% were female. After considering possible confounding variables, such as district of service and work experience, female officers were significantly less likely to report confiscating syringes or arresting individuals for syringe possession. Consideration of officer gender is important in the design of interventions to improve the health and human rights of people who inject drugs and other highly policed groups, as well as measures to safeguard officer occupational safety. The feminization of law enforcement deserves special consideration as an imperative in reducing the public health harms of policing.

Interactive Versus Video-Based Training of Police to Communicate Syringe Legality to People Who Inject Drugs: The SHIELD Study, Mexico, 2015-2016.

Objectives. To assess how instructional techniques affect officers' intent to communicate syringe legality during searches in Tijuana, Mexico, where pervasive syringe confiscation potentiates risk of HIV and HCV among people who inject drugs (PWID) and of occupational needle-stick injury among police. Methods. Using the SHIELD (Safety and Health Integration in the Enforcement of Laws on Drugs) model, Tijuana police underwent training to encourage communication of syringe possession legality to PWID. Trainees received either passive video or interactive role-play exercise on safer search techniques. We used logistic regression to assess the training's impact on self-reported intent to communicate syringe legality by training type and gender. Results. Officers (n = 1749) were mostly men (86%) assigned to patrol (84%). After the training, intent to communicate the law improved markedly: from 20% to 39% (video group) and 20% to 58% (interactive group). Gender and training type significantly predicted intent to communicate syringe legality. Male and female officers' adjusted odds ratios in the interactive group were 5.37 (95% confidence interval [CI] = 4.56, 6.33) and 9.16 (95% CI = 5.88, 14.28), respectively, after the training. Conclusions. To more effectively persuade police to endorse harm reduction and occupational safety practices, police trainings should include interactive elements.

Factors associated with HIV testing among men who have sex with men in Guatemala City.

Although men who have sex with men (MSM) have the highest human immunodeficiency virus (HIV) prevalence in Guatemala, prevention efforts have been focused on other vulnerable populations. Respondent-driven sampling was used to recruit 444 MSM in Guatemala City to explore factors related to HIV testing among MSM. About 56% of participants reported HIV testing in the past 12 months, which was associated with a public MSM status (adjusted odds ratio (AOR) 2.08; 95% CI 1.02-4.26), participating in peer HIV prevention intervention (AOR 3.71; 95% CI 1.86-7.43), having at least one casual male partner (AOR 2.16; 95% CI 1.11-4.20), and practicing only insertive anal sex (AOR 3.35; 95% CI 1.59-7.09). Men with comprehensive HIV knowledge (AOR 2.63; 95% CI 1.38-5.02) were also more likely to have been tested. Further interventions in Guatemala targeting the most hidden MSM are needed.

Substance Use among Female Sex Workers in Two US-Mexico Border Cities: Associations with Age of Entry.

BACKGROUND: Research has documented consistent associations between entry into sex work as a minor and sexual HIV risk. However, previous studies have not examined whether substance use and related HIV risk are elevated among those who enter sex work under age 18. METHODS: Quantitative data were collected via time-location sampling of 603 female sex workers (FSWs) ages 18 years and older residing in two Mexico-US border cities. Age of entry into sex work (categorized as 15 years or younger, 16-17 years, or 18 years and older) was assessed as a predictor of substance use (forced and voluntary) within the first month post-entry and recent (past 30 days) substance use with clients. RESULTS: Compared to those who entered as adults, participants who entered sex work at age 15 or younger were significantly more likely to report drug use (AOR = 5.2, CI = 2.9-8.9) and forced drug use within the first 30 days of entry (AOR= 6.0, CI = 1.9-18.9), as well as past month drug use with clients (AOR= 3.4, CI = 1.9-5.8). Similar results were found among participants who entered sex work at age 16-17. CONCLUSIONS: Increased risk of recent substance use with clients indicates continuing elevated risk for those entering sex work at these early ages. Early and forced substance use at entry may underlie the elevated risk of HIV infection consistently observed among this population.