BackgroundFSWs who inject drugs (FSW-IDUs) can acquire HIV through high risk sexual and injection behaviors. We studied correlates of HIV infection among FSW-IDUs in northern Mexico, where sex work is quasi-legal and syringes can be legally obtained without a prescription.MethodsFSW-IDUs>18 years old who reported injecting drugs and recent unprotected sex with clients in Tijuana and Ciudad Juarez underwent surveys and HIV/STI testing. Logistic regression identified correlates of HIV infection.ResultsOf 620 FSW-IDUs, prevalence of HIV, gonorrhea, Chlamydia, trichomonas, syphilis titers ≥1∶8, or any of these infections was 5.3%, 4%, 13%, 35%, 10% and 72%, respectively. Compared to other FSW-IDUs, HIV-positive women were more likely to: have syphilis titers ≥1∶8 (36% vs. 9%, p<0.001), often/always inject drugs with clients (55% vs. 32%, p = 0.01), and experience confiscation of syringes by police (49% vs. 28%, p = 0.02). Factors independently associated with HIV infection were syphilis titers ≥1∶8, often/always injecting with clients and police confiscation of syringes. Women who obtained syringes from NEPs (needle exchange programs) within the last month had lower odds of HIV infection associated with active syphilis, but among non-NEP attenders, the odds of HIV infection associated with active syphilis was significantly elevated.ConclusionsFactors operating in both the micro-social environment (i.e., injecting drugs with clients) and policy environment (i.e., having syringes confiscated by police, attending NEPs) predominated as factors associated with risk of HIV infection, rather than individual-level risk behaviors. Interventions should target unjustified policing practices, clients' risk behaviors and HIV/STI prevention through NEPs.

Objective: To characterize the overlap between injection drug use and sex work by women in Tijuana and Cd. Juarez, situated on the Mexico-U.S. border. Methods:FSWs aged ≥18 years who were not knowingly HIV-positive and reported having unprotected sex with ≥1 client in the prior two months underwent interviews and testing for HIV, syphilis gonorrhea and Chlamydia. Logistic regression identified factors associated with injecting drugs within the last month.Results: Of 924 FSWs, 18.0% had ever injected drugs. Among FSW-IDUs (N=114), prevalence of HIV, syphilis titers >1:8, gonorrhea and Chlamydia was significantly higher at 12.3%, 22.7%, 15.2% and 21.2% compared to 4.8%, 13.1%, 5.2% and 11.9% among other FSWs (N=810). FSWIDUs also had more clients in the past six months (median: 300 vs. 240, p=0.02). Factors independently associated with injecting drugs in the past month included living in Tijuana, being younger, being married/common-law, longer duration in the sex trade, speaking English, earning Corresponding Author and Reprint Requests: Thomas L. Patterson, PhD Department of Psychiatry (0680) University of California, San Diego 9500 Gilman Drive La Jolla, CA 92093-0680 Phone: 858-534-3354; Fax: 858-534-7723 E-mail: tpatterson@ucsd.edu. Contributors Drs. Patterson and Semple designed the behavioral intervention study (NIMH R01 MH065849), supervised data collection, and contributed to manuscript writing. Dr. Strathdee planned the analysis, assisted with interpreting results, and wrote the majority of the manuscript. Ms. Philbin and Ms. Pu conducted the analyses and assisted with interpreting results and writing the manuscript. Drs. de la Torre, Amaro, Magis, Salazar assisted with study design and interpreting results and revising the manuscript. Drs. Lozada, Staines, Martinez and Fraga supervised data collection and assisted with the manuscript. Ms. Orozovich supervised data collection and provided oversight of the intervention study. All authors contributed to and have approved the final manuscript. Conflict of InterestThe authors have no conflicts of interest to disclose.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusions: FSW-IDUs had higher STI levels, engaged in riskier behaviors and were more vulnerable to having unsafe sex with clients compared to other FSWs, indicating that this subgroup is an important bridge population requiring focused prevention. NIH Public Access

Objective To examine efficacy of a brief behavioral intervention to promote condom use among female sex workers (FSWs) in two Mexico-U.S. border cities. Methods 924 FSWs aged ≥18 years without known HIV infection living in Tijuana and Ciudad Juarez having recent unprotected sex with clients were randomized to a 30 minute behavioral intervention integrating motivational interviewing and principles of behavior change, or a didactic control condition. At baseline and six months, women underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia. Results Comparing intervention versus control groups, we observed a 40% decline in cumulative STI incidence (p=0.049). Incidence density for the intervention vs. control was 13.8 vs 24.92 per 100 person years (py) for STIs combined (p=0.034), and 0 vs. 2.01 per 100 py for HIV (p<0.001), with concomitant increases in total numbers and percentages of protected sex acts and decreases in total numbers of unprotected sex acts with clients (p<0.05). Conclusions This brief behavioral intervention shows promise in reducing HIV/STI risk behaviors among FSWs in two Mexican-U.S border cities, and may be transferable to other resource-constrained settings.

Culturally appropriate interventions are needed to identify and treat ulcerative sexually transmitted infections and reduce HIV risks associated with stimulants among FSWs in the Mexico-US border region.

BackgroundWe evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico during 2008–2010, when harm reduction coverage was expanding rapidly in Tijuana, but less so in Juarez.MethodsFSW-IDUs ≥18 years reporting sharing injection equipment and unprotected sex with clients within the last month participated in a randomized factorial trial comparing four brief, single-session conditions combining either an interactive or didactic version of a sexual risk intervention to promote safer sex in the context of drug use, and an injection risk intervention to reduce sharing of needles/injection paraphernalia. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and Trichomonas, blinding interviewers and assessors to assignment. Poisson regression with robust variance estimation and repeated measures ordinal logistic regression examined effects on combined HIV/STI incidence and receptive needle sharing frequency.FindingsOf 584 initially HIV-negative FSW-IDUs, retention was ≥90%. After 12 months, HIV/STI incidence decreased >50% in the interactive vs. didactic sex intervention (Tijuana:AdjRR:0.38,95% CI:0.16–0.89; Juarez: AdjRR:0.44,95% CI:0.19–0.99). In Juarez, women receiving interactive vs. didactic injection risk interventions decreased receptive needle-sharing by 85% vs. 71%, respectively (p = 0.04); in Tijuana, receptive needle sharing declined by 95%, but was similar in active versus didactic groups. Tijuana women reported significant increases in access to syringes and condoms, but Juarez women did not.InterpretationAfter 12 months in both cities, the interactive sexual risk intervention significantly reduced HIV/STI incidence. Expanding free access to sterile syringes coupled with brief, didactic education on safer injection was necessary and sufficient for achieving robust, sustained injection risk reductions in Tijuana. In the absence of expanding syringe access in Juarez, the injection risk intervention achieved significant, albeit more modest reductions, suggesting that community-level interventions incorporating harm reduction are more powerful than individual-level interventions.Trial Registrationclinicaltrials.gov NCT00840658

BackgroundFemale sex workers who inject drugs (FSW-IDUs) are at risk of acquiring HIV, sexually transmitted infections (STI) and blood-borne infections through unprotected sex and sharing injection equipment. We conducted a 2×2 factorial randomized controlled trial to evaluate combination interventions to simultaneously reduce sexual and injection risks among FSW-IDUs in Tijuana and Ciudad Juarez, Mexico.Methods/designFSW-IDUs ≥18 years reporting sharing injection equipment and unprotected sex with clients within the last month were randomized to one of four conditions based on an a priori randomization schedule, blinding interviewer/counselors to assignment. Due to the extreme vulnerability of this population, we did not include a control group that would deny some women access to preventive information. All women received similar information regardless of group allocation; the difference was in the way the information was delivered and the extent to which women had an interactive role. Each condition was a single 60-minute session, including either an interactive or didactic version of an injection risk intervention and sexual risk intervention. Women underwent interviewer-administered surveys and testing for HIV, syphilis, gonorrhea, Chlamydia, and Trichomonas at baseline and quarterly for 12 months. Combined HIV/STI incidence will be the primary outcome. Secondary outcomes are proportionate reductions in sharing of injection equipment and unprotected sex with clients.DiscussionOf 1,132 women, 548 (48.4%) were excluded (88.9% were ineligible; 11.1% refused to participate or did not return); 584 eligible women enrolled (284 in Tijuana; 300 in Ciudad Juarez). All 584 participants completed the baseline interview, provided biological samples and were randomized to one of the four groups. During follow-up, 17 participants (2.9%) were lost to follow-up, of whom 10 (58.8%) had died, leaving 567 participants for analysis. This study appears to be the first intervention to attempt to simultaneously reduce injection and sexual risk behaviors among FSW-IDUs. The factorial design will permit analysis to determine whether the combination of the two interactive interventions and/or its respective components are effective in reducing injection and/or sexual risks, which will have direct, tangible policy implications for Mexico and potentially other resource-poor countries.Trial registrationNCT00840658

The purpose of this study was to examine whether a brief behavioral intervention promoting condom use among female sex workers (FSWs) and their clients had the added benefit of increasing condom use among FSWs and their steady, non-commercial partners (e.g., husbands, boyfriends). Participants were 362 FSWs, aged ≥ 18, living in Tijuana or Ciudad Juarez, Mexico, who received a behavioral intervention to promote condom use with clients. Repeated measures negative binomial regression was used to assess FSWs' condom use with steady partners versus clients across time. Results showed that FSWs engaged in unprotected sex with steady partners more than with their clients, and that the intervention changed FSWs' condom use with clients but not their steady partners. HIV prevention interventions for FSWs should promote consistent condom use across partner type. Targeting couples rather than individuals may also be necessary.

Purpose-To examine correlates of early initiation into sex work in two Mexico-U.S. border cities.Methods-Female sex workers (FSWs) ≥18 years without known HIV infection living in Tijuana and Ciudad Juarez who had recent unprotected sex with clients underwent baseline interviews. Correlates of initiation into sex work before age 18 were identified with logistic regression.Results-Of 920 FSWs interviewed in Tijuana (N=474) and Ciudad Juarez (N=446), 9.8% (N=90) were early initiators (<18 years) into sex work. Median age of entry into sex work was 26 years (range: 6-58). After adjusting for age, compared to older initiators, early initiators were more likely to use inhalants (21.1% vs 9.6%, p=0.002), initiate sex work to pay for alcohol (36.7% vs 18.4%, p<.001), report abuse as a child (42.2% vs 18.7%, p<.0001), and they were less likely to be migrants (47.8% vs 62.3%, p=0.02). Factors independently associated with early initiation included inhalant use (adjOR=2.39), initiating sex work to pay for alcohol (adjOR=1.88) and history of child abuse (adjOR=2.92). Factors associated with later initiation included less education (adjOR=0.43 per 5-year increase), migration (adjOR=0.47), and initiating sex work for better pay (adjOR=0.44) or to support children (adjOR=0.03).