Female sex workers who inject drugs (FSW-IDUs) face elevated risk for HIV/ STIs and constitute a key population for public health prevention. Through direct and indirect pathways including human rights violations, policing practices like syringe confiscation can compound FSW-IDU health risk and facilitate the spread of disease. We studied correlates of experiencing syringe confiscation among FSW-IDUs in northern Mexico, where formal policy allows for syringes to be available over the counter without a prescription, but police practices are often at odds with the law. FSWIDUs reporting recent syringe sharing and unprotected sex with clients in Tijuana and Ciudad Juarez were administered surveys and HIV/STI testing. Logistic regression was used to identify correlates of syringe confiscation. Among 624 respondent FSW-IDUs, prevalence of syringe confiscation in the last 6 months was 48 %. The following factors were positively associated with syringe confiscation: testing positive for HIV (adjusted odds ratio [aOR]=2.54, 95 % confidence interval [CI]=1.11-5.80), reporting sexual abuse by police (aOR=12.76, 95 % CI=6.58-24.72), engaging in groin injection (aOR=1.84, 95 % CI=1.15-2.93), injecting in public (aOR=1.64; 95 % CI=1.14-2.36), and obtaining syringes from pharmacies (aOR=1.54; 95 % CI=1.06-2.23). Higher education level was negatively associated with syringe confiscation (aOR= 0.92, 95 % CI=0.87-0.98) as was frequent injection with clients within the last month (aOR=0.64,). This analysis adds to the body of evidence linking unauthorized law enforcement actions targeting high-risk groups with HIV and other adverse health outcomes. Using a public health lens to conceptualize abuse as a structural risk factor, we advocate for multi-prong prevention, systematic monitoring, and evidence-based intervention response to deleterious police practices.

IntroductionPolicing practices are key drivers of HIV among people who inject drugs (PWID). This paper describes the protocol for the first study to prospectively examine the impact of a police education programme (PEP) to align law enforcement and HIV prevention. PEPs incorporating HIV prevention (including harm reduction programmes like syringe exchange) have been successfully piloted in several countries but were limited to brief pre–post assessments; the impact of PEPs on policing behaviours and occupational safety is unknown.ObjectivesProyecto ESCUDO (SHIELD) aims to evaluate the efficacy of the PEP on uptake of occupational safety procedures, as assessed through the incidence of needle stick injuries (NSIs) (primary outcome) and changes in knowledge of transmission, prevention and treatment of HIV and viral hepatitis; attitudes towards PWID, adverse behaviours that interfere with HIV prevention and protective behaviours (secondary outcomes).Methods/analysisESCUDO is a hybrid type I design that simultaneously tests an intervention and an implementation strategy. Using a modified stepped-wedge design involving all active duty street-level police officers in Tijuana (N=∼1200), we will administer one 3 h PEP course to groups of 20–50 officers until the entire force is trained. NSI incidence and geocoded arrest data will be assessed from department-wide de-identified data. Of the consenting police officers, a subcohort (N=500) will be randomly sampled from each class to undergo pre-PEP and post-PEP surveys with a semiannual follow-up for 2 years to assess self-reported NSIs, attitudes and behaviour changes. The impact on PWIDs will be externally validated through a parallel cohort of Tijuana PWIDs.Ethics/disseminationResearch ethics approval was obtained from the USA and Mexico. Findings will be disseminated through open access to protocol materials through the Law Enforcement and HIV Network.Trial registration numberNCT02444403.

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Background Policing practices such as syringe confiscation and arrest can act as important social-structural drivers of HIV risk among people who inject drugs (PWID). However, police referral to treatment and other services may improve the health of PWID. Little is known about the role of modifiable attitudinal and knowledge factors in shaping officer behavior. Using baseline findings from a police education program (PEP), we assessed relationships between drug policy knowledge and attitudes towards public health interventions with self-reported syringe confiscation, drug arrest, and service referral among street-level police in Tijuana, Mexico. Methods Between February, 2015 and May, 2016 we surveyed 1,319 police officers who reported syringe contact. The self-administered survey focused on attitudes, knowledge, and behaviors related to drug policy, public health, and occupational safety. We used ordinal logistic regression to model the odds of syringe confiscation, arrest for heroin possession, and referring PWID to health/social programs. Results The sample was mostly male (87%) and had at least a high school education (80%). In the last six months, a minority reported always/sometimes confiscating syringes (49%), arresting someone for heroin possession (43%), and referring PWID to health and social programs (37%). Those reporting needlestick injuries (NSI) had 1.38 (95% CI: 1.02–1.87) higher odds of reporting syringe confiscation. Officers who had favorable views on laws that treat addiction as a public health issue had lower odds (aOR= 0.78; 95% CI: 0.59–1.03) of arresting PWID. Those agreeing that it was their role to refer PWID to health and social programs had higher odds of reporting such referrals (aOR: 3.32, 95% CI: 2.52–4.37). Legal knowledge was not associated with these practices. Conclusion Changing drug policy and knowledge may be insufficient in shifting police behavior. Modifying officers’ occupational risks and attitudes towards harm reduction interventions can facilitate efforts to align police practices with PWID health.

BackgroundMexico’s 2009 “narcomenudeo reform” decriminalized small amounts of drugs, shifting some drug law enforcement to the states and mandating drug treatment diversion instead of incarceration. Data from Tijuana suggested limited implementation of this harm reduction-oriented policy. We studied whether a police education program (PEP) improved officers’ drug and syringe policy knowledge, and aimed to identify participant characteristics associated with improvement of drug policy knowledge.MethodsPre- and post-training surveys were self-administered by municipal police officers to measure legal knowledge. Training impact was assessed through matched paired nominal data using McNemar’s tests. Multivariable logistic regression was used to identify predictors of improved legal knowledge, as measured by officers’ ability to identify conceptual legal provisions related to syringe possession and thresholds of drugs covered under the reform.ResultsOf 1750 respondents comparing pre- versus post training, officers reported significant improvement (p < 0.001) in their technical understanding of syringe possession (56 to 91%) and drug amounts decriminalized, including marijuana (9 to 52%), heroin (8 to 71%), and methamphetamine (7 to 70%). The training was associated with even greater success in improving conceptual legal knowledge for syringe possession (67 to 96%) (p < 0.001), marijuana (16 to 91%), heroin (11 to 91%), and methamphetamine (11 to 89%). In multivariable modeling, those with at least a high school education were more likely to exhibit improvement of conceptual legal knowledge of syringe possession (adjusted odds ratio [aOR] 2.6, 95% CI 1.4–3.2) and decriminalization for heroin (aOR 2.7, 95% CI 1.3–4.3), methamphetamine (aOR 2.2, 95% CI 1.4–3.2), and marijuana (aOR 2.5, 95% CI 1.6–4).ConclusionsDrug policy reform is often necessary, but not sufficient to achieve public health goals because of gaps in translating formal laws to policing practice. To close such gaps, PEP initiatives bundling occupational safety information with relevant legal content demonstrate clear promise. Our findings underscore additional efforts needed to raise technical knowledge of the law among personnel tasked with its enforcement. Police professionalization, including minimum educational standards, appear critical for aligning policing with harm reduction goals.

In 2009, Mexico decriminalized the possession of small amounts of illicit drugs for personal use in order to refocus law enforcement resources on drug dealers and traffickers. This study examines the spatial distribution of law enforcement encounters reported by people who inject drugs (PWID) in Tijuana, Mexico to identify concentrated areas of policing activity after implementation of the new drug policy. Mapping the physical location of law enforcement encounters provided by PWID (n = 461) recruited through targeted sampling, we identified hotspots of extra-judicial encounters (e.g., physical/sexual abuse, syringe confiscation, and money extortion by law enforcement) and routine authorized encounters (e.g., being arrested or stopped but not arrested) using point density maps and the Getis-Ord Gi* statistic calculated at the neighborhood-level. Approximately half of the participants encountered law enforcement more than once in a calendar year and nearly one third of these encounters did not result in arrest but involved harassment or abuse by law enforcement. Statistically significant hotspots of law enforcement encounters were identified in a limited number of neighborhoods located in areas with known drug markets. At the local-level, law enforcement activities continue to target drug users despite a national drug policy that emphasizes drug treatment diversion rather than punitive enforcement. There is a need for law enforcement training and improved monitoring of policing tactics to better align policing with public health goals.

IntroductionPolice officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection. We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational safety and simultaneously reduce HIV risks among police and PWID.MethodsTijuana's Department of Municipal Public Safety (SSPM) is among Mexico's largest. Our binational, multi-sectoral team analyzed de-identified data from SSPM's 2014 anonymous self-administered occupational health survey. The prevalence of NSI and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating equations identified factors associated with ever having an occupational NSI.ResultsApproximately one-quarter of the Tijuana police force was given the occupational health survey (N=503). Respondents were predominantly male (86.5%) and ≤35 years old (42.6%). Nearly one in six officers reported ever having a NSI while working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering needles/syringes while on duty (n=473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56–5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29–3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22–0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19–0.91).ConclusionsTijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe confiscation) – factors that also impact HIV transmission among PWID and other members of the community.

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