Social and Structural Factors Associated with HIV Infection among Female Sex Workers Who Inject Drugs in the Mexico-US Border Region

Abstract

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.

Syringe Confiscation as an HIV Risk Factor: The Public Health Implications of Arbitrary Policing in Tijuana and Ciudad Juarez, Mexico

“…18 In short, in 2008-2009, we recruited females in venues frequented by sex workers as part of an intervention study on risky sex and injection behavior. Eligibility criteria included: being at least 18, reporting recent unprotected sex with a male client and sharing injection paraphernalia within the last month, and agreeing to undergo STI treatment.…”

“…[7][8][9][10][11][12][13][14][15][16][17] From an epidemiological perspective, FSW-IDUs command special focus because they can acquire communicable infections through both the sexual and injection routes, making them critical to community-level HIV and STI prevention. [18][19][20] From a human rights perspective, this population is doubly marginalized by policies criminalizing drug use and prostitution. By pushing their activities underground and restricting access to formal support frameworks, laws can limit these individuals' ability to negotiate safer practices and avoid psychological and physical victimization, including sexual assault, at the hands of clients, pimps, and intimate partners.…”

“…By pushing their activities underground and restricting access to formal support frameworks, laws can limit these individuals' ability to negotiate safer practices and avoid psychological and physical victimization, including sexual assault, at the hands of clients, pimps, and intimate partners. 10,11,13,16 Police practices rooted in such laws can further facilitate individuals' risky behavior (including receptive syringe sharing and unprotected sex) 18,21 and interfere with public health efforts targeting high-risk populations. 9,[22][23][24] Formal policies and their enforcement are increasingly seen as critical structural factors that shape the "risk environment" for the production of health and disease among vulnerable groups and society at large, including vulnerability to HIV infection.…”

“…29 We also previously reported that being arrested for having track marks (a visible marker of drug use) and experiencing syringe confiscation was independently associated with HIV infection. 18,30 Police confiscation of syringes from IDUs carries an especially onerous potential to generate population health detriment. Removal of injection equipment directly reduces drug user access to sterile syringes.…”

“…22,34,35 In aggregate, the real and perceived barriers to safer practices and service access help explain the observed associations between report of syringe confiscation and risk behavior among IDUs. 23,24,29,36 Expanding on the findings from a broader initiative to understand the risk environment of FSW-IDUs along Mexico's Northern Border, 16,18 this analysis focuses on identifying behavioral and health status correlates of syringe confiscation. Based on existing empirical and theoretical literature, we hypothesized that exposure to syringe confiscation may be associated with respondent risk behavior (e.g., receptive syringe sharing, unprotected sex) and increase the odds of positive STI/HIV diagnoses.…”