Female sex workers (FSWs) are at risk for multiple health harms, including HIV. This article describes a mixed methods study of the social support networks of 19 FSWs and their primary male sex partners in Tijuana, Mexico. We collected quantitative and qualitative social network data, including quantitative network measures, qualitative narratives, and network visualizations. Methodologically, we illustrate how a convergent mixed methods approach to studying personal social support networks of female sex workers can yield a more holistic understanding of network composition and role. From a health-related perspective, we show how migration/deportation and stigma shape social networks and might be leveraged to support HIV prevention interventions. We believe others can benefit from a mixed methods approach to studying social networks.

Background: The current epidemic of opioid overdoses in the United States necessitates a robust public health and clinical response. We described patterns of non-fatal opioid overdoses (NFOODs) in a small western region using data from the 9-1-1 Computer Assisted Dispatch (CAD) record and electronic Patient Clinical Records (ePCR) completed by EMS responders. We determined whether CAD and ePCR variables could identify NFOOD cases in 9-1-1 data for intervention and surveillance efforts. Methods: We conducted a retrospective analysis of 1 year of 9-1-1 emergency medical CAD and ePCR (including naloxone administration) data from the sole EMS provider in the response area. Cases were identified based on clinician review of the ePCR, and categorized as definitive NFOOD, probable NFOOD, or non-OOD. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) of the most prevalent CAD and ePCR variables were calculated. We used a machine learning technique-Random-Forests (RF) modeling-to optimize our ability to accurately predict NFOOD cases within census blocks. Results: Of 37,960 9-1-1 calls, clinical review identified 158 NFOOD cases (0.4%), of which 123 (77.8%) were definitive and 35 (22.2%) were probable cases. Overall, 106 (67.1%) received naloxone from the EMS responder at the scene. As a predictor of NFOOD, naloxone administration by paramedics had 67.1% sensitivity, 99.6% specificity, 44% PPV, and 99.9% NPV. Using CAD variables alone achieved a sensitivity of 36.7% and specificity of 99.7%. Combining ePCR variables with CAD variables increased the diagnostic accuracy with the best RF model yielding 75.9% sensitivity, 99.9% specificity, 71.4% PPV, and 99.9% NPV. Conclusion: CAD problem type variables and naloxone administration, used alone or in combination, had sub-optimal predictive accuracy. However, a Random Forests modeling approach improved accuracy of identification, which could foster improved surveillance and intervention efforts. We identified the set of NFOODs that EMS encountered in a year and may be useful for future surveillance efforts.

Background

Research has focused on male clients of female sex workers (FSWs) and their risk for HIV/sexually transmitted infections (STIs). However, it is unclear whether the commercial sex behaviors of these men are limited to paying for sex or whether they may also be paid for sex themselves.

Methods

We analyzed the interview data and HIV/STI test results from 170 drug-using male clients of FSWs in Tijuana, Mexico, to determine the extent to which these men report being paid for sex and the association with positive HIV/STI results.

Results

More than one quarter of men reported having been paid for sex in the past 4 months. In a multivariate logistic regression model, reporting having been paid for sex was significantly associated with testing positive for any HIV/STI (adjusted odds ratio [AdjOR], 3.53; 95% confidence interval [CI], 1.33-9.35), being bisexual (AdjOR, 15.59; 95% CI, 4.81-50.53), injection drug use in the past 4 months (AdjOR, 2.65; 95% CI, 1.16-6.03), and cocaine use in the past 4 months (AdjOR, 2.93; 95% CI, 1.22-7.01).

Conclusions

Findings suggest that drug-using male clients of FSWs may be characterized by unique risk profiles that require tailored HIV prevention interventions.

Background

Studies of injection drug-using couples suggest a gendered performance of risk in which men exert greater control over drug use and render their female partners vulnerable to HIV infection and other negative health outcomes. This study assesses gender roles in injection drug use as practiced among female sex workers and their intimate male partners within a risk environment marked by rapid socioeconomic changes.

Methods

We draw on quantitative surveys, semi-structured interviews, and ethnographic fieldwork conducted as part of cohort study of HIV/STI risk among female sex workers and their intimate, non-commercial partners along the Mexico-U.S. border. This study employed descriptive statistics and inductive analyses of transcripts and field notes to examine practices related to drug procurement, syringe sharing, and injection assistance among couples in which both partners reported injecting drugs in the past 6 months.

Results

Among 156 couples in which both partners injected drugs (n=312), our analyses revealed that women's roles in drug use were active and multidimensional, and both partners' injection risk practices represented embodied forms of cooperation and compassion. Women often earned money to purchase drugs and procured drugs to protect their partners from the police. Sharing drugs and syringes and seeking injection assistance were common among couples due to drug market characteristics (e.g., the use of "black tar" heroin that clogs syringes and damages veins). Both women and men provided and received injection assistance, which was typically framed as caring for the partner in need of help.

Conclusion

Our mixed methods study suggests that in certain risk environments, women are more active participants in injection-related practices than has often been revealed. This participation is shaped by dynamic relationship and structural factors. Our suggestion to consider gendered injection risk as a nuanced and relational process has direct implications for future research and interventions.

Background

Illegal drug markets are shaped by multiple forces, including local actors and broader economic, political, social, and criminal justice systems that intertwine to impact health and social wellbeing. Ethnographic analyses that interrogate multiple dimensions of drug markets may offer both applied and theoretical insights into drug use, particularly in developing nations where new markets and local patterns of use traditionally have not been well understood. This paper explores the emergent drug market in Kisumu, western Kenya, where our research team recently documented evidence of injection drug use.

Methods

Our exploratory study of injection drug use was conducted in Kisumu from 2013 to 2014. We draw on 151 surveys, 29 in-depth interviews, and 8 months of ethnographic fieldwork to describe the drug market from the perspective of injectors, focusing on their perceptions of the market and reports of drug use therein.

Results

Injectors described a dynamic market in which the availability of drugs and proliferation of injection drug use have taken on growing importance in Kisumu. In addition to reports of white and brown forms of heroin and concerns about drug adulteration in the market, we unexpectedly documented widespread perceptions of cocaine availability and injection in Kisumu. Examining price data and socio-pharmacological experiences of cocaine injection left us with unconfirmed evidence of its existence, but opened further possibilities about how the chaos of new drug markets and diffusion of injection-related beliefs and practices may lend insight into the sociopolitical context of western Kenya.

Conclusions

We suggest a need for expanded drug surveillance, education and programming responsive to local conditions, and further ethnographic inquiry into the social meanings of emergent drug markets in Kenya and across sub-Saharan Africa.

The transmission of HIV is shaped by individual-environment inter-actions. Social epidemiologic approaches thus seek to capture the dynamic and reciprocal relationships of individual-environment interactions in the production and reduction of risk. This presents considerable methodological, theoretical and disciplinary challenges. Drawing upon four research case studies, we consider how methods and concepts in the social and epidemiologic sciences might be brought together towards understanding HIV risk as an effect of social, cultural and political condition. The case studies draw upon different combinations of methods (qualitative, ethnographic and quantitative) and disciplines (sociology, anthropology and epidemiology) in different social contexts of HIV vulnerability (street settings in Russia, Serbia and North America and a cross-border setting in Mexico) among a range of marginalised high-risk populations (injection drug users and female and transvestite sex workers). These case studies illustrate the relevance of the social science concepts of structural violence and structural vulnerability for a social epidemiology of HIV risk. They also explore how social epidemiologic work can benefit from the mixing of social science methods and theories. We contend that social epidemiology cannot advance in its understanding of structural vulnerability without embracing and relying upon ethnographic and qualitative approaches. We put -forward the linked concepts of structural violence, structural vulnerability and risk environment as building blocks for a theory-informed social epidemiology of HIV risk among marginalised populations.

Background

The prevalence of HIV and Hepatitis C Virus (HCV) are significantly lower among people who inject drugs (PWID) in San Diego, CA, USA compared with PWID in Tijuana, Mexico, located directly across the border. We investigated associations between cross-border injection drug use (IDU), HIV and HCV seroprevalence and engagement in injecting risk behaviours while on each side of the border.

Methods

Using baseline interviews and serologic testing data from STAHR II, a longitudinal cohort study of PWID in San Diego, bivariate and multivariable logistic regression analyses examined associations between recent (past six months) cross-border IDU and HIV and HCV antibody seropositivity, socio-demographics, drug use characteristics, and participants' connections to, and perceptions about Mexico. Chi-squared tests and McNemar tests examined associations between cross-border IDU and injecting risk behaviours.

Results

Of the 567 participants (93% U.S.-born, 73% male, median age 45 years), 86 (15%) reported recent cross-border IDU. Cross-border IDU was not associated with HIV (OR: 0.85, 95% CI: 0.37-1.95) or HCV seropositivity (OR: 1.01, 95% CI: 0.62-1.65). Age, identifying as Hispanic or Latino/a, and being concerned about risk of violence when travelling to Mexico were independently associated with decreased odds of recent cross-border IDU. Injecting cocaine at least weekly, having ever lived in Mexico and knowing PWID who reside in Mexico were associated with increased odds of recent cross-border IDU. PWID who reported cross-border IDU were significantly less likely to engage in receptive needle sharing, equipment sharing, and public injection while in Mexico compared with in San Diego (all p<0.001).

Conclusion

Prevalence of HIV and HCV infection was similar among PWID who had and had not injected in Mexico, possibly due to practising safer injecting while in Mexico. Research is needed to elucidate contextual factors enabling U.S. PWID to inject safely while in Mexico.