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Steffanie A. Strathdee, Ph.D. Associate Dean of Global Health Sciences, Harold Simon Professor; Chief, Division of Global Public Health, Department of Medicine, University of California, San Diego [email protected]

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slide1

Steffanie A. Strathdee, Ph.D.

Associate Dean of Global Health Sciences,

Harold Simon Professor;

Chief, Division of Global Public Health,

Department of Medicine, University of California, San Diego

[email protected]

Borderline: Cross-border Mobility and its Link to Transmission of HIV, Syphilis and TB in the Mexico-US Border Region
overview
Overview
  • Unique features about the context of HIV risks along the Mexico/U.S. border
  • Recent border studies
    • HIV
    • Syphilis
    • TB
  • Influencing policy
slide3

MEXICO

U.S.

slide4

U.S.

MEXICO

what makes the mexico us border region different
What makes the Mexico-US border region different?
  • Volume of cross-border traffic

~60 million crossings per year

  • Major drug trafficking route
  • Sex work is quasi-legal
  • Main corridor for migration fueled by huge economic disparities

>>Confluence of risk factors for infectious diseases (e.g. HIV, STIs, TB)

slide6

Major US Drug Trafficking Routes

Major U.S. Drug Trafficking Routes

Tijuana

Cd. Juarez

Source: National Drug Intelligence Center, National Drug Threat Assessment 2006

slide7

Tijuana has one of the fastest growing populations of injection drug users (IDUs) in Mexico, with ~21,000 drug users, and ~10,000 IDUs

slide9

Place of Birth among Tijuana’s

Injection Drug Users

2/3rds born Outside of Baja California

Number

of

subjects

hiv and migration what is the link
HIV and Migration:What is the link?
  • Family separation, changes in cultural environment, homelessness, poverty, social isolation, greater sense of anonymity(Deren, 2003; Lagarde, 2003; Organista et al, 2004; Parrado, 2004)
  • Mobility can increase the chance of encountering HIV-positive persons(Kottiri et al, 2002)
  • Mobile persons can act as bridge populations between groups that normally wouldn’t interact(Paschane, 2000)
  • Mobility can change sexual networks in the sending or receiving community (Aral, 2007)
slide12

Tijuana

ADAPTED FROM: Report on the Global AIDS Epidemic, UNAIDS, 2008

slide15

Explanation #1: Is Deportation a marker for a high risk subgroup of male IDUs who acquired HIV

in the US?

Courtesy of La Frontera, 2008

slide16

Explanation #2:

Is Deportation

a Risk Factor

for HIV Acquisition?

All photos shared with permission

hiv prevalence and incidence among idus in tijuana 2006 2008
HIV Prevalence and Incidence among IDUs in Tijuana: 2006-2008

Prevalence

HIV Prevalence

Male IDU

sex work in mexico
Sex Work in Mexico
  • Quasi legal in Mexico
    • Zone of tolerance (zona roja)
    • Work permit
  • Up to 9000 FSWs in Tijuana,

~4000 in Ciudad Juarez

  • Many women/girls from

S. Mexico/Central America

  • ‘Sex tourism’ is common
sex work in the mexico us border region
70% of FSWs in Tijuana and Cd. Juarez are migrants

Migrant FSWs have:

Lower HIV and STI prevalence

Less drug use

More condom use

Over time, protective factors associated with being a migrant appear to erode

Sex work in the Mexico-US Border Region

Ojeda et al, Sex Transm Infect 2009

factors associated with hiv infection in fsws in tijuana and ciudad juarez n 924
Factors associated with HIV infection in FSWs in Tijuana and Ciudad Juarez(n=924)

*

HIV prevalence: 6%

* Consistent with active infection

Patterson et al, J Inf Dis (2008)

male clients of fsws in tijuana and ciudad juarez
Male Clients of FSWsin Tijuana and Ciudad Juarez
  • 70% of FSWs have U.S. clients
  • FSWs with U.S. clients more likely to have:
    • Syphilis titers ≥ 1:8
    • Injected drugs
    • High client volumes
    • Been paid more for unprotected sex

Strathdee et al, Sex Trans Dis 2008

prevalence of hiv testing and hiv stis among mexican n 200 and u s clients n 200 of tijuana fsws
Prevalence of HIV testing and HIV/STIs among Mexican (N=200) and U.S. clients (N=200) of Tijuana FSWs

Prevalence

Patterson et al, AIDS 2009

slide24
Factors Independently Associated with HIV Infection among Male Clients of FSWs in Tijuana, Mexico (N=400)

Patterson et al, AIDS 2009

slide26

United States

National syphilis incidence: 4.5 (2008)

CA

AZ

NM

TX

7.4

B.C.

3.8

SON

CHI

COH

NL

Mexico

National Syphilis Incidence: 1.2 (2007)

TAM

Syphilis Incidence on the U.S.-Mexico Border (Per 100,000)

5.7

San Diego

(increased

from 3.8 to 11.8 from 2003 to 2007)

Sources: CONASIDA, US Centers for Disease Control, SD County Health Dept

slide27

California – Primary and Secondary SyphilisRates by County, 2008

Source: California Department of Public Health, STD Control Branch

Mexico

slide28
Prevalence of HIV and lifetime syphilis infection among high risk groups in Tijuana and Cd. Juarez (2004-2009)
slide29
Proportion of Lifetime Syphilis Infections with current titers > 1:8* by Risk Group in Tijuana and Cd. Juarez

*Consistent with active infection

slide30

Tijuana

ADAPTED FROM: Report on the Global AIDS Epidemic, UNAIDS, 2008

slide33

TB Incidence on the U.S.-Mexico Border

United States

National TB Incidence: 4.4

CA

7.5

AZ

NM

4.8

2.6

TX

57.3

B.C.

6.3

25.4

18.7

SON

CHI

11.7

COH

21.9

NL

31.1

Mexico

National TB Incidence: 15.7

TAM

San Diego

(9.0)

Source: CDC, USA ,2007 & DGE Mexico, 2004. Incidence per 100,000 population

hiv and tb co infection what s the link
HIV and TB Co-infection: What’s the link?
  • Of ~42 million people with HIV worldwide, one third also have TB.
  • Among HIV+ people, risk of progressing from latent to active TB is 10% per year.
slide36

Factors independently associated with HIV-TB co-infection in San Diego (1999-2007)*

Rodwell et al, AJPH 2010

prevalence of latent tb infection ltbi among high risk populations in tijuana mexico
Prevalence of Latent TB Infection (LTBI)* among High Risk Populations in Tijuana, Mexico

Prevalence

FSWs(N=115)

IDUs(N=232)

Homeless(N=280)

Non-IDUs(N=311)

LTBI incidenceamong IDUs (N=503)

*Tested through IGRA (Quantiferon Gold), Cellestis Inc; IDUs=injection drug users; FSWs= female sex workers.

Garfein et al, Emerg Inf Dis (in press)

slide38

Factors associated with tuberculosis infection among high risk groups for HIV in Tijuana: 2007

Garfein et al, in press

characteristics of active tb cases among idus in tijuana n 103 1060
Characteristics of Active TB Cases among IDUs in Tijuana (n=103/1060)

Prevalence

Received Anti-TB Meds

TB tx stopped due to deportation

Previously Dx’ed with Active TB

Active TB Dx’ed in US

TB tx Prematurely Stopped

Deiss et al, AJPH 2009

influencing policy
Influencing Policy
  • Donated a mobile vehicle for HIV prevention to our partner NGO which became the prototype for HIV service delivery across Mexico

The Prevemovihl

lessons learned
Lessons Learned
  • The Mexico-U.S. border region is vulnerable to epidemics of HIV, syphilis and TB
  • Cross-border infectious disease transmission is bi-directional, and depends on factors such as:
    • Host
    • Agent
    • Environment (physical, social, economic, policy)
implications
Implications
  • Mobility can confer either protection or risk shaping an individual’s risk of infection.
  • Immigration policies and health policies should not work at odds.
  • Discrimination and blame represent significant barriers to prevention and treatment of mobile populations in border regions.
  • Prevention and treatment for overlapping epidemics requires binational cooperation
acknowledgements
Acknowledgements
  • UCSD Center for AIDS Research , USAID
  • National Institutes of Drug Abuse and Mental Health: K01 DA020364, R01 DA019829, RO1 MH065849 ; T32 DA023356
  • Staff from the PrevenCasa, A. C., Patronato Pro-COMUSIDA, UCSD, and Programa Companeros
  • San Diego County Public Health Dept
  • Most importantly, the participants who gave their time
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