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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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Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

MEXICO

U.S.


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Major US Drug Trafficking Routes

Major U.S. Drug Trafficking Routes

Tijuana

Cd. Juarez

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Most frequent drug injection sites in Tijuana (n=995)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

San Diego Tribune, Reuters, CNN, March 1, 2006


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Tijuana

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


Reasons for moving to tijuana by gender

Reasons for moving to Tijuana, by gender


Factors independently associated with hiv infection by gender

Factors Independently Associated with HIV infection by Gender

All p<0.05


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Explanation #2:

Is Deportation

a Risk Factor

for HIV Acquisition?

All photos shared with permission


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Impact of deportation on families


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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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

Patterson et al, AIDS 2009


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

California – Primary and Secondary SyphilisRates by County, 2008

Source: California Department of Public Health, STD Control Branch

Mexico


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Prevalence of HIV and lifetime syphilis infection among high risk groups in Tijuana and Cd. Juarez (2004-2009)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Proportion of Lifetime Syphilis Infections with current titers > 1:8* by Risk Group in Tijuana and Cd. Juarez

*Consistent with active infection


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

Tijuana

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

TB - The forgotten epidemic


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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.


Trends in hiv tb co infection in san diego by ethnicity 1993 2007

Trends in HIV-TB Co-infection in San Diego by Ethnicity (1993-2007)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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)


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

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


Steffanie a strathdee ph d associate dean of global health sciences harold simon professor

2010: Mexico to receive $76 M USD

for HIV Prevention


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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