Steffanie A. Strathdee, Ph.D.
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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;

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

  • Unique features about the context of HIV risks along the Mexico/U.S. border

  • Recent border studies

    • HIV

    • Syphilis

    • TB

  • Influencing policy


MEXICO

U.S.


U.S.

MEXICO


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)


Major US Drug Trafficking Routes

Major U.S. Drug Trafficking Routes

Tijuana

Cd. Juarez

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


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


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


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?

  • 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)


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


Tijuana

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


Reasons for moving to Tijuana, by gender


Factors Independently Associated with HIV infection by Gender

All p<0.05


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


Explanation #2:

Is Deportation

a Risk Factor

for HIV Acquisition?

All photos shared with permission


Impact of deportation on families


HIV Prevalence and Incidence among IDUs in Tijuana: 2006-2008

Prevalence

HIV Prevalence

Male IDU


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


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)

*

HIV prevalence: 6%

* Consistent with active infection

Patterson et al, J Inf Dis (2008)


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

Patterson et al, AIDS 2009


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

Patterson et al, AIDS 2009


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


California – Primary and Secondary SyphilisRates by County, 2008

Source: California Department of Public Health, STD Control Branch

Mexico


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


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

*Consistent with active infection


Tijuana

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


TB - The forgotten epidemic


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?

  • 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)


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

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)


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)

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

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

The Prevemovihl


2010: Mexico to receive $76 M USD

for HIV Prevention


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

  • 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

  • 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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