Carlos Magis-Rodriguez

Prevalence and Correlates of HIV Infection among Female Sex Workers in 2 Mexico—US Border Cities

BACKGROUND We examined human immunodeficiency virus (HIV) prevalence and correlates among female sex workers (FSWs) in Tijuana and Ciudad Juarez, 2 large cities on the Mexico-US border. METHODS FSWs aged > or =18 years underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia. Logistic regression identified factors associated with HIV infection. RESULTS In 924 FSWs, the prevalence of HIV, gonorrhea, chlamydia, and syphilis titers > or =1:8 was 6%, 6.4%, 13%, and 14.2%, respectively. Factors independently associated with HIV were the injection of cocaine (odds ratio [OR], 2.96); the smoking, snorting, or inhalation of methamphetamine (OR, 3.32); and syphilis titers > or =1:8 (OR, 4.16). CONCLUSIONS Culturally appropriate interventions are needed to identify and treat ulcerative sexually transmitted infections and reduce HIV risks associated with stimulants among FSWs in the Mexico-US border region.

Individual, Social, and Environmental Influences Associated With HIV Infection Among Injection Drug Users in Tijuana, Mexico

Objective:We examined correlates of HIV infection among injection drug users (IDUs) in Tijuana, Mexico, a city bordering the United States, which is situated on major migration and drug trafficking routes. Methods:IDUs aged ≥18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and structured interviews. Weighted logistic regression identified correlates of HIV infection. Results:Of 1056 IDUs, the median age was 37 years, 86% were male, and 76% were migrants. HIV prevalence was higher in female participants than in male participants (8% vs. 3%; P = 0.01). Most IDUs testing HIV-positive were previously unaware of their serostatus (93%). IDUs reported injecting with a median of 2 people in the prior 6 months and had been arrested for having injection stigmata (ie, “track-marks”) a median of 3 times. Factors independently associated with HIV infection were being female, syphilis titers consistent with active infection, larger numbers of recent injection partners, living in Tijuana for a shorter duration, and being arrested for having track-marks. Conclusions:Individual, social, and environmental factors were independently associated with HIV infection among IDUs in Tijuana. These findings suggest the need to intervene not solely on individual risk behaviors but on social processes that drive these behaviors, including problematic policing practices.

Trends in Production, Trafficking, and Consumption of Methamphetamine and Cocaine in Mexico

Over the past decade, Mexico has experienced a significant increase in trafficking of cocaine and trafficking and production of methamphetamine. An estimated 70% of United States cocaine originating in South America passes through the Central America–Mexico corridor. Mexico-based groups are now believed to control 70%–90% of methamphetamine production and distribution in the United States. Increased availability of these drugs at reduced prices has led to a parallel rise in local drug consumption. Methamphetamine abuse is now the primary reason for seeking drug abuse treatment in a number of cities, primarily in northwestern Mexico. Although cocaine and methamphetamine use have been linked with the sex trade and high-risk behaviors, such as shooting gallery attendance and unprotected sex in other settings, comparatively little is known about the risk behaviors associated with use of these drugs in Mexico, especially for methamphetamines. We review historical aspects and current trends in cocaine and methamphetamine production, trafficking, and consumption in Mexico, with special emphasis on the border cities of Ciudad Juarez and Tijuana. Additionally, we discuss the potential public health consequences of cocaine use and the recent increase in methamphetamine use, especially in regards to the spread of bloodborne and other infections, in an effort to inform appropriate public health interventions.

Efficacy of a Brief Behavioral Intervention to Promote Condom Use Among Female Sex Workers in Tijuana and Ciudad Juarez, Mexico

OBJECTIVES We examined the efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. METHODS We randomized 924 female sex workers 18 years or older without known HIV infection living in Tijuana and Ciudad Juarez who had recently had unprotected sex with clients to a 30-minute behavioral intervention or a didactic control condition. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia. RESULTS We observed a 40% decline in cumulative sexually transmitted illness incidence (P = .049) in the intervention group. Incidence density for the intervention versus control groups was 13.8 versus 24.92 per 100 person-years for sexually transmitted illnesses combined (P = .034) and 0 versus 2.01 per 100 person-years for HIV (P < .001). There were concomitant increases in the number and percentage of protected sex acts and decreases in the number of unprotected sex acts with clients (P < .05). CONCLUSIONS This brief behavioral intervention shows promise in reducing HIV and sexually transmitted illness risk behaviors among female sex workers and may be transferable to other resource-constrained settings.

Migration and AIDS in Mexico: An overview based on recent evidence

Objectives:Provide an overview of the relation between migration to the United States and AIDS cases in Mexico. Characterize the sexual behaviors of Mexican migrants. Describe HIV/AIDS prevention and clinical attention actions developed. Methods:The following were analyzed: AIDS cases databases, various prevalence studies, the migrants survey, and information of the Ministries of the Interior and of Health. A documental analysis was undertaken of works published between 1992 and 2000 on migration and AIDS. Results:In terms of their sexual practices, migrants in the past year had more sexual partners, tended to use a condom in their most recent relation in greater proportion, and had greater use of injected medicines and drugs. Two bi-national programs undertake epidemiological surveillance activities, while several initiatives have used innovative formats to provide prevention information to migrants. Imminent universal coverage leaves the challenge to assure quality of attention for migrants. Conclusions:Studies to evaluate the impact of international migration on distribution of infected persons will be indispensable to establish priorities in prevention and attention among migrants. More information is needed on bi-national health projects to understand the impact they may have in prevention, while continuity of the prevention initiatives must be guaranteed. Attention to migrants in bi-national contexts requires information exchange agreements on migrants living with the HIV/AIDS.

Mexico's Evolving HIV Epidemic

This year marks the first time the International AIDS Conference will be held in a Latin American country, with Mexico as its host. Accordingly, it is timely to revisit Mexico’s status as a country thought to have averted a major human immunodeficiency virus (HIV) epidemic, in contrast to some nearby countries (eg, the United States and Honduras). An estimated 180 000 HIV-positive individuals were living in Mexico in 2006, which translates to a prevalence of 0.3%.1 Yet with a pandemic that may shift rapidly, national HIV prevalence can mask considerable heterogeneity at the state level. In Mexico, a dynamic HIV subepidemic on its northern border with the United States now threatens its designation as a country of low prevalence and high risk. Among Mexico’s 32 states, Baja California—abutting California in the United States—has consistently had the highest cumulative AIDS incidence, second only to the federal district (ie, Mexico City).1 Tijuana, a city of 1.5 million people adjacent to San Diego, California, is situated on a major drug trafficking route. Approximately 90% of methamphetamine and 30% of heroin entering the United States are produced or manufactured in Mexico.2 Like many other Mexico-US border cities (eg, Nuevo Laredo and Ciudad Juarez), Tijuana also has a thriving zona roja [red-light zone], attracting thousands of sex tourists each year.3 The co-occurrence of the drug and sex trades may be contributing to increasing rates of HIV and sexually transmitted infections (STIs) in some cities along the Mexican-US border.2-7 Prevalence of HIV was 6% in 924 female sex workers (FSWs) recruited for an intervention study between January 2004 and January 2006 in Tijuana and Ciudad Juarez (bordering El Paso, Texas)4; among the 368 FSWs who were followed up in the control group, HIV incidence was 2.01 per 100 person-years.5 Although HIV prevalence among 1052 injection drug users (IDUs) recruited in Tijuana via respondent-driven sampling from 2006 to 2007 was lower at 3%,6 HIV incidence among 618 IDUs who returned for follow-up was 2.18 per 100 person-years.7 Prevalence of HIV was 12% among FSWs who inject drugs in these cities, among whom nearly half had at least 1 active STI.2 In 2006, the rate of acquired syphilis was 12.6 per 100 000 in Baja California,1 twice that of the United States. In a large study of pregnant women in Tijuana, HIV prevalence was 1% and among those who used drugs was 6%8; all HIV cases were previously unidentified and linked to drug use. As many as 1 in 125 individuals aged 15 to 49 years in Tijuana was infected with HIV in 2005,8 suggesting that the city’s HIV epidemic had already increased from a low level to a more concentrated prevalence. Tijuana’s HIV epidemic may influence its neighbors to the north and south. Because of the substantial median income gap between Mexico and the United States, strong migratory forces from Mexico’s interior have led Tijuana to experience one of the highest population growth rates in Latin America. Tijuana and San Diego share the busiest land-border crossing in the world, with 45.9 million northbound legal border crossings in 2006 alone. Considerable bidirectional mobility exists among high-risk populations at this international border crossing. Nearly half of men having sex with men (MSM) in Tijuana and three-quarters of MSM in San Diego report having male sex partners from across the border.9 In 2005, one-fifth of IDUs in Tijuana had traveled to the United States in the previous year.10 Of 924 FSWs studied in Tijuana, 69% report being patronized by US clients; those who are report greater tendencies to inject drugs, have high syphilis titers, and engage in unprotected sex for higher pay.3 While the role of mobility in Mexico’s evolving HIV epidemic remains unclear, a review on this topic reported that 40.6% of Mexican male international migrants report having sex with sex workers, 35.3% report sex with nonregular and commercial partners, and 9% to 20% inject drugs, vitamins, or antibiotics.11 Because two-thirds of Tijuana’s inhabitants originate from outside Baja California, migrants may be infected with HIV when they return home. In the southern states of Michoacan and Zacatecas, 20.6% and 20.5%, respectively, of AIDS cases reported by the end of 2000 were among individuals who had resided in the United States.11 Bisexuality is an important risk factor in Mexico’s HIV epidemic.11-13 In a study of MSM in 4 Mexican cities (ie, Acapulco, Netzahualcoyotl, Monterrey, and Tampico), 42% reported having sex with women in the previous 6 months13; a percentage identical to that in Tijuana.9 Of male IDUs studied in Tijuana, 28% reported having sex with other males.6 Social stigma surrounding bisexuality and homosexuality may be contributing to a feminization of Mexico’s HIV epidemic, a consequence of bisexual men infecting their wives, or other women.12 The proportion of women among reported AIDS cases diagnosed in 2006 was 20.7% compared with 16.0% for cumulative cases reported from 1983-2006,1 and increasing numbers of Mexican women report unprotected sex with their husbands as their sole risk factor.12 The ratio of male to female HIV cases appears narrower in Tijuana, at approximately 3:1.8 Unless HIV prevention is scaled up immediately, Tijuana’s HIV epidemic could become increasingly generalized. Recent Tijuana studies demonstrated that 46% of MSM9 and 41% of IDUs6 have ever had an HIV test, indicating the need to expand voluntary testing and counseling to these and other high-risk groups (eg, FSWs and migrants). In response, the Federal Ministry of Health, through the Centro Nacional para la Prevencion y Control del SIDA, Mexico City, Mexico, and state health officials, implemented mobile clinics (condonetas) in Tijuana and several other Mexican cities to deliver condoms, rapid HIV testing kits, educational materials, and syringe exchange to high-risk neighborhoods. Equipped with loudspeakers on their roofs, video screens on their bumpers, and emblazoned with brightly colored condom caricatures, condonetas take HIV prevention to the streets, challenging the sexual silence of this otherwise conservative country. Nongovernmental organizations, witnessing an emerging HIV epidemic unfold, have responded enthusiastically. In 2006, 119 million free condoms were distributed with aid from federal health authorities. In 2007, nationwide routine HIV screening was integrated into prenatal care to identify HIV infections earlier and offer antiretroviral therapy (ART) to mother and child. Until recently, the only needle exchange program (NEP) in Mexico was operated by a nongovernmental organization in Ciudad Juarez. However, NEPs are now operating in at least 6 Mexican states and NEP attendance increased from 20% to 59% among Tijuana IDUs from 2006-2007.7 These important steps need to be amplified and sustained, but other challenges remain at the national level. Efforts to integrate HIV and STI diagnosis and treatment are needed, given the high prevalence of syphilis that has been closely linked to HIV transmission among FSWs and IDUs.4,6 While ART is provided free to medically eligible individuals in Mexico through government-sponsored health care, structural barriers hamper ART rollout, such as a health care system that struggles to meet the demand, an inability to negotiate ART price discounts due to factors that may include NAFTA, unacceptably high rates of prescribing inappropriate antiretroviral regimens,14 and inefficiencies in delivery of voluntary testing and counseling.15 A federally sponsored program to improve ART clinical decision making is under way. What can other countries learn from Mexico’s experience? First, even when an HIV epidemic is avoided early, vigilant epidemiological and behavioral surveillance needs to be closely coordinated with prevention and treatment, matched at the appropriate scale14,15 to ensure that outbreaks are contained. Second, migration and mobility need to be recognized as critical drivers of HIV vulnerability,6,9-12 suggesting that HIV interventions should incorporate sexual geographies that shape individual and network-level risks.12 Third, border regions may represent especially high-risk locations deserving of heightened HIV surveillance in the context of binational cooperation. In light of increased HIV prevalence and incidence and high levels of bidirectional mobility, Tijuana’s HIV epidemic profile may represent what lies ahead for Mexico and possibly Central America. Effective HIV and STI prevention, diagnosis, and treatment will need to involve a shared responsibility between bordering countries. A multipronged plan is urgently required that increases access to and uptake of voluntary testing and counseling, expands preventive HIV and STI interventions for high-risk groups, and provides consistent, medically appropriate ART to prevent the spread of HIV infection through the Americas.

Differential Effects of Migration and Deportation on HIV Infection among Male and Female Injection Drug Users in Tijuana, Mexico

HIV prevalence is rising, especially among high risk females in Tijuana, Baja California, a Mexico-US border city situated on major migration and drug trafficking routes. We compared factors associated with HIV infection among male and female injection drug users (IDUs) in Tijuana in an effort to inform HIV prevention and treatment programs. IDUs aged ≥18 years were recruited using respondent-driven sampling and underwent testing for HIV, syphilis and structured interviews. Logistic regression identified correlates of HIV infection, stratified by gender. Among 1056 IDUs, most were Mexican-born but 67% were born outside Tijuana. Reasons for moving to Tijuana included deportation from the US (56% for males, 29% for females), and looking for work/better life (34% for females, 15% for males). HIV prevalence was higher in females versus males (10.2% vs. 3.5%, p = 0.001). Among females (N = 158), factors independently associated with higher HIV prevalence included younger age, lifetime syphilis infection and living in Tijuana for longer durations. Among males (N = 898), factors independently associated with higher HIV prevalence were syphilis titers consistent with active infection, being arrested for having ‘track-marks’, having larger numbers of recent injection partners and living in Tijuana for shorter durations. An interaction between gender and number of years lived in Tijuana regressed on HIV infection was significant (p = 0.03). Upon further analysis, deportation from the U.S. explained the association between shorter duration lived in Tijuana and HIV infection among males; odds of HIV infection were four-fold higher among male injectors deported from the US, compared to other males, adjusting for all other significant correlates (p = 0.002). Geographic mobility has a profound influence on Tijuanas evolving HIV epidemic, and its impact is significantly modified by gender. Future studies are needed to elucidate the context of mobility and HIV acquisition in this region, and whether US immigration policies adversely affect HIV risk.

The epidemiology of HIV among Mexican migrants and recent immigrants in California and Mexico.

For Mexican migrants and recent immigrants, the impact of migration from Mexico to California has the potential to lead to an increased risk for HIV infection. Until recently, the prevalence of HIV in Mexico and among Mexican migrants in California appeared to be stable and relatively low. Recent studies have raised new concerns, however, that the HIV epidemic may expand more aggressively among this population in the coming years. Unfortunately, the insufficient amount of data available within recent years makes it difficult to fully assess the potential for rapid spread of the HIV epidemic among this population. Consequently, there is a critical need for an ongoing binational surveillance system to assess prevalence and trends in HIV/STD/TB disease and related risk behaviors among this population both in Calfornia and within this population’s states of origin in Mexico. This enhanced epidemiologic surveillance system should provide improved data on the subpopulations at the highest risk for HIV/STD/TB, such as men who have sex with men, and should provide the opportunity to evaluate the impact of migration on the transmission dynamics, risk behaviors, and determinants of behavior on each side of the border. It is essential that this potential threat be assessed and that intervention programs are developed and implemented to combat this possible escalation in the HIV epidemic.

Going North: Mexican migrants and their vulnerability to HIV.

Background: Mexican migrants are at higher risk for HIV than Mexicans who do not migrate to the United States. Migration to the United States was the driving factor of the early Mexican HIV epidemic, and it is likely that it continues to strongly influence incidence. An overview of migration of Mexicans to the United States identifies many pervasive environmental and structural factors as well as risk behaviors that render migrants vulnerable to HIV infection. However, published studies sampling Mexicans while in the United States suggest a relatively low prevalence of HIV among the general migrant population. To better understand this apparent paradox, we sought to identify any demographic variables among Mexicans while in Mexico that may indicate that migrants have or acquire resources that have a protective effect from their vulnerability due to migration. Methods: A California-Mexico binational collaboration project, with a respondent-driven sample with population-based quotas, was conducted in five Mexican states from December 2004 to January 2005, in areas with a high index of migration to the United States. We compared demographic and behavior variables of Mexicans with a history of migration to the United States in the past 12 months to nonmigrant Mexicans living in the same community. Results: A total of 1539 migrants and 1236 nonmigrants were recruited from five Mexican states. Migrants (men and women) reported more HIV risk behavior than nonmigrants in the past 12 months. Migrants reported more sexual partners and noninjected drug use. Migrants reported higher condom use during vaginal sex and were more likely to have taken an HIV test. Conclusion: Though migrants reported higher HIV-related risk behaviors, they also reported higher condom use. Migrants were more likely to have accessed an HIV test indicating an opportunity for a prevention intervention. More binational collaborations are needed to research the different levels of vulnerability among Mexican migrants and actual acquisition of HIV infection. In addition, more research is needed to identify protective factors for HIV prevention interventions among Mexican migrant communities in Mexico and in the United States.

Characteristics of Female Sex Workers With US Clients in Two Mexico-US Border Cities

Background: HIV prevalence is increasing among female sex workers (FSWs) in Tijuana and Ciudad Juarez, 2 Mexican cities on the US border. Quasilegal prostitution in both cities attracts large numbers of sex tourists. We compared FSWs with and without US clients in both cities. Methods: FSWs aged ≥18 years reporting unprotected sex with ≥1 client within the last 2 months, who were not knowingly HIV-infected, were enrolled in a behavioral intervention study. At baseline, participants underwent interviews, antibody testing for HIV and syphilis, and vaginal swabs for detecting gonorrhea and Chlamydia. Logistic regression identified factors associated with reporting >1 US client. Results: Of 924 FSWs, 69% had US clients. Median age and duration in sex work were 32 and 4 years. Prevalence of HIV, infectious syphilis (titer ≥1:8), gonorrhea, Chlamydia, and any STI was 6%, 14%, 6%, 13%, and 27%, respectively. Compared with other FSWs, FSWs with US clients were more likely to have syphilis titers ≥1:8 (16% vs. 10%, P = 0.01), gonorrhea (8% vs. 2%, P <0.001) or any STI, including HIV (30% vs. 20%, P = 0.002). Factors independently associated with having US clients were: living in Tijuana, being younger, speaking English, being paid more for having sex without a condom, having >250 clients in the last 6 months, having syphilis titers ≥1:8, and injecting drugs. Conclusions: In these border cities, FSWs reporting US clients were more likely to have current STIs and to engage in higher-risk behaviors. Intensified binational prevention efforts involving both FSWs and their clients are urgently needed.