1. No Man’s Land: Deportation and Migration as Risk Factors versus Protective Factors for HIV Infection Among Male and Female Injection Drug Users in Tijuana, Mexico Steffanie A. Strathdee, Ph.D. Harold Simon Professor and Chief, Division of International Health & Cross-Cultural Medicine, University of California, San Diego, U.S.A. sstrathdee@ucsd.edu Published in PLoS ONE; July 29, 2008

2. Co-Authors Remedios Lozada, MD Victoria Ojeda, PhD Alicia Vera, MPH Robin Pollini, MPH, PhD Kimberly Brouwer, PhD Wayne Cornelius, PhD Lucie Nguyen, MS Carlos Magis-Rodriguez, MD, PhD Thomas L Patterson, PhD Proyecto El Cuete and Prevencasa

3. Map of Mexico-US Border Region

4. To examine risk factors for HIV infection at the level of the individual, network and environment To determine whether HIV risk factors differ by gender Objective USA Mexico

5. Methods Baseline data from prospective cohort in Tijuana 2006-2007 Eligibility: ≥18 years old Injected drugs within prior month Reside in Tijuana Recruited through respondent driven sampling Serology for HIV, syphilis and latent TB infection Logistic regression of HIV correlates, examining potential effect modification by gender, adjusted for correlations between recruiters and recruits

6. Strathdee et al, JAIDS 2008; Strathdee and Magis-Rodriguez, JAMA, 2008 HIV Prevalence and Incidence among IDUs in Tijuana: 2006-2008 HIV incidenceHIV Prevalence

7. Factors independently associated with HIV infection among IDUs in Tijuana, Mexico (n=1056) Strathdee et al, JAIDS, 2008 Variable Adj. Odds Ratio* 95% Confidence Interval Female2.841.31-6.17 Number of years lived in Tijuana (per 10 year increase) 0.780.61-1.01 Syphilis antibody titer>=1:83.601.55-8.35 # of different people usually injects with* (per 5 people) 1.241.07-1.43 # of arrests for track marks (per 5 arrests) 1.121.01-1.25

8. Factors independently associated with HIV infection among IDUs in Tijuana (TJ), Mexico (n=1047) Variable Adj. Odds Ratio*95% CI Gender x Number years lived in TJ 0.550.35-0.89 Female 1.330.47-3.73 # Years lived in TJ (per 10 yr increase) 1.170.85-1.60 # of different people usually injects with* (per 5 people) 1.241.07-1.43 Syphilis antibody titer>=1:8 4.361.83-10.39 # of arrests for track marks (per 5 arrests) 1.121.01-1.24 *Adjusted for correlation between recruiters and recruitees

9. Interaction between Gender and # Years Lived in Tijuana Regressed on Log (Odds of Testing HIV+)

10. The Missing Link: Deportation among Male IDUs # years lived in Tijuana: Male deportees from US: 8 years Other males: XX years Median #Years lived in Tjuana: Male deportees: 5 years Other migrant males: 17 years

11. Reasons for moving to Tijuana, by gender

12. Factors Independently Associated with HIV infection by Gender Variable FemalesMales Number of years lived in Tijuana (per 10 year increase) 1.8-- Deportation--4.0 Age (per 10 years) 0.2-- Syphilis 4.55.6 # of different people usually injects with* (per 5 people) --1.3 # of arrests for track marks (per 5 arrests) --1.1 All p<0.05 *Adjusted for correlation between recruiters and recruitees

13. Explanation #1: Is Deportation a Marker for a High Risk Subgroup of Male IDUs? The San Diego/Tijuana border crossing is the busiest land border crossing in the world, with over 46 million north-bound crossings per year alone Courtesy of La Frontera, 2008

14. Explanation #2: Is Deportation a Risk Factor for HIV Acquisition? All photos shared with permission

15. Lessons Learned  Beyond individual risk factors, structural factors such as geographic mobility are important epidemic drivers.  Mobility should be ‘unpacked’ to disentangle risk and protective factors  e.g., consider gender and intention  The Mexico/US border is a vulnerable region in need of HIV interventions and binational cooperation, especially for IDUs who are among the most marginalized.

16. Acknowledgements NIH Grants: R01DA019829, R21DA024381, K01DA022923, K01DA020364 and DA019829-03S1 Staff from the PrevenCasa, A. C., Patronato Pro- COMUSIDA and UCSD San Diego County Public Health Laboratory CENSIDA, ISESALUD and Tijuana General Hospital Most importantly, the participants who shared their stories.

18. Extra Slides

19. Characteristics of IDUs with and without HIV infection in Tijuana, Mexico: 2006-2007 Baseline Characteristics HIV Positive N=42 HIV Negative N=1010 Total N=1052P-value Individual Factors Median age 3437 0.04 Female 29%13%14%0.01 Born outside Baja California 83%66%67%0.02 Median # yrs injected 1015 0.04 Any receptive needle sharing* 52%59% 0.42 Syphilis titer >1:8 22%7% 0.002 Social Influences Median # people inject with recently 3 220.002 Environmental Influences Median # yrs lived in Tijuana 1015 0.12 Deported from USA 52%38%39%0.09 Median # times arrested for having track marks 3330.35