1. www.aids2014.org Eileen V. Pitpitan, 2 Thomas L. Patterson 1, Shirley J. Semple 1, Claudia V. Chavarin 1, Carlos Magis-Rodriguez 3, & Steffanie A. Strathdee 2 1 Department of Psychiatry, University of California, San Diego (UCSD), California, U.S.A.; 2 Division of Global Public Health, Department of Medicine, UCSD; 3 Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA), Mexico City, D.F., Mexico

2. www.aids2014.org Background 6,000-10,000 FSWs in Tijuana Mexico Male clients of FSWs are at high risk of transmitting HIV/STIs Clients are a “bridge population” -originate mostly from both Tijuana and San Diego Tijuana’s HIV prevalence is double Mexico’s national average HIV prevalence is highest among: MSM (~20%) PWID (5%) FSWs (~6%) Male clients of FSWs (~5%)

3. www.aids2014.org Sex Work in Mexico Quasi legal in Mexico –Zone of tolerance (zona roja) –Work permit Sex tourist destination Work environments complex –Bar girls –Street (“paraditas”) –Beauty/massage parlors –Table dancers –In-call services

4. www.aids2014.org Study Aims Few intervention designed to promote safer sex among clients ‘Hombre Seguro’ developed based on qualitative interviews and previous intervention experience with high risk men and FSWs. AIM 1. Test a brief theory based intervention designed for U.S. and Mexican clients of FSWs in Tijuana AIM 2. Determine if clients experiencing syndemics experience greater benefit from the intervention

5. www.aids2014.org Syndemics (Singer, 1999) Co-occurrence of substance use, experiences of violence, poor mental health, and other factors that have an additive effect on HIV risk behavior Hypothesis: More psychosocial and health problems (e.g. substance use, depression) more likely to engage in higher sexual risk behavior (dose-response relationship) Painful reality. Many deported heroin users who live in the Tijuana River Canal consider California home.

6. www.aids2014.org Measures Drug Use Syndemic Risk Factors Alcohol Use Depression Abuse Incarceration Primary Outcome Recent (past 4 mo) and frequent use (≥ 1x per week) marijuana, heroin, inhalants, methamphetamine, ecstasy, and 9 others (including “any other drug” Alcohol Use Disorders Identification Test (AUDIT) (score of ≤8 = “hazardous drinker”) Center for Epidemiological Studies–Depression (CES-D) scale (10 items, mood over last week, scale of 0 to 3. Cutoff = 11 or greater) Three items queried lifetime emotional, physical or sexual abuse Any incarceration in past 4 months? (1=yes, 0=no) AIM 1 OUTCOME: Total recent (past 4 months) unprotected sex acts with FSWs at baseline

7. www.aids2014.org Hombre Seguro Participants Recruited in Tijuana Zona Roja N = 400 (half reside in U.S., half in Tijuana) Eligibility criteria:  biologically male  >18 years old  obtained sex from an FSW in exchange for money, drugs, shelter or goods  unprotected vaginal or anal sex with FSW  test HIV-negative at baseline  agree to receive treatment for a active STIs

8. www.aids2014.org Study Design Baseline Assessment Hombres Seguro (200 clients: 100 U.S., 100 Mexican) One 60-minute one-on-one Counseling Session 6- 12-Month Assessment Didactic Safer Sex (200 clients: 100 U.S., 100 Mexican) One 60-minute one-on-one Counseling Sessions

9. www.aids2014.org Hombre Seguro Intervention: Theory Based Social Cognitive Theory –Knowledge –Self-Efficacy –Outcome expectancies Theory of Reasoned Action –Intention to change Transtheoretical or “Stages of Change” Model –Readiness to change

10. www.aids2014.org Mujer Segura Counseling Topics* TopicDescription Context of Develop insights into motivations/triggers of unsafe sex. Unsafe sex. Set plan and goals for safer sex Condom UseMI and skill-building to induce behavior change. Match counseling to individual’s stage of change Negotiation of MI and skill-building to teach negotiation skills to Safer Sex move participants into action *incorporating motivational interviewing (MI) and social cognitive theory

11. www.aids2014.org Results Aim 1: Was Hombres Seguro efficacious? Both groups significantly reduced unsafe sex acts with FSWs. BUT …Intervention and Control conditions did not differ (i.e., both benefited). Photo By: Oralia Loza

12. www.aids2014.org Results Aim 2: Did clients with more syndemic exposures benefit more from the intervention? Source: Wikipedia Commons, 2009 Source: Wikipedia Commons, 2007

13. www.aids2014.org GEE significantly and positively associated with more unprotected sex acts with FSWs in the past 4 months (B = 0.20, p = 0.01, 95% CI 0.05, 0.35).

14. www.aids2014.org Total Unprotected Vaginal and Anal Sex Acts with FSWs in past 4 months (reported at 12 months) Change in unprotected sex with FSWs by Syndemic Group

15. www.aids2014.org Conclusions Both Hombres Seguro and the didactic control condition resulted in significant decreases in risk behavior. At baseline, more syndemic problems were associated with more unprotected sex in both Hombres Seguro and the information only control condition At 12-months post intervention: Among Hombres Seguro participants, syndemic risk moderated the effect of the intervention on sexual risk behavior. Among control participants, the syndemic relationship was no longer significant

16. www.aids2014.org Conclusions, Continued First study to demonstrate an intervention “buffering” the negative impact of syndemic problems on HIV risk. Hombre Seguro aimed at reducing sexual risk. –Counseling session was tailored to the specific individual’s issues and risk profile –Appeared to alleviate the composite negative impact of drug use, alcohol use, violence, depression, and incarceration on sexual risk. Psychosocial problems do not exist in silos and thus integrated combination interventions are needed.

17. www.aids2014.org Acknowledgments This study was funded by the National Institute on Drug Abuse (NIDA) (R01DA029008). This work was also supported by Diversity Supplement (R01 DA029008-04S1) and a K01 Award (K01 DA036447-01) to Dr. Pitpitan.

18. www.aids2014.org Thanks Project staff and co-investigators Most importantly, the participants who gave of their time and seldom have a voice San Diego Department of Health Others Patronato Pro- Comusida Tijuana, AC

19. www.aids2014.org Source: Shira Goldenberg

20. www.aids2014.org The table above shows the intercorrelations between the risk factors. We found that out of ten possible associations, 5 were statistically significant (p <.05) and 1 was marginally significant (p <.10).