1. Operationalizing the Enabling Environment: A Binational Partnership Steffanie A. Strathdee (University of California San Diego, La Jolla, CA, USA), Leo Beletsky (Northeastern University School of Law and Bouvé College of Health Sciences, Boston, U.S),

3. Local Context: Mexico Legal to purchase and/or carry syringes without a prescription yet police regularly confiscate syringesLegal to purchase and/or carry syringes without a prescription yet police regularly confiscate syringes Recent drug policy reform (“narcomenudeo”) partially decriminalizing small amounts of drugs for personal possessionRecent drug policy reform (“narcomenudeo”) partially decriminalizing small amounts of drugs for personal possession

4. Q: Can you tell me, do you know if it is legal for you to carry syringes? A: No. Every time I’ve had them I’ve gotten into trouble. It’s a joke! I have bought them literally for six pesos. But you can’t carry them on you; I don’t understand that. How come you’re allowed to buy them but not carry? (Female, 31 years) Case Study: Where syringe purchase and possession is legal without a prescription

5. Direct Effects of Law Enforcement on HIV Risks Discourages PWID from carrying sterile or used syringes Discourages PWID from carrying sterile or used syringes Fuel risky injection via “hurried injecting” Fuel risky injection via “hurried injecting” Pressures PWID to inject in unsafe spaces (e.g., shooting galleries) Pressures PWID to inject in unsafe spaces (e.g., shooting galleries) Prompts risky drug and syringe storage practices that can contribute to needlestick injuries (NSI) Prompts risky drug and syringe storage practices that can contribute to needlestick injuries (NSI)

6. Indirect Effects of Law Enforcement on HIV Risks Displaces PWID into unsafe environments Displaces PWID into unsafe environments Discourages PWID from accessing HIV prevention programs (e.g., NSP, OST) Discourages PWID from accessing HIV prevention programs (e.g., NSP, OST) Discourages PWID from accessing emergency response Discourages PWID from accessing emergency response

7. Extra-Legal Behaviors: Police Misconduct Sexual AbuseSexual Abuse Physical AbusePhysical Abuse Soliciting BribesSoliciting Bribes Evidence PlantingEvidence Planting Precipitating forced drug withdrawalPrecipitating forced drug withdrawal

8. Of 33% who reported sexual favors for police, 86.2% of these were in exchange for not being arrested. Beletsky et al, 2012

9. Police Perspective Fear of needle stick injury (NSI) and other occupational risksFear of needle stick injury (NSI) and other occupational risks Poor knowledge of infectious disease transmissionPoor knowledge of infectious disease transmission Often unaware of evidence demonstrating effectiveness of harm reduction, laws relating to syringe purchase and possession and availability and location of local harm reduction servicesOften unaware of evidence demonstrating effectiveness of harm reduction, laws relating to syringe purchase and possession and availability and location of local harm reduction services Beletsky et al, 2005

10. Structural Interventions to Realign Policing and Public Health Two main types of intervention approaches:Two main types of intervention approaches: 1)Law on the Books: through legislative advocacy or impact litigation, change the laws affecting PWID 2)Law on the Streets: Change the way the laws on the books are enforced (or not)

11. Police Education Programs Bundling occupational safety with HIV prevention information  Occupational Safety Basic infectious disease info and Prevention tipsBasic infectious disease info and Prevention tips Glove and sharps containers distributionGlove and sharps containers distribution  Law relating to harm reduction efforts (e.g., syringe possession)  Public health rationale for harm reduction efforts  Service referral information 4. Law Enforcement and HIV Network (LEAHN) Statement of Support Davis & Beletsky, 2009

12. Chronology of Partnership between UCSD and Tijuana Police Department MOU with police chief (2013)MOU with police chief (2013) Tijuana Mayor mandates police education including harm reduction (May, 2014)Tijuana Mayor mandates police education including harm reduction (May, 2014) First survey of NSI among TJ police department (June, 2014)First survey of NSI among TJ police department (June, 2014) Launch of NSI reporting and surveillance (Fall, 2014)Launch of NSI reporting and surveillance (Fall, 2014) Pre-post PEP pilot (Fall, 2014)Pre-post PEP pilot (Fall, 2014)

13. *among those ever report NSI

14. Percentage

15. Encounters needles that contain drugs while on duty frequently/all the time 2.98 (1.56-5.67) Reports breaking used needles when encountering them 2.25 (1.29-3.91) In case of an NSI would contact emergency services 0.39 (0.22-0.69) Wears needle-stick resistant gloves0.43 (0.19-0.91) *among those ever reporting encountering needles/syringes while on duty

16. Policing practices are a pervasive barrier to the implementation and effectiveness of harm reduction programs There is an urgent need to re-align harm reduction and law enforcement approaches to support prevention and treatment of HIV and viral hepatitis among PWID Police departments can be willing partners receptive to harm reduction when framed as occupational safety Conclusions

17.  Collaborators: Gudelia Rangel, Jaime Arredondo, Efrain Patino, Maria Luisa Rolon, Arnulfo Banuelos, Dir. Olivarria  People who use drugs who have shared their stories of abuse, humiliation, violence, torture, and loss  National Institute on Drug Abuse grant R37 DA019829,  Open Society Foundation Acknowledgements