Threading the Needle: Interventions to Reduce HIV and Related Harms among Female Sex Workers who Inject Drugs

Transcription

1 Threading the Needle: Interventions to Reduce HIV and Related Harms among Female Sex Workers who Inject Drugs Steffanie A. Strathdee, Harold Simon Professor, Associate Dean of Global Health Sciences, UC San Diego

2 Co-Investigators Remedios Lozada, ISESALUD, Tijuana, Mx. Gustavo Martinez, SADEC-FEMAP, Cd. Juarez, Mx. Gudelia Rangel, COLEF, Baja California, Mx. Hugo Staines, UACJ, Cd. Juarez, Mx. Daniela Abramovitz, UCSD, USA Alicia Vera, UABC, Tijuana, Mx. Carlos Magis-Rodriguez, CISIDAT, Mx. Thomas L Patterson, UCSD NIH grants R01DA and R01MH65849 Clinical trial registration number: NCT

3 Background Considerable overlap between injection drug use and sex work in some regions (e.g., parts of southeast Asia, E. Europe) Sex workers who inject drugs may acquire HIV through unprotected sex or sharing of injection equipment Heightened vulnerability due to withdrawal, police harassment, exposure to violence To date, no intervention has attempted to simultaneously reduce HIV through both transmission routes

4 Background Sex work is quasi-legal in Mexico Sex tourism is common in Mexican-U.S. border cities ~9000 female sex workers (FSWs) in Tijuana; ~4000 in Cd. Juarez Both cities situated on major drug trafficking routes

5 Factors associated with HIV infection in FSWs in Tijuana and Ciudad Juarez (n=924) Baseline Characteristics Adjusted Odds Ratio, 95% CI Injected cocaine past month 2.96 (1.29, 6.80) Smoked, inhaled, or snorted methamphetamine past month 3.32 (1.85, 5.95) Syphilis titer >1:8 * 4.16 (2.28, 7.59) HIV prevalence: 6% * Consistent with active infection Patterson et al, J Inf Dis (2008)

6 Baseline HIV/STI Prevalence among FSWs who do and do not Inject Drugs: Tijuana and Cd. Juarez Percent Positive 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% p < % 13.8% p <.00 1 p < % 23.9% FSW p < % FSW+IDU 15.6% 11.1% 22.0% 22.8% 46.1% HIV+ Syphilis Gonorrhea Chlamydia Any STI > 1:8 STI Type p =.001 p <.001

7 Objectives: Mujer Mas Segura (Safer Women) To evaluate brief combination interventions to simultaneously reduce sexual and injection risks among FSW-IDUs in Tijuana and Cd. Juarez To compare efficacy of these interventions in Tijuana vs. Cd. Juarez, since availability to sterile syringes and condoms was increasing rapidly in Tijuana, and less so in Juarez. Vera et al, 2012

8 Eligibility Criteria Biologically female >18 years old Live in Tijuana or Cd. Juarez Tested HIV-negative at baseline Agree to STI treatment if testing positive Began trading sex > 6 months ago Self reported behaviors within the last month: one episode of unprotected sex with clients one episode of injecting drugs and sharing injection equipment

9 Methods: Data Collection At baseline and quarterly for 12 months: Interviewer-administered surveys Biologic testing and on-site STI treatment: HIV antibody Syphilis Gonorrhea and Chlamydia Trichomonas vaginalis 2x2 factorial trial: Simultaneously examine two interventions - Interactive vs. Lecture formats

10 2x2 Factorial Design to Simultaneously Evaluate Injection and Sexual Risk Reduction Interventions Interactive Injection Risk Intervention No Yes Interactive Sexual Risk Intervention No Yes Group A (control) (N=144) Group C (N=148) Group B (N=146) Group D (N=146) Each group received a total of 60 minutes of intervention (30 min per condition)

11 Two Theory-Based Interventions* Interactive Sexual Risk Intervention (30 min.) Based on Mujer Segura and Fastlane interventions MI, role-play and goal-setting on condom negotiation within context of their own and/or clients substance use Interactive Injection Risk Intervention (30 min.) Based on DUIT and STRIVE interventions: Risk ladder exercise using MI and goal-setting 5-min video illustrating contamination of injection equipment Syringe disinfection role-play Lecture formats of each intervention (30 min each) One-way sharing of information No discussion, role playing or goal-setting * Social cognitive theory, theory of reasoned action

12 Mujer Mas Segura: Syringe Contamination Video Conceived of and featuring women from the sex worker Community* *all women gave written permission for full use of video and photos

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22 Mujer Mas Segura: Risk Ladder Exercise Injecting with someone else s used syringe Injecting with somebody else s bleached syringe Sharing water, cotton, and bleached cooker Re-using your own syringes and equipment Preparing and splitting drugs with someone else s used syringe Sharing water, cotton and unbleached cooker Using only new syringes and cookers and new cotton and water to split drugs Not injecting drugs Use a new syringe and equipment for every injection Not using drugs

23 Statistical Analysis Intention-to-treat; followed recommended approach for factorial trials (McAlister et a, JAMA 2003) Primary Outcome: Combined HIV/STI Incidence Poisson regression with robust variance estimation Secondary Outcomes: Receptive needle sharing, sharing of injection paraphernalia, injection risk index Repeated measures ordinal logistic regression via GEE

24 >90% follow-up at each visit for both sites Randomization worked; no major significant differences between 4 groups

25 HIV/STI incidence* per 100 person-years (py) after 12 months: Tijuana Interactive Injection Risk Intervention (95% CI*) No Yes Group A (control) Group B Interactive Sex Risk intervention No Yes (34.58, 93.95) Group C (18.84, 73.29) Group D (12.31, 58.72) (9.21, 50.81) * HIV, syphilis, gonorrhea, Chlamydia, trichomonas

26 Intervention effects on HIV/STI incidence after 12 months: Tijuana Interactive Injection Risk Intervention (Adj RR; 95% CI*) No Yes Group A (control) Group B Interactive Sex Risk intervention No Yes Reference Group C ( ) Group D 0.37 (0.16, 0.89) (0.16, 0.89) *Adjusted for # of unprotected sex acts with non-regular clients, and arrests prior to enrolment

27 HIV/STI incidence per 100 py after 12 months: Cd. Juarez Interactive Injection Risk Intervention (95% CI*) No Yes Group A (control) Group B Interactive Sex Risk intervention No Yes (30.17,102.02) Group C (51.20, ) Group D (12.01, 57.29) (45.14,122.66) * HIV, syphilis, gonorrhea, Chlamydia, trichomonas

28 Intervention effects on HIV/STI incidence after 12 months: Cd. Juarez Interactive Injection Risk Intervention (Adj RR; 95% CI*) No Yes Group A (control) Group B Interactive Sex Risk intervention No Yes Reference Group C ( ) Group D 1.12 (0.19, 0.99) (0.56, 2.25 ) *Adjusted for $ earned per unprotected sex act and cocaine use in month prior to enrollment

29 Impact of Injection Risk Interventions on Receptive Needle Sharing: Tijuana and Cd. Juarez

30 Impact of Injection Risk Interventions on Injection Risk Index: Tijuana and Cd. Juarez

31 Reported Numbers of Syringes Exchanged and Prevenkits* Distributed in Tijuana and Cd. Juarez Year Study Period Cd. Juarez Syringes Cd. Juarez Prevenkits Tijuana Syringes Tijuana Prevenkits *kits with sterile water, cooker, cotton & syringes

32 Impact of Interactive Injection Risk Intervention on Receptive Needle Sharing, adjusting for Access to Sterile Syringes : Cd. Juarez Predictor Proportional Odds Ratio 95% CI P-value Intervention vs. Control Reported easy access to sterile syringes Age beginning sex work** Visit 2 * <.0001 Visit 3 * <.0001 Visit 4 * <.0001 *reference = baseline; **per year

33 Injection intervention effects on safe injection self-efficacy by experience of police syringe confiscation in Cd. Juarez (n=190) 3 Self Efficacy Score Police did not confiscate syringe Police confiscated syringe 2 Didactic Injection Risk Intervention (Group AC) Interactive Injection Risk Intervention (Group BD) Pitpitan et al., under review

34 Implications: Safer Sex Intervention Results extend findings of Mujer Segura; - FSWs who inject drugs can experience significant reductions in HIV/STI incidence. Strong intervention effect on HIV/STI incidence sustained after 12 months in both cities. Slightly stronger effect for Tijuana, where participants reported greater access to condoms Suggests that condom provision is necessary but not sufficient for achieving reductions in HIV/STI incidence; Negotiation skills are required. Strathdee et al, PLOS ONE 2013

35 Implications: Injection Risk Intervention The lecture format of the injection risk intervention coupled with expanded sterile injection equipment was both necessary and sufficient to achieve significant reductions in injection risk. Impacted both sharing of needles and injection equipment. Effects sustained after 12 months. Supports critical importance of syringe exchange coverage. Significant, albeit more modest reductions in Cd. Juarez Intervention has value in settings with sub-optimal syringe access. Better to scale-up free access to injection equipment at the community-level with minimal harm reduction education than to provide an intensive individual-level intervention without adequate syringe coverage.

36 Acknowledgements Co-investigators, participants and the sex worker communities in Tijuana and Cd. Juarez NIH grants R01DA and R01MH65849 Staff from SADEC-FEMAP, PrevenCasa and Programa Companeros San Diego County Public Health Laboratory Consultants: H. Amaro; T. Coates; C. Latkin