Objective Directly observed therapy is recommended worldwide for monitoring tuberculosis (TB) treatment; yet transportation and personnel requirements limit its use. We evaluated the feasibility and acceptability of “Video DOT” (VDOT), which allowed patients to record and transmit medication ingestion videos that were watched remotely by healthcare providers to document adherence. Methods We conducted a single-arm trial among TB patients in San Diego, CA (n=43) and Tijuana, B.C., Mexico (n=9) to represent high- and low-resources settings. Pre/post treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses. Results Mean age was 34 years (range: 18–86), 54% were male, and 77% were non-Caucasian. Mean duration of VDOT use was 5.5 months (range: 1–11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT; 81% thought VDOT was more confidential; 89% never/rarely had problems recording videos; and 100% would recommend VDOT to others. Overall, 7 (13%) participants were returned to in-person DOT and 6 (12%) separate participants had their phone lost, broken or stolen. Conclusions VDOT was feasible and acceptable with high adherence in high- and low-resource settings. Efficacy and cost-effectiveness studies are needed.

BackgroundWe evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico during 2008–2010, when harm reduction coverage was expanding rapidly in Tijuana, but less so in Juarez.MethodsFSW-IDUs ≥18 years reporting sharing injection equipment and unprotected sex with clients within the last month participated in a randomized factorial trial comparing four brief, single-session conditions combining either an interactive or didactic version of a sexual risk intervention to promote safer sex in the context of drug use, and an injection risk intervention to reduce sharing of needles/injection paraphernalia. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and Trichomonas, blinding interviewers and assessors to assignment. Poisson regression with robust variance estimation and repeated measures ordinal logistic regression examined effects on combined HIV/STI incidence and receptive needle sharing frequency.FindingsOf 584 initially HIV-negative FSW-IDUs, retention was ≥90%. After 12 months, HIV/STI incidence decreased >50% in the interactive vs. didactic sex intervention (Tijuana:AdjRR:0.38,95% CI:0.16–0.89; Juarez: AdjRR:0.44,95% CI:0.19–0.99). In Juarez, women receiving interactive vs. didactic injection risk interventions decreased receptive needle-sharing by 85% vs. 71%, respectively (p = 0.04); in Tijuana, receptive needle sharing declined by 95%, but was similar in active versus didactic groups. Tijuana women reported significant increases in access to syringes and condoms, but Juarez women did not.InterpretationAfter 12 months in both cities, the interactive sexual risk intervention significantly reduced HIV/STI incidence. Expanding free access to sterile syringes coupled with brief, didactic education on safer injection was necessary and sufficient for achieving robust, sustained injection risk reductions in Tijuana. In the absence of expanding syringe access in Juarez, the injection risk intervention achieved significant, albeit more modest reductions, suggesting that community-level interventions incorporating harm reduction are more powerful than individual-level interventions.Trial Registrationclinicaltrials.gov NCT00840658

Female sex workers who inject drugs (FSW-IDUs) face elevated risk for HIV/ STIs and constitute a key population for public health prevention. Through direct and indirect pathways including human rights violations, policing practices like syringe confiscation can compound FSW-IDU health risk and facilitate the spread of disease. We studied correlates of experiencing syringe confiscation among FSW-IDUs in northern Mexico, where formal policy allows for syringes to be available over the counter without a prescription, but police practices are often at odds with the law. FSWIDUs reporting recent syringe sharing and unprotected sex with clients in Tijuana and Ciudad Juarez were administered surveys and HIV/STI testing. Logistic regression was used to identify correlates of syringe confiscation. Among 624 respondent FSW-IDUs, prevalence of syringe confiscation in the last 6 months was 48 %. The following factors were positively associated with syringe confiscation: testing positive for HIV (adjusted odds ratio [aOR]=2.54, 95 % confidence interval [CI]=1.11-5.80), reporting sexual abuse by police (aOR=12.76, 95 % CI=6.58-24.72), engaging in groin injection (aOR=1.84, 95 % CI=1.15-2.93), injecting in public (aOR=1.64; 95 % CI=1.14-2.36), and obtaining syringes from pharmacies (aOR=1.54; 95 % CI=1.06-2.23). Higher education level was negatively associated with syringe confiscation (aOR= 0.92, 95 % CI=0.87-0.98) as was frequent injection with clients within the last month (aOR=0.64,). This analysis adds to the body of evidence linking unauthorized law enforcement actions targeting high-risk groups with HIV and other adverse health outcomes. Using a public health lens to conceptualize abuse as a structural risk factor, we advocate for multi-prong prevention, systematic monitoring, and evidence-based intervention response to deleterious police practices.

Although sex work and younger age increase HIV vulnerability, empirical data regarding the impacts of underage sex work are lacking. We explored associations between features of the risk environment, sex work and drug use history, and underage sex work entry among 624 female sex workers(FSWs) in Tijuana and Ciudad Juarez, Mexico. Forty-one percent (n=253) of women began sex work as minors, among whom HIV and any STI/HIV prevalence were 5.2% and 60.7%. Factors independently associated with increased odds of underage sex work were inhalants as the first drug used, forced first injection, number of drug treatment attempts, and recent receptive syringe-sharing. Number of recent condom negotiation attempts with steady partners and depression as a reason for first injecting were negatively associated with underage entry. These results underscore the importance of efforts to prevent underage sex work and the wider factors contributing to HIV risk among vulnerable youth and underage FSWs.

This mixed methods study examined the prevalence and characteristics of physical and sexual abuse and depression symptoms among 624 injection drug-using female sex workers (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico; a subset of 47 from Tijuana also underwent qualitative interviews. Linear regressions identified correlates of current depression symptoms. In the interviews, FSW-IDUs identified drug use as a method of coping with the trauma they experienced from abuse that occurred before and after age 18 and during the course of sex work. In a multivariate linear regression model, two factors—ever experiencing forced sex and forced sex in the context of sex work—were significantly associated with higher levels of depression symptoms. Our findings suggest the need for integrated mental health and drug abuse services for FSW-IDUs addressing history of trauma as well as for further research on violence revictimization in the context of sex work in Mexico.