Steffanie A. Strathdee, Ph.D. Associate Dean of Global Health Sciences, Harold Simon Professor;

1. Steffanie A. Strathdee, Ph.D. Associate Dean of Global Health Sciences, Harold Simon Professor; Chief, Division of Global Public Health, Department of Medicine, University of California, San Diego sstrathdee@ucsd.edu Borderline: Cross-border Mobility and its Link to Transmission of HIV, Syphilis and TB in the Mexico-US Border Region

2. Overview • Unique features about the context of HIV risks along the Mexico/U.S. border • Recent border studies • HIV • Syphilis • TB • Influencing policy

3. MEXICO U.S.

4. U.S. MEXICO

5. What makes the Mexico-US border region different? • Volume of cross-border traffic ~60 million crossings per year • Major drug trafficking route • Sex work is quasi-legal • Main corridor for migration fueled by huge economic disparities >>Confluence of risk factors for infectious diseases (e.g. HIV, STIs, TB)

6. Major US Drug Trafficking Routes Major U.S. Drug Trafficking Routes Tijuana Cd. Juarez Source: National Drug Intelligence Center, National Drug Threat Assessment 2006

7. Tijuana has one of the fastest growing populations of injection drug users (IDUs) in Mexico, with ~21,000 drug users, and ~10,000 IDUs

8. Most frequent drug injection sites in Tijuana (n=995)

9. Place of Birth among Tijuana’s Injection Drug Users 2/3rds born Outside of Baja California Number of subjects

10. HIV and Migration:What is the link? • Family separation, changes in cultural environment, homelessness, poverty, social isolation, greater sense of anonymity(Deren, 2003; Lagarde, 2003; Organista et al, 2004; Parrado, 2004) • Mobility can increase the chance of encountering HIV-positive persons(Kottiri et al, 2002) • Mobile persons can act as bridge populations between groups that normally wouldn’t interact(Paschane, 2000) • Mobility can change sexual networks in the sending or receiving community (Aral, 2007)

11. San Diego Tribune, Reuters, CNN, March 1, 2006

12. Tijuana ADAPTED FROM: Report on the Global AIDS Epidemic, UNAIDS, 2008

13. Reasons for moving to Tijuana, by gender

14. Factors Independently Associated with HIV infection by Gender All p<0.05

15. Explanation #1: Is Deportation a marker for a high risk subgroup of male IDUs who acquired HIV in the US? Courtesy of La Frontera, 2008

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

17. Impact of deportation on families

18. HIV Prevalence and Incidence among IDUs in Tijuana: 2006-2008 Prevalence HIV Prevalence Male IDU

19. Sex Work in Mexico • Quasi legal in Mexico • Zone of tolerance (zona roja) • Work permit • Up to 9000 FSWs in Tijuana, ~4000 in Ciudad Juarez • Many women/girls from S. Mexico/Central America • ‘Sex tourism’ is common

20. 70% of FSWs in Tijuana and Cd. Juarez are migrants Migrant FSWs have: Lower HIV and STI prevalence Less drug use More condom use Over time, protective factors associated with being a migrant appear to erode Sex work in the Mexico-US Border Region Ojeda et al, Sex Transm Infect 2009

21. Factors associated with HIV infection in FSWs in Tijuana and Ciudad Juarez(n=924) * HIV prevalence: 6% * Consistent with active infection Patterson et al, J Inf Dis (2008)

22. Male Clients of FSWsin Tijuana and Ciudad Juarez • 70% of FSWs have U.S. clients • FSWs with U.S. clients more likely to have: • Syphilis titers ≥ 1:8 • Injected drugs • High client volumes • Been paid more for unprotected sex Strathdee et al, Sex Trans Dis 2008

23. Prevalence of HIV testing and HIV/STIs among Mexican (N=200) and U.S. clients (N=200) of Tijuana FSWs Prevalence Patterson et al, AIDS 2009

24. Factors Independently Associated with HIV Infection among Male Clients of FSWs in Tijuana, Mexico (N=400) Patterson et al, AIDS 2009

26. United States National syphilis incidence: 4.5 (2008) CA AZ NM TX 7.4 B.C. 3.8 SON CHI COH NL Mexico National Syphilis Incidence: 1.2 (2007) TAM Syphilis Incidence on the U.S.-Mexico Border (Per 100,000) 5.7 San Diego (increased from 3.8 to 11.8 from 2003 to 2007) Sources: CONASIDA, US Centers for Disease Control, SD County Health Dept

27. California – Primary and Secondary SyphilisRates by County, 2008 Source: California Department of Public Health, STD Control Branch Mexico

28. Prevalence of HIV and lifetime syphilis infection among high risk groups in Tijuana and Cd. Juarez (2004-2009)

29. Proportion of Lifetime Syphilis Infections with current titers > 1:8* by Risk Group in Tijuana and Cd. Juarez *Consistent with active infection

30. Tijuana ADAPTED FROM: Report on the Global AIDS Epidemic, UNAIDS, 2008

32. TB - The forgotten epidemic

33. TB Incidence on the U.S.-Mexico Border United States National TB Incidence: 4.4 CA 7.5 AZ NM 4.8 2.6 TX 57.3 B.C. 6.3 25.4 18.7 SON CHI 11.7 COH 21.9 NL 31.1 Mexico National TB Incidence: 15.7 TAM San Diego (9.0) Source: CDC, USA ,2007 & DGE Mexico, 2004. Incidence per 100,000 population

34. HIV and TB Co-infection: What’s the link? • Of ~42 million people with HIV worldwide, one third also have TB. • Among HIV+ people, risk of progressing from latent to active TB is 10% per year.

35. Trends in HIV-TB Co-infection in San Diego by Ethnicity (1993-2007)

36. Factors independently associated with HIV-TB co-infection in San Diego (1999-2007)* Rodwell et al, AJPH 2010

37. Prevalence of Latent TB Infection (LTBI)* among High Risk Populations in Tijuana, Mexico Prevalence FSWs(N=115) IDUs(N=232) Homeless(N=280) Non-IDUs(N=311) LTBI incidenceamong IDUs (N=503) *Tested through IGRA (Quantiferon Gold), Cellestis Inc; IDUs=injection drug users; FSWs= female sex workers. Garfein et al, Emerg Inf Dis (in press)

38. Factors associated with tuberculosis infection among high risk groups for HIV in Tijuana: 2007 Garfein et al, in press

39. Characteristics of Active TB Cases among IDUs in Tijuana (n=103/1060) Prevalence Received Anti-TB Meds TB tx stopped due to deportation Previously Dx’ed with Active TB Active TB Dx’ed in US TB tx Prematurely Stopped Deiss et al, AJPH 2009

40. Influencing Policy • Donated a mobile vehicle for HIV prevention to our partner NGO which became the prototype for HIV service delivery across Mexico The Prevemovihl

42. 2010: Mexico to receive $76 M USD for HIV Prevention

43. Lessons Learned • The Mexico-U.S. border region is vulnerable to epidemics of HIV, syphilis and TB • Cross-border infectious disease transmission is bi-directional, and depends on factors such as: • Host • Agent • Environment (physical, social, economic, policy)

44. Implications • Mobility can confer either protection or risk shaping an individual’s risk of infection. • Immigration policies and health policies should not work at odds. • Discrimination and blame represent significant barriers to prevention and treatment of mobile populations in border regions. • Prevention and treatment for overlapping epidemics requires binational cooperation

45. Acknowledgements • UCSD Center for AIDS Research , USAID • National Institutes of Drug Abuse and Mental Health: K01 DA020364, R01 DA019829, RO1 MH065849 ; T32 DA023356 • Staff from the PrevenCasa, A. C., Patronato Pro-COMUSIDA, UCSD, and Programa Companeros • San Diego County Public Health Dept • Most importantly, the participants who gave their time