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Background: Women who inject drugs (WWID) experience unique risks and adverse health outcomes related to injection initiation and patterns of injection drug use. However, there is limited information on injection initiation experiences and injection patterns among women and the protective strategies employed to limit injection-related harms, especially in low- and middle-income settings. Therefore, this study sought to explore injection initiation and current injection patterns (e.g., relying on someone else to inject) among women who inject drugs and engage in sex work in Tijuana, Mexico. Methods: Semistructured in-depth interviews were conducted with 30 WWID on the following topics: injection initiation, current injection patterns, places where women inject, and protective strategies (i.e., risk reduction). All interviews were audio-recorded, transcribed, and de-identified. An inductive thematic analysis was conducted to identify and compare common themes and patterns across participants. Results: The interviews revealed that the vast majority of study participants were first initiated by another person who injects drugs (PWID), often a male sexual partner. However, the majority of the women transitioned to become self-injectors in order to avoid risks associated with relying on others for injection, including overdose, interpersonal violence, sexual abuse, and wounds. Those who relied on others indicated that they would prefer to inject themselves without assistance from others if they were able to. Conclusions: The narratives uncovered in this study reveal the importance of multiple risk environments in shaping perceived risks associated with injection drug use among women in Tijuana, Mexico. Specifically, the interviews elucidate the connection between interpersonal relationships with other PWID and protective strategies used to minimize risk and harm. These findings highlight the need for women-centered harm reduction programs to facilitate the development of safer drug use environments among WWID in Tijuana, Mexico. [ABSTRACT FROM AUTHOR]

Introduction and Aims: HIV and hepatitis C virus transmission among people who inject drugs (PWID) is fuelled by personal and environmental factors that vary by sex. We studied PWID in Mexico to identify sex differences in multilevel determinants of injection risk. Design and Methods: From 2011 to 2013, 734 PWID (female: 277, male: 457) were enrolled into an observational cohort study in Tijuana. Participants completed interviews on injection and sexual risks. Utilising baseline data, we conducted multiple generalised linear models stratified by sex to identify factors associated with injection risk scores (e.g. frequency of injection risk behaviours). Results: For both sexes, difficult access to sterile syringes was associated with elevated injection risk (b = 1.24, 95% confidence interval [CI] 1.16–1.33), using syringes from a safe source (e.g. needle exchange programs) was associated with lower injection risk (b = 0.87, 95% CI 0.82–0.94), and for every one‐unit increase in safe injection self‐efficacy we observed a 20% decrease in injection risk (b = 0.80, 95% CI 0.76–0.84). Females had a higher safe injection self‐efficacy score compared to males (median 2.83, interquartile range 2.2–3 vs. median 2.83, interquartile range 2–3; P = 0.01). Among females, incarceration (b = 1.22, 95% CI 1.09–1.36) and police confiscation of syringes in the past 6 months (b = 1.16, 95% CI 1.01–1.33) were associated with elevated injection risk. Among males, sex work (b = 1.16, 95% CI 1.04–1.30) and polysubstance use in the past 6 months (b = 1.22, 95% CI 1.13–1.31) were associated with elevated injection risk. Discussion and Conclusions: Interventions to reduce HIV and hepatitis C virus transmission among PWID in Tijuana should be sex‐specific and consider multilevel determinants of injection risk to create safer drug use environments. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) experience multiple risk factors for mortality; yet, we know little about causes of death among PWID in Tijuana, Mexico, an area with high levels of injecting and changes in policy/law enforcement responses to substance use. This study examines rates, causes, and predictors of mortality among Tijuana PWID.Methods: Data come from a community-based cohort of PWID aged ≥18 who injected drugs in the past month. Mortality was confirmed by death certificate over 78 months during 2011-2018. Predictors of mortality were identified using time-updated Cox regression, controlling for age.Results: Among 734 participants, there were 130 deaths (54 confirmed, 76 unconfirmed), with an incidence rate of 17.74 deaths per 1000 person-years for confirmed deaths (95% Confidence Interval (CI)=13.01, 22.48) and 39.52 for unconfirmed deaths (CI=32.72, 46.31). Confirmed deaths resulted from homicide/trauma (26%), overdose (26%), septic shock (18%) and HIV-related causes (9%). In multivariable analysis of confirmed deaths, baseline HIV seropositivity (adjusted Hazard Ratio [aHR]=6.77, CI=1.98, 23.17), incident HIV infection (aHR=3.19, CI=1.02, 9.96), and number of times being beaten by police in the past 6 months at baseline (aHR=1.08 per time, CI=1.04, 1.12) were predictive of death; whereas, injection cessation for 6+ months during time at risk (aHR=0.25, CI=0.33, 0.79) was protective.Conclusion: In addition to overdose and HIV prevention efforts, attention to structural conditions that potentiate mortality is needed, including improved access to medication-assisted treatment to support injection cessation and a shift from police as a source of harm to harm reduction. [ABSTRACT FROM AUTHOR]