How could these epidemiologic data be leveraged to generate thoughtful policy changes without the US or Mexico blaming each other for its HIV epidemic? Members of our binational team, which included federal and state health officials, NGO leaders and researchers, spent long hours contemplating this problem and embarked on a strategy to elicit a binational response. Based on available HIV prevalence and census data, we conducted a modeling exercise to estimate the number of HIV-infected persons in Tijuana using a ‘low risk’ and a ‘high risk’ scenario. In the high risk scenario, models were generated based on the upper end of the 95% confidence intervals for each HIV prevalence estimate, which suggested that one in 125 persons aged 15–49 in Tijuana was HIV-infected in 2005.73
These data indicated that that the city’s HIV epidemic had moved from low-level to concentrated, according to UNAIDS categorizations. Epidemiologic data were used to demonstrate the extent to which mobility was bi-directional
among high risk populations at the Mexico-US border, which emphasized the potential for cross-border transmission of HIV and STIs from north to south or vice versa. Coinciding with its publication in 2006, the findings from this paper were prepared in a press release in Spanish and English, shared with municipal, state and federal health officials in Mexico before the press embargo was lifted, and released simultaneously to media in both countries. The findings received widespread coverage in both countries, and the research team was subsequently invited to present policy recommendations to the Governor of Baja California and the Mayor of San Diego in a joint meeting. Meanwhile, the Secretary of Health of Baja California, who had formerly served as the Health Commissioner in Tijuana stated publicly that he endorsed NEPs as a critical component of a comprehensive strategy to prevent HIV infection. By 2008, dedicated HIV clinics (CAPACITS) were established in Tijuana and Ciudad Juarez. However, in Tijuana, local pressures from some religious and political figures forced the clinic to be located away from colonias
where HIV was most concentrated, which remains a barrier to HIV care for vulnerable populations without means of transportation.
In 2007, following the example of using mobile vans for HIV prevention service delivery that had been employed both in Mexico City and by our NGO partner’s Prevemovihl in Tijuana, federal and state health officials in Mexico commissioned a fleet of customized mobile vans that would later be delivered to every Mexican state. Equipped with a loudspeaker on the roof, a TV screen in the rear, adequate space for outreach workers to provide condoms and exchange syringes, and painted neon green with caricatures of dancing condoms, the condoneta was born. In conjunction, the national guidelines supporting harm reduction that had been published by CENSIDA without fanfare in 2005 now had ample epidemiologic data to justify the implementation of NEPs across Mexico. By 2007, there were small-scale NEPs supported by Mexico’s federal government operating in seven states–Baja California, Chihuahua, Coahuila, Nuevo Leon, Oaxaca, Sonora, Zacatecas, and by 2010, nine Mexican states had NEPs.
The team also learned that the press could wield a double-edged sword. In 2008, a study of the male clients of FSWs in Tijuana showed that HIV prevalence was 5%, and was equivalent among the clients who lived in the U.S. versus Mexico.38
More than two thirds of FSWs in Tijuana and Ciudad Juarez reported being patronized by clients from the U.S.; these FSWs reported a greater tendency to inject drugs, have syphilis and engage in unprotected sex for higher pay.74
However, the highly politicized nature of these data proved difficult to manage; the headline from the San Diego Tribune read: “Sex with Americans Risky for Mexican Hookers.”
A more successful approach was met by working with U.S. health officials at the National Institute of Health to identify research questions that were of public health significance to both Mexico and the U.S, which subsequently led to six successful peer-reviewed R01 grant applications with Mexican Co-PIs. In addition to funding received by the National Institute on Drug Abuse (NIDA) to study risk factors for HIV infection among IDUs at the individual, social and environmental level, both NIDA and the National Institute of Mental Health funded behavioral intervention studies aimed at increasing condom use and reducing drug-related risk behaviors among FSWs and their clients. One such study demonstrated that a brief intervention incorporating motivational interviewing and role play surrounding condom use negotiation was associated with a 40% reduction in HIV/STI incidence among FSWs in Tijuana and Ciudad Juarez.62
A subsequent project was recently funded by NIMH with support from the Mexican federal government to study the organizational factors that promote or impede the scale-up of this intervention in twelve Mexican cities.
In 2010, NIDA funds were awarded to study the impact of drug policy reform on drug use behaviors in Tijuana, following Mexico’s enactment of an unprecedented law that deregulates possession of small specified amounts of cocaine, heroin, methamphetamine, and marijuana for personal use.75
The law specifies that police who apprehend individuals who possess sub-threshold amounts of these drugs will not pursue penal action until a third apprehension, when such individuals will be required to enter drug treatment or jail. This law is intended to re-direct law enforcement to drug dealers and traffickers, while embracing more of a harm reduction approach with the scale-up of NEPs and methadone maintenance treatment programs. Whether these reforms will have an impact on risk behaviors and HIV incidence is an open question, but in a high-profile Lancet commentary, national and state-level policy makers publicly pledged to ensure that their future health and drug policy decisions are evidence-based and grounded in a human rights approach.76
Mexico’s evolving HIV epidemic also garnered an international response. In 2009, Mexico was successful in its bid to secure funds from the Global Fund for HIV, TB and Malaria for the first time. HIV prevalence and incidence data from the epidemiologic studies conducted on Mexico’s northern border were instrumental in showing that HIV prevalence had surpassed 5% in more than one risk group, which was a requirement for Global Fund eligibility. Accordingly, $76M USD was awarded to scale up HIV prevention programs, which includes support for IDUs in Tijuana and Ciudad Juarez, as well as two cities where HIV prevalence among IDUs had recently begun to rise (i.e., Hermosillo and Guadalajara).
Central to the success of these studies is a commitment to recognizing binational partnerships. Study findings were published following guidelines for publication that were generated by the team that were included both US and Mexican partners. NIDA, the Fogarty International Center, Hispanic Serving Health Professions Schools and USAID also provided funding to support training programs to develop research skills and programmatic capacity-building for both U.S. and Mexican students and fellows. The majority of the team’s publications to date have been led by students and fellows, many of whom are Mexican or Mexican-American.