Deportation Experiences of
Mexican Drug Users:
Implications for U.S.-Based HIV
and Drug Use Research
Victoria D. Ojeda, PhD, MPH
Division of Global Public Health
UCSD School of Medicine
vojeda@ucsd.edu
Community Disrup.on and HIV/AIDS Risk in the District of Columbia
September 13, 2012
Photos by VD. Ojeda unless otherwise noted
Acknowledgements
•
Funding
–  NIDA Grants K01DA025504, T32DA023356,
and R36DA032376
–  NIMH Grant R01 MH065849
–  NIDA Grant R01 DA019829-S2
–  UCSD Academic Senate Grant RI296HOJEDA
–  Dr. Peter Hartsock,
NIDA Program Officer
•
Special Thanks to UCSD faculty, staff,
and students:
–
•
•
•
Steffanie Strathdee, PhD, Thomas Patterson,
PhD; Sarah Hiller, MA, Angela Robertson, MPH;
Alicia Vera, MPH; Ana Alvarez-Malo, MD; Norma
Aguirre, MD, Jose Luis Burgos, MD, Wayne
Cornelius, PhD, Larry Palinkas, PhD, Gudelia
Rangel, PhD, Carlos Magis, MD, PhD
PrevenCasa staff: Armando Macías, Psic.
Proyecto El Cuete participants
Deportee Study Participants
Session Overview
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•
•
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US-Mexico Border Region
Mexico’s HIV epidemic
Migration and Health
Key findings from 3 Tijuana Studies
–  Proyecto El Cuete
–  Deportee Pilot Qualitative Study
–  Mujer Más Segura
•  Implications for U.S.-based research examining
deportation and migration and HIV risks
Characteristics of the US-Mexico Border Region
•
~2000 miles of shared border
•
100 km (~62.5 miles) north and
south of the border
•
~12 million people in U.S. and
Mexico
border region (combined)
•
Challenges include: migration,
poverty, lower educational
attainment
h"p://www.borderhealth.org/
border_region.php San Diego/Tijuana Border Region
•
Population
–  Tijuana ~1.6 million people
–  San Diego County ~3.1 million
•
San Diego-Tijuana crossing is the busiest in the world:
~48 million crossings in 2006
•
Tijuana: Located on major drug trafficking routes
–  Thriving sex and drug economies: ~10,000 IDUs; up to
9,000 sex workers
•
Mexico HIV prevalence: 0.3%
–  Low national prevalence masks regional variance
•
Dynamic “sub-epidemic” in the border region
•
Tijuana
Photo Oralia Loza: San Ysidro/Tijuana port of entry –  Intersection of drug trafficking routes, injection drug use
epicenter, and established sex work industry driving higher
HIV transmission
–  Cross-over potential to U.S., other Mexican populations
Sources: Strathdee et al., 2008; US Census Bureau, 2006.; U.S. Customs Service. quickfacts.census.gov/qfd/states/06/06073.html h"p://cuentame.inegi.org.mx/monografias/informacion/bc/poblacion/default.aspx?tema=me&e=02 •
DeportaWon, is highly prevalent in the U.S.-­‐Mexico context –  >50% U.S. undocumented migrants are Mexican-­‐
born •
The majority (86%) of persons apprehended in 2009 were Mexican naWonals –  ~72% of 393,289 persons removed from U.S. •
Deportees include those apprehended Photo © Michael Stravato, The New York Times; 2009 –  While crossing the border –  During workplace raids –  During other criminal charges, increasingly drug-­‐related •
•
Most deportees are men (~89% in 2010) Many Mexican deportees are released in Baja CA (~40% in 2010) –  Tijuana receives the largest share (>127k) Sources: Capps, & Fix, 2004; U.S. Dept. of Homeland Security 2001 & 2007; Passel, 2006; Passel, Slevin, 2010; NaWonal MigraWon InsWtute, 2010a DATA SOURCES PROYECTO EL CUETE (N=1,056) (Epidemiological cohort study in Tijuana of InjecWon Drug Users ≥18yrs recruited through Respondent Driven Sampling) •  Qualita.ve sub-­‐study •  n=12 female deported IDUs •  n=24 deported male IDUs •  Quan.ta.ve sub-­‐study •  N=328 deported male IDUs All studies approved by ethics boards; Photo courtesy of: Oralia Loza 7 Prevalence of HIV in Injection Drug
Users, Tijuana, 2006-2007
3% overall HIV prevalence*
•  5.4% among women (n=157)
•  2.4% among men (n=896)
•  In multivariate regression models, males who were
deported were 4 times more likely to test positive for HIV
(vs. non-deported males)
*Prevalence esWmates are adjusted for RDS sampling approach Sources: DifferenWal Effects of MigraWon and DeportaWon on HIV InfecWon among Male and Female InjecWon Drug Users in Tijuana, Mexico By: Steffanie A. Strathdee, Remedios Lozada, Victoria D. Ojeda, Robin A. Pollini, Kimberly C. Brouwer, Alicia Vera, Wayne Cornelius, Lucie Nguyen, Carlos Magis-­‐Rodriguez, Thomas L. Pa"erson for Proyecto El Cuete Characteristics of IDUs with and without HIV
infection at baseline, Tijuana 2006-2007
HIV+ (N=42)
HIV– (N=1010)
34 37 37 29%
83%
13%
66%
14%
67%
10 15 15 Shared syringes (last 6 months)
52%
59%
59%
AcWve syphilis infecWon*
22%
7%
7%
# of injecWng partners (mean, last 6 months)
*
3 2
2 # years living in Tijuana* (mean)
13
18
17
Age (mean)*
Female*
Migrated to Baja California*
# years injecWng* (mean) Deported from the U.S.*
52%
38%
# Wmes arrested for injecWon marks* (mean) 12
7
Total N=1052
39%
8 Source: Strathdee et al., JAIDS, 2008. Slide: Ojeda, 2008 Qualitative Interviews with
El Cuete Male Deportees
(n=24)
•  Interview topics included:
–  Migration History
•
•
•
•
–
–
–
–
Pre-migration Mexico, reasons for leaving
Life in the U.S.
Deportation/detention
Post-deportation in Tijuana
Substance use histories
Sexual risk behaviors
Life in Tijuana as an IDU
Plans for the future
Regular U.S. Drug Use
•
Drugs Consumed: Marijuana (12), heroin (12), cocaine (11), methamphetamine (9),
crack (6), alcohol (6)*, PCP (4), acid (2), other Rx drugs such as Valium (1)
•
Context of US drug use:
–  Drug Trends
–  Crime
–  Employment
•  At first it [drug use] did not affect me, then later on it did affect me- I began to miss
work, and the nausea was strong and I would become desperate at work because I
couldn’t use. So, I would wait until I was home since I had my drugs there and I would
take a hit and I would calm down.” (deportee who was a crack & heroin smoker in
US)
•  Robertson et al., found that U.S. injection initiation was related to U.S.
incarceration (AOR: 6.00, 95% CI: 2.84, 12.68).
–  Contact with U.S. criminal justice system was connected drug abuse including: early
delinquency, drug-related crimes, poor access to drug treatment and coping with
emotions tied to criminal activity
Source: Robertson AM, Lozada R, Pollini RA, Rangel G, Ojeda. Correlates and Contexts of US InjecWon Drug IniWaWon Among Undocumented Mexican Migrant Men Who Were Deported from the United States. AIDS Behav. 2012 Aug;16
(6):1670-­‐80. PMID: 22246511 Deportation & Drug Addiction
….the use of drugs made me land in jail because my addicWon was so great that I could not afford that habit. I stopped selling drugs And then the bills just kept coming, so I sold some stereos that I had at home and my wife kept asking for more money, and I was neglecWng my obligaWons. I lived only to get high… Heroin with Meth is expensive and if you take Crystal only, you don’t avoid withdrawal and if you consume the heroin only you don’t avoid the withdrawal from the meth, so that you need to use both simultaneously. I neglected my family, I mean my wife, I did not pay the rent and I kept geung in problems unWl I eventually landed in jail. Drug Use Post-­‐DeportaWon in Tijuana •  Many were already IDUs pre-deportation (14+)
• Some injected new drugs/combos in TJ
•  Heroin or meth alone
•  Heroin/meth combo
•  Some reported that it was easy to return to
injecting once in TJ (even after being clean)
•  Local drug culture, lifestyle, environment
•  Drugs (& syringes) seem cheaper & easier to
obtain (vs.US)
•  Fewer consequences*
Well, here it is easier (to use) than over
there (in the US) (Frequent heroin/meth
injector deported 3yrs prior to interview)
Drug Treatment Post-Deportation
My addiction is so bad that drugs win out over my kids and it’s bad, I need to
rehabilitate myself to be able to go [to the U.S.], because why go if I keep
injecting, I’m going to commit errors and again have problems with the
police, go back to jail, do time, in federal prison, 36 months, and since I have
two lifetime deportations, because of that I think about going once I’ve been
through rehab and not do it anymore, and be with them, but I tell myself not
this year, next year, and now I’ve been here three years.
Family Separation Due to
Deportation
It [drug use] affected me, destroyed part, destroyed all, all of my life, it’s
torn my life to pieces because I keep getting high, my family is far
away… and (they tell me) Papá when are you coming? (I respond)
Tomorrow I’ll go maybe, and (they tell me) I’m going to have my
birthday, are you going to come? (And I say) Yes. (They tell me) Papá
what a liar you are, you say you’re coming and you’re not going to
come.
When I call, I ask who is there (my daughter responds) it’s me, Alondra.
And my heart is glad, because I left her when she was 6 months old,
and now she answers the phone; I didn’t see her crawl, I didn’t see her
walk, and now she´s going to enter school.
Challenges to returning to the U.S. When I was in detention, I thought
about my wife, I thought about my kids,
I thought about getting to Tijuana,
finding a coyote and returning fast to
be with them. But in these three years
those have always been my thoughts,
day after day, night after night, I go to
sleep and I wake up and Tijuana,
Tijuana, Tijuana, it’s too much now, I
never imagined I would be in Tijuana
so long.
Photo: Victoria Ojeda, 2009
Qualita.ve interviews with female deportees from El Cuete (n=12) •  Women reported heavy drug use pre & post-­‐deportaWon but greater financial instability and physical danger following deportaWon (vs. in U.S.) •  US re-­‐entry for family reunificaWon and improved financial stability (n = 5), but women who were “banned” from returning to the U.S. worried about addiWonal criminal charges and incarceraWon. !""#$%&'()*+,-,)'()*#)*.%#/()&!"#$%&"'()(*$+&",+-$+&!"./0/!"
123455666!7%&!89%57%&5319:9)(--&;<5/=.>?/@=0>A@/0BC.0???A.=//!1:%-"
Women’s Post-­‐Deporta.on Emo.ons [post-­‐deportaAon, in Tijuana] I felt alone. I felt abandoned. . . . Before my deportaAon, I did use drugs but not like right now. . . . I had my house, my children. My children were young. I sAll have my children but they are older now, married. . . . Well, the deportaAon affected me a lot since in the past, I did not use drugs on the street. I feel humiliated. Conclusions from Proyecto El Cuete Studies
•  Limitations:
–  Established cohort of drug users
–  Limited number of female deportees
–  Generalizability of data to other deportees
•  Prevalence/correlates of HIV vary by
gender among Tijuana IDUs: Recently
arrived male deportees are at greater risk for
HIV infection but gaps in knowledge exist (i.e.,
site of infection? Site of diagnosis? Interrupted
treatment?)
•  Qualitative data suggest that individual
and family effects of deportation & drug
use are notable but need to be
assessed systematically
Next Steps In U.S.-­‐Based Research With Migrants And Deportees •  Data needs: –  HIV prevalence among deportees –  HIV knowledge/risk factors among deportees –  Need for and acceptability of and barriers to using drug treatment services (LaWnos/deportees) –  Assess mental health status of migrants pre and post-­‐deportaWon to assist with triaging to appropriate care –  Social networks in Mexico and U.S. to understand drug/HIV risks –  Drug use and HIV risk behaviors pre-migration and in U.S.,
including in criminal justice systems
•  Health Services/access to care issues:
–  Improve HIV screening among Latinos/immigrants
–  Improve linkages to HIV care for binational migrants
–  Develop/provide mental health services for deportees Ethics & Deporta.on •  Displacement of deportees to distant communiWes (vs. sending communiWes) –  Safety; ExploitaWon; employment; housing access; social networks •  Re-­‐entry of incarcerated deportees into community (U.S. and Mexico) •  HIV posiWve and drug using deportees in research •  DestabilizaWon of families and implicaWons for youths vis-­‐à-­‐vis social and health outcomes Access to Care Among Deportees:
Health Frontiers in Tijuana Free Clinic
•  Opened April 30, 2011 •  BinaWonal student-­‐run free clinic in Tijuana serving all who come, Saturdays. •  450 paWents to-­‐date •  PaWent SaWsfacWon Survey (n=142): •  73% of paWents have ever been to U.S. (n=103) –  ~64% of U.S. migrant paWents were ever deported (n=67) Photo: Dr. Jose Luis Burgos; HFiT Clinic, Tijuana, BC; 8/20/11 Collaborators and Data Sources
University of California San Diego Hospital General de Tijuana Programa COMPAÑEROS Slide: Ojeda, 2008 Patronato Pro-­‐Comusida Tijuana A.C. THANK YOU! SUPPORTING MATERIALS El Cuete Study Methods
•  Sampling& Recruitment
–  Respondent Driven Sampling technique
–  Eligibility: ≥18, evidence of recent injection (past month), no plans to
move, provided informed consent (including at all follow-up visits)
•  Study Site: Downtown and Zona Norte, Tijuana
–  High concentration of IDUs and picaderos (i.e., shooting galleries,
where IDUs go to buy/use/inject drugs)
–  Store-front office for data collection and HIV/Syphilis/STD testing
–  PREVEMOVIHL/RV mobile clinic
–  Regular outreach visits to areas where IDUs congregate (e.g., parks,
the Tijuana river canal, streets, neighborhoods) to distribute information
and conduct follow-up outreach and data collection
Qualitative Deportee Study Methods
•  Objective:
–  To explore the relationships between deportation, social and economic
vulnerability, and engagement in HIV risk behaviors among IDUs in Tijuana
•  Interview protocol informed by Proyecto El Cuete
•  24 male and 12 female deported IDUs from El Cuete were
recruited (IDUs)
•  Semi-structured, digitally recorded interviews (30-90min)
by trained bilingual interviewers (2008 )
•  IRB protocol approved by USCD
•  All participants provided informed consent
Factors independently associated with
HIV among 1056 IDUs in Tijuana
OR Men Age(/10 years) AcWve Syphilis OR Women 0.18 (0.08-­‐0.42) 5.61 (2.16, 14.55) -­‐-­‐ # number of unique injecWon partners (/5 people) 1.28 (1.10-­‐1.48) 4.50 (1.40-­‐14.51) # of Wmes arrested for having injecWon marks 1.10 (0.97-­‐1.24) -­‐-­‐ -­‐-­‐ 1.81 (1.12-­‐2.94) 4.00 (1.67-­‐9.44) -­‐-­‐ # of years living in Tijuana Ever deported from the U.S. Source: Strathdee et al., 2009. ADDITIONAL QUALITATIVE DATA FINDINGS Migration & Deportation Histories
•  24 male deportees
•  1st migration ~19yrs
•  Sending states:
Sonora (5), Jalisco (4), Sinaloa (4),
DF (2), Veracruz (2), Zacatecas
(2), Michoacan, Chihuahua,
Nayarit, Guerrero, Morelos
•  Migration objectives:
Economic (14), curiosity (5),
leaving home (4), grown up (3),
taken as a child (2), Mex. law (1)
Photo: Victoria Ojeda, 2009
•  All resided in CA, some also migrated to WA, OR, NV, NM, TX
•  Average 5.5 total deportations, most recent ~7 years ago*
•  Almost half reported being banned from US (n=11)
Pre-Migration Drug Use in Mexico:
Male deportees
•  Many never used any illicit substances before emigrating (8)
–  "No conocia ni la mota, nada, ni fumaba, casi nada. Cuando yo
empece', fue en los Estado Unidos.
(male deportee originally from Veracruz)
•  Many were exposed to alcohol and some drugs (13)
–  Marijuana (12), beer (5), inhalants (3), tequila (1)
•  Few used hard drugs (3)
–  1 departed for US age 33, used heroin in TJ waiting to cross
–  1 exposed to drugs in Sinaloa then living in TJ on way to US
–  1 exposed to cocaine by family members & saw heroin addicts in
Sonora hometown; used hard drugs once or twice pre-migration
Drug Initiation/Evolution in the US

Reasons for using (new/harder) drugs in US:
◦  Parties with Mexican relatives & friends (16)
  Examples: weddings, quinceañeros, neighborhood parties
◦  Girlfriends were already using drugs (3)
◦  Work-related; co-workers shared their drugs (3)
  Stimulants to help stay alert during long shifts
◦  Depression and/or loneliness (3)
  Separation from family (Mexico) or family problems (US)
◦  Involvement in drug trade/transit
◦  Already using hard drugs
◦  Heavy drinking
Injection Drug Use in the U.S.
•  About half became regular IDUs while living in US:
–  Never (10) or occasionally (3)
–  Regularly injected heroin, cocaine, or meth (11)
•  Reasons for starting to inject drugs in US:
–  Friends and girlfriends were injecting drugs
–  Tired of smoking/snorting, wanted stronger effect
•  Sharing and Access to Injection Equipment
–  Most IDUs shared equipment due to lack of knowledge; norms
–  Access to syringes was a more mixed story
Study 3 Methods
•  328 deportees recruited from El Cuete
•  Data collected Jan-April, 2010
•  Questionnaire content was informed by
qualitative interviews
–  Migration history, drug use history, sexual
behaviors in pre/during/post deportation
contexts
New Drug Use Post-Deportation
•  4.6% HIV prevalence (15 of 328 men) •  16% of male deportees consumed new drugs following their most recent deportaWon •  Factors independently associated with trying new drugs post-­‐
deportaWon: –
–
–
–
U.S. incarceraWon Increasing # of deportaWons Feeling sad post-­‐deportaWon Perceiving that one’s lifestyle increases HIV risk Source: Robertson AM, Rangel MG, Lozada R, Vera A, Ojeda VD. Male injection drug users try
new drugs following U.S. deportation to Tijuana, Mexico. Drug Alcohol Depend. 2011 Aug 9. [Epub
ahead of print] PMID: 21835559
El PREVEMOVIHL
•  An RV modified to
serve as a mobile
clinic is used in
multiple studies,
including El Cuete
•  The “prevemovihl” is
now a model for the
diffusion of HIV
services throughout
Mexico.
.