Eileen V. Pitpitan, 2 Thomas L. Patterson 1 , Shirley J. Semple 1 ,
Claudia V. Chavarin 1 , Carlos Magis-Rodriguez 3 ,
& Steffanie A. Strathdee 2
3
1 Department of Psychiatry, University of California, San Diego (UCSD), California, U.S.A.;
2 Division of Global Public Health, Department of Medicine, UCSD;
Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA), Mexico City, D.F., Mexico www.aids2014.org

• 6,000-10,000 FSWs in Tijuana Mexico
• Male clients of FSWs are at high risk of transmitting HIV/STIs
• Clients are a “bridge population”
-originate mostly from both Tijuana and
San Diego
• Tijuana’s HIV prevalence is double Mexico’s national average
• HIV prevalence is highest among:
• MSM (~20%)
• PWID (5%)
• FSWs (~6%)
• Male clients of FSWs (~5%) www.aids2014.org

• Quasi legal in Mexico
– Zone of tolerance (zona roja)
– Work permit
• Sex tourist destination
• Work environments complex
– Bar girls
– Street (“paraditas”)
– Beauty/massage parlors
– Table dancers
– In-call services www.aids2014.org

• Few intervention designed to promote safer sex among clients
• ‘Hombre Seguro’ developed based on qualitative interviews and previous intervention experience with high risk men and FSWs.
• AIM 1. Test a brief theory based intervention designed for U.S. and Mexican clients of FSWs in Tijuana
• AIM 2. Determine if clients experiencing syndemics experience greater benefit from the intervention www.aids2014.org

• Co-occurrence of substance use, experiences of violence, poor mental health, and other factors that have an additive effect on HIV risk behavior
• Hypothesis: More psychosocial and health problems (e.g. substance use, depression) more likely to engage in higher sexual risk behavior (dose-response relationship) www.aids2014.org
Painful reality. Many deported heroin users who live in the Tijuana River Canal consider

Drug Use
Alcohol Use
Depression
Abuse
Incarceration
• Recent (past 4 mo) and frequent use (≥ 1x per week) marijuana, heroin, inhalants, methamphetamine, ecstasy, and 9 others
(including “any other drug”
• Alcohol Use Disorders Identification Test (AUDIT)
(score of ≤8 = “hazardous drinker”)
•
Center for Epidemiological Studies
–Depression
(CES-D) scale (10 items, mood over last week, scale of 0 to 3. Cutoff = 11 or greater)
• Three items queried lifetime emotional, physical or sexual abuse
•
Any incarceration in past 4 months? (1=yes, 0=no)
Primary Outcome
•
AIM 1 OUTCOME: Total recent (past 4 months) unprotected sex acts with FSWs at baseline www.aids2014.org

• Recruited in Tijuana Zona Roja
• N = 400 (half reside in U.S., half in
Tijuana)
• Eligibility criteria:
 biologically male
 >18 years old
 obtained sex from an FSW in exchange for money, drugs, shelter or goods
 unprotected vaginal or anal sex with
FSW
 test HIV-negative at baseline
 agree to receive treatment for a active STIs www.aids2014.org

Baseline Assessment
Hombres Seguro
(200 clients: 100 U.S., 100 Mexican)
One 60-minute one-on-one
Counseling Session
Didactic Safer Sex
(200 clients: 100 U.S., 100 Mexican)
One 60-minute one-on-one
Counseling Sessions
6- 12-Month Assessment www.aids2014.org

• Social Cognitive Theory
– Knowledge
– Self-Efficacy
– Outcome expectancies
• Theory of Reasoned Action
– Intention to change
• Transtheoretical or “Stages of
Change” Model
– Readiness to change www.aids2014.org

Topic
Description
Context of unsafe sex.
Condom Use
Develop insights into motivations/triggers of
Unsafe sex. Set plan and goals for safer sex
MI and skill-building to induce behavior change.
Match counseling to individual’s stage of change
Negotiation of MI and skill-building to teach negotiation skills to
Safer Sex move participants into action
*incorporating motivational interviewing (MI) and social cognitive theory www.aids2014.org

• Both groups significantly reduced unsafe sex acts with FSWs.
• BUT …Intervention and Control conditions did not differ (i.e., both benefited).
www.aids2014.org
Photo By: Oralia Loza

Source: Wikipedia Commons, Source: Wikipedia Commons, 2007

Figure 1 . Total Unprotected Sex Acts w ith
FSWs at Baseline by Syndemic Risk
18
16
14
12
10
8
6
4
2
0
0 (n= 32) 1 (n= 89) 2 (n= 125) 3 (n= 97) 4 (n= 39) 5 (n= 16)
Num b er of Syndem ic Risk s
GEE significantly and positively associated with more unprotected sex acts with FSWs in the past 4 months (B = 0.20, p = 0.01, 95% CI 0.05, 0.35). www.aids2014.org

Change in unprotected sex with FSWs by Syndemic Group www.aids2014.org

• Both Hombres Seguro and the didactic control condition resulted in significant decreases in risk behavior.
• At baseline, more syndemic problems were associated with more unprotected sex in both Hombres Seguro and the information only control condition
• At 12-months post intervention:
• Among Hombres Seguro participants, syndemic risk moderated the effect of the intervention on sexual risk behavior.
• Among control participants, the syndemic relationship was no longer significant www.aids2014.org

• First study to demonstrate an intervention “buffering” the negative impact of syndemic problems on HIV risk.
• Hombre Seguro aimed at reducing sexual risk.
–Counseling session was tailored to the specific individual’s issues and risk profile
–Appeared to alleviate the composite negative impact of drug use, alcohol use, violence, depression, and incarceration on sexual risk.
• Psychosocial problems do not exist in silos and thus integrated combination interventions are needed. www.aids2014.org

This study was funded by the National Institute on Drug Abuse (NIDA) (R01DA029008). This work was also supported by Diversity
Supplement (R01 DA029008-04S1) and a K01
Award (K01 DA036447-01) to Dr. Pitpitan. www.aids2014.org

• Project staff and co-investigators
• Most importantly, the participants who gave of their time and seldom have a voice
• San Diego Department of Health
• Others www.aids2014.org
Patronato Pro-
Comusida
Tijuana, AC

www.aids2014.org
Source: Shira Goldenberg

The table above shows the intercorrelations between the risk factors. We found that out of ten possible associations, 5 were statistically significant ( p < .05) and 1 was marginally significant ( p < .10). www.aids2014.org