Amixedmethodsapproachtounderstandinginjectiondrug‐relatedHIVriskamongfemalesexworkersandtheirnon‐commercialpartners:
AcasestudyfromNorthernMexico
Jennifer L. Syvertsen, PhD, MPH;Angela M. Robertson, PhD;M. Gudelia Rangel, PhD; Gustavo Martinez, MD;
Lawrence A. Palinkas, PhD & Steffanie A. Strathdee, PhD
CFAR International HIV/AIDS Research Day
September 18, 2012
Acknowledgements• INVESTIGATORS & STAFF
• Investigators: Steffanie Strathdee (PI), Thomas Patterson, Lawrence Palinkas, Monica Ulibarri, Melanie Rusch, Victoria Ojeda, Davey Smith, Jennifer Syvertsen, Angela Robertson, Gudelia Rangel (Tijuana), Hugo Staines, Gustavo Martinez (Cd. Juarez)
• Consultants: Nabila El‐Bassel, Carlos Magis‐Rodriguez, Hortensia Amaro, Martina Morris• Statisticians: Daniela Abramovitz, Irina Artamonova, Shirley Rosas• Field Coordinators: Patricia Gonzales & Alicia Vera (Tijuana), Alma Barron Perez (Juarez)• Research Assistants: Maria Luisa Rolon and Daniel Hernandez• Editorial: Karla Wagner
• RECRUITERS & INTERVIEWERS• PROJECT PARTICIPANTS• FUNDING: National Institute on Drug Abuse
• R01‐DA027772, T32‐DA023356, R36‐DA032376, T32‐AI007384‐21A1
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Mixedmethods:whatcanwelearnaboutHIVrisk?
Objective of today’s presentation: • illustrate how different methodological approaches shape our understanding of HIV risk among female sex workers (FSWs) and their intimate, non‐commercial partners
Quantitative
Qualitative
Ethnographic
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Background• Intimate relationships shape HIV risk in complex ways requiring innovative methodological approaches
• Drug‐using intimate couples:• Dual sexual and drug‐related risks• Syringe sharing common among injecting partners
• FSWs are at high risk for HIV• Intimate partners risk?
• Low condom use; drug use
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Rhodes & Quirk 1998; Simmons & Singer 2006; Stoebenau et al 2009; Lam 2008
Mexico‐U.S.bordercontextTijuana and Ciudad Juarez are largest border cities• Concentrated areas of sex work & drug abuse• HIV prevalence: FSWs (6%) & FSW‐IDU (12%)• Intervention reduced FSWs’ risk with clients but no
effect on behaviors with intimate partners
Proyecto Parejas:mixed methods study of HIV/STI & risk behaviors among FSWs &their non‐commercial partners in Mexico
5Source: PAHO
Patterson et al. 2008; Strathdee et al. 2008; Ulibarri et al. 2012
Parejas studyprotocol• Eligibility: FSWs & their non‐commercial partners (e.g., boyfriends, spouses)
• Sampling: Targeted & snowball sampling through women first
• Screening: 2 step process
1. Primary Screener (73% eligible)
• Check women’s eligibility & intimate partner violence
2. Couple Verification Screening (96% eligible)• Questions “tested” partners’ knowledge of each other
• Total enrolled: 214 couples (n individuals= 428)
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Syvertsen et al. BMC Public Health, 2012, 12:136 Photo: Evang
elinaOlivas, 201
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Quantitative Qualitative Ethnographic
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EpistemologyPositivism; testing a priori hypotheses
Iterative; open to modifications
+ Immersion; learn from daily life
Researcher‐participant relationship
Objective, neutral Social interaction, build rapport & trust
+ in‐depth, reflexive involvement
Focus Measurement & quantification
“Lived experience” –behaviors, beliefs, meaning, emotions
+ Cultural context
Examples of methods ‐questions
Surveys: closed‐ended questions:“How often have you used a syringe after someone else?”
Semi‐structured interviews: “tell me about the last time you injected drugs” – set of prompts
+ Observations, fieldnotes: what are they actually doing?
Parejas:Datasources
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QUANTITATIVEn=214 couples(428 individuals)
QUALITATIVEn=44 couples(88 individuals)
ETHNOGRAPHICn=7 couples
(14 individuals)
QUANTITATIVE: ALL couples participate in surveys & HIV/STI testing at baseline & 6‐month visits for 24 months to assess behavioral & clinical outcomes
QUALITATIVE interviews with a subset of dyads at baseline and 1‐yr follow‐up to examine the social context of relationships
ETHNOGRAPHICmethods: in‐depth interviewing, photo elicitation & observations to further explore the context of injection‐related HIV risk
Parejasquantitativemethods• Design & Data Collection:
• Designed by binational team• Pilot tested in Tijuana • Computer‐assisted surveys administered by trained interviewers
• Measures include: • Socio‐demographics and relationship characteristics• Sexual behaviors and sex work• Drug use: injection drug use, syringe sharing, HIV risk behaviors
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Photo: Ang
ela Ro
bertson, 201
1
Parejas qualitativemethods• Purposeful sub‐sample:
• age, relationship duration, drug use, male employment
• Semi‐structured joint & individual interviews:• Major themes: relationship, finances, sex, sex work, drug use and drug treatment
• Follow‐up: changes in relationship dynamics & project experiences
• Grounded theory analysis• Emergent themes grounded in participants’ experiences to build theories 10
Photo: Jenn
ifer Syvertsen, 201
2
ParejasEthnographicmethods
• Semi‐structured & ethnographic interviewing
• Photo elicitation (participants took photos interviews)
• Ethnographic observations
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The Tijuana River Canal, where injectors often congregate to buy, sell & use drugs
Photo: Jenn
ifer Syvertsen, 201
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Whatistheprevalenceofinjection‐relatedHIVriskbehaviors?
• “Sharing” behaviors? • Social context of risk?• Need to understand injection‐related risk in the context of the drug market & type of heroin used on the border:• Mexican black tar heroin (sticky, like tar)• Cannot easily share in raw form; must be dissolved in water and heated into an injectable form
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Past6monthinjectionriskbehaviors(n=254,59%ofParejas sample)
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Recent Injection behaviorsMalesn=122 (48%)
Femalesn=132 (52%)
Total n=254
Indirect sharing (cooker, water, filter) 52 (41.9) 63 (47.7) 115 (44.9)
Share syringe to divide drugs 50 (40.3) 53 (40.2) 103 (40.2)
Receptive syringe sharing 48 (38.7) 59 (44.4) 107 (41.6)
Receptive syringe sharing partners n=48 (44.9%)
n=59 (55.1%) Total n=107
Partner 23 (47.9) 40 (67.8) 63 (58.9)
Friends 19 (39.6) 20 (33.9) 39 (36.4)
Acquaintances 15 (31.3) 8 (13.6) 23 (21.5)
Strangers 4 (8.3) 1 (1.7) 5 (4.7)
Family 1 (2.1) 2 (3.4) 3 (2.8)
QualitativedataonHIVrisk• Couples’ sharing: with each other vs. outside of relationship• Sharing patterns shaped by:
• relationship dynamics (e.g., trust)• context of risk behaviors (e.g., spaces of drug use)
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Quantitative data: next steps ‐conduct further analyses that account for interdependence in dyadic data
Ethnographic data: further explore the sociocultural context of HIV risk
Qualitativeunderstanding
Ethnographiccontext• Spaces (physical and social) in which injection occurs shapes HIV risk
• Public vs. private spaces• Some injected in risky public places, like picaderos(shooting galleries)
• Social vs. isolated• Couples preferred injecting at home, but observations revealed different risk environments:
• Some pooled resources to share with family & friends• Others were socially isolated and only injected together 15
Takehomemessages• PROYECTO PAREJAS
• Complexity of HIV risk • Behaviors are embedded in social context
• Risk constructed differentially by participants
• One data source incomplete view of risk
• Better understanding improved research designs, prevention & care
Quantitative
Qualitative
Ethnographic
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ThankyouContact information: Jennifer Syvertsen, PhD, [email protected] Fellow, UCSD Division of Global Public HealthSchool of Medicine
* Note: The original CFAR presentation contained images of drug use and the contexts in which drug use occurred. These photos were taken by the researchers and participants themselves as part of the study. Due to ethical concerns, I purposely omitted these images from this version of the presentation. I also request that the images that remain in this version not be duplicated without permission.
Anyone interested in hearing & viewing the original presentation may contact me. I am happy to give a talk that features the photos.
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