Deportation and HIV risk among sex workers’ clients

1. SHIRA M GOLDENBERG, MSC1,2; MANUEL GALLARDO CRUZ, MD3; STEFFANIE A STRATHDEE, PHD1; THOMAS L PATTERSON, PHD4 COEMH Workshop MAY 13, 2010 “People here are alone, deported, using drugs, selling their body” Deportation and HIV risk among sex workers’ clients 1 DIVISION OF GLOBAL PUBLIC HEALTH, UCSD 2 SDSU/UCSD JOINT DOCTORAL PROGRAM IN PUBLIC HEALTH, GLOBAL HEALTH 3 INSTITUTO DE SERVICIOS ESTATALES DE SALUD PÚBLICA, TIJUANA, MEXICO 4 DEPARTMENT OF PSYCHIATRY, UCSD

2. Background: Migration and HIV References: 1. Brockerhoff M, Biddlecom AE. Migration, Sexual Behavior and the Risk of HIV in Kenya. International Migration Review 1999;33:833-56. 2. Desmond N, Allen C. C, S., Justine, B., Mzugu, J., Plummer, M.L., Watson-Jones, D., Ross, D.A. A typology of groups at risk of HIV/STI in a gold mining town in north-western Tanzania. Social Science & Medicine. 2005;60:1739-1749. 3. Lippman SA, Pulerwitz J, Chinaglia M, Hubbard A, Reingold A, Diaz J. Mobility and its liminal context: exploring sexual partnering among truck drivers crossing the Southern Brazilian border. Soc Sci Med 2007;65(12):2464-73. 4. Meekers D. Going underground and going after women: trends in sexual risk behaviour among gold miners in South Africa. International Journal of STD & AIDS 2000;11:21-26. 5. Steen R, Vuylsteke B, DeCoito T, et al. Evidence of declining STD prevalence in a South African mining community following a core-group intervention. Sexually transmitted diseases 2000;27(1):1-8. Social isolation, partner separation New social norms Economic necessity and sex trade Psychosocial vulnerability Prevalence in different communities

3. Objective Source: Dreamstime To examine the influence of deportation on HIV risk among female sex workers’ (FSW) male clients in Tijuana

4. Study setting: Tijuana, Mexico MEXICO USA Source: CALTRANS 1. Iñiguez-Stevens, E., et al. (2009). [Estimating the 2006 prevalence of HIV by gender and risk groups in Tijuana, Mexico] [article in Spanish]. Gaceta Médica de México,145(3):189–195. • Emerging HIV epidemic: 1/116 adults (2009)1 • Sex work: Draws local, U.S., international clients • Mobility: World’s busiest international land crossing

5. Methods: Data collection Source: Shira Goldenberg 1. Rhodes, T. (2009). Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy, 20(3), 193–201. In-depth qualitative interviews with male clients (n=30) in Tijuana • Purposive sampling from parent study* • English/Spanish • Honorarium • Topics : • Motivations for visiting FSWs • Condom use • Perceived STI/HIV risk • Social factors (e.g., relationships with FSWs) • Structural experiences (e.g., deportation) • HIV risk environment1 theoretical framework *Parent study • 400 Mexico and U.S. residing clients ≥ 18 years old who paid/traded for sex with a FSW in Tijuana in the past 4 months

6. Socio-demographic profile

7. Findings: Social isolation Harmful vs. potentially protective effects of bi-national experiences… • Some described their experiences on both sides of the border as protective • Separation from partners and families al otro lado • Perceived as influencing HIV risk through: (1) unprotected sex (2) exacerbating substance use

8. “Here you have no family, you feel abandoned, nobody cares and you stop caring about yourself. I ain’t got no prospects in life. I’m gonna die anyways. So they start having sex like that. They stop using protection. There’s the core problem right here, ’cuz they don’t have nobody here. Everybody here, they have no family here. The people here are deported and have nobody to help them out. They’re using drugs, selling their body and even men turn gay and start selling their body. Tripped me out when I first saw this. Whoa, what’s all this, you know what I mean?” [MCL329, age 31, deportee, San Diego resident] “[Being deported] It is, it is kind of hard…I don’t have no family. I survive by just what I do. You know what I mean? I suffer a lot, but I take care of myself from everything I learned in the U.S., all the knowledge I got in the U.S. helped me when I got here. People that are raised here are not aware […] You have to pay here to go to school, so they don’t have enough knowledge…I’m a heroin addict. Around here, they use someone else’ syringe like it’s the thing to do. They do it here in Tijuana like there is nothing wrong with it. They are not educated about HIV. Me, I see that and it’s like, wow, these guys are sharing needles. I’ve seen a lot of it since I got here seven years ago. I’ve seen a lot of them die from HIV.”

9. “Here you have no family, you feel abandoned, nobody cares and you stop caring about yourself. I ain’t got no prospects in life. I’m gonna die anyways. So they start having sex like that. They stop using protection. There’s the core problem right here, ‘cuz they don’t have nobody here. Everybody here, they have no family here. The people here are deported and have nobody to help them out. They’re using drugs, selling their body and even men turn gay and start selling their body. Tripped me out when I first saw this. Whoa, what’s all this, you know what I mean?” “[Being deported] It is kind of hard…I don’t have no family. I survive by just what I do. You know what I mean? I suffer a lot, but I take care of myself from everything I learned in the U.S. All the knowledge I got in the U.S. helped me when I got here. People that are raised here are not aware […] You have to pay here to go to school, so they don’t have enough knowledge…I’m a heroin addict. Around here, they use someone else’ syringe like it’s the thing to do. They do it here in Tijuana like there is nothing wrong with it. They are not educated about HIV. Me, I see that and it’s like, wow, these guys are sharing needles. I’ve seen a lot of it since I got here seven years ago. I’ve seen a lot of them die from HIV.” [MCL028, age 33, Deportee, Tijuana resident]

10. Findings: Economic vulnerability • Deportees often repatriated with few economic prospects • Tijuana’s sex and drug trades as sources of income: Interviewer: “How did you handle the situation when you first got here?” Client: “At first, it was very difficult because I didn’t have anything and I didn’t know anybody. But I was street smart. Here with all the tourists, I quickly learned how to survive […] I went to the streets and talked to tourists and started working as a jalador…The girls[FSWs] see me with Americans and ask me to find them clients; I help them find work and they pay me for finding a client. That’s how one survives around here.” [MCL184, age 33, deportee, Tijuana resident] • Protective and harmful effects of jalador role

11. MICRO • Jaladorpeer education, condom distribution • Counseling and support for deportees • MACRO • Economic and social support for deportees • HIV/STI prevention and testing, drug treatment services for deportees Implications and suggested interventions SUGGESTED INTERVENTIONS DRIVERS OF HIV VULNERABILITY1 Root causes Proximal causes 1. HIV Risk Environment framework, adapted from Rhodes, 2009

12. Acknowledgements For more information • Study participants • Staff from PrevenCasa, A. C., Pro-COMUSIDA and UCSD • San Diego County Public Health Laboratory • Funding: UCSD Center for AIDS Research, NIH P30AI036214, R01DA23877-01A1(S1), R01 DA029008 • Training: CIHR and U.S.-Canada Fulbright awards • Please contact: • Shira Goldenberg • Division of Global Public Health, UCSD • sgoldenberg@ucsd.edu