A mixed methods approach to understanding injection drug‐related HIV risk among female sex workers and their non‐commercial partners: A case study from Northern Mexico

1. A mixed methods approach to understanding
injection drug‐related HIV risk among female sex
workers and their non‐commercial partners:
A case study from Northern Mexico
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

2. 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
2

3. Mixed methods: what can we learn
about HIV risk?
Quantitative
Objective of today’s presentation:
• illustrate how different
methodological approaches shape Qualitative
our understanding of HIV risk
among female sex workers (FSWs)
and their intimate, non‐commercial
partners Ethnographic
3

4. 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
4
Rhodes & Quirk 1998; Simmons & Singer 2006; Stoebenau et al 2009; Lam 2008

5. Mexico‐U.S. border context
Tijuana 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
Source: PAHO
Patterson et al. 2008; Strathdee et al. 2008; Ulibarri et al. 2012 5

6. Parejas study protocol
• 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
Photo: Evangelina Olivas, 2010
• Total enrolled:
214 couples (n individuals= 428)
6
Syvertsen et al. BMC Public Health, 2012, 12:136

7. Quantitative Qualitative Ethnographic
Positivism; testing Iterative; open to + Immersion; learn
Epistemology a priori hypotheses modifications from daily life
Researcher‐ Objective, neutral Social interaction, + in‐depth, reflexive
participant build rapport & trust involvement
relationship
“Lived experience” –
Measurement & + Cultural context
Focus behaviors, beliefs,
quantification
meaning, emotions
Surveys: closed‐ Semi‐structured + Observations,
Examples of ended questions: interviews: “tell me fieldnotes: what are
methods ‐ “How often have you about the last time they actually doing?
questions used a syringe after you injected drugs”
someone else?” – set of prompts
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8. Parejas: Data sources
QUANTITATIVE QUANTITATIVE: ALL couples participate in surveys
n=214 couples & HIV/STI testing at baseline & 6‐month visits for
24 months to assess behavioral & clinical outcomes
(428 individuals)
QUALITATIVE QUALITATIVE interviews with a subset of
n=44 couples dyads at baseline and 1‐yr follow‐up to
examine the social context of relationships
(88 individuals)
ETHNOGRAPHIC methods:
ETHNOGRAPHIC
in‐depth interviewing, photo
n=7 couples elicitation & observations to
(14 individuals) further explore the context of 8
injection‐related HIV risk

9. Parejas quantitative methods
• Design & Data Collection:
Photo: Angela Robertson, 2011
• 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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10. Parejas qualitative methods
• 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
Photo: Jennifer Syvertsen, 2012
• Grounded theory analysis
• Emergent themes grounded
in participants’ experiences
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to build theories

11. Parejas Ethnographic methods
• Semi‐structured & ethnographic interviewing
• Photo elicitation (participants took photos  interviews)
• Ethnographic observations
Photo: Jennifer Syvertsen, 2012
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The Tijuana River Canal, where injectors often congregate to buy, sell & use drugs

12. What is the prevalence of injection‐
related HIV risk behaviors?
• “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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13. Past 6 month injection risk behaviors
(n=254, 59% of Parejas sample)
Males Females
Recent Injection behaviors n=122 n=132 Total n=254
(48%) (52%)
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)
n=48 n=59
Receptive syringe sharing partners Total n=107
(44.9%) (55.1%)
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)
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Family 1 (2.1) 2 (3.4) 3 (2.8)

14. Qualitative data on HIV risk
• 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)
Quantitative data: next steps ‐
conduct further analyses that
Qualitative account for interdependence in
understanding dyadic data
Ethnographic data: further
explore the sociocultural context 14
of HIV risk

15. Ethnographic context
• 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

16. Take home messages
• PROYECTO PAREJAS Ethnographic
• Complexity of HIV risk
• Behaviors are embedded in
social context
• Risk constructed Qualitative
differentially by participants
• One data source 
incomplete view of risk
Quantitative
• Better understanding 
improved research designs, 16
prevention & care

17. Thank you
Contact information:
Jennifer Syvertsen, PhD, MPH
jsyvertsen@ucsd.edu
Postdoctoral Fellow, UCSD Division of Global Public Health
School 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 17
contact me. I am happy to give a talk that features the photos.