Project Encuentro is a collaboration between Lehigh University and the Alliance of Border Collaboratives, with Programa Companeros as a key implementation partner.
Encuentro is predominantly a study funded by NIH formally entitled: “Adaptation and Implementation of Project Encuentro in the U.S.-Mexico Border”, to increase access to rapid HIV testing, a peer network behavioral intervention to reduce sexual and drug use risk, and community-wide events targeting structural factors affecting HIV risk.
The study targets active drug users traversing the cities of Ciudad Juarez and El Paso, a metropolitan area of over 2,200,000 people, making it one of the largest international border communities. Encuentro is a strong partnership of university researchers and community based organizations with the ultimate goal of strengthening community resources to address HIV and drug use in the region.
The primary aims of the proposed study are to:
1. Elucidate how the social context of crack and heroin use within and across the two cities changed, emphasizing participants’ perspectives of changes, after the upsurge in violence.
2. Adapt the intervention following an iterative process of intervention adaptation and consumer feedback.
3. Test the effectiveness of an intervention “Encuentro"
4. Perform an implementation evaluation to understand barriers and facilitators of implementation in local partner organizations serving drug users on both sides of the border.
Encuentro has concluded the formative research that included 40 in-depth interviews and a social network survey of 200 (100 per city) drug users.
We are still do conduct focus groups. We will be using the findings will inform the adaptation of the intervention, guide recruitment and intervention efforts to networks and areas in the region most in need, and feasibility and acceptability. The adaptation should begin this year. Next year will then test intervention effectiveness by tracking HIV testing rates and reductions in HIV risk using a repeated time series design consisting of six cross-sectional surveys (N=600). Finally, we will conduct naturalistic observations of intervention implementation and key informant interviews as well as fidelity checklists and process evaluation of project activities.
There is also a structural component to the project that may be of particular interest since this is the component that intersects with the interest you expressed. These were the structural conditions going into the project:
The unprecedented levels of violence and ensuing damage to the economy of the region has left the health care infrastructure of the region more fragile and has accentuated structural level precursors of HIV risk. Although current estimates indicate that violence has decreased by 80%, vulnerable communities have been stripped of resources to deal with its aftermath. Five years ago, Ciudad Juarez had approximately 9 centers to offer services to drug users. Today, less than one-third of the organizations remain. Research conducted with drug users in the region pre-violence indicated that only 60% had a high perception of HIV risk, only 30% had ever had an HIV test, and only 40% had used a clean or new syringe to inject drugs in the last six months. We anticipate these estimates to be worse presently as stated above, the region has experienced a considerable shrinking of drug use and HIV prevention and treatment resources. In addition, the high levels of violence accentuated structural level factors of HIV risk. Epidemiological research conducted during the peak of the violence indicates increases in sex work, violation of human rights of the most vulnerable groups, high risk of HIV infection and reduced protective behaviors of drug users. For example, research conducted during the peak in violence indicated that violence increased police persecution of drug users and increased control on selling of sterile syringes in pharmacies. A study with 206 IDUs in Ciudad Juarez indicate that half of participants reported being arrested for possession of a syringe. Importantly, drug users who reported being arrested were two times more likely to report syringe sharing and injecting in the street.Furthermore, participants reported being arrested for 36 hours, which is the maximum penalty in Mexico for minor infractions. Participants reporting being incarcerated for such a long time reported experiencing painful heroin withdrawal causing them to engage in riskier practices such as syringe sharing and injecting secretly and quickly upon release. Furthermore, as a result of police persecution, participants reported injecting in informal shooting galleries such as abandoned houses, old cars, or isolated places to avoid police. Female drug users reported instances of sexual violence by police officers such as demands for sex to avoid arrest and sometimes rape.Analysis of in-depth interview with drug users in Juarez indicated that fear of arrest has an influence on injection practices. For example, participants indicated that they would leave their syringe behind in a public space just to avoid police searching and potential arrest.
The presence of structural level precursors of HIV risk such as high incarceration rates of drug users disrupts their social networks which may lead to changes in the characteristics and function of networks affecting in turn, individual level risk such as increases in sex for drugs exchanges. Past research has documented the influence of structural level factors of risk on the characteristics of social networks.For example, places with high incarceration rates of drug users lead to the formation of dense risk social networks. Denser networks in turn, means more opportunities for HIV transmission. By the same token, research indicates that housing destruction and forced migration disrupt social networks leading to a loss of social control, loss in resources, and increased HIV risk. For example, social disruption leads to disruption of supportive social networks. Social networks serve the purpose of connecting disenfranchised members with resources including conveying critical information and making financial and non-financial resources available. Disruption of social support networks may result in an increased reliance on sex for money or drug exchanges. In addition, individuals fleeing their community of origin into unknown territory as in the case of Juarez residents migrating to El Paso to flee the violence may intensify within-group interactions in the new territory in an attempt to recreate supportive social networks and such interactions may also be composed of behaviors that facilitate HIV transmission such as substance use and sexual risk, including the serving as a link for previously isolated networks.
In each city two leadership groups were formed to insure that the project would have an impact on structures and policies to create a supportive social environment to promote behavior change.