Occupational Hazards: How the Job of Policing Affects Health and Well-being of Police Officers

Research article

Prevalence and correlates of needle-stick injuries among active

duty police officers in Tijuana, Mexico

Marı́a Luisa Mittal 1,2 , Leo Beletsky

1,3 , Efraı́n Patiño

2,4 , Daniela Abramovitz

1 , Teresita Rocha

1 , Jaime Arredondo

1 ,

Arnulfo Bañuelos 5 , Gudelia Rangel

6,7 and Steffanie A Strathdee

§,1

§ Corresponding author: Steffanie A Strathdee, Division of Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive,

La Jolla, CA 92093-0507, USA. Tel: �1 858 822 1952. ([email protected])

Abstract

Introduction: Police officers are at an elevated risk for needle-stick injuries (NSI), which pose a serious and costly occupational

health risk for HIV and viral hepatitis. However, research on NSIs among police officers is limited, especially in low- and middle-

income countries. Despite the legality of syringe possession in Mexico, half of people who inject drugs (PWID) in Tijuana report

extrajudicial syringe-related arrests and confiscation by police, which has been associated with needle-sharing and HIV infection.

We assessed the prevalence and correlates of NSIs among Tijuana police officers to inform efforts to improve occupational

safety and simultaneously reduce HIV risks among police and PWID.

Methods: Tijuana’s Department of Municipal Public Safety (SSPM) is among Mexico’s largest. Our binational, multi-sectoral team

analyzed de-identified data from SSPM’s 2014 anonymous self-administered occupational health survey. The prevalence of NSI

and syringe disposal practices was determined. Logistic regression with robust variance estimation via generalized estimating

equations identified factors associated with ever having an occupational NSI.

Results: Approximately one-quarter of the Tijuana police force was given the occupational health survey (N�503). Respondents were predominantly male (86.5%) and 535 years old (42.6%). Nearly one in six officers reported ever having a NSI while

working at SSPM (15.3%), of whom 14.3% reported a NSI within the past year. Most participants reported encountering

needles/syringes while on duty (n�473, 94%); factors independently associated with elevated odds of NSIs included frequently finding syringes that contain drugs (adjusted odds ratio (AOR): 2.98; 95% confidence interval (CI): 1.56�5.67) and breaking used needles (AOR: 2.25; 95% CI: 1.29�3.91), while protective factors included being willing to contact emergency services in case of NSIs (AOR: 0.39; 95% CI: 0.22�0.69), and wearing needle-stick resistant gloves (AOR: 0.43; 95% CI: 0.19�0.91). Conclusions: Tijuana police face an elevated and unaddressed occupational NSI burden associated with unsafe syringe-handling

practices, exposing them to substantial risk of HIV and other blood-borne infections. These findings spurred the development

and tailoring of training to reduce NSI by modifying officer knowledge, attitudes and enforcement practices (e.g. syringe

confiscation) � factors that also impact HIV transmission among PWID and other members of the community.

Keywords: occupational accidents; HIV; viral hepatitis; syringe disposal; syringe confiscation; policing; law enforcement; harm

reduction.

Received 26 December 2015; Revised 25 April 2016; Accepted 2 May 2016; Published 18 July 2016

Copyright: – 2016 Mittal ML et al; licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any

medium, provided the original work is properly cited.

Introduction Syringe confiscation and syringe-related arrests by police are

widespread in settings where injection drug use is prevalent

[1�11]. Handling used syringes in high-risk areas can expose law enforcement personnel to a serious occupational health

risk [12�29]. Occupational needle-stick injuries (NSIs) carry a 0.2 to 0.5% risk of HIV acquisition, while the odds of acquiring

viral hepatitis are substantially higher (3�10% for hepatitis C virus (HCV) and 2�40% for hepatitis B virus (HBV)) [30]. Documented virus survival lasting more than four weeks for

HIV and more than two months for HCV in contaminated

syringes contribute to the hazards of occupational exposure

[15,19,31]. Additionally, police officers also report substantial

anxiety about NSI risk, fear of HIV disease transmission and a

burden on family relationships, contributing to the alarmingly

elevated levels of job-related stress and turnover among

police [2,20,32]. Physical and mental health harms aside,

financial and human resource costs of NSIs can be very high

[33].

Police officers have some of the greatest occupational

exposures to sharps (objects that may lacerate or puncture

skin) as well as blood and bodily fluids [2,17,18,21�28,34].The New York City Police Department has reported a transcuta-

neous exposure rate of 38.7 per 10,000 officers per year [24].

In Denver, 9.5% of occupational exposures to blood were from

NSIs [18]. In the 1990s, 0.9% of police officers in Atlanta,

Fulton and Oakland, reported NSIs via used syringes in the

past six months [22]. In Amsterdam, 11% of police officers

reported an occupational NSI during a four-year period [25].

The lifetime prevalence of reported occupational NSIs among

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police officers varies widely (e.g. 3.8% in North Carolina,

6.4% in Rhode Island, 29.7% in San Diego, California, in the

United States), and is thought to be greatly under-reported

[2,26,27]. Yet, there is little research focusing on this occupa-

tional hazard and its prevention.

Situated along a major drug trafficking route, Tijuana,

Mexico, exhibits elevated levels of injection drug use, along

with concentrated epidemics of HIV and viral hepatitis: 3.0%

HIV, 85% HBV and 96 to 98.7% HCV [35,36]. Police occupa-

tional risk from NSI in this locale may be compounded by risk

of infection from the number of high dead-space syringes,

popular in Mexico, due to blood retained in the syringe hubs

[37�39]. Despite the legality of syringe possession and the decriminalization of small-scale drug possession in August

2009, 48 to 57% of Tijuana’s people who inject drugs (PWID)

report syringe-related arrests and confiscation by police

[3�5,40]. As elsewhere globally, such encounters have been associated with HIV risk behaviours and HIV acquisition

among PWID [3�5]. In previous literature, a number of NSI risk factors have

been identified among law enforcement, including working

for less than 10 years, evening shifts, pat-down searches, little

or no time to put on protective gloves, lack of needle-stick

resistant gloves and serving on street-level patrol [18,24,26].

Adverse interactions with PWID, including harassment

and syringe confiscation in HIV incidence hotspots, can also

increase NSI risk for police, especially since PWID may not

be willing to volunteer syringe possession during searches

[23,41]. As part of a larger effort to align policing and public

health efforts to prevent the spread of blood-borne pathogens

in Tijuana, Mexico, we assessed the prevalence and correlates

of NSIs among police officers, hypothesizing that officers who

engage in syringe confiscation and syringe-related arrests may

be at an elevated risk of NSI.

Methods Study population

The Secretarı́a de Seguridad Pública Municipal (SSPM, Depart-

ment of Municipal Public Safety) in Tijuana is among Mexico’s

largest municipal police force with approximately 2100

active duty officers. Approximately 80% of the force is male,

the mean age is 38 years old, about 60% have completed

high school and/or higher education, 56.6% report a monthly

of income of less than 15,000 pesos (around $1000 USD)

and 95.3% report access to universal healthcare services [42].

Officers must be at least 18 years old and, since 2009, are

required to have a high school diploma when entering the

force [43].

Survey development

An anonymous self-administered survey of a conveni-

ence sample of active duty police officers was conducted

during June and July 2014. The instrument covered socio-

demographics, work environment and occupational health

domains. Occupational health survey items focused on safety

practices in the line of duty (e.g. syringe encounters and

handling), occupational accidents (e.g.‘‘Have you ever had any

NSIs while you were working?’’) and post-exposure follow-up

(e.g. seeking medical attention).

Data collection

Data was collected by SSPM throughout 11 police districts

and three special departments (i.e. tourist, special ops and

forensic/expert police).The police officers who participated in

the study completed self-administered surveys while on

duty. Surveys were completed in a closed room within the

precinct, lasting approximately 15 minutes. Existing data

without person-identifiable information was approved by

SSPM for a secondary analysis by the UCSD research team

through a Memorandum of Understanding. We obtained IRB

exemption for analysis of de-identified data from the UC San

Diego Human Research Protections Program.

Statistical analysis

Chi-Square tests were used to compare police officers who

reported ever having sustained a NSI versus those who did

not. To identify individual factors associated with having at

least one NSI, univariate and multivariate logistic regression

models used generalized estimating equations with robust

variance estimation [44]; variables that yielded in the uni-

variate regressions p-values equal or less than 0.10 were

considered for inclusion in the multivariable model. The

model was checked for integrity by examining and ruling out

interactions and multi-collinearity. Analyses were performed

using SPSS Statistics Version 21 (IBM, Armonk, New York).

Results Socio-demographics and occupational characteristics

A total of 531 active duty police officers participated,

representing approximately one-quarter of the entire Tijuana

police force. Most (N�503; 95%) answered the occupational health portion of the survey. The surveyed officers were

predominantly male 86.5%, 13.1% female; more than half

were older than 35 years (see Table 1). Surveyed officers have

lived almost 30 years in Tijuana on average and have worked

in the police force for an average almost 10 years. The most

frequent rank was officer (92.4%), with 84.5% reported

patrolling in sedans or vans as their main duty.

The overwhelming majority (94%) of officers reported ever

encountering syringes while on duty. Almost 40% of all

surveyed officers said it was rare to find new syringes when

searching a person. When searching a person, 86.3% of

officers reported ever encountering syringes that contain

drugs. When asked what they did when encountering syringes

that contain drugs, more than half said they put them in the

trash. Alarmingly, one-third reported breaking syringes and

more than one-fifth said they retained them to present to

the authorities. Overall, a troublingly low number of officers

(5.9%) reported proper syringe disposal (see Table 1).

Prevalence of NSIs

Of the 503 police officers that answered the occupational

accidents portion of the questionnaire, 77 (15.3%) reported

ever having a NSI during their work at SSPM, of whom 11

(14.3%) reported a NSI in the last year. Only two-thirds of

officers (66.2%) sought medical attention after having a NSI.

About one-fifth of officers who had a NSI said they did not

think it was important to report NSIs (22.6%) (see Table 1).

Marı́a Luisa Mittal et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20874

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Correlates of NSIs

Univariate analysis identified the number of years working for

SSPM, frequently encountering syringes, using no measures

to prevent NSIs, and breaking syringes that contain drugs

as factors associated with having at least one NSI (see

Table 2).

Among the officers who reported ever encountering

needles or syringes that contain drugs while on duty

(n�434), factors independently associated with having NSIs included frequently finding syringes that contain drugs while

on duty (adjusted odds ratio (AOR): 2.98; 95% confidence

interval (CI): 1.56�5.67), breaking used needles when encountering them (AOR: 2.25; 95% CI: 1.29�3.91), in case of NSI contacting emergency services (AOR: 0.39; 95%

CI: 0.22�0.69), wearing needle-stick resistant gloves as a measure to prevent NSIs (AOR: 0.43; 95% CI: 0.19�0.91) (see Table 3).

Discussion This study of active duty police officers in Tijuana found

that nearly one in six officers reported ever having an

occupational NSI, of whom a similar proportion reported

having had a NSI in the last year. These findings are especially

salient in view of alarming levels of very risky syringe-handling

practices � all in an environment in which PWID have a higher prevalence of blood-borne viral infections than the rest of the

population. Lifetime prevalence of NSI among our respon-

dents was four times greater than in a recent North Carolina

study and more than twice the prevalence in Rhode Island;

however, it was half the reported prevalence in the adjacent

border city of San Diego, California [2,26,27]. Overall, the

prevalence of NSI in our and other samples may be under-

reported, as only two out of three officers (66.2%) reported

seeking medical attention post-exposure. Nevertheless, the

proportion seeking medical attention was higher as compared

Table 1. Socio-demographic and work environment characteristics of Tijuana police officers (N�503)

Variable

Ever experienced

NSI, n�77

Did not experience

NSI, n�426 p

Total,

N�503

Socio-demographic characteristics

Male 65 (84.4%) 370 (86.9%) 0.45 435 (86.5%)

Female 12 (15.6%) 54 (12.7%) 0.45 66 (13.1%)

Age 535 years old 34 (44.2%) 180 (42.3%) 0.78 214 (42.5%)

Age �35 years old 43 (55.8%) 246 (57.7%) 0.77 289 (57.5%)

Mean years lived in Tijuana 27.75 27.33 0.79 27.39

Work environment

Mean years worked at SSPM 11.16 9.59 0.02 9.38

Job position: police officer 70 (90.9%) 368 (86.4%) 0.44 438 (87.0%)

Main duty patrol (sedan/van) 61 (79.2%) 338 (79.3%) 0.98 399 (79.3%)

Occupational safety in the line of duty

Ever encounters syringes when searching a person 76 (98.7%) 397 (93.2%) 0.06 473 (94.0%)

Ever encounters syringes that contain drugs when searching a person 70 (90.9%) 364 (85.4%) 0.20 434 (86.3%)

Rarely encounters new/unused syringes when searching a person 33 (42.9%) 157 (36.9%) 0.32 190 (37.8%)

Used syringe disposal, n�423

Biohazard sharps container 2 (2.6%) 23 (5.4%) 0.25 25 (5.9%)

Other resistant receptacle 6 (7.8%) 36 (8.5%) 0.71 42 (9.9%)

Throw in sewer or ditch 3 (3.9%) 18 (4.2%) 0.78 21 (5.0%)

Break them 35 (45.5%) 109 (25.6%) 0.00 144 (34.0%)

Throws in trash 24 (31.2%) 128 (30.0%) 0.84 152 (36.0%)

Asks person to throw in trash 12 (15.6%) 56 (13.1%) 0.57 68 (16.1%)

Retain to present to authorities 12 (15.6%) 79 (18.5%) 0.36 91 (21.5%)

Occupational accidents

NSI was in past year, n�77 11 (14.3%) � � 11 (14.3%)

Would report NSI to supervisor 13 (16.9%) 58 (13.6%) 0.46 71 (14.1%)

Aware of standard NSI response protocol 21 (27.3%) 98 (23.0%) 0.45 119 (23.7%)

Post-exposure experience

Ever sought medical attention post NSI, n�77 51 (66.2%) � � 51 (66.2%)

Reasons for not reporting NSI, n�62

Did not have time to report it 7 (11.3%) � � 7 (11.3%)

Did not know what was the procedure to report it 13 (21.0%) � � 13 (21.0%)

I didn’t think it was important to report 14 (22.6%) � � 14 (22.6%)

NSI: needle-stick injury; SSPM: Secretarı́a de Seguridad Pública Municipal (Tijuana Police Department).

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to other settings. This study did not present an opportunity to

ascertain whether experiencing a NSI resulted in actual

disease transmission or HIV post-exposure prophylaxis (HIV-

PEP) [24�26]. In other settings, 8 to 19% of officers who report a NSI start HIV-PEP [17,21,25], but the SSPM did not have an

occupational NSI response or PEP programme when this study

was conducted. Lack of uniform measures of NSI time periods

across different research studies (i.e. in the past six months,

past year, four-year period or lifetime) and inconsistency in the

type of transcutaneous exposure (i.e. NSI, human bite or other

sharp object) do not allow for more precise cross-sample

comparisons [2,24�28]. The confluence of poor implementation of drug policy

provisions and poor occupational safety knowledge and

practices creates an overall risk environment that endangers

both police and PWID. The overwhelming majority of our

respondents encountered syringes that contain drugs in their

daily duties, which was independently associated with three

times higher odds of NSI. Recent changes in drug laws (i.e.

the decriminalization of small-scale drug possession) should

precipitate the discontinuation of syringe confiscation, but

our other research suggests that this law � as well as the long- standing legal status of syringes � may be often ignored in day- to-day drug law enforcement practices [4]. As a result, police

continue to put themselves at risk of NSI by handling syringes

during encounters and undertake transporting them to legal

authorities for weighing [4]. Our data supplements previous

research on street-level policing behaviours (e.g. syringe

Table 2. Correlates of lifetime needle-stick injuries among Tijuana police officers

n a

Unadjusted odds ratio (95% CI)

Socio-demographic characteristics

35 years old or younger 503 1.08 (0.66�1.76)

Number of years lived in Tijuana 498 1.00 (0.98�1.03)

Work environment

Number of years working at SSPM 503 1.03 (1.00�1.06)*

Worked for at least 1 year at SSPM 503 2.77 (0.84�9.16)

Worked for at least 5 years at SSPM 424 3.03 (0.91�10.07)

Foot patrol as main duty 473 1.81 (0.78�4.19)

Occupational safety in the line of duty

Encounters syringes frequently or all the time 499 2.16 (1.29�3.62)*

Encounters syringes that contain drugs frequently or all the time 479 2.34 (1.29�4.26)*

Encounters injection related drug paraphernalia frequently or all the time 476 1.95 (1.121�3.39)

Syringe disposal when encountering syringes that contain drugs

Put them in biohazard receptacle for sharp objects 423 0.43 (0.10�1.87)

Put them in other resistant receptacle (i.e. detergent bottle) 423 0.84 (0.34�2.08)

Package them to present to authorities 423 0.73 (0.38�1.43)

Occupational accidents

Measures to prevent NSIs

Wear latex gloves 486 1.08 (0.62�1.87)

Wears needle-resistant gloves 486 0.48 (0.25�0.95)*

Ask suspect to-be-registered if they have sharp objects 486 0.83 (0.50�1.39)

Only handle capped syringes 486 0.60 (0.08�4.84)

Deposit confiscated syringes into receptacle 486 0.53 (0.16�1.78)

None 486 2.06 (1.04�4.08)*

In case of experiencing a NSI

Would contact immediate supervisor 487 1.28 (0.66�2.47)

Would not contact anybody 487 2.52 (0.76�8.41)

Would contact emergency services 487 0.49 (0.30�0.82)*

Would not know who to contact 487 2.52 (0.76�8.41)

Aware of standard NSI response protocol 485 1.24 (0.71�2.15)

When encountering syringes that contain drugs

Asks suspect to put syringe in trash 423 1.12 (0.57�2.22)

Throws syringe into the trash 423 0.94 (0.55�1.62)

Breaks syringes that contain drugs 423 2.31 (1.37�3.90)*

Throws them in sewer or ditch 423 0.85 (0.24�2.96)

a Change in sample size due to different number of observations available for each variable. 95% CI: 95% confidence intervals; *significant at

pB0.05; SSPM: Secretarı́a de Seguridad Pública Municipal (Tijuana Police Department); NSI: needle-stick injury.

Marı́a Luisa Mittal et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20874

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confiscation and disposal) that, in addition to elevating

police occupational risk, also led PWID to share syringes and

experience elevated HIV risk or overdose mortality [3�6,45]. These policing practices contribute to the global HIV pandemic

by increasing drug-related behaviours among PWID and

placing police officers at higher risk for NSI [6�9,46]. Our findings also provide a baseline prevalence of

protective behaviours that offer a promising platform for

intervention. Our analysis suggests that police officers wearing

needle-stick resistant gloves had lower odds of NSI. Needle-

stick resistant gloves offer a protective barrier for officers

exposed to syringes but are not provided by Mexican police

departments. With more than half of police officers earning

$15,000 Mexican pesos per month (�$938 USD) [42],

purchasing these gloves in Mexico can amount to 10% of

their monthly household income. Anecdotally, some officers

disliked using these gloves because they reduced sensitivity

during pat-down searches.

Our analysis found that officers who break syringes had two

times higher odds of experiencing a NSI. Although this finding

is not unexpected, to our knowledge, this is the first time this

alarming behaviour has been systematically documented

among police officers in association with NSI risk. Fortunately,

this behaviour could be reversed: studies have shown that

police officers are receptive to occupational safety techni-

ques, including safe syringe disposal [2,34]. Interestingly,

for officers frequently encountering syringes in their daily

activities, considering contacting emergency services in case

of NSI was a protective factor for NSI. Decreased NSI-related

anxiety, based on improved knowledge of proper NSI proto-

cols, could reduce unjustified syringe confiscation, leading to

both occupational and public health benefits [2,10].

When our binational, multi-sectoral team presented these

data to law enforcement and municipal authorities in Tijuana

in 2014, the mayor requested that our team work with the

SSPM to implement a Police Education Program (PEP) focused

on occupational safety and HIV prevention that was man-

dated to all active duty police officers [29]. The resulting

programme, which is being implemented and evaluated

through Proyecto ESCUDO Tijuana (Project SHIELD), is taught

by police academy instructors and addresses occupational

safety transmission, prevention and treatment of HIV and

related infections (sexually transmitted infections and viral

hepatitis), safe syringe disposal and HIV-PEP [29]. Syringe and

drug possession laws are also addressed in order to reduce

occupational risk [2,29,34]. In parallel, we also introduced a

NSI response and surveillance system for the entire force. This

project strengthened the relationship between public health

and public safety and the creation of a system-wide

NSI surveillance programme that can be used for further

studies necessary to determine the quality and time-sensitive

access and implementation of programmes to help increase

preventative measures such as hepatitis B immunization

[19�22,24,29]. Increasing PWID access to low dead-space syringes and aligning harm reduction efforts with law

enforcement practices may further diminish the HIV and viral

hepatitis risks of both police officers and the broader com-

munity [9,11,38].

Our study limitations included limited generalizability

due to convenience sampling and a likely underestimate of

reported frequencies of NSI due to self-reporting [18,26].

Under-reporting of NSIs has been found in other settings due

to lack of awareness of requirements and policies, lack of

time, perception that injuries were low risk, fear of outcome

and dissatisfaction with follow-up procedures [16]. Survey

administration by SSPM peers while on duty may have also

contributed to under-reporting.

Despite these limitations, this is the first study of its kind

among police officers in Latin America, and to our knowledge,

among the first to examine NSIs among police in low-

and middle-income countries. Our findings led to a unique

binational and multi-sectoral collaboration addressing public

health and public safety concerns. For police officers, handling

used syringes is a serious occupational and healthcare

risk. Knowledge of this occupational health risk can provide

sufficient motivations for officers to change policing beha-

viours while protecting their health [2,47].

Conclusions Police officers face a substantial, but poorly addressed risk of

occupational risk from NSI. This study highlights the need

for evidence-driven prevention, including training to help

police officers reduce their riskof NSIs while modifying policing

behaviours to improve the HIV risk environment for PWID [29].

These data also helped support the need for a standardized

system to track exposures and injuries that may facilitate

urgent access to integral healthcare services including HIV-PEP.

Because syringe and small-scale drug possession is legal

in Mexico, law enforcement authorities should discontinue

syringe confiscation practices in order to decrease unneces-

sary occupational exposures while preventing PWID from

sharing syringes.

Authors’ affiliations 1 Division of Global Public Health, Department of Medicine, University of

California San Diego, La Jolla, CA, USA; 2 School of Medicine, Universidad

Xochicalco, Tijuana, México; 3 School of Law & Bouvé College of Health

Sciences, Northeastern University, Boston, MA, USA; 4 Public Safety Support

Table 3. Factors independently associated with experiencing

any lifetime needle-stick injuries among Tijuana police officers

who encountered syringes that contain drugs while on duty

(n�434a)

Adjusted

odds ratio

95% confidence

interval*

Number of years in the

department

1.04 1.01�1.08

Encounters syringes that contain

drugs frequently or all the time

2.98 1.56�5.67

Breaks syringes that contain drugs 2.24 1.29�3.90

Wears needle-resistant gloves 0.43 0.19�0.91

Would contact emergency

services in case of NSI

0.39 0.22�0.69

a Due to missing data (as noted in Table 2), only 407 observations

were used in the model. *All significant at pB0.05. NSI: needle-stick

injury.

Marı́a Luisa Mittal et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20874

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5

Department, Dirección Municipal de Salud, Tijuana, México; 5 Department of

Planning and Special Projects, Secretarı́a de Seguridad Pública Municipal,

Tijuana, México; 6 Comisión de Salud Fronteriza México-EEUU, Sección México,

Tijuana, México; 7 Department of Migrant Health, Secretarı́a de Salud, México

DF, México

Competing interests

The authors have no competing interests to declare.

Authors’ contributions

All authors read and assisted in editing the manuscript. All authors have read

and approved the final manuscript.

Acknowledgements

Special thanks to Tijuana Mayor Dr. Jorge Enrique Astiazarán Orcı́, Former

Police Chief Alejandro Lares Valladares, Lic. Héctor Omar Olivarrı́a Horcasitas

and the Secretarı́a de Seguridad Pública Municipal in Tijuana for their

continuous support, the Fogarty International Center of the National Institutes

of Health Award Numbers D43TW008633 (AITRP: Mittal nee Rolón, Patiño,

Arredondo, Rocha and Strathdee) and R25TW009343 (GloCal: Mittal), the

Open Society Foundations Latin America Program Grants OR2013-11352 &

OR2014-18327, and UCSD Center for AIDS Research (CFAR) International Pilot

Grant NIAID 5P30AI036214 (Beletsky & Magis) and NIDA R01DA039073

(Strathdee, Beletsky and Rangel).

References

1. Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, et al.

HIV and risk environment for injecting drug users: the past, present, and

future. Lancet. 2010;376(9737):268�84. 2. Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer N, Heimer R. Can

police training help align law enforcement and HIV prevention? Preliminary

evidence from the field. Am J Public Health. 2011;101(11):2012�5. 3. Pollini RA, Brouwer KC, Lozada RM, Ramos R, Cruz MF, Magis-Rodriguez C,

et al. Syringe possession arrests are associated with receptive syringe sharing

in two Mexico�US border cities. Addiction. 2008;103(1):101�8. 4. Beletsky L, Wagner KD, Arredondo J, Palinkas L, Rodrı́guez CM, Kalic N, et al.

Implementing Mexico’s ‘‘Narcomenudeo’’ drug law reform a mixed methods

assessment of early experiences among people who inject drugs. J Mixed Meth

Res. 2015: 1�18, doi: http://dx.doi.org/10.1177/1558689815575862 5. Beletsky L, Lozada R, Gaines T, Abramovitz D, Staines H, Vera A, et al. Syringe

confiscation as an HIV risk factor: the public health implications of arbitrary

policing in Tijuana and Ciudad Juarez, Mexico. J Urban Health. 2013;90(2):

284�98. 6. Werb D, Wood E, Small W, Strathdee S, Li K, Montaner J, et al. Effects of

police confiscation of illicit drugs and syringes among injection drug users in

Vancouver. Int J Drug Policy. 2008;19(4):332�8. 7. Aitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police

crackdown on a street drug scene: evidence from the street. Int J Drug Policy.

2002;13(3):193�202. 8. Miller CL, Firestone M, Ramos R, Burris S, Ramos ME, Case P, et al. Injecting

drug users’ experiences of policing practices in two Mexican�US border cities: public health perspectives. Int J Drug Policy. 2008;19(4):324�31. 9. Volkmann T, Lozada R, Anderson CM, Patterson TL, Vera A, Strathdee SA.

Factors associated with drug-related harms related to policing in Tijuana,

Mexico. Harm Reduct J. 2011;8:7.

10. Beletsky L, Grau LE, White E, Bowman S, Heimer R. The roles of law, client

race, and program visibility in shaping police interference with the operation of

US Syringe Exchange Programs. Addiction. 2011;106(2):357�65. 11. Rhodes T, Platt L, Sarang A, Vlasov A, Mikhailova L, Monaghan G. Street

policing, injecting drug use and harm reduction in a Russian city: a qualitative

study of police perspectives. J Urban Health. 2006;83(5):911�25. 12. Rischitelli G, Harris J, McCauley L, Gershon R, Guidotti T. The risk of

acquiring hepatitis B or C among public safety workers: a systematic review.

Am J Prev Med. 2001;20(4):299�306. 13. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D,

et al. A case�control study of HIV seroconversion in health care workers after percutaneous exposure. New Engl J Med. 1997;337(21):1485�90. 14. Ridzon R, Gallagher K, Ciesielski C, Mast EE, Ginsberg MB, Robertson BJ,

et al. Simultaneous transmission of human immunodeficiency virus and

hepatitis C virus from a needle-stick injury. New Engl J Med. 1997;336(13):

919�22.

15. Paintsil E, He H, Peters C, Lindenbach BD, Heimer R. Survival of hepatitis C

virus in syringes: implication for transmission among injection drug users.

J Infect Dis. 2010;202(7):984�90. 16. Rich S. Sharps injuries are a significant occupational health risk. Kai Tiaki

Nurs N Z. 2012;18(10):26�8. 17. Merchant RC, Nettleton JE, Mayer KH, Becker BM. HIV post-exposure

prophylaxis among police and corrections officers. Occup Med. 2008;58(7):

502�5. 18. Hoffman RE, Henderson N, O’Keefe K, Wood RC. Occupational exposure

to human immunodeficiency virus (HIV)-infected blood in Denver, Colorado,

police officers. Am J Epidemiol. 1994;139(9):910�7. 19. Thompson SC, Boughton CR, Dore GJ. Blood-borne viruses and their

survival in the environment: is public concern about community needlestick

exposures justified? Aust N Z J Public Health. 2003;27(6):602�7. 20. Dunleavy K, Taylor A, Gow J, Cullen B, Roy K. Police officer anxiety after

occupational blood and body fluid exposure. Occup Med. 2012;62(5):382�4. 21. O’Leary FM, Green TC. Community acquired needlestick injuries in non-

health care workers presenting to an urban emergency department. Emerg

Med. 2003;15(5�6):434�40. 22. Averhoff FM, Moyer LA, Woodruff BA, Deladisma AM, Nunnery J, Alter MJ,

et al. Occupational exposures and risk of hepatitis B virus infection among

public safety workers. J Occup Environ Med. 2002;44(6):591�6. 23. Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ.

Impact of increased legal access to needles and syringes on practices of

injecting-drug users and police officers-Connecticut, 1992�1993. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;10(1):82�9. 24. Pagane J, Chanmugam A, Kirsch T, Kelen G. New York City police officers

incidence of transcutaneous exposures. Occup Med. 1996;46(4):285�8. 25. Sonder GJ, Bovée LP, Coutinho RA, Baayen D, Spaargaren J, van den Hoek

A. Occupational exposure to bloodborne viruses in the Amsterdam police

force, 2000�2003. Am J Prev Med. 2005;28(2):169�74. 26. Lorentz J, Hill L, Samimi B. Occupational needlestick injuries in a

metropolitan police force. Am J Prev Med. 2000;18(2):146�50. 27. Davis CS, Johnston J, de Saxe Zerden L, Clark K, Castillo T, Childs R.

Attitudes of North Carolina law enforcement officers toward syringe decrimi-

nalization. Drug Alcohol Depend. 2014;144:265�9. 28. Dunleavy K, Taylor A, Gow J, Cullen B, Roy K. Management of blood and

body fluid exposures in police service staff. Occup Med. 2010;60(7):540�5. 29. Strathdee SA, Arredondo J, Rocha T, Abramovitz D, Rolon ML, Mandujano

EP, et al. A police education programme to integrate occupational safety

and HIV prevention: protocol for a modified stepped-wedge study design

with parallel prospective cohorts to assess behavioural outcomes. BMJ Open.

2015;5(8):e008958.

30. Gerberding JL. Management of occupational exposures to blood-borne

viruses. New Engl J Med. 1995;332(7):444�51. 31. Abdala N, Stephens CP, Griffith BP, Heimer R. Survival of HIV-1 in syringes.

J Acquir Immune Defic Syndr Hum Retrovirol. 1999;20(1):73�80. 32. Beletsky L, Macalino GE, Burris S. Attitudes of police officers towards

syringe access, occupational needle-sticks, and drug use: a qualitative study of

one city police department in the United States. Int J Drug Policy. 2005;

16(4):267�74. 33. O’Malley EM, Scott RD, Gayle J, Dekutoski J, Foltzer M, Lundstrom TS, et al.

Costs of management of occupational exposures to blood and body fluids.

Infect Contr Hosp Epidemiol. 2007;28(7):774�82. 34. Davis CS, Beletsky L. Bundling occupational safety with harm reduction

information as a feasible method for improving police receptiveness to syringe

access programs: evidence from three US cities. Harm Reduct J. 2009;6(16):

1�18. 35. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee

SA, et al. Global epidemiology of injecting drug use and HIV among people who

inject drugs: a systematic review. Lancet. 2008;372(9651):1733�45. 36. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al.

Global epidemiology of hepatitis B and hepatitis C in people who inject drugs:

results of systematic reviews. Lancet. 2011;378(9791):571�83. 37. Wong DL. Significance of dead space in syringes. Am J Nurs. 1982;

82(8):1237.

38. Zule WA, Cross HE, Stover J, Pretorius C. Are major reductions in new HIV

infections possible with people who inject drugs? The case for low dead-space

syringes in highly affected countries. Int J Drug Pol. 2013;24(1):1�7. 39. Rafful C, Zule W, Gonzalez-Zuñiga PE, Medina-Mora ME, Magis-Rodriguez

C, Strathdee SA, et al. High dead-space syringe use among people who inject

drugs in Tijuana, Mexico. Am J Drug Alcohol Depend. 2015;146:e75.

Marı́a Luisa Mittal et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20874

http://www.jiasociety.org/index.php/jias/article/view/20874 | http://dx.doi.org/10.7448/IAS.19.4.20874

6

40. Secretarı́a de Gobernación. Programa para la Seguridad Nacional 2009� 2012. México City: Diario Oficial de la Federación; 2009.

41. Kori N, Roth AM, Lozada R, Vera A, Brouwer KC. Correlates of injecting in

an HIV incidence hotspot among substance users in Tijuana, Mexico. Int J Drug

Policy. 2014;25(3):525�32. 42. Shirk DA, Suárez de Garay ME, Rodrı́guez Ferreira O. Justiciabarómetro:

Diagnóstico Integral de la Policı́a Municipal de Tijuana. San Diego, CA:

University of San Diego; 2015.

43. Secretarı́a de Seguridad Pública. Decreto por el que se expide la Ley

General del Sistema Nacional de Seguridad Pública (2 de enero de 2009).

Mexico City: Diario Oficial de la Federación; 2010.

44. Zorn CJ. Generalized estimating equation models for correlated data: a

review with applications. Am J Polit Sci. 2001;45(2):470�90. 45. Bohnert AS, Nandi A, Tracy M, Cerdá M, Tardiff KJ, Vlahov D, et al. Policing

and risk of overdose mortality in urban neighborhoods. Drug Alcohol Depend.

2011;113(1):62�8. 46. Global Commission on Drug Policy. The war on drugs and HIV/AIDS: how

the criminalization of drug use fuels the global pandemic. Rio de Janeiro:

Global Commission on Drug Policy; 2012.

47. Chan DK-C, Hagger MS. Autonomous forms of motivation underpinning

injury prevention and rehabilitation among police officers: an application of

the trans-contextual model. Motiv Emot. 2012;36(3):349�64.

Marı́a Luisa Mittal et al. Journal of the International AIDS Society 2016, 19(Suppl 3):20874

http://www.jiasociety.org/index.php/jias/article/view/20874 | http://dx.doi.org/10.7448/IAS.19.4.20874

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