Tijuana's AIDS Epidemic Is a Binational Threat

By Ceci Connolly
Washington Post Staff Writer
Friday, August 1, 2008

TIJUANA, Mexico -- Half a dozen prostitutes swarm Angel Cabrera's car as he inches along the traffic-choked streets of downtown Tijuana on a balmy Friday evening.

"Muchacho," they beckon. "Come here, handsome!"

It isn't just the women in four-inch heels. Cabdrivers, bar bouncers and the 60-something lady hawking sodas on the corner all want what Cabrera is carrying: condoms, thousands of them. All gratis.

When President Felipe Calderón opens the 17th International AIDS Conference in Mexico City on Sunday, he can rightfully boast that his country has one of the lowest HIV rates in the Americas. The percentage of people living with HIV-AIDS in Mexico is half that of the United States and one-third that of Guatemala, El Salvador and Panama, according to the most recent statistics from the United Nations agency UNAIDS.

But in Tijuana, a chaotic border city of 1.5 million people, the HIV infection rate is nearly triple the national average, and it has been rising steadily for more than a decade. Today, about one in 125 adults in the city is infected with the virus that causes AIDS.

And with Mexico's border cities serving as funnels for workers and goods traversing the two countries, Tijuana's AIDS crisis poses a direct threat to the United States.

"I call HIV the uninvited hitchhiker," said Steffanie Strathdee, a leading AIDS researcher at the University of California's Division of International Health and Cross-Cultural Medicine.

A survey by university researchers found that 64 percent of 116 HIV-positive Tijuana residents crossed into the United States at least once a month. Nearly half of men having sex with men in Tijuana and 75 percent of those in San Diego reported having partners across the border. And of 1,000 prostitutes interviewed in Tijuana, 69 percent had U.S. clients who crossed the border for their services.

One of the busiest border crossings in the world, Tijuana is the front line of Mexico's war against AIDS -- and Cabrera is an unlikely foot soldier. A former drug addict with an old bullet wound in the back, he now spends his days and many nights distributing condoms and clean needles to almost anyone who will take them.

His daily patrols along the city's cacophonous tourist strip, filthy alleyways and concrete canal tunnels are known in academic parlance as "harm reduction," an effort to curtail risky behaviors such as needle sharing and unprotected sex that have helped fuel Tijuana's exploding epidemic.

At a time when the Bush administration is attempting to kill the District of Columbia's new needle-exchange program, harm reduction is emerging elsewhere around the globe as a central strategy in slowing the spread of HIV. The federal government opposes clean-needle initiatives, though some local governments and charities fund smaller programs around the United States.

But in Mexico, a heavily Catholic, conservative country, the government has quietly supported controversial measures such as condom and needle distribution in an attempt to catch the epidemic before it extends deeper into the country.

"Before, it was taboo to even talk openly about condoms," said Jorge Saavedra, chief of Mexico's AIDS office. "Groups still oppose condom use, but at least we can mention the word."

The shift came about after a sustained push by health leaders to discuss condom use in a scientific context, rather than focusing on moral implications. Saavedra's own story became part of the narrative. He is gay and HIV-positive and not afraid to talk about it, a startling approach for a Mexican official.

He argues that needle exchange, like condoms, is a public health strategy.

"We are not giving needles to people who are not drug users. We're giving needles to people who are already using those drugs," he said in an interview. "This is a way to avoid HIV infections."

In Tijuana, 20 miles south of San Diego, Cabrera conducts fieldwork for researchers studying transmission patterns in the highly mobile, economically distressed, binational population.

As an 8-year-old in Mexico City, he sniffed glue, and at age 12 he hopped trains to the border with two teenage toughs, "Devil" and "Hunchback." Glue led to marijuana, then cocaine and finally heroin.

He would live for a stretch in Tijuana, then sneak into the United States. He sold drugs to American tourists, smuggled cash for the cartels and even stole from a family that took him in. He was "always looking for action," he said.

At his most desperate, he sold his body to men for sex. For 25 years, Cabrera engaged in every type of high-risk behavior. Only a life-threatening case of tuberculosis motivated him to quit and take a job in rehab. By his own admission, it is a near-miracle that he is not infected with HIV.

Cabrera's former cross-border existence mirrors the lives of many here who shuttle back and forth for financial, cultural and legal reasons. In 2007, U.S. Customs and Border Protection counted 38 million legal border crossings from Tijuana into California. Often, the virus that causes AIDS moves with them.

"It's really deportation that's driving the epidemic," said Strathdee, who has documented significantly higher HIV rates in deported drug users. "They're stuck in Tijuana with no job, no home, no resources. They end up turning to a life of crime, and if they are selling their body or addicted to drugs, they're tempted to have unprotected sex for more money."

Cabrera was one of them, which makes him ideal for outreach, Strathdee said. "He has been on the other side of the needle," she said.

"I'm an addict," Cabrera agrees, as he turns down an abandoned dead-end street known as "the hole."

As he parks, a former cabdriver in tattered, smelly clothes with an abscess on one arm approaches the car.

"I lost everything," says the man, who goes by the nickname "Rascal." "I don't have any motivation."

"Your life is your motivation," Cabrera replies in Spanish. "I know it's difficult, but it's not impossible. I know you have moments of desperation."

"Somos iguales," Cabrera tells him. We are the same.

Cabrera wants junkies such as Rascal to quit, but for now he focuses on persuading them to at least use a clean needle. It has not been easy lately as drug raids and deportations send more users to jail, where they have no access to clean needles.

"One user will share a needle with 50 others if he has to," Cabrera says. "Just imagine the epidemic that can spark."

On a visit to the concrete canal separating Tijuana and California, several men line up beside Cabrera, dropping syringes into a red biohazard box in exchange for new ones.

One of them, "El Chino," silently takes a fistful and vanishes behind a solid steel grate. Only a few minutes later, he reemerges to swap one of the new needles -- now used -- for another clean one.

For Cabrera, it is a modest victory.

Usually the work is more difficult. Cabrera and Strathdee saw promise in a 46-year-old woman named Marilu, who did not want her last name published.

For years, Marilu said, she bounced from boyfriend to husband, from Los Angeles to Tijuana, from prison to church group. She turned tricks for drug money and held a bartending job. She has given birth to six children, had two abortions and left one son, Sergio, in the care of her parents. She wears a tattoo with his name.

Hooked on heroin and methamphetamine, Marilu decided to quit after her eldest daughter, Alma, died of AIDS complications, leaving Marilu to care for Alma's HIV-positive daughter.

"I just said, 'Why me, God?' " she recalled.

Last winter, Strathdee agreed to pay half the $8 daily cost of methadone treatment for Marilu's heroin addiction. In exchange, she would help recruit study participants.

She began treatment on Dec. 20, 2007. In an interview on June 2 she complained it did nothing for her meth cravings.

"It's just so hard," she said, crying, as the grandchild played at her feet.

She hasn't been seen since.

Reporting for this article was supported by the Project for International Health Journalism Fellowship, a part of the Henry J. Kaiser Family Foundation's Media Fellowships Program.

View all comments that have been posted about this article.

© 2008 The Washington Post Company