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"Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region.

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Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.

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