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Factors associated with extrajudicial arrest for syringe possession: results of a department-wide survey… Morales, Mario; Rafful, Claudia; Gaines, Tommi L; Cepeda, Javier A; Abramovitz, Daniela; Artamonova, Irina; Baker, Pieter; Clairgue, Erika; Mittal, Maria L; Rocha-Jimenez, Teresita; Arredondo, Jaime; Kerr, Thomas; Bañuelos, Arnulfo; Strathdee, Steffanie A; Beletsky, Leo Sep 15, 2018

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RESEARCH ARTICLE Open AccessFactors associated with extrajudicial arrestfor syringe possession: results of adepartment-wide survey of municipalpolice in Tijuana, MexicoMario Morales1, Claudia Rafful1,2, Tommi L. Gaines1, Javier A. Cepeda1, Daniela Abramovitz1, Irina Artamonova1,Pieter Baker1, Erika Clairgue1, Maria Luisa Mittal1,3, Teresita Rocha-Jimenez1,4, Jaime Arredondo1,4, Thomas Kerr5,Arnulfo Bañuelos6, Steffanie A. Strathdee1 and Leo Beletsky1,7*AbstractBackground: Mexican law permits syringe purchase and possession without prescription. Nonetheless, people whoinject drugs (PWID) frequently report arrest for syringe possession. Extrajudicial arrests not only violate human rights,but also significantly increase the risk of blood-borne infection transmission and other health harms among PWID andpolice personnel. To better understand how police practices contribute to the PWID risk environment, prior researchhas primarily examined drug user perspectives and experiences. This study focuses on municipal police officers (MPOs)in Tijuana, Mexico to identify factors associated with self-reported arrests for syringe possession.Methods: Participants were active police officers aged ≥18 years, who completed a self-administered questionnaire onknowledge, attitudes and behaviors related to occupational safety, drug laws, and harm reduction strategies.Univariable and multivariable logistic regression was used to identify correlates of recent syringe possession arrest.Results: Among 1044 MPOs, nearly half (47.9%) reported always/sometimes making arrests for syringe possession(previous 6mo). Factors independently associated with more frequent arrest included being male (Adjusted Odds Ratio[AOR] = 1.62; 95% Confidence Interval [95% CI] =1.04–2.52; working in a district along Tijuana River Canal(where PWID congregate) (AOR = 2.85; 95%CI = 2.16–3.77); having recently experienced a physical altercation withPWID (AOR = 2.83; 95% CI = 2.15–3.74); and having recently referred PWID to social and health services (AOR = 1.97;95% CI = 1.48–2.61). Conversely, odds were significantly lower among officers reporting knowing that syringepossession is legal (AOR = 0.61; 95% CI = 0.46–0.82).Conclusions: Police and related criminal justice stakeholders (e.g., municipal judges, prosecutors) play a key role inshaping PWID risk environment. Findings highlight the urgent need for structural interventions to reduce extra-judicialsyringe possession arrests. Police training, increasing gender and other forms of diversity, and policy reforms at variousgovernmental and institutional levels are necessary to reduce police occupational risks, improve knowledge of druglaws, and facilitate harm reduction strategies that promote human rights and community health.Keywords: Persons who inject drug, Drug policy, Justice, Human rights, Police, Arrests, Syringe possession* Correspondence: lbeletsky@ucsd.edu1Division of Infectious Diseases and Global Public Health, School of Medicine,University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego,California 92093, USA7Health in Justice Action Lab, School of Law and Bouvé College of HealthSciences, Northeastern University, Boston 02115, USAFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Morales et al. BMC International Health and Human Rights  (2018) 18:36 https://doi.org/10.1186/s12914-018-0175-1BackgroundRestrictive laws and aggressive police enforcement ofdrug and syringe possession are pervasive risk factors forHIV and other blood-borne infections among peoplewho inject drugs (PWID) [1–20]. Worldwide, law en-forcement has negatively impacted PWID willingness topurchase and carry sterile syringes, avoidance of sharingsyringes and shooting galleries, and utilization of syringeexchange programs [21–35]. Police confiscation of bothused and unused syringes negatively influences the wayPWID consume drugs [4, 8, 10, 13–17, 23, 36–48]. Inaddition to the negative health outcomes of incarcer-ation in terms of infectious disease transmission, over-dose, and structural vulnerability risk [49, 50], arrests forsyringe possession constitute a human rights and globalhealth concern that may cause immediate and down-stream harm to PWID.Police encounters with PWID involving syringes mayalso have a negative health impact on police officers [5,6, 36, 51–57]. In 1996, among 803 participants in theSan Diego Police Department, 29.7% had at least oneneedle stick injury (NSI) ever, of which 27.7% had hadtwo or more; only 39.2% sought medical attention forthe NSI [51]. In Baltimore, between 2010 and 2012, 8%of police officers reported lifetime prevalence of NSI[36] and 4% among officers in North Carolina between2010 and 2012 [55]. Municipal police officers (MPOs) inTijuana, Mexico, reported a higher prevalence of NSI in2014 (14.3%) [56]. High rates of NSI put Tijuana MPOsat an elevated risk of blood-borne infections such asHIV, HCV and HBV. The potential for HCV transmis-sion is especially high due to the elevated antibody sero-prevalence (96%) among PWID in Tijuana [58].Police knowledge, attitudes, and behaviors towardsPWID are potentially modifiable factors that are relatedto arrest for syringe possession. Previous research sug-gests these factors vary and may often be detrimentaland antithetical to human rights [2, 5, 6, 36, 38, 59–61].Police officers in Togliatti (Russia) and Tijuana stoppedand frisked PWID because they considered them poten-tial crime suspects [2, 62]. In Rhode Island, police offi-cers (U.S.) were misinformed about the syringepossession law, and those who knew that it was legal tocarry syringes continued to treat syringes as contraband[5]. Before receipt of a training on occupational safety,legal knowledge, and harm reduction strategies, half ofRhode Island’s police officers who were trained reportedthat syringe access increased drug use (51%) and policeNSI (58%) [6]. However, Kyrgyz police officers who re-ceived a similar (though more lengthy) training as inRhode Island, were significantly more likely to have im-proved their occupational safety knowledge, syringe con-fiscation avoidance, and supporting referrals to harmreduction organizations [60].Laws allowing syringe possession or acquisition with-out a prescription are a noted structural intervention toimprove community health. However, extrajudicial syr-inge possession arrests continue even in context of syr-inge legality. Police knowledge of the law may be a keyfactor shaping syringe possession arrests. In Mexico, thelevel of legal knowledge on syringe possession is lowamong police and among PWID. Previously, we foundthat only approximately half (56%) of MPOs in Tijuanacorrectly reported that suspects can possess unlimitednumbers of syringes under the law of Baja California[61] and 49% of MPOs reported always/sometimes con-fiscating syringes in the last 6 months [47]. The discrep-ancy between black letter law and its understanding waseven more pronounced among PWID, where 86% of theparticipants reported incorrect knowledge of the syringepossession law [38].In Tijuana, Mexico, the gap between syringes’ formallegal standing and their status under the law on thestreets has dire public health implications. HIV preva-lence there is triple the national average (0.9% vs. 0.3%)[44], and transmission remains concentrated among highrisk populations [63]. Syringe confiscations amongPWID are concentrated in the Centro district [47] andalong the Tijuana River Canal, an open-air water arterywhere PWID congregate and consume drugs [37]. Re-ports of syringe confiscations in the city have been inde-pendently associated with PWID risk behaviors such asreceptive syringe sharing [16], seeking assistance to in-ject [17], using high-dead space syringes (which aremore likely to transmit blood-borne infections) [64],injecting in shooting galleries [23], and a higher overallprevalence of HIV infection [39, 65].Despite the critical role of these encounters in shapinghealth risk, no previous research (to our knowledge) haselucidated factors associated with syringe possession ar-rests from the perspective of police officers rather thanPWID. In general, police officers have poor knowledgeof occupational safety related to NSI, syringe possessionlaws and harm reduction strategies, and also often holdnegative attitudes towards PWID, decriminalization andsyringe access initiatives [5, 6, 60]. To better understandwhat drives these detrimental practices, we aimed toidentify factors associated with self-reported syringe pos-session arrests in a large sample of MPOs. We hypothe-sized that negative experiences with PWID, not referringPWID to social and health services, and inadequateknowledge of the syringe possession law in Mexicowould be positively and significantly associated with ar-rests for syringe possession.MethodsThis analysis was undertaken as part of the Escudo(Shield) project, described in detail elsewhere [56, 61, 66].Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 2 of 10From February 2015 to May 2016, 85% of the municipalpolice force in Tijuana (over 1800 participants) wastrained on: [1] occupational safety related to interactionswith PWID and blood-borne infections, [2] Mexican druglaws, and [3] harm reduction strategies. Inclusion criteriawere: ≥18 years of age, being an active MPO, and willingand able to provide consent. To focus on participants whowould be expected to interact with PWID and engage indrug law enforcement, we excluded top police officialsand officers engaged in administrative, or other non-street enforcement duties. Baseline surveys were self-administered prior to the Escudo training and datawere collected on participants’ knowledge, attitudesand behaviors towards the three training topics. Thestudy protocol was approved by the Human ResearchProtections Program of the University of California,San Diego, and by the Institutional Review Board atUniversidad Xochicalco, Tijuana.MeasuresThe outcome, syringe possession arrests, was measuredby the item: “In the last 6 months, how often have youarrested someone for syringe possession?”. This variablewas self-reported and measured on a 5-point Likertscale: “always,” “sometimes,” “rarely,” “never,” and “donot know.” The outcome was dichotomized to always/sometimes, and never/rarely in order to distinguish thefrequency of arrests.Independent variables included sociodemographic char-acteristics (i.e., sex, age, education, and marital status), po-licing characteristics (i.e., years in law enforcement, everbeen stuck with a needle, and district of service), attitudestowards drug users (i.e., PWID do not care about health,addiction is a disease, and PWID do not deserve to betreated as other people), interactions with PWID (i.e., re-cent referral of PWID to social and health services and re-cent physical altercation), and knowledge of the syringepossession law in Baja California.We generated an ordinal variable to differentiate thenumber of times that an MPO had ever been stuck witha needle on duty: 0, 1 and 2 or more. The current dis-trict of service variable describes the physical locationwhere MPOs were commissioned at the time of the sur-vey. This binary variable differentiates police districts ac-cording to their proximity to the Tijuana River Canal:along the Canal (Centro, La Mesa and Mesa de Otay dis-tricts) or elsewhere (all other eight districts).Attitudes towards drug use included three items:“People addicted to drugs do not care about theirhealth,” “Drug addiction is a disease,” and “Drug usersdo not deserve to be treated as other people.” The firsttwo variables were measured on a 4-point Likert scale(agree, neither agree nor disagree, disagree and do notknow). The last variable was measured on a 6-pointLikert scale (strongly agree, agree, neither agree nor dis-agree, disagree, strongly disagree and do not know) andwas trichotomized to strongly agree/agree, neither agreenor disagree, and strongly disagree/disagree.Interactions with PWID were measured by the items:“In the last 6 months, how many times have you referreddrug users to social or health programs?”, and “In the last6 months, how often have you had a physical altercationwith a drug user suspect?”. Both variables were measuredon a 5-point Likert scale (always, sometimes, rarely,never and do not know) and were dichotomized for theanalysis: always/sometimes and never/rarely.Knowledge of the law of syringe possession indicatedwhether an MPO was aware that syringe possession islegal in Baja California. It was measured by posing thefollowing statement: “Please circle the selection that ac-curately describes what a suspect can currently possessunder the law of Baja California” (none, 2, 5, 15, asmany [syringes] as they want, or do not know). Know-ledge was dichotomized to “yes” (if the police officers re-ported that it is legal to carry at least one syringe), and“no” (if they reported that it is illegal to carry anysyringe).Statistical analysisThe analysis used data from the baseline assessment.Those who reported arresting always/sometimes for syr-inge possession in the last 6 months (arrestors) werecompared to those who reported never/rarely conduct-ing such arrests (non-arrestors) with respect to selectedsociodemographic, knowledge and behavioral character-istics by calculating descriptive statistics. Chi-square andMann-Whitney tests were used for the comparisons thatinvolved categorical and continuous variables, respect-ively. Univariable and multivariable logistic regressionanalyses were conducted to identify characteristics asso-ciated with syringe possession arrests. The multivariablelogistic regression model was built by entering signifi-cant (p < 0.10) variables from the univariable analysesusing a forward stepwise procedure. The log likelihoodtest statistic was used to assess model fit and to comparenested models. Potential confounders were consideredfor inclusion in the multivariable model. Multicollinear-ity was assessed and ruled out upon obtaining appropri-ate values for the variance inflation factors and largestcondition indices.ResultsA total of 1751 participants were enrolled and com-pleted the Escudo baseline data collection, but 707MPOs were excluded because they were either higherrank officers, assigned to non-patrol duties, or in servicein more than one district. In the resulting sample (N =1044; Table 1), median age was 37 and median yearsMorales et al. BMC International Health and Human Rights  (2018) 18:36 Page 3 of 10Table 1 Descriptive statistics of municipal police officers by arrest for syringe possession in last 6 months (N = 1044)aNon-arrestor Arrestorn = 544 n = 500n/median %/ IQR n/median %/ IQR Total % p-valueSociodemographicSexMen 471 51.0 452 49.0 923 88.5 0.064Women 72 60.0 48 40.0 120 11.5Age 37 32–43 37 32–43 1041 100 0.984Education<High school 105 52.5 95 47.5 200 20.9 0.947= High School 302 51.6 283 48.4 585 61.1>High school 91 52.9 81 47.1 172 18.0Marital statusSingle/Never married 70 59.3 48 40.7 118 15.9 0.230Married/Common law 301 52.4 273 47.6 574 77.2Separated/Divorced/Widowed 24 46.2 28 53.9 52 7.0Policing characteristicsYears in law enforcement 10.5 6.8–16.3 10.5 5.8–17 975 100 0.991Number of times ever been stuck by a needle0 485 53.5 422 46.5 907 86.9 0.0241 38 48.7 40 51.3 78 7.52 or more 21 35.6 38 64.4 59 5.7District of serviceAlong Tijuana River Canal 153 37.9 251 62.1 404 38.7 < 0.001Elsewhere 391 61.1 249 38.9 640 61.3Attitudes towards drug usePWUD do not care about their healthDisagree 45 60.0 30 40.0 75 7.2 0.275Agree 434 51.9 403 48.2 837 80.3Neither agree nor disagree 63 48.5 67 51.5 130 12.5Drug addiction is a diseaseDisagree 52 55.3 42 44.7 94 9.1 0.201Agree 452 51.1 433 48.9 885 86.1Neither agree nor disagree 31 63.3 18 36.7 49 4.8PWUD do not deserve to be treated as other peopleDisagree 413 53.9 354 46.2 767 74.0 0.148Agree 74 49.3 76 50.7 150 14.5Neither agree nor disagree 54 45.0 66 55.0 120 11.6Interactions with PWUDReferrals of PWUD to social/health programsaNever/Rarely 379 69.7 246 49.3 625 59.9 < 0.001Always/Sometimes 165 30.3 253 50.7 418 40.1Physical altercation with PWUDaNever/Rarely 356 65.6 199 40.0 555 53.4 < 0.001Always/Sometimes 187 34.4 298 60.0 485 46.6Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 4 of 10working in law enforcement agencies was 10.5 acrossgroups. Most participants were male (88.5%), married(77.2%) and had at least a high school education (79.1%).Finally, almost half of the participants (47.9%) reportedalways/sometimes arresting people for syringe posses-sion in the last 6 months.Relative to the non-arrestors, the arrestor group exhib-ited a significantly-higher proportion of MPOs whoalways/sometimes had recent physical altercations withPWID (60% vs. 34.4%, p < 0.001), as well as asignificantly-higher proportion of recent arrests for syr-inge possession along the Tijuana River Canal (Centro,La Mesa and Mesa de Otay districts) (62.1% vs. 37.9%,p < 0.001). Compared to the non-arrestors, the arrestorgroup was also more likely to always/sometimes referPWID to services (50.7% vs. 30.3%, p < 0.001) and had ahigher proportion of MPOs who have been stuck by aneedle two or more times (64.4% vs. 35.6%, p = 0.024).Conversely, the non-arrestor groups had a higher pro-portion of MPOs with the correct understanding of thesyringe possession law as compared to the arrestorgroup (70.3% vs. 62.1%, p = 0.006). A marginally-higherproportion of non-arrestors were female relative to thearrestors (60% vs. 40%, p = 0.064). Finally, no significantdifferences were found between the arrestors andnon-arrestors with regards to attitudes towards drug useand users.Table 2 presents the results of the univariable andmultivariable logistic regression models. According tothe multivariable analysis, MPOs working along the Ti-juana River Canal were 2.85 (95% Confidence Interval[CI] = 2.16–3.77) times more likely to always/sometimesarrest somebody for syringe possession, when comparedto MPOs working elsewhere. The odds of always/some-times arresting someone for syringe possession of MPOswho reported a recent physical altercation with PWIDwere 2.83 (CI = 2.15–3.74) times the corresponding oddsof MPOs who did not face such altercation. Additionally,the odds of always/sometimes arresting someone for car-rying a syringe were 1.97 (CI = 1.48–2.61) times higheramong MPOs who referred PWID to social and healthprograms as compared to those who did not. MaleMPOs were 1.62 (CI = 1.04–2.52) times more likely toalways/sometimes arrest somebody for syringe posses-sion, as compared to a female MPOs. Finally, the oddsof always/sometimes arresting someone for carrying asyringe among MPOs who knew syringe possession islegal in Baja California were 0.61 (CI = 0.46–0.82) timesthe corresponding odds of MPOs who did not know thesyringe possession law. Despite being significant in theunivariable logistic regression model, having been stuckwith a needle was not significant in the final model, nordid it affect the significance of other variables in themodel.Missing values represented 4.68% of the total observa-tions in the model and 0.97% in the overall sample. “Donot know” answers in the outcome and all the covariateswere excluded from the analysis because of their lownumber of cases (outcome = 0.003%, referral = 0.003%,altercation = 0.006%, and syringe possession law =0.043%). The model did not present missing values prob-lem considering that the borderline for the missing valueanalysis on randomness is 5% [67].DiscussionIn this large study of MPOs in Tijuana, nearly half re-ported arresting PWID for syringe possession in the past6 months, despite syringes’ legal status. This proportionis nearly identical to that reported in a study of PWID inTijuana 10 years earlier [16]. These findings echo datafrom elsewhere suggesting that liberalizing drug and syr-inge access policy alone are not sufficient to reduceharm to PWID flowing from policing practices [68].While knowledge of the syringe law was associated witha lower frequency of arrest for syringe possession, fac-tors like experiences of physical altercation with PWID,having referred PWID to social or health services, pa-trolling high-intensity drug areas, and being male arealso predictive of more frequent syringe possessionarrests.This study’s identification of a significant associationbetween knowledge of syringe possession law and arrestsfor syringe possession is novel. This link between policyknowledge and street practice adds credence to claimsTable 1 Descriptive statistics of municipal police officers by arrest for syringe possession in last 6 months (N = 1044)a (Continued)Non-arrestor Arrestorn = 544 n = 500n/median %/ IQR n/median %/ IQR Total % p-valueKnowledge of the law of syringe possessionCan a person possess syringes under the law of Baja California, Mexico?No 156 29.7 180 37.9 336 33.6 0.006Yes 369 70.3 295 62.1 664 66.4IQR Interquartile range, PWUD people who use drugs, athe question refers to the last 6 months, p < 0.05 are boldedTable 1 and Table 2 refer to PWUD, rather than PWID to accurately reflect the Escudo survey as it asks MPOs about attitudes towards PWUD and interactions withPWUD, rather than attitudes towards PWID or interactions with PWIDMorales et al. BMC International Health and Human Rights  (2018) 18:36 Page 5 of 10that formal law reform, when operationalized through edu-cation programs, may be an effective structural interventionto address officer safety and community health [69]. Thisfinding is particularly relevant considering a previous ana-lysis comparing pre- and post-training surveys with this co-hort of MPOs that found significant improvement (p <0.001) in their conceptual knowledge of syringe possessionlaw (from 67 to 96%), defined as the recognition that it islegal to carry one or more syringes [61].We also found that female MPOs were significantlyless likely to report syringe possession arrests comparedto male MPOs. Policing is a male-dominated professionand women have been underrepresented in its ranks[70]. This study highlights the role of female MPOs asTable 2 Odds of arresting for syringe possession among municipal police officers (n = 995)OR 95% CI p-value AOR 95% CI p-valueSociodemographicSex (Ref: Women)Men 1.44 0.98 2.12 0.065 1.62 1.04 2.52 0.033Age 1.00 0.98 1.01 0.795Education (Ref: <High School)= High School 1.04 0.75 1.43 0.831> High School 0.98 0.65 1.48 0.938Marital status (Ref: Single/Never married)Married/Common law 1.32 0.88 1.98 0.173Separated/Divorced/Widowed 1.70 0.88 3.28 0.113Policing characteristicYears in law enforcement 1.00 0.98 1.01 0.806Number of times ever been stuck by a needle1 (Ref: 0) 1.21 0.76 1.92 0.4202 or more 2.08 1.20 3.60 0.009District of service (Ref: Elsewhere)Along Tijuana River Canal 2.58 1.99 3.33 < 0.001 2.85 2.16 3.77 < 0.001Attitudes towards drug usePWUD do not care about their healthAgree (Ref: Disagree) 1.39 0.86 2.25 0.177Neither agree nor disagree 1.60 0.90 2.84 0.112Drug addiction is a diseaseAgree (Ref: Disagree) 1.19 0.77 1.82 0.434Neither agree nor disagree 0.72 0.35 1.46 0.362PWUD do not deserve to be treated as other peopleAgree (Ref: Disagree) 1.20 0.84 1.70 0.311Neither agree nor disagree 1.43 0.97 2.10 0.072Interactions with PWUDReferrals of PWUD to social/health programsaAll the time/Sometimes (Ref: Never/Rarely) 2.36 1.83 3.04 < 0.001 1.97 1.48 2.61 < 0.001Physical altercation with PWUDaAll the time/Sometimes (Ref: Never/Rarely) 2.85 2.22 3.67 < 0.001 2.83 2.14 3.74 < 0.001Knowledge of the law of syringe possessionCan a person possess syringes under the law of Baja California, Mexico? (Ref: No)Yes 0.69 0.53 0.90 0.006 0.61 0.46 0.82 < 0.001OR odds ratio, AOR adjusted odds ratio, CI confidence intervals, Ref reference group, athe question refers to the last 6 months, PWUD people who use drugs,Significant variables at p < 0.05 are boldedMorales et al. BMC International Health and Human Rights  (2018) 18:36 Page 6 of 10vital to reducing occupational risks and promoting harmreduction practices among police [47]. Previous researchsuggests female police officers possess greater empathyand communication skills, and are less likely to engagein aggressive behavior, such as threats, use of forceincidents, and extra-judicial search and arrest [71–73].Interventions that capitalize upon the positive role of fe-male MPOs could have a multiplier effect by improvingrelations with people who use drugs and the broadercommunity, while advancing officer occupational safetyand morale. Beyond individual-level behavior, femaleMPOs may exert positive peer pressure or other norma-tive influence on policing ecosystems in ways that sup-press overall arrests for syringe possession.Neighborhoods with high drug using activity have pre-viously been identified as key locations for MPOs en-counters with PWID [14, 37, 45]. Our findings areconsistent with previous analyses of MPOs that identi-fied a positive association between being stationed inCentro, La Mesa and Mesa de Otay districts (high druguse districts along the Tijuana River Canal) and syringeconfiscation [37, 45, 47]. In the face of police abuse andharassment reports by PWID [4, 8, 10, 15, 41, 43], policetraining on harm reduction strategies and enhancedmonitoring of arrests for syringe possession are espe-cially important in high drug use neighborhoods.Unexpectedly, MPOs who reported more frequent re-ferrals of PWID to social and health services during last6 months were more likely to arrest for syringe posses-sion in the same period of time; it is not clear whetherthese actions occurred within the context of the sameencounter, however. It is possible that these referralswere made to compulsory treatment facilities as a pun-ishment for aberrant behavior that did not qualify as aviolation of criminal law [3], or were part of azero-tolerance approach advanced by the Tijuana’s Min-istry of Public Safety [45]. Between December 2014 andMarch 2015, a policing program known as TijuanaMejora implemented along the Tijuana River Canal re-sulted in the displacement of 800 to 1000 people, themajority of whom were involuntary transported to“treatment” centers [74]. Future research should assesswhat MPOs understand as a referral and whether it ischaracterized as voluntary or compulsory.MPOs often present PWID in front of a municipaljudge after arresting them for syringe possession [62]. Inthese instances, municipal judges—not the officers—have the authority to dismiss the arrest and/or divertPWID to social and health services. Thus, future inter-ventions should recognize the critical role of municipaljudges and other interactors within the criminal justicesystem above and beyond MPOs. Regardless of how re-ferrals occur, there are limited services specialized forPWID in Tijuana [75]. Many existing substance usetreatment facilities offer only abstinence-based modal-ities that are not evidence-based and may, in fact, becausing more harm than good [75]. In other settings, po-lice referrals to places like substance use treatment pro-viders or safe injection facilities can be a source ofbenefit for PWID and an opportunity to align publichealth and security efforts [76]. It is important to under-stand the current nature of these referrals and work toimprove them, concurrently addressing the quality, ac-ceptability, and affordability of substance use resourcesavailable in Tijuana, elsewhere in Mexico, and beyond.This study has several limitations. As a cross-sectionalanalysis, we cannot infer causal relationships. Qualitativeresearch may assist in elucidating the temporality ofthese associations, in addition to future analyses fromEscudo that will assess these associations longitudinally.As this analysis is based on self-reported data while offi-cers were on duty for mandated occupational training,we cannot assume unbiased reporting. Bias may havebeen minimized since surveys did not include identifyinginformation and were collected by study staff who werenot employed by the police department or the policeacademy. Additionally, precision of our outcome may bea concern since it was not clear how the four answer op-tions of our dependent variable were understood by theparticipants because it conflated exposure and fre-quency. For example, an MPO who stops 40 people andarrests 10 is not differentiated from the MPO who stops10 people and arrest them all. There may also be differ-ential understanding by the MPOs as to what constitutesa referral (voluntary or compulsory) and what consti-tutes a physical altercation. Further qualitative researchneeds to define those differences. In this analysis, wecannot determine the impact of peer pressure on arrestsfor syringe possession. Finally, considering that policingis not a lone activity, there is a need to further explorethis topic in subsequent qualitative research. For in-stance, MPOs may feel pressure from superiors or peersto meet arrest or other encounter quotas.Overall, in order to reduce harm to PWID and im-prove occupational safety among police officers, drugand syringe access policy reform should be coupled withpolice education programs, police oversight mechanismsand structures, effective referral processes, and scale-upin evidence-based drug treatment resources. High druguse neighborhoods should receive particular attentionand the critical role of female police officers should berecognized. Future research and interventions are re-quired to maximize MPOs’ knowledge (on occupationalsafety, drug laws and harm reduction), improve policingtactics and reduce harm in the context of drug and syr-inge access policy reform. Efforts are also needed to in-clude training of municipal judges, who are responsiblefor referring PWID to social and health services.Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 7 of 10ConclusionsOur study highlights the need for structural interven-tions targeting MPOs and related key stakeholders, suchas municipal judges and prosecutors. Knowledge of thesyringe possession law is associated with reduced arrestsfor carrying syringes, but altercations with PWID, refer-rals to services, patrolling hot spots and being male in-creases the odds of those arrests. Thus, police training,personnel diversification, and policy reforms at variousgovernmental and institutional levels are necessary to re-duce police occupational risks, improve knowledge ofdrug laws, and facilitate harm reduction strategies thatpromote human rights and community health.AbbreviationsHBV: Hepatitis B virus; HCV: Hepatitis C virus; HIV: Human immunodeficiencyvirus; MPO: Municipal police officer; NSI: Needlestick injury; PWID: Peoplewho inject drugsAcknowledgementsThe authors also acknowledge assistance from the Ministry of Public Safetyin Tijuana and its Police Academy.FundingSupport for the Escudo project was provided through grants from the OpenSociety Foundations Latin America Program grant OR2013–11352 andOR2014–18327, UCSD Center for AIDS Research International Pilot GrantNIAID 5P30AI036214, and the National Institute on Drug Abuse (NIDA;R01DA039073 and R37DA019829). The Fogarty International Center of theNational Institutes of Health under award Number D43TW008633 supportedMLM, TR, CR and JA. NIDA supported MLM and JAC through T32DA023356and K01DA043421. UC-MEXUS/CONACT scholarship supported TR, CR andJA. UC MEXUS Dissertation Grant DI 15–42, and NIDA R25 DA026401 alsosupported CR. This publication resulted in part from research supported bythe University of California, San Diego, Center for AIDS Research (CFAR), anNIH-funded program (P30 AI036214), which is supported by the followingNIH Institutes and Centers: NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA,NIGMS, and NIDDK. The above-mentioned funding sources had no involve-ment in the study design, collection, analysis, and interpretation of data; inthe writing of the report; or in the decision to submit the manuscript forpublication.Availability of data and materialsThe datasets used and/or analyzed during the current study are availablefrom the corresponding author upon reasonable request.Authors’ contributionsLB, SAS designed and conceived of the study. MM, DA and IA undertook theanalysis. LB, PB, CR, TLG, JAC, EC, MLM, TRJ, JA, TK and AB contributed to datainterpretation. MM drafted the manuscript and all authors reviewed and editeddrafts of the manuscript. All authors read and approved the final manuscript.Ethics approval and consent to participateThe study protocol and consent documentation was approved by the HumanResearch Protections Program of the University of California, San Diego, and bythe Institutional Review Board at Universidad Xochicalco, Tijuana.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Division of Infectious Diseases and Global Public Health, School of Medicine,University of California San Diego, 9500 Gilman Dr., La Jolla, San Diego,California 92093, USA. 2Centre for Urban Health Solutions, St. Michael’sHospital, Toronto, Canada. 3School of Medicine, Universidad Xochicalco, 4850Calle Rampa Yumalinda, Chapultepec Alamar, 22110 Tijuana, Baja California,Mexico. 4School of Public Health, San Diego State University, 5500 CampanileDr, San Diego, California 92182, USA. 5Center of Excellence in HIV/AIDS,University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3,Canada. 6Department of Planning and Special Projects, Secretaría deSeguridad Pública Municipal, 2141 Blvd Cuauhtémoc Sur y Río Suchiate,22015 Tijuana, Mexico. 7Health in Justice Action Lab, School of Law andBouvé College of Health Sciences, Northeastern University, Boston 02115,USA.Received: 19 April 2018 Accepted: 29 August 2018References1. Rhodes T. The 'risk environment': a framework for understanding andreducing drug-related harm. Int J Drug Policy. 2002;13:85–94.2. Rhodes T, Platt L, Sarang A, Vlasov A, Mikhailova L, Monaghan G. Streetpolicing, injecting drug use and harm reduction in a Russian city: aqualitative study of police perspectives. J Urban Health. 2006;83(5):911–25.3. Sarang A, Rhodes T, Sheon N, Page K. Policing drug users in Russia: risk, fear,and structural violence. Subst Use Misuse. 2010;45:813–64.4. Strathdee S, Lozada R, Pollini RA, Brouwer KC, Mantsios A, Abramovitz DA,et al. Individual, social, and environmental influences associated with HIVinfection among injection drug users in Tijuana, Mexico. J Acquir ImmuneDefic Syndr. 2008;47(3):369–76.5. Beletsky L, Macalino GE, Burris S. Attitudes of police officers towards syringeaccess, occupational needle-sticks, and drug use: a qualitative study of one citypolice department in the United States. Int J Drug Policy. 2005;16:267–74.6. Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer N, Heimer R. Policetraining to align law enforcement and HIV prevention: preliminary evidencefrom the field. Am J Public Health. 2011;101(11):2012–5.7. Beletsky L, Bhatti U, Closic C, Graff J, Fennell DN. Harmonizing harmreduction and law enforcement: strategies for prevention, monitoring, andresponse. 2008.8. Beletsky L, Martinez G, Gaines T, Nguyen L, Lozada R, Rangel G, et al.Mexico's northern border conflict: collateral damage to health and humanrights of vulnerable groups. Rev Panam Salud Publica. 2012;31(5):403–10.9. Beletsky L, Thomas R, Smelyanskaya M, Artamonova I, Shumskaya N,Dooronbekova A, et al. Policy reform to shift the health and human rightsenvironment for vulnerable groups: the case of Kyrgyztan's instruction 417.Health Hum Rights. 2012;14(2):34–48.10. Beletsky L, Lozada R, Gaines T, Abramovitz D, Staines H, Vera A, Rangel G,Arredondo J, Strathdee SA. Syringe confiscation as an HIV risk factor: thepublic health implications of arbitrary policing in Tijuana and Ciudad Juarez,Mexico. J Urban Health. 2013;90(2):284–98.11. Beletsky L, Heller D, Jenness SM, Neaigus A, Gelpi-Acosta C, Haga H. Syringeaccess, syringe sharing, and police encounters among people who injectdrugs in new York City: a community-level perspective. Int J Drug Policy.2014;25(1):105–11.12. Davis CS, Beletsky L. Bundling occupational safety with harm reductioninformation as a feasible method for improving police receptiveness to syringeaccess programs: evidence from three U.S. cities. Harm Reduction J. 2009;6:16.13. Werb D, Wagner KD, Beletsky L, Gonzalez-Zuniga P, Rangel G, Strathdee SA.Police bribery and access to methadone maintenance therapy within thecontext of drug policy reform in Tijuana, Mexico. Drug Alcohol Depend.2015;148:221–5.14. Werb D, Strathdee SA, Vera A, Arredondo J, Beletsky L, Gonzalez-Zuniga P,et al. Spatial patterns of arrests, police assault and addiction treatmentcenter locations in Tijuana, Mexico. Addiction. 2016;111:1246–56.15. Pinedo M, Burgos JL, Zuniga ML, Perez R, Macera CA, Ojeda VD. Policevictimization among persons who inject drugs along the US-Mexico border.J Stud Alcohol Drugs. 2015;76(5):758–63.16. Pollini RA, Brouwer KC, Lozada R, Ramos R, Cruz MF, Magis-Rodriguez C,et al. Syringe possession arrests are associated with receptive syringesharing in two Mexico-US border cities. Addiction. 2007;103:101–8.Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 8 of 1017. Robertson AM, Vera A, Gallardo M, Pollini RA, Patterson TL, Case P, et al.Correlates of seeking injection assistance among injection drug users inTijuana, Mexico. Am J Addict. 2010;19(4):357–63.18. Ahmed T, Long TN, Huong PT, Steward DE. Drug injecting and HIV riskamong injecting drug users in Hai Phong, Vietnam: a qualitative analysis.BioMed Central Public Health. 2015;15(32):13.19. Case P, Meehan T, Jones TS. Arrests and incarceration of injection drugusers for syringe possession in Massachusetts: implications for HIVprevention. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18(1):S71–75.20. Global Commission on Drug Policy. Taking Control: Pathways to DrugPolicies that Work. Geneva: Global Commission on Drug Policy; 2014. p 25.21. Hammett TM, Bartlett NA, Chen Y, Ngu D, Cuong DD, Phuong NM, et al.Law enforcement incluences on HIV prevention for injection drug users:observations from a cross-border project in China and Vietnam. Int J DrugPolicy. 2005;16:235–45.22. Bluthenthal RN, Lorvick J, Kral AH, Erringer EA, Kahn JG. Collateral damage inthe war on drugs: HIV risk behaviors among injection drug users. Int J DrugPolicy. 1999;10:25–38.23. Philbin M, Pollini RA, Ramos R, Lozada R, Brouwer KC, Ramos ME, et al.Shooting gallery attendance among IDUs in Tijuana and ciudad Juarez,Mexico: correlates, prevention opportunities, and the role of theenvironment. AIDS Behav. 2008;12:552–60.24. Strathdee SA, Beletsky L, Kerr T. HIV, drugs and the legal environment. Int JDrug Policy. 2015;26:S27–32.25. Rhodes T, Mikhailova L, Sarang A, Lowndes CM, Rylkov A, Khutorskoy M,et al. Situational factors influencing drug injecting, risk reduction andsyringe exchange in Togliatti City, Russian Federation: a qualitative study ofmicro risk environment. Soc Sci Med. 2003;57(1):39–54.26. Koester SK. Copping, running, and paraphernalia Laws: contextual variablesand needle risk behavior among injection drug users in Denver. HumOrgan. 1994;53(3):287–95.27. Strathdee SA, Zafar T, Brahmbhatt H, Baksh A, ul Hassan S. Rise in needlesharing among injection drug users in Pakistan during the Afghanistan war.Drug Alcohol Depend. 2003;71(1):17–24.28. Harvey E, Strathdee SA, Patrick DM, Ofner M, Archibald CP, Eades G, et al. Aqualitative investigation into an HIV outbreak among injection drug users inVancouver, British Columbia. AIDS Care. 1998;10(3):313–21.29. Maher L, Dixon D. Policing and public health: law enforcement and harmminimization in a street-level drug market. The Br J Criminol. 1999;39(4):488–512.30. Wood E, Kerr T, Small W, Jones J, Schechter MT, Tyndall MW. The impact ofa police presence on access to needle exchange programs. J AcquirImmune Defic Syndr. 2003;34(1):116–7.31. Cooper H, Moore L, Gruskin S, Krieger N. The impact of a police drugcrackdown on drug injectors' ability to practice harm reduction: aqualitative study. Soc Sci Med. 2005;61(3):673–84.32. Burris S, Strathdee SA. To serve and protect? Toward a better relationshipbetween drug control policy and public health. AIDS. 2006;20:117–8.33. Rich JD, Dickinson BP, Liu KL, Case P, Jesdale B, Ingegneri RM, et al. Strictsyringe laws in Rhode Island are associated with high rates of reusingsyringes and HIV risks among injection drug users. J Acquir Immune DeficSyndr Hum Retrovirol. 1998;18(1):140–1.34. Beletsky L, Grau LE, White E, Bowman S, Heimer R. The roles of law, clientrace and program visibility in shaping police interference with theoperation of US syringe exchange programs. Addiction. 2011;106(2):357–65.35. Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P, et al.Addressing the "risk environment" for injection drug users: the mysteriouscase of the missing cop. Milbank Q. 2004;82(1):125–56.36. Cepeda JA, Beletsky L, Sawyer A, Serio-Chapman C, Smelyanskaya M, Han J,et al. Occupational safety in the age of the opioid crisis: needle stick injuryamong Baltimore police. J Urban Health. 2017;94(1):100–3.37. Gaines T, Beletsky L, Arredondo J, Werb D, Rangel G, Vera A, et al.Examining the spatial distribution of law enforcement encounters amongpeople who inject drugs after implementation of Mexico's drug policyreform. J Urban Health. 2014;92(2):338–51.38. Beletsky L, Wagner KN, Arredondo J, Palinkas L, Magis-Rodriguez C,Strathdee SA. Implementing Mexico's "Narcomenudeo" Drug Law Reform: AMixed-Methods Assessment of Early Experiences among People Who InjectDrugs. 2016;10(4):384–401.39. Strathdee S, Lozada R, Martinez G, Vera A, Rusch M, Nguyen L, et al.Social and structural factors associated with HIV infection amongfemale sex workers who inject drugs in the Mexico-US border region.PLoS One. 2011;6(4):8.40. Strathdee S, Davila W, Case P, Firestone M, Brouwer KC, Perez SG, et al. "vivoPara consumirla y la consumo Para vivir" ["I live to inject and inject to live"]:high-risk injection behaviors in Tijuana, Mexico. J Urban Health. 2005;82(3):iv58–73.41. Miller CL, Firestone M, Ramos R, Burris S, Ramos ME, Case P, et al. Injectingdrug Users' experiences of policing practices in two Mexican-U.S. bordercities: public health Prespectives. Int J Drug Policy. 2008;19(4):324–31.42. Pollini RA, Alvelais J, Gallardo M, Vera A, Lozada R, Magis C, et al. The harminside: injection during incarceration among male injection drug users inTijuana, Mexico. Drug Alcohol Depend. 2009;103(1–2):52–8.43. Volkmann T, Lozada R, Anderson CM, Patterson TL, Vera A, Strathdee SA.Factors associated with drug-related harms related to policing in Tijuana.Mex Harm Reduction J. 2011;8(7):1–8.44. Pinedo M, Burgos JL, Ojeda VD. A critical review of social and structuralconditions that influence HIV risk among Mexican deportees. MicrobesInfect. 2014;16:379–90.45. Gaines T, Werb D, Arredondo J, Alaniz VM, Vilalta C, Beletsky L. Thespatial-temporal pattern of policing following a drug policy reform:triangulating self-reported arrests with official crime statistics. Subst Use Misuse.2017;52(2):214–22.46. Wood EF, Werb D, Beletsky L, Rangel G, Cuevas Mota J, Garfein RS, et al.Differential experiences of Mexican policing by people who inject drugsresiding in Tijuana and San Diego. Int J Drug Policy. 2017;41:132–9.47. Cepeda JA, Strathdee SA, Arredondo J, Mittal ML, Rocha T, Morales M, et al.Assessing police officers' attitudes and legal knowledge on behaviors thatimpact HIV transmission among people who inject drugs. Int J Drug Policy.2017;50:56–63.48. Rafful C, Zule W, Gonzalez-Zuniga P, Werb D, Medina-Mora ME, Magis-Rodriguez C, et al. High dead-space syringe use among people who injectdrugs in Tijuana, Mexico. Am J Drug Alcohol Abuse. 2015:41(3):220–5.49. Kwásniewski A, Jahangir A, Fuentes C, Gaviria G, Zedillo E, Henrique-CardosoF, et al. The war on drugs and HIV/AIDS. How the criminalization of druguse fuels the global pandemic. In: Global Commision on drug policy; 2012.50. Global Commission on Drug Policy. The negative impact of the war ondrugs on public health: the hidden hepatitis C epidemic. Geneva: GlobalCommission on Drug Policy; 2013. p 24.51. Lorentz J, Hill L, Samimi B. Occupational Needlestick injuries in ametropolitan police force. Am J Prev Med. 2000;18(2):146–50.52. Groseclose SL, Weinstein B, Stephen-Jones T, Valleroy LA, Fehrs LJ, KasslerWJ. Impact of increased legal access to needle and syringes on practices ofinjecting-drug users and police officers-Connecticut, 1992-1993. J AcquirImmune Defic Syndr Hum Retrovirol. 1995;10:82–9.53. Pagane J, Chanmugam A, Kirsch T, Kelen GD. New York city police officersincidence of transcutaneous exposure. Occup Med. 1996;46(4):285–8.54. Sonder GJB, Bovée LPMJ, Coutinho RA, Baayen D, Spaargaren J, Van denHoek A. Occupational exposure to bloodborne viruses in the Amsterdampolice force, 2000-2003. Am J Prev Med. 2005;28(2):169–74.55. Davis CS, Johnston J, de Saxe Zerden L, Clark K, Castillo T, Childs R. Attitudesof North Carolina law enforcement officers towards syringe decriminalization.Drug Alcohol Depend. 2014;144:265–9.56. Mittal ML, Beletsky L, Patino E, Abramovitz D, Rocha T, Arredondo J, et al.Prevalence and correlates of needle-stick injuries among active duty policeofficers in Tijuana, Mexico. J Int AIDS Soc. 2016;19(4S3):20874.57. Flavin J. Police and HIV/AIDS: the risk, the reality, the response. Am J CrimJustice. 1998;23(1):33–58.58. Ramos R, Ferreira-Pinto JB, Brouwer KC, Ramos ME, Lozada RM, Firestone-Cruz M, et al. A tale of two cities: social and environmental influencesshaping risk factors and protective behaviorss in two Mexico-US bordercities. Health Place. 2009;15(4):999–1005.59. Beyer L, Crofts N, Reid G. Drug offending and criminal justice responses:practitioners' perspectives. Int J Drug Policy. 2002;13(3):203–11.60. Beletsky L, Thomas R, Shumskaya N, Artamonova I, Smelyanskaya M. Policeeducation as a component of national HIV response: lessons fromKyrgyzstan. Drug Alcohol Depend. 2013;132(1). https://doi.org/10.1016/j.drugalcdep.2013.06.02761. Arredondo J, Strathdee SA, Cepeda JA, Abramovitz D, Artamonova I,Clairgue E, et al. Measuring improvement in knowledge of drug policyreforms following a police education program in Tijuana, Mexico. HarmReduction J. 2017;14(72):1–10.Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 9 of 1062. Morales M, Mittal ML, Rocha T, Rafful C, Clairgue E, Arredondo J, et al.Translating drug policy reform: a qualitative study of police officerknowledge, perceptions, and beliefs following a training on Mexico'sNarcomenudeo law. ISSDP conference, Aarhus, Denmark. 2017.63. Strathdee SA, Magis-Rodriguez C, Mays VM, Jimenez R, Patterson TL. Theemerging HIV epidemic on the Mexico-US border: an international casestudy characterizing the role of epidemiology in surveillance and response.Ann Epidemiol. 2012;22(6):426–38.64. Bobashev GV, Zule WA. Modeling the effect of high dead-space syringes onthe human immudeficiency virus (HIV) epidemic among injecting drugusers. Addiction. 2010;105:1439–47.65. Borquez A, Beletsky L, Nosyk B, Strathdee SA, Madrazo A, Abramovitz D, et al.The effect of public health-oriented drug law reform on HIV incidence inpeople who inject drugs in Tijuana, Mexico: an epidemic modelling study.Lancet Public Health. 2018; https://doi.org/10.1016/S2468-2667/(18)30097-5.66. Strathdee SA, Arredondo J, Rocha T, Abramovitz D, Rolon ML, Patino E, et al.A police education programme to integrate occupational safety and HIVprevention: protocol for a modified stepped-wedge study design withparallel prospective cohorts to assess behavioural outcomes. BMJ Open.2015;5:e008958. https://doi.org/10.1136/bmjopen-2015-00895867. Glantz SA. Primer of biostatistics. 7th ed. ed. New York: McGraw-Hill; 2012.68. Beyrer C. HIV epidemiology update and transmission factors: risks and riskcontexts--16th international AIDS conference epidemiology plenary. ClinInfect Dis. 2007;44(7):981–7.69. Strathdee SA, Beletsky L. Harmonizing law enforcement and HIV preventionthrough a police education program La Jolla: UCSD Division of GlobalPublic Health; 2015. [4/9/2015]. Available from: https://gph.ucsd.edu/research/active-projects/Pages/harmonizing.aspx70. Fitzsimmons T. A lack of female officers causes police brutality. In: CothranH, editor. Police brutality: Opposing viewpoints. San Diego, CA.: GreenhavenPress; 2001. p. 75–83.71. Rabe-Hemp CE. Female officers and the ethic of care: does officer genderimpact police behaviors? J Crim Just. 2008;36:426–34.72. Schuck AM, Rabe-Hemp C. Women police: the use of force by and againstfemale officers. Women Crim Just. 2008;16(4):91–117.73. Prenzler T. Police corruption. Preventing misconduct and maintainingintegrity. New York: CRC Press; 2009.74. Duran L, Caballero Y. Limpieza. In: en Bordo dispersa adictos. Frontera; 2015.75. CONADIC. Directorio de establecimientos especializados en el tratamientode las adicciones en modalidad residencial reconocidos por la Comisi'onNacional contra las Adicciones. In: Adicciones CNcl, editor. México 2017.76. DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T. Police andpublic health partnerships: evidence from the evaluation of Vancouver'ssupervised injection facility. Subst Abuse Treat Prev Policy. 2008;3:11.Morales et al. BMC International Health and Human Rights  (2018) 18:36 Page 10 of 10


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