Injection risk norms and practices among migrant Puerto Rican people who inject drugs in New York City: The limits of acculturation theory.

BACKGROUND: Among people who inject drugs (PWID) in New York City (NYC), racial minorities are disproportionately infected with HIV and hepatitis C (HCV). Prior research has shown that PWID who started injecting drugs in Puerto Rico (P.R.) tend to maintain the risky injection behaviors learned there. This study identifies the P.R.-native norms supporting the continued injection risk behavior of migrant Puerto Rican PWID in NYC to inform a culturally appropriate risk-reduction intervention. METHODS: 40 migrant Puerto Rican PWID were recruited in NYC for a longitudinal qualitative study. The sample was stratified to include 20 migrants with <3 years in NYC and 20 migrants with >3-6 years in NYC. Time-location sampling was used to curb possible network bias in recruitment. Over 12 months, migrants completed semi-structured interviews at baseline, monthly follow-ups, and study exit. Analyses were guided by grounded theory. RESULTS: Most participants (90%) reported having had chronic HCV, and 22.5% reported being HIV-positive. Syringe- and cooker-/cotton-sharing were widespread in both P.R. and NYC. The ubiquitous practice of cleaning used syringes by "water-rinsing and air-blowing" was guided by a normative belief, learned in P.R., that "water and air kill HIV." Sterile syringe use was not a priority. HCV was not a concern. P.R.-native abstinence-only narratives discouraged opioid agonist treatment (OAT) enrollment among recent migrants (≤3 years). Experiences with drug dealers, prison-power groups, and injection doctors ("Gancheros") in P.R. influenced migrants' injection risk behavior in NYC. Those who were Gancheros in P.R. continued working as Gancheros in NYC. CONCLUSIONS: Injection risks make migrant Puerto Rican PWID in NYC vulnerable to HIV/HCV. Harm reduction programs should pay closer attention to the rationales behind these injection risks. A risk-reduction intervention that incorporates the Ganchero figure may be a credible way to help migrants reduce injection risk and accept OAT and syringe exchange programs (SEP).

Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis.

OBJECTIVE: From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision. DESIGN: Costing study and longitudinal cohort study. SETTING: Tijuana, Mexico. PARTICIPANTS: Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study. PRIMARY OUTCOME MEASURES: Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal. RESULTS: During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02). CONCLUSIONS: Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.

Gender differences in the provision of injection initiation assistance: a comparison of three North American settings.

AIM: Individuals experience differential risks in their initiation into drug injecting based on their gender. Data suggest women are more likely to be injected after their initiator and to share injection equipment. Little is known, however, regarding how gender influences the risk that people who inject drugs (PWID) may assist others into injection initiation. We therefore sought to investigate the role of "initiator" gender in the provision of injection initiation assistance across multiple settings. METHODS: We employed data from PReventing Injecting by Modifying Existing Responses (PRIMER), a multi-cohort study investigating factors influencing injection initiation assistance provision. Data were drawn from three cohort studies of PWID in San Diego, USA (STAHR II); Tijuana, Mexico (El Cuete IV); and Vancouver, Canada (VDUS). Site-specific logistic regression models were fit, with lifetime provision of injection initiation assistance as the outcome and gender as the independent variable. RESULTS: Overall, 3.2% (24/746) of the women and 4.6% (63/1367) of the men reported providing injection initiation assistance. In Tijuana, men were more than twice as likely to have provided injection initiation assistance after controlling for potential confounders (adjusted odds ratio = 2.17, 95% confidence interval: 1.22-3.84). Gender was not significantly associated with providing injection initiation assistance in other sites. CONCLUSION: We identified that being male in Tijuana, specifically, was associated with providing injection initiation assistance, which could inform targeted outreach aimed at reducing the influence of PWID populations on non-injectors in this site. This will likely require that existing interventions address gender- and site-specific factors for effectiveness.

Injecting drug use: Gendered risk.

BACKGROUND: Research demonstrates gender related differences in drug-use practices and risk behaviours. Females' structural vulnerability stemming from traditional gender roles and gender-power relations may enhance their propensity to experience injecting related risk. In this paper we explore gender differences in injection practices at the initiation event, during the first year of injecting and in the most recent 12-month period, to inform more effective harm reduction strategies. METHODS: Data used in this study were drawn from the Global Drug Survey 2015. The study employs chi-square and logistic regression to assess gender differences in injection behaviours in a sample of current injectors residing in six global regions: North-West Europe; Southern Eastern Europe; North America. South America and Oceania. RESULTS: Females were more likely than males to report being injected by an intimate partner at initiation (OR = 4.4, 95%CI: 2.2-8.8), during the first year of injecting (OR = 4.8, 95% CI: 2.4-9.3) and in the most recent 12-month period (OR = 2.5, 95%CI: 1.0-6.2). Females reported greater difficulties accessing sterile equipment (X2(2,N = 453) = 8.2, p = 0.02) and were more likely to share injecting equipment than males (X2(1,N = 463) = 3.9, p = 0.05). CONCLUSIONS: Our findings highlight females' continued dependence on their intimate partner to administer the injection into the first year of their injecting career. Females remained more likely than males to rely on intimate partners for injection during the most recent 12-month period. Females report greater difficulties in sourcing sterile equipment and are more likely to share injecting equipment. We suggest that these findings reflect the broader social structure in which females are disempowered through traditional gender roles and the lack of gender appropriate harm reduction services.

Measuring improvement in knowledge of drug policy reforms following a police education program in Tijuana, Mexico.

BACKGROUND: Mexico's 2009 "narcomenudeo reform" decriminalized small amounts of drugs, shifting some drug law enforcement to the states and mandating drug treatment diversion instead of incarceration. Data from Tijuana suggested limited implementation of this harm reduction-oriented policy. We studied whether a police education program (PEP) improved officers' drug and syringe policy knowledge, and aimed to identify participant characteristics associated with improvement of drug policy knowledge. METHODS: Pre- and post-training surveys were self-administered by municipal police officers to measure legal knowledge. Training impact was assessed through matched paired nominal data using McNemar's tests. Multivariable logistic regression was used to identify predictors of improved legal knowledge, as measured by officers' ability to identify conceptual legal provisions related to syringe possession and thresholds of drugs covered under the reform. RESULTS: Of 1750 respondents comparing pre- versus post training, officers reported significant improvement (p < 0.001) in their technical understanding of syringe possession (56 to 91%) and drug amounts decriminalized, including marijuana (9 to 52%), heroin (8 to 71%), and methamphetamine (7 to 70%). The training was associated with even greater success in improving conceptual legal knowledge for syringe possession (67 to 96%) (p < 0.001), marijuana (16 to 91%), heroin (11 to 91%), and methamphetamine (11 to 89%). In multivariable modeling, those with at least a high school education were more likely to exhibit improvement of conceptual legal knowledge of syringe possession (adjusted odds ratio [aOR] 2.6, 95% CI 1.4-3.2) and decriminalization for heroin (aOR 2.7, 95% CI 1.3-4.3), methamphetamine (aOR 2.2, 95% CI 1.4-3.2), and marijuana (aOR 2.5, 95% CI 1.6-4). CONCLUSIONS: Drug policy reform is often necessary, but not sufficient to achieve public health goals because of gaps in translating formal laws to policing practice. To close such gaps, PEP initiatives bundling occupational safety information with relevant legal content demonstrate clear promise. Our findings underscore additional efforts needed to raise technical knowledge of the law among personnel tasked with its enforcement. Police professionalization, including minimum educational standards, appear critical for aligning policing with harm reduction goals.

Needle acquisition patterns, network risk and social capital among rural PWID in Puerto Rico.

BACKGROUND: People who inject drugs (PWID) take on significant risks of contracting blood-borne infection, including injecting with a large number of partners and acquiring needles from unsafe sources. When combined, risk of infection can be magnified. METHODS: Using a sample of PWID in rural Puerto Rico, we model the relationship between a subject's number of injection partners and the likelihood of having used an unsafe source of injection syringes. Data collection with 315 current injectors identified six sources of needles. RESULTS: Of the six possible sources, only acquisition from a seller (paid or free), or using syringes found on the street, was significantly related to number of partners. CONCLUSIONS: These results suggest that sources of syringes do serve to multiply risk of infection caused by multi-partner injection concurrency. They also suggest that prior research on distinct forms of social capital among PWID may need to be rethought.

Differential access to syringe exchange and other prevention activities among people who inject drugs in rural and urban areas of Puerto Rico.

BACKGROUND: Injection drug use and its associated blood-borne infections has become a rapidly increasing problem in rural areas of the US recently. Syringe exchange programs have been shown to be effective for reducing transmission of blood borne infections, however access to these prevention efforts may be limited in rural areas. METHODS: This paper utilizes two separate community samples of people who inject drugs (PWID) in Puerto Rico to achieve the following research objectives: (1) compare rural and urban access to syringe exchange programs, free sterile syringes and other HIV/HCV prevention activities, and (2) examine whether utilization of prevention activities is associated with lower injection risk behaviors. Two samples were recruited with RDS (n=315 rural sample; n=512 urban sample) and included adults aged 18 years and older who have injected drugs within the past month. RESULTS: 78.5% of the urban sample utilized a syringe exchange program in the past year, compared to 58.4% of the rural sample (p<.001). 71.4% of the urban sample received free sterile needles, compared to 58.4% of the rural sample (p<.001). 66% of the urban sample received free works compared to 59% of the rural sample (p=.034). 29% of urban PWID had a conversation with an outreach worker about HIV prevention compared to 18% of the rural sample (p<0.001). Receiving free needles significantly increases the frequency of using a sterile needle to inject (p<.001). CONCLUSION: Urban PWID were significantly more likely to have utilized syringe exchange programs, received free sterile needles, received free works, and to have talked about HIV prevention with an outreach worker during the past year than PWID residing in rural areas. Individuals who accessed these prevention activities were significantly less likely to exhibit risky injection behavior. Policy implications call for increasing access to prevention services in rural areas to reduce disease transmission.

Predictors of needle exchange program utilization during its implementation and expansion in Tijuana, Mexico.

OBJECTIVE: Until the early 2000s, there was only one needle exchange program (NEP) offered in Mexico. In 2004, the second Mexican NEP opened in Tijuana, but its utilization has not been studied. We studied predictors of initiating NEP during its early expansion in Tijuana, Mexico. METHODS: From April 2006 to April 2007, people who inject drugs (PWID) residing in Tijuana who had injected within the last month were recruited using respondent-driven sampling. Weighted Poisson regression incorporating generalized estimating equations was used to identify predictors of initiating NEP, while accounting for correlation between recruiter and recruits. RESULTS: NEP uptake increased from 20% at baseline to 59% after 6 months. Among a subsample of PWID not accessing NEP at baseline (n = 480), 83% were male and median age was 37 years (Interquartile Range: 32-43). At baseline, 4.4% were HIV-infected and 5.9% had syphilis titers >1:8. In multivariate models, factors associated with NEP initiation (p < .05) were attending shooting galleries (Adjusted Relative Risk [ARR]: 1.54); arrest for track-marks (ARR: 1.38); having a family member that ever used drugs (ARR: 1.37); and having a larger PWID network (ARR: 1.01 per 10 persons). NEP initiation was inversely associated with obtaining syringes at pharmacies (ARR: .56); earning >2500 pesos/month (ARR: .66); and reporting needle sharing (ARR: .71). CONCLUSIONS: Uptake of NEP expansion in Tijuana was vigorous among PWID. We identified a range of factors that influenced the likelihood of NEP initiation, including police interaction. These findings have important implications for the scale-up of NEP in Mexico.

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.

INTRODUCTION: Policing practices are key drivers of HIV among people who inject drugs (PWID). This paper describes the protocol for the first study to prospectively examine the impact of a police education programme (PEP) to align law enforcement and HIV prevention. PEPs incorporating HIV prevention (including harm reduction programmes like syringe exchange) have been successfully piloted in several countries but were limited to brief pre-post assessments; the impact of PEPs on policing behaviours and occupational safety is unknown. OBJECTIVES: Proyecto ESCUDO (SHIELD) aims to evaluate the efficacy of the PEP on uptake of occupational safety procedures, as assessed through the incidence of needle stick injuries (NSIs) (primary outcome) and changes in knowledge of transmission, prevention and treatment of HIV and viral hepatitis; attitudes towards PWID, adverse behaviours that interfere with HIV prevention and protective behaviours (secondary outcomes). METHODS/ANALYSIS: ESCUDO is a hybrid type I design that simultaneously tests an intervention and an implementation strategy. Using a modified stepped-wedge design involving all active duty street-level police officers in Tijuana (N = ∼ 1200), we will administer one 3 h PEP course to groups of 20-50 officers until the entire force is trained. NSI incidence and geocoded arrest data will be assessed from department-wide de-identified data. Of the consenting police officers, a subcohort (N=500) will be randomly sampled from each class to undergo pre-PEP and post-PEP surveys with a semiannual follow-up for 2 years to assess self-reported NSIs, attitudes and behaviour changes. The impact on PWIDs will be externally validated through a parallel cohort of Tijuana PWIDs. ETHICS/DISSEMINATION: Research ethics approval was obtained from the USA and Mexico. Findings will be disseminated through open access to protocol materials through the Law Enforcement and HIV Network. TRIAL REGISTRATION NUMBER: NCT02444403.

High dead-space syringe use among people who inject drugs in Tijuana, Mexico.

BACKGROUND: High dead-space syringes (HDSS) are believed to confer an elevated risk of acquiring HIV and other blood-borne infections. OBJECTIVES: We identified prevalence and correlates of HDSS use among injection drug users (IDU) in Tijuana, Mexico, where syringe purchase and possession is legal without a prescription. METHODS: Beginning in 2011, IDU who reported being 18 years or older and injected drugs within the last month were recruited into a prospective study. At baseline and semi-annually, 557 IDU underwent HIV-testing and interviewer-administered surveys. Logistic regression was used to identify correlates of using HDSS. RESULTS: Of 557 IDU, 40% had ever used HDSS, mostly because no other syringe type was available (72%), or because they were easier to get (20%). Controlling for sex and age at first injection, use of HDSS was associated with cocaine as the first drug injected (Adjusted Odds Ratio [AOR]: 2.68; Confidence Interval 95% [CI]: 1.15-6.22), having been stopped or arrested by police (AOR: 1.84; 95% CI: 1.11-3.07), being deported from the US (AOR: 1.64; 95% CI:1.06-2.53), and believing it is illegal to carry syringes (AOR:1.78; 95% CI: 1.01-3.15). CONCLUSION: Use of HDSS is surprisingly common among IDU in Tijuana. Efforts are needed to expand coverage of low-dead space syringes through existing syringe exchange programs. Education is required to increase awareness of the harms associated with HDSS, and to inform IDU that syringe possession is legal across Mexico.

Addressing the HIV/AIDS epidemic among Puerto Rican people who inject drugs: the need for a multiregion approach.

High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemic. Advances in HIV prevention and treatment have reduced HIV among people who inject drugs (PWID) in the United States. We examined HIV-related data for PRPWID in Puerto Rico and the US Northeast to assess whether disparities continue. Injection drug use as a risk for HIV is still overrepresented among Puerto Ricans. Lower availability of syringe exchanges, drug abuse treatment, and antiretroviral treatment for PWID in Puerto Rico contribute to higher HIV risk and incidence. These disparities should be addressed by the development of a federally supported Northeast-Puerto Rico collaboration to facilitate and coordinate efforts throughout both regions.

Absceso post-inyección en personas que asistieron a la Unidad de Salud La Joya. Tegucigalpa, Honduras / Post-Injection Abscess in patients attending health Unit La Joya, Tegucigalpa, Honduras

La presente investigación es sobre absceso post-inyección en el centro de salud La Joya. Objetivo: Establecerlos factores de riesgo deabscesopost-inyección en pacientesque asistieron ala unidad de salud. Material y Métodos: Tipo de estudio retrospectivo transversal. Se revisó un total de 3,256 expedientes de personas que acudieron a la unidad de salud La Joya, Tegucigalpa, de enero a octubre de 2012, se elaboró una hoja de registro para recolectar información de los expedientes clínicos, los formularios de atención ambulatoria, y entrevistas telefónicas con los pacientes que presentaron absceso post inyección. Así mismo, se elaboró una encuesta de 12 preguntas cerradas aplicada al personal de la unidad de salud. Para determinar el grado de contaminación y agentes existentes en el área de tratamiento de la unidad de salud, se tomó muestras para cultivo microbiológico del personal de salud, del ambiente y del material y equipo. Resultados: 15 pacientes resultaron con absceso en la región glútea, el 93% fueron del sexo femenino, en su mayoría obesas (60%), de 4-59 años de edad (80%), con higiene personal diaria deficiente. La mayor parte del personal afirmó utilizar las normas de asepsia en la aplicación de inyecciones y mantener los principios básicos de desinfección de superficies en el área de tratamiento. En el análisis microbiológico se reportó crecimiento bacteriano en todas las muestras tomadas, incluyendo las muestras de manos del personal de salud. Conclusión: Son diversos los factores de riesgo para la formación de abscesos glúteos post inyección, se señalan factores particulares del paciente, factores relacionados con el personal y los propios del área de inyecciones del centro de salud La Joya; las medidas de asepsia y de aseo en el área, reduce la incidencia de abscesos glúteos post-inyección y de sus complicaciones...(AU)

Evaluating the impact of Mexico's drug policy reforms on people who inject drugs in Tijuana, B.C., Mexico, and San Diego, CA, United States: a binational mixed methods research agenda.

BACKGROUND: Policymakers and researchers seek answers to how liberalized drug policies affect people who inject drugs (PWID). In response to concerns about the failing "war on drugs," Mexico recently implemented drug policy reforms that partially decriminalized possession of small amounts of drugs for personal use while promoting drug treatment. Recognizing important epidemiologic, policy, and socioeconomic differences between the United States-where possession of any psychoactive drugs without a prescription remains illegal-and Mexico-where possession of small quantities for personal use was partially decriminalized, we sought to assess changes over time in knowledge, attitudes, behaviors, and infectious disease profiles among PWID in the adjacent border cities of San Diego, CA, USA, and Tijuana, Baja California, Mexico. METHODS: Based on extensive binational experience and collaboration, from 2012-2014 we initiated two parallel, prospective, mixed methods studies: Proyecto El Cuete IV in Tijuana (n = 785) and the STAHR II Study in San Diego (n = 575). Methods for sampling, recruitment, and data collection were designed to be compatible in both studies. All participants completed quantitative behavioral and geographic assessments and serological testing (HIV in both studies; hepatitis C virus and tuberculosis in STAHR II) at baseline and four semi-annual follow-up visits. Between follow-up assessment visits, subsets of participants completed qualitative interviews to explore contextual factors relating to study aims and other emergent phenomena. Planned analyses include descriptive and inferential statistics for quantitative data, content analysis and other mixed-methods approaches for qualitative data, and phylogenetic analysis of HIV-positive samples to understand cross-border transmission dynamics. RESULTS: Investigators and research staff shared preliminary findings across studies to provide feedback on instruments and insights regarding local phenomena. As a result, recruitment and data collection procedures have been implemented successfully, demonstrating the importance of binational collaboration in evaluating the impact of structural-level drug policy reforms on the behaviors, health, and wellbeing of PWID across an international border. CONCLUSIONS: Our prospective, mixed methods approach allows each study to be responsive to emerging phenomena within local contexts while regular collaboration promotes sharing insights across studies. The strengths and limitations of this approach may serve as a guide for other evaluations of harm reduction policies internationally.

Negotiating access: social barriers to purchasing syringes at pharmacies in Tijuana, Mexico.

BACKGROUND: One common public health response to the emergence of HIV has been the provision of sterile syringes to people who inject drugs. In Mexico specialized syringe exchanges are rare, and the sale of needles through pharmacies is often the only way people who inject drugs can obtain sterile syringes. However, people who inject drugs in Tijuana, Mexico report considerable social barriers to successfully purchasing syringes at pharmacies. METHODS: Between October 2008 and March 2009 we conducted seven in-depth focus groups with 47 people who inject drugs in Tijuana, Mexico. Focus group transcripts were analysed using a descriptive and thematic approach rooted in grounded theory. RESULTS: We found that injectors offered a number of explanations for why pharmacies were reluctant to sell them syringes, including fear of police; attitudes toward drug use; fear of stereotypical drug user behaviour such as petty theft, violence, or distressing behaviour; and related fears that an obvious drug using clientèle would drive away other customers. Injectors described a range of ways of attempting to re-frame or negotiate interactions with pharmacy staff so that these and related concerns were ameliorated. These included tactics as simple as borrowing cleaner clothing, through to strategies for becoming 'known' to pharmacy staff as an individual rather than as a member of a stigmatized group. CONCLUSION: Increasing the ability of pharmacy staff and people who inject drugs to successfully negotiate syringe sales are highly desirable. Interventions designed to improve this likelihood need to capitalize on existing solutions developed ad hoc by people who inject drugs and pharmacy staff, and should focus on broadening the range of 'identities' which pharmacy staff are able to accept as legitimate customers. Approaches to achieve this end might include sensitizing pharmacy staff to the needs of people who inject drugs; facilitating individual drug users meeting individual pharmacy staff; and working with drug users to reduce behaviours seen as problematic by pharmacy staff.

The emerging HIV epidemic on the Mexico-U.S. border: an international case study characterizing the role of epidemiology in surveillance and response.

PURPOSE: Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome surveillance data are critical for monitoring epidemic trends, but they can mask dynamic subepidemics, especially in vulnerable populations that underuse HIV testing. In this case study, we describe community-based epidemiologic data among injection drug users (IDUs) and female sex workers (FSWs) in two northern Mexico-U.S. border states that identified an emerging HIV epidemic and generated a policy response. METHODS: We draw from quantitative and qualitative cross-sectional and prospective epidemiologic studies and behavioral intervention studies among IDUs and FSWs in Tijuana, Baja California, and Ciudad Juarez, Chihuahua. RESULTS: The recognition that the HIV epidemic on Mexico's northern border was already well established in subgroups in whom it had been presumed to be insignificant was met with calls for action and enhanced prevention efforts from researchers, nongovernmental organizations, and policy makers. CONCLUSIONS: Successful policies and program outcomes included expansion of needle-exchange programs, a nationwide mobile HIV prevention program targeting marginalized populations, a successful funding bid from the Global Fund for HIV, TB, and Malaria to scale up targeted HIV-prevention programs, and the establishment of bi-national training programs on prevention of HIV and substance use. We discuss how epidemiologic data informed HIV prevention policies and suggest how other countries may learn from Mexico's experience.

Reconciling incongruous qualitative and quantitative findings in mixed methods research: exemplars from research with drug using populations.

Mixed methods research is increasingly being promoted in the health sciences as a way to gain more comprehensive understandings of how social processes and individual behaviours shape human health. Mixed methods research most commonly combines qualitative and quantitative data collection and analysis strategies. Often, integrating findings from multiple methods is assumed to confirm or validate the findings from one method with the findings from another, seeking convergence or agreement between methods. Cases in which findings from different methods are congruous are generally thought of as ideal, whilst conflicting findings may, at first glance, appear problematic. However, the latter situation provides the opportunity for a process through which apparently discordant results are reconciled, potentially leading to new emergent understandings of complex social phenomena. This paper presents three case studies drawn from the authors' research on HIV risk amongst injection drug users in which mixed methods studies yielded apparently discrepant results. We use these case studies (involving injection drug users [IDUs] using a Needle/Syringe Exchange Program in Los Angeles, CA, USA; IDUs seeking to purchase needle/syringes at pharmacies in Tijuana, Mexico; and young street-based IDUs in San Francisco, CA, USA) to identify challenges associated with integrating findings from mixed methods projects, summarize lessons learned, and make recommendations for how to more successfully anticipate and manage the integration of findings. Despite the challenges inherent in reconciling apparently conflicting findings from qualitative and quantitative approaches, in keeping with others who have argued in favour of integrating mixed methods findings, we contend that such an undertaking has the potential to yield benefits that emerge only through the struggle to reconcile discrepant results and may provide a sum that is greater than the individual qualitative and quantitative parts.