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We studied PWID in Mexico to identify sex differences in multilevel determinants of injection risk.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design and Methods<\/jats:title><jats:p>From 2011 to 2013, 734 PWID (female: 277, male: 457) were enrolled into an observational cohort study in Tijuana. Participants completed interviews on injection and sexual risks. Utilising baseline data, we conducted multiple generalised linear models stratified by sex to identify factors associated with injection risk scores (e.g. frequency of injection risk behaviours).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>For both sexes, difficult access to sterile syringes was associated with elevated injection risk (<jats:italic>b<\/jats:italic> = 1.24, 95% confidence interval [CI] 1.16\u20131.33), using syringes from a safe source (e.g. needle exchange programs) was associated with lower injection risk (<jats:italic>b<\/jats:italic> = 0.87, 95% CI 0.82\u20130.94), and for every one\u2010unit increase in safe injection self\u2010efficacy we observed a 20% decrease in injection risk (<jats:italic>b<\/jats:italic> = 0.80, 95% CI 0.76\u20130.84). Females had a higher safe injection self\u2010efficacy score compared to males (median 2.83, interquartile range 2.2\u20133 vs. median 2.83, interquartile range 2\u20133; <jats:italic>P<\/jats:italic> = 0.01). Among females, incarceration (<jats:italic>b<\/jats:italic> = 1.22, 95% CI 1.09\u20131.36) and police confiscation of syringes in the past 6\u2009months (<jats:italic>b<\/jats:italic> = 1.16, 95% CI 1.01\u20131.33) were associated with elevated injection risk. Among males, sex work (<jats:italic>b<\/jats:italic> = 1.16, 95% CI 1.04\u20131.30) and polysubstance use in the past 6\u2009months (<jats:italic>b<\/jats:italic> = 1.22, 95% CI 1.13\u20131.31) were associated with elevated injection risk.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion and Conclusions<\/jats:title><jats:p>Interventions to reduce HIV and hepatitis C virus transmission among PWID in Tijuana should be sex\u2010specific and consider multilevel determinants of injection risk to create safer drug use environments.<\/jats:p><\/jats:sec>","DOI":"10.1111\/dar.13134","type":"journal-article","created":{"date-parts":[[2020,8,15]],"date-time":"2020-08-15T04:57:11Z","timestamp":1597467431000},"page":"898-907","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Sex differences in the multilevel determinants of injection risk behaviours among people who inject drugs in Tijuana, Mexico"],"prefix":"10.1111","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6339-1649","authenticated-orcid":false,"given":"Jennifer P.","family":"Jain","sequence":"first","affiliation":[{"name":"School of Medicine, University of California, San Diego  San Diego USA"},{"name":"School of Medicine, University of California, San Francisco  San Francisco USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steffanie A.","family":"Strathdee","sequence":"additional","affiliation":[{"name":"School of Medicine, University of California, San Diego  San Diego USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brooke S.","family":"West","sequence":"additional","affiliation":[{"name":"School of Social Work, Columbia University  New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patricia","family":"Gonzalez\u2010Zuniga","sequence":"additional","affiliation":[{"name":"School of Medicine, University of California, San Diego  San Diego USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gudelia","family":"Rangel","sequence":"additional","affiliation":[{"name":"United States\u2010Mexico Border Health Commission and El Colegio de la Frontera Norte  Tijuana Mexico"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eileen V.","family":"Pitpitan","sequence":"additional","affiliation":[{"name":"School of Social Work, San Diego State University  San Diego USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2020,8,14]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.drugalcdep.2005.02.003"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/00002030-200212003-00006"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11524-005-9027-0"},{"key":"e_1_2_8_5_1","unstructured":"StrathdeeSA. 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