Dual HIV risk: receptive syringe sharing and unprotected sex among HIV-negative injection drug users in New York City

Factors associated with receptive injection equipment sharing among people who inject drugs: findings from a multistate study at the start of the COVID-19 pandemic

BACKGROUND

Receptive injection equipment sharing (i.e., injecting with syringes, cookers, rinse water previously used by another person) plays a central role in the transmission of infectious diseases (e.g., HIV, viral hepatitis) among people who inject drugs. Better understanding these behaviors in the context of COVID-19 may afford insights about potential intervention opportunities in future health crises.

OBJECTIVE

This study examines factors associated with receptive injection equipment sharing among people who inject drugs in the context of COVID-19.

METHODS

From August 2020 to January 2021, people who inject drugs were recruited from 22 substance use disorder treatment programs and harm reduction service providers in nine states and the District of Columbia to complete a survey that ascertained how the COVID-19 pandemic affected substance use behaviors. We used logistic regression to identify factors associated with people who inject drugs having recently engaged in receptive injection equipment sharing.

RESULTS

One in four people who inject drugs in our sample reported having engaged in receptive injection equipment sharing in the past month. Factors associated with greater odds of receptive injection equipment sharing included: having a high school education or equivalent (adjusted odds ratio [aOR] = 2.14, 95% confidence interval [95% CI] 1.24, 3.69), experiencing hunger at least weekly (aOR = 1.89, 95% CI 1.01, 3.56), and number of drugs injected (aOR = 1.15, 95% CI 1.02, 1.30). Older age (aOR = 0.97, 95% CI 0.94, 1.00) and living in a non-metropolitan area (aOR = 0.43, 95% CI 0.18, 1.02) were marginally associated with decreased odds of receptive injection equipment sharing.

CONCLUSIONS

Receptive injection equipment sharing was relatively common among our sample during the early months of the COVID-19 pandemic. Our findings contribute to existing literature that examines receptive injection equipment sharing by demonstrating that this behavior was associated with factors identified in similar research that occurred before COVID. Eliminating high-risk injection practices among people who inject drugs requires investments in low-threshold and evidence-based services that ensure persons have access to sterile injection equipment.

Association Between Dual Partnership and Sexual and Injecting Behaviors Among Persons Who Inject Drugs in 23 US Cities, 2018

Persons who inject drugs (PWID) engaging in receptive syringe sharing with their sex partner (dual partnership) may have different behavior patterns than people who have only sex or syringe sharing partnerships. PWID from 23 US cities were recruited for the National HIV Behavioral Surveillance in 2018 using respondent-driven sampling, interviewed, and tested for HIV. Log-linked Poisson regression was conducted to examine the associations between injecting and sexual behaviors and dual partnership. A total of 3435 PWID reported receptive syringe sharing and 42% engaged in dual partnership with their last sharing injecting partner. PWID who reported condomless vaginal or anal sex at last sex were more likely to engage in dual partnership (aPR = 1.85, 95% CI = 1.65-2.08). PWID who reported having two or more sex partners (aPR = 0.67, 95% CI = 0.62-0.72) or two or more sharing injecting partners (aPR = 0.54, 95% CI = 0.50-0.59) were less likely to engage in dual partnership. Findings suggest opportunities for tailored prevention intervention, including couple-based HIV testing, pre-exposure prophylaxis, and access to syringe services programs coupled with safer injection education to help reduce HIV risk.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention’s women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women’s focus; and consider providing same-day PrEP.

Reduction in injection risk behaviors after implementation of a syringe services program, Miami, Florida

INTRODUCTION

Syringe services programs (SSPs) are evidence-based HIV prevention programs for people who inject drugs. However, not all SSPs operate evidence-based syringe distribution models, such as needs-based distribution. This study aims to provide preliminary evidence from the IDEA SSP on changes in injection risk behaviors over time, and to examine factors, including syringe coverage, associated with injection risk behavior trajectories over time under a one-for-one syringe distribution model.

METHODS

We used a prospective observational study design to generate a cohort of SSP clients who completed three behavioral assessments at SSP service visits between December 2016 and January 2020 (N = 115). The study used generalized estimating equations (GEE) to examine the relationship between covariate measures and the primary outcomes. The primary outcomes were 1) sharing of any injection equipment (e.g. syringes, needles, cookers, cottons) in the previous 30 days (yes/no) and 2) reusing of needles/syringes in the previous 30 days (yes/no).

RESULTS

Men were more likely to report reusing syringes (aRR = 1.15, 95% CI: 1.01-1.37) and those who reported injecting in public were less likely to report reusing syringes (aRR = 0.90, 95% CI: 0.82-0.99). HCV-positive clients had a 62% reduction in sharing injection equipment and those who reported public injection had a 62% increase in sharing injection equipment over time. Most importantly, increasing syringe coverage was associated with a decrease in both sharing injection equipment (aRR = 0.42, 95% CI: 0.25-0.72) and reusing syringes (aRR = 0.79, 95% CI: 0.66-0.95).

CONCLUSION

This study provides preliminary evidence of reductions in injection-related risk behaviors from the IDEA SSP and highlights potential high priority groups, such as people experiencing homelessness, that may need additional intervention. In addition, improving syringe coverage among SSP clients may be an important factor in reducing behaviors that place individuals at risk for contracting HIV and HCV.

A Pilot Study to Evaluate a Novel Pre-exposure Prophylaxis Peer Outreach and Navigation Intervention for Women at High Risk for HIV Infection

Pre-exposure prophylaxis (PrEP) uptake remains woefully low among U.S. women at high risk for HIV acquisition. We evaluated a pilot intervention which involved Peers providing brief PrEP education and counseling at mobile syringe exchange sites and at sex worker and syringe exchange drop-in centers followed by navigation to PrEP care. Peers recruited English-proficient, self-identified women (i.e., cisgender and transgender women and persons with other transfeminine identities) over a 3-month period and delivered the intervention to 52 HIV-negative/status unknown participants. Thirty-eight participants (73.1%) reported PrEP interest, 27 (51.9%) accepted the offer of a PrEP appointment, 13 (25.0%) scheduled a PrEP appointment, 3 (5.8%) attended an initial PrEP appointment, and none were prescribed PrEP. We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.

Prevalence and correlates of receptive syringe-sharing among people who inject drugs in rural Appalachia

BACKGROUND AND AIMS

Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia.

DESIGN

Observational, cross-sectional sample from a capture-recapture parent study.

SETTING

Cabell County, West Virginia (WV), USA, June-July 2018.

PARTICIPANTS

The sample was restricted to people who reported injecting drugs in the past 6 months (n = 420). A total of 180 participants (43%) reported recent (past 6 months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%).

MEASUREMENTS

The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS.

FINDINGS

PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) = 2.27, 95% confidence interval (CI) = 1.26-4.09], unemployment (aOR = 1.67, 95% CI = 1.03-1.72), number of drug types injected (aOR = 1.33, 95% CI = 1.15-1.53) and injection in a public location (aOR = 2.59, 95% CI = 1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR = 0.57, 95% CI = 0.35-0.92).

CONCLUSION

The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

Correlates of Transactional Sex and Violent Victimization among Men Who Inject Drugs in Los Angeles and San Francisco, California

Men who inject drugs (MWID) and engage in transactional sex (i.e., receive money or drugs in exchange for sex) are vulnerable to HIV and violence. However, MWID who engage in transactional sex have been less studied than women. We examine factors associated with transactional sex among MWID in Los Angeles and San Francisco and whether transactional sex is associated with violent victimization. MWID were recruited using targeted sampling methods in 2011-2013 and completed surveys that covered demographics, drug use, HIV risk, violence, transactional sex, and other items. Multivariable logistic regression was used to (1) determine factors independently associated with transactional sex and (2) determine if transactional sex was independently associated with violence victimization in the last 6 months among MWID. An interaction term between income source and sexual identity was included in the transactional sex model. Of the 572 male PWID in the sample, 47 (8%) reported transactional sex in the past 6 months. Self-reported HIV infection was 7% for MWID who did not report transactional sex, 17% for MWID who reported transactional sex, and 24% for MWID who reported transactional sex and reported gay or bisexual identity. In multivariable analysis, transactional sex was positively associated with gay or bisexual identity (GB without illegal income adjusted odds ratio [AOR] = 5.16; 95% confidence interval [CI] = 1.86-14.27; GB with illegal income AOR = 13.55, CI = 4.57-40.13), coerced sex in the last 12 months (AOR = 11.66, CI = 1.94-70.12), and violent victimization in the last 12 months (AOR = 2.31, CI = 1.13-4.75). Transactional sex was negatively associated with heroin injection (last 30 days) (AOR = 0.37; 95% CI = 0.18-0.78). Transactional sex was independently associated with violent victimization in the last 12 months (AOR = 2.04; 95% CI = 1.00-4.14) while controlling for confounders. MWID who engaged in transactional sex are at elevated risk for HIV and multiple forms of violent victimization. Interventions focused on this at-risk subpopulation are urgently needed and should include access to substance use disorder treatment, victimization services, and harm reduction services across the HIV care continuum.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia

BACKGROUND

Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations.

OBJECTIVES

We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP.

METHODS

PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP.

RESULTS

Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979).

CONCLUSION

PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Sociodemographic Factors Associated With HIV/HCV High-Risk Behaviors Among People Who Use Drugs on Methadone Maintenance Treatment: A 10-Year Observational Study

Background: Sociodemographic factors have an impact worldwide on the behavior of people who use drugs (PWUD). This study attempts to clarify the sociodemographic factors related to HIV/HCV high-risk behaviors (injection drug use, syringe sharing, and multiple sex partners) among PWUD on methadone maintenance treatment (MMT) in the long term. Methods: The 13,300 PWUD recruited into the MMT program were followed during 2006-2015. Generalized estimating equations were used to examine the relationship between sociodemographic characteristics and HIV/HCV high-risk behaviors. Results: We found that male (vs. female), living alone (vs. living with family or relatives), temporary income, financial support from family/friends, and financial support from social welfare (vs. regular salary) were positively associated with injection drug use. Age of initial drug use was negatively associated with injection drug use and syringe sharing. For both genders, being unmarried (vs. married or in cohabitation), living with friends, living alone (vs. living with family or relatives), temporary income, financial supports from family/friends (vs. regular salary), being employed (vs. unemployed/between jobs) was positively associated. In contrast, age at baseline was negatively associated with having multiple sexual partners for both genders. Ethnic of non-Han (vs. Han) was positively associated with having multiple sexual partners simply for males. Being divorced or widowed (vs. married or cohabitated) was positively associated with having multiple sexual partners merely for females. Conclusion: HIV/HCV high-risk behaviors correlated with certain sociodemographic factors of PWUD receiving MMT. There is a need for improving the well-being, employment, and housing status of PWUD on MMT to reduce their HIV/HCV risk behaviors.

Motivations for PrEP-Related Interpersonal Communication Among Women Who Inject Drugs: A Qualitative Egocentric Network Study

A qualitative egocentric social network approach was taken to explore motivations for pre-exposure prophylaxis (PrEP)-related communication between women who inject drugs and network members. Eligible participants were HIV-negative, 18 years or older, and participating in a PrEP demonstration project in Philadelphia, PA, USA. The study employed content analysis of in-depth interviews to identify themes related to contextual and relational factors impacting PrEP communication within networks. Participants (n = 20) named on average three network members, resulting in a total of 57 unique relationships. PrEP conversations occurred within 30 of the 57 relationships, and motivations were to benefit others, to benefit themselves, and due to a sense of obligation. Some conversations also occurred when a peer unexpectedly found their pills. Taking a qualitative approach to network analysis provided a nuanced understanding of how interpersonal characteristics motivated PrEP conversations. Network interventions that facilitate information diffusion and social support may increase PrEP uptake and adherence among women who inject drugs.

HIV Pre-Exposure Prophylaxis Prevention Awareness, Willingness, and Perceived Barriers among People Who Inject Drugs in Los Angeles and San Francisco, CA, 2016-2018

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention is indicated for people who inject drugs (PWID), yet most studies do not focus on PWID. This study examines factors associated with PrEP awareness and willingness, and identifies perceived barriers to PrEP among PWID. Methods: PWID were interviewed in Los Angeles and San Francisco, CA from 2016 to 2018. We analyzed data from self-reported HIV-negative participants who had injected drugs within the past 6 months (n = 469). Questions on PrEP included awareness, willingness, barriers, and uptake. Multiple logistic regression models of factors associated with awareness of, and willingness to, take PrEP were developed. Descriptive statistics on perceived PrEP barriers are reported. Results: Among HIV-negative PWID, 40% were aware of PrEP, 59% reported willingness to take PrEP, and 2% were currently taking PrEP. In multivariable analysis, PrEP awareness was associated with study site and sexual minority status, higher educational attainment, and HIV testing in the last 6 months. Willingness to take PrEP was associated with self-reported risk (paying sex partner in the last 6 months, sharing drug paraphernalia, and being injected by another PWID) and perceived HIV risk. The most common perceived barriers to PrEP were copays, concerns about increased HIV or sexually transmitted risk with PrEP, and concerns about reduction of medication efficacy without daily use. Conclusion: PrEP awareness among PWID remains inadequate. Willingness to take PrEP was moderate and was most desired by PWID who engaged in high-risk behaviors. Interventions to increase PrEP awareness and willingness, and to facilitate PrEP uptake among PWID are needed.

The role of syringe exchange programs and sexual identity in awareness of pre-exposure prophylaxis (PrEP) for male persons who inject drugs

BACKGROUND

Male persons who inject drugs (male PWID) are at heightened risk for HIV, particularly if they also have sex with men. Pre-exposure prophylaxis (PrEP) could aid in HIV prevention for this population, but PrEP awareness within different sexual identities among male PWID is not well-understood. We report factors associated with greater awareness among male PWID to identify efficient means of awareness dissemination.

METHODS

Data from the 2015 National HIV Behavioral Surveillance (NHBS) system cycle on injection drug use collected in New York City (NYC) were used. Bivariable analyses, using chi-squared statistics, were conducted to examine correlates of awareness of PrEP with socio-demographic, behavioral, and health care variables. Log-linked Poisson regression with robust standard errors was used to estimate adjusted prevalence ratios and determine differences in awareness of PrEP.

RESULTS

Among a sample of 332 male PWID (i.e., PWID who identified as male, not transgender) we find awareness of PrEP to be low (23%) among male PWID despite 68% reporting condomless vaginal/anal sex and 32% reporting injection equipment sharing in the last twelve months. Multivariable analysis found greater PrEP awareness associated with gay or bisexual identity (aPR: 2.77, 95% CI: 1.81-4.24) and having a conversation about HIV prevention at a syringe exchange program (SEP) (aPR: 2.71, 95% CI: 1.87-3.94) to be associated with increased PrEP awareness.

CONCLUSION

We found low rates of PrEP awareness among male PWID. However, our findings provide insight into information diffusion that can be utilized to increase PrEP awareness among male PWID and among all PWID. We suggest that gay and bisexual social networks and syringe exchange programs are diffusing PrEP awareness among male PWID and can be harnessed to increase PrEP awareness among male PWID.

PrEP awareness, eligibility, and interest among people who inject drugs in Baltimore, Maryland

BACKGROUND

Limited research has examined pre-exposure prophylaxis (PrEP) interest among people who inject drugs (PWID). To date, few studies have examined the relationship between PrEP eligibility and PrEP interest among PWID.

METHODS

Data were from an anonymous, cross-sectional survey of Baltimore Syringe Services Program (SSP) clients and non-client peers, restricted to HIV-uninfected participants (N = 265). Participants were classified as PrEP eligible/ineligible based on injection related criteria outlined in the CDC's PrEP guidelines. Participants were asked if they were previously aware of PrEP, would be interested in taking PrEP, and the ease of taking PrEP daily. Participants self-reported their sociodemographic characteristics, health diagnoses, and recent drug use, overdose, and drug treatment history. We estimated bivariate and multivariate logistic regression models to test for significant predictors of interest in PrEP.

RESULTS

One-quarter of PWID had previously heard of PrEP and 63% of the sample was interested in taking PrEP. Only two respondents were currently taking PrEP. The majority (89%) thought taking PrEP every day would be easy. In the presence of other variables, PrEP interest was associated with PrEP eligibility (adjusted odds ratio [aOR] = 2.46; 95% Confidence Interval [CI]:1.34,4.50) and the number of medical diagnoses (aOR = 1.16; 95% CI:1.01,1.33) CONCLUSIONS: Most PWID were unaware of PrEP but interested in taking it. PWID who were eligible for PrEP are more likely to be interested in taking it. Having co-morbid conditions was an important correlate of PrEP interest. These results underscore the importance of providers across the healthcare sector engaging PWID in discussions about PrEP.

Exchange Sex Among Persons Who Inject Drugs in the New York Metropolitan Area: The Importance of Local Context, Gender and Sexual Identity

Exchanging sex for money or drugs is known to increase risk for HIV among persons who inject drugs (PWID). To better understand determinants of exchange sex among PWID we examined factors associated with exchange sex in the New York metropolitan area-defined as New York City (NYC), NY; Newark, NJ; and Long Island, NY-using data from the 2012 National HIV Behavioral Surveillance system cycle on injection drug use. Of the 1160 PWID in this analysis, 24% reported exchange sex, with differences in gender and sexual identity by location. In multivariable analysis gay/bisexual men, heterosexual women, and lesbian, gay, or bisexual (LGB) women were more likely to exchange sex compared to heterosexual men. Exchange sex was also associated with race/ethnicity, homelessness, incarceration, location, and non-injection crack and cocaine use. We find that heterosexual women and LGB women who injected drugs residing in Newark were more likely to report exchange sex compared to NYC. This study highlights how local conditions impact exchange sex.

Factors Associated with the Separate and Concurrent Experiences of Food and Housing Insecurity Among Women Living with HIV in Canada

People living with HIV are disproportionately affected by food and housing insecurity. We assessed factors associated with experiencing food and/or housing insecurity among women living with HIV (WLHIV) in Canada. In our sample of WLHIV (N = 1403) 65% reported an income less than $20,000 per year. Most (78.69%) participants reported food and/or housing insecurity: 27.16% reported experiencing food insecurity alone, 14.26% reported housing insecurity alone, and 37.28% reported experiencing food and housing insecurity concurrently. In adjusted multivariable logistic regression analyses, experiencing concurrent food and housing insecurity was associated with: lower income, Black ethnicity versus White, province of residence, current injection drug use, lower resilience, HIV-related stigma, and racial discrimination. Findings underscore the urgent need for health professionals to assess for food and housing insecurity, to address the root causes of poverty, and for federal policy to allocate resources to ameliorate economic insecurity for WLHIV in Canada.

HIV Prevalence, Knowledge, Attitudes, and Practices Among Polydrug Users in Brazil: A Biological Survey Using Respondent Driven Sampling

Brazil has a concentrated HIV epidemic among key populations. In 2009, the Ministry of Health conducted a survey in 10 Brazilian cities aiming to estimate HIV prevalence, knowledge, and associated risk behaviors of polysubstance users (PSU). Using Respondent Driven Sampling (RDS), 3449 PSU were recruited, answered an Audio-Computer Self Assisted Interview (ACASI) and were tested for HIV and syphilis. Analyses were weighted by individual's social network size generated on RDSAT. Pooled HIV prevalence was 5.8% but varied across cities. Most PSU were male, non-white, without income, unemployed, with low levels of education. Overall, 12.0% used injectable drugs, 48.7% had sex with occasional partners and 46.4% engaged in commercial sex. A majority received free condoms (71.4%) but 76.7% exhibited inconsistent condom use. Findings can support policies aiming to improve health care and preventive interventions tailored to this population that remains at high risk of acquiring and transmitting HIV/STI in multiple scenarios.

Syringe Sharing Among a Prospective Cohort of Street-Involved Youth: Implications for Needle Distribution Programs

The sharing of previously used syringes is associated with the transmission of Hepatitis C and HIV. This longitudinal study examines syringe borrowing and syringe lending within a prospective cohort of street-involved youth in Vancouver, Canada. From September 2005 to May 2014, data were collected from the At-Risk Youth Study, a cohort of street-involved youth age 14-26 at enrollment, and analyzed using generalized estimating equations. Among 505 participants, 142 (28.1%) reported syringe borrowing and 132 (26.1%) reported syringe lending during the study period. In separate multivariable analyses, having difficulty finding clean needles and homelessness were significantly associated with syringe borrowing (Adjusted Odds Ratio (AOR) = 2.28, 95% CI 1.66-3.12 and AOR = 1.52, CI 1.05-2.21, respectively) and syringe lending (AOR = 1.89, 95% CI 1.32-2.71 and AOR = 1.65, 95% CI 1.11-2.44, respectively) (all p values < 0.05). Findings highlight gaps in syringe access for vulnerable young injectors and suggest that service delivery for youth may be suboptimal. Further examination of how needle distribution efforts might be improved to better meet the needs of young people is warranted.

Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention

BACKGROUND

Women who inject drugs (WWID) are at heightened risk for HIV due to biological, behavioral, and structural factors. Pre-exposure prophylaxis (PrEP) could aid in HIV prevention for WWID. However, little is known about WWID awareness of PrEP, which is a necessary step that must occur before PrEP uptake. We report factors associated with greater awareness among WWID to identify efficient means of awareness dissemination.

METHODS

Data from the 2015 National HIV Behavioral Surveillance (NHBS) system cycle on injection drug use collected in New York City (NYC) were used. Bivariable analyses, using chi-squared statistics, were conducted to examine correlates of awareness of PrEP with socio-demographic, behavioral, and health care variables. Multivariable logistic regression was used to estimate adjusted associations and determine differences in awareness of PrEP.

RESULTS

The analysis consisted of 118 WWID. Awareness of PrEP was relatively low (31%), and risk factors were high. In the last 12 months, almost two thirds (65%) reported condomless sex, approximately one third (31%) reported transactional sex, and one third (32%) reported sharing injection equipment. In multivariable logistic regression, increased PrEP awareness was associated with reported transactional sex (AOR 3.32, 95% CI 1.22-9.00) and having a conversation about HIV prevention at a syringe exchange program (SEP) (AOR 7.61, 95% CI 2.65-21.84). We did not find race, education, household income, age, binge drinking, or sexual identity to be significantly associated with PrEP awareness.

CONCLUSIONS

Large proportions of WWID were unaware of PrEP. These findings suggest that social networks (specifically sex work and SEP networks) are an efficient means for disseminating messaging about prevention materials such as PrEP. We recommend that SEP access increase, SEP processes be adopted in other health care settings, and WWID networks be utilized to increase PrEP awareness.

Patterns of HIV Risks and Related Factors among People Who Inject Drugs in Kermanshah, Iran: A Latent Class Analysis

The objective of this study was to explore patterns of drug use and sexual risk behaviors among people who inject drugs (PWID) in Iran. We surveyed 500 PWID in Kermanshah concerning demographic characteristics, sexual risk behaviors, and drug-related risk behaviors in the month prior to study. We used latent class analysis (LCA) to establish a baseline model of risk profiles and to identify the optimal number of latent classes, and we used ordinal regression to identify factors associated with class membership. Three classes of multiple HIV risk were identified. The probability of membership in the high-risk class was 0.33, compared to 0.26 and 0.40 for the low- and moderate-risk classes, respectively. Compared to members in the lowest-risk class (reference group), the highest-risk class members had higher odds of being homeless (OR = 4.5, CI: 1.44-8.22; p = 0.001) in the past 12 months. Members of the high-risk class had lower odds of regularly visiting a needle and syringe exchange program as compared to the lowest-risk class members (AOR = 0.42, CI: 0.2-0.81; p = 0.01). Findings show the sexual and drug-related HIV risk clusters among PWID in Iran, and emphasize the importance of developing targeted prevention and harm reduction programs for all domains of risk behaviors, both sexual and drug use related.

A Multilevel Ecological Model of HIV Risk for People Who Are Homeless or Unstably Housed and Who Use Drugs in the Urban United States

Elevated HIV prevalence has been observed among urban U.S. individuals who use drugs and who lack stable housing. This article synthesizes extant research on this population and situates it in a multilevel, ecologically based model of HIV risk. Based on a multidisciplinary review of the literature, the model applies social-ecological theory on human development to identify factors shaping the HIV risk context for individuals who use drugs and who are unstably housed at global, societal, neighborhood, household, and individual levels of influence. At the global level, the model includes neoliberal ideologies contributing to the social inequalities that frame the HIV epidemic. U.S. housing and drug policy, including urban renewal, HOPE VI, and the War on Drugs, is the focus of the societal level. At the neighborhood level, mechanisms of the built environment and psychosocial mechanisms are explored for their salience to HIV risk. Research on the association between housing instability and HIV risk is reviewed at the household level. At the last level, relevant individual differences in biology, psychology, and cognition are discussed. Modeling risk at multiple levels of the environment underscores the need to expand the focus of research, treatment, and prevention interventions for HIV/AIDS and addictions beyond individuals and their risk behaviors to address facets of structural violence and incorporate the broader social, political, and economic contexts of risk and health.

Time Since Migration and HIV Risk Behaviors Among Puerto Ricans Who Inject Drugs in New York City

BACKGROUND

Among people who inject drugs (PWID) in the United States, those who initiated drug injection in Puerto Rico (immigrant Puerto Rican PWID) engage in more injection and sexual risk behaviors, and have higher HIV incidence than non-Hispanic whites.

OBJECTIVE

Understand the persistence of these HIV behaviors.

METHODS

In a cross-sectional study conducted in New York City (NYC) in 2012 (National HIV Behavioral Surveillance), PWID aged ≥18 years were recruited using Respondent-Driven Sampling, interviewed, and tested for HIV. Participants were categorized into 5 different groups: (1) US-born non-Hispanic PWID, (2) US-born Puerto Rican PWID, (3) recent immigrant Puerto Rican PWID (≤3 years in NYC), (4) medium-term immigrant Puerto Rican PWID (>3 and ≤10 years in NYC), and (5) long-term immigrant Puerto Rican PWID (>10 years in NYC). We examined the relationship between time since migrating on sexual and injection risk behaviors among immigrant Puerto Rican PWID, compared with U.S.-born Puerto Rican PWID and US-born non-Hispanic PWID. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated using logistic regression.

RESULTS

A total of 481 PWID were recruited. In adjusted analyses using US-born non-Hispanic PWID as the comparison group, syringe sharing was significantly more likely among medium-term immigrants; and unprotected sex with casual partners was more likely among recent and long-term immigrants.

CONCLUSIONS

The risk-acculturation process for immigrant Puerto Rican PWID may be nonlinear and may not necessarily lead to risk reduction over time. Research is needed to better understand this process.

Bisexual Behavior Among Male Injection Drug Users in New York City

Drug using men who have sex with men and women (MSMW) may be at high risk for HIV infection and transmitting HIV to sex partners. In 2012, injection drug users (IDUs) were sampled in New York City for the National HIV Behavioral Surveillance cross-sectional study using respondent-driven sampling. Logistic regression was used to calculate crude and adjusted odds ratios (aOR) and 95 % confidence intervals (95 %CI) to determine correlates of bisexual behavior in the past 12 months. Of 333 participants, 47(14.1 %) reported MSMW. Variables independently associated (p < 0.05) with MSMW included bisexual sexual identity (vs. "straight") (adjusted odds ratio (aOR) 92.6; 95 % CI 18.9, 454.5), Bronx residence [vs. Manhattan (aOR 8.4; 95 %CI 1.6,43.7)], past 12 month behaviors of having sex with ≥3 sex partners (aOR 18.1; 95 % CI 3.3,98.4), "sold" sex (aOR 8.5; 95 % CI 2.3, 31.5), "bought" sex (aOR 0.2; 95 % CI 0.1, 0.9), and injection methamphetamine use (aOR 20.5; 95 % CI 3.0, 139.7). MSM IDUs are an important subgroup to consider for HIV interventions, as they may not be reached through HIV prevention programming aimed at MSM.

Factors Associated to a Reactive Result of Rapid-HIV Test in Socio-culturally Adapted Services in Primary Care in Spain

The Services of Prevention and Early diagnosis of HIV in Madrid (Spain) are set in selected primary care centers. Cultural mediators targeted to vulnerable groups (economic immigrants, MSM, sex workers…) perform risk assessment and counselling. Between 2010 and 2014 they performed 6 039 rapid-HIV test, 27.8 % in MSM, 41.2 % in men who have sex exclusively with women (MSW) and 31.0 % in women; 35.7 % in immigrants, mainly from Latin America. A reactive result was more common among MSM (6.0 %) compared to women (0.6 %) and MSW (0.5 %). In MSM it was associated to being immigrant and to antecedents of sexually transmitted infections (STI). Among MSW the factors associated to a reactive result were: seropositivity of sexual partner and heroine consumption, and in women: infrequent use of condoms, seropositivity of sexual partner and antecedents of STI. Preventive interventions to reduce risk of HIV transmission and for early detection should be adapted and targeted to high risk population.

An exploratory study of mental health and HIV risk behavior among drug-using rural women in jail

OBJECTIVE

Rural women, particularly those in the criminal justice system, are at risk for HIV related to the increasing prevalence of injection drug use as well as limited services. Research on HIV risk correlates, including drug use and mental health, has primarily focused on urban women incarcerated in prisons. The purpose of this exploratory study is to examine dual HIV risk by 3 different mental health problems (depression, anxiety, and posttraumatic stress disorder [PTSD]) among drug-using women in rural jails.

METHOD

This study involved random selection, screening, and face-to-face interviews with 136 women in 1 Appalachian state. Analyses focused on the relationship between mental health and HIV risk.

RESULTS

Nearly 80% of women self-reported symptoms of depression, and more than 60% endorsed symptoms consistent with anxiety and PTSD symptoms. Mental health significantly correlated with severity of certain types of drug use, as well as risky sexual activity. In addition, for women experiencing anxiety and PTSD, injection drug use moderated the relationship between mental health and risky sexual activity.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Based on these rates of drug use, mental health problems, and the emergence of injection drug use in rural Appalachia, the need to explore the relationships between these issues among vulnerable and understudied populations, such as rural women, is critical. Because of service limitations in rural communities, criminal justice venues such as jails provide opportune settings for screening, assessment, and intervention for drug use, mental health, and HIV education and prevention. (PsycINFO Database Record

Prevalence of HIV and other infections and correlates of needle and syringe sharing among people who inject drugs in Podgorica, Montenegro: a respondent-driven sampling survey

BACKGROUND

People who inject drugs (PWID) have significantly higher rates of blood borne and sexually transmitted infections due to unsafe injecting practices and risky sexual behaviors.

METHODS

We carried out an HIV bio-behavioral survey using respondent-driven sampling (RDS) in people who use drugs (PWID) in Podgorica, Montenegro in 2013 in order to determine the prevalence of HIV, hepatitis C (HCV), hepatitis B surface antigen (HBsAg) and risk behaviors. Data were analyzed using RDS Analyst and SPSS 12.0 to obtain prevalence estimates of key bio-behavioral indicators and assess correlates of needle and syringe sharing using multivariate logistic regression.

RESULTS

A total of 402 PWID were recruited. HIV prevalence was 1.1%, while the prevalence of HCV and HBsAg was 53.0% and 1.4%, respectively. In the multivariate analysis, significant correlates of needle and syringe sharing in the past month were being older than 26 years, female, injecting drugs more than once per day, injecting in parks or on streets, not being able to obtaining free-of-charge sterile needles and syringes and reporting more than four partners in the past 12 months.

CONCLUSIONS

The results indicate that the HIV epidemic in PWID in Montenegro might still be at a low level, though the HCV epidemic is well-established.

Tailored combination prevention packages and PrEP for young key populations

INTRODUCTION

Young key populations, defined in this article as men who have sex with men, transgender persons, people who sell sex and people who inject drugs, are at particularly high risk for HIV. Due to the often marginalized and sometimes criminalized status of young people who identify as members of key populations, there is a need for HIV prevention packages that account for the unique and challenging circumstances they face. Pre-exposure prophylaxis (PrEP) is likely to become an important element of combination prevention for many young key populations.

OBJECTIVE

In this paper, we discuss important challenges to HIV prevention among young key populations, identify key components of a tailored combination prevention package for this population and examine the role of PrEP in these prevention packages.

METHODS

We conducted a comprehensive review of the evidence to date on prevention strategies, challenges to prevention and combination prevention packages for young key populations. We focused specifically on the role of PrEP in these prevention packages and on young people under the age of 24, and 18 in particular.

RESULTS AND DISCUSSION

Combination prevention packages that include effective, acceptable and scalable behavioural, structural and biologic interventions are needed for all key populations to prevent new HIV infections. Interventions in these packages should meaningfully involve beneficiaries in the design and implementation of the intervention, and take into account the context in which the intervention is being delivered to thoughtfully address issues of stigma and discrimination. These interventions will likely be most effective if implemented in conjunction with strategies to facilitate an enabling environment, including increasing access to HIV testing and health services for PrEP and other prevention strategies, decriminalizing key populations' practices, increasing access to prevention and care, reducing stigma and discrimination, and fostering community empowerment. PrEP could offer a highly effective, time-limited primary prevention for young key populations if it is implemented in combination with other programs to increase access to health services and encourage the reliable use of PrEP while at risk of HIV exposure.

CONCLUSIONS

Reductions in HIV incidence will only be achieved through the implementation of combinations of interventions that include biomedical and behavioural interventions, as well as components that address social, economic and other structural factors that influence HIV prevention and transmission.

Correlates of selling sex among male injection drug users in New York City

BACKGROUND

Compared to female IDUs, the correlates of receiving money, drugs, or other things in exchange for sex ("selling sex") among male IDUs are not well understood.

METHODS

In 2012, IDUs were sampled in New York City for the National HIV Behavioral Surveillance cross-sectional study using respondent driven sampling. Analyses were limited to male participants. Logistic regression was used to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) to determine the correlates of selling sex to (1) men and (2) women in the past 12 months.

RESULTS

Of 394 males, 35 (8.9%) sold sex to men and 66 (16.8%) sold sex to women. Correlates of selling sex to men included bisexual/gay identity (aOR: 31.0; 95% CI: 8.1, 119.1), Bronx residence (vs. Manhattan) (aOR: 38.1; 95% CI: 6.2, 235.5), and in the past 12 months, being homeless (aOR: 9.9; 95% CI: 2.0, 49.6), ≥3 sex partners (aOR: 26.2; 95% CI: 4.7, 147.6), non-injection cocaine use (aOR: 5.4; 95% CI: 1.6, 18.2), and injecting methamphetamine (aOR: 36.9; 95% CI: 5.7, 240.0). Correlates of selling sex to women included, in the past 12 months, ≥3 sex partners (aOR: 14.6; 95% CI: 6.6, 31.9), binge drinking at least once a week (aOR: 3.1; 95% CI: 1.6, 6.1), non-injection crack use (aOR: 3.3; 95% CI: 1.6, 6.7), most frequently injected "speedball" (vs. heroin) (aOR: 2.1; 95% CI: 1.1, 4.2), and receptively shared syringes (aOR: 2.4; 95%CI: 1.2, 4.8).

CONCLUSIONS

Among male IDUs, those who sold sex had more sex partners, which may facilitate the sexual spread of HIV among IDUs and to non-IDU male and female sex partners. HIV prevention interventions aimed at male IDUs who sell sex should consider both their sexual and parenteral risks and the greater risk of engaging in exchange sex associated with the use of injection and non-injection stimulant drugs.

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.

Using the National HIV Behavioral Surveillance System to inform HIV prevention efforts in the United States

The National HIV Behavioral Surveillance system (NHBS) was designed to monitor HIV prevalence and risk factors for infection among higher-risk individuals, i.e., sexually active men who have sex with men who attend venues, injection drug users who injected in the past 12 months, and heterosexuals living in low socioeconomic urban areas. These groups were selected as priorities for behavioral surveillance since they represent the major HIV transmission routes and the populations with the highest HIV burden. NHBS contributes to the nation's program of HIV surveillance by being the only multi-site population-based system that provides estimates on key HIV prevention measures among high-risk HIV-negative individuals, HIV-positive individuals unaware of their infection, and HIV-positive individuals aware of their infection who are in and out of care. Accurate and precise data on the behaviors in these populations are critical for tracking the epidemic, planning effective responses, and monitoring and evaluating those responses. Reports in this supplement illustrate the uses of NHBS data at the national and local level and reflect ongoing efforts to improve the system and remains essential for characterizing and monitoring the burden of HIV infection and sexual and behavioral risks.

The potential for bridging: HIV status awareness and risky sexual behaviour of injection drug users who have non-injecting permanent partners in Ukraine

Objective

To quantify potential bridging of HIV transmission between the injection drug using subpopulation to the non-injection drug using population through unprotected heterosexual sex.

Design

Secondary analysis of cross-sectional data.

Methods

A sub-sample of participants who reported having a permanent partner who are not injection drug users and have not injected drugs in the past (N=1379) was selected from a survey implemented in 26 Ukrainian cities in 2011. This study evaluates the association between consistent condom use and awareness of HIV status as measured by rapid testing during the study (known/unknown HIV+, known/unknown HIV− and undetermined) among a sub-sample of male injection drug users (IDUs) who have a non-injecting permanent partner. Poisson regression, with robust variance estimates, was utilized to identify associations while adjusting for other factors.

Results

Reported consistent condom use varied between 15.5% (unknown HIV−) and 37.5% (known HIV+); average use was 19.3%. In multivariate analysis, males who were aware of their HIV+ status were more likely to report recent consistent condom use compared to those who were unaware of their HIV+ status. This association remains after adjustment for age, region, education level, years of injection, alcohol use, self-reported primary drug use and being an NGO client (prevalence ratio=1.65; 95% CI 1.03–2.64). No such association was found for those who were HIV−.

Conclusions

Our results regarding HIV-positive male IDUs reinforce previous findings that HIV testing and counselling may be an effective means of secondary prevention. Further research is needed to understand how to effectively promote safer sex behaviours for IDUs who are currently HIV−.