A longitudinal study of syringe acquisition by Puerto Rican injection drug users in New York and Puerto Rico: implications for syringe exchange and distribution programs

Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico

INTRODUCTION

As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico.

METHODS

The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis.

RESULTS

Of the 150 participants, 89 % were male; 11 % were female; 72 % identified as mixed race; and the median duration of drug injection was 17.8 years. The mean age was 43.1 years, with 64 % of the population being from 23 to 45 years old. Among study participants (n = 150), the prevalence of HCV Ab was 73 %, and HCV RNA was 53 %. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity.

CONCLUSIONS

Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.

Seroprevalence and risk factors associated with hepatitis C: a cross-sectional study of persons who inject drugs in Puerto Rico, 2018

BACKGROUND

People Who Inject Drugs (PWID) are at a higher risk of acquiring bloodborne infections. We aimed to estimate the seroprevalence of the Hepatitis C Virus (HCV) in PWID and identify correlates and risk factors using data from the Puerto Rico National HIV Behavioral Surveillance System, PWID cycle 5, conducted in 2018.

METHODS

A total of 502 San Juan Metropolitan Statistical Area participants were recruited through the Respondent Driven Sampling method. Sociodemographic, health-related, and behavioral characteristics were assessed. Testing for HCV antibodies was completed after the face-to-face survey. Descriptive and logistic regression analyses were performed.

RESULTS

Overall seroprevalence of HCV was 76.5% (95% CI: 70.8-81.4%). A significantly (p < 0.05) higher HCV seroprevalence was observed among PWID with the following characteristics: heterosexuals (78.5%), high school graduates (81.3%), tested for sexually transmitted infections (STI) in the past 12 months (86.1%), frequent speedball injection (79.4%), and knowing the HCV serostatus of the last sharing partner (95.4%). Adjusted logistic regression models showed that having completed high school and reported STI testing in the past 12 months were significantly associated with HCV infection (OR_a = 2.23; 95% CI: 1.06-4.69; OR_a = 2.14; 95% CI: 1.06-4.30, respectively).

CONCLUSIONS

We report a high seroprevalence of HCV infection in PWID. Social health disparities and potential missed opportunities validate the continuing call for local action for public health and prevention strategies.

When "the Cure" Is the Risk: Understanding How Substance Use Affects HIV and HCV in a Layered Risk Environment in San Juan, Puerto Rico

BACKGROUND

Substance use, particularly injection drug use, continues to fuel the HIV/HCV (hepatitis C virus) epidemics in San Juan, Puerto Rico (PR).

AIM

This article examines individual and sociostructural factors that affect HIV/HCV risk among people who use drugs (PWUD) living with or at risk for HIV/HCV in San Juan, PR. Findings were used to inform a community-level intervention to enhance HIV care access and retention for this population.

METHOD

A rapid ethnographic assessment in collaboration with a community-based organization was conducted. Data collection took place between June and December 2013 and included field observations, 49 unstructured interviews with PWUD, and 19 key informant interviews with community stakeholders. Fieldnotes, photographs, and interview transcripts were analyzed for recurrent themes and to address the intervention-planning needs. Study results are presented as fieldnote excerpts, direct quotes from interviews, and photographs.

RESULTS

Findings suggest that PWUD in PR face myriad challenges that affect HIV/HCV risk and hinder linkage to and retention in care. Results describe a layered risk environment where PWUD encounter many barriers to prevention, care, and treatment such as transience, social isolation, stigma, limited housing options, and inadequate medical and substance use disorder treatment services.

DISCUSSION

These observed circumstances provide an empirical basis for the development and evaluation of comprehensive interventions that may serve to reduce barriers to care and link individuals to other supportive services.

CONCLUSION

New approaches and comprehensive interventions are needed to break the structures that perpetuate risk and lack of engagement and retention in HIV care and substance use disorder treatment in San Juan.

Hepatitis-C multimedia prevention program in poor Hispanic HIV-infected injecting drug users: six months after intervention

BACKGROUND

In order to prevent the spread of the hepatitis C virus (HCV) amongst Hispanic injection drug users (IDUs), we developed, validated, and implemented a multimedia educational intervention program.

METHODS

A pre-post intervention study design was used to evaluate long-lasting knowledge and behavior changes in a group of 88 low-income Hispanic HIV-infected IDUs. Pre-intervention data was compared with data measured six months after the intervention.

RESULTS

A significant increase in the awareness regarding HCV clinical manifestations, HCV risky behaviors, HCV prevention practices, and HIV/HCV co-infection synergisms was observed in the group six months post-intervention.

CONCLUSION

Our study confirms the long-lasting benefits of multimedia based intervention programs for disseminating HCV prevention strategies in IDUs. Preventive educational approaches that use images, figures, and animations tools can be recommended to target and tailor interventions for vulnerable populations.

Conducting peer outreach to migrants: outcomes for drug treatment patients

Peer outreach models have been successful in addressing HIV risk behaviors of drug users. Patients in methadone maintenance treatment programs who were migrants from Puerto Rico and/or familiar with drug use there were trained to conduct HIV-related peer outreach. A group randomized design was implemented; patients in the Experimental (E) condition (n = 80) received training and conducted 12 weeks of outreach. Half of the patients completed the training and outreach. At follow-up, patients in the E condition who conducted outreach felt they were more helpful to their community, showed a trend for engaging in more vocational activities, and were more likely to talk with others about HIV, compared to those who did not conduct outreach and those in the Control condition (n = 78). Drug treatment patients who are migrants can be trained as peer outreach workers and short-term benefits were found. Longer term maintenance of benefits should be assessed.

HIV risks and seroprevalence among Mexican American injection drug users in California

Latinos in the United States are an ethnically diverse group disproportionately affected by HIV/AIDS. We describe HIV seroprevalence, HIV risk behaviors and utilization of health services among Mexican American injection drug users (IDUs) in California (n = 286) and compare them to White (n = 830) and African American (n = 314) IDUs. Study participants were recruited from syringe exchange programs (n = 24) in California. HIV seroprevalence among Mexican Americans (0.5%) was dramatically lower than Whites (5%) and African Americans (8%). Mexican Americans reported fewer sex-related risks than Whites and African Americans though injection-related risks remained high. Compared to Whites, Mexican Americans were more likely to participate in drug treatment during a 6 month period (AOR 1.5, 95% CI 1.1, 2.0) but less likely to receive any health care (AOR 0.6, 95% CI 0.5, 0.8). Exploring cultural and structural factors among Mexican American IDUs may offer new insights into how to maintain low rates of HIV seroprevalence and reduce barriers to health care utilization.

Needle sharing among Puerto Rican injection drug users in Puerto Rico and Massachusetts: place of birth and residence matter

This study explored whether place of birth and residence was associated with needle sharing for Puerto Rican injection drug users (IDUs) (N = 348). In-person interviews were conducted in Puerto Rico and Massachusetts during 2005-2007. Multivariate regression analyses revealed IDUs born and living in Puerto Rico were four times more likely to have shared needles compared to those residing in Massachusetts. Respondents residing in Massachusetts were 76% less likely to have ever shared needles with an HIV-positive individual, controlling for covariates. Findings highlight the increased HIV-risk of Puerto Rican IDUs born and residing in Puerto Rico. Prevention and treatment needs are discussed.

Pilot trial of an intervention aimed at modifying drug preparation practices among injection drug users in Puerto Rico

Injection drug users (IDUs) contaminate preparation materials with blood-borne pathogens by using syringes as measuring and dispensing devices. In collaboration with IDUs, we developed a preventive intervention consisting of four new preparation practices aimed at avoiding the use of syringes in the preparation, and reducing the contamination of the materials. This report describes the results of a pilot trial introducing the new practices to ascertain their adoption potential and their potential efficacy in reducing contamination. Participants comprised 37 active IDUs among whom the new practices were promoted during 16 weeks. In addition to self-reported behaviors, the study collected cookers and plastic caps from shooting galleries and tested them for the presence of blood residues. Adoption rates were: (1) cleaning of skin area with hand sanitizer--65.6%; (2) directly pouring water with a dropper into the cooker--56.3%; (3) drawing drug solution with a preparation syringe and syringe filter--34.4%; and, (4) backload rinsing syringes--53.1%. Rates of blood residues detected in cookers and plastic caps were 41.7% prior to the trial, 28.6% at week 8, 24.6% at week 14, and 12.0% at week 18. We believe the results of the pilot trial are compelling and suggest that this intervention merits further formal testing.

Gender comparisons of factors associated with drug treatment utilization among Puerto Rican drug users

OBJECTIVE

This study examined gender-specific effects of social bonds, network characteristics, and other factors on drug treatment enrollment among Puerto Rican drug users.

METHOD

Participants (425 women; 1,374 men) were recruited in New York and Puerto Rico in 1998-2003.

RESULTS

Gender differences were found: education (< high school/GED) and having a sex partner who is an injection drug user (IDU) were significantly related to current enrollment in drug treatment (EDT) for women; for men, having an IDU friend (negatively) had a main effect on EDT, and having an IDU friend also had a significant interaction effect with their own injection drug use on EDT. For both women and men, recruitment site (New York), having health insurance, and prior methadone treatment were significant predictors of EDT.

CONCLUSION

The findings may be useful in developing gender-differentiated drug counseling and treatment efforts that engage women's sex partners and men's friendship networks to build support for drug treatment.

Migrant drug users: predictors of HIV-related sexual and injection risk behaviors

BACKGROUND

Puerto Rican drug users recruited in NY who previously used drugs in Puerto Rico (PR) have been found to have higher HIV injection and sex-related risk behaviors than those who had not used in PR. This study examined predictors of risk among migrant Puerto Rican drug users. (For the purpose of this paper, the term "migrant" was used to designate Puerto Rican drug users who had used drugs in Puerto Rico and were recruited in New York or New Jersey).

METHODS

A total of 290 drug users who had previously used drugs in PR were recruited in NY and New Jersey and interviewed regarding drug use history and HIV risk behaviors.

RESULTS

Participants engaged in high risk behaviors, e.g., 39% shared injection paraphernalia and 62% reported unprotected sex. Multivariate analyses found that predictors of injection-related risk included being born in PR and purchasing drugs jointly with other drug users; predictors of sex-related risk included younger age and homelessness.

DISCUSSION

Addressing risk reduction among those drug users who were born in Puerto Rico and are younger or homeless was indicated, and efforts to reach those at highest risk through NEPs was recommended.

Designing an experimental HIV/HCV intervention to promote the safe re-use of drug preparation materials by injection drug users in Puerto Rico

Injection drug users (IDUs) in San Juan, Puerto Rico are characterized by high rates of daily injecting, injection of shared drugs, re-use of injection syringes, and use of shooting galleries. They lack adequate access to new injection syringes and drug preparation equipment, and experience elevated rates of HIV and HCV infection. Between April and August, 2006, researchers and active IDUs collaborated in the development of an experimental HIV/HCV intervention aimed at identifying drug preparation items and practices that will enable IDUs to make drug solutions without potentially contaminated injection syringes contacting materials used to prepare drugs. The collaboration involved discussing and testing a variety of drug preparation items and practices in office and community settings. The process was repeated until concerns that had been raised were resolved, and a tentative set of intervention items and practices to be evaluated in a community field trial was identified. Throughout, a strong emphasis was placed on the capacity of an item or practice to address common problems confronted by IDUs (blunted needles, clogged syringes, injected particles) in addition to the core aim of reducing contamination of preparation materials by blood in injection syringes. This report describes the final selection of items and practices: 1) A small water bottle that permits IDUs to add approximately .05 cc water drops directly to drug powder in cookers; 2) A preparation syringe (a type of ancillary equipment not used for injecting) that permits IDUs to pull up a measurable amount of water to add to drug powder, an alternative to producing water drops; 3) A filtering device, the Sterifilt filter, attached to a preparation syringe, which eliminates the need for cotton or cigarette filters; 4) Use of a preparation syringe to distribute drug solution by backloading to injection syringe(s); 5) A small water bottle enabling IDUs to clean injection syringes by backload rinsing. The overarching aim of this experimental HIV/HCV intervention was to promote the safe re-use of drug preparation and injection items, and to impact the large number of IDUs in San Juan who maintain personal injection syringes, but currently use communal ancillary equipment in shooting galleries and inject drug solutions prepared with other IDUs' injection syringes.

Elicitation of salient beliefs related to drug preparation practices among injection drug users in Puerto Rico

Even when IDUs use their own syringes, the common use of drug preparation materials can expose them to blood-borne pathogens. Notwithstanding the accumulated evidence about the riskiness of drug preparation practices (DPPs), the factors that lead IDUs to engage in DPPs have remained understudied. We conducted 80 semi-structured interviews to elicit salient beliefs about engaging in low-risk DPPs. Data were content analyzed for consequences, normative influences, and barriers. For the most part respondents described positive consequences of engaging in low-risk DPPs. The majority of respondents mentioned IDU peers as a major source of pressure to engage in high-risk DPPs. Lack of access to clean materials and the need to carry materials on oneself were the most salient barriers elicited. The results suggest that preventive interventions need to address the preference for re-using filters, help develop skills to fend off pressures from peers, and increase the accessibility of materials in ways that do not require IDUs to carry additional items.