Homelessness and HIV risk behaviors among drug injectors in Puerto Rico

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.

High prevalence of hepatitis C virus infection and low level of awareness among people who recently started injecting drugs in a cross-sectional study in Germany, 2011-2014: missed opportunities for hepatitis C testing

Background

In Germany, risk of hepatitis C virus (HCV) infection is highest among people who inject drugs (PWID). New injectors (NI) are particularly vulnerable for HCV-acquisition, but little is known about health seeking behaviour and opportunities for intervention in this group. We describe characteristics, HCV prevalence, estimated HCV incidence and awareness of HCV-status among NIs and missed opportunities for hepatitis C testing.

Methods

People who had injected drugs in the last 12 months were recruited into a cross-sectional serobehavioural study using respondent-driven sampling in 8 German cities, 2011–2014. Data on sociodemographic characteristics, previous HCV testing and access to care were collected through questionnaire-based interviews. Capillary blood was tested for HCV. People injecting drugs < 5 years were considered NI.

Results

Of 2059 participants with available information on duration of injection drug use, 232 (11% were NI. Estimated HCV incidence among NI was 19.6 infections/100 person years at risk (95% CI 16–24). Thirty-six percent of NI were HCV-positive (thereof 76% with detectable RNA) and 41% of those HCV-positive were unaware of their HCV-status. Overall, 27% of NI reported never having been HCV-tested. Of NI with available information, more than 80% had attended low-threshold drug services in the last 30 days, 24% were released from prison in the last 12 months and medical care was most commonly accessed in hospitals, opioid substitution therapy (OST)-practices, practices without OST and prison hospitals.

Conclusion

We found high HCV-positivity and low HCV-status awareness among NI, often with missed opportunities for HCV-testing. To increase early diagnosis and facilitate treatment, HCV-testing should be offered in all facilities, where NI can be reached, especially low-threshold drug services and addiction therapy, but also prisons, hospitals and practices without OST.

Latent Risk Subtypes Based on Injection and Sexual Behavior Among People Who Inject Drugs in Rural Puerto Rico

BACKGROUND

People who inject drugs (PWID) in Puerto Rico engage in high levels of injection and sexual risk behavior, and they are at high risk for HIV and hepatitis C (HCV) infection, relative to their US counterparts. Less is known, however, about the clustering of risk behavior conducive to HIV and HCV infection among rural Puerto Rican communities.

OBJECTIVES

The purpose of this study was to examine concurrent injection and sexual risk subtypes among a rural sample of PWID in Puerto Rico.

METHODS

Data were drawn from a respondent-driven sample collected in 2015 of 315 PWID in 4 rural communities approximately 30-40 miles from San Juan. Latent class analysis (LCA) was used to examine risk subtypes using 3 injection and 3 sexual risk indicators. In addition, demographic and other PWID characteristics were examined as possible predictors of latent class membership.

RESULTS

Four LCA subtypes were identified: low risk (36%), high injection/low sexual risk (22%), low injection/high sexual risk (20%), and high risk (22%). Younger age and past year homelessness predicted high risk latent class membership, relative to the other classes. In addition, daily speedball use predicted membership in the high injection/low sexual risk class, relative to the low risk and low injection/high sexual risk classes.

CONCLUSION/IMPORTANCE

The findings suggest ways in which PWID risk clusters can be identified for targeted interventions.

High Prevalence and Incidence of HIV and HCV Among New Injecting Drug Users With a Large Proportion of Migrants--Is Prevention Failing?

OBJECTIVES

The aim of this study was to assess differences in the prevalence of HIV and HCV infection and associated risk factors between new (injecting for ≤5 years) and long-term injectors and to estimate HIV/HCV incidence among new injectors.

METHODS

Cross-sectional study among people who inject drugs (PWID) who attended harm reduction centers in Catalonia in 2010-11. Anonymous questionnaires and oral fluid samples were collected. Poisson regression models were applied to determine the association between HIV/HCV infection and risk factors.

RESULTS

Of the 761 participants, 21.4% were new injectors. New injectors were younger than long-term injectors (mean age = 31.6 vs. 37.8) and were more likely to be immigrants (59.0% vs. 33.4%). HIV and HCV prevalence was 20.6% and 59.4% among new injectors, and estimated HIV and HCV incidence 8.7 and 25.1 /100 person-years, respectively. Among new injectors, HIV infection was associated with homelessness (PR = 3.10) and reporting a previous sexually transmitted infection (PR = 1.79). Reporting front/backloading (PR = 1.33) and daily injection (PR = 1.35) were risk-factors for HCV infection. For long-term injectors, HIV risk factors were: having shared syringes (PR = 1.85), having injected cocaine (PR = 1.38), reporting front/backloading (PR = 1.30) and ever having been in prison (PR = 2.03).

CONCLUSION

A large proportion of PWID in Catalonia are new injectors, a subgroup with a high level of both sexual and parenteral exposure and a high incidence rate of HIV/ HCV infections. It is important to improve early diagnosis of these infections among this group, in particular among migrants. To identify and address risk factors for homelessness PWID should be a priority.

Big Events in Greece and HIV Infection Among People Who Inject Drugs

Big Events are processes like macroeconomic transitions that have lowered social well-being in various settings in the past. Greece has been hit by the global crisis and experienced an HIV outbreak among people who inject drugs. Since the crisis began (2008), Greece has seen population displacement, inter-communal violence, cuts in governmental expenditures, and social movements. These may have affected normative regulation, networks, and behaviors. However, most pathways to risk remain unknown or unmeasured. We use what is known and unknown about the Greek HIV outbreak to suggest modifications in Big Events models and the need for additional research.

Homelessness and Other Risk Factors for HIV Infection in the Current Outbreak Among Injection Drug Users in Athens, Greece

Objectives. We examined HIV prevalence and risk factors among injection drug users (IDUs) in Athens, Greece, during an HIV outbreak. Methods. We used respondent-driven sampling (RDS) to recruit 1404 IDUs to the Aristotle intervention in August to October 2012. We interviewed participants and tested for HIV. We performed bivariate and multivariate analyses. Results. Estimated HIV prevalence was 19.8% (RDS-weighted prevalence = 14.8%). Odds of infection were 2.3 times as high in homeless as in housed IDUs and 2.1 times as high among IDUs who injected at least once per day as among less frequent injectors (both, P < .001). Six percent of men and 23.5% of women reported transactional sex in the past 12 months, and condom use was low. Intercourse with non-IDUs was common (53.2% of men, 25.6% of women). Among IDUs who had been injecting for 2 years or less the estimated incidence rate was 23.4 new HIV cases per 100 person-years at risk. Conclusions. Efforts to reduce HIV transmission should address homelessness as well as scaling up prevention services, such as needle and syringe distribution and other risk reduction interventions.

Housing instability among people who inject drugs: results from the Australian needle and syringe program survey

High rates of substance dependence are consistently documented among homeless people, and are associated with a broad range of negative outcomes among this population. Investigations of homelessness among drug users are less readily available. This study examined the prevalence and correlates of housing instability among clients of needle syringe programs (NSPs) via the Australian NSP Survey, annual cross-sectional seroprevalence studies among NSP attendees. Following self-completion of a brief, anonymous survey and provision of a capillary blood sample by 2,396 NSP clients, multivariate logistic regressions identified the variables independently associated with housing instability. Nineteen percent of ANSPS participants reported current unstable housing, with primary ('sleeping rough'; 5 %), secondary (staying with friends/relatives or in specialist homelessness services; 8 %), and tertiary (residential arrangements involving neither secure lease nor private facilities; 6 %) homelessness all evident. Extensive histories of housing instability were apparent among the sample: 66 % reported at least one period of sleeping rough, while 77 % had shifted between friends/relatives (73 %) and/or resided in crisis accommodation (52 %). Participants with a history of homelessness had cycled in and out of homelessness over an average of 10 years; and one third reported first being homeless before age 15. Compared to their stably housed counterparts, unstably housed participants were younger, more likely to be male, of Indigenous Australian descent, and to report previous incarceration; they also reported higher rates of key risk behaviors including public injecting and receptive sharing of injecting equipment. The high prevalence of both historical and current housing instability among this group, particularly when considered in the light of other research documenting the many adverse outcomes associated with this particular form of disadvantage, highlights the need for increased supply of secure, affordable public housing in locations removed from established drug markets and serviced by health, social, and welfare support agencies.

HIV and syphilis infection among men attending a [corrected] sexually transmitted infection clinic in Puerto Rico

OBJECTIVE

This study aimed to assess the demographic, behavioral, and clinical factors associated with HIV and syphilis infection among a sample of men attending a sexually transmitted infection clinic during 2009 to 2010 in San Juan, Puerto Rico (PR).

METHODS

A sample of 350 clinical records from men visiting the clinic for the first time during 2009 to 2010 was reviewed. Descriptive statistics were used to describe the study sample, and bivariate analyses were performed separately for HIV and syphilis to identify factors associated with these infectious diseases. Variables that were significantly associated (p < 0.05) with HIV and syphilis in the bivariate analysis were considered for inclusion in the logistic regression models.

RESULTS

Overall, 11.2% and 14.1% of the men were infected with HIV and syphilis, respectively, and 5.1% were coinfected with HIV and syphilis. In multivariate logistic regression models, ever injecting drugs (POR = 8.1; 95% CI 3.0, 21.8) and being a man who has sex with men (MSM) (POR = 5.3; 95% CI 2.3, 11.9) were positively associated with HIV infection. Being a man older than 45 years (POR = 4.0; 95% CI: 1.9, 8.9) and being an MSM (POR = 2.5; 95% CI: 1.3, 4.9) were both significantly associated with syphilis infection.

CONCLUSION

These findings reinforce the need for greater education and prevention efforts for HIV and other STIs among men in PR, particularly those who are MSM. However, there is a need to make an a priori assessment of the level of health literacy in the members of this group so that a culturally sensitive intervention can be provided to the men who attend this STI clinic.

Prevalence of Drug Resistance and Associated Mutations in a Population of HIV-1(+) Puerto Ricans: 2006-2010

This is a continuation of our efforts to maintain a record of the evolution of HIV-1 infection in Puerto Rico by monitoring the expression levels of antiretroviral drug-resistance-associated mutations. Samples from 2,500 patients from 2006–2010 were analyzed using the TruGene HIV-1 genotyping kit and the OpenGene DNA sequencing system. Results show that 58.8% of males and 65.3% of females had HIV-1 with resistance to at least one medication. The average number of HIV mutations was 6.0 in males and 6.1 in females. Statistically significant differences between men and women were recorded in the levels of HIV-1 expressed mutations and antiretroviral drug resistance. The most prevalent antiretroviral medication resistance shifted from zalcitabine to nevirapine and efavirenz in the five-year period. M184V and L63P were the dominant mutations for the reverse transcriptase and the protease genes, respectively, but an increase in the incidence of minority mutations was observed.

HIV and risk environment for injecting drug users: the past, present, and future

We systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. We then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. We estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting IDUs' access to HIV prevention and treatment could substantially curtail HIV epidemics.

Comportamentos de risco ao HIV em utilizadores de heroína em um distrito português: estudo qualitativo

OBJETIVO: Explorar relatos de utilizadores de heroína sobre seus comportamentos de risco para transmissão do vírus da imunodeficiência humana (HIV) no distrito de Vila Real, Portugal, já que a heroína é a droga predominante no que se refere ao uso problemático de drogas em Portugal, e 48% de todas as notificações de infecção por HIV no país são associadas à dependência de drogas. MÉTODO: Utilizadores de heroína recebendo tratamento ambulatorial para dependência em clínica pública foram selecionados aleatoriamente e convidados a participar do estudo. A coleta de dados foi realizada através de entrevista qualitativa semiestruturada, desenvolvida para explorar os relatos dos participantes sobre seu comportamento de risco associado ao uso de heroína. RESULTADOS: Vinte e cinco entrevistas foram realizadas. A idade média foi de 32 anos, e 92% eram homens. Os participantes relataram um tempo médio de uso de heroína de 14,7 anos, e 64% deles mencionaram uso diário da droga. Dois terços relataram uso de heroína e 16% referiram uso intravenoso da droga nos 30 dias anteriores à entrevista. 75% referiram compartilhamento de seringas ou parafernália de injeção. Front-loading ou back-loading foram técnicas comuns e não reconhecidas como comportamento de risco. 84% referiram ter sido testados anteriormente para o HIV. CONCLUSÕES: O desenvolvimento de melhores programas de prevenção ao HIV para este grupo de risco é essencial através do uso de informações sobre movimentos demográficos e padrões de comportamento de utilizadores de heroína, abordando seus comportamentos de risco nas práticas sexuais e no compartilhamento de parafernália de injeção.

Prevalence of infections, HIV risk behaviors and factors associated with HIV infection among male injecting drug users attending a needle/syringe exchange program in Dhaka, Bangladesh

Injecting drug users (IDU) in Bangladesh are at the early stages of an HIV epidemic. To understand the dynamics of the HIV epidemic, male IDU (n = 561) were recruited from the needle/syringe exchange program in Dhaka in 2002, who underwent a risk-behavior survey and were tested for HIV, syphilis, hepatitis C, and hepatitis B. Correlates of HIV infection were determined by conducting bivariate and multiple regression analyses. The median age of the IDU was 35 years, 39.6% had no formal education, approximately half were married and/or living with their regular sex partner and 26% were currently homeless. The median age at first injection was 29 years. HIV was detected in 5.9% of the IDU and homelessness was the only factor independently associated with HIV (OR = 5.5). Urgent measures must be undertaken to prevent escalation of the HIV epidemic. The study's limitations are noted.

Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV

OBJECTIVES

We examined the efficacy of the Healthy Living Program in reducing risky sexual behavior and substance use among adults with HIV infection who were marginally housed (i.e., homeless at some point over a 37-month period).

METHODS

We had previously conducted a randomized controlled trial with 936 adults living with HIV infection. In that study, 3 intervention modules of 5 sessions each addressed different goals: reducing risky sexual acts and drug use, improving the quality of life, and adhering to healthful behaviors. Participants were interviewed at baseline and at 5, 10, 15, 20, and 25 months; 746 completed 4 or more assessments. In this study, we analyzed sexual behavior and drug use outcomes for the 35% (n = 270 of 767) of participants who were considered marginally housed.

RESULTS

Among the marginally housed participants, there were significantly greater reductions in unprotected risky sexual acts, the number of sexual partners of HIV negative or unknown serostatus, alcohol or marijuana use, and hard drug use among the intervention group than among the control group.

CONCLUSIONS

Intensive, skill-focused intervention programs may improve the lives of marginally housed adults living with HIV infection.

Individual, social, and environmental influences associated with HIV infection among injection drug users in Tijuana, Mexico

OBJECTIVE

We examined correlates of HIV infection among injection drug users (IDUs) in Tijuana, Mexico, a city bordering the United States, which is situated on major migration and drug trafficking routes.

METHODS

IDUs aged > or =18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and structured interviews. Weighted logistic regression identified correlates of HIV infection.

RESULTS

Of 1056 IDUs, the median age was 37 years, 86% were male, and 76% were migrants. HIV prevalence was higher in female participants than in male participants (8% vs. 3%; P = 0.01). Most IDUs testing HIV-positive were previously unaware of their serostatus (93%). IDUs reported injecting with a median of 2 people in the prior 6 months and had been arrested for having injection stigmata (ie, "track-marks") a median of 3 times. Factors independently associated with HIV infection were being female, syphilis titers consistent with active infection, larger numbers of recent injection partners, living in Tijuana for a shorter duration, and being arrested for having track-marks.

CONCLUSIONS

Individual, social, and environmental factors were independently associated with HIV infection among IDUs in Tijuana. These findings suggest the need to intervene not solely on individual risk behaviors but on social processes that drive these behaviors, including problematic policing practices.

Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities

AIMS

To identify factors associated with receptive syringe sharing among injection drug users (IDUs) and elucidate the association between syringe possession arrests and syringe sharing.

DESIGN

Cross-sectional study.

SETTING

Mexican border cities of Tijuana, Baja California and Ciudad Juarez, Chihuahua.

PARTICIPANTS

IDUs in Tijuana (n = 222) and Ciudad Juarez (n = 206) were recruited using respondent-driven sampling (RDS). IDUs were > or = 18 years and had injected illicit drugs in the past month.

MEASUREMENTS

An interviewer-administered survey was used to collect quantitative data on socio-demographic, behavioral and contextual characteristics, including self-reported syringe sharing and arrests for syringe possession. Associations with receptive syringe sharing were investigated using logistic regression with RDS adjustment.

FINDINGS

Overall, 48% of participants reported ever being arrested for carrying an unused/sterile syringe, even though syringe purchase and possession is legal in Mexico. Arrest for possessing unused/sterile syringes was associated independently with receptive syringe sharing [adjusted odds ratio (AOR) = 2.05; 95% confidence interval (CI): 1.26, 3.35], as was injecting in a shooting gallery (AOR = 3.60; 95% CI: 2.21, 5.87), injecting in the street (AOR = 2.05; 95% CI: 1.18, 3.54) and injecting methamphetamine (AOR = 2.77; 95% CI: 1.41, 5.47) or cocaine (AOR = 1.96; 95% CI: 1.15, 3.36). More than half of participants (57%) had been arrested for possessing a used syringe; in a second model, arrest for used syringe possession was also associated independently with receptive sharing (AOR = 2.87; 95% CI: 1.76, 4.69).

CONCLUSIONS

We documented high levels of syringe-related arrests in two Mexican-US border cities and an independent association between these arrests and risky injection practices. Public health collaborations with law enforcement to modify the risk environment in which drug use occurs are essential to facilitate safer injection practices.

Housing status and associated differences in HIV risk behaviors among young injection drug users (IDUs)

Using cross-sectional analysis we examined residential status and associated differences in HIV risk behaviors among 3266 young IDUs enrolled in an HIV prevention trial. A three-level outcome (homeless (37%), equivocally housed (17%), housed (46%)) was defined based on responses to two questions assessing subjective and objective criteria for homelessness: "equivocally housed" participants were discordant on these measures. In multivariate analysis, antecedents of homelessness were having lived in an out-of-home placement, been thrown out of the home or in juvenile detention, and experienced childhood abuse; while correlates included receiving income from other and illegal sources, drinking alcohol or using methamphetamine at least daily, using shooting galleries, backloading, and sex work. A subset of these variables was associated with being equivocally housed. HIV risk varies by housing status, with homeless IDUs at highest risk. Programs for IDUs should utilize a more specific definition of residential status to target IDUs needing intervention.

Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients

OBJECTIVE

To determine if adequate syringe coverage --"one shot for one syringe"--among syringe exchange program (SEP) clients is associated with injection-related HIV risk behaviors and syringe disposal.

DESIGN

HIV risk assessments with 1577 injection drug users (IDUs) recruited from 24 SEPs in California between 2001 and 2003. Individual syringe coverage was calculated as a proportion of syringes retained from SEP visits to total number of injections in the last 30 days.

RESULTS

Participants were divided into four groups based on syringe coverage: <50%, 50-99%, 100-149%, and 150% or more. In multivariate logistic regression, SEP clients with less than 50% syringe coverage had significantly higher odds of reporting receptive syringe sharing in the last 30 days (adjusted odds ratio [AOR]=2.3; 95% confidence interval [CI]=1.4, 3.6) and those with 150% or more coverage had lower odds of reporting receptive syringe sharing (AOR=0.5; 95%CI=0.3, 0.8) as compared to SEP clients with adequate syringe coverage of 100-149%. Similar associations were observed for other main outcomes of distributive syringe sharing and syringe re-use. No differences in safe syringe disposal were observed by syringe coverage.

CONCLUSIONS

Individual syringe coverage is strongly associated with safer injection behaviors without impacting syringe disposal among SEP clients. Syringe coverage is a useful measure for determining if IDUs are obtaining sufficient syringes to lower HIV risk.

A systematic review and meta-analysis of behavioral interventions to reduce HIV risk behaviors of Hispanics in the United States and Puerto Rico

This systematic review examines the overall efficacy of HIV behavioral interventions designed to reduce HIV risk behaviors or incident sexually transmitted diseases (STDs) among Hispanics residing in the United States or Puerto Rico. Data from 20 randomized and nonrandomized trials (N = 6,173 participants) available through January 2006 were included in this review. Interventions successfully reduced the odds of unprotected sex and number of sex partners, increased the odds of condom use, and decreased the odds of acquiring new STD infections. Interventions successful in reducing the odds of any sex risk behavior used non-peer deliverers; included >or=4 intervention sessions; taught condom use or problem solving skills; or addressed barriers to condom use, sexual abstinence, or peer norms. Interventions that included the Hispanic cultural belief of machismo or those developed based on ethnographic interviews were successful in reducing the odds of sex risk behaviors among non-drug users. Interventions targeting injection drug users (IDUs; N = 3,569) significantly reduced the odds of injection drug use and the odds of sharing cotton or cookers, but did not significantly reduce the odds of engaging in risky sex behavior or needle sharing. Further development of culturally appropriate HIV prevention interventions for Hispanic populations, particularly men and persons living with HIV, are warranted.