Between–City Variation in Frequency of Injection Among Puerto Rican Injection Drug Users: East Harlem, New York, and Bayamon, Puerto Rico:

"It didn't hurt me": patients' and providers' perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico

BACKGROUND

During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl-related overdose deaths and other drug-related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take-home-dose delivery.

METHODS

In-depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days.

RESULTS

Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take-home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes.

CONCLUSION

This study underscores the importance of insider perspectives on harm-reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.

Migration to the US among rural Puerto Ricans who inject drugs: influential factors, sources of support, and challenges for harm reduction interventions

BACKGROUND

While PWID of Puerto Rican origin have been migrating to the US for decades, the range of factors influencing their migration to the US and the resources they draw on to do so are not well understood. This is particularly true for rural Puerto Rican PWID, and the present study is the first empirical research to document migration patterns among this population. The specificities of their migration raise important challenges that need to be documented in order to implement more effective harm reduction policies at home (Puerto Rico) and abroad (US).

METHODS

This paper draws from data obtained employing a modified NHBS survey which was administered to (N =296) PWID in four rural municipalities of Puerto Rico with participants 18 years or older. The primary dependent variables for this paper are the number of times a person has lived in the continental US, and if they are planning on moving to the continental US in the future.

RESULTS

Findings suggest that 65% of the sample reported ever lived in the US and that 49% are planning on moving in the future. The number of times living in the US is associated with higher education and older age, but not with self-reported positive HIV or HCV statuses. Planning to move to the US is associated with knowing PWID who have moved or plan to move, negatively associated with age, and is not associated with HIV or HCV status. Around one third of those that lived in the US reported having some sort of support, with the majority receiving support from family sources. No participant received help to enter HIV/HCV treatment.

CONCLUSIONS

A multi-region approach to prevention is required to make a dent in curbing HIV/HCV transmission in this population. Understanding PWID migration patterns, risk behaviors, and health care needs in the US is now more important than ever as natural disasters prompted by human-made climate change will only increase in the future, raising demands not only for service providers but also harm reduction policies to cope with an increasing influx of "climate refugees" as PWID move across national borders.

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

BACKGROUND

People who inject drugs (PWID) take on significant risks of contracting blood-borne infection, including injecting with a large number of partners and acquiring needles from unsafe sources. When combined, risk of infection can be magnified.

METHODS

Using a sample of PWID in rural Puerto Rico, we model the relationship between a subject's number of injection partners and the likelihood of having used an unsafe source of injection syringes. Data collection with 315 current injectors identified six sources of needles.

RESULTS

Of the six possible sources, only acquisition from a seller (paid or free), or using syringes found on the street, was significantly related to number of partners.

CONCLUSIONS

These results suggest that sources of syringes do serve to multiply risk of infection caused by multi-partner injection concurrency. They also suggest that prior research on distinct forms of social capital among PWID may need to be rethought.

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.

Towards an HIV Role Theory: Drug-related Peer Beliefs and Role Strain Indicators as Predictors of Injection Risk Behaviors among Puerto Rican Injection Drug Users in New York and Puerto Rico

This study assesses whether injection risk behaviors (e.g., syringe sharing and sharing injection paraphernalia) can be understood using a model that highlights drug related peer beliefs and role strain/deprivation. Data were collected on 561 Puerto Rican injection drug users in New York and 313 in Puerto Rico. A drug peer beliefs scale and three indicators of role strain were used with other control variables in a hierarchical multiple logistic regression model. Both aspects of the model were significant predictors of HIV risk behaviors in New York, but only role strain was a significant predictor for injection drug users (IDUs) in Puerto Rico. Individual-based paradigms should incorporate peer beliefs and role strain/deprivation in order to reduce HIV risk behaviors.

Innovative community-based educational face-to-face intervention to reduce HIV, hepatitis C virus and other blood-borne infectious risks in difficult-to-reach people who inject drugs: results from the ANRS-AERLI intervention study

AIMS

To study the effectiveness of an educational intervention on risks associated with drug injection, comparing primary [unsafe HIV-hepatitis C virus (HCV) practices] and secondary (local complications at injecting site) end-points in harm reduction (HR) programmes offering this intervention versus HR programmes not offering it.

DESIGN

This non-random clustered intervention study was conducted in nine intervention groups (programmes offering the intervention) and eight control groups (programmes not offering it). Each participant was followed-up through a telephone interview at enrolment and at 6 and 12 months.

SETTING

The study took place in 17 cities throughout France.

PARTICIPANTS

Of the 271 participants, 144 were enrolled into the intervention group and 127 in the control group. Of the latter, 113 received at least one educational session.

INTERVENTION

A series of participant-centred face-to-face educational sessions. Each session included direct observation by trained non-governmental organization (NGO) staff or volunteers of participants' self-injecting the psychoactive product they used habitually; analysis by the trained NGO staff or volunteers of the participant's injecting practices, identification of injection-related risks and explanation of safer injecting practices; and an educational exchange on the individual participant's injection practices and the questions he or she asked.

MEASUREMENTS

Primary and secondary outcomes were 'at least one unsafe HIV-HCV practice' and at least one injection-related complication (derived from a checklist).

FINDINGS

The proportion of participants with at least one unsafe HIV-HCV practice in the intervention group decreased significantly, from 44% at M0 to 25% at M6, as well as complications at the injection site (from 66 to 39% at M12), while in the control group it remained mainly stable. Multivariate probit analyses showed that the intervention group experienced a significant reduction in unsafe HIV-HCV practices at M6 [coefficient, 95% confidence interval (CI) = -0.73 (-1.47 to 0.01)] and in injection-related complications at M12 [coefficient, 95% CI = -1.01 (-1.77 to -0.24)], compared with the control group.

CONCLUSIONS

An inexpensive and easily implemented educational intervention on risks associated with drug injection reduces significantly unsafe HIV-HCV transmission practices and injection-related complications.

Estimates of the population prevalence of injection drug users among hispanic residents of large US metropolitan areas

Little information exists on the population prevalence or geographic distribution of injection drug users (IDUs) who are Hispanic in the USA. Here, we present yearly estimates of IDU population prevalence among Hispanic residents of the 96 most populated US metropolitan statistical areas (MSAs) for 1992-2002. First, yearly estimates of the proportion of IDUs who were Hispanic in each MSA were created by combining data on (1) IDUs receiving drug treatment services in Substance Abuse and Mental Health Services Administration (SAMHSA)'s Treatment Entry Data System, (2) IDUs being tested in the Centers for Disease Control and Prevention (CDC) HIV-Counseling and Testing System, and (3) incident AIDS diagnoses among IDUs, supplemented by (4) data on IDUs who were living with AIDS. Then, the resulting proportions were multiplied by published yearly estimates of the number of IDUs of all racial/ethnic groups in each MSA to produce Hispanic IDU population estimates. These were divided by Hispanic population data to produce population prevalence rates. Time trends were tested using mixed-effects regression models. Hispanic IDU prevalence declined significantly on average (1992 mean = 192, median = 133; 2002 mean = 144, median = 93; units are per 10,000 Hispanics aged 15-64). The highest prevalence rates across time tended to be in smaller northeastern MSAs. Comparing the last three study years to the first three, prevalence decreased in 82% of MSAs and increased in 18%. Comparisons with data on drug-related mortality and hepatitis C mortality supported the validity of the estimates. Generally, estimates of Hispanic IDU population prevalence were higher than published estimates for non-Hispanic White residents and lower than published estimates for non-Hispanic Black residents. Further analysis indicated that the proportion of IDUs that was Hispanic decreased in 52% and increased in 48% of MSAs between 2002 and 2007. The estimates resulting from this study can be used to investigate MSA-level social and economic factors that may have contributed to variations across MSAs and to help guide prevention program planning for Hispanic IDUs within MSAs. Future research should attempt to determine to what extent these trends are applicable to Hispanic national origin subgroups.

Neighborhood disorganization, substance use, and violence among adolescents in Puerto Rico

This study investigates the role of neighborhoods in adolescent violence in poor neighborhoods in San Juan, Puerto Rico. The study is part of a larger longitudinal project examining risk and resilience in adolescents' ages 12 to 15 years old and their caregivers. Using a cross-sectional design, a self-completion questionnaire, and an interviewer questionnaire, the authors assessed violent behaviors among participants across demographics, characteristics, and neighborhood social disorganization using the concepts of physical disorders and social disorder. Adolescent violence was positively associated with social disorder. The finding that adults in these neighborhoods walk around with visible firearms and engage in fighting, may have led adolescents to perceive that violence is an accepted behavior. Furthermore, socially disorganized neighborhoods might be less likely to organize on their own behalf because the occurrence of negative experience limits the amount of social support and resources that are available in the neighborhood.

Sex risk behaviors of drug users: a dual site study of predictors over time

Reducing sex risk behaviors among high-risk injection drug users (IDUs) and crack smokers is a continuing challenge for HIV prevention. Based on a longitudinal study of sexually active Puerto Rican IDUs and crack smokers in New York (n = 573) and Puerto Rico (n = 264), baseline predictors of changes in sex risk (number of unprotected sex acts) at 6- and 36-month follow-up interviews were examined. In New York, predictors of higher sex risk were being younger, having primary partners, having more other sex partners, never exchanging sex, having lower self-efficacy for reducing sex risk behaviors and being HIV-negative, and these predictors were significant at both postbaseline periods. In Puerto Rico, short-term predictors included being male, having primary partners, never exchanging sex, lower sex risk norms and lower self-efficacy. However, only having primary partners was significant in longer-term behaviors. Results indicated the need for enhancing self-efficacy and for developing risk reduction strategies related to community differences.

GC-MS confirmation of xylazine (Rompun), a veterinary sedative, in exchanged needles

In order to assess the extent of xylazine (Xyz) injection in Puerto Rico, two waves of used-syringe collections were performed. In the first, syringes were gathered, anonymously and without additional information; in the second, a short interview, also anonymous, was administered. We found Xyz in 37.6% of the collected syringes; the majority of the Xyz-containing syringes came from ranching communities. Syringes containing Xyz more frequently also contained "speedball" than those without (90.6% and 66.7%, respectively). Self-reports of Xyz injection deviated markedly from actual detection: only 50% (self-described users) and 22% (self-described non-users) of the collected syringes contained the drug. With a high prevalence of skin ulcers (38.5% vs. 6.8%; p<0.001), Xyz users were more likely to be in poor health compared to non-users. Surprisingly, though a higher percentage of Xyz users than non-users had college-level educations (23.1% vs. 5.5%), they were more likely to be homeless (64.1% vs. 37%).

Puerto Rican injection drug users: Prevention implications in Massachusetts and Puerto Rico

This study examines whether place of residence is a factor associated with reporting a positive HIV/AIDS, Hepatitis C (HCV), or Sexually Transmitted Disease (STD) status in a sample of 400 injection drug users (IDUs) residing on the Island of Puerto Rico (N=139) and in western Massachusetts (N=261). Logistic regression models revealed that IDUs residing in western Massachusetts were 66% less likely to be HIV positive compared to IDUs residing in Puerto Rico (p<.000) while IDUs residing in western Massachusetts were about 67% less likely to have a positive STD status than those residing in Puerto Rico (p<.000). Place of residence was not significantly associated with HCV status. Results indicate the need to develop prevention programs tailored to the unique socio-cultural context of Puerto Rican IDUs residing on the Island of Puerto Rico whose circumstances differ from those in the mainland US. To reduce drug use, HIV/AIDS, HCV, and STDs among Puerto Ricans in both locales, the Capacity Enhancement Model is proposed in order to develop more effective prevention programs.

Seroprevalence of hepatitis C virus and associated risk behaviours: a population-based study in San Juan, Puerto Rico

BACKGROUND

Limited information about the epidemiology of hepatitis C virus (HCV) infection is available in Puerto Rico, one of the areas hardest hit by the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) epidemic. We estimated the prevalence of HCV infection and identified correlates of seropositivity in the municipality of San Juan, Puerto Rico.

METHODS

A probability cluster design was employed to select a sample of households representative of the population aged 21-64 years in San Juan during 2001-2002. All 964 subjects completed a face-to-face interview to gather data on demographics and self-reported risk behaviours followed by venipuncture for HCV antibody testing. Variables that were at least marginally associated with HCV seroprevalence (P < 0.10) in the bivariate analyses were considered for inclusion into the multiple logistic regression model to estimate the adjusted prevalence odds ratio (POR).

RESULTS

Overall weighted prevalence of HCV infection was 6.3% (95% CI 3.6-10.9%). A significant (P < 0.05) higher prevalence was observed among subjects with the following characteristics: age 30-49 (9.5%), male sex (10.6%), < or =12 years of education (9.6%), no health coverage (12.6%), lifetime heroin use (39.2%), lifetime cocaine use (39.6%), tattooing practices (34.2%), history of imprisonment (32.8%), and self-reported histories of hepatitis B virus infection (30.4%) and HIV/AIDS (92.1%). Multivariate logistic regression revealed that tattooing practices (POR = 8.9; 95% CI 1.7-44.7), lifetime cocaine use (POR = 5.5; 95% CI 2.2-13.5), blood transfusions prior to 1992 (POR = 4.0; 95% CI 1.6-10.1), lifetime heroin use (POR = 3.3; 95% CI 1.4-7.8), and history of imprisonment (POR = 2.3; 95% CI 1.1-4.9) remained significantly associated with HCV seropositivity.

CONCLUSIONS

The large prevalence of HCV infection observed in Puerto Rican adults residing in San Juan suggest that HCV infection is an emerging public health concern and merits further investigation.

Egocentric HIV risk networks among Puerto Rican crack users in New York and in Puerto Rico: impact on sex risk behaviors over time

This study examined risk network characteristics of Puerto Rican crack users and the relationship between the network and HIV-related sex risk behavior over time. The participants (N = 383 in New York; N = 165 in Puerto Rico), recruited through street outreach, were interviewed at both baseline and 6-month follow-up. The majority of crack users (88%, New York; 92%, Puerto Rico) in the sample named one or more personal risk network members. As compared with New York participants, crack users in Puerto Rico reported larger risk networks and were more likely to engage in sex risk behaviors with strangers or acquaintances. In multivariate analyses, a significant variable in predicting sex risk behaviors at follow-up in both sites was the baseline measure of the dependent variable. Significant network variables were: having any known crack use member less than 6 months and having acquaintance/stranger in network in New York; communicating with network members about using condoms in Puerto Rico. More attention to sex risk behaviors are needed in HIV/AIDS prevention and education programs.