Exchange Sex and HIV Infection Among Women Who Inject Drugs-20 US Cities, 2009

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Factors Associated with Exchange Sex Among Cisgender Persons Who Inject Drugs: Women and MSM-23 U.S. Cities, 2018

Persons who inject drugs (PWID) and exchange sex face disproportionate HIV rates. We assessed prevalence of exchange sex (receiving money/drugs for sex from ≥ 1 male partner(s) during the past year) among cisgender PWID, separately for women and men with a history of sex with men (MSM). We examined factors associated with exchange sex, including sociodemographic characteristics, sexual and drug use behaviors, and healthcare access/utilization. Over one-third of the 4657 participants reported exchange sex (women: 36.2%; MSM: 34.8%). Women who exchanged sex (WES) were significantly more likely to test HIV-positive than other women. Men who exchanged sex with men (MESM) showed a similar trend. WES and MESM shared many characteristics, including being uninsured, experiencing recent homelessness, condomless sex, polydrug use, and receptive/distributive needle sharing. These findings highlight a need to strengthen prevention interventions and address structural determinants of HIV for WES and MESM, particularly PWID who exchange sex.

NEXT: description, rationale, and evaluation of a novel internet-based mail-delivered syringe service program

Background

Despite proven health benefits, harm reduction services provided through in-person syringe services programs (SSPs) and pharmacies are largely unavailable to most people who inject drugs (PWID). Internet-based mail-delivered harm reduction services could overcome barriers to in-person SSPs. This manuscript describes Needle Exchange Technology (NEXT) Harm Reduction, the first formal internet-based mail delivery SSP in the US.

Methods

We examined the trajectory of NEXT's growth between February 2018 and August 2021. Descriptive statistics were used to characterize program participants. All analysis were run using STATA statistical software.

Results

Over the course of 42 months, 1,669 unique participants enrolled in NEXT. The program distributed 1,648,162 total syringes with a median of 79,449 syringes per month. Most participants ordered multiple times (61%); 31% had more 5 or more orders (upper range = 48 orders). The total number of syringes per month and total number of first-time syringe orders per month increased steadily over time, particularly after the onset of the COVID-19 pandemic.

Conclusions

The online platform and mail-delivery model appears successful in reaching PWID at high risk for harms from IDU. Changes to state laws and additional funding support are needed to make mail-delivery harm reduction more widely available throughout the US.

Mapping Interests in Event-Driven and Long-Acting Pre-exposure Prophylaxis Formulations onto the HIV Risk Environment of Street-Based Female Sex Workers: A Latent Class Analysis

Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model: Injectable Acceptors (~ 24% of sample), Universal Acceptors (~ 18%), and Non-Acceptors (~ 58%). Compared to Non-Acceptors, Universal Acceptors had significantly (p < 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to Non-Acceptors, Injectable Acceptors were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.

Client Characteristics Associated with Desire for Additional Services at Syringe Exchange Programs

Objectives

The objective of this study was to explore the relationship between client characteristics and desired services offered at syringe exchange program (SEP) sites among women who inject drugs (WWID). We investigated whether a desire for additional services varied as a function of these client characteristics.

Methods

A sample of 69 women who were syringe exchange clients participated in a survey about adding services to syringe exchange programs. Three Poisson regression analyses were run to examine if client age, education, housing status, polysubstance use, and previous pregnancies were associated with overall desire for services, desire for health-related services, and desire basic needs services.

Results

Participant characteristics of polysubstance use (IRR 1.62, 95% CI 1.34-1.96; p < .01) and greater number of previous pregnancies (IRR 1.14, 95% CI 1.08-1.22; p < .05), were predictive of a greater number of desired services. Engagement in polysubstance use was predictive of a greater number of desired basic need services (IRR 1.45, 95% CI 1.23-1.70; p < .05).

Conclusions

WWID desired services at SEP sites can inform policymakers to formulate policies to better promote utilization of health-related and basic need services among WWID and, in turn, facilitate improved outcomes for WWID.

Participants of a mail delivery syringe services program are underserved by other safe sources for sterile injection supplies

BACKGROUND

In the United States, accessing sterile injection supplies remains challenging for many people who inject drugs (PWID). Although women are less likely to inject drugs than men, women who do inject are disproportionately affected by IDU-related complications. Needle Exchange Technology (NEXT), the first formal online accessed mail delivery syringe services program (SSP) in the US, may overcome access barriers. We evaluated whether NEXT was reaching women participants and people without access to other safe sources of sterile injection supplies.

METHODS

This cross-sectional study examined NEXT participants who enrolled in the mail-delivery SSP from February 2018 through March 2021. All NEXT participants completed an online questionnaire during enrollment, which included sociodemographic and clinical characteristics and injection-related risk factors (including prior sources of sterile injection supplies). Multivariable logistic regression (MVR) was used to examine associations between gender and prior use of safe sources of injection supplies (i.e., SSPs or pharmacies).

RESULTS

1,032 participants received injection supplies. Median age was 34 and participants were mostly cis-gendered women (55%) and white (93%). 34% reported infection with HCV; women were more likely to report HCV infection than men (38% vs 28%; p < 0.01). 68% of participants acquired injection supplies from less safe sources. Few participants exclusively used safe sources for injection supplies (26%). In adjusted MVR analysis, women participants had significantly lower odds than men of having exclusively used safe sources for injection supplies (adjusted OR 0.71, 95% CI 0.52, 0.98).

CONCLUSION

Our findings suggest that NEXT services are utilized by women and people without prior access to sterile injection supplies. Women participants were less likely than men to have exclusively used safe sources for sterile injection supplies. Future research should explore women's preference for mail-delivery over in-person SSPs and determine whether online accessed mail delivery services can reach other underserved populations of PWID.

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.

Exchange Sex Among High School Students-Washington, DC, 2017

PURPOSE

Exchange sex, the exchange of money or nonmonetary items for sex, is associated with sexually transmitted diseases and HIV. We sought to identify prevalence and characteristics associated with exchange sex among District of Columbia (DC) high school students.

METHODS

We used the 2017 DC Youth Risk Behavior Survey, a cross-sectional survey of students in grades 9-12 (n = 8,578). We performed multivariable logistic regression to examine associations between exchange sex and demographic, home environment, and substance use measures.

RESULTS

In 2017, a total of 7.4% (95% confidence interval [CI]: 6.6-8.2) of students reported ever having engaged in exchange sex. Odds of exchange sex were higher among males (adjusted odds ratio [AOR]: 2.5; 95% CI: 1.6-4.0) and students who had sexual contact with partners of both sexes (AOR: 2.4; 95% CI: 1.2-4.9), compared with students having sexual contact with partners of opposite sex only. Exchange sex was also associated with having been kicked out, run away, or abandoned during the past 30 days (AOR: 10.7; 95% CI: 7.0-16.3]); going hungry during the past 30 days (AOR: 2.2; 95% CI: 1.1-4.5); and ever using synthetic marijuana (AOR: 2.6; 95% CI: 1.3-5.0) or cocaine, heroin, methamphetamines, or ecstasy (AOR: 2.9; 95% CI: 1.6-5.3]), compared with those who had not.

CONCLUSIONS

Approximately one in 14 DC high school students engaged in exchange sex. Programs providing services to youth with unstable housing, food insecurity, or who use drugs should incorporate sexual health services to address exchange sex practices.

Interest in linkage to PrEP among people who inject drugs accessing syringe services; Miami, Florida

Background

People who inject drugs (PWID) are at an increased risk for HIV infection due to injection and sexual risk behaviors. This study aims to examine PrEP knowledge, awareness, and willingness to be linked to PrEP services at a syringe services program (SSP), and examine the relationship between substance use and interest in PrEP linkage.

Methods

Data were collected using a cross-sectional survey of IDEA SSP clients in Miami, FL (N = 157). Based on reported substance injected, participants were classified into opioid-only injection or polysubstance injection. Socio-demographics and HIV risk were examined using Pearson’s Chi-Squared analysis. Bivariate and multivariable logistic regression models were used to test for significant correlates of interest in PrEP linkage.

Results

Only 28.3% of PWID surveyed had previously heard of PrEP. However, 57.2% were interested in receiving more information about PrEP. In the adjusted model, people with opioid-only use were significantly less likely to report interest in being linked to PrEP.

Conclusion

Knowledge, awareness, and interest in being linked to PrEP were low among PWID surveyed. No participants of the study were successfully linked to PrEP services through direct referrals. Further research is needed to examine low threshold service delivery of PrEP to PWID at SSPs.

Implementing Respondent-Driven Sampling to Recruit Women Who Exchange Sex in New York City: Factors Associated with Recruitment and Lessons Learned

Respondent-driven sampling (RDS) relies on productive peer recruitment to capture hidden populations. Domestic studies have identified characteristics of productive recruitment among RDS samples of men who have sex with men and persons who use drugs, but not of women who exchange sex, a group vulnerable to HIV infection. We examined sociodemographic-, behavioral-, exchange-sex-, and protocol-related factors associated with recruitment among seeds (n = 25) and peers (n = 297) in the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on women who exchange sex. Recruiter productivity was significantly associated with not having been recently incarcerated, lower rate of HIV testing, and larger exchange sex networks among seeds, and with HIV-prevention services usage among peers. We describe challenges and lessons learned from implementing RDS in this population. Our study identifies seed characteristics and protocol improvements researchers can utilize when implementing future RDS studies among women who exchange sex.

Reproductive Health Care Utilization by Women Who Inject Drugs and Exchange Sex in the Seattle Area

Few data exist regarding reproductive health needs of women who inject drugs (WWID) and exchange sex. This group is at increased risk of unintended pregnancy and sexually transmitted infections (STI). They also face stigma and other barriers to accessing reproductive health care. Purpose: To evaluate contraceptive usage, pregnancy intention, and uptake of general and reproductive health services among WWID and exchange sex. Methods: This analysis of the 2016 Seattle area National HIV Behavioral Surveillance survey included women aged 18-49 years who exchanged sex for money or drugs and injected drugs in the last year. We evaluated contraceptive utilization, pregnancy intention, and reproductive health care access. Results: Among 144 respondents meeting inclusion criteria, the median age was 39 (IQR 33-45), the median age at first injection was 22 (IQR 17-28), and the most commonly injected drug was heroin (62.0%). A minority (10.3%) desired pregnancy in the next year. Among women wanting to avoid pregnancy, 65.5% had not used any prescription contraception (pill/patch/ring, injection, intrauterine device, or implant) in the last year. In the last year, nearly all (92.4%) respondents had received health care and over half (59.0%) had had an STI test. Of women eligible for the HPV vaccine, 28.6% had received at least one dose. Conclusions: Most WWID and exchange sex want to avoid pregnancy. Despite accessing health care, a minority are using prescribed contraception. Health care tailored to these women's preferences may reduce unmet contraceptive need and improve access to well-woman care and preconception counseling.

Suboptimal HIV Pre-exposure Prophylaxis Awareness and Willingness to Use Among Women Who Use Drugs in the United States: A Systematic Review and Meta-analysis

In the United States (U.S.), more than 12 million women reported illicit drug use in the past month. Drug use has been linked to increased risk for HIV, but little is known about the uptake of HIV pre-exposure prophylaxis (PrEP) to prevent HIV among women who use drugs (WWUD). Following the PRISMA guideline, we conducted a multi-database literature search to assess engagement along the PrEP care continuum among WWUD in the U.S. Seven studies with a total of 755 women were included in the review: 370 (49%) Black, 126 (16.7%) Hispanics, and 259 (34.3%) Whites. Employing random-effect models, data indicate 20.6% (95% CI 8.7%, 32.4%) of WWUD were aware of PrEP, and 60.2% (95% CI 52.2%, 68.2%) of those aware were also willing to use PrEP. Notwithstanding study limitations, our findings suggest there may be potential to increase PrEP uptake among WWUD, but efforts must first concentrate on improving PrEP awareness among this population.

Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs

AIMS

To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW-IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition.

DESIGN

Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study.

SETTING

Baltimore, MD, USA PARTICIPANTS: One hundred and eighty FSW-IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married.

MEASUREMENTS

Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio-demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural-level factors included methods of syringe access.

FINDINGS

Nearly all FSW-IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW-IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi-level mixed-effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09-4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98-4.85), being injected by others (aOR = 4.95, 95% CI = 2.42-10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94-3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21-8.90).

CONCLUSIONS

Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs.

Health implications of sex trading characteristics in Long Beach, California, USA

This study examined the comparative health risk behaviors of women who (a) traded sex for money, (b) traded sex for drugs, (c) traded sex for both drugs and money, or (d) did not trade sex. Self-report data were collected from 2369 women who received services through HIV and sexually transmitted infection (STI) testing programs and a subset were tested for HIV, hepatitis B, hepatitis C, and syphilis. Results revealed those women who traded sex only for money used condoms, were tested for HIV, and received the HIV test results more often than the other women. Women who traded sex for both drugs and money reported a significantly higher prevalence of gonorrhea, hepatitis B, and syphilis; were more likely to test positive for hepatitis B, syphilis, and HIV; engaged more often in sex acts without condoms; and were incarcerated for significantly more days. Based on these findings, the targets with greatest potential for STI prevention interventions are female sex workers who trade sex for both drugs and money.

Achieving Greater HIV Prevention Impact Through CDC's National HIV Behavioral Surveillance System

The National HIV Behavioral Surveillance system was designed to monitor risk factors for HIV infection and HIV prevalence among individuals at higher risk for HIV infection, that is, sexually active men who have sex with men who attend venues, persons who recently injected drugs, and heterosexuals of low socioeconomic status living in urban areas. These groups were selected as priorities for behavioral surveillance because they represent the major HIV transmission routes and the populations with the highest HIV burden. Accurate data on the behaviors in these populations are critical for understanding trends in HIV infections and planning and evaluating effective HIV prevention activities. The articles in this supplement illustrate how National HIV Behavioral Surveillance data can be used to assess HIV risk behaviors, prevalence, and service utilization of the populations most affected by HIV in the United States and guide local and national high-impact prevention strategies to meet national HIV prevention goals.