Comparing the San Juan and New York City HIV Epidemics among Puerto Rican Drug Users: Evidence of a Public Health Emerg

1. Comparing the San Juan and New York City HIV Epidemics among Puerto Rican Drug Users: Evidence of a Public Health Emergency in Puerto Rico Sherry Deren, Ph.D. National Development & Research Institutes, Inc. Center for Drug Use & HIV Research in New York, New York Rafaela Robles, Ed.D. Héctor Colón, Ph.D., Universidad Central del Caribe Center for Addiction Studies Bayamón, Puerto Rico Presented at the “Turning Research into Practice” Meeting, Centers for Disease Control and Prevention, Atlanta, GA, December 10, 2003 The ARIBBA Study was supported by the National Institute on Drug Abuse Grant # R01DA10425; drug treatment provider surveys were funded by SAMHSA Contracts #270-95-0026, 270-98-7056

2. Summary • Two teams of investigators, in Puerto Rico and New York, have been studying Puerto Rican drug users, particularly in terms of risks for HIV/AIDS, since 1988 • Findings from many sources indicate that: • the drug use-HIV/AIDS epidemic in Puerto Rico is one of the largest in the United States and the Caribbean • compared with Puerto Rican drug users in New York, drug users in Puerto Rico • engage in higher HIV-related risk behaviors • have lower access to HIV and other health related services • have higher HIV seroconversion and mortality rates

3. Summary Cont. • Their HIV seroconversion and death rates constitute a public health emergency for drug users in Puerto Rico • There is an urgent need for additional HIV prevention and other health services.

4. Sources of Information • AIDS case data for Puerto Rico, New York, the United States, and the Caribbean (CDC HIV Surveillance Reports;UNAIDS, Pan American Health Organization [PAHO]) • Alliance for Research in El Barrio and Bayamón (the ARIBBA study), funded by the National Institute on Drug Abuse since 1996 to study Puerto Rican injection drug users and crack smokers in East Harlem, New York and Bayamón, Puerto Rico

5. Sources of Information • Mortality data for project participants from Puerto Rico and New York (from the CDC National Death Index) • Drug treatment provider surveys conducted in Puerto Rico in 1998 and 2002; Puerto Rico Demographic Registry.

6. Puerto Rico has one of the largest HIV/AIDS epidemics in the U.S. and the Caribbean

7. The number of AIDS cases is Disproportionately Higher in Puerto Rico Than in Most U.S. States • Compared to the 50 U.S. States, Puerto Rico • ranks 27th in population size (3.8 million people). However, Puerto Rico has the: • 8th highest cumulative number of AIDS cases among adults/adolescents (26,847) as December 2002 • 5th highest rate of new AIDS cases in 2002 (1,139 new AIDS cases; 29.5/100,000 population)

8. AIDS cases in Puerto Rico, as compared to the rest of the Caribbean, receives insufficient attention • In the Caribbean, Puerto Rico ranks 1st in total number of AIDS cases. • The 2 Caribbean nations targeted in President Bush’s 2003 AIDS Initiative are Haiti and Guyana. However, in total cases as of June 2002, Puerto Rico (with 27,443 cases) has more than 3 times the cases in Haiti (8,903) but about half its population size. It also has more than 18 times the cases in Guyana (1,492), and about 5 times its population. Source: AIDS Surveillance in the Americas, PAHO, 2002

9. AIDS cases in Puerto Rico, as compared to the rest of the Caribbean, receives insufficient attention • Although Puerto Rico is in the Caribbean, because of its unique relationship to the US, it is often excluded in reports on HIV/AIDS in the Caribbean. In addition, geopolitical factors may have contributed to its being overlooked in terms of the mainland US epidemic. Source: AIDS Surveillance in the Americas, PAHO, 2002

10. Latin America and the Caribbean, AIDS Cases by Country: “The Top 10” (cumulative cases to June 2002) 215810 51017 27,443 19959 12184 11789 8902 9814 6120 5102 Source: AIDS Surveillance in the Americas, PAHO, 2002

11. Latin America and the Caribbean: Cumulative AIDS Cases in “The Top 10” Countries as Percent of Total Population Percent of Population Source: AIDS Surveillance in the Americas, PAHO, 2002

12. HIV/AIDS Among Puerto Ricans: A Drug Use Epidemic

13. Risk Categories of AIDS Cases in Puerto Rico (Cumulative cases as of April 2003) Source: Puerto Rican Department of Health, April 2003

14. Risk Categories of AIDS Cases among Hispanics in the U.S., reported in 2001, by Place of Birth Note: Based only cases with an identified risk category Source: CDC HIV/AIDS Surveillance Report, December 2002

15. Distribution of Hispanic Population, US 2000, by Hispanic Subgroup

16. Alliance for Research in El Barrio and Bayamón:The ARIBBA Study

17. The ARIBBA Study • Funded by NIDA since 1996, the ARIBBA study focuses on identifying determinants of HIV-related risk behaviors among Puerto Rican IDUs and crack smokers in East Harlem, NY and Bayamón, PR • Qualitative methods include mapping, focus groups, ethnographic interviews, and observations • Quantitative methods include baseline and multiple follow-up interviews and HIV testing

18. Each community was divided into sectors (3 in Bayamón and 5 in East Harlem) based on ethnographic mapping of drug copping and drug using locations Sectors for daily recruitment were randomly selected Participants were recruited by outreach workers using targeted sampling Survey Recruitment

19. Criteria for recruitment: (a) age 18 or older; (b) self-report as Puerto Rican; (c) injected drugs or smoked crack in prior 30 days Participants were escorted to the field site for: (a) verification of recent drug use (urinalysis for heroin or cocaine); (b) informed consent procedures; (c)computer-assisted interviewing; (d) HIV counseling and testing Survey Recruitment

20. East Harlem Densely populated with about 110,000- 52% Hispanic, an area of approximately 3 square miles. Labor participation rate: 47.1%; individual poverty rate: 36.4% Includes 5 methadone programs (with 12 clinics), and four NEPs Bayamón Population of about 220,000, study focused on an area encompassing approximately 2.7 miles Labor participation rate: 42.1%; individual poverty rate: 34.9% Includes 1 MMTP clinic, 1 mobile NEP Profile of East Harlem and Bayamón Source: US Census 2000

21. IDUs Crack Smokers IDU/Crack Smoker Drug Use Categories for Survey Sample(based on prior 30 days) NY (n=800) PR (n=399)

22. Drug Use Patterns of IDUs:Drugs Injected (prior 30 days) % Heroin alone*** Cocaine alone*** Heroin & Cocaine*** Puerto Rico New York Source: ARIBBA Baseline Data ***p<..001

23. Sociodemographic Characteristics of the ARIBBA Samples Age*** Completed HS/GED* Mean % Gender (Male)* Ever in Jail/Prison*** 87 100 74 80 % % 60 40 20 0 Puerto Rico (n=399) *p<.05 ***p<.001 New York (n=800) Source: ARIBBA Baseline Data

24. Higher HIV-Related Risk BehaviorsIn Puerto Rico

25. Injection-Related Risk Behaviors(prior 30 days) Frequency of Injection*** Puerto Rico # New York # Times each Syringe Used*** # ***p<.001 Source: ARIBBA Baseline Data

26. Injection –Related Sharing Behaviors % Used others’ needles*** Loaned others your needle*** Shared your cooker with others*** Used others’ cookers*** Puerto Rico (n=313) 100 79 72 New York (n=561) 80 % 60 44 40 23 20 0 Used shooting galleries*** Pooled money to buy drugs*** ***p<.001 Source: ARIBBA Baseline Data

27. Incarceration and HIV Risk Behavior(During Last Incarceration Episode) Puerto Rico New York Incarceration risks Injected while incarcerated*** 31% 12% if yes, shared equipment** 74% 52% Non-injection drug use*** 14% 37% Gang affiliation while incarcerated*** 73% 32% **p<.01 ; *** p<.001 Source: ARIBBA Baseline Data

28. Sex-Related HIV Risk Behaviors (prior 30 days) IDUs a Crack Users PR NY PR NY Engaged in sex 45% 58%*** 76% 70% Traded sex Males 10% 8% 30% 14%* Females 78% 32%*** 62% 28%*** Multiple partners 36% 27%* 58% 27%*** a Includes those who also used crack *p<.05 ***p<.001 Source: ARIBBA Baseline Data

29. Unprotected Sex by Partner Type(prior 30 days) Puerto Rico New York % Main** Casual*** Paid Partner Type Source: ARIBBA Baseline Data **p<.01; ***p<.001

30. Drug Users in Puerto Rico Have Less Access to HIV Prevention andOther Health Services

31. Services Received % Received Condoms *** Referred to HIV testing *** Referred to TB testing *** Referred to drug Tx *** NEP Use and Services Received from NEPs (prior 30 days) NEP Use # # syringes obtained*** # times accessed Puerto Rico New York Source: ARIBBA Baseline Data ***p<.001

32. Sources of Syringes (prior 30 days) % Pharmacy*** Syringe seller*** NEP*** Puerto Rico New York ***p<.001 Source: ARIBBA Baseline Data

33. Drug Treatment Services (prior 6 months) Puerto Rico (n=334) New York (n=617) % MMTP*** Outpatient In-patient*** Prison-based*** Source: ARIBBA 6 Month Follow-up Interview ***p<.001

34. Use ofHealth Services and HIV Medications (Prior 6 Months) Puerto Rico (n=334) New York (n=617) % Source: ARIBBA 6 Month Follow-up Interview ***p<.001

35. Higher HIVIncidence in Puerto Rico

36. HIV Seroprevalence Among IDUs, 1992-1999 % HIV+ Source: NIDA CooperativeAgreement Study and ARIBBA Baseline Data For both trends, p<.001

37. HIV Seroincidence RatesAs of November 2002 there were a total of 32 serovonverters, 9 in NY and 23 in PR Seroincidence (per 100PY) NY (1,019 py) PR (683 py) p<.0001 Source: ARIBBA Baseline and Follow-up Data (as of November 2002)

38. Declining Drug Treatment Services in Puerto Rico

39. Drug Treatment Services in Puerto Rico: Patients Treated (for drugs, last month) , by Type of Provider and Survey Year #

40. Drug Treatment Services in Puerto Rico: Comparison of 1998 and 2002 Surveys

41. The Risk Behaviors of IDUs from Puerto Rico Decline After Immigrating to an Environment with more HIV Prevention Resources

42. Puerto Rican Migrant IDUs in New York Compared with other New York Puerto Rican IDUs Injection sharing behaviors % Shared syringes Shared other paraphernalia*** Injection-related risks % # Used shooting gallery*** Frequency of injection* Migrants Others Source: ARIBBA Baseline Data *p<.05; *** p<.001

43. Higher Mortality Rates in Puerto Rico

44. Age Adjusted Drug Induced Death Rates, Puerto Rico and United States, 1990-2000 Year

45. Preliminary Mortality Rates of ARIBBA Participants Death Rates per 100 py Source: National Death Index, CDC, as of December 2001

46. Conclusions and Recommendations

47. Conclusions • These findings constitute evidence of a public health emergency for drug users in Puerto Rico. • Despite the large drug-use AIDS epidemic on the island, there is insufficient access to HIV prevention and other health-related services. • This results in high levels of risk behaviors, and high HIV incidence and mortality rates. • Based on public health and ethical principles, immediate action is needed to address the public health crisis for drug users in Puerto Rico

48. Recommendations Regarding NY • While the situation among Puerto Rican drug users in NY, compared with Puerto Rico, indicates greater access to services and lower risk behaviors, recent data indicating that risk reduction has stabilized points to the need to continue services and risk reduction programs. • Efforts to address sex risk behaviors are important in NY (as well as in PR). • There is a need to identify those populations at highest risk in New York for targeted intervention efforts. For example, intervention efforts for migrant IDUs, those individual who previously injected in Puerto Rico and are now injecting in New York, are needed.

49. Recommendations Regarding Puerto Rico • There is an urgent need for increased funding for HIV prevention and other health programs for drug users. • Increases in substance abuse treatment and in the availability of new syringes are needed to reduce HIV incidence and mortality rates • A task force consisting of federal and local government officials, providers, and researchers should be established to help focus and monitor the progress of efforts, and provide technical and surveillance assistance.