Transcript Hector Colón, Ph.D. Sherry Deren, Ph.D. Universidad Central del

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
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
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.
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
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.
Puerto Rico has one of the largest HIV/AIDS
epidemics in the U.S. and the Caribbean
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)
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
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
Latin America and the Caribbean, AIDS Cases by Country: “The
Top 10” (cumulative cases to June 2002)
250000
215810
200000
150000
100000
51017
50000
27,443
19959
12184
11789
9814
8902
6120
5102
0
Brazil
Mexico
Puerto
Rico
Argentina
Peru
Source: AIDS Surveillance in the Americas, PAHO, 2002
Honduras Columbia
Haiti
Dominican
Republic
Jamaica
Latin America and the Caribbean: Cumulative AIDS Cases in “The Top 10”
Countries as Percent of Total Population
0.8%
Percent of Population
0.7%
0.6%
0.5%
0.4%
0.3%
0.2%
0.1%
0.0%
Brazil
Mexico
Puerto
Rico
Argentina
Peru
Source: AIDS Surveillance in the Americas, PAHO, 2002
Honduras Columbia
Haiti
Dominican
Republic
Jamaica
HIV/AIDS Among Puerto Ricans:
A Drug Use Epidemic
Risk Categories of AIDS Cases in Puerto Rico
(Cumulative cases as of April 2003)
24
50
17
7
IDU
Heterosexual
MSM
2
Other/not reported
Source: Puerto Rican Department of Health, April 2003
MSM & IDU
Risk Categories of AIDS Cases among Hispanics in the U.S., reported
in 2001, by Place of Birth
100%
80%
60%
40%
20%
0%
U.S.
IDU
MSM
Central &
South
America
MSM & IDU
Cuba
Heterosexual
Mexico Puerto Rico
Hemophilia, Transfusion
Note: Based only cases with an identified risk category
Source: CDC HIV/AIDS Surveillance Report, December 2002
Distribution of Hispanic Population, US 2000, by Hispanic
Subgroup
3.5
8.6
9.6
58.5
Mexico
Cuba
19.8
Central & South America
Puerto Rico
Other
Alliance for Research in El Barrio and Bayamón:
The ARIBBA Study
The ARIBBA Study
 Funded by NIDA since 1996, the ARIBBA study
focuses on identifying determinants of HIVrelated 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
Survey Recruitment
 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
 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
Profile of East Harlem and Bayamón
 East Harlem
 Bayamón
 Densely populated with
about 110,000- 52%
Hispanic, an area of
approximately 3 square
miles.
 Population of about
220,000, study focused
on an area
encompassing
approximately 2.7 miles
 Labor participation rate:
47.1%;
 Labor participation rate:
42.1%;
 individual poverty rate:
36.4%
 individual poverty rate:
34.9%
 Includes 5 methadone
programs (with 12
clinics), and four NEPs
 Includes 1 MMTP clinic,
1 mobile NEP
Source: US Census 2000
Drug Use Categories for Survey Sample
(based on prior 30 days)
NY (n=800)
PR (n=399)
39%
53%
31%
30%
25%
IDUs
Crack Smokers
IDU/Crack Smoker
22%
Drug Use Patterns of IDUs:
Drugs Injected (prior 30 days)
%
100
90
80
70
60
50
40
30
20
10
0
88
66
91
67
54
46
Heroin alone***
Puerto Rico
Source: ARIBBA Baseline Data
Cocaine alone***
Heroin & Cocaine***
New York
***p<..001
Sociodemographic Characteristics of the ARIBBA
Samples
Age***
Mean
Completed HS/GED*
100
100
80
80
60
38
33
%
40
20
46
60
37
40
20
0
0
Gender (Male)*
79
100
Ever in Jail/Prison***
73
100
80
%
80
%
60
40
40
20
20
0
*p<.05
60
0
***p<.001
Source: ARIBBA Baseline Data
Puerto Rico (n=399)
New York (n=800)
87
74
Higher HIV-Related Risk Behaviors
In Puerto Rico
Injection-Related Risk Behaviors
(prior 30 days)
Frequency of Injection***
184
200
150
76
#
100
Puerto Rico
New York
50
0
# Times each Syringe Used***
6
8
2.9
4
#
0
Source: ARIBBA Baseline Data
***p<.001
Injection –Related Sharing Behaviors
100
80
%
40
20
0
100
34
31
20
8
7
Used others’
needles***
Loaned
others your
needle***
79
7
10
Used others’
cookers***
Shared your
cooker with
others***
Puerto Rico (n=313)
New York (n=561)
72
80
%
52
60
60
44
40
23
20
0
Used shooting
galleries***
Source: ARIBBA Baseline Data
Pooled money to
buy drugs***
***p<.001
Incarceration and HIV Risk Behavior
(During Last Incarceration Episode)
Puerto Rico
Incarceration risks
Injected while incarcerated***
if yes, shared equipment**
New York
31%
74%
12%
52%
Non-injection drug use***
14%
37%
Gang affiliation while incarcerated***
73%
32%
Source: ARIBBA Baseline Data
**p<.01 ; *** p<.001
Sex-Related HIV Risk Behaviors (prior 30 days)
PR
IDUs a
NY
Crack Users
PR
NY
Engaged in sex
45%
58%***
76%
70%
Traded sex
Males
10%
8%
30%
14%*
Females
78%
32%***
62%
28%***
36%
27%*
58%
27%***
Multiple partners
a
Includes those who also used crack
Source: ARIBBA Baseline Data
*p<.05
***p<.001
Unprotected Sex by Partner Type
(prior 30 days)
100
80
64
80
%
Puerto Rico
New York
60
69
36
37
35
40
20
0
Main**
Source: ARIBBA Baseline Data
Casual***
Partner Type
Paid
**p<.01; ***p<.001
Drug Users in Puerto Rico Have
Less Access to HIV Prevention and
Other Health Services
NEP Use and Services Received from NEPs (prior 30 days)
#
110
100
90
80
70
60
50
40
30
20
10
0
Services Received
NEP Use
104.5
99.2
100
90
79
80
69.4
70
66.1
58.1
60
%
50
40
30
3.0
20
9
15.2
12.2
10
2.8
8.3
0
# times
accessed
# syringes
obtained***
Referred Received
to drug Tx Condoms
***
***
Referred to Referred to
HIV testing TB testing
***
***
Puerto Rico
Source: ARIBBA Baseline Data
New York
***p<.001
Sources of Syringes
(prior 30 days)
60
55
50
45
40
%
30
22.9
20
18.0
10
17.6
3.6
0
Pharmacy***
Syringe seller***
NEP***
Puerto Rico
New York
Source: ARIBBA Baseline Data
***p<.001
Drug Treatment Services
(prior 6 months)
Puerto Rico (n=334)
70
63.3
New York (n=617)
60
50
40
%
30
18
20
12.3
10
4.5
2.1
2.1
3.7
5.1
0
MMTP***
Outpatient
Source: ARIBBA 6 Month Follow-up Interview
In-patient*** Prison-based***
***p<.001
100
Use of Health Services and HIV Medications
(Prior 6 Months)
Puerto Rico (n=334)
New York (n=617)
80
65
60
51.7
%
40
21.5
18.6
17.8
20
3
5
2.7
0
Inpatient***
Outpatient***
Source: ARIBBA 6 Month Follow-up Interview
Mental Health***
Taking HIV
Meds(among HIV+
participants)***
***p<.001
Higher HIV
Incidence in Puerto Rico
HIV Seroprevalence Among IDUs,
1992-1999
%
HIV+
Source: NIDA Cooperative Agreement Study and ARIBBA Baseline Data
For both trends, p<.001
HIV Seroincidence Rates
Seroincidence (per 100PY)
As of November 2002 there were a total of 32 serovonverters, 9 in NY and 23 in PR
5.0
4.0
3.37
3.0
2.0
1.0
0.88
0.0
NY (1,019 py)
PR (683 py)
Source: ARIBBA Baseline and Follow-up Data (as of November 2002)
p<.0001
Declining Drug Treatment Services
in Puerto Rico
Drug Treatment Services in Puerto Rico: Patients Treated (for drugs, last
month) , by Type of Provider and Survey Year
1998 (14,209)
2002 (8,305)
10000
8000
6000
#
4000
2000
0
Government
CBO Lay
CBO Faith
PPP
Drug Treatment Services in Puerto Rico: Comparison of 1998
and 2002 Surveys
1998
2002
Change
Population Treated
Primary drug condition
14,209
8,305
-41.6%
3,740
2,265
-39.4%
Static capacity (one month)
20,870
13,632
-34.7%
Capacity utilization
86.0%
77.5%
-9.8%
2,989
1,894
-36.7%
Primary alcohol condition
Treatment Capacity
Direct Service Staff
FTEs
The Risk Behaviors of IDUs from Puerto Rico
Decline After Immigrating to an Environment
with more HIV Prevention Resources
Puerto Rican Migrant IDUs in New York Compared with other
New York Puerto Rican IDUs
Injection-related risks
87
100
100
69
80
80
#
%
60
60
40
40
20
20
0
0
80
Injection sharing behaviors
41
% 60
40
18
Used shooting gallery***
Frequency of injection*
100
32
10
Migrants
28
Others
10
20
0
Shared syringes
Source: ARIBBA Baseline Data
Shared other paraphernalia***
*p<.05; *** p<.001
Higher Mortality Rates in Puerto Rico
Age Adjusted Drug Induced Death Rates, Puerto Rico and
United States, 1990-2000
Puerto Rico
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
United States
13.4
10.8
10.8
13.2
13.2
11.1
10.1
8.1
6.2
3.8
6
4.1
4.6
11.4
7.3
5.1
5.3
5.3
5.5
5.9
7.4
6.1
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
Preliminary Mortality Rates of ARIBBA Participants
5.0
Death Rates per 100 py
4.0
3.5
3.0
2.0
1.5
1.0
0.0
New York (2,524 py)
Source: National Death Index, CDC, as of December 2001
Puerto Rico (1,169 py)
Conclusions and Recommendations
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
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.
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.