Bienvenida

1. Bienvenida Bienvenue Welkom Welcome

2. Hector Colón, Ph.D., Rafaela Robles, Ed.D.Centro de Estudios en AdicciónUniversidad Central del CaribeBayamón, Puerto Rico HIV/AIDS Among Drug Users in Puerto Rico: Evidence of a Public Health Emergency Sherry Deren, Ph.D. National Development & Research Institutes, Inc. Center for Drug Use & HIV Research New York, New York El Caribe, varios idiomas y muchas culturas, unidos para combatir el VIH/SIDASanto Domingo, Dominican Republic, March 5-7, 2004 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

3. 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 20025th highest rate of new AIDS cases in 2002 (1,139 new AIDS cases; 29.5/100,000 population) The number of AIDS cases is Disproportionately Higher in Puerto Rico Than in Most U.S. States Source: HIV/AIDS Surveillance Report, Cases reported through December 2002, CDC 2002

4. 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

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

6. 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

7. Profile of East Harlem and Bayamón 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 Source: US Census 2000

8. Higher HIV-Related Risk Behaviors In Puerto Rico

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

10. % Used others’ needles*** Loaned others your needle*** Shared your cooker with others*** Used others’ cookers*** Puerto Rico (n=313) New York (n=561) % Used shooting galleries*** Pooled money to buy drugs*** ***p<.001 Source: ARIBBA Baseline Data Injection –Related Sharing Behaviors

11. 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% **p<.01 ; *** p<.001 Source: ARIBBA Baseline Data

12. 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

13. Drug Users in Puerto Rico Have Less Access to HIV Prevention and Other Health Services

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

15. 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

16. 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

17. Higher HIV Incidence in Puerto Rico

18. 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)

19. Declining Drug Treatment Services in Puerto Rico

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

21. Higher Mortality Rates in Puerto Rico

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

23. Age Adjusted Drug Overdose Death Rates, Puerto Rico, New York State, and United States, 1990-2000

24. Conclusions and Recommendations

25. 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

27. CDARI The Caribbean Drug Abuse Research Institute

28. HIV Risk Behaviors Among Homeless Out-of-Treatment Drug Users In Two Caribbean StatesPort of Spain, Trinidad and Castries, Saint LuciaAuthors:Marcus Day, Jessy G. Devieux, Sandra D. Reid, Dionne J. Jones,Joseph Meharris, and Robert Malow

29. This presentation is based on data derived from an ongoing research project entitled Needs Analysis for Primary Health Care among the Street Drug Using Communities of the Urban Caribbean Principal Investigator Marcus Day Director The Caribbean Drug Abuse Research Institute

30. Introduction • The prevalence of HIV infection in the Caribbean is estimated at 2.4%, second only to sub-Saharan Africa (UNAIDS/WHO, 2002). • In several Caribbean states, AIDS is the leading cause of death among men 15-44 years old. • Several sub-groups of persons have been identified as higher risk for HIV infection because of their associated risky sexual behaviours. Included in this group are homeless out of treatment drug abusers.

31. BACKGROUND • In the urban Caribbean the homeless are usually found in well defined areas where there exists opportunities for: • causal labour • charity meals • soliciting or begging • The convenience sample discussed in this presentation was taken from such areas of Castries and Port of Spain.

32. BACKGROUND • Numerous NIH supported research have shown that crack consumption promotes: • physical and mental ill health • homelessness • loss of jobs • undoing of families • incarceration • violence

33. Method • A convenience sample of homeless1 persons were recruited. • All 74 participants (26 in St. Lucia and 48 in Trinidad) who were approached agreed to participate in the study. • Informed written consent was obtained • Structured questionnaires were used to conduct anonymous and confidential interviews. 1 The UK based Centre for Architectural Research and Development Overseas

34. Method • Interviewers were harm reduction outreach workers who were known in the areas. • Interviewers were trained in administration of the questionnaire, which took about 90 minutes to complete. • Data was collected on demographic characteristics, substance use, sexual behaviour, general health, and health-care seeking behaviour. • An incentive of $20 in local currency was paid to all respondents

35. The Problem • No study has addressed the primary health care needs needs of Caribbean homeless, out-of-treatment drug abusers who are expected to be at even higher risk of acquiring and transmitting the human immunodeficiency virus. • The study assesses those needs while this presentation looks at substance use, sexual behaviours and knowledge of risk

36. Participants

37. Demographics • Mean Age: 40.32 years (SD 7.22) • Total Sample (n=74) • Sex: Females (n=21) Males (n=52) Transvestite (n=1) • Ethnicity: Afro Caribbean (n=65) Indo Caribbean (n=5) Mixed Race (n=4)

38. Age Left School

39. Education

40. Currently Working

41. Occupation

42. Marital Status • Never Married 79.6% • Married 12.2% • Divorced 8.2%

43. Number of Children

44. Results

45. Criminal Justice Contact

46. Victim of Violence

47. Family Variables • The majority of subjects reported that they do not see their family regularly (53.4% vs. 46.6%) • The majority reported that their families know that they take drugs (94.4% vs. 5.6%) • 52.1% reported that no one in their family takes drugs (compared with 38.4% who said that at least one member of their family takes drugs and 9.5% answered “I don’t know”).

48. 30 Day Drug Use

49. Drug Use and Sexual Behavior • 41% said that at some point in time they exchanged sex for crack or money. • 47.1% reported that at some point in time they exchanged crack or money for sex. • Gender was significantly related to exchanging sex for money or drugs. • The majority (85%) reported that they have tried to stop smoking crack at some point in time.

50. HIV Status and Sexual Risk Behaviours • 26% self reported positive for HIV. (33% POS, 12% Castries) • Although 71% reported not having tested HIV positive most of those respondents had never had an HIV test. • The majority (75%) reported that they either sometimes, often, or always have unprotected sex. • Females were about as likely to have unprotected sex as males (74% vs. 76% respectively). • The majority of the respondents who knew their HIV status was positive, reported having unprotected sex most of the time