Designing an experimental HIV/HCV intervention to promote the safe re-use of drug preparation materials by injection drug users in Puerto Rico.

Injection drug users (IDUs) in San Juan, Puerto Rico are characterized by high rates of daily injecting, injection of shared drugs, re-use of injection syringes, and use of shooting galleries. They lack adequate access to new injection syringes and drug preparation equipment, and experience elevated rates of HIV and HCV infection. Between April and August, 2006, researchers and active IDUs collaborated in the development of an experimental HIV/HCV intervention aimed at identifying drug preparation items and practices that will enable IDUs to make drug solutions without potentially contaminated injection syringes contacting materials used to prepare drugs. The collaboration involved discussing and testing a variety of drug preparation items and practices in office and community settings. The process was repeated until concerns that had been raised were resolved, and a tentative set of intervention items and practices to be evaluated in a community field trial was identified. Throughout, a strong emphasis was placed on the capacity of an item or practice to address common problems confronted by IDUs (blunted needles, clogged syringes, injected particles) in addition to the core aim of reducing contamination of preparation materials by blood in injection syringes. This report describes the final selection of items and practices: 1) A small water bottle that permits IDUs to add approximately .05 cc water drops directly to drug powder in cookers; 2) A preparation syringe (a type of ancillary equipment not used for injecting) that permits IDUs to pull up a measurable amount of water to add to drug powder, an alternative to producing water drops; 3) A filtering device, the Sterifilt filter, attached to a preparation syringe, which eliminates the need for cotton or cigarette filters; 4) Use of a preparation syringe to distribute drug solution by backloading to injection syringe(s); 5) A small water bottle enabling IDUs to clean injection syringes by backload rinsing. The overarching aim of this experimental HIV/HCV intervention was to promote the safe re-use of drug preparation and injection items, and to impact the large number of IDUs in San Juan who maintain personal injection syringes, but currently use communal ancillary equipment in shooting galleries and inject drug solutions prepared with other IDUs' injection syringes.

A longitudinal study of syringe acquisition by Puerto Rican injection drug users in New York and Puerto Rico: implications for syringe exchange and distribution programs.

Increasing access to sterile syringes and new drug preparation materials is an effective means of reducing HIV transmission among injection drug users (IDUs), and a fundamental component of harm reduction ideology. The purpose of this study is to examine changes during a three-year period in syringe acquisition by street-recruited Puerto Rican IDUs characterized by frequent drug injection and high HIV seroprevalence. At baseline (1998-1999) and 36-month follow-up, 103 IDUs recruited in East Harlem, New York (NY), and 135 from Bayamón, Puerto Rico (PR) were surveyed about syringe sources and HIV risk behaviors in the prior 30 days. A majority of participants in both sites were male (NY 78.6%, PR 84.4%), were born in Puerto Rico (NY 59.2%, PR 87.4%), and had not completed high school (NY 56.3%, PR 51.9%). Compared to PR IDUs at follow-up, NY IDUs injected less (3.4 vs. 7.0 times/day, p < .001), and re-used syringes less (3.1 vs. 8.0 times, p < .001). Between baseline and follow-up, in NY the proportion of syringes from syringe exchange programs (SEPs) increased from 54.2% to 72.9% (p = .001); syringes from pharmacies did not increase significantly (0.2% to 2.5%, p = .095). In PR, the proportions of syringes from major sources did not change significantly: private sellers (50.9% to 50.9%, p = .996); pharmacies (18.6% to 19.0%, p = .867); SEP (12.8% to 14.4%, p = .585). The study indicates that NY SEPs became more dominant, while NY pharmacies remained a minor source even though a law enacted in 2001 legalized syringe purchases without prescription. Private sellers in PR remained the dominant and most expensive source. The only source of free syringes, the SEP, permitted more syringes to be exchanged but the increase was not statistically significant. Implications for syringe exchange and distribution programs are discussed.

An exploratory qualitative study of polydrug use histories among recently initiated injection drug users in San Juan, Puerto Rico.

It is well documented that drug users often modulate the effects of their primary drugs of use (e.g., cocaine) by using other drugs (e.g., alcohol), yet the effect of modulating and primary drug interactions on transitions from one class of drugs to another and from noninjected drugs to injected drugs is not clear. This issue, which is critical for understanding polydrug abuse,1 is explored in formative research based on in-depth qualitative interviews conducted during 2003-2004 with 25 recently initiated drug injectors residing in San Juan, Puerto Rico. This study suggests that increased use of a primary drug (e.g., cocaine) was influenced by enhancing or attenuating drugs, which were used in a particular order (e.g., alcohol, heroin) reflecting effectiveness in modulating primary drugs at different use intensities, as well as by participants' perceptions of the relative dangers associated with different drugs. Neither availability nor access appeared to affect the order in which participants used modulating drugs.

Sexual identity formation and AIDS prevention: an exploratory study of non-gay-identified Puerto Rican MSM from working class neighborhoods.

As a subgroup of men who have sex with men (MSM), non-gay-identified (NGI) behaviorally bisexual Latino MSM are associated with heightened probabilities of HIV transmission, yet they have eluded HIV/AIDS interventionists. This exploratory study of Puerto Rican MSM drug users employed multi-session qualitative interviews to examine early life experiences related to gender identity and sexual orientation, and the place of risky drug and sexual behaviors in the process of sexual identity formation. NGI participants experienced sexual debut between ages 13 and 20, and most were recruited to prostitution as young teens by NGI age mates who were also members of drug use networks. Participants emphasized their role as insertive sexual partners and that they maintained relationships with pasivo biological males. It is feasible to recruit NGI MSM through primary male sexual partners and drug use networks. HIV/AIDS prevention based on awareness of developmental histories holds promise for intervening before NGI youth engage in male prostitution or injection drug use.

Elicitation of salient beliefs related to drug preparation practices among injection drug users in Puerto Rico.

Even when IDUs use their own syringes, the common use of drug preparation materials can expose them to blood-borne pathogens. Notwithstanding the accumulated evidence about the riskiness of drug preparation practices (DPPs), the factors that lead IDUs to engage in DPPs have remained understudied. We conducted 80 semi-structured interviews to elicit salient beliefs about engaging in low-risk DPPs. Data were content analyzed for consequences, normative influences, and barriers. For the most part respondents described positive consequences of engaging in low-risk DPPs. The majority of respondents mentioned IDU peers as a major source of pressure to engage in high-risk DPPs. Lack of access to clean materials and the need to carry materials on oneself were the most salient barriers elicited. The results suggest that preventive interventions need to address the preference for re-using filters, help develop skills to fend off pressures from peers, and increase the accessibility of materials in ways that do not require IDUs to carry additional items.

Homelessness and HIV risk behaviors among drug injectors in Puerto Rico.

This report examines associations between homelessness and HIV risk behaviors among injection drug users (IDUs) in Puerto Rico. The study sample consisted of 557 IDUs who were not in treatment, recruited in inner-city neighborhoods of the North Metro Health Care Region. Subjects were categorized into three groups by residential status (last 30 days): housed, transitionally housed (living with friends, family, or others but considering themselves homeless), and on-the-street homeless (living on the street or in a shelter). Multiple logistic regression models were fitted to assess effects of residential status on each HIV risk behavior after adjusting for sociodemographic and drug-use related covariates. Transitionally housed and on-the-street homeless subjects made up 16% of the total sample. On-the-street homeless IDUs were more likely to test positive for HIV than were transitionally housed and housed IDUs. In the adjusted analysis, on-the-street homeless subjects were significantly more likely to share needles, share rinse water, and practice back loading than the other two groups. Sexual risk behaviors (last 30 days) were not significantly associated with residential status after adjustment. Findings from this study present an added challenge to drug treatment and HIV prevention and treatment programs, to provide services that can address the additional needs of drug users suffering the stressors of homelessness.

Injecting shared drugs: an observational study of the process of drug acquisition, preparation, and injection by Puerto Rican drug users.

The practice of injecting shared drugs, in which drug users prepare, divide and inject portions of a drug solution, is a means of transmitting HIV, HCV, and other blood-borne pathogens. This study examined the process of injecting shared drugs among drug users in San Juan, Puerto Rico, through detailed observations of 25 episodes of the injection of shared drugs, and by informal interviewing of episode participants. The ways in which price and packaging of drugs, access to drug preparation materials, and social and economic relations between drug-sharing "partners" influence the process of injecting shared drugs are explored. Because differential power relations, and in turn, injection drug users' exposure to HIV and HCV, are apparent in some drug-sharing partnerships, a key objective of this study was to extend our understanding of contributions or "investments" made by different drug-sharing partners, the benefits and costs that different partners experience, and the extent to which IDUs assume different partner roles. The findings of this small, in-depth qualitative study provide insight into drug users' motivations for injecting shared drugs, and suggest reasons why certain standardized, countrywide HIV/HCV intervention efforts have not been entirely successful in preventing the devastating illnesses that disproportionately affect injection drug users.

Puerto Rican drug users experiences of physical and sexual abuse: comparisons based on sexual identities.

This study integrates the results of quantitative and qualitative methods to elucidate the association between sexual identity and physical and sexual abuse among Puerto Rican drug users. A structured questionnaire was administered to 800 subjects in New York and 399 in Puerto Rico. A total of 93 subjects (7.9%) self-identified as homosexual or bisexual. Gay males were significantly more likely than heterosexual males to report first occurrence of physical abuse by a family member in childhood. Both gay and bisexual males were more likely than their heterosexual counterparts to report first experiencing unwanted sex in childhood and intimate partner physical abuse later in life. Lesbians were more likely than female heterosexuals to report unwanted sex in childhood. Qualitative data were collected through in-depth life histories with 21 subjects and suggest that gay and lesbian subjects perceive antihomosexual prejudice on the part of family members as one cause of childhood physical and sexual abuse.

Perspectives related to the potential use of vaginal microbicides among drug-involved women: focus groups in three cities in the United States and Puerto Rico.

HIV transmission through heterosexual contact remains the greatest risk factor for women globally. Topical microbicides applied intravaginally may offer a female-initiated HIV prevention option for many who are unable or unwilling to use male condoms or who would want additional protection. This article presents results of focus groups in Bridgeport, Connecticut, Providence, Rhode Island, and San Juan, Puerto Rico, with women who use crack or heroin or have male partners who inject illegal drugs. Participants revealed motivation for and openness to using microbicides effective against HIV should they become available. Additional lubrication during intercourse was one of several expected positive features of microbicides; women saw lubrication as a means of enhancing pleasure and reducing condom irritation and breakage while also protecting them from infection. Conversely, some women feared that their male partners would interpret excessive lubrication as an indication of infection, improper hygiene, or evidence of sex with another man. Focus groups also provided insight into how aspects of different women's sexual lives, including partner type, might influence the issues that would concern them if and when they tried out new microbicidal products in the future.