When "the Cure" Is the Risk: Understanding How Substance Use Affects HIV and HCV in a Layered Risk Environment in San Juan, Puerto Rico.

BACKGROUND: Substance use, particularly injection drug use, continues to fuel the HIV/HCV (hepatitis C virus) epidemics in San Juan, Puerto Rico (PR). AIM: This article examines individual and sociostructural factors that affect HIV/HCV risk among people who use drugs (PWUD) living with or at risk for HIV/HCV in San Juan, PR. Findings were used to inform a community-level intervention to enhance HIV care access and retention for this population. METHOD: A rapid ethnographic assessment in collaboration with a community-based organization was conducted. Data collection took place between June and December 2013 and included field observations, 49 unstructured interviews with PWUD, and 19 key informant interviews with community stakeholders. Fieldnotes, photographs, and interview transcripts were analyzed for recurrent themes and to address the intervention-planning needs. Study results are presented as fieldnote excerpts, direct quotes from interviews, and photographs. RESULTS: Findings suggest that PWUD in PR face myriad challenges that affect HIV/HCV risk and hinder linkage to and retention in care. Results describe a layered risk environment where PWUD encounter many barriers to prevention, care, and treatment such as transience, social isolation, stigma, limited housing options, and inadequate medical and substance use disorder treatment services. DISCUSSION: These observed circumstances provide an empirical basis for the development and evaluation of comprehensive interventions that may serve to reduce barriers to care and link individuals to other supportive services. CONCLUSION: New approaches and comprehensive interventions are needed to break the structures that perpetuate risk and lack of engagement and retention in HIV care and substance use disorder treatment in San Juan.

GC-MS confirmation of xylazine (Rompun), a veterinary sedative, in exchanged needles.

In order to assess the extent of xylazine (Xyz) injection in Puerto Rico, two waves of used-syringe collections were performed. In the first, syringes were gathered, anonymously and without additional information; in the second, a short interview, also anonymous, was administered. We found Xyz in 37.6% of the collected syringes; the majority of the Xyz-containing syringes came from ranching communities. Syringes containing Xyz more frequently also contained "speedball" than those without (90.6% and 66.7%, respectively). Self-reports of Xyz injection deviated markedly from actual detection: only 50% (self-described users) and 22% (self-described non-users) of the collected syringes contained the drug. With a high prevalence of skin ulcers (38.5% vs. 6.8%; p<0.001), Xyz users were more likely to be in poor health compared to non-users. Surprisingly, though a higher percentage of Xyz users than non-users had college-level educations (23.1% vs. 5.5%), they were more likely to be homeless (64.1% vs. 37%).