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

Abstract

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.

Keywords

community-based interventions ethnography HIV people who use drugs Puerto Rico risk environments

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References

Aidala

A. A.

Wilson

M. G.

Shubert

Gogolishvili

Globerman

Rueda

. . . Rourke

S. B.

(2016). Housing status, medical care, and health outcomes among people living with HIV/AIDS: A systematic review. American Journal of Public Health, 106, e1-e23.

Asencio Toro

Burns

Pimentel

Sánchez Peraza

L. R.

Rivera Lugo

. (2006). Using a multisectoral approach to assess HIV/AIDS Services in the western region of Puerto Rico. American Journal of Public Health, 96, 995-1000.

Bourgois

(1998). Just another night in a shooting gallery. Theory, Culture & Society, 15(2), 37-66.

Carlson

Wang

Siegal

Falck

Guo

(1994). An ethnographic approach to targeted sampling: Problems and solutions in AIDS prevention research among injection drug and crack-cocaine users. Human Organization, 53, 279-286.

Centers for Disease Control and Prevention. (2009). Incidence and diagnoses of HIV infection—Puerto Rico, 2006. Morbidity and Mortality Weekly Report, 58(21), 589-591.

Centers for Disease Control and Prevention. (2016). Diagnoses of HIV infection in the United States and dependent areas, 2015 (HIV Surveillance Report No. 27). Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf

Colón

H. M.

Deren

Robles

R. R.

Kang

S.-Y.

Cabassa

Sahai

(2006). A comparative study of mortality among Puerto Rican injection drug users in East Harlem, New York, and Bayamon, Puerto Rico. Journal of Urban Health, 83, 1114-1126.

Colón

H. M.

Robles

R. R.

Deren

Sahai

Finlinson

H. A.

Andía

. . . Oliver-Vélez

(2001). Between-city variation in frequency of injection among Puerto Rican injection drug users: East Harlem, New York, and Bayamon, Puerto Rico. Journal of Acquired Immune Deficiency Syndromes, 27, 405-413.

Creswell

J. W.

(2012). Qualitative inquiry and research design: Choosing among five approaches. Thousand Oaks, CA: Sage.

10.

Deren

Gelpí-Acosta

Albizu-García

C. E.

González

Á.

Des Jarlais

D. C.

Santiago-Negrón

(2014). Addressing the HIV/AIDS epidemic among Puerto Rican people who inject drugs: The need for a multiregion approach. American Journal of Public Health, 104, 2030-2036.

11.

Deren

Kang

S.-Y.

Colón

H. M.

Andia

J. F.

Robles

R. R.

Oliver-Velez

Finlinson

(2003). Migration and HIV risk behaviors: Puerto Rican drug injectors in New York City and Puerto Rico. American Journal of Public Health, 93,812-816.

12.

Deren

Kang

S.-Y.

Colón

H. M.

Robles

R. R.

(2007). The Puerto Rico-New York airbridge for drug users: Description and relationship to HIV risk behaviors. Journal of Urban Health, 84, 243-254.

13.

Emerson

R. M.

Fretz

R. I.

Shaw

L. L.

(2011). Writing ethnographic fieldnotes (2nd ed.). Chicago, IL: University of Chicago Press.

14.

Finlinson

Colón

Robles

Deren

López

Muñoz

(1999). Access to sterile syringes by injection drug users in Puerto Rico. Human Organization, 58, 201-211.

15.

Finlinson

H. A.

Oliver-Vélez

Deren

Cant

J. G. H.

Colón

H. M.

Robles

R. R.

. . . Andía

J. F.

(2006). 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. Substance Use & Misuse, 41, 1313-1336.

16.

Friedman

S. R.

Kang

S.-Y.

Deren

Robles

Colón

H. M.

Andia

. . . Finlinson

(2002). Drug-scene roles and HIV risk among Puerto Rican injection drug users in East Harlem, New York and Bayamón, Puerto Rico. Journal of Psychoactive Drugs, 34, 363-369.

17.

Garcia

Colson

P. W.

Parker

Hirsch

J. S.

(2015). Passing the baton: Community-based ethnography to design a randomized clinical trial on the effectiveness of oral pre-exposure prophylaxis for HIV prevention among black men who have sex with men. Contemporary Clinical Trials, 45, 244-251.

18.

Leff

J. A.

Hernández

Teixeira

P. A.

Castellón

P. C.

Feaster

D. J.

Rodriguez

A. E.

. . . Schackman

B. R.

(2017). The structural and health policy environment for delivering integrated HIV and substance use disorder treatments in Puerto Rico. BMC Health Services Research, 17(1), 232.

19.

Maher

White

Donald

Bates

Enriquez

Pham

Liao

(2010). Using ethnographic fieldwork to inform hepatitis C vaccine preparedness studies with people who inject drugs. International Journal on Drug Policy, 21, 194-201.

20.

Messac

Ciccarone

Draine

Bourgois

(2013). The good-enough science-and-politics of anthropological collaboration with evidence-based clinical research: Four ethnographic case studies. Social Science & Medicine, 99, 176-186.

21.

Mino

Deren

Colón

H. M.

(2011). HIV and drug use in Puerto Rico: Findings from the ARIBBA study. Journal of the International Association of Physicians in AIDS Care, 10, 248-259.

22.

Needle

R. H.

Trotter

R. T.

Singer

Bates

Page

J. B.

Metzger

Marcelin

L. H.

(2003). Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority communities: An approach for timely community interventions. American Journal of Public Health, 93, 970-979.

23.

Oliver-Velez

Deren

Finlinson

Shedlin

Robles

R. R.

Andia

. . . Kang

S. Y.

(2003). Sexual risk behaviors of Puerto Rican drug users in East Harlem New York and Bayamón, Puerto Rico. Culture, Health & Sexuality, 5, 19-35.

24.

Padgett

D. K.

Stanhope

Henwood

B. F.

Stefancic

(2011). Substance use outcomes among homeless clients with serious mental illness: Comparing housing first with treatment first programs. Community Mental Health Journal, 47, 227-232.

25.

Puerto Rico Department of Health. (2015). CDC national HIV behavioral surveillance, Injection Drug Use Cycle 4 [Data file]. San Juan, Puerto Rico: Author.

26.

Puerto Rico Department of Health. (2017). Puerto Rico HIV/AIDS surveillance system (Data reported through 03/31/2017) [Surveillance data system]. San Juan, Puerto Rico: Author.

27.

Reyes

J. C.

Negrón

J. L.

Colón

H. M.

Padilla

A. M.

Millán

M. Y.

Matos

T. D.

Robles

R. R.

(2012). The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico. Journal of Urban Health, 89, 519-526.

28.

Rhodes

(2002). The “risk environment”: A framework for understanding and reducing drug-related harm. International Journal of Drug Policy, 13, 85-94.

29.

Robles

R. R.

Marrero

C. A.

Reyes

J. C.

Colón

H. M.

Matos

T. D.

Finlinson

H. A.

. . . Sahai

(1998). Risk behaviors, HIV seropositivity, and tuberculosis infection in injecting drug users who operate shooting galleries in Puerto Rico. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 17, 477-483.

30.

Robles

R. R.

Matos

T. D.

Colón

H. M.

Deren

Reyes

J. C.

Andía

. . . Sahai

(2003). Determinants of health care use among Puerto Rican drug users in Puerto Rico and New York City. Clinical Infectious Diseases, 37(Suppl. 5), S392-S403.

31.

Robles

R. R.

Matos

T. D.

Colón

H. M.

Sahai

Reyes

J. C.

Marrero

C. A.

Calderón

J. M.

(2003). Mortality among Hispanic drug users in Puerto Rico. Puerto Rico Health Sciences Journal, 22, 369-376.

32.

Roman

(2015). The Puerto Rico healthcare crisis. Annals of the American Thoracic Society, 12, 1760-1763.

33.

Schensul

S. L.

Saggurti

Singh

Verma

R. K.

Nastasi

B. K.

Mazumder

P. G.

(2009). Multilevel perspectives on community intervention: An example from an Indo-US HIV prevention project in Mumbai, India. American Journal of Community Psychology, 43, 277-291.

34.

Schensul

S. L.

Schensul

J. J.

LeCompte

M. D.

(1999). Essential ethnographic methods: Observations, interviews, and questionnaires (Vol. 2). Walnut Creek, CA: Altamira Press.

35.

Semaan

Lauby

Liebman

(2002). Street and network sampling in evaluation studies of HIV risk-reduction interventions. AIDS Reviews, 4, 213-223.

36.

Torruella

R. A.

(2011). Xylazine (veterinary sedative) use in Puerto Rico. Substance Abuse Treatment, Prevention, and Policy, 6, 7.

37.

Trickett

E. J.

Pequegnat

(Eds.). (2005). Community Interventions and AIDS (1st ed.). New York, NY: Oxford University Press.

38.

U.S. National Library of Medicine. (2013). Enhanced access to HIV care for drug users in San Juan, Puerto Rico (Identifier NCT01792752). Retrieved from http://clinicaltrials.gov/ct2/show/NCT01792752