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

El Caribe, varios idiomas y muchas culturas, unidos para combatir el VIH/SIDA

Santo 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

Sherry Deren, Ph.D. National Development &Research Institutes, Inc. Center for Drug Use & HIV Research New York, New York

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)

Source: HIV/AIDS Surveillance Report, Cases reported through December 2002, CDC 2002

Latin America and the Caribbean: Cumulative AIDS Cases in “The Top 10” Countries as Percent of Total Population

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

Brazil Mexico PuertoRico

Argentina Peru Honduras Columbia Haiti DominicanRepublic

Jamaica

Source: AIDS Surveillance in the Americas, PAHO, 2002

Per

cent

of

Pop

ulat

ion

24

17

2

50

7IDU Heterosexual MSM Other/not reported MSM & IDU

Risk Categories of AIDS Cases in Puerto Rico(Cumulative cases as of April 2003)

Source: Puerto Rican Department of Health, April 2003

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

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

Higher HIV-Related Risk BehaviorsIn Puerto Rico

Injection-Related Risk Behaviors(prior 30 days)

184

76

0

50

100

150

200

Frequency of Injection***

#

***p<.001

New York

Puerto Rico

Source: ARIBBA Baseline Data

#

6

2.9

0

4

8

# Times each Syringe Used***

Injection –Related Sharing Behaviors

***p<.001

New York (n=561)

Puerto Rico (n=313)

207

31

8

34

7

52

100

20

40

60

80

100

Used others’ needles***

Loaned others your needle***

Shared your cooker with others***

%

Used others’ cookers***

Source: ARIBBA Baseline Data

Used shooting galleries***

Pooled money to buy drugs***

79

23

72

44

0

20

40

60

80

100

%

Incarceration and HIV Risk Behavior(During Last Incarceration Episode)

Puerto Rico New York

Incarceration risksInjected while incarcerated*** 31% 12% if yes, shared equipment** 74% 52%

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

Sex-Related HIV Risk Behaviors (prior 30 days)

IDUs a Crack UsersPR NY PR NY

Engaged in sex 45% 58%*** 76% 70%

Traded sexMales 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<.001Source: ARIBBA Baseline Data

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)

15.2

69.4

79

99.2

12.2

66.1

8.3

58.1

0

10

20

30

40

50

60

70

80

90

100

Referred to drug Tx

***

ReceivedCondoms

***

Referred toTB testing

***

Referred toHIV testing

***

%

Services Received

Puerto Rico

New York

3.0 2.89

104.5

0

10

20

30

40

50

60

70

80

90

100

110

# times accessed

# syringes obtained***

#

NEP Use

Source: ARIBBA Baseline Data ***p<.001

4.5

63.3

2.1 2.1

18

3.75.1

12.3

0

10

20

30

40

50

60

70 Puerto Rico (n=334)

New York (n=617)

Drug Treatment Services (prior 6 months)

MMTP*** Outpatient In-patient*** Prison-based***

Source: ARIBBA 6 Month Follow-up Interview ***p<.001

%

%

Use of Health Services and HIV Medications (Prior 6 Months)

3

18.6

5

65

2.7

17.821.5

51.7

0

20

40

60

80

100

Inpatient*** Outpatient*** Mental Health*** Taking HIVMeds(among HIV+

participants)***

Puerto Rico (n=334)New York (n=617)

***p<.001Source: ARIBBA 6 Month Follow-up Interview

Higher HIVIncidence in Puerto Rico

0.88

3.37

0.0

1.0

2.0

3.0

4.0

5.0

Ser

oinc

iden

ce (

per

100P

Y)

HIV Seroincidence RatesAs of November 2002 there were a total of 32 serovonverters, 9 in NY and 23

in PR

Source: ARIBBA Baseline and Follow-up Data (as of November 2002) p<.0001

NY (1,019 py) PR (683 py)

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

0

2000

4000

6000

8000

10000

Government CBO Lay CBO Faith PPP

1998 (14,209) 2002 (8,305)

#

Higher Mortality Rates in Puerto Rico

1.5

4.6

0.0

1.0

2.0

3.0

4.0

5.0

New York (2,522 py) Puerto Rico (1,141 py)

Dea

th R

ates

per

100

py

Preliminary Mortality Rates of ARIBBA Participants

Source: National Death Index, CDC, as of December 2001

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

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Puerto Rico 3.3 2.9 4.5 6.0 6.9 9.9 7.0 11.5 8.6 9.1 11.1

New York 1.9 3.9 4.2 5.2 5.2 5.1 4.5 4.9 4.4 4.4 3.5

United States 1.8 2.0 2.3 2.8 3.0 3.0 3.1 3.3 3.6 4.4 4.5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

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

CDARIThe Caribbean

Drug Abuse Research Institute

HIV Risk Behaviors Among Homeless

Out-of-Treatment Drug Users In Two Caribbean States

Port of Spain, Trinidad and

Castries, Saint Lucia

Authors:Marcus Day, Jessy G. Devieux, Sandra D. Reid, Dionne J.

Jones,Joseph Meharris, and Robert Malow

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 DayDirector The Caribbean Drug Abuse Research Institute

IntroductionThe 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.

BACKGROUNDIn 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.

BACKGROUNDNumerous NIH supported research have

shown that crack consumption promotes:

physical and mental ill health

homelessness

loss of jobs

undoing of families

incarceration

violence 

MethodA 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

MethodInterviewers 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

The ProblemNo 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

Participants

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)

Age Left School

School Leaving Age

11.5%

55.8%

29.5%

3.2%

0%10%20%30%

40%50%60%70%

8-12 yrs 13-15 yrs 16-19 yrs 20-22 yrs

EducationHighest Level of Education

37.0%

2.7% 2.7% 4.2%

53.4%

0%

10%

20%

30%

40%

50%

60%

70%

Primary Secondary Diploma Tertiary Tradediploma

Currently WorkingCurrently Working

28.4%

71.6%

0%10%20%30%40%50%60%70%80%90%

Yes No

Occupation

Primary Occupation

16.1%8.1%

30.7% 27.4%

1.6%

14.5%

1.6%0%

10%

20%

30%

40%

50%

Marital Status

Never Married 79.6%

Married 12.2%

Divorced 8.2%

Number of Children

Number of Children

20.8%

51.4%

27.8%

0%

10%

20%

30%

40%

50%

60%

70%

No Children 1-3 Children >3 Children

Results

Criminal Justice ContactEver Been Arrested

86.5%

13.5%

0%

20%

40%

60%

80%

100%

Yes No

Victim of ViolenceVictim of Violence

72.2%64.6%

0%

20%

40%

60%

80%

100%

Victim of Violence N=71 Need Medical Care N=48

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”).

30 Day Drug Use30 Day Drug Use

95%

57%

4%

0%

20%

40%

60%

80%

100%

CRACK COCAINE MARIJUANA HEROIN

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.

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

Crack Initiation The majority (76.6%) reported that their first

experiences with crack occurred with a friend and that their friend gave them (they did not pay) for their first “rock”.

More than half of all respondents became regular users within weeks after their introduction to crack.

Significant gender differences were found in Trinidad, where 56% of females reported being introduced to crack by a friend, compared to 81% of males.

Perceived Dangers of Crack

Before using crack, the majority of respondents believed that crack was “not at all dangerous” or “did not know” it was dangerous,

At the time of the interview, almost 90% reported that they now felt that crack was “very dangerous.”

A majority of respondents attributed their homelessness to their crack use.

ConclusionsMost respondents reported becoming regular

users within weeks after being introduced to crack.

The majority of respondents who were HIV positive reported using condoms infrequently.

Prior to their introduction to crack,

respondents appeared to have little knowledge of the dangers associated with its use. This raises the question of the effectiveness of drug prevention education in these Caribbean islands.

Conclusions Males and females in both countries admitted

to engaging in high-risk behaviours such as trading sex for drugs or money and having unprotected intercourse.

These findings point to the urgent need to design culturally tailored interventions, including intensive educational programs with this population of homeless drug users who are at high risk for transmitting the virus to their partners

Prevention education targeting non-crack users need to be “substance specific rather than the current “generic all drugs are equally villenous” education programmes currently in place

Drug Use in the Dominican Republic and its connection to HIV/AIDS:

an exploratory study

Michele Shedlin,Ph.D.*,Francisco I. Cáceres Ureña,Ph.D.**,

and Sherry Deren,Ph.D.*

*National Development and Research Institutes, Inc. (NDRI)** Asociación Dominicana Pro-Bienestar de la Familia (PROFAMILIA)

El consumo de drogas en la República Dominicana y su vínculo con el

VIH/SIDA: un estudio exploratorio

Acknowledgements

National Institute on Drug Use (NIDA), National Institutes of Health (NIH)

Asociación Dominicana Pro-Bienestar de la Familia (PROFAMILIA) (DR)

National Development and Research Institutes, Institute for AIDS Research (NDRI) (NY)

Programa de Prevención del Uso Indebido de Drogas (PROPUID) (DR)

Universidad Central del Caribe, Centro de Estudios de Adicción (PR)

Range of Drugs Used

Crack Cocaine Marijuana Morphine Heroin Ecstasy

Special K Speed Mushrooms PCP Hashish

Drugs mentioned by users included:

Pharmaceuticals  ("fármacos") reported:

Percodan Sinicuon Tussionex

Demerol Taffil

Codeina Tonopan Diazepan Roignol Tiamon

Catgon Ambenil Baralgina Valium Fringamol

Rothiphenol

Tincent Ativan Novain Mandrax

Sani Optacidon

Largatil Orocepan

Amberil

Study Sample: Injectors

45% have injected sometime

69% (of injectors) have shared needles

Study Sample: Use of Protection

65% do not protect against STIs and AIDS 85% students60% upper middle class42% gay men70% sex workers 39% prisoners44% persons in treatment40% heroin users

Study Sample: Non-sex workers who have

sex for money and/or drugs 23% students77% prisoners50% persons in treatment20% heroin users92% gay men100% sex workers

Awareness of Drug Use

“There is a grave problem of drug use in our country that over time, through the years, has grown so that today we have a palpable problem …”

“Dentro de nuestro país, hay un grave problema de consumo de drogas que con el tiempo, a medida de los años, se ha ido acrecentando hasta llegar a ser hoy, una problemática palpable...”

Awareness of Drug Use – Cont.

“…here in the Dominican Republic there are a lot of drugs everywhere...I don’t know why they try to cover the sun with a finger and say ‘there isn’t’…”

“...aquí en la República Dominicana hay mucha droga por donde quiera...yo no sé por qué tratan de tapar el sol con un dedo y dicen que ‘no’…”

Awareness of Drug Use – Cont.

 “there does not seem to be reliable data on drug use. ...there is an information crisis”

“no parece haber muchos datos confiables sobre el consumo de drogas. ...hay una crisis de información”

The Drug “Bridge”

“It [the country] is not only a bridge, but is becoming a large consumer…”

“No solamente [el país] es puente sino se está convirtiendo en un gran consumidor...”

The Drug “Bridge” - Cont.

“trafficking means that a large part stays here to sell and consume”

“it’s a business like any other business, the only difference is that it’s prohibited”

Relationship Between Selling and Use

“In most of the cases, everyone that sells uses because, as a man near my house says, ‘if I am selling oranges, I need to know if the orange is good’…”  

“En la mayoría de los casos, todo el que vende consume porque es como dice un señor por mi casa, ‘si yo vendo china, yo tengo que saber si la china es buena’...”

Crisis of Values Perceived

“The crisis of our own values in this society is a product of the pressures of poverty and modernization...a series of factors intervene: media, the influence of North American society, the migration of Dominicans to the U.S....to the point where a family here in the country doesn’t care if their relative is selling drugs...what is important are better economic conditions...”

“la crisis de los valores propios de nuestra sociedad [es] producto de la presión de la pobreza y producto de ese proceso de modernización... intervienen una serie de factores: los medios de comunicación; la influencia de la sociedad norteamericana; la migración de los Dominicanos hacia EEUU....a tal punto que a una familia aquí en el país no le importa que su familiar esté vendiendo droga....lo importante es que mejore las condiciones económicas”

Barrio Youth

“Here there are many youth that we are losing; they are slipping through our hands and we are not paying attention…”

“Aquí hay mucha juventud que se nos está perdiendo, se nos está yendo de la mano y no nos estamos dando cuenta...”

“The drugs in the schools...the situation now is alarming…”

“Las drogas en las escuelas...es alarmante la situación ahora mismo...”

Barrio Youth – Cont.

Students report perceived high risk for marijuana (63%), crack (61%) and cocaine (56%); regular use of inhalants (50%) 

1% perceived no risk for marijuana or crack and 0.7% saw no risk for cocaine use.

[Encuesta Nacional de Escolares (PACARDO 2000)]

Women “…women [users] are viewed as much worse

because of their children...their role as mother educating those children...I mean, they question more the fact that she uses drugs, much more than the father”.

 “...la gente ve mucho peor la mujer por los hijos...con su rol de madre debe educar esos muchachos...es decir, cuestionan mucho el hecho de que ella consuma drogas, mucho más que el padre”.

“…women are always blamed more for all sorts of things”

“...siempre es más condenada la mujer en todos tipos de cosas”

Gay Men

“...there are guys that when they are going to have sex with you, the first thing they say is, ‘if there is no coke I won’t go to bed with you’...”

“...hay muchachos que cuando van a tener sexo con uno lo primero que dicen es ‘si no hay perico, no me acuesto contigo’…”

Effects of Tourism, Out-Migration & Returning Deportees

“…we suffer from a serious problem which is that we are recipients of many cultures...the fact that the Dominican creates a style of life that is not real but rather is based on lifestyles adopted from other cultures”

“...sufrimos un grave problema que es que nosotros somos receptores de múltiples culturas...el hecho que el Dominicano cree una forma de vida que no es real sino son formas de vida adoptadas de otras culturas...”

Effects of Tourism, Out-Migration & Returning Deportees – Cont.

“…the major influence in our country is New York, this is undeniable, New York is where there is the most drug use”

“...la mayor influencia en nuestro país viene de Nueva York, eso es innegable...es de Nueva York que es donde más, donde más se consume...”

Effects of Tourism, Out Migration & Returning Deportees – Cont.

“...looking for a new way of life, the Dominican who emigrates to New York returns frequently 3-4 times a year for special dates such as Mother’s Day, Christmas, Easter, Carnaval, the Merengue Festival. In each of these trips for these holidays, with them comes a new system...the vice that is crack...”

 “..ese Dominicano que emigra a Nueva York viene frequentemente...en cada una de esas venidas...con ellos traen un nuevo sistema de vicio que es el crack...”

Relationship of Drug Use & HIV

“We don’t yet understand that the drug addict has an illness and that the person with AIDS is also another sick person; for us Dominicans, it is an affront, something shameful...”

 “Todavía no tenemos conciencia de que el drogadicto es un enfermo y de que él que tiene SIDA también es otro enfermo...para nosotros los Dominicanos, es una afrenta, es una vergüenza...”

Recommendations

Policy

1. Acknowledge and identify the problem of drug use and addiction in the population

2. Separate trafficking and consumption as policy issues

3. Clearly establish the link between HIV/AIDS and drug use

Recommendations

Policy

4. Re-enforce traditional values which work to support prevention and treatment

5. Respond quickly to the growing drug crisis in youth

6. Develop and implement education and

prevention activities in all sectors of the population, not only the most vulnerable and involved

Recommendations

Programs

1. Prevention education and treatment alternatives are clearly indicated

2. A resource assessment is needed which will permit the support of already existing efforts by community- based agencies and others; mobilize the community to create “protected micro-environments”

[‘micro-ambientes protectores’]

Thank you for your attention.

Muchas gracias por su atención.

Por favor deje su auricular en su silla.

Veuillez laisser le casque d'écoute sur votre chaise.

Laat uw koptelefoons s.v.p. in uw stoel liggen.

Please leave your headphones on your chair.

Por favor deje su auricular en su silla.

Veuillez laisser le casque d'écoute sur votre chaise.

Laat uw koptelefoons s.v.p. in uw stoel liggen.

Please leave your headphones on your chair.