HIV risk behaviors and alcohol intoxication among injection drug users in Puerto Rico

doi:10.1016/j.drugalcdep.2004.05.007

Drug and Alcohol Dependence

Volume 76, Issue 3, 7 December 2004, Pages 229-234

https://doi.org/10.1016/j.drugalcdep.2004.05.007 Get rights and content

Abstract

This paper reports results of an analysis of the association between alcohol intoxication and injection and sexual HIV risk behaviors among 557 Hispanic heroin and cocaine injectors, not in treatment, who were recruited in poor communities in Puerto Rico. Subjects were part of a longitudinal prevention-intervention study aimed at reducing drug use and HIV risk behaviors. Participants reported a high prevalence of co-occurring conditions, particularly symptoms of severe depression (52%) and severe anxiety (37%), measured by Beck’s Depression Index and Beck’s Anxiety Index, respectively. Alcohol intoxication during the last 30 days was reported by 18% of participants. Associations were found between alcohol intoxication and both injection and sexual risk behaviors. In the bivariate analysis, subjects reporting alcohol intoxication were more likely to inject three or more times per day, pool money to buy drugs, share needles, and share cotton. They were also significantly more likely to have a casual or paying sex partner and to have unprotected sex with these partners. After adjustment, sharing needles and cotton, having sex with a paying partner or casual partner, and exchanging sex for money or drugs were significantly related to alcohol intoxication. HIV prevention programs, to be effective, must address alcohol intoxication and its relation to injection and sexual risk behaviors as a central issue in HIV prevention among drug injectors.

Introduction

Multiple studies have shown that comorbid alcohol abuse and dependence are common among drug users (Kessler et al., 1997, Stein et al., 2000, Burns and Teesson, 2002). However, the relationship between alcohol use disorders and HIV risk behaviors among drug users has received less attention in the research community. This has been attributed to a perception among researchers, clinicians, and drug users that alcohol-related problems are of less importance compared with such problems as trauma and injury; overdose; depression; other health conditions such as HIV, hepatitis, and tuberculosis; and violent death that drug users are likely to suffer.

Moreover, most studies that have addressed HIV risk behaviors have been conducted among subjects enrolled in needle-exchange clinics or drug treatment programs, and have included mainly sexual risk behaviors (Rees et al., 2002, Thomas et al., 1991). Those studies addressing both injection-related and sexual risk behaviors have reported mixed findings. A recent study among patients in a drug detoxification program found alcohol consumption to be significantly associated with sexual risk behaviors but not with drug use-related risk behaviors (Rees et al., 2001). Fenaughty and Fisher (1998) reported that drug users classified as high risk on the basis of current and lifetime alcohol use patterns were significantly more likely to report multiple sex partners and inconsistent use of condoms than drug users without alcohol use. Stein et al. (2001) and Stein et al. (2000) reported that among drug users who were participants in a needle-exchange program, hazardous drinking was significantly associated with higher rates of drug use-related and sexual risk behaviors.

Injection drug use accounts for 50% of all AIDS cases in Puerto Rico (Puerto Rico Department of Health, 2003). The incidence of AIDS among injection drug users (IDUs) has placed the Island among the AIDS epicenters in the United States (Centers for Disease Control and Prevention, 2002). As in other sites in the US, the Island has recorded a decrease in the AIDS incidence rate. However, the prevalence of HIV risk behaviors among Hispanic IDUs in Puerto Rico has continued to be notably high compared with IDUs in other sites in the US, including Puerto Ricans residing in New York City (Deren et al., 2003a). This high rate of HIV risk behaviors among drug users in the Island has persisted even after 10 years of substantial prevention efforts by multiple service organizations, researchers, and drug treatment providers. This study is an effort to increase understanding of the association between alcohol intoxication and HIV risk behaviors among injection drug users in Puerto Rico. The goal is to search for injection drug users’ behaviors that may be related to HIV risk behaviors and that have not been addressed in previous epidemiological surveys and HIV prevention-intervention studies on comorbid substance use.

Section snippets

Subjects

Subjects in this analysis were recruited as part of a research project entitled, “Addressing HIV Risk and Health Care Needs under Managed Care,” a longitudinal experimental study designed to test the efficacy of a two-facet intervention (involving counseling and case management) in reducing drug use and HIV risk behaviors, encouraging participation in a drug treatment program, and increasing self-efficacy among drug injectors. Outreach workers recruited self-identified drug injectors, age 18

Results

Table 1 presents a general profile of the study sample including demographics, type of drug use, and health characteristics. Almost 90% of participants were males; 43% had completed high school; and 6% reported being homeless. The mean age for the sample was 30.0 years (S.D. = 8.7 years), with one-third of participants (36%) classified as young adults (18–24 years). Heroin and cocaine were the most frequently used drugs, each reported by over 90% of the sample. Marijuana and sedative use were

Discussion

Findings of the present study seem to suggest that, among drug injectors, the association between alcohol intoxication and both injection and sexual risk behaviors is straightforward. This differs from previous findings, including those of Stein et al. (2001), who reported that alcohol intoxication was associated with drug use risk behaviors but not with sexual behaviors, and Rees et al. (2001), who found alcohol consumption to be associated with sexual behaviors but not with injection risk

Acknowledgements

This study was supported by a grant from the National Institute on Drug Abuse of the National Institutes of Health (NIDA Grant No. 5 R01 DA10636).

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Rural and urban comparisons of polysubstance use profiles and associated injection behaviors among people who inject drugs in Puerto Rico
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In contrast to urban populations, little is known about polysubstance use among rural people who inject drugs (PWID), particularly in Puerto Rico where injection drug use and related health consequences are prevalent. The aim of the study is to compare injection and non-injection substance use profiles among separate urban and rural samples of Puerto Rican PWID.
Data for the urban sample come from 455 PWID who participated in the CDC’s National HIV Behavioral Surveillance survey of injection drug use in San Juan. The data for the rural sample come from 315 PWID residing in four rural cities approximately 40-miles from San Juan. Latent class analysis was used to derive separate urban and rural profiles of weekly injection and non-injection substance use. Injection behaviors were examined as possible correlates of latent class membership.
Five latent classes were identified in the urban sample, and three latent classes were identified in the rural sample. Classes were similar across samples; however, key differences emerged. Both samples had classes of primary heroin injectors, primary speedball injectors, and cocaine-heroin injectors. The urban sample had one high polysubstance class. Polysubstance use profiles that shared similar characteristics between samples also shared similar injection patterns, with some variation.
Variations in substance use patterns and associated health risks are likely shaped by social and geographic boundaries.
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Evidence relating alcohol use to risky drug use behaviors, however, is mixed. Some studies have found associations between alcohol use and risky injection behaviors (Matos et al., 2004), whereas others have found less evidence of such a relationship (Rash & Petry, 2009; Rees, Saitz, Horton, & Samet, 2001). For example, Rees et al. (2001) found no association between past-30-day alcohol use and recent risky injection behavior among illicit drug users.
People who inject drugs (PWID) are at increased risk of HIV infection. Although methadone maintenance therapy can help lower this risk, many methadone patients continue to engage in HIV risk behaviors, especially patients who use cocaine and alcohol. The purpose of the current study was to investigate relations between alcohol use disorders and HIV risk behavior in 239 cocaine-dependent methadone patients participating in a randomized controlled trial of a behavioral intervention to promote cocaine abstinence. Past 3-month HIV Risk-taking Behavior Scale (HRBS) scores were compared between cocaine-dependent methadone patients who met DSM-IV-TR diagnostic criteria for alcohol abuse or dependence and those who did not meet these criteria. No significant differences in HRBS drug subscale scores were observed between participants with and without alcohol use disorders, indicating risky drug use was similar between groups. However, alcohol use disorder was significantly associated with HRBS sex subscale scores (t = 2.59, p = 0.01), indicating participants with alcohol use disorders were more likely to engage in risky sexual behavior. Item-level analyses of the sex-related HRBS questions showed participants with alcohol use disorders were significantly more likely than participants without alcohol use disorders to have unprotected sex, engage in transactional (paid) sex, and have anal sex. Interventions are needed to reduce risky sexual behavior and attenuate the spread of HIV in this high-risk population.
Association between alcohol consumption and injection and sexual risk behaviors among people who inject drugs in rural Puerto Rico
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Despite this relative low prevalence of heavy quantity drinkers, the results show that both high frequency of binge drinking and high quantity alcohol consumption, compared to less frequent binge drinking and low quantity consumption, increase both risky injection and sexual risk behaviors conducive to HIV and HCV acquisition and transmission. These associations with both injection and sexual risk factors are consistent with past research among PWID (Arasteh & Des Jarlais, 2009; Le Marchand et al., 2013; Matos et al., 2004), and studies that separately analyzed injection (Hottes, Bruneau, & Daniel, 2011; Stein et al., 2000; Stein, Charuvastra, Maksad, & Anderson, 2002; Wang et al., 2014) and sexual risk (Stein, Charuvastra, Anderson, Sobota, & Friedmann, 2002). These results also support polysubstance use research among PWID, such that co-use of alcohol and other injection drugs predict increased risk of injection and sexual behavior, compared to primary use of one substance (Harrell et al., 2012; Keen et al., 2014).
Although alcohol use has been associated with risky behavior generally, the relationship between alcohol use and multiple types of risk behaviors that could lead to the acquisition and transmission of HIV and hepatitis C (HCV) among people who inject drugs (PWID) has not been fully examined. The current study seeks to contribute to the understanding of how alcohol use is related to both injection risk and sexual risk, among a non-treatment, cross-sectional sample of mostly male PWID in rural Puerto Rico (n = 315). “At-risk” alcohol use was defined as consuming ≥ 14 drinks per week for males and ≥ 7 drinks per week for females. Binge drinking frequency was defined as consuming ≥ 5 drinks on one occasion for males and ≥ 4 drinks on a single occasion for females. Multivariate regression models were used to examine the association between the alcohol use variables and injection and sexual risk outcomes, adjusting for demographic characteristics. Overall, 14% (n = 45) of the participants in this sample were considered at-risk drinkers (44% low risk drinkers and 42% alcohol abstainers), and participants reported binge drinking, on average, at least once per month. At-risk drinking, compared to low risk or no drinking, increased both injection and sexual risk behaviors. Frequency of past year binge drinking was also associated with both injection and sexual risk behaviors. Interventions aimed at reducing HIV and HCV transmission among injection drug users non-PWID networks should both target individuals who drink alcohol frequently and in high volumes, and include strategies for reducing risky behaviors while heavy drinking is occurring.
Low knowledge and perceived Hepatitis C risk despite high risk behaviour among injection drug users in Kathmandu, Nepal
2016, International Journal of Drug Policy
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When exploring correlates of risky injection behaviour, daily drinking proved to be an important predictor. The link between drinking and risky injecting practices is corroborated by past data from the study area (Poudel et al., 2010) as well as from the international research community (Matos et al., 2005; Stein et al., 2000). While less than a fifth of daily drinkers engaged in risky injection practices in the past week, the prevalence of risky injection was over three times that of non-daily drinkers.
In Nepal, prevalence of Hepatitis C (HCV) among injecting drug users (IDUs) has been measured at 50% and knowledge of the virus is low. Rehabilitation and harm reduction attendees constitute populations to whom health care providers can deliver services. As such, characterizing their drug use and risk profiles is important for developing targeted service delivery. We measured drug use and risk patterns of IDUs participating in residential rehabilitation as well as those contacted through needle exchanges to identify correlates of drug use frequency, risky injection practices as well as HCV testing, knowledge and perceived risk.
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Correlates of sharing injection equipment among male injecting drug users in Kathmandu, Nepal
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HIV prevalence is high and risky injection practices occur frequently among injecting drug users (IDUs) in Nepal. We explored the correlates of sharing injection equipment (having injected with a needle or syringe previously used by another) among male IDUs in Kathmandu, Nepal.
From August to September 2007, we anonymously interviewed 296 male IDUs in Kathmandu, Nepal, using a structured questionnaire. We performed bivariate and multivariable logistic regression analysis and identified variables associated with sharing injection equipment.
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IDUs who drank alcohol or who could not obtain new needles when needed were more likely to share injection equipment. Our results suggest that reducing alcohol use and increasing the availability of new needles and syringes might improve safer injection practices among male IDUs in Kathmandu, Nepal.
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We assess the association between time fixed and time varying participant characteristics and subsequent alcohol consumption in 1968 injection drug users (median age 37 years, 28% female, 90% African-American) followed semi-annually from 1988 to 2008. Median alcohol consumption was seven drinks per week at study entry (first and third quartile: 1, 26) with 36% reporting binge drinking. Alcohol consumption and binge drinking decreased over follow-up. Older individuals and women reported consuming fewer drinks per week. Higher typical alcohol consumption was reported by those participants who reported in the prior 6 months: non-injection cocaine use, injection drug use, having one or more sex partners, or among men, a same sex partner. Associations were generally similar for drinks per week and binge drinking. This study demonstrates that in a large urban cohort of persons with a history of injection drug use, risky drug use and sexual risk behavior are associated with subsequent alcohol consumption.

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HIV risk behaviors and alcohol intoxication among injection drug users in Puerto Rico

Abstract

Introduction

Section snippets

Subjects

Results

Discussion

Acknowledgements

Clin. Psychol. Rev

Drug Alcohol Depend

J. Affect. Disord

Drug Alcohol Depend

J. Subst. Abuse Treat

J. Subst. Abuse Treat

Eval. Program Plann

Between city variation in frequency of injection among Puerto Rican injection drug users: East Harlem, New York, and Bayamón, Puerto Rico

J. Acquir. Immune. Defic. Syndr

Migration and HIV risk behaviors: Puerto Rican drug injectors in New York City and Puerto Rico

Am. J. Public Health

Integrating qualitative and quantitative methods: comparing HIV-related risk behaviors among Puerto Rican drug users in Puerto Rico and New York

Subst. Use Misuse

High-risk sexual behavior among drug users. The utility of a typology of alcohol variables

Sex. Transm. Dis