2. Hector Colón, Ph.D., Rafaela Robles, Ed.D. Centro de Estudios en Adicción Universidad Central del Caribe Bayamón, 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

3. 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 27 th in population size (3.8 million people). However, Puerto Rico has the: 8 th highest cumulative number of AIDS cases among adults/adolescents (26,847) as December 2002 5 th 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

4. Latin America and the Caribbean: Cumulative AIDS Cases in The Top 10 Countries as Percent of Total Population Source: AIDS Surveillance in the Americas, PAHO, 2002 Percent of Population

5. Risk Categories of AIDS Cases in Puerto Rico (Cumulative cases as of April 2003) Source: Puerto Rican Department of Health, April 2003

6. 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

7. 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

8. Higher HIV-Related Risk Behaviors In Puerto Rico

9. Injection-Related Risk Behaviors (prior 30 days) Frequency of Injection*** # ***p<.001 New York Puerto Rico Source: ARIBBA Baseline Data # # Times each Syringe Used***

10. Injection –Related Sharing Behaviors ***p<.001 New York (n=561) Puerto Rico (n=313) 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*** %

11. Incarceration and HIV Risk Behavior (During Last Incarceration Episode) Puerto Rico New York Incarceration risks Injected while incarcerated*** 31%12% if yes, shared equipment**74%52% Source: ARIBBA Baseline Data **p<.01 ; *** p<.001

12. Sex-Related HIV Risk Behaviors (prior 30 days) IDUs a Crack Users PRNYPR NY Engaged in sex 45% 58%*** 76% 70% Traded sex Males 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<.001 Source: ARIBBA Baseline Data

13. Drug Users in Puerto Rico Have Less Access to HIV Prevention and Other Health Services

14. NEP Use and Services Received from NEPs (prior 30 days) Referred to drug Tx *** Received Condoms *** Referred to TB testing *** Referred to HIV testing *** % Services Received Puerto Rico New York # times accessed # syringes obtained*** # NEP Use Source: ARIBBA Baseline Data ***p<.001

15. Puerto Rico (n=334) New York (n=617) Drug Treatment Services (prior 6 months) MMTP***OutpatientIn-patient***Prison-based*** Source: ARIBBA 6 Month Follow-up Interview ***p<.001 %

16. % Use of Health Services and HIV Medications (Prior 6 Months) Puerto Rico (n=334) New York (n=617) ***p<.001Source: ARIBBA 6 Month Follow-up Interview

17. Higher HIV Incidence in Puerto Rico

18. Seroincidence (per 100PY) HIV Seroincidence Rates As 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)

19. Declining Drug Treatment Services in Puerto Rico

20. Drug Treatment Services in Puerto Rico: Patients Treated (for drugs, last month), by Type of Provider and Survey Year #

21. Higher Mortality Rates in Puerto Rico

22. Death Rates per 100 py Preliminary Mortality Rates of ARIBBA Participants Source: National Death Index, CDC, as of December 2001

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

24. Conclusions and Recommendations

25. 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

27. CDARI The Caribbean Drug Abuse Research Institute

28. 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

29. 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 Day Director The Caribbean Drug Abuse Research Institute

30. Introduction The 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.

31. BACKGROUND In 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.

32. BACKGROUND Numerous NIH supported research have shown that crack consumption promotes: physical and mental ill health homelessness loss of jobs undoing of families incarceration violence

33. Method A convenience sample of homeless 1 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

34. Method Interviewers 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

35. The Problem No 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

36. Participants

37. 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)

38. Age Left School

39. Education

40. Currently Working

41. Occupation

42. Marital Status Never Married 79.6% Married 12.2% Divorced 8.2%

43. Number of Children

44. Results

45. Criminal Justice Contact

46. Victim of Violence

47. 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 dont know).

48. 30 Day Drug Use

49. 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.

50. 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

51. 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.

52. 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.

53. Conclusions Most 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.

54. 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

56. 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

57. 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)

59. Range of Drugs Used Crack Cocaine Marijuana Morphine Heroin Ecstasy Special K Speed Mushrooms PCP Hashish Drugs mentioned by users included:

60. Pharmaceuticals ("fármacos") reported: PercodanSinicuonTussionexDemerolTaffil CodeinaTonopanDiazepanRoignolTiamon CatgonAmbenilBaralginaValiumFringamol RothiphenolTincentAtivanNovainMandrax SaniOptacidonLargatilOrocepanAmberil

61. Study Sample: Injectors 45% have injected sometime 69% (of injectors) have shared needles

62. Study Sample: Use of Protection 65% do not protect against STIs and AIDS 85% students 60% upper middle class 42% gay men 70% sex workers 39% prisoners 44% persons in treatment 40% heroin users

63. Study Sample: Non-sex workers who have sex for money and/or drugs 23% students 77% prisoners 50% persons in treatment 20% heroin users 92% gay men 100% sex workers

66. 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...

67. Awareness of Drug Use – Cont. …here in the Dominican Republic there are a lot of drugs everywhere...I dont know why they try to cover the sun with a finger and say there isnt…...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…

68. 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

69. The Drug Bridge It [the country] is not only a bridge, but is becoming a large consumer… No solamente [el pa í s] es puente sino se está convirtiendo en un gran consumidor...

70. The Drug Bridge - Cont. trafficking means that a large part stays here to sell and consume its a business like any other business, the only difference is that its prohibited

71. 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...

72. 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 doesnt care if their relative is selling drugs...what is important are better economic conditions...

73. 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

74. 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...

75. 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)]

76. 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

77. 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 wont 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…

78. 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...

79. 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...

80. 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 Mothers 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...

81. Relationship of Drug Use & HIV We dont 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...

82. 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

83. 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

84. 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]

85. Thank you for your attention. Muchas gracias por su atención.

86. 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.