Richard S. Garfein, PhD

Professor Division of Global Public Health

UCSD School of Medicine

(April 11, 2014)

Objectives Describe the harms of injection drug use

Describe an ongoing cohort study of injection drug

users (IDUs) in San Diego

Share preliminary findings from the study

Why talk about injection drug use?

Health impacts HIV/AIDS HCV, HBV Other STDs Bacterial infections Tuberculosis Overdose

Social impacts Economic costs

Medical care Law enforcement Lost productivity

Crime Lost potential

Source: UNODC 2013.

UNODC and Reference Group to the United Nations on HIV and Injecting Drug Use.

Prevalence of HIV among IDUs

Source: Mathers et al., 2008

Nature Medicine 19, 850–858 (2013)

Global Prevalence of HCV

Lancet. 2011 Aug 13;378(9791):571-83. Jul 27.

Prevalence of HCV among IDUs

CIDUS II - HIV, HBV, and HCV Seroprevalence among 18-30 Year Old IDUs

City

0 10 20 30 40 50 60 70 80 90

100

Prev

alen

ce (%

) HCV HBV HIV

Garfein, et al.

CIDUS II - Prevalence and Incidence of Viral Infections among 18-30 y.o. IDUs

Prevalence Incidence

N (% pos)

N

# pos Rate

/100 PY

95% CI

HIV 2,181 ( 4.7) 1,050 12 1.3 ( 0.6 - 2.0)

HBV 2,071 (22.2) 800 76 11.3 ( 8.9 -13.7)

HCV 2,074 (36.2) 673 83 15.6 (12.6-18.6)

Garfein, et al.

Thomas, et al, Nature Medicine 19, 850–858 (2013)

HCV Infection Prevalence by Frequency of Selected Groups in the US Population

Hemophilia patients

0 5 10 15 20 80 90 100 Percentage

Injection Drug Users

Dialysis patients

STD patients

Healthcare workers

General population

HCV Group

Gro

up

Volunteer Blood Donors

Injection Preparation Table, Pakistan

Carefully open sterile water, dissolve medication in sterile vial, fill syringe.

Avoid using multidose vials.

Clean patient’s skin, inject into anticubital vein, safely discard syringe.

Importance of HIV and TB Among individuals with latent TB infection (LTBI), the

LIFETIME risk of reactivation is 5%-10%

Among HIV infected individuals with LTBI, the risk reactivation is 10% PER YEAR

TB is a leading cause of death among AIDS patients worldwide

Reported TB Cases, United States, 1982–2009

1985-1992 Resurgence

11,545 cases reported nationwide in 2009

CA

AZ NM

TX

SON CHI

COH

TAM NL

B.C.

NATIONAL

BORDER

Cases

13,142

4,180

Rate*

4.2

6.8

NATIONAL

BORDER

Cases

15,649

4,290

Rate*

14.1

25.7

* Rate = cases per 100,000 population

26.4 17.1

16.5

31.9

40.5

19.9

7.0

3.5 3.0

6.2

Adapted from: Schneider E, et al. Rev Panam Salud Publica. 2004;16(1):23–34.

Mexico and U.S. Tuberculosis Incidence Rates* By State

San Diego: 8.4

Tijuana: 46.1

CDC, 2008; CDPH, 2008; DGEPI Mexico, 2008; INEGI, 2005; SINAVE, 2007.

Seroprevalence among IDUs in the US/Mexico Border Region

San Diego Tijuana HIV 4.2%a 4%-10%b

HCV 26.9%a 96%c

Mtb 14.6%d 67%e

a Garfein, et al. J Urban Health. 2013 Jun;90(3):516-28. b Strathdee, et al. Lancet 2010; 376(9737):268-284 c White, et al., Salud Publica Mex. 2007 May–Jun; 49(3): 165–172 d Among HIV+ IDU, UCSD CFAR 2010 e Garfein, et al. Emerg Infect Dis, 2010 May

New Mexican Drug Law Aug. 2009 – Mexico passed a law decriminalizing

possession of “personal size” quantities of illicit drugs

First two offenses optional drug treatment

Third offence mandatory drug treatment or jail

STAHR II: Study of TB, AIDS, and Hepatitis C Risk

Design: Longitudinal, mixed-methods, cohort study

Dates: August 2011 - May 2016

Study Locations: San Diego County Hillcrest storefront Mobile unit parked in National City and Escondido Mobile unit parked at venues around county

STAHR II: Specific Aims Aim 1: To identify sociodemographic, behavioral, and

health status differences between IDUs in San Diego who do and do not inject in Mexico.

Aim 2: To describe changes in San Diegan IDUs’ knowledge, attitudes, and experiences related to drug policy reforms in Mexico and assess their influences on decisions about injecting in Mexico.

Aim 3: To determine whether IDUs from San Diego who inject in Mexico are at increased risk for incident HCV and Mtb infection compared to IDUs who do not inject in Mexico and identify risk factors for infection.

STAHR II: Eligibility Criteria • >18 years old

• Speaks English or Spanish

• San Diego resident planning to stay >24 months

• Injected within the last 30 days

• Agrees to provide contact information

• Agrees to a blood draw for HIV, HCV and Mtb testing

Recruitment Street outreach

Targeted advertising

Community referrals

Magazine ads

Mobile Unit

STAHR II Recruitment Sites

Procedures • Eligibility screening (5-10 minutes)

• Obtain written informed consent

• Interviewed about sociodemographics, risk behaviors, health status, travel to Mexico, knowledge of drug laws

• Serologic testing and counseling for HIV, HCV and Mtb (QuantiFERON TB Gold [QFT]) infections

• Interviews and serologic testing repeated at 6, 12, 18, and 24 months for those previously tested negative

Qualitative Interviews Purpose:

provide insight into the quantitative findings explore emerging issues inform subsequent rounds of quantitative interviews validate interpretations (member checking)

Occur after each wave of quantitative visits N=20 per cycle Purposive sampling based on assessment interview

responses (e.g., travel to Mexico) Reimbursement: $30

Incentives for Participation Participants compensated according to the following schedule:

Baseline and 6 Month Assessment: $25

12-month Assessment : $30

18-month Assessment : $35

24-month Assessment : $50

Plus $10 for result visit after each assessment visit

Plus $5 for updating their contact information between visits at 3, 9, 15 and 21 months

Enrollment June 4, 2012 to January 6, 2014

726 – Screened for eligibility

662 via storefront 64 via mobile unit

579 – Enrolled 40 – Qualitative interviews

STAHR II: Enrollment Status

Results: Demographics Mean age: 43.4 years (range: 18-70) Male: 73%, Transgender: 1.1% Race/ethnicity

Black: 8.8% Hispanic: 31% White: 51% Other: 9.2%

Born in Mexico: 2.5% Ever Homeless: 61%

Question 1 What is the prevalence of HIV among IDUs in San Diego?

1. 0.9% 2. 5.0% 3. 9.5% 4. 12.9% 5. 15.1%

HIV+ = 52/545 = 9.5% HCV+ = 359/545 = 65.9% QFT+ = 117/500 = 23.4%

Results: Baseline Serostatus

Question 2 Is QFT-positivity similar among HIV+ and HIV- IDUs in San Diego?

1. The same 2. Higher among HIV+ 3. Higher among HIV-

Results: Co-Infection

HIV+ n (%)

HIV- n (%)

HCV+ 26 (50.0%) 335 (67.5%)

QFT+ 45 ( 8.2%) 114 (25.6%)

QFT +/- 0 ( 0.0%) 2 ( 0.5%)

Results: Travel to Mexico

Ever

Past 6 Months

Traveled to Mexico 87% 28% Bought drugs in Mexico 50% 19% Used (not injected) drugs in Mexico 40% 12% Injected drugs in Mexico 36% 15%

Results: Drug Law Differences

in the US (n=338)

in Mexico (n=329)

Automatically arrested 266 (78.7%) 86 (26.1%) Automatically sent to drug treatment 4 ( 1.2%) 3 ( 0.9%) Given three warnings and then required to enter drug treatment 14 ( 4.1%) 10 ( 3.0%) Given three warnings and then sent to jail 12 ( 3.6%) 5 ( 1.5%) Don't know 42 (12.4%) 225 (68.4%)

What happens if you are caught with drugs for personal use…

Question 3 What percentage of IDUs in San Diego have shared a syringe to inject in the past 6 months?

1. 7% 2. 21% 3. 43% 4. 59% 5. 90%

Question 4 Does San Diego have a syringe exchange program?

1. Yes 2. No 3. Don’t know

Results: Syringe Source Safe sources = syringe exchange program (SEP), pharmacy, clinic Unsafe sources = another person, on the street, shooting gallery

60% any used Safe Sources in past 6 months 30% reported always injecting with new/sterile syringes 59% shared a syringe that had been used before.

Factors associated with using safe sources AOR 95% CI

>High school education 1.65 1.08-2.54

Injecting methamphetamine combined with heroin 1.99 1.55-3.44

Aware of the SEP in San Diego 2.65 1.34-5.21

Have own car 3.05 1.76-5.31

Hispanic (ref = white) 0.52 0.33-0.82

Black (ref = white) 0.24 0.11-0.55

Prior police encounters 0.40 0.18-0.84

Results: Prefilled Syringe Use 34% reported ever using prefilled syringes

Factors associated with prefilled syringe use AOR 95% CI

Shared injection paraphernalia in past 6 months 4.45 2.63, 7.53

Ever bought or used drugs in Mexico 1.84 1.24, 2.73

HCV seropositive 1.48 0.99, 2.25

Results: Drug Use Class Used latent class analysis to examine patterns of drug

use among IDUs

Classified IDUs based on drug type and route of administration (injected, smoked, sniffed, swallowed)

Identified factors associated with class membership using multivariable logistic regression

Results: Drug Use Class Class 1 mostly methamphetamine users (multi-route) Class 2 mostly heroin by injection

Class 1 51% (SE=0.03)

Class 2 49% (SE = 0.03)

Heroin injecting 28.8% 82.5%

Methamphetamine smoking 71.6% 10.8%

Methamphetamine snorting 34.1% 1.1%

Methamphetamine injecting 81.2% 0.7%

Prescription drug swallowing 15.3% 18.8%

Binge drinking (≥5 drinks in one sitting) 21.9% 19.8%

Marijuana smoking 48.6% 25.4%

Drug/route variables are not mutually exclusive.

Results: Drug Use Class (n=431) Multivariable analysis of factors associated with heroin class membership AOR* 95% CI p - value

Race/Ethnicity (ref = white) 0.01 Black 3.23 1.53, 6.84 Hispanic 1.84 1.14, 3.01 Other 1.29 0.66, 2.55

Hepatitis C virus Seropositive 2.25 1.37, 3.72 0.01 Ever overdosed on opioids 1.89 1.23, 2.89 <0.001 Age (per 10 year increase) 0.79 0.65, 0.96 0.01 Ever diagnosed with STI (self-report) 0.59 0.38, 0.91 0.02 Homeless, past 6 months 0.42 0.27, 0.65 <0.001 Tested HIV Seropositive 0.17 0.07, 0.44 <0.001 *Ref=Class 1, primarily methamphetamine users multi-routes of administration. Class 2, primarily heroin injectors.

Qualitative Wave 1 Eligibility • Goal - To describe experiences, attitudes and perceptions of: 1. Drug markets in Mexico & San Diego 2. Safety of traveling to and from Mexico 3. Law enforcement in Mexico & San Diego 4. Drug reform law in Mexico • Sampling

– Criterion sampling based on two baseline questions: a. In the last 6 months, have you used drugs while in Mexico (not

injected)? (Y/N) b. In the last 6 months, have you injected drugs while in Mexico? (Y/N)

– Purposive sampling (e.g., gender, age, race/ethnicity, zip code) • 4 week window period

Qualitative Wave 2 Eligibility • Goal - Describe behavior changes and decision-making

processes in: 1. Starting travel to Mexico (“Initiators”) 2. Stopping travel to Mexico (“Terminators”) 3. Continuing to travel to Mexico (“Continuers”)

• Sampling: – Criterion sampling based on comparisons of drug use behavior

in Mexico between Baseline and 6-month Interviews – All participants meeting criteria were invited to participate

• No Window Period

Qualitative Demographics Wave 1 (n=25)

n (%) Wave 2 (n=24)

n (%) Mean Age (range) 37 yrs (21-60 yrs) 46 yrs (23-64 yrs)

Gender (Male) 15 (60%) 22 (92%)

Ethnicity Hispanic/Latino Race Non-Hispanic White African American/Black Other

7 (28%)

12 (48%) 4 (16%) 9 (36%)

9 (38%)

14 (58%) 2 ( 8%) 6 (25%)

Country of Origin US 22 (88%) 23 (96%) Bilingual (Eng & Span) 6 (25%) 9 (39%)

Valid Passport 2 ( 8%) 3 (12%)

Traveled to MX (last 6 months) Used drugs by injection Used drugs by other route

18 (72%) 18(100%) 12 (67%)

12 (50%) 7 (58%) 8 (67%)

Initiators Terminators Continuers

N/A 5 (21%) 15 (63%) 4 (17%)

Qualitative Preliminary Findings • Motivations to travel to Mexico “The vacation vibe, the more relaxed setting, the more comfortable, the setting is more

comfortable. It give you more a sense that you there to vacation and relax and have a good time instead of out here you’re using but you’re on the run, going from place to place, meeting your friends, picking up money, selling drugs . . .”

Latino Male, Age 36

“Well he told me how much it [methadone dose] costs [in Mexico] and that’s -- $6 every day, but over here [in San Diego] it’s $25 the first time you go and after that it’s $10 a day, so it don’t take a rocket scientist ….

African American/Blk female, Age 61

“I started working and started saving up money to get a place and I got my mom and my brothers and sister over here but I kept going back to see my relative but also to get you know a little something [drugs]”

Latino Male, Age 31

Qualitative Preliminary Findings • Catering to American IDUs and Drug Use Setting

“Where, where I went to is I got everything I needed right there. . . I got (chuckles) everything I wanted. I got uh, I got the girl, I got the dope, I got the needle, I got the room. So then it was like, I was happy. “

Latino-African American/Blk Male, Age 60 “The places that I had gone, like some of the restaurants, you know? Um, they would, they would, just bring you everything, they would bring you whatever you know if you needed foil? Or if you needed a pipe or you needed a syringe or something, and then you just go into the bathroom and go handle your business, or you know, some of the guys they had like little …. like, you know little like shops with random crap all over the walls, and it’s like all dusty stuff cause they don’t really sell anything there, (passive laugh) and they you know, they just have a little back room where you can go and, go and get high.”

Latino Male, Age 25

Qualitative Preliminary Findings

• Knowledge of Mexican Drug Laws “In between 5 years and now, Mexico came up with an idea that worked. Alright, the Bush administration was going in. Mexico came up with this idea, anything under a gram, any kind of dope, heroin, whatever, cocaine, crack, speed, whatever, under a gram, the Mexican police in Tijuana could not arrest you and take you to jail. . . . But what it does is that it keeps the jails open for dangerous criminals, but it keeps the junkies like me go on my destination. . . .”

Latino-African American/Blk Male, Age 60

Qualitative Preliminary Findings • Policing in Mexico versus US “ Over here [San Diego] they’ll just throw the cuffs on you, throw you in the jail cell and

wait till you go to court. Over there you go in front of the magistrate of the judge. He’ll tell you 24 hours, 48 hours, 3 days a week and then you’re gone. Here you’ve got to wait and go through the whole process. Over there they’ll tell you the same day. Either you have the fine and you have the money to pay the fine or you’ll have to do the time.”

Latino Male, Age 36

• Not having a passport is not a barrier “I don’t have a passport and then I got a criminal record so every time I go I go to

secondary… “ White Male, Age 49

(92% of Wave 1 and 88% of Wave 2 participants did not have a passport)

Challenges • Building rapport with participant

• Establishing trust (overcoming medical distrust)

• Retention among a transient community

• Maintaining the mobile unit

• Mental health of participants

Successes • Building community collaborations

• Established good reputation among IDUs

• Everyone is treated with dignity and respect

• Connecting participants to local services

• Drug treatment

• Counseling

• HIV and health care

• Housing

• Food stamps

• Participants appreciate being heard

What is next? • Finish follow-up interviews by January 2016 • Analyze baseline data • Analyze follow-up data

• Develop interventions to lower risk among IDUs

• Disseminate findings to participants and the

broader community

Contributors Karla Wagner Steffanie Strathdee Peter Davidson Fatima Muñoz Lin Liu Victoria Ojeda Jose Luis Burgos Sergio Aguilar-Gaxiola (UCD) Avelardo Valdez (USC) Alfredo Velasco (in memorial)

Jazmine Cuevas Everardo Aguilar Carlos Vera Pilar Santamaria Natasha Ludwig Barron Richard Armenta Kelly Collins SDSU Interns

* This study was funded by the National Institute on Drug Abuse (R01-DA031074) * Funding also received as gifts from Las Patronas, Rotary Club, and CECO