Jonny F. Andía

Integrating Qualitative and Quantitative Methods: Comparing HIV-Related Risk Behaviors Among Puerto Rican Drug Users in Puerto Rico and New York

A dual site project was conducted to assess determinants of injection and sex-related risk behaviors among Puerto Rican drug users. The project focused on injection drug users and crack smokers, and was conducted in East Harlem, NY and Bayamón, PR in 1996–2000. Qualitative methods included ethnographic mapping, focus groups, in-depth interviews, and observations. A survey component (East Harlem, n = 800; Bayamón, n = 400) was also conducted. Procedures to ensure integration of methodologies and comparability of data were developed. This paper describes the qualitative and survey methods used, and presents the comparative HIV risk behaviors. The integration of the two methodologies served multiple functions: each component identified issues to be addressed in the other, enhanced cross-site comparability of data, and assisted in interpretation of findings. The survey data showed high levels of risk behaviors in both communities, with significantly higher levels of risk reported in Bayamón. Conducting studies of similar ethnic groups in different communities provides opportunities to examine diverse sources of influence on risk behaviors. The integration of qualitative and quantitative methods can enhance comparability and understanding of findings, particularly when there are differences in behaviors between communities.

Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program.

Background:Effective on January 1, 2001, New York State enacted the Expanded Syringe Access Demonstration Program (ESAP), which allows syringes to be sold in pharmacies without a prescription or dispensed through doctors, hospitals, and clinics to persons 18 years of age or older and permits the possession of those syringes for the purposes of injecting drugs. Objective:To assess changes in receptive syringe sharing since the inception of the ESAP. Methods:Sociodemographic characteristics and syringe use data regarding the last injection episode were combined from 3 projects (n = 1181) recruiting injection drug users in ongoing studies in Harlem and the Bronx in New York City from January 2001 through June 2003. These data were analyzed as serial cross sections by calendar quarter. Results:Receptive sharing decreased significantly over time, from 13.4% in the first quarter to 3.6% in the last quarter. Obtaining the last injection syringe from an ESAP source (mostly pharmacies) increased significantly over time, from 7.5% in the first quarter to 25.0% in the last quarter. In multiple logistic regression analysis, variables that were significantly associated with less receptive sharing were syringe exchange and ESAP syringe source as well as time since ESAP inception. Female gender and white race/ethnicity were significantly associated with greater receptive sharing. Conclusions:The increase in the use of pharmacies and other ESAP syringe sources in this sample has been accompanied by a decline in receptive sharing.

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

Summary: Frequency of injection has been consistently found to be higher among Puerto Rican Injection drug users (IDUs) than among other groups of IDUs. Several explanations have been suggested, but an empirical explanation has yet to be presented. This study compares the frequency of injection of Puerto Rican IDUs in East Harlem, New York, with that of IDUs in Bayamon, Puerto Rico. Study subjects comprised 521 Puerto Rican IDUs from East Harlem and 303 IDUs from Bayamon. The mean frequency of injection among IDUs in East Harlem was 2.8, the corresponding mean in Bayamon was 5.4. Younger IDUs reported a higher number of daily injection episodes than older IDUs, and the IDU group in Bayamon was 5 years younger than the group in East Harlem. The drug use variables accounted for a greater portion of the between‐city difference than the demographic and psychosocial variables. Use of noninjected drugs, as well as the use of prescribed methadone, were found to be associated with a lower number of daily injections. Conversely, injection of cocaine, injection of cocaine mixed with heroin (“speedball”), and injection of larger amounts of drug solution were found to be associated with a higher number of daily injections.

HIV incidence among high-risk Puerto Rican drug users: a comparison of East Harlem, New York, and Bayamón, Puerto Rico.

Summary:Significant differences in HIV-related risk behaviors have been found between Puerto Rican drug users in New York City (NY) and Puerto Rico (PR). An examination of HIV incidence rates and characteristics of seroconverters in each location was undertaken. Baseline and follow-up interviewing and HIV testing were conducted in 1998 to 2002 with seronegative Puerto Rican injection drug users (IDUs) and crack smokers from East Harlem, NY (n = 455) and Bayamón, PR (n = 268). There were a total of 32 seroconverters, 9 in NY and 23 in PR, for seroconversion rates of 0.88/100 person-years at risk (pyr; 95% CI, 0.31–1.45) in NY and 3.37/100 pyr (95% CI, 2.02–4.72) in PR (P < 0.001). In PR, variables significantly related to seroconversion were younger age and using shooting galleries. Being in methadone treatment was protective against seroconversion. In NY, crack use was significantly related to seroconversion. The higher seroconversion rate found in PR indicates a need to enhance HIV prevention efforts, including increasing methadone treatment and access to sterile syringes. The need to address sexual risk behaviors in both locations was also indicated. Resources focusing on reducing HIV transmission in the Caribbean should include efforts to target the drug use-HIV epidemic in PR.

Trends in HIV seroprevalence and needle sharing among Puerto Rican drug injectors in Puerto Rico and New York: 1992-1999

Summary: This study assessed trends in HIV seroprevalence and needle‐sharing behaviors among Puerto Rican injection drug users (IDUs) in Puerto Rico and New York. Data from two studies of IDUs conducted from 1992 through 1995 and 1998 through 1999 in Bayamón, Puerto Rico, and East Harlem, New York, were examined to assess trends over this period. Separate analyses were conducted for IDUs who were current crack smokers. Significant decreasing trends in seroprevalence were found among IDUs in the New York and Puerto Rico samples (p < .001). Significant decreasing trends in receptive and distributive needle sharing were found in the New York sample, and a significant decline in receptive sharing was found in the Puerto Rico sample. Overall, higher levels of needle‐sharing behaviors were reported in Puerto Rico compared with New York. Decreasing trends in needle sharing and seroprevalence in both communities are an encouraging finding. Ongoing epidemiologic studies to monitor the epidemic and continued prevention efforts to help maintain or further these declines are needed, particularly to address the higher rates of needle sharing in Puerto Rico.

HIV transmission behaviors in jail/prison among puerto rican drug injectors in New York and Puerto Rico.

This study examined HIV risk behavior in jail/prison among Puerto Rican drug injectors in New York (NY, n = 300) and Puerto Rico (PR, n = 200), and its relationship with later drug and sex risk behaviors. During 3 years prior to interview, 66% of NY and 43% of PR samples were incarcerated at least once. While incarcerated, 5% of NY and 53% of PR injected drugs. Few reported engaging in sex inside jail/prison (5% in both sites). Of those who engaged in risk behaviors in jail/prison, almost all reported having unprotected sex and sharing injection equipment. The impact of jail/prison risk behaviors on risk behaviors after release differed between the two sites: they were more related to subsequent sex risk behaviors in NY, and subsequent injection risk behaviors in PR. The findings indicate a need for effective drug treatment programs inside jail/prisons to reduce HIV-related risk behaviors among drug injectors during incarceration and after release.

Residential status and HIV risk behaviors among Puerto Rican drug injectors in New York and Puerto Rico.

This article investigates the association between residential status and human immunodeficiency virus (HIV) risk behaviors among island and New York Puerto Rican injection drug users (IDUs). We assigned 561 subjects from New York City and 312 from Puerto Rico to five residential status categories: living in parents home, living in own home, living in others home, living in temporary housing (hotel, single-room occupancy [SRO] hotels), and homeless (living in streets/shelters). Dependent variables included injection- and sex-related risk behaviors (sharing syringes, sharing other injection paraphernalia, shooting gallery use, and having paid sex). Chi square, t tests, and multivariate logistic analysis tests were performed separately by site. About one-quarter of the sample in each site was homeless. Island Puerto Ricans were more likely to live with their parents (44% vs. 12%, p <. 001), and more New York IDUs lived in their own home (30% vs. 14%, p <. 001). In New York, gallery use and paid sex were associated with living in others home, living in parents home, and being homeless. Sharing paraphernalia was related to living in others home, living in temporary housing, and being homeless. In Puerto Rico, having paid sex was associated with homelessness. High-risk behaviors were more likely among homeless IDUs in both sites. Programs to provide housing and target outreach and other prevention programs for homeless IDUs would be helpful in reducing HIV risk.

Syringe Acquisition and Use of Syringe Exchange Programs by Puerto Rican Drug Injectors in New York and Puerto Rico: Comparisons Based on Quantitative and Qualitative Methods

Quantitative and qualitative data are used to compare alternative sources of syringes, including syringe exchange programs (SEPs), accessed by 165 Puerto Rican injection drug users (IDUs) in East Harlem, New York (NY), and 115 in Bayamón, Puerto Rico (PR). IDUs in PR obtained, on average, 45.2% of their syringes from “syringe sellers,” 18.0% from pharmacies, and 17.6% from a SEP. By contrast, IDUs in NY obtained 55.0% of their syringes from SEPs and 22.9% from “syringe sellers.” Compared to their island counterparts, IDUs in NY received significantly more syringes from SEPs (NY, 104.5; PR, 9.2) in the prior 30 days, and were more likely to be referred by SEPs to drug treatment and HIV/TB-testing services. The results of this study suggest the need in Puerto Rico to eliminate restrictive syringe exchange policies, reform drug paraphernalia laws to protect SEP clients, and address police harassment related to carrying syringes.

Determinants of health care use among Puerto Rican drug users in Puerto Rico and New York City.

This study was conducted to identify factors accounting for differences in health care and drug treatment utilization between Puerto Rican drug users residing in 2 separate locations. Survey findings from 334 drug users in Puerto Rico and 617 in New York City showed that those in Puerto Rico were 6 times less likely than their counterparts in New York to have used inpatient medical services and 13 to 14 times less likely to have used outpatient medical services or methadone. They also were less likely to have health insurance or past drug treatment. After site was controlled for, health insurance and previous use of physical or mental health services remained significant predictors of health care and drug treatment utilization during the study period. Although Puerto Rican drug users in Puerto Rico are not an ethnic minority, they reported significant disparities in health services use compared with Puerto Rican drug users in New York.

Joint drug purchases and drug preparation risk behaviors among Puerto Rican injection drug users

In the process of preparing jointly purchased drugs, injection drug users (IDUs) may share drug preparation materials and use a single syringe to distribute injectable drugs. The aim of this study was to examine the association of joint drug purchasing with drug preparation risk behaviors among Puerto Rican IDUs. The study sample comprised 555 IDUs from New York City and 297 from Puerto Rico. IDUs reported pooling money for 12% of the injection episodes in New York, and for 14% of the injection episodes in Puerto Rico. In both study sites, all correlation coefficients between frequency of pooling money and drug preparation behaviors were .30 or larger. After controlling for sociodemographics, drugs injected, and injection frequency, pooling money was significantly associated to all four drug preparation behaviors in both study sites. HIV prevention interventions need to be cognizant of the joint purchasing of drugs and its relationship to drug preparation risk behaviors.