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Substance Abuse, Sexual Behaviors, HIV/STD/HCV Testing, and Prevention Service

Utilization among Injection Drug Users in Dallas, Texas, 2005-2006

Shane U. Sheu, MPH, Sonia Arbona, PhD,

Erin Elbel, Doug Kershaw,

Praveen R. Pannala, MD, MPHSharon K. Melville, MD, MPH

Texas Department of State Health Services May 25, 2010

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Objectives

To obtain prevalence estimates using respondent driven sampling (RDS) among injection drug users in Dallas for

Substance abuse behaviors Sexual behaviors Testing behaviors Prevention services utilizations

To explore the relationship between concomitant substance abuse and

Unprotected sex HIV/STD/HCV testing behaviors Prevention service utilizations

Background

Persons Living with HIV/AIDS and New HIV/AIDS Cases, Texas, 2002-2008

Data Source: Texas HIV/AIDS Reporting System (HARS); 2002-2008

63,01959,829

56,88454,292

51,04847,776

44,508

5,159 4,483 4,512 4,486 4,112 4,403 4,481

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2002 2003 2004 2005 2006 2007 2008

Year

HIV

/AID

S C

ases

Persons living with HIV/AIDSNew HIV/AIDS cases

Proportion of AIDS Cases by Transmission Category, Texas, 1990-2008

0

10

20

30

40

50

60

70

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Year of Diagnosis

Cas

es, %

Male-to-male sexual contact (MSM)

High risk heterosexual contact*

Injection drug use (IDU)

MSM and IDU

•Heterosexual contact with person known to have or to be at high risk for HIV infection

Data Source: Texas HIV/AIDS Reporting System (HARS); 1990-2008

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National HIV Behavioral Surveillance System Sites

Atlanta

Ft. Lauderdale

MiamiSan Juan

New Orleans

Dallas

Houston

San Diego

Los AngelesLas Vegas

San Francisco

Seattle

DenverSt. Louis

Chicago

Detroit

BostonNew HavenNassau

New York CityNewarkPhiladelphiaBaltimoreWashington, DCNorfolk

High risk population cycles:

• IDU

• MSM

• Heterosexuals

Source: Centers for Disease Control and Prevention

Methods

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NHBS Overall Strategy

Survey componentsCore questions

Demographic characteristics Alcohol and drug use risk behaviors Sexual risk behaviors Testing behaviors: HIV, HCV, syphilis Prevention services utilization

Local questions tailored to each site

HIV testing (Not done in Dallas IDU1)

Sample size Target = Minimum of 500 persons interviewed each cycle

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Respondent Driven Sampling Recruitment

Study team recruited initial participants (seeds) through outreach

Seeds recruited up to 3 other participants

Those participants recruited up to 3 others

Done until sample size was met

Incentives provided for participation and recruitment $20 for interview and

$10 for each recruitment

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NHBS IDU1 Eligibility Criteria

At least 18 years old

Resident of Dallas Fort Worth MSA

Injected non-prescribed drugs in past 12 months

Visible signs of injection and/or detailed knowledge of injection practices

Alert and able to complete survey in English or Spanish

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Dallas NHBS IDU1 Overview

Conducted in Dallas/Fort Worth Metropolitan Statistical Area (MSA) in 2005 -2006

DSHS and University of Texas Southwestern Medical Center

Sites in Dallas/Fort Worth: 5

Completed interviews: 597 (17 seeds and 580 recruits)

Implementing RDS at Multiple Sites for NHBS IDU1 Dallas

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Statistical Analysis

Weighted prevalence estimates with RDSAT analysis tool 6.0

Chi square test for bivariate analyses of un-weighted data with SAS 9.2

Results

NHBS IDU1 Demographic Characteristics

Gender Male 377 (63.1%) Female 215 (36.0%)

Race/Ethnicity African American 451 (75.6%) White 103 (17.3%) Hispanic 30 (5.0%) Multiracial 10 (1.6%)

Data Source: Texas National HIV Behavioral Surveillance- 2005-2006, IDU1 Data

N=597

NHBS IDU1 Demographic Characteristics continue

Age Groups 18-24 29 (4.9%) 25-34 56 (9.4%) 35-44 124 (20.8%) 45-54 303 (50.8%) ≥ 55 84 (14.1%)

Education < High School 35 (5.9%) High School or GED 427 (71.6%) > High School 134 (22.5%)


N=597

NHBS IDU1 Recruitment Network of Participants by Race and Ethnicity

White - homophily 0.401

Race and ethnicity

Afr Am - homophily 0.545

Hispanic - homophily 0.330

Am Indian/Alaska Native - homophily -1

Multiracial - homophily 0.032

- Most participants recruited were African American

- Four seeds recruited the majority of the participants


NHBS IDU1 Prevalence Estimates of Unprotected Sex

68%

32%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Sex without condom Sex with condom

Pre

va

len

ce


N=597

NHBS IDU1 Prevalence Estimates of Using Drugs or Alcohol before or during Sex


N=597

85%

15%

Using drugs or alcohol before or while having sex

Not using drugs or alcohol before or while having sex

NHBS IDU1 Prevalence Estimates of Testing Behaviors


N=597

87%

42%

22%

11%

25%

69%

2%

33%

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ever tested for HIV Ever tested for HCV Tested for Syphilisin the past 12

months

Pre

vale

nce

Yes

No

M/D/R

NHBS IDU1 Prevalence Estimates of Prevention Service Utilization


N=597

55%

14%

77%

69% 70%

84%

4%1% 1% 2% 2%

28%30%

22%

41%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

ReceivedFree

Condoms

ReceivedFree Sterile

Syringes

ReceivedFree Drug

Kits

One to OneCounseling

GroupCounseling

Pre

vale

nce Yes

NoM/D/R

NHBS IDU1 Participants Using Drugs or Alcohol before or during Sex by Unprotected Sex

Sex without condom

Sex withcondom

2

P value

Using drug or alcohol before or during sex (n=522)

80.3% 19.7%

<.0001Not using drug or alcohol before or during sex (n=75)

30.7% 69.3%


N=597

NHBS IDU1 Participants Using Drugs or Alcohol before or during Sex by Sharing Injection Equipment

Sharing injection equipment

Not sharing injection equipment

2

P value

Using drug or alcohol before or during sex (n=522)

78.9% 21.1%

0.01Not using drug or alcohol before or during sex (n=74)

66.2% 33.8%


N=597

NHBS IDU1 Participants Using Drugs or Alcohol before or during Sex by Syringe Sharing

Syringe Sharing

No syringe sharing

2

P value

Using drug or alcohol before or during sex (n=521) 54.9% 45.1%

<.0001Not using drug or alcohol before or during sex (n=73) 28.8% 71.2%


N=597

Factors P-value

Ever tested for HIV 0.29

Ever tested for HCV 0.67

Tested to check for syphilis in the past 12 months 0.38

Received free condoms in the past 12 months 0.90

Received sterile needles in past 12 months 0.69

Used free new sterile needles 0.72

Received free kits in the past 12 months 0.85

Used free kits 0.32

Talked to counselor one on one about HIV prevention in the past 12 months

0.53

Participated in group session about HIV prevention in the past 12 months

0.81

NHBS IDU1 Other Factors Found Not to be Statistically Significant with Participants Using Drugs or Alcohol before or during Sex

Results Summary

Majority of NHBS injection drug users Have sex without condoms Are having alcohol or drugs before or during sex Have tested for HIV and HCV in their lifetime Not tested for syphilis in the past year Never received free sterile needles, free drug kits, one on one

counseling or group counseling about HIV prevention

Statistically significant relationship between those using drug or alcohol before or during sex and Unprotected sex Sharing injection equipment Sharing syringe

No statistical significant relationship between those having drug or alcohol before or during sex and HIV/STD/HCV testing behaviors Prevention service utilization

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Data Limitations

Self-reported data

Temporality or causal relationship cannot be established

Generalizability African Americans Dallas vs. Texas vs. U.S.

Conclusions

Use of drugs and alcohol before or during sex may influence individual’s practice of high risk sexual behavior and injection sharing behaviors

Substance abuse may increase the probability of having unprotected sex which subsequently may increase the risk for HIV transmission among IDU and their sexual partners

Contact with or use of prevention services does not seem to reduce risky behaviors

Implications for Programs, Policy, and Research

Understanding risk behaviors among IDU would help tailor HIV prevention services

Better education for IDUs on how HIV is spread, either by one on one counseling and/or group counseling

Encourage condom use, discourage drug use, and encourage use of sterile drug preparation equipment and syringes

Data suggest the need for developing effective prevention strategies to promote positive behavior change

Promote attendance to prevention service organizations

Easy access to prevention service organizations

Implications for Programs, Policy, and Research

Explore the feasibility of using respondent driven sampling method To increase awareness of prevention programs To increase awareness of injection drug use risk To encourage testing behavior

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References

1. Arasteh K, Jarlais DCD, Perlis TE. Alcohol and HIV Sexual Risk Behaviors among Injection Drug Users. Drug Alcohol Depend. 2008;95:54-61.

2. Heckathorn, DD. Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations. Social Problems.1997;44:174-199.

3. Heckathorn, DD. Respondent-Driven Sampling II: Deriving Valid Population Estimates from Chain Referral Samples of Hidden Populations. Social Problems. 2002; 49:11-34.

4. Purcell DW, Mizuno Y, Metsch LR, Garfein R, Tobin K, Knight K, Latka MH. Unprotected Sexual Behavior Among Heterosexual HIV-Positive Injection Drug Using Men: Association by Partner Type and Partner Serostatus. J Urban Health. 2006;83:656-668.

5. Richards JE, Risser, JM, Padgett PM, Rehman HU, Wolverton ML, Arafat RR. Condom use among high-risk heterosexual women with concurrent sexual partnerships, Houston, Texas, USA. International Journal of STD & AIDS. 2008;19:768-771.

6. Risser JM, Padgett P, Wolverton M, Risser WL. Relationship between heterosexual anal sex, injection drug use and HIV infection among black men and women. Int J STD AIDS. 2009;20:310-4.

7. Volkow ND, Wang GJ, Fowler JS, Telang F, Jayne M, Wong, C. Stimulant-Induced Enhanced Sexual Desire as Potential Contributing Factor in HIV Transmission. Am J Psychiatry. 2007;164:157-160.

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Acknowledgements

We would like to acknowledge our colleagues at the Centers for Disease Control and Prevention, and University of Texas Southwestern Medical Center:

Elizabeth A. DiNenno, PhD Melissa Cribbin, MPH Anne Freeman, MSPH Douglas Shehan Other UT Southwestern Community Prevention and

Intervention Unit Staff

Thank you

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Questions?

Shane Sheu, MPHEpidemiologist/Coordinator

TB/HIV/STD Epidemiology and Surveillance BranchHSES, Mail Code 1873

Texas Department of State Health ServicesP.O. Box 149347

Austin, Texas 78714Phone: (512) 533-3044

[email protected]