The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico.

During the last decade, the veterinary anesthetics have gained popularity as recreational drugs. The aim of this study was to document the use of "anestecia de caballo" (xylazine) and its consequences among drug users in Puerto Rico. The study combined a cross-sectional survey with 89 drug users and two focus groups conducted in Mayagüez with frontline drug treatment providers. Drug users were recruited from communities of the San Juan metropolitan area using a variety of ethnographic and outreach strategies. A short questionnaire developed for the study collected information on sociodemographics, xylazine use, and its consequences. The two focus groups were conducted to discuss the details related to xylazine use, its consequences, and utilization awareness. The sample comprised 63 males (70.8%) and 26 females with a mean age of 37.2 years. The mean number of years of drug use was 14.3, with a mean frequency of drug use of 5.9 times daily. More than 65% reported speedball as the principal drug of use. The prevalence of xylazine use was 80.7%. More than 42% of the sample used xylazine in a mixture with speedball. The main route of administration of xylazine was injection but 14% reported the use of xylazine by inhalation. More than 35% of the sample reported skin lesions and 21.1% reported at least one overdose episode. Multiple logistic regression analysis revealed that males (OR = 3.47, CI = 1.10-12.00) and those who reported speedball as their main drug of use (OR = 9.34, CI = 2.51-34.70) were significantly more likely to be xylazine users. Focus groups revealed that drug users claimed to recognize the presence of xylaxine in a mixture of speedball based on its effects, taste, the color of the drug (dark brown), and its odor. In conclusion, the use of xylazine among drug users in Puerto Rico seems to be an emerging trend with potentially serious health consequences.

Hepatitis B immune status of non-injecting drugusers 18- to 25-years-old in Puerto Rico.

INTRODUCTION: Ilicit drug users are the population group at highest risk of HBV infection in most Western countries. In this study we assessed hepatitis B virus (HBV) immune status in a cohort of young non-injecting drug users in Puerto Rico. METHODS: Subjects were eligible if they were 18- to 25-years-old, had never injected any drugs, and had recently used heroin or cocaine. A total of 541 subjects were recruited from community settings during 2004 and 2005. Subjects were interviewed and tested for HBV immune status and infection. RESULTS: Overall, 36.6% showed evidence of HBV immunity. Among subjects not HBV immune, 63.0% reported being vaccinated against HBV. Rates of HBV immunity were 47.6% among subjects who were 12-years-old or less in 1995 when mandatory school verification of HBV vaccination was established and 23.0% among those who were older than 12 in 1995 (p<.001). HBV immunity was 52.5% among non intravenous drug user who were 12-years-old or less in 1995 if they had not dropped out of school before the 8th grade compared to 23.9% (p<.001) among those who did drop out before the 8th grade. CONCLUSIONS: Mandatory school verification of HBV vaccination seems to have had a substantial effect in increasing coverage among young illicit drug users. However, the impact of mandatory school verification appears to be limited by the fact that many illicit drug users drop out of school early after completing the primary level.

Alcohol use among adolescents in Puerto Rico: the influence of physical and social neighborhood disorder.

INTRODUCTION: The characteristics of social settings are increasingly being recognized as important factors influencing the health of individuals. This study examines the association of neighborhood physical and social disorganization with alcohol consumption in a sample of adolescents 12- to 15-years-old residing in communities of the San Juan metropolitan area with high availability of illicit drugs. METHODS: The sampling frame was developed encompassing all census sectors in three municipalities of the San Juan metropolitan area with outdoor illegal drug-selling areas operating within them. Consent from parents and their adolescent offspring was obtained from 691 of these households for a response rate of 96%. Alcohol use was measured by asking adolescents if they had consumed alcohol during the last 12 months. Neighborhood social disorganization included hearing gunfire in the neighborhood, seeing neighbors selling stolen merchandise and drugs, vandalism, neighbors using alcohol and drugs, and seeing persons carrying weapons. Neighborhood physical disorganization included the presence of abandoned vehicles and buildings in the neighborhood, graffiti, and places where people go to inject drugs. RESULTS: Multiple logistic regression analysis revealed that older participants were more likely to use alcohol. Neighborhood social disorder was significantly associated with alcohol use. The strong positive gradient between neighborhood social disorder and alcohol use remained highly significant after controlling by sociodemographic characteristics. In contrast, neighborhood physical disorder was not significantly associated with alcohol use. CONCLUSION: These findings suggest that social signs of neighborhood disorganization have a more direct influence over adolescents' behaviors than the physical signs. Health professionals need to be cognizant of the strong effects that social environments have on adolescents and develop strategies to address these when intervening with adolescents.

Behavioral effects of receiving HIV test results among injecting drug users in Puerto Rico.

OBJECTIVES: To examine the influence of knowledge of HIV serostatus on changes in risk behaviors among injecting drug users (IDU). PROCEDURES: IDU were recruited through sampling conducted at street drug-selling areas. Of 374 participants, 88.8% consented to be HIV tested and returned for their test results, and 73.5% were relocated and interviewed 6 months later. RESULTS: Of the 176 IDU who reported a seronegative test result prior to baseline, 29 tested seropositive at baseline. No significant differences were found between HIV-positive and HIV-negative IDU in needle risk behaviors. HIV-positive IDU were significantly less likely to report being sexually active [odds ratio (OR), 0.41 : 95% confidence interval (CI), 0.22-0.75] and more likely to use condoms during vaginal (OR, 4.43; 95% CI, 1.48-13.29) and oral sex (OR, 6.67; 95% CI, 1.42-31.33). CONCLUSION: The findings of this study show the importance of encouraging IDU to undergo periodic retesting. HIV testing could have an important role in reducing heterosexual transmission from IDU.

The validity of drug use responses in a household survey in Puerto Rico: comparison of survey responses of cocaine and heroin use with hair tests.

BACKGROUND: Despite the widespread use of household surveys to assess the epidemiology of illicit drug use and abuse, there is very little information about the willingness of respondents to disclose their use of drugs in household studies outside the US. METHODS: As part of a household study of substance use disorders in Puerto Rico, we collected hair specimens from a sub-sample of 114 respondents. Hair specimens were screened using a radio immunoassay. Screened-positive specimens were confirmed using gas chromatography/mass spectrometry. RESULTS: Using hair-test results as the standard, specificity of self-reports was 98% or higher for both drugs. The sensitivity of all self-reports was low, although lifetime use reports had somewhat higher sensitivities. The sensitivity of self-reports of recent cocaine use was particularly low, 7.1%. The sensitivity of heroin use reports was somewhat higher, 33.3% for recent use and 66.7% for lifetime use. The estimate of recent cocaine use based on hair tests was 13.7 times the estimate generated from interview reports. For heroin use, the test-based estimate was 2.9 times the rate generated from the interview reports. A shift from the cut-off level of 0.2 ng/mg to 0.5 ng/mg had only a marginal improvement on validity, with sensitivity increasing from 7.1% to 11.1% for self-reported recent cocaine use. CONCLUSIONS: The results suggest that drug users, for the most part, are not willing to disclose their use of drugs in household surveys in Puerto Rico. Methods to increase the willingness of respondents to disclose their use of drugs are needed.

Behavioural risk factors and HIV infection of injection drug users at detoxification clinics in Puerto Rico.

BACKGROUND: The ethnic and geographical variations of AIDS prevalence among injection drug users (IDU) have highlighted the need to understand the role of the relevant risk factors in specific subpopulations of IDU. In this study we examine the factors related to seropositivity among IDU entering drug detoxification facilities in metropolitan San Juan, Puerto Rico. METHODS: From October 1990 until August 1991, 390 IDU were interviewed. Four groups of risk factors were examined: sexual practices, drug injection behaviours, risk behaviours while in US Mainland cities, and while incarcerated. A stepwise logistic regression model was used to simultaneously assess the independent effects of the behavioural risk factors on HIV seropositivity. RESULTS: Of the 342 IDU who were tested for HIV antibodies, 29.5% were seropositive. The behaviours found to be associated with seropositivity were: having sex with an IDU in the last 6 months; having injected drugs for over 5 years; and injecting with used needles while incarcerated. DISCUSSION: Public health programmes will need to establish more effective collaborative links with correctional institutions in order to reduce the spread of HIV among IDU in Puerto Rico.

PIP: In Puerto Rico between October, 1990 and August, 1991, 342 intravenous (IV) drug users at 3 detoxification clinics serving San Juan and its environs were interviewed, and blood samples were taken. Researchers wanted to determine the behavioral risk factors linked to HIV infection in a population of IV drug users in drug treatment. Most (84.9%) of the IV drug users were male. The HIV seropositivity rate was 29.5% (28.7% for males and 34% for females), which was lower than that for out-of- treatment IV drug users in metropolitan San Juan (47.5%). A stepwise logistic regression model revealed that having sexual intercourse with an IV drug user within the last 6 months (42.5% vs. 26%; adjusted odds ratio [AOR] = 1.9; p = .046), having used IV drugs for more than 5 years (32.4% for 6-10 years and 47.5% for 10 years vs. 8.8%; AOR = 4.69 and 9.64, respectively; p .001), and shooting up with used needles while imprisoned (56.8% vs. 26.2%; AOR = 3.59; p = .002) were significant behavioral risk factors of HIV infection. The significant risk factor of having sex with an IV drug user within the last 6 months suggests that sexual transmission of HIV among IV drug users in Puerto Rico is becoming as important an HIV-transmission mode as needle sharing. Since a considerable proportion of this IV drug use population in a treatment program (54.9%) has been incarcerated, and since needle sharing while in prison has an independent significant effect on HIV transmission, public health officials in Puerto Rico need to implement innovative and aggressive interventions in correctional institutions to induce risk reduction behaviors particular to IV drug inmates.

Prevalence and correlates of anergy among drug users in Puerto Rico.

OBJECTIVES: This study assessed prevalence and correlates of anergy among a cohort of drug users in communities in the San Juan metropolitan area. METHODS: In all, 719 drug injectors and crack users were recruited in neighbourhoods in the San Juan metropolitan area following a stratified cluster design of 30 copping areas (places where drugs are sold). RESULTS: Slightly more than one-third of the total proportion of participants, 34.2%, were HIV positive and 30.3% anergic. Subjects with a history of incarceration, the HIV positive, and those reporting chronic illness were more likely to be anergic than those subjects without these characteristics. CONCLUSIONS: Most studies addressing drug users' immune system dysfunction are related to HIV infection. Additional studies are needed to provide a more comprehensive understanding of drug users' immune systems.

Prospective effects of perceived risk of developing HIV/AIDS on risk behaviors among injection drug users in Puerto Rico.

The relationship between perceived risk of developing AIDS and subsequent behavioral risk status is estimated for 1740 Puerto Rican injection drug users (IDUs). Prospective behavioral effects were examined comparing data collected at two intervals approximately 6 months apart. We estimated the association between perceived risk at baseline and risky behaviors at follow-up with unadjusted odds ratios. We confirmed the results with adjusted odds ratios using logistic regressions which included baseline risk status as well as socio-demographic and health status covariates. The analyses showed that having a high HIV/AIDS risk perception was related to subsequent sharing of needles, injection of drugs in shooting galleries and sharing of cookers. None of the tests between risk perception and sex risk behaviors showed a significance association. Increasing IDUs' perceived vulnerability to HIV/AIDS might not be effective in helping reduce HIV risk behaviors. IDUs perceiving themselves to be at high risk of AIDS might believe there is little they can do to reverse the consequences of risky behavior.

Effects of a community outreach program in HIV risk behaviors among injection drug users in San Juan, Puerto Rico: an analysis of trends.

This report assesses the effects of a community outreach program in reducing HIV risk behaviors among injection drug users (IDUs) in San Juan, Puerto Rico. Participants were 1,113 IDUs, 88.3% of whom were also assessed at post-intervention. The analytic strategy consisted in modeling pre- and post-intervention trends in risk behavior levels from successive cohorts of IDUs. The trend analyses showed that secular trends, unrelated to the direct effects of the outreach intervention, accounted for significant portions of the reported risk reductions. Nevertheless, the post-intervention trends in the shared use of cookers and in needle bleaching showed shifts that could not be accounted for by the modeled secular trends. The outreach intervention appears to have had significant but partial effects on the behavioral risks associated to drug injection and no effect on sexual behaviors. The strengths and weaknesses of time-trend analyses for evaluating community HIV-prevention programs lacking experimental designs are discussed.

Syringe and needle exchange as HIV/AIDS prevention for injection drug users in Puerto Rico.

This study evaluated the effectiveness of the first needle exchange program (NEP) established in Puerto Rico. The data for this study were collected during the first months of the NEP from July 1995 to March 1996 in 13 communities of the San Juan metropolitan area. Subjects were the participants of two modalities of the NEP: a mobile team and a community-based drug treatment program. During the 3-week evaluation period, 2401 injection drug users (IDUs) were recruited, resulting in a total of 19,195 exchange contacts and 146,323 syringes exchanged. No significant change in drug injection was observed. However, the program was effective in reducing sharing of syringes and cookers. The study suggests that the NEP did help in reducing needle sharing in Puerto Rico. However, the HIV seropositivity in returned syringes suggests the need to continue aggressive prevention programs to arrest the epidemic among IDUs. However, factors related to the socio-cultural environment as well as cultural norms and traditions need to be considered when planning and expanding NEPs.

Psychiatric symptomatology and health care utilization.

This paper examines the relationship between psychiatric symptoms and dysfunctions and utilization of general and mental health services. A sample of two hundred community members, 18 to 64 years old, was selected using a stratified random sampling based on the criteria of sex and age. Respondents were categorized according to their aggregated scores on the validated Psychiatric Symptom and Dysfunction Scales. Patterns of utilization were ascertained according to identified levels of psychiatric symptoms. Results indicated that as the level of psychiatric symptoms increased so did the proportion of users of mental health services. Subjects scoring high in psychiatric symptomatology were also found to make more use of general health services and prescribed drugs than those with low levels of psychiatric symptoms and dysfunctions. Worth mentioning is the fact that 61.12% of the respondents, who were identified as in need of mental health services, reported that they had not received such services. This result suggests that other factors, in addition to psychiatric symptomatology, also influence the use of general and mental health services.

Sociodemographic, cultural and interpersonal risk factors as indicators of mental health needs.

The goal of this paper is to examine an integrated model of mental health needs which takes into consideration psychiatric symptoms and dysfunctions, behavioral dimensions, as well as socioeconomic and cultural factors. This model presupposes that specific life situations and positions of the respondent in different dimensions of the social structure are basic factors for the identification of mental health needs. The method of data collection was a personal interview with a sample of two hundred community members, 18 to 64 years, selected using a stratified random sampling based on the criteria of sex and age. Statistically significant differences were identified between age, sex, education, social role performance, subjective perceptions, and levels of mental health need. This evidence suggests that social roles and specific risk factors are basic elements in determining mental health needs.

Effects of a HIV risk reduction education program among injection drug users in Puerto Rico.

This report examines the extent to which an educational component enhanced the efficacy of a community outreach program in reducing HIV transmission behaviors among injecting drug users (IDUs). The experimental enhancement comprised three group educational sessions where detailed information on HIV risk and protective behaviors was conveyed, protective behaviors were shown and practiced, and a problem solving perspective guided discussion of serostatus results. Substantial risk reduction in behaviors were prospectively measured. However, IDUs assigned on a random basis to the enhanced intervention showed no significant differences in levels of risk reduction when compared to those assigned to the standard-only intervention. The chronic and intensive use of injected drugs among the IDUs studied and their high level of HIV infection suggest the need of interventions geared to maximize the utilization of health care services and enhance the supportive functions of familial and social networks of IDUs.

Health care services and sterilization among Puerto Rican women.

This paper considers the variables related to the type of health care utilization for sterilization and family planning among Puerto Rican women. The study is based on a representative sample of 1,375 women between the ages of 15-49 years. The data shows that the majority of women used the private sector of health care for their sterilization. Younger women, women with a low level of education, unemployed, living in consensual marriages and those who had their children as adolescents, made more use of the public services for their sterilization. It is a well proven fact that women with the above mentioned characteristics are more socioeconomically deprived than the educated, married and working women. Thus, it is to be expected that this group of women does not have the economic resources needed to utilize the private health care system.

Crack use in Puerto Rico: evidence of a recent epidemic.

This study examines the prevalence of crack use among out-of-treatment drug users in the San Juan metropolitan area. Of the sample of 849 drug users, 310 (36.5%) were crack users only, 179 (21.1%) were drug injectors and crack users, and 360 (42.4%) were drug injectors only. To study the characteristics of crack users we selected the subjects who reported the use of crack only. Of the 310 subjects, 193 (62.3%) men and 117 (37.7%) women, the mean age was 29 years. Significant differences were observed by gender. Females reported higher education, living in a nuclear family, crack/cocaine as the first drug used, history of sexually transmitted diseases and higher rates of HIV seropositivity. Males were more likely to report income from illegal activities, incarceration, use of multiple drugs, and more years of drug use. Among those sexually active, females were more likely to practice unprotected vaginal sex, have multiple sex partners, engage in prostitution (exchange of sex for money and/or drugs) and use condoms.

Mycobacterium tuberculosis infection among crack and injection drug users in San Juan, Puerto Rico.

This study aims to determine the prevalence of Mycobacterium tuberculosis infection and its association with HIV and other health risk factors among drug users. A sample of 716 IDUs and crack users were enrolled from community sites. Consenting subjects were tested for HIV serum antibody status. Drug users with an unknown PPD status were administered a PPD skin test and an anergy panel of three antigens (Candida, mumps and tetanus). Overall, 68 (10.3%) were reactive to the PPD skin test, 240 (34.7%) were HIV positive and 195 (29.5%) showed cutaneous anergy. Participants infected with tuberculosis (TB) were more likely to be HIV seropositive, and to have a history of incarceration and residential drug treatment than those not infected. In addition, TB infection was more prevalent among intravenous drug users (IDUs) and shooting gallery managers. These findings suggest that drug users should be considered at high risk for TB and HIV infection. Innovative programs to monitor both infections among drug users are needed to arrest what can become a dual epidemic of HIV and TB in the near future.

HIV/AIDS risk perception, HIV risk behaviors, and HIV seropositivity among injection drug users in Puerto Rico.

This paper assesses the factors related to self perception of developing AIDS among a group of 1,568 Puerto Rican injection drug users (IDUs). Incarceration history, years of drug injection, sharing needles, renting and borrowing needles, sharing rinse water or cooker, and having an IDU sex partner yielded a moderate association with HIV/AIDS risk perception. Use of sterile needles, shooting drugs alone, having had previous treatment episodes, and all the variables related to health status were also moderately associated with HIV/AIDS risk perception. A logistic regression model based on backwards elimination procedure, which included statistically significant variables in the bivariate analyses, yielded the variables living with children, sex with an IDU partner, shooting drugs alone, perception of health, having had a sexually transmitted disease, and results of HIV testing as statistically significant (p < 0.05).

Human immunodeficiency virus infection and risk behaviors among injection drug users in four Puerto Rican communities.

This study compares the prevalence of human immunodeficiency virus (HIV) infection and HIV risk behaviors among 1,702 injection drug users (IDUs) recruited within four catchment areas in metropolitan San Juan (79.9% male and 20.1% female). To assess the impact of different antecedent variables on intercommunity risk differences, we constructed separate logistic regression models for each one of the catchment areas in the analysis. Old San Juan/Santurce has the highest rate of HIV seropositivity. Furthermore, Old San Juan/Santurce IDUs were more likely to have had incarceration experience, to report using drugs only by injection, and to have been injecting drugs for 16 years or more. Also, this group was more likely to report practicing prostitution and to have been diagnosed with sexually transmitted diseases (STDs) than their peers from the other sites. The need of preventive programs in specific communities within metropolitan urban areas is discussed.

Incarceration history as a risk factor for HIV infection among Puerto Rican injection drug users.

This study assesses factors associated with incarceration history and HIV seropositivity among 1,700 out-of-treatment drug injectors recruited in Puerto Rico between 1989-1990 from health care centers, emergency rooms, copping areas, shooting galleries, bars, billiard rooms and street corners. Analysis links incarceration history with criminal involvement and chronic drug use. After controlling for sociodemographics and previously reported correlates of HIV status, regression analysis shows incarceration history significantly relates to HIV status. The only predictor of incarceration history not related to HIV status was illegal activity as a major source of income. Analysis emphasizes HIV prevention programs within the penal system.

HIV risk behaviors and HIV seropositivity among young injection drug users.

Although injection drug use (IDU) is the major risk category for HIV infection in Puerto Rico and injection drug users start their drug injection careers very young, there is little information related to drug injection patterns of young IDUs. In this paper we report on factors found to be associated with HIV seropositivity among 255 young IDUs (16-24 years old). Overall, 23.5% subjects were HIV seropositive. Being 22 to 24 years old, having dropped out of school, having a history of incarceration, and having been diagnosed with STDs, and initiating drug use injection before 17 years of age were the factors significantly related to HIV seropositivity. Findings suggest that prevention programs should begin early in the development of youngsters. Special HIV and STD preventive programs for youngsters at risk of leaving school before completing high school should be a priority.