Empirical Development of a Behavioral Intervention for African American/Black and Latino Persons with Unsuppressed HIV Viral Load Levels: An Application of the Multiphase Optimization Strategy (MOST) Using Cost-Effectiveness as an Optimization Objective.

We used results from an optimization randomized controlled trial which tested five behavioral intervention components to support HIV antiretroviral adherence/HIV viral suppression, grounded in the multiphase optimization strategy and using a fractional factorial design to identify intervention components with cost-effectiveness sufficiently favorable for scalability. Results were incorporated into a validated HIV computer simulation to simulate longer-term effects of combinations of components on health and costs. We simulated the 32 corresponding long-term trajectories for viral load suppression, health related quality of life (HRQoL), and costs. The components were designed to be culturally and structurally salient. They were: motivational interviewing counseling sessions (MI), pre-adherence skill building (SB), peer mentorship (PM), focused support groups (SG), and patient navigation (short version [NS], long version [NL]. All participants also received health education on HIV treatment. We examined four scenarios: one-time intervention with and without discounting and continuous interventions with and without discounting. In all four scenarios, interventions that comprise or include SB and NL (and including health education) were cost effective (< $100,000/quality-adjusted life year). Further, with consideration of HRQoL impact, maximal intervention became cost-effective enough to be scalable. Thus, a fractional factorial experiment coupled with cost-effectiveness analysis is a promising approach to optimize multi-component interventions for scalability. The present study can guide service planning efforts for HIV care settings and health departments.

Utility of self-report antiretroviral adherence for predicting HIV viral load among persons who inject drugs in Hai Phong Vietnam: assessing differences by methamphetamine use.

ABSTRACTIn resource-limited settings, alternatives to HIV viral load testing may be necessary to monitor the health of people living with HIV. We assessed the utility of self-report antiretroviral therapy (ART) to screen for HIV viral load among persons who inject drugs in Hai Phong Vietnam, and consider differences by recent methamphetamine use. From 2016 to 2018 we recruited PWID through cross sectional surveys and collected self-report ART adherence and HIV viral load to estimate sensitivity, specificity, positive and negative predictive values (PPV, NPV) and likelihood ratios (LR+, LR-) for self-reported ART adherence as a screening test for HIV viral load. We used three HIV viral load thresholds: < 1000, 500 and 250 copies/mL; laboratory-confirmed HIV viral load was the gold standard. Among 792 PWID recruited, PPV remained above 90% regardless of recent methamphetamine use with slightly higher PPV among those not reporting recent methamphetamine use. The results remained consistent across all three HIV viral load thresholds. Our findings suggest that when HIV viral load testing is not possible, self-reported ART adherence may inform decisions about how to prioritize HIV viral load testing among PWID. The high PPV values suggest self-reported high ART adherence indicates likely HIV viral suppression, irrespective of methamphetamine use.

Field Testing the "Avoid the Needle" Intervention for Persons at Risk for Transitioning to Injecting Drug Use in Tallinn, Estonia and New York City, USA.

This study aimed to field tested the "Avoid the Needle" (AtN) intervention to reduce transitions from non-injecting to injecting drug use in two different epidemiological settings. Respondent driven sampling was used to recruit current non-injecting drug users (NIDUs) in Tallinn, Estonia in 2018-19 and in New York City (NYC) in 2019-20. Both persons who had never injected and persons who had previously injected but not in the last 6 months were eligible; a structured interview was administered, a blood sample collected, and the intervention administered by trained interventionists. We recruited 19 non-injectors from Tallinn and 140 from NYC. Participants in Tallinn were younger and had begun using drugs at earlier ages than participants in NYC. The primary drugs used in Tallinn were amphetamine, fentanyl, and opioid analgesics, while in NYC they were heroin, cocaine, speedball, and fentanyl. Six-month follow-up data were obtained from 95% of participants in Tallinn. The study was interrupted by COVID-19 lockdown in NYC, but follow-up data were obtained from 59% of participants. There were minimal transitions to injecting: 1/18 in Tallinn and 0/83 in NYC. There were significant declines in the frequencies of using readily injectable drugs (fentanyl, amphetamine, heroin, cocaine) from baseline to follow-up in both sites (Cochran-Armitage tests for trend, χ2 = 21.3, p < 0.001 for New York City; and χ2 = 3.9, p = 0.048 for Tallinn). Reducing transitions into injecting is a potentially very important method for reducing HIV transmission and other harms of drug use. Further investigation and implementation of AtN type interventions is warranted.

Mediation of the Effect of Incarceration on Selling Sex Among Black Sexual Minority Men and Black Transgender Women in the HPTN 061 Study.

Incarceration among Black sexual minority men and Black transgender women (BSMM/BTW) is disproportionately high in the United States. Limited research has documented the disruptive effect of incarceration on sexual networks and sexual partnership exchange among BSMM/BTW. We estimate the influence of incarceration on selling sex and mediating pathways among 1169 BSMM/BTW enrolled in the HIV Prevention Trials Network (HPTN) 061 cohort to assess this relationship. Mediators investigated were social support, violence, illicit drug use, and distress due to experienced racism and homophobia. During the 6 months following baseline, 14% of the cohort was incarcerated, including 24% of BTW. After adjustment, recent incarceration was associated with 1.57 (95% CI 1.02, 2.42) times the risk of subsequently selling sex. The hypothesized mediators together explained 25% of the relationship, with an indirect effect risk ratio of 1.09 (95% CI 0.97, 1.24). Our results document an association and call for more research investigating mechanisms.

Does the Association Between Stimulant use and High Risk Sexual Behavior Vary by Injection Drug Use, Sexual Minority Status, or HIV Infection Status? A Meta-analysis.

There is strong evidence linking stimulant use, namely methamphetamine use, to sexual risk behavior among sexual minority men (SMM); we do not, however, have a good understanding of this relationship among other at-risk populations. In this study, we systematically reviewed associations between stimulant use (i.e., methamphetamine, crack cocaine, cocaine) and sexual risk behaviors among populations facing elevated risk of HIV transmission and acquisition (i.e., SMM, people who inject drugs (PWID), and people living with HIV/AIDS (PLWH)). Random-effects meta-analyses and sensitivity analyses that included crude and adjusted estimates separately were conducted to evaluate the impact of potential confounding variables. The results showed strong relationships between stimulant use and condomless sex, transactional sex, and multiple sexual partners. Results were broadly consistent when analyses were stratified by type of stimulant (methamphetamine, crack cocaine, and other stimulants) and risk group. Sensitivity analyses with confounding variables did not greatly impact results. The results indicate that stimulant use is associated with numerous sexual risk behaviors regardless of risk group, suggesting prevention efforts focused on reducing methamphetamine-related HIV risk should target a range of at-risk populations.

Gender Differences in HIV, HCV risk and Prevention Needs Among People who Inject drug in Vietnam.

We examined gender differences among people who inject drug (PWID) in Hai Phong, Vietnam in term of blood-borne infections, risk behaviors, and access to care. Using respondent-driven-sampling surveys, we recruited 3146 PWID from 2016 to 2018. Inclusion criteria included a positive urine test for heroin and recent injection marks. There were 155 female PWID (4,9%), including 82 at RDS-2016, 32 at RDS-2017 and 38 at RDS-2018. The age mean was 36.3 ± 7.2 years. The majority of female PWID had less than high school education (90.9%) and were unemployed (51.3%). There was no difference in the proportion of HIV and HCV positive by gender. However, women had several significant differences in risk behaviors than men in multivariable logistic regression. Being a woman was independently associated with being unemployed, being a sex worker, having unstable housing, having uses drugs for less than 5 years, more use of methamphetamine, having a partner who ever injected drugs, and less access to methadone treatment. Interventions targeting female PWID are needed, possibly through community organizations and peer educators.

Challenges Unique to Transgender Persons in US Correctional Settings: a Scoping Review.

US correctional facilities operate under a binary interpretation of gender, which can yield inherent risks and conflicts for incarcerated transgender people. We conducted a scoping literature review on challenges unique to transgender individuals within US correctional settings. Online databases were searched to identify papers that addressed the challenges of incarcerated transgender adults age 18 + within US correctional institutions. A concurrent analysis of legal literature was reviewed with key policy recommendations extracted. A total of 33 papers (21 scientific studies and 12 legal analyses) met criteria for inclusion. Of the 21 scientific studies, the majority of papers (n = 14) focused on transgender women and most (n = 13) utilized qualitative methods. Emerging themes revealed challenges in key domains of violence, health, healthcare access, housing, and a pervasive culture of transphobia. Legal analyses supported policy changes such as implementing case-by-case housing classification systems, providing all forms of gender-affirming care, and safeguarding gender expression. Transgender persons face distinct obstacles while incarcerated in US correctional facilities and are in need of expanded protections. Working in tandem with efforts to decarcerate and reduce criminal legal involvement, widespread institutional policy change, such as redefining housing assignment policies, ensuring gender-affirming healthcare, and expanding transgender-specific competency trainings for correctional staff, is necessary.

HIV treatment, antiretroviral adherence and AIDS mortality in people who inject drugs: a scoping review.

BACKGROUND: People who inject drugs (PWID) are a key population for the prevention and care of HIV infection. METHODS: This scoping review covers recent (post-2010) systematic reviews on engagement of PWID in sequential stages of HIV care from uptake, to achieving viral suppression, and to avoiding AIDS-related mortality. RESULTS: We found that data on engagement of PWID into antiretroviral therapy (ART) were particularly scarce, but generally indicated very low engagement in ART. Studies of adherence and achieving viral suppression showed varying results, with PWID sometimes doing as well as other patient groups. The severity of social, medical and psychiatric disability in this population poses significant treatment challenges and leads to a marked gap in AIDS mortality between PWID and other population groups. CONCLUSIONS: Given the multi-level barriers, it will be difficult to reach current targets (UNAIDS fast-track targets of 95-95-95) for ART for PWID in many locations. We suggest giving priority to reducing the likelihood that HIV seropositive PWID will transmit HIV to others and reducing morbidity and mortality from HIV infection and from other comorbidities.

COVID-19 vaccination and HIV transmission among persons who inject drugs during the first two years of the COVID-19 pandemic in New York City.

BACKGROUND: To examine COVID-19 vaccination and HIV transmission among persons who inject drugs (PWID) during the COVID-19 pandemic (2020-2022) in New York City (NYC). METHODS: Two hundred and seventy five PWID were recruited from October 2021 to September 2022. A structured questionnaire was used to measure demographics, drug use behaviors, overdose experiences, substance use treatment history, COVID-19 infection, vaccination, and attitudes. Serum samples were collected for HIV, HCV, and SARS-CoV-2 (COVID-19) antibody testing. RESULTS: Participants were: 71% male, the mean age was 49 (SD 11), 81% reported at least one COVID-19 immunization, 76% were fully vaccinated and 64% of the unvaccinated had antibodies for COVID-19. Self-reported injection risk behaviors were very low. HIV seroprevalence was 7%. Eighty-nine percent of the HIV seropositive respondents reported knowing they were HIV seropositive and being on antiretroviral therapy prior to the COVID-19 pandemic. There were two likely seroconversions in 518.83 person-years at risk from the March 2020 start of the pandemic to the times of interviews, for an estimated incidence rate of 0.39/100 person-years, 95% Poisson CI 0.05-1.39/100 person-years. CONCLUSIONS: There is concern that the COVID-19 pandemic disruptions to HIV prevention services and the psychological stress of the pandemic may lead to increased risk behavior and increased HIV transmission. These data indicate adaptive/resilient behaviors in both obtaining COVID-19 vaccination and maintaining a low rate of HIV transmission among this sample of PWID during the first two years of the COVID-19 pandemic in NYC.

Incarceration and Sexual Risk Behavior and Incident Sexually Transmitted Infection/HIV in HIV Prevention Trials Network 061: Differences by Study City and Among Black Sexual Minority Men Who Have Sex With Men, Black Sexual Minority Men Who Have Sex With Men and Women, and Black Transgender Women.

BACKGROUND: Black sexual minority men (BSMM) and Black transgender women face a disproportionate risk of incarceration and sexually transmitted infection (STI)/HIV, yet research on the longitudinal association between incarceration and STI/HIV risk in these groups is limited. METHODS: We used data from the HIV Prevention Trials Network (HPTN) 061 study conducted among BSMM and Black transgender women in Atlanta, Boston, Los Angeles, New York City, San Francisco, and Washington, DC, restricting analyses to those who returned for the 6-month follow-up visit when recent incarceration was measured (n = 1169). Using inverse probability of treatment weighting, we measured associations between incarceration and next 6-month multiple partnerships; selling or buying sex; condomless anal intercourse; and incident chlamydia, gonorrhea, syphilis, and HIV. We explored differences by study city, and among BSMM who had sex with men only, BSMM who had sex with men and women, and Black transgender women. RESULTS: Approximately 14% reported past 6-month incarceration. Incarceration was associated with next 6-month selling sex (adjusted risk ratio [ARR], 1.80; 95% confidence interval [CI], 1.12-2.87) in the overall sample and multiple partnerships among BSMM who had sex with men and women (ARR, 1.34; 95% CI, 1.10-1.63) and transgender women (ARR, 1.77; 95% CI, 1.22-2.57). There is evidence suggesting that incarceration may predict gonorrhea (ARR, 2.35; 95% CI, 0.95-5.77), with particularly strong associations observed in Los Angeles (ARR, 6.48; 95% CI, 1.48-28.38). CONCLUSIONS: Incarceration may increase STI/HIV risk among BSMM and Black transgender women. Additional mixed-methods research is needed to validate associations and understand pathways.

The associations of incarceration and depression with healthcare experiences and utilization among Black men who have sex with men in HPTN 061.

Associations of incarceration with healthcare access and utilization among Black sexual minority men (BSMM) and differences in association among those with and without pre-incarceration symptoms of depression were measured. Secondary analysis using survey data from the longitudinal cohort HIV Prevention Trials Network 061 study was conducted among 1553 BSMM from six major U.S. cities from 2009 to 2011. We used modified log-binomial regression with robust standard errors to estimate associations of incarceration (reported at 6 month follow-up) on next six-month healthcare utilization and access (reported at the 12 month follow-up). We tested the significance of baseline depressive symptoms by incarceration interaction and reported differences in associations when observed. Participants with a history of incarceration were more likely to have depressive symptoms at baseline compared to those without. Recent incarceration was associated with almost twice the risk of mistrust in healthcare providers and emergency room utilization. Among men reporting depressive symptoms, a history of incarceration was associated with almost tripled risk of reporting providers do not communicate understandably. Among those with depression, one in five reported a missed visit regardless of incarceration status.

Longitudinal Associations between Police Harassment and Experiences of Violence among Black Men Who Have Sex with Men in Six US Cities: the HPTN 061 Study.

Interactions with the police may result in police brutality, particularly for people of color. Black men who have sex with men (BMSM) face disproportionate risk of police contact and may experience elevated violence risk. We measured longitudinal associations between discriminatory police harassment (DPH) and subsequent risk of a range of interpersonal violence experiences, including intimate partner violence (IPV). In this study, we estimated associations between DPH motivated by racism, homophobia, or both, and subsequent violent experiences (being physically harassed, hit, threatened with weapons, and intimate partner violence) among BMSM. Bivariate and multivariable regression analyses were used to control for demographic and behavioral factors. Among 1160 BMSM included at 12-month follow-up, experiencing DPH motivated by racism and homophobia was associated with over four times the odds of being threatened with violence (AOR 4.85, 95% CI 3.20, 7.33), four times the odds of or experiencing violence defined as being punched, kicked, or beaten, or having an object thrown at them (AOR 4.51, 95% CI 2.82, 7.19), and nearly three times the odds of physical partner abuse (AOR 3.49, 95% CI 1.69, 7.19). Findings suggest that for BMSM, DPH is associated with the threat and experience of violence, with a dose-response relationship between DPH motivated by one or more causes. Given that BMSM are a population particularly vulnerable to both police harassment related to race and sexual orientation and violence coupled with stigma, additional research evaluating mechanisms linking these associations is needed in order to develop additional supportive interventions.

Pre-Exposure Prophylaxis (PrEP) Awareness Among Black Men Who Have Sex with Men with a History of Criminal Justice Involvement in Six U.S. Cities: Findings from the HPTN 061 Study.

Transition from detention to the community for Black men who have sex with men with criminal justice involvement (BMSM-CJI) represents a particularly vulnerable period for HIV acquisition and transmission. We examined levels of HIV PrEP awareness among BMSM-CJI. PrEP awareness among BMSM-CJI was low (7.9%) with evidence of lower awareness levels among those with STI. There was evidence that HIV testing history was associated with higher PrEP awareness. Study findings highlight needs for further assessment of PrEP knowledge among BMSM-CJI. The strong association between HIV testing and PrEP awareness underscores an opportunity to integrate PrEP education within HIV/STI testing services.

Is your syringe services program cost-saving to society? A methodological case study.

BACKGROUND: While there is a general acceptance among public health officials and policy-makers that syringe services programs can be effective in reducing HIV transmission among persons who inject drugs, local syringe services programs are often asked to provide economic justifications for their activities. A cost-effectiveness study, estimating the cost of preventing one HIV infection, would be the preferred methods for addressing this economic question, but few local syringe services programs have the needed data, staff and epidemiologic modeling resources needed for a cost-effectiveness study. We present a method for estimating a threshold value for the number of HIV infections prevented above which the program will be cost-saving to society. An intervention is considered "cost-saving" when it leads to a desirable health outcome a lower cost than the alternative. METHODS: The research literature on the effectiveness of syringe services programs in controlling HIV transmission among persons who inject drugs and guidelines for syringe services program that are "functioning very well" were used to estimate the cost-saving threshold at which a syringe services program becomes cost-saving through preventing HIV infections versus lifetime treatment of HIV. Three steps are involved: (1) determining if HIV transmission in the local persons who inject drugs (PWID) population is being controlled, (2) determining if the local syringe services program is functioning very well, and then (3) dividing the annual budget of the syringe services program by the lifetime cost of treating a single HIV infection. RESULTS: A syringe services program in an area with controlled HIV transmission (with HIV incidence of 1/100 person-years or less), functioning very well (with high syringe coverage, linkages to other services, and monitoring the local drug use situation), and an annual budget of $500,000 would need to prevent only 3 new HIV infections per year to be cost-saving. CONCLUSIONS: Given the high costs of treating HIV infections, syringe services programs that are operating according to very good practices ("functioning very well") and in communities in which HIV transmission is being controlled among persons who inject drugs, will almost certainly be cost-saving to society.

The Relative Economy and Drug Overdose Deaths.

BACKGROUND: Overdose deaths increased exponentially in the United States to be the leading cause of adult injury deaths, and declining economic opportunity may contribute. To our knowledge, there has been no quantitative research into the impact of relative economic measures on overdose risk. Prior longitudinal studies on impact of socioeconomic conditions used fixed effects approaches that can result in biased estimates in the presence of time-varying confounders. METHODS: We estimated county-level longitudinal associations between drug overdose deaths and unemployment and labor-force nonparticipation rates by gender and racial/ethnic subgroup using longitudinal g-computation and the clustered bootstrap. RESULTS: We find evidence for associations between both overall and relative aspects of unemployment and labor-force nonparticipation and drug overdose mortality; patterns of associations differed, sometime qualitatively, across subgroups. For males across racial-ethnic groups, greater overall and relative unemployment rates were generally associated with greater overdose mortality in both the short and long terms [e.g., for white males, increasing the overall percentage of unemployed adults by 5% points in 2000, 2009, and 2015 is associated with an increase of 3.2 overdose deaths (95% confidence interval [CI] = -2.8, 14) in 2015, and increasing the ratio by 0.5 in 2000, 2009, and 2015 is associated with an increase of 9.1 overdose deaths (95% CI = 1.6, 24)]. CONCLUSIONS: These findings point to important complexity in how the economic and contextual landscape differentially shapes overdose risks, underscoring a need for increased understanding of the mechanisms operating for women and minority groups.

Expansion of Syringe Service Programs in the United States, 2015-2018.

Objectives. To report on the expansion of syringe service programs (SSPs) in the United States from 2015 to 2018.Methods. We obtained data from records of the Buyers' Club of the Dave Purchase Project/North American Syringe Exchange Network (NASEN), including the number of US SSPs and the numbers of sterile syringes purchased by programs. We conducted a subset analysis of states with high numbers of counties defined as "vulnerable" by the Centers for Disease Control and Prevention.Results. SSP participation in the Buyers' Club increased from 141 in 2015 to 292 in 2018, with an increase in syringes purchased from 42 million to 88 million. In addition to these large increases in numbers of programs and in syringes purchased, there were also indications of instability among new programs in vulnerable states.Conclusions. There have been substantial increases in the number of programs established and the number of syringes distributed in response to the opioid epidemic. Ensuring high-quality services in these new programs will be critical to successfully addressing the current epidemic.

Injection and Heterosexual Risk Behaviors for HIV Infection Among Non-gay Identifying Men Who Have Sex with Men and Women.

Non-gay identifying men who have sex with men and women (MSMW) are an important subgroup of men who have sex with men (MSM) and have been underrepresented in studies of MSM that only use gay venues to draw their samples. We assessed heterosexual and drug use risks of MSMW who use drugs in a sample of male entrants to the Mount Sinai Beth Israel drug treatment programs from 2005 to 2018. Blood samples were collected and tested for HIV and HSV-2 infections. Among HIV seronegative participants, MSMW had significantly greater odds of sharing used needles with others, and reporting unprotected sex with female casual partners and female commercial sex partners, compared to their counterparts who reported sex with women exclusively (MSWE). Although not recruited from gay venues, MSMW had a significantly higher HIV prevalence than MSWE (23% vs. 10%, p < 0.001). Interventions that are specifically tailored to HIV prevention among MSMW are needed to ameliorate the prevalence of HIV risks and infection.

Implementing an Updated "Break the Cycle" Intervention to Reduce Initiating Persons into Injecting Drug Use in an Eastern European and a US "opioid epidemic" Setting.

We tested the hypothesis that an updated "Break the Cycle" (BtC) intervention, based in social cognitive theory and motivational interviewing, would reduce the likelihood that current persons who inject drugs (PWID) would assist persons who do not inject drugs (non-PWID) with first injections in Tallinn, Estonia and Staten Island, New York City. 402 PWID were recruited, a baseline interview covering demographics, drug use, and assisting non-PWID with first drug injections was administered, followed by BtC intervention. 296 follow-up interviews were conducted 6 months post-intervention. Percentages assisting with first injections declined from 4.7 to 1.3% (73% reduction) in Tallinn (p < 0.02), and from 15 to 6% (60% reduction) in Staten Island (p < 0.05). Persons assisted with first injections declined from 11 to 3 in Tallinn (p = 0.02) and from 32 to 13 in Staten Island. (p = 0.024). Further implementation research on BtC interventions is urgently needed where injecting drug use is driving HIV/HCV epidemics and areas experiencing opioid epidemics.

Working With Persons Who Inject Drugs and Live in Rural Areas: Implications From China/Vietnam for the USA.

PURPOSE OF REVIEW: To describe a small city/rural area HIV prevention project (the Cross Border Project) implemented in Ning Ming County, Guangxi Province, China, and Lang Son province, Vietnam, and consider its implications for addressing the opioid/heroin epidemic in small cities/rural areas in the USA. The description and the outcomes of the Cross Border project were taken from published reports, project records, and recent data provided by local public health authorities. Evaluation included serial cross-sectional surveys of people who inject drugs to assess trends in risk behaviors and HIV prevalence. HIV incidence was estimated from prevalence among new injectors and through BED testing. RECENT FINDINGS: The Cross Border project operated from 2002 to 2010. Key components of the project 2 included the use of peer outreach workers for HIV/AIDS education, distribution of sterile injection equipment and condoms, and collection of used injection equipment. The project had the strong support of local authorities, including law enforcement, and the general community. Significant reductions in risk behavior, HIV prevalence, and estimated HIV incidence were observed. Community support for the project was maintained. Activities have been continued and expanded since the project formally ended. The Cross Border project faced challenges similar to those occurring in the current opioid crisis in US small cities/rural areas: poor transportation, limited resources (particularly trained staff), poverty, and potential community opposition to helping people who use drugs. It should be possible to adapt the strategies used in the Cross Border project to small cities/rural areas in the US opioid epidemic.

Risk Behaviors for HIV and HCV Infection Among People Who Inject Drugs in Hai Phong, Viet Nam, 2014.

We examined the potential for HIV and hepatitis C (HCV) transmission across persons who inject drugs (PWID), men-who-have-sex-with-men (MSM) and female commercial sex workers (CSW) PWID and the potential for sexual transmission of HIV from PWID to the general population in Hai Phong, Viet Nam. Using respondent driven and convenience sampling we recruited 603 participants in 2014. All participants used heroin; 24% used non-injected methamphetamine. HIV prevalence was 25%; HCV prevalence was 67%. HIV infection was associated with HCV prevalence and both infections were associated with length of injecting career. Reported injecting risk behaviors were low; unsafe sexual behavior was high among MSM-PWID and CSW-PWID. There is strong possibility of sexual transmission to primary partners facilitated by methamphetamine use. We would suggest future HIV prevention programs utilize multiple interventions including "treatment as prevention" to potential sexual transmission of HIV among MSM and CSW-PWID and from PWID to the general population.