Immune profiling in Puerto Rican injection drug users with and without HIV-1 infection.

Antiretroviral therapy has been effective in suppressing HIV viral load and enabling people living with HIV to experience longer, more conventional lives. However, as people living with HIV are living longer, they are developing aging-related diseases prematurely and are more susceptible to comorbidities that have been linked to chronic inflammation. Coincident with HIV infection and aging, drug abuse has also been independently associated with gut dysbiosis, microbial translocation, and inflammation. Here, we hypothesized that injection drug use would exacerbate HIV-induced immune activation and inflammation, thereby intensifying immune dysfunction. We recruited 50 individuals not using injection drugs (36/50 HIV+) and 47 people who inject drugs (PWID, 12/47 HIV+). All but 3 of the HIV+ subjects were on antiretroviral therapy. Plasma immune profiles were characterized by immunoproteomics, and cellular immunophenotypes were assessed using mass cytometry. The immune profiles of HIV+/PWID-, HIV-/PWID+, and HIV+/PWID+ were each significantly different from controls; however, few differences between these groups were detected, and only 3 inflammatory mediators and 2 immune cell populations demonstrated a combinatorial effect of injection drug use and HIV infection. In conclusion, a comprehensive analysis of inflammatory mediators and cell immunophenotypes revealed remarkably similar patterns of immune dysfunction in HIV-infected individuals and in people who inject drugs with and without HIV-1 infection.

Employing Respondent Driven Sampling (RDS) to recruit people who inject drugs (PWID) and other hard-to-reach populations during COVID-19: Lessons learned.

Background: Respondent Driven Sampling (RDS) is an effective sampling strategy to recruit hard-to-reach populations but the impact of the COVID-19 pandemic on the use of this strategy in the collection of data involving human subjects, particularly among marginalized and vulnerable populations, is not known. Based on an ongoing study using RDS to recruit and study the interactions between HIV infection, injection drug use, and the microbiome in Puerto Rico, this paper explores the effectiveness of RDS during the pandemic and provided potential strategies that could improve recruitment and data collection. Results: RDS was employed to evaluate its effectiveness in recruiting a group of people who inject drugs (PWID) and controls (N = 127) into a study in the midst of the COVID-19 pandemic. The participants were distributed among three subsets: 15 were HIV+ and PWID, 58 were HIV- PWID, and 54 were HIV+ and not PWID. Findings: Results show that recruitment through peer networks using RDS was possible across all sub-groups. Yet, while those in the HIV+ PWID sub-group managed to recruit from other-sub groups of HIV- PWID and HIV+, this occurred at a lower frequency. Conclusion: Despite the barriers introduced by COVID-19, it is clear that even in this environment, RDS continues to play a powerful role in recruiting hard-to-reach populations. Yet, more attention should be paid at how future pandemics, natural disasters, and other big events might affect RDS recruitment of vulnerable and hard-to-reach populations.

Social Network Analysis of an Agricultural Center: Stakeholders and the Transfer of Information.

We conducted a social network analysis (SNA) of Central States Center for Agricultural Safety and Health (CS-CASH) to describe stakeholder networks for agricultural Research and Education/Outreach. This was a two-phase study. First, the Leader Survey went to N = 9 CS-CASH leaders to identify their key stakeholders. Next, the Stakeholder Survey was sent to these stakeholders to learn about their stakeholder collaborations, interactions, and communications. The Pajek Network Analysis measured SNA metrics for density, centrality, betweenness, k-core, and created the sociograms. The Leader Survey had a 100% response rate and generated N = 337 unique stakeholders. Most were researchers (44%) and educators (20%), with a primary sphere of influence in Nebraska-only (40%). The Stakeholder Survey had 46% response rate, and generated N = 199 names in the extended Education/Outreach network and N = 140 in the extended Research network. Stakeholders in both networks were employed mostly in universities/schools (61%) or non-profits (15%). Both networks had a single main component and 7/9 CS-CASH leaders had central roles in these components. CS-CASH is well positioned in the extended stakeholder networks based on SNA metrics. Stakeholders utilize CS-CASH resources, and they seek and exchange information with its leaders. To strengthen knowledge transfer, it will be useful to build on connections with stakeholders outside academia.

Treatment trajectories and barriers in opioid agonist therapy for people who inject drugs in rural Puerto Rico.

BACKGROUND: Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention. METHODS: We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment. RESULTS: Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico. CONCLUSION: Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.

"He's under oath": Privacy and Confidentiality Views Among People Who Inject Drugs Enrolled in a Study of Social Networks and Human Immunodeficiency Virus/Hepatitis C Virus Risk.

Despite the promise of social network research, this method raises important ethical questions regarding privacy and confidentiality. Although researchers and bioethicists have considered research obligations in relation to marginal or vulnerable populations, the views of people who inject drugs (PWIDs) have not been sufficiently considered. To elicit participants' views of research obligations, we conducted in-depth interviews with a subset (n = 40) of active PWIDs enrolled in a large social network study. Findings suggest participants have an expectation of confidentiality but believe this obligation need not be absolute and can be waived if a participant violates community norms or place others at risk. Ethics boards should recognize that marginalized populations are able to articulate complex moral views about privacy and confidentiality. Engaging participants in dialogue about the responsible conduct of research presents an opportunity to correct under- or overestimations of research vulnerabilities when such decisions are restricted to the perspectives of investigators or Institutional Review Board members.

Social Integration and Domestic Violence Support in an Indigenous Community: Women's Recommendations of Formal Versus Informal Sources of Support.

Throughout North America, indigenous women experience higher rates of intimate partner violence and sexual violence than any other ethnic group, and so it is of particular importance to understand sources of support for Native American women. In this article, we use social network analysis to study the relationship between social integration and women's access to domestic violence support by examining the recommendations they would give to another woman in need. We ask two main questions: First, are less integrated women more likely to make no recommendation at all when compared with more socially integrated women? Second, are less integrated women more likely than more integrated women to nominate a formal source of support rather than an informal one? We use network data collected from interviews with 158 Canadian women residing in an indigenous community to measure their access to support. We find that, in general, less integrated women are less likely to make a recommendation than more integrated women. However, when they do make a recommendation, less integrated women are more likely to recommend a formal source of support than women who are more integrated. These results add to our understanding of how access to two types of domestic violence support is embedded in the larger set of social relations of an indigenous community.

Competing forces of withdrawal and disease avoidance in the risk networks of people who inject drugs.

We analyze a network of needle-sharing ties among 117 people who inject drugs (PWID) in rural Puerto Rico, using exponential random graph modeling to examine whether network members engage in partner restriction to lower their risk of contracting HIV or hepatitis C (HCV), or in informed altruism to prevent others from contracting these infections. Although sharing of used syringes is a significant risk factor for transmission of these diseases among PWID, we find limited evidence for partner restriction or informed altruism in the network of reported needle-sharing ties. We find however that sharing of needles is strongly reciprocal, and individuals with higher injection frequency are more likely to have injected with a used needle. Drawing on our ethnographic work, we discuss how the network structures we observe may relate to a decision-making rationale focused on avoiding withdrawal sickness, which leads to risk-taking behaviors in this poor, rural context where economic considerations often lead PWID to cooperate in the acquisition and use of drugs.

A Systematic Review of Indian Boarding Schools and Attachment in the Context of Substance Use Studies of Native Americans.

This PRISMA style literature review was used to explore substance abuse studies focused on Native American populations in the context of historical trauma (from experiences at Indian boarding schools) and the critical loss of family relationships from colonization. It was found that while Indian boarding schools are recognized as being important research topics related to substance use, they are usually mentioned as a part of the colonization process rather than examined for their specific historical/personal impacts. Furthermore, social science may fail to recognize how detrimental the loss of family relationships was to the traditional bond of a Native American family. Beginning with an extensive list of 402 articles, two criteria were used to arrive at a systematic list of research in the topic areas: the acknowledgment of Indian boarding school attendance and the impact on family relationships. The final list included 27 studies which looked at Indian boarding schools and family relationship's relation to substance use among Native Americans. Overall, this review revealed that family discord should not be singled out as a causal link for Native American families; rather, it should be included in the argument to explain the relationship between Indian boarding school attendance and substance use.

Cost-effectiveness of Direct Antiviral Agents for Hepatitis C Virus Infection and a Combined Intervention of Syringe Access and Medication-assisted Therapy for Opioid Use Disorders in an Injection Drug Use Population.

BACKGROUND: There are too many plausible permutations and scale-up scenarios of combination hepatitis C virus (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used a computer simulation to project the health and economic impacts of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct antiviral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). METHODS: We performed an allocative efficiency study, using a mathematical model to simulate the progression of HCV in PWID and its related consequences. We combined 2 previously validated simulations to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health-sector and societal perspective, with a 15-year time horizon and a discount rate of 3%. RESULTS: From a health-sector perspective (excluding criminal justice system-related costs), 4 potential strategies fell on the cost-efficiency frontier. At 20% coverage, DAAs had an incremental cost-effectiveness ratio (ICER) of $27 251/quality-adjusted life-year (QALY). Combinations of DAA at 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165 985/QALY, $325 860/QALY, and $399 189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA at 20% with MAT+ at 80% was the most effective intervention and was cost saving. While DAA at 20% with MAT+ at 80% was more expensive (eg, less cost saving) than MAT+ at 80% alone without DAA, it offered a favorable value compared to MAT+ at 80% alone ($23 932/QALY). CONCLUSIONS: When considering health-sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together became the most cost-effective intervention.

Community mobilization for rural suicide prevention: Process, learning and behavioral outcomes from Promoting Community Conversations About Research to End Suicide (PC CARES) in Northwest Alaska.

RATIONALE: This study evaluates the process and preliminary outcomes of Promoting Community Conversations About Research to End Suicide (PC CARES), an intervention that brings key stakeholders together so they can discuss suicide prevention research and find ways to put it into practice. Originally piloted in remote and rural Alaskan communities, the approach shows promise. METHOD: Using a multi-method design, the study describes a series of locally-facilitated "learning circles" over 15 months and their preliminary results. Sign-in sheets documented participation. Transcriptions of audio-recorded sessions captured facilitator fidelity, accuracy, and the dominant themes of community discussions. Linked participant surveys (n=83) compared attendees' perceived knowledge, skills, attitudes, and their 'community of practice' at baseline and follow-up. A cross-sectional design compared 112 participants' with 335 non-participants' scores on knowledge and prevention behaviors, and considered the social impact with social network analyses. RESULTS: Demonstrating feasibility in small rural communities, local PC CARES facilitators hosted 59 two to three hour learning circles with 535 participants (376 unique). Local facilitators achieved acceptable fidelity to the model (80%), and interpreted the research accurately 81% of the time. Discussions reflected participants' understanding of the research content and its use in their lives. Participants showed positive changes in perceived knowledge, skills, and attitudes and strengthened their 'community of practice' from baseline to follow-up. Social network analyses indicate PC CARES had social impact, sustaining and enhancing prevention activities of non-participants who were 'close to' participants. These close associates were more likely take preventive actions than other non-participants after the intervention. CONCLUSION: PC CARES offers a practical, scalable method for community-based translation of research evidence into selfdetermined, culturally-responsive suicide prevention practice.

Prevalence and Risk Factors associated with Homelessness among Drug Users in Puerto Rico.

OBJECTIVE: This study aimed to determine the association between years of drug injection and homelessness among drug users in rural Puerto Rico. METHODS: Respondent-driven sampling methods allowed us to obtain a sample of 315 intravenous drug users (IDUs) in rural Puerto Rico. Information about sociodemographic characteristics, drug use patterns, homelessness and risk behaviors was obtained through structured interviews. HIV and HCV statuses were assessed via rapid antibody tests. Frequency distributions were used to describe the study sample. Bivariate analysis and multivariate logistic regressions were used to assess covariates of homelessness. The study received IRB approval through the University of Nebraska-Lincoln and the University of Puerto Rico. RESULTS: Almost 91% of the study participants were males. The mean age was 41.7 years and the majority of the participants had not completed high school (47.6%). The prevalence of current homelessness was 21.9%. After controlling for sociodemographic characteristics, homelessness was strongly associated with the number of years of injection drug use. The odds of being homeless for IDUs with 21 years or more of drug injection was almost 3 times higher than were the odds of being homeless for IDUs with fewer than 10 years of injection (OR = 2.58 95%; CI=1.21,5.48). CONCLUSION: In rural Puerto Rico, the prevalence of current homelessness in IDUs was 21.7%. In the sample, 6.0% were HIV positive and 78.4% were HCV positive. Our results highlight the necessity of increasing accessibility to substance abuse treatment and establishing additional needle-exchange programs (currently, there is only 1) in rural Puerto Rico.

Injection-related hepatitis C serosorting behaviors among people who inject drugs: An urban/rural comparison.

Although previous research has focused on injection drug use behaviors in both urban and rural settings, few have drawn direct comparisons between adjacent rural and urban areas. Using data from the National HIV Behavioral Surveillance study as well as original data collected in a similar fashion, we compare the risk behaviors of people who inject drugs (PWID) in San Juan, Puerto Rico, with those of PWID in nearby rural areas. Specifically, we examine whether one's own hepatitis C (HCV) infection status can be used to predict whether one asked their most recent co-injection partner about their HCV status. Acquiring such information allows injectors to seek out co-injection partners of concordant status as a way to minimize the risk of viral transmission. Results indicate that urban PWID with a known HCV+ status were more likely to know their last co-injector partner's HCV status than were their peers with a negative or unknown HCV status. However, this relationship was not present in the rural data. These findings suggest that there are different risk norms in rural and urban PWID communities and that interventions successful in one type of community may not be so in others.

A Review of Health Survey Research for People with Refugee Background Resettled from Africa: Research Gaps and Methodological Issues.

We reviewed 27 studies on adults with a refugee background resettled from Africa published between 1999 and 2017 to appraise their methodological issues for survey research. Out of 27 studies, eleven used a single sampling method (referral = 1, convenience = 10), and 16 relied on multiple sampling methods, many of which were combinations of referral and convenience. The two most salient recruitment strategies found were building trusted relationships with the community (n = 15), and using recruiters who were culturally and linguistically matched to the refugee communities of interest (n = 14). Fifteen studies used existing data collection instruments, while in 13 studies, researchers developed their own data collection instruments. In-person or phone interviews using bilingual interviewers (n = 21) were the most frequently used mode of data collection, followed by a self-administered survey (n = 7). Our review presents methodological gaps in current refugee health studies, such as limited use of probability sampling approach due to system barriers, lack of information in community engagement and recruitment processes, and insufficient considerations of unique culture and experiences of refugee communities when developing or adapting the instruments. Efforts can be made to guide and facilitate appropriate reporting and development of more scientifically robust survey methodologies for refugee health studies, as well as to improve registration system infrastructure that may help identify these hidden populations more effectively.

Mapping the structure of perceptions in helping networks of Alaska Natives.

This paper introduces a new method for acquiring and interpreting data on cognitive (or perceptual) networks. The proposed method involves the collection of multiple reports on randomly chosen pairs of individuals, and statistical means for aggregating these reports into data of conventional sociometric form. We refer to the method as "perceptual tomography" to emphasize that it aggregates multiple 3rd-party data on the perceived presence or absence of individual properties and pairwise relationships. Key features of the method include its low respondent burden, flexible interpretation, as well as its ability to find "robust intransitive" ties in the form of perceived non-edges. This latter feature, in turn, allows for the application of conventional balance clustering routines to perceptual tomography data. In what follows, we will describe both the method and an example of the implementation of the method from a recent community study among Alaska Natives. Interview data from 170 community residents is used to ascribe 4446 perceived relationships (2146 perceived edges, 2300 perceived non-edges) among 393 community members, and to assert the perceived presence (or absence) of 16 community-oriented helping behaviors to each individual in the community. Using balance theory-based partitioning of the perceptual network, we show that people in the community perceive distinct helping roles as structural associations among community members. The fact that role classes can be detected in network renderings of "tomographic" perceptual information lends support to the suggestion that this method is capable of producing meaningful new kinds of data about perceptual networks.

Combination interventions for Hepatitis C and Cirrhosis reduction among people who inject drugs: An agent-based, networked population simulation experiment.

Hepatitis C virus (HCV) infection is endemic in people who inject drugs (PWID), with prevalence estimates above 60% for PWID in the United States. Previous modeling studies suggest that direct acting antiviral (DAA) treatment can lower overall prevalence in this population, but treatment is often delayed until the onset of advanced liver disease (fibrosis stage 3 or later) due to cost. Lower cost interventions featuring syringe access (SA) and medically assisted treatment (MAT) have shown mixed results in lowering HCV rates below current levels. However. little is known about the potential cumulative effects of combining DAA and MAT treatment. While simulation experiments can reveal likely long-term effects, most prior simulations have been performed on closed populations of model agents-a scenario quite different from the open, mobile populations known to most health agencies. This paper uses data from the Centers for Disease Control's National HIV Behavioral Surveillance project, IDU round 3, collected in New York City in 2012 to parameterize simulations of open populations. To test the effect of combining DAA treatment with SA/MAT participation, multiple, scaled implementations of the two intervention strategies were simulated. Our results show that, in an open population, SA/MAT by itself has only small effects on HCV prevalence, while DAA treatment by itself can lower both HCV and HCV-related advanced liver disease prevalence. More importantly, the simulation experiments suggest that combinations of the two strategies can, when implemented together and at sufficient levels, dramatically reduce HCV incidence. We conclude that adopting SA/MAT implementations alongside DAA interventions can play a critical role in reducing the long-term consequences of ongoing HCV infection.

Agency and social constraint among victims of domestic minor sex trafficking: A method for measuring free will.

Human agency has been a focus of philosophical and sociological concern from early debates about "free will" to recent themes in poststructuralism. Debates over the proper understanding of structure, agency, and constraint are hindered by the fact that few if any empirical measures of these concepts have been proposed. As sociologists have long recognized, the total results of the decisions of a group's members can be viewed as a distribution, and parameters can be fit to obtain a description of observed distributions. Here we propose the use of negative binomial curve to model population survival outcomes, and suggest that the parameters of such a curve represent reasonable surrogates for measures of agency, opportunity, and constraint when the decision process can be thought of as akin to a Bernoulli process. To provide an illustration of this approach, we discuss participation of legal minors in commercial sex (commonly referred to as victims of domestic minor sex trafficking (VDMST) or commercially sexually exploited children (CSEC)). In popular and advocacy-based accounts, considerable focus has been placed on the relative powerlessness of female VDMST. Using the proposed modeling technique, we test the extent to which male versus female VDMST appear to possess greater agency (or function under more limiting constraint) when deciding whether to remain in sex work or "leave the life". Contrary to existing literature, our results indicate that male and female underage sex workers are experiencing similar levels of agency, and differ mainly in opportunity, and constraint. Other individual circumstances are shown to contribute to varying levels of agency and constraint among sex workers, including street work status, community trouble, drug use, and the availability of an alternative income.

One-step estimation of networked population size: Respondent-driven capture-recapture with anonymity.

Size estimation is particularly important for populations whose members experience disproportionate health issues or pose elevated health risks to the ambient social structures in which they are embedded. Efforts to derive size estimates are often frustrated when the population is hidden or hard-to-reach in ways that preclude conventional survey strategies, as is the case when social stigma is associated with group membership or when group members are involved in illegal activities. This paper extends prior research on the problem of network population size estimation, building on established survey/sampling methodologies commonly used with hard-to-reach groups. Three novel one-step, network-based population size estimators are presented, for use in the context of uniform random sampling, respondent-driven sampling, and when networks exhibit significant clustering effects. We give provably sufficient conditions for the consistency of these estimators in large configuration networks. Simulation experiments across a wide range of synthetic network topologies validate the performance of the estimators, which also perform well on a real-world location-based social networking data set with significant clustering. Finally, the proposed schemes are extended to allow them to be used in settings where participant anonymity is required. Systematic experiments show favorable tradeoffs between anonymity guarantees and estimator performance. Taken together, we demonstrate that reasonable population size estimates are derived from anonymous respondent driven samples of 250-750 individuals, within ambient populations of 5,000-40,000. The method thus represents a novel and cost-effective means for health planners and those agencies concerned with health and disease surveillance to estimate the size of hidden populations. We discuss limitations and future work in the concluding section.

Rural and urban injection drug use in Puerto Rico: Network implications for human immunodeficiency virus and hepatitis C virus infection.

Understanding the short- and long-term transmission dynamics of blood-borne illnesses in network contexts represents an important public health priority for people who inject drugs and the general population that surrounds them. The purpose of this article is to compare the risk networks of urban and rural people who inject drugs in Puerto Rico. In the current study, network characteristics are drawn from the sampling "trees" used to recruit participants to the study. We found that injection frequency is the only factor significantly related to clustering behavior among both urban and rural people who inject drugs.

Latent Risk Subtypes Based on Injection and Sexual Behavior Among People Who Inject Drugs in Rural Puerto Rico.

BACKGROUND: People who inject drugs (PWID) in Puerto Rico engage in high levels of injection and sexual risk behavior, and they are at high risk for HIV and hepatitis C (HCV) infection, relative to their US counterparts. Less is known, however, about the clustering of risk behavior conducive to HIV and HCV infection among rural Puerto Rican communities. OBJECTIVES: The purpose of this study was to examine concurrent injection and sexual risk subtypes among a rural sample of PWID in Puerto Rico. METHODS: Data were drawn from a respondent-driven sample collected in 2015 of 315 PWID in 4 rural communities approximately 30-40 miles from San Juan. Latent class analysis (LCA) was used to examine risk subtypes using 3 injection and 3 sexual risk indicators. In addition, demographic and other PWID characteristics were examined as possible predictors of latent class membership. RESULTS: Four LCA subtypes were identified: low risk (36%), high injection/low sexual risk (22%), low injection/high sexual risk (20%), and high risk (22%). Younger age and past year homelessness predicted high risk latent class membership, relative to the other classes. In addition, daily speedball use predicted membership in the high injection/low sexual risk class, relative to the low risk and low injection/high sexual risk classes. CONCLUSION/IMPORTANCE: The findings suggest ways in which PWID risk clusters can be identified for targeted interventions.

Injection Partners, HCV, and HIV Status among Rural Persons Who Inject Drugs in Puerto Rico.

BACKGROUND: The prevalence of hepatitis C (HCV) and HIV among persons who inject drugs (PWID) and the ability of these diseases to spread through injection networks are well documented in urban areas. However, less is known about injection behaviors in rural areas. OBJECTIVES: This study focuses on the association between the number of self-reported injection partners with the PWID's self-reported HCV and HIV status. Injection networks provide paths for infection and information to flow, and are important to consider when developing prevention and intervention strategies. METHODS: Respondent driven sampling was used to conduct 315 interviews with PWID in rural Puerto Rico during 2015. Negative binomial regression was used to test for associations between the number of self-reported injection partners and self-reported HCV and HIV statuses. Multinomial logistic regression was used to test for associations with the participant's self-reported HCV and HIV statuses. RESULTS: Self-reported HCV status is significantly associated with injection risk network size. Injection partner networks of self-reported HCV- respondents are half what is reported by those with a positive or unknown status. Self-reported HIV statuses are not associated with different numbers of injection partners. CONCLUSIONS: Smaller injection networks among those who self-report a HCV- status suggests that those who believe their status to be negative may take protective action by reducing their injection network compared to those have a self-reported HCV+ or an unknown status. Although the cross-sectional design of the study makes it difficult verify, such behavior has implications for prevention programs attempting to prevent HCV transmission.