A comparative study of mortality among Puerto Rican injection drug users in East Harlem, New York, and Bayamon, Puerto Rico.

Drug users have been found to be at high risk of mortality but the mortality experience of Hispanic drug users remains understudied. This study assessed mortality among Puerto Rican injection drug users (IDUs) in New York City (NY), and in Puerto Rico (PR). Study subjects were 637 IDUs from NY and 319 IDUs from PR. Mortality was ascertained using data from the National Death Index. Annual mortality rate of the NY cohort was 1.3 per 100 person years compared to the PR cohort with a rate of 4.8. Compared to the Hispanic population of New York City, the standardized mortality ratio (SMR) of the NY cohort was 4.4. Compared to the population of Puerto Rico, the SMR of the PR cohort was 16.2. The four principal causes of death were: NY-HIV/AIDS (50.0%), drug overdoses (13.3%), cardiovascular conditions (13.3%), and pulmonary conditions (10.0%); PR-HIV/AIDS (37.0%), drug overdoses (24.1%), sepsis (13.0%), and homicide (11.1%). Modeling time to death using Cox proportional hazards regression, the relative risk of mortality of the PR cohort as compared to the NY cohort was 9.2. The other covariates found to be significantly associated with time to death were age, gender, education, social isolation, intoxication with alcohol, and HIV seropositivity. The large disparity in mortality rates found in this study suggests that health disparities research should be expanded to identify intra-group disparities. Furthermore, these results point to an urgent need to reduce excess mortality among IDUs in Puerto Rico.

Drug treatment disparities among Hispanic drug-using women in Puerto Rico and New York City.

This paper reports findings on 334 out-of-treatment drug users in Puerto Rico and 617 in New York City, at the 6-month follow-up interview of a Longitudinal Survey. Main outcomes were health care and drug treatment utilization since baseline, assessed by asking participants if they had received physical or mental health services (including HIV medications), and if they had been in methadone maintenance, inpatient or outpatient drug treatment, or drug treatment while incarcerated. Chi-square tests were used to evaluate associations between gender and the various correlates. Logistic regression was used to calculate the contribution of each variable in predicting use of drug treatment. The analysis suggests that women in both sites were likely to suffer from disparities in both health care and drug treatment utilization when compared with men, albeit women in New York utilized more drug treatment resources and were more embedded in the immediate family than their female peers in Puerto Rico. Further research to specify the impact of contextual factors at the organizational and community levels, among members of the same ethnic group residing in different sites, may prove valuable in identifying the health needs and the factors that impede or facilitate drug-using women in obtaining the most appropriate treatment. Findings from these studies can help in developing appropriate public health policy and science-based drug treatment programs to eliminate disparities such as the ones detected in this study.

Factors associated with drug treatment dropout among injection drug users in Puerto Rico.

This study examined factors associated with drug treatment dropout among injection drug users (IDUs) in Puerto Rico, a group that has contributed significantly to the self-sustaining AIDS epidemic in the island since the mid-1980s. A total of 557 IDUs were recruited from communities in a semirural region of Puerto Rico, as part of a longitudinal study testing the efficacy of a two-facet intervention model, based on motivational interviewing. Of 124 IDUs who had entered drug treatment at follow-up, 33 (26.6%) dropped out before completing all recommended sessions. Multiple logistic regression analysis showed that age, homelessness, and speedball use were significantly associated with drug treatment dropout. Conversely, participants who received the two-facet intervention were significantly less likely to drop out of drug treatment. Receiving psychiatric services also reduced the odds of treatment dropout. Improving adherence to drug treatment and reducing dropout rates are complex processes that need to be addressed at the individual behavioral and social support levels, as well as the program process and resource levels.

HIV risk behaviors and alcohol intoxication among injection drug users in Puerto Rico.

This paper reports results of an analysis of the association between alcohol intoxication and injection and sexual HIV risk behaviors among 557 Hispanic heroin and cocaine injectors, not in treatment, who were recruited in poor communities in Puerto Rico. Subjects were part of a longitudinal prevention-intervention study aimed at reducing drug use and HIV risk behaviors. Participants reported a high prevalence of co-occurring conditions, particularly symptoms of severe depression (52%) and severe anxiety (37%), measured by Beck's Depression Index and Beck's Anxiety Index, respectively. Alcohol intoxication during the last 30 days was reported by 18% of participants. Associations were found between alcohol intoxication and both injection and sexual risk behaviors. In the bivariate analysis, subjects reporting alcohol intoxication were more likely to inject three or more times per day, pool money to buy drugs, share needles, and share cotton. They were also significantly more likely to have a casual or paying sex partner and to have unprotected sex with these partners. After adjustment, sharing needles and cotton, having sex with a paying partner or casual partner, and exchanging sex for money or drugs were significantly related to alcohol intoxication. HIV prevention programs, to be effective, must address alcohol intoxication and its relation to injection and sexual risk behaviors as a central issue in HIV prevention among drug injectors.

Effects of combined counseling and case management to reduce HIV risk behaviors among Hispanic drug injectors in Puerto Rico: a randomized controlled study.

This study examined the effectiveness of a combined counseling and case management behavioral intervention, using motivational interviewing strategies, in engaging Hispanic injection drug users in treatment and reducing drug use and injection-related HIV risk behaviors. Follow up data are presented on 440 (79.0%) of 557 randomized participants, 6 months after the initial interview. Subjects in the experimental arm were significantly less likely to continue drug injection independent of entering drug treatment, and were also more likely to enter drug treatment. Subjects in both arms who entered drug treatment were less likely to continue drug injection. Among subjects who continued drug injection, those in the experimental arm were significantly less likely to share needles. Confirming the outcomes of this study in other Hispanic sites and populations could be a critical step towards reducing factors that contribute to the self-sustaining HIV/AIDS epidemic in Puerto Rico and communities in the U.S. mainland.

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

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

Influence of environmental tobacco smoke on vitamin C status in children.

BACKGROUND: It is known that vitamin C status is compromised in smokers. The vitamin C status of nonsmokers who are exposed to environmental tobacco smoke (ETS) is now being elucidated. OBJECTIVE: We assessed vitamin C status in children who were either exposed or not exposed to ETS, and we sought to associate changes in vitamin C status with the amount of ETS exposure. DESIGN: The study group included 512 children aged 2-12 y; 50% of them were exposed to ETS in the home because their parents smoked. Dietary intake of vitamin C, obtained with a 24-h recall questionnaire, and blood ascorbate concentrations were compared in the exposed and unexposed groups. Smoke exposure was assessed by measuring a biomarker, urinary cotinine. Age, sex, and body mass index were examined as potential correlates of vitamin C status in each exposure category. RESULTS: Plasma ascorbate concentrations were lower, by 3.2 micro mol/L on average, in ETS-exposed children than in unexposed children who consumed equivalent amounts of vitamin C; this was a highly significant difference (P = 0.002). This reduction in plasma ascorbate occurred even with very low exposure to ETS. CONCLUSIONS: ETS can reduce concentrations of ascorbate, an important blood antioxidant, even when the amount of smoke exposure is minimal. Children exposed to ETS should be encouraged to consume increased amounts of foods rich in vitamin C or should be given the equivalent amount of this vitamin as a supplement.

Mortality among Hispanic drug users in Puerto Rico.

This paper assesses mortality rate for a cohort of drug users in Puerto Rico compared with that of the Island's general population, examining causes of death and estimating relative risk of death. Date and cause of death were obtained from death certificates during 1998. Vital status was confirmed through contact with subjects, family, and friends. HIV/AIDS was the major cause of death (47.7%), followed by homicide (14.6%), and accidental poisoning (6.3%). Females had higher relative risk of death than males in all age categories. Not living with a sex partner and not receiving drug treatment were related to higher mortality due to HIV/AIDS. Drug injection was the only variable explaining relative risk of death due to overdose. Puerto Rico needs to continue developing programs to prevent HIV/AIDS among drug users. Special attention should be given to young women, who appear to be in greatest need of programs to prevent early mortality.

The validity of drug use self-reports among hard core drug users in a household survey in Puerto Rico: comparison of survey responses of cocaine and heroin use with hair tests.

The extent to which underreporting of drug use in household surveys affects the validity of epidemiological studies of drug use disorders is largely unknown. We developed a list of known hard core drug users as part of a larger household study in Puerto Rico. The known drug users were recruited and interviewed with the same procedures used for the respondents selected through area-probability sampling. Upon completion of the interview, subjects were asked to provide a sample of scalp hair. A total of 78 hair specimens were collected from the known drug users. Hair specimens were screened for cocaine and heroin using radio immunoassay, and confirmed using gas chromatography/mass spectrometry. Using the cutoff of 0.2 ng/mg of hair, 93.2% of the hair specimens were classified positive for cocaine and 75.7% for heroin. With the hair test results as the gold-standard, we calculated specificity and sensitivity statistics as measures of the validity of self-reports. Self-reports of drug use in the past 3 months had a specificity of 78% or higher for both drugs. The sensitivity of self-reports was 69.6% for reports of recent cocaine use and 78.6% for reports of recent heroin use. Sensitivity increased with reports of use in more remote time periods, among subjects reporting DSM-IV drug disorder symptoms, and among those reporting use of both drugs. The results suggest that while drug reports of hard core drug users interviewed in household surveys might be more valid than those of the general population, there still remains considerable under-reporting.

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

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 per cent male and 20.1 per cent 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

HIV risk and prior drug treatment among Puerto Rican intravenous drug users

El uso compartido de aparatos para la inyección de drogas constituye el medio más comúm de transmissión del VIH en Puerto Rico. Existe una gran necesidad de información sobre estilos de vida y conducta de riesgo de usuarios de drogas inyectadas (UDI's) que no están bajo tratamiento. El estudio analiza los patrones de utilización de programas de tratamiento entre 862 UDI's y las diferencias entre UDI's con y sin historial de tratamiento. Los resultados revelam que los terceras partes de los UDI's habían estado bajo tratamiento; en un promedio de tres veces, con una estadía promedio de tres semanas. Un análisis discriminante escalonado reveló que el número de años inyectándose, estadias en prisión, diagnósticos previos de hepatitis y vivir con los padres son los factores más relevantes para discrimianr entre aquellos con y sin historial previo de tratamiento. Las implicaciones de política pública de los resultados son también mencionados