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HIV Risk Behavior Remains Common Among People Who Inject Drugs in U.S.

An analysis from the CDC's National HIV Behavioral Surveillance system found that 11% of injection drug users in 20 U.S. cities were HIV-positive in 2012, according to a report in the March 20 Morbidity and Mortality Weekly Report. One-third of the interviewees reported sharing used injection equipment, putting them at risk for acquiring HIV and hepatitis B and C, while a majority reported sex without condoms.

Michael Spillerand colleagues from the Centers for Disease Control and Prevention (CDC) analyzed cross-sectional data on HIV prevalence and behaviors associated with HIV risk and prevention among people who inject drugs (PWID). Data were collected in 2012 from anonymous face-to-face interviews and anonymous HIV testing in cities with high AIDS prevalence. Incentives were offered for interview completion, HIV testing, and recruitment of other participants.

The analysis included data from 10,002 people who inject drugs in Boston, Nassau-Suffolk county in New York, New York City, Newark, and Philadelphia (Northeast region); Atlanta, Baltimore, Dallas, Houston, Miami, New Orleans, and Washington, DC (South region); Chicago and Detroit (Midwest region); and Denver, Los Angeles, San Diego, San Francisco, Seattle (West region); and San Juan, Puerto Rico. Of these, 9425 were included in a behavioral analysis; people who had already tested HIV-positive were excluded, as knowledge of HIV status may influence risk behaviors.

Two-thirds of participants were men, 41% were black or African-American, 30% were white, and 24% were Hispanic/Latino. Reflecting an aging population, 42% were age 50 or older, 27% were age 40-49, 18% were 30-39, and 13% were 18-29. Although a majority were low-income (79% below the federal poverty level), 66% had finished at least high school and 69% had health insurance.

Findings

• HIV prevalence did not change significantly from 2009 (9%) to 2012 (11%), nor did risk behaviors.
• Among the 10,002 PWID tested, 11% tested positive for HIV, with some notable differences among subgroups:

o   HIV prevalence was similar among men (10%) and women (12%);

o   12% of all men reported sex with other men, and this subgroup had the highest HIV prevalence (27%);

o   Prevalence was higher among blacks (16%) and Hispanics/Latinos (11%) compared to whites (5%);

o   Prevalence was higher in the older age groups (18% for age 40-49 and 11% for age 50 or older) compared with the younger groups (6% for 30-39 and just 1% for 18-29);

o   By region, prevalence was 11% in the Northeast, 13% in the South, 8% in the Midwest, and 7% in the West;

o   While 7% of people who injected only heroin tested HIV-positive, this rose to 17% for those who said they injected other or multiple drugs.

• 63% of the HIV-positive PWID were aware of their HIV status.
• Among 9425 people included in the behavioral analysis, the following HIV risk factors were reported during the previous 12 months:

o   30% receptively shared syringes (used after someone else);

o   The youngest injectors (age 18-29) were most likely to report receptive sharing of injection equipment;

o   70% reported vaginal sex without a condom;

o   25% had heterosexual anal sex without a condom;

o   5% of men had sex with another man without a condom.

• Among PWID in the behavioral analysis, 51% had been tested for HIV, 25% had participated in an HIV behavioral intervention, and 39% had participated in substance use treatment during the prior year, and 78% had ever been tested for hepatitis C virus (HCV).  

"Additional efforts are needed to reduce risk behaviors and increase access to HIV testing, drug treatment, and other HIV prevention programs to further reduce HIV infections among PWID," the study authors recommended. "The high-risk behaviors observed among PWID represent an opportunity to prevent future increases in HIV infections caused by sharing injection equipment or having sex without a condom."

Given that people with health insurance were more likely to have been tested for HIV and hepatitis C and participated in behavioral interventions, they added, "These differences suggest that expanding health insurance coverage might allow more PWID to become aware of their HIV and HCV status and to have access to important treatment and prevention interventions."

"At the center of any response to HIV among PWID is a comprehensive, multifaceted prevention strategy, which includes access to sterile injection and drug preparation equipment; treatment for substance use and mental disorders; opioid substitution therapy; counseling, testing, and treatment for HIV infection; education on drug-related and sex-related risks and risk-reduction for PWID and their sex partners; and pre-exposure prophylaxis for adult PWID at substantial risk for HIV acquisition," they concluded. "An effective prevention approach for PWID also includes prevention and treatment of other infections, including HCV; thus, integration of multiple service programs for PWID might increase the effectiveness of HIV prevention efforts."

4/19/15

Reference

MW Spiller, D Broz, C Wejnert, et al (National HIV Behavioral Surveillance System Study Group). Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs -- 20 Cities, United States, 2012. Morbidity and Mortality Weekly Report 64(10):270-275. March 20, 2015.