Background Injection drug use and its associated blood-borne infections has become a rapidly increasing problem in rural areas of the US recently. Syringe exchange programs have been shown to be effective for reducing transmission of blood borne infections, however access to these prevention efforts may be limited in rural areas. Methods This paper utilizes two separate community samples of people who inject drugs (PWID) in Puerto Rico to achieve the following research objectives: 1) compare rural and urban access to syringe exchange programs, free sterile syringes and other HIV/HCV prevention activities, and 2) examine whether utilization of prevention activities is associated with lower injection risk behaviors. Two samples were recruited with RDS (n=315 rural sample; n=512 urban sample) and included adults aged 18 years and older who have injected drugs within the past month. Results 78.5% of the urban sample utilized a syringe exchange program in the past year, compared to 58.4% of the rural sample (p<.001). 71.4% of the urban sample received free sterile needles, compared to 58.4% of the rural sample (p<.001). 66% of the urban sample received free works compared to 59% of the rural sample (p=.034). 29% of urban PWID had a conversation with an outreach worker about HIV prevention compared to 18% of the rural sample (p<0.001). Receiving free needles significantly increases the frequency of using a sterile needle to inject (p<.001). Conclusion Urban PWID were significantly more likely to have utilized syringe exchange programs, received free sterile needles, received free works, and to have talked about HIV prevention with an outreach worker during the past year than PWID residing in rural areas. Individuals who accessed these prevention activities were significantly less likely to exhibit risky injection behavior. Policy implications call for increasing access to prevention services in rural areas to reduce disease transmission.

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BackgroundHIV prevalence in Puerto Rico is nearly twice that of the mainland United States, a level that was substantially fueled by injection drug use. Puerto Rico has a longstanding history of health provision by the public sector that directly affects how HIV and substance use disorder (SUD) treatment services are provided and funded. As part of pre-implementation research for a randomized trial of a community-level intervention to enhance HIV care access for substance users in San Juan, Puerto Rico, we sought to understand the structural and health policy environment for providing HIV and SUD treatments.MethodsWe conducted semi-structured qualitative interviews (n = 8) with government and program administrators in English and Spanish. Data were analyzed to identify dominant and recurrent themes.ResultsParticipants discussed how lack of integration among medical and mental health service providers, lack of public transportation, and turnover in appointed government officials were barriers to integrated HIV and SUD treatment. Federal funding for support services for HIV patients was a facilitator. The Affordable Care Act has limited impact in Puerto Rico because provisions related to health insurance reform do not apply to U.S. territories.Discussion and ConclusionsImplications for intervention design include the need to provide care coordination for services from multiple providers, who are often physically separated and working in different reimbursement systems, and the potential for mobile and patient transportation services to bridge these gaps. Continuous interaction with political leaders is needed to maintain current facilitators. These findings are relevant as the current economic crisis in Puerto Rico affects funding, and may be relevant for other settings with substance use-driven epidemics.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2174-7) contains supplementary material, which is available to authorized users.

According to National HIV Behavioral Surveillance system data, human immunodeficiency virus (HIV) testing increased among gay, bisexual, and other men who have sex with men from 2008 to 2011 in cities funded by the Centers for Disease Control and Prevention's Expanded Testing Initiative, suggesting that focused HIV testing initiatives might have positive effects.

Background Substance use, particularly injection drug use, continues to fuel the HIV/HCV epidemics in San Juan, Puerto Rico (PR). Aim This manuscript examines individual and socio-structural factors that impact HIV/HCV risk among people who use drugs (PWUD) living with or at risk for HIV/HCV in San Juan, PR. Findings were used to inform a community-level intervention to enhance HIV care access and retention for this population. Methods A rapid ethnographic assessment in collaboration with a community-based organization was conducted. Data collection took place between June and December 2013 and included field observations, 49 unstructured interviews with PWUD and 19 key informant interviews with community stakeholders. Fieldnotes, photographs and interview transcripts were analyzed for recurrent themes and to address the intervention planning needs. Study results are presented as fieldnote excerpts, direct quotes from interviews and photographs. Results Findings suggest that PWUD in PR face myriad challenges that affect HIV/HCV risk and hinder linkage to and retention in care. Results describe a layered risk environment where PWUD encounter many barriers to prevention, care and treatment such as transience, social isolation, stigma, limited housing options and inadequate medical and substance use disorders treatment services. Discussion These observed circumstances provide an empirical basis for the development and evaluation of comprehensive interventions that may serve to reduce barriers to care and link individuals to other supportive services. Conclusion New approaches and comprehensive interventions are needed to break the structures that perpetuate risk and lack of engagement and retention in HIV care and SUD treatment in San Juan.

Background Medicaid expansion under the Affordable Care Act increased insurance coverage, access to healthcare, and substance use disorder treatment, for many Americans. We assessed differences in healthcare access and utilization among persons who inject drugs (PWID) by state Medicaid expansion status. Methods In 2018, PWID were interviewed in 22 US cities for National HIV Behavioral Surveillance. We analyzed data from PWID aged 18–64 years who reported illicit use of opioids (n = 9957) in the past 12 months. Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were used to examine differences by Medicaid expansion status in indicators of healthcare access and utilization. Results Persons who inject drugs in Medicaid expansion states were more likely to have insurance (87% vs 36%; aPR, 2.3; 95% CI, 2.0–2.6), a usual source of healthcare (53% vs 34%; aPR, 1.5; 95% CI, 1.3–1.9), and have used medication-assisted treatment (61% vs 36%; aPR, 1.4; 95% CI, 1.1–1.7), and they were less likely to have an unmet need for care (21% vs 39%; aPR, 0.6; 95% CI, 0.4–0.7) than those in nonexpansion states. Conclusions Low insurance coverage, healthcare access, and medication-assisted treatment utilization among PWID in some areas could hinder efforts to end the intertwined human immunodeficiency virus and opioid overdose epidemics.