Differential access to syringe exchange and other prevention activities among people who inject drugs in rural and urban areas of Puerto Rico

Abstract

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.

Rural and urban comparisons of polysubstance use profiles and associated injection behaviors among people who inject drugs in Puerto Rico

“…Indeed, a key difference to emerge across the rural and urban samples was obtaining sterile needles from a service agency. This was far more common in the urban sample, and not surprising, recent research shows that urban Puerto Rican PWID are more likely to access needle exchange programs than their rural counterparts (Welch-Lazoritz et al, 2017). …”

“…Polysubstance use among Puerto Rican PWID has been associated with increased injection risk behavior compared to use of primarily one injection substance (Hautala et al, 2017). Others suggest that the use of alcohol with injection drugs also increases injection risk behavior (Matos et al, 2004; Welch-Lazoritz et al, 2017). Despite suspected risks, the association between various substance use combinations and injection risk behaviors among PWID is not well understood, particularly in Puerto Rico, and particularly for rural users.…”

“…Prior research among rural non-Hispanic populations in the U.S. suggests important differences in types of substances used (Gfroerer et al, 2007), patterns and emergence of substance use disorders (Brooks et al, 2017), and routes of administration (Young et al, 2010). Because rural communities in Puerto Rico have limited access to safe injection resources compared to their counterparts in urban San Juan (Des Jarlais et al, 2013; Welch-Lazoritz et al, 2017), the association between substance use patterns and injection-related behavior may vary considerably across rural and urban distinctions, with important implications for tailoring treatment and harm reduction services.…”

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

“…Moreover, demographic factors, particularly age, homelessness, and daily speedball injection, predicted membership into these latent risk classes. Needle exchange programs and behavioral interventions among Hispanic populations have been found to be relatively effective at reducing HIV and HCV seroprevalence, and decreasing risky injection and sexual behaviors . At present, there is only 1 needle exchange program serving rural Puerto Rican communities .…”

“…Understanding subtypes of risk is particularly important for rural Puerto Rican communities, because services such as needle exchange programs are limited and underutilized in these settings. 27,28 This study drew participants from 4 mountainous rural districts in central Puerto Rico, with population densities generally less than 1,000 residents per square mile. Difficult travel between locations due to the mountain terrain added to the geographical isolation of the area.…”