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Non-intravenous drug users

“Hispanic” label masks the specificity of the Puerto Rican #HIV problem in US Northeast

12 Nov, 14 | by Leslie Goode, Blogmaster

Interventions for HIV prevention should be informed by an understanding of the long-term source of infection, and not just by recent distribution (Mishra & Boily (STIs)).  Amongst recent studies that have sought to inform future interventions are investigations of known subgroups thought to be a potential bridge into the wider population – such as migrant workers, or sex workers (STI/Kissinger & Shedlin; STI/Faisel & Cleland).  There are other investigations that seek to refine on the definition of such groups (STIs/Davies & Tucker; STIs/Bayer & Coates).  But could there be instances where classifications established for the purposes of data collection actually mask the existence of the groups that could have epidemiological importance?

Puerto Ricans in the north-east of the US may be an interesting case in point.  A recent article (Deren & Santiago-Negron(D&S)) claims that the classification “Hispanic”, generally applied to Puerto Ricans for the purpose of data collection, may have obfuscated the distinctiveness of a Puerto Rican subgroup with its own specific risk profile, and considerable unmet medical health needs.   As though to illustrate the point, D&S assemble various data relating to strong correlations, for example: between AIDS diagnosis and being Hispanic; between residence in the North East of the US and IDU-associated HIV; between HIV incidence and being a Hispanic IDU.  Cumulatively – and taken along with the concentration of Puerto Ricans in the NE, and what is known of the high incidence of IDU-associated HIV in Puerto Rico itself – these data indicate the probability of a strong association, at least for the US North Eastern states, between Puerto Rican Hispanic identity and a high risk of drug-derived or heterosexually-transmitted HIV.  Furthermore, it is not only the subgroup of US Porto Ricans that have tended to slip under the net, according to D & J; high levels of IDU-transmitted HIV in the island of Puerto Rico itself have failed to attract due attention, on account of the peculiar status of Puerto Rico – which is a US territory, without being a US state.  As a result, Puerto Rico tends to figure neither in statistics for the Caribbean (as a US territory), nor in statistics for the US (since it is not a US state).

For Puerto Ricans – with an AIDS fatality at six times the US average and rates of new IDU and heterosexual infection twice that of the US – the problems of their anomalous status do not end with inadequate reporting.   Budgets for syringe exchange programs (SEPs) are only a fifth of what they are in the US Northeast, while Puerto Rican IDUs are only a fifth as likely to be in treatment.  SEP schemes cannot be funded by the US federal government, while the local Puerto Rican response to the drugs problem has, until recently, been largely provided through faith-based programs, with addiction defined by the Mental Health Law (2000) as a spiritual and social problem rather than a mental disorder.  Relocation to the US Northeast for drug treatment has become a commonly recommended option, with 85% of Puerto Rican admission to drug treatment taking place in the US Northeast.

In view of all this, D&S recommend partnership between federal, local and private entities to develop a cross-regional approach to the Puerto-Rican epidemic.  They also point out the challenges posed for such an approach by the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast.

HIV epidemic among heterosexual non-intravenous drug-users: could HSV-2 co-infection be the driver?

24 Jul, 14 | by Leslie Goode, Blogmaster

Why such high HIV prevalence reported for non-injecting drug users who are predominantly heterosexual?  This reaches 37% in Porto Alegre, Brazil; 43% in China; 13% in Canada; 20% in Florida; 19% in New York City; 24% in Portugal; 29% in Russia?  Possible factors include impaired decision making under the influence of drugs or the exchange of sex for drugs.  Studies published in STI Journal also propose high prevalence of, amonst other STI infections,  HSV-2 as a particular risk for HIV amongst non-injecting drug users (STIs/Plitt & Taha), and comparable groups, e.g. Tanzanian female bar-workers (STIs/Riedner & Hayes).  HSV increases susceptibility to HIV through disruption of the epithelial surface, as well as increasing transmissibility from persons co-infected with HSV and HIV through raising levels of plasma HIV-1 RNA.

A recent study of non-injecting drug users (NIDU)  (Jarlais & Cooper) attending a New York drug detoxification centre and a methadone maintenance programme – 785 over the period 1995-1999 and 1,764 over the period 2005-2011 – claims that HSV-2 co-infection is the principal driver of HIV transmission, especially amongst female NIDUs.  Over both periods that latter group shows: very high levels of HSV-2 mono-infection (78% and 86% respectively), high levels of HIV/HSV-2 co-infection (10% and 21%, and negligible HIV mono-infection.  The pattern is similar though less pronounced in the case of males.  As between the two periods (1995-1999 & 2005-2011) there is a doubling in the prevalence of HIV (from 7% to 13% overall) which is represented more or less uniformly across all ethic and behavioural groups.  Though the specific quantitative contribution of HSV-2 to the HIV infection cannot be determined by this type of study, these results suggest that the rise in HIV among NIDUs should be considered an epidemic of HSV-2/HIV co-infection, and that HSV-2 is likely to be the driver of the increased HIV incidence.

So what should be done to minimize HIV transmission among non-injecting drug users?  The obvious response would be suppressive HSV-2 therapy.  Unfortunately, however, trials have not as yet shown this to be effective in reducing HIV transmission (STIs/Mujugira & Wald; Barnabas & Celum).  The authors recommend further research into the effectiveness of higher dosages of HSV-2 suppressive therapy: also of HSV-2 suppressive therapy prior to ART or in combination with ART – since a recent study found evidence of HIV in the semen of men who had reached viral suppression on ART (Politch & Anderson).  At all events, HIV/HSV-2 co-infected NIDUs would appear to be a priority for ART as prevention, and the authors recommend providing ART to this group at all CD4 cell counts.  (New York introduced in 2011 a new policy of offering ART to all HIV sero-positive persons in the city regardless of CD4 count).

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