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      Reported Heroin Use, Use Disorder, and Injection Among Adults in the United States, 2002-2018

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      American Medical Association (AMA)

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          This study uses National Surveys on Drug Use and Health data to characterize trends in heroin use, heroin use disorder, and heroin injection overall and by age, race, and geographic region.

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          Notes from the Field: HIV Diagnoses Among Persons Who Inject Drugs — Northeastern Massachusetts, 2015–2018

          From 2000 to 2014, the number of annual diagnoses of human immunodeficiency virus (HIV) infection in Massachusetts declined 47% ( 1 ). In August 2016, however, the Massachusetts Department of Public Health (MDPH) received reports of five new HIV cases among persons who inject drugs from a single community health center in the City of Lawrence ( 2 ). On average, less than one case per month among persons who inject drugs had been reported in Lawrence during 2014–2015 from all providers. Surveillance identified additional cases of HIV infection among such persons linked to Lawrence and Lowell, in northeastern Massachusetts, during 2016–2017. In 2018, MDPH and CDC conducted an investigation to characterize the outbreak and recommend control measures. Investigators reviewed surveillance data and HIV-1 polymerase (pol) gene nucleotide sequences derived from drug resistance testing and interviewed persons with HIV infection in northeastern Massachusetts. Cases were defined as diagnoses of HIV infection in northeastern Massachusetts during January 2015–May 2018 in 1) a person who injects drugs who received medical care, experienced homelessness, resided, or injected drugs in Lawrence or Lowell; 2) a person who was epidemiologically linked as an injecting or sex partner of a person with HIV infection connected to Lawrence or Lowell; or 3) a person with an HIV-1 pol nucleotide sequence molecularly linked at a genetic distance of ≤1.5% (as determined by pairwise sequence analysis) to that of another person in the investigation who was connected to Lawrence or Lowell. Qualitative interviews were conducted with a purposeful sample of 34 persons who inject drugs to assess risk factors for HIV infection and with 19 clinicians and other stakeholders in Lawrence and Lowell to identify available medical and social services. As of June 30, 2018, a total of 129 persons meeting the case definition were identified; 74 (57%) were male, 94 (73%) were aged 20–39 years at diagnosis, 87 (67%) were non-Hispanic white, and 38 (29%) were Hispanic. Most (114; 88%) reported a history of injection drug use (Figure), including four (3%) who also reported male-to-male sexual contact; 116 (90%) had laboratory evidence of past or current hepatitis C virus infection. Median CD4+ cell count at diagnosis was 550 cells/μL (range = 1–1,470), suggestive of a number of recent infections ( 3 ). Molecular analysis aided case identification: 28 (22%) cases had epidemiologic links only; 69 (53%) had both epidemiologic and molecular links; and 32 (25%) had molecular links only. Four clusters of ≥5 cases were identified using molecular links; two of these clusters accounted for 78 (60%) cases. FIGURE Human immunodeficiency virus diagnoses linked to Lawrence and Lowell, Massachusetts, January 2015–May 2018 The figure is a histogram showing human immunodeficiency virus diagnoses linked to Lawrence and Lowell, Massachusetts, during January 2015 through May 2018. In qualitative interviews, the 34 persons who inject drugs variously identified opioids alone, stimulants (i.e., cocaine and methamphetamine) alone, or both opioids and stimulants as their drugs of choice. Sharing syringes and other equipment, experiencing homelessness, being incarcerated, or exchanging sex for drugs during the previous year also were reported. Stakeholders reported that fentanyl had replaced heroin in local communities, was cheaper in Lawrence than in other cities in the region, and had increased injection frequency. The reported increased frequency of fentanyl injection might have increased transmission in Lawrence and Lowell. Stakeholders also reported that frequent homelessness and incarceration among injection drug users undermined HIV treatment success because of interrupted treatment, missed appointments, and having multiple care providers. An additional challenge noted was syringe services program (SSP) accessibility. Lowell had a privately funded SSP with limited days and hours of operation; since 2017, Lawrence had a state-funded SSP with daily availability, but no weekend or evening hours. Opioid overdose deaths have increased rapidly in Lawrence and Lowell since 2013 ( 4 ), with postmortem fentanyl detection increasing statewide ( 5 ). The presence of multiple molecular clusters and unlinked infections suggests multiple introductions of HIV among persons who inject drugs as well as recent and rapid transmission in the context of some longstanding HIV infections. Lawrence and Lowell approved state-funded SSPs in 2016 and 2018, respectively. MDPH has since deployed additional field staff members to link persons with HIV infection to care and to provide partner services. MDPH and local partners are expanding services that address social instability attributable to homelessness and incarceration and increase knowledge about safer injection practices among persons who inject drugs. MDPH will continue HIV testing, field investigation, and molecular cluster detection and response statewide.
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            Outbreak of Human Immunodeficiency Virus Infection Among Heterosexual Persons Who Are Living Homeless and Inject Drugs — Seattle, Washington, 2018

            Although diagnoses of human immunodeficiency virus (HIV) infection among persons who inject drugs in the United States are declining, an HIV outbreak among such persons in rural Indiana demonstrated that population’s vulnerability to HIV infection ( 1 ). In August 2018, Public Health–Seattle and King County (PHSKC) identified a cluster of cases of HIV infection among persons living homeless, most of whom injected drugs. Investigation identified 14 related cases diagnosed from February to mid-November 2018 among women who inject drugs and men who have sex with women (MSW) who inject drugs and their sex partners. All 14 persons were living homeless in an approximately 3–square-mile area and were part of a cluster of 23 cases diagnosed since 2008. Twenty-seven cases of HIV infection were diagnosed among women and MSW who inject drugs in King County during January 1–November 15, 2018, a 286% increase over the seven cases diagnosed in 2017. PHSKC has alerted medical and social service providers and the public about the outbreak, expanded HIV testing among persons who inject drugs or who are living homeless, and is working to increase the availability of clinical and prevention services in the geographic area of the outbreak. This outbreak highlights the vulnerability of persons who inject drugs, particularly those who also are living homeless, to outbreaks of HIV infection, even in areas with high levels of viral suppression and large syringe services programs (SSPs). Investigation and Findings Cluster cases met one or more of the following criteria: 1) HIV infection diagnosis in a woman or MSW in 2018, with partner services data indicating sex or sharing injection-drug equipment with a person in a previously identified cluster case; 2) HIV infection diagnosis in 2018 in a woman or MSW living homeless in the outbreak area; 3) molecular analysis indicating HIV infection with a strain related to those identified among persons meeting either of the first two criteria (HIV-TRACE genetic distance ≤1.5%) ( 2 ). Cases were excluded if molecular analysis indicated infection with an HIV strain unrelated to the cluster. In July 2018, an MSW living homeless in north Seattle tested positive for acute HIV infection (HIV Ag/Ab positive, Geenius HIV negative, HIV RNA positive) at an emergency department (ED) after being evaluated with fever (patient 6) (Table 1). He did not report injecting drugs, but had paid a woman for sex. That woman was living homeless in the area, injected heroin, and had tested HIV-positive in June (patient 5). A social media search performed by a public health disease intervention specialist linked her to a man who injected drugs and was living homeless who had tested HIV-positive in July (patient 7). PHSKC was aware of three other recently diagnosed cases of HIV infection among women who inject drugs and were living homeless in north Seattle (patients 1, 2, and 3); none of these women had known epidemiologic links to other recently diagnosed cases. Subsequent molecular analyses conducted with HIV TRACE ( 2 ), a program that uses HIV genotypes to identify cases with related HIV strains based on HIV genetic sequence data, confirmed that four of the recently diagnosed cases in women and MSW who inject drugs, including the three without known epidemiologic links to other 2018 diagnoses, were infected with related HIV strains (patients 1–4). Molecular analysis also linked the seven recently diagnosed cases to eight cases diagnosed during 2008–2017 (patients 15–21 and 23) and two cases identified in September 2018 (patients 11 and 12). As of November 20, 2018, the cluster included 23 cases (Figure) (Table 2), 14 of which were diagnosed in 2018, demonstrating that transmission was at least intermittently ongoing since 2008, with evidence suggesting an acceleration in transmission during 2017–2018. TABLE 1 Clinical and epidemiologic characteristics of a cluster of human immunodeficiency virus (HIV) cases among 23 persons living homeless who inject drugs and their sex partners and molecularly linked cases — Seattle, Washington, 2008–2018 Patient no. Diagnosis
quarter/yr Gender HIV risk factor and substance use Reported exchange of sex Reason for HIV testing Date last HIV test* Links to other cases identified through investigation Related HIV strain Cluster criteria† Care status§ HIV infection diagnosed 2018 1 Q1, 2018 F Heroin/meth (IDU) No Regular testing Q4, 2013 None Yes 2,3 Suppressed 2 Q1, 2018 F Heroin/meth (IDU uncertain) No STD symptoms Unknown Sex Yes 1,2,3 In care, not suppressed 3 Q1, 2018 F Heroin/meth (IDU) No Acute HIV symptoms Never tested None Yes 2,3 Suppressed 4 Q2, 2018 M Heroin (IDU); meth (smoke) No Hospitalized Q1, 2017 IDU Yes 1,2,3 In care, not suppressed 5 Q2, 2018 F Heroin (IDU); meth (smoke) Yes Court-ordered testing Unknown Sex; IDU ND 1,2 Out of care 6¶ Q3, 2018 M NIR: presumed heterosexual; heroin, meth (non-IDU) Yes Acute HIV symptoms Unknown Sex ND 1,2 In care, not suppressed 7 Q3, 2018 M Heroin/meth (IDU) No Surveillance outreach testing Unknown Social media; IDU ND 1,2 Out of care 8 Q3, 2018 F Heroin (IDU); meth (smoke) Yes Outreach Q4, 2017 None ND 2 Out of care 9 Q3, 2018 F Heroin (IDU); meth (smoke) Yes Outreach Q4, 2016 None ND 2 Suppressed 10 Q3, 2018 F Unknown drugs (IDU) Yes Acute HIV symptoms Unknown No interview ND 2 Out of care 11 Q3, 2018 F Meth (IDU) Yes ED screening Q1, 2018 No interview Yes 2,3 In care, not suppressed 12 Q3, 2018 F Heterosexual Yes Outreach Q3, 2018 Sex Yes 2,3 Suppressed 13 Q4, 2018 F Heroin (IDU); meth (unknown route) Yes Mobile clinic Q4, 2013 No interview ND 2 In care, not suppressed 14 Q4, 2018 F Meth (IDU) Yes Outreach Q1, 2018 No interview ND 2 Out of care HIV infection diagnosed 2008–2017 15 Q1, 2008 F Heterosexual Unknown Unknown Q1, 2006 No interview Yes 3 Deceased 16 Q2, 2008 M Unknown drugs (IDU) Unknown Unknown Unknown None Yes 3 Deceased 17 Q3, 2011 M NIR; Unknown drug use Unknown Unknown 2009 Sex Yes 1,3 Out of care 18 Q3, 2014 F NIR; history of IDU (none recently) No Acute HIV symptoms 2000 None Yes 3 In care, not suppressed 19 Q4, 2016 F Heroin (IDU); crack cocaine Yes HIV-unrelated infection Q4, 2008 None Yes 3 Suppressed 20 Q4, 2016 M Heroin/meth (IDU) Unknown Unknown 2014 No interview Yes 3 Suppressed 21 Q4, 2016 F Unknown drugs (IDU) Unknown Unknown Unknown Sex Yes 1,3 Suppressed 22 Q2, 2017 M Heterosexual; unknown drug use Unknown Unknown Unknown Sex ND 1 Out of care 23 Q4, 2017 F Heroin (IDU); meth (unknown route) No Regular testing Unknown None Yes 3 Suppressed Abbreviations: ED = emergency department; F = female; IDU = injection drug use; M = male; Meth = methamphetamine; MSW = men who have sex with women; ND = no data available; NIR = no identified risk; Q = quarter. * Most recent test based on patient self-report or verified result from medical record. Quarter not specified when unknown. † Cluster criteria: 1 = HIV infection diagnosis in a woman or MSW in 2018, with partner services data indicating sex or sharing injection-drug equipment with a previously identified cluster case; 2 = HIV infection diagnosis in 2018 in a woman or MSW living homeless in the outbreak area; 3 = molecular analysis indicating HIV infection with a strain related to those identified among persons meeting either of the first two criteria (HIV-TRACE genetic distance ≤1.5%). Cases were excluded if molecular analysis indicated infection with an HIV strain unrelated to the cluster. § Suppression ( 7 million syringes to persons who inject drugs in 2017; 79% of persons who inject drugs report using SSPs, and syringe sharing among persons who inject drugs has declined over time ( 5 ). Only 1%–3% of the approximately 21,000 women and MSW who inject drugs in the county have HIV infection, and 80% of those with a diagnosis are virally suppressed ( 4 ). Despite these successes, the current outbreak, similar to a recent outbreak in Massachusetts, demonstrates that vulnerability to outbreaks of HIV infection among persons who inject drugs is widespread in the United States ( 6 ). The outbreak described here is part of a larger increase in HIV infection among heterosexual persons who inject drugs that is ongoing in King County. During 2018, the county experienced a nearly threefold increase in new HIV infections among women and MSW who inject drugs. Several factors might contribute to King County’s vulnerability. First, although access to HIV care and prevention in the county is generally good, this outbreak was concentrated in an area where syringe and clinical services for persons who inject drugs are limited, highlighting the need to expand access. Second, like much of the United States, King County faces growing epidemics of opioid overdose and homelessness. From 2007 to 2018, the number of heroin overdose deaths in the county increased 264% ( 7 ), and from 2007 to 2017, the number of country residents living homeless increased 47% ( 8 ). Among SSP users surveyed in 2017, 43% were living homeless, and an additional 26% were unstably housed, a 19% increase from 2015 ( 4 ). Thus, the area has a rapidly growing population who inject drugs and are living homeless, a group for whom accessing services is particularly difficult. These factors have resulted in a new population-level susceptibility to HIV transmission. The King County outbreak also illustrates both the value and limitations of disease intervention specialist investigations and molecular HIV analyses. Disease intervention specialists initially identified the outbreak, and PHSKC and the Washington State Department of Health used molecular analyses to recognize related cases not identified through disease investigation and to confirm relationships suggested by epidemiologic linkages. Retrospective review of the molecular data demonstrated that 10 related cases (eight with genetic sequence data available) were diagnosed from December 2016 to August 2018, when the cluster was first identified. Had the molecular data been available and analyzed more quickly, it might have been possible to respond earlier, possibly averting some cases. CDC recently initiated a national effort to expand the use of molecular HIV analyses to identify growing clusters of cases ( 9 ). The experience described here suggests how such analyses might be useful if they were available and analyzed in real time with appropriate thresholds for action. Finally, the King County outbreak demonstrates how difficult it is to engage the most socially marginalized persons with medical care. As of mid-November 2018, seven of the 21 living persons in the cluster were not receiving HIV care. Disease intervention specialists are actively seeking these persons to link them to a clinic that provides walk-in HIV medical care ( 10 ). Persons who inject drugs remain vulnerable to outbreaks of HIV infection, even in cities with large HIV prevention programs and shrinking HIV epidemics. A new U.S. Department of Health and Human Services initiative, Ending the HIV Epidemic: A Plan for America,* defines molecular HIV surveillance and associated responses as one of four central pillars for ending the epidemic. The outbreak described in this report illustrates the benefits of integrating disease investigations and molecular HIV analyses to more rapidly and efficiently identify and respond to localized outbreaks of HIV infection and should prompt health departments in other jurisdictions to investigate whether similar outbreaks are ongoing in their areas. Summary What is already known about this topic? Although diagnoses of human immunodeficiency virus (HIV) infection among persons who inject drugs in the United States are declining, an HIV outbreak among such persons in rural Indiana demonstrated that population’s vulnerability to HIV infection. What is added by this report? In 2018, disease investigation and molecular HIV surveillance in Seattle, Washington, identified 14 related HIV diagnoses among heterosexuals who were living homeless, most of whom injected drugs. From 2017 to mid-November 2018, the number of HIV diagnoses among heterosexuals in King County, Washington, who inject drugs increased 286%. What are the implications for public health practice? Persons who inject drugs, particularly those living homeless, remain vulnerable to outbreaks of HIV infection, even in cities with large HIV prevention programs and shrinking HIV epidemics.
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              HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs — 20 Cities, United States, 2015

              In the United States, 9% of human immunodeficiency virus (HIV) infections diagnosed in 2015 were attributed to injection drug use ( 1 ). In 2015, 79% of diagnoses of HIV infection among persons who inject drugs occurred in urban areas ( 2 ). To monitor the prevalence of HIV infection and associated behaviors among persons who inject drugs, CDC’s National HIV Behavioral Surveillance (NHBS) conducts interviews and HIV testing in selected metropolitan statistical areas (MSAs) ( 3 ). The prevalence of HIV infection among persons who inject drugs in 20 MSAs in 2015 was 7%. In a behavioral analysis of HIV-negative persons who inject drugs, an estimated 27% receptively shared syringes and 67% had condomless vaginal sex in the previous 12 months. During the same period, 58% had tested for HIV infection and 52% received syringes from a syringe services program. Given the increased number of persons newly injecting drugs who are at risk for HIV infection because of the recent opioid epidemic ( 2 , 4 ), these findings underscore the importance of continuing and expanding health services, HIV prevention programs, and community-based strategies, such as those provided by syringe services programs, for this population. In 2015, NHBS staff members in 20 MSAs* collected cross-sectional behavioral survey data and conducted HIV testing among persons who inject drugs; survey participants were recruited using respondent-driven sampling (RDS), † a peer-referral sampling method ( 5 ). Eligible participants § completed a standardized questionnaire administered face-to-face by trained interviewers. All participants were offered anonymous HIV testing ¶ ; a nonreactive screening test result was considered HIV-negative and a reactive screening test result was considered HIV-positive if confirmed by western blot or indirect immunofluorescence assay. Incentives were offered for completing the interview, HIV testing, and recruitment.** Participants were asked about behaviors in the previous 12 months, including high-risk injection (receptive sharing) †† or sexual behaviors, §§ testing for HIV and hepatitis C virus (HCV) infection, participation in HIV behavioral interventions, ¶¶ and receiving any syringes from a syringe services program or all syringes from sterile sources.*** Because knowledge of personal HIV infection status could influence risk behaviors ( 6 ), behavioral analysis was limited to HIV-negative persons who inject drugs. ††† Data from each MSA were analyzed using the RDS Analysis Tool that produces estimates adjusted for differences in peer recruitment patterns and the size of the network of persons who inject drugs and estimated 95% confidence intervals (CIs) ( 5 ). All comparisons were considered significant if there was no overlap in their adjusted 95% CIs; because of the sampling methodology, RDS analysis is limited to calculating point estimates with CIs and precludes any other statistical testing. A weighted average of MSA-level estimates was calculated using the estimated size of the population of persons who inject drugs in each MSA to describe aggregated prevalence of HIV and percentage of participants engaging in selected behaviors ( 7 ). §§§ In 2015, 13,633 persons were recruited to participate; 2,955 (22%) were ineligible and 330 (3%) were excluded because of incomplete data. ¶¶¶ Among the 10,348 persons who injected drugs who tested for HIV, 709 (6.9%) tested HIV-positive and 9,639 tested HIV-negative. Adjusted HIV prevalence in the 20 MSAs was estimated to be 7% (Table 1). HIV prevalence was higher**** among blacks (11%) than whites (6%) and among persons in the South U.S. Census region (10%) than in the Midwest (3%) and Northeast (5%) regions. The prevalence of HIV infection was 24% among males who inject drugs who reported male-to-male sex in the previous 12 months. TABLE 1 Estimated prevalence of human immunodeficiency virus (HIV) infection among persons who inject drugs (N = 10,348), by selected characteristics — National HIV Behavioral Surveillance, 20 cities, United States, 2015 Characteristic Overall* HIV prevalence* % (95% CI) % (95% CI) Overall 100 — 7(6–8) Sex Men 69(67–71) 6 (5–7) Women 31(29–33) 9 (7–12) Race/Ethnicity Black, non-Hispanic 39 (36–42) 11 (8–15) Hispanic† 21(19–23) 7 (4–9) White, non-Hispanic 39 (36–41) 6 (5–8) Other§ 2 (1–2) — ¶ Age group (yrs) 18–29 14 (12–16) 2(1–3) 30–39 21(19–23) 5(3–6) 40–49 24(22–26) 11(9–13) ≥50 41(39–44) 9(7–11) Education Less than HS diploma 28 (26–30) 8(4–12) HS diploma 41(39–44) 8 (6–9) More than HS diploma 31 (29–33) 6 (0–13) Health insurance No 18 (17–20) 3(2–4) Yes 82 (80–83) 8 (6–9) Poverty level** At or below FPL 78 (76–79) 7 (6–9) Above FPL 22(21–24) 6 (5–8) Drug injected most frequently Heroin only 65(63–67) 5(2–8) Other/Multiple †† 35(33–37) 11(9–13) Male-male sex, last 12 months (among males only) No 90(88–93) 5(3–6) Yes 10(7–12) 24(15–33) U.S. Census region §§ Northeast 24(24–51) 5(3–7) South 36(15–42) 10(8–13) Midwest 11(0–22) 3(1–5) West 24(10–37) 7(5–9) Abbreviations: CI = confidence interval; FPL = federal poverty level; HS = high school. * Aggregate estimates are weighted averages of MSA (metropolitan statistical areas) -level percentages. MSA-level percentages were adjusted for differences in recruitment and the size of participant peer networks of persons who inject drugs, then proportionally weighted by the size of the population of persons who inject drugs in each city. † Persons of Hispanic ethnicity might be of any race or combination of races. § Includes American Indian/Alaska Natives, Asians, Native Hawaiian or other Pacific Islanders, and persons of multiple races. ¶ Insufficient data. ** Poverty level is based on household income and household size. †† Other drugs injected alone or two or more drugs injected with the same frequency. §§ The Northeast region includes the MSAs of Boston, Massachusetts; Nassau-Suffolk, New York; New York, New York; Newark, New Jersey; and Philadelphia, Pennsylvania. South region includes Atlanta, Georgia; Baltimore, Maryland; Dallas, Texas; Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, District of Columbia. Midwest region includes Chicago, Illinois and Detroit, Michigan. West region includes Denver, Colorado; Los Angeles, California; San Diego, California; San Francisco, California; and Seattle, Washington. San Juan, Puerto Rico was not included. Among the HIV-negative participants, 27% receptively shared syringes, 67% had condomless vaginal sex, 22% had condomless heterosexual anal sex, and 45% had more than one opposite sex partner (Table 2). Receptive syringe sharing was higher among whites (39%) than among Hispanics (24%) and blacks (17%); similar patterns were seen for sharing injection equipment (61%, 45%, and 41%, respectively). Condomless vaginal and anal sex was higher among whites (74% and 25%, respectively) than among blacks (62% and 17%, respectively). TABLE 2 Estimated percentage* of HIV-negative participants who inject drugs (n = 9,639) who engaged in behaviors † associated with HIV infection in the previous 12 months, by selected characteristics — National HIV Behavioral Surveillance, 20 cities, United States, 2015 Characteristics Receptive syringe sharing,† % (95% CI) Receptive injection equipment sharing,† % (95% CI) Had vaginal sex, % (95% CI) Had condomless vaginal sex, % (95% CI) Had heterosexual anal sex, % (95% CI) Had condomless heterosexual anal sex, % (95% CI) Had condomless heterosexual sex or receptive syringe sharing, % (95% CI) Had more than one opposite sex partner, % (95% CI) Overall 27 (25–29) 49 (46–51) 78 (76–80) 67 (65–70) 28 (26–30) 22 (20–24) 72 (70–75) 45 (42–47) Sex Men 27 (25–29) 48 (46–51) 77 (74–79) 65 (63–68) 27 (25–29) 20 (19–22) 73 (71–75) 44 (42–47) Women 28 (24–31) 49 (45–54) 82 (78–86) 73 (68–77) 29 (24–34) 24 (20–29) 77 (72–81) 44 (39–48) Race/Ethnicity § Black, non-Hispanic 17 (14–19) 41 (37–45) 75 (72–79) 62 (58–66) 22 (19–24) 17 (14–19) 68 (65–71) 41 (38–45) Hispanic¶ 24 (20–27) 45 (41–49) 79 (74–84) 68 (62–73) 33 (28–38) 26 (22–31) 74 (69–79) 43 (38–47) White, non-Hispanic 39 (35–42) 61 (57–64) 82 (79–85) 74 (71–77) 31 (27–34) 25 (22–28) 81 (78–84) 48 (44–52) Age group (yrs) 18–29 41 (36–46) 63 (56–69) 89 (85–93) 80 (75–85) 43 (36–49) 33 (28–39) 85 (80–91) 62 (56–68) 30–39 38 (33–42) 58 (53–62) 90 (87–92) 82 (78–85) 37 (31–42) 30 (25–35) 86 (83–89) 53 (48–58) 40–49 25 (22–28) 47 (42–52) 77 (72–81) 69 (65–73) 27 (23–30) 20 (18–23) 76 (72–80) 41 (37–46) ≥50 17 (14–19) 41 (38–45) 68 (65–72) 56 (53–60) 18 (15–20) 12 (10–14) 61 (57–64) 34 (31–38) Education Less than HS diploma 26 (23–29) 47 (43–51) 78 (75–82) 66 (62–70) 29 (25–32) 22 (19–25) 76 (73–79) 47 (43–52) HS diploma 28 (25–30) 50 (46–54) 80 (77–83) 70 (67–74) 29 (26–33) 23 (20–26) 75 (72–78) 44 (41–47) More than HS diploma 27 (24–31) 50 (45–55) 76 (72–80) 70 (66–74) 27 (23–31) 22 (18–25) 75 (71–79) 44 (40–49) Health insurance No 36 (32–40) 55 (51–59) 80 (77–84) 71 (67–75) 29 (26–33) 24 (20–27) 79 (75–82) 52 (48–56) Yes 26 (24–28) 48 (45–51) 78 (75–80) 67 (64–69) 27 (25–30) 21 (19–23) 71 (68–74) 41 (38–43) Poverty level** At or below FPL 27 (25–29) 48 (45–51) 78 (75–80) 66 (64–69) 27 (25–30) 21 (19–23) 71 (69–74) 43 (41–46) Above FPL 26 (23–29) 51 (46–55) 80 (76–84) 73 (68–77) 31 (27–35) 26 (22–29) 77 (72–81) 47 (43–52) Drug injected most frequently Heroin only 27 (25–29) 49 (46–52) 77 (75–80) 66 (63–68) 25 (23–28) 20 (18–22) 71 (68–73) 39 (37–42) Other/Multiple†† 27 (23–30) 46 (41–50) 80 (77–84) 71 (67–75) 34 (30–37) 26 (23–29) 76 (72–79) 52 (49–56) Region§§ Northeast 25 (21–28) 43 (38–48) 82 (78–87) 69 (64–74) 31 (27–36) 23 (19–27) 72 (67–77) 53 (47–59) South 26 (23–30) 50 (46–54) 78 (75–81) 68 (64–71) 25 (22–28) 19 (17–22) 73 (70–76) 42 (38–45) Midwest 24 (20–28) 44 (39–49) 71 (66–77) 60 (55–65) 16 (13–20) 12 (10–15) 68 (62–73) 34 (30–39) West 32 (29–36) 57 (53–61) 75 (71–78) 67 (64–71) 28 (25–32) 25 (22–28) 74 (70–77) 43 (40–47) Abbreviations: CI = confidence interval; FPL = federal poverty level; HS = high school. * Aggregate estimates are weighted averages of MSA (metropolitan statistical areas)-level percentages. MSA-level percentages were adjusted for differences in recruitment and, the size of participant persons who inject drugs peer networks, then proportionally weighted by the size of the persons who inject drugs population in each city. † Receptive syringe sharing was defined as “using needles that someone else had already injected with,” and receptive injection equipment sharing was defined as using equipment such as cookers, cottons, or water used to rinse needles or prepare drugs “that someone else had already used.” Condomless vaginal or anal sex was defined as “sex without a condom.” § Aggregate estimates for “Other” race/ethnicity excluded due to insufficient data. “Other” includes American Indian/Alaska Natives, Asians, Native Hawaiian or other Pacific Islanders, and persons of multiple races. ¶ Persons of Hispanic ethnicity might be of any race or combination of races. ** Poverty level is based on household income and household size. †† Other drugs injected alone or two or more drugs injected with the same frequency. §§ The Northeast region includes the MSAs of Boston, Massachusetts; Nassau-Suffolk, New York; New York, New York; Newark, New Jersey; and Philadelphia, Pennsylvania. South region includes Atlanta, Georgia; Baltimore, Maryland; Dallas, Texas; Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, District of Columbia. Midwest region includes Chicago, Illinois and Detroit, Michigan. West region includes Denver, Colorado; Los Angeles, California; San Diego, California; San Francisco, California; and Seattle, Washington. San Juan, Puerto Rico was not included. In the 12 months preceding the interview, 58% of HIV-negative participants received an HIV test, 26% participated in an HIV behavioral intervention, 52% received syringes from syringe services programs and 34% received all their syringes from sterile sources (Table 3). Ever testing for HCV was reported by 82% of participants. Fewer white participants were tested for HIV in the preceding 12 months (51%) than were black (65%) and Hispanic (62%) participants. Fewer persons who inject drugs in the South obtained syringes from a syringe services program (36%) than did those in the Northeast (61%), Midwest (50%), and West (66%). Fewer persons who inject drugs from the South (26%) and West (28%) regions obtained syringes solely from sterile sources than did those the Northeast (44%) and Midwest (43%) regions. TABLE 3 Estimated percentage* of HIV-negative participants who inject drugs (n = 9,639) who received testing and HIV prevention services, by selected characteristics — National HIV Behavioral Surveillance, 20 cities, United States, 2015 Characteristics Tested for HIV infection in the previous 12 months, % (95% CI) Participated in HIV behavioral interventions in the previous 12 months,†% (95% CI) Ever tested for hepatitis C,% (95% CI) Received syringes from SSP in the previous 12 months,§% (95% CI) Received syringes from sterile sources only in the previous 12 months,§% (95% CI) Overall 58 (56–60) 26 (23–28) 82 (80–84) 52 (49–55) 34 (32–37) Sex Men 58 (55–60) 25 (22–27) 82 (80–84) 49 (45–52) 33 (30–35) Women 62 (58–66) 28 (24–32) 83 (81–86) 57 (51–62) 38 (33–43) Race/Ethnicity ¶ Black, non-Hispanic 65 (62–69) 29 (25–33) 82 (79–85) 51 (47–56) 36 (33–40) Hispanic** 62 (58–67) 27 (22–32) 78 (73–83) 53 (48–58) 38 (33–43) White, non-Hispanic 51 (47–55) 23 (20–26) 84 (82–87) 54 (49–58) 28 (25–31) Age group (yrs) 18–29 58 (53–64) 23 (18–28) 74 (69–78) 46 (39–54) 26 (21–31) 30–39 58 (52–63) 20 (16–24) 84 (81–87) 54 (48–61) 30 (25–35) 40–49 61 (57–64) 31 (26–35) 82 (78–86) 56 (52–61) 35 (31–39) ≥50 61 (57–64) 27 (23–31) 86 (83–88) 54 (50–57) 38 (35–42) Education Less than HS diploma 58 (54–62) 24 (20–28) 81 (79–84) 53 (48–57) 34 (30–38) HS diploma 61 (59–64) 24 (21–28) 82 (79–85) 52 (48–56) 35 (32–39) More than HS diploma 55 (51–60) 29 (25–34) 84 (81–87) 50 (45–55) 31 (26–36) Health insurance No 47 (43–51) 15 (12–18) 70 (66–74) 36 (32–40) 23 (20–27) Yes 61 (58–63) 28 (25–31) 85 (83–87) 55 (52–59) 37 (34–40) Poverty level †† At or below FPL 59 (57–62) 26 (23–29) 83 (81–85) 52 (49–56) 35 (32–37) Above FPL 55 (51–59) 25 (21–29) 81 (78–85) 50 (44–56) 33 (28–38) Drug injected most frequently Heroin only 58 (55–61) 26 (23–28) 83 (81–85) 54 (50–57) 36 (33–39) Other/Multiple§§ 59 (56–62) 26 (22–29) 80 (77–83) 45 (42–49) 29 (25–33) Region ¶¶ Northeast 63 (58–68) 33 (28–38) 87 (84–91) 61 (54–67) 44 (39–50) South 62 (59–66) 23 (19–26) 79 (76–82) 36 (32–39) 26 (23–30) Midwest 47 (42–52) 19 (15–22) 78 (74–82) 50 (44–55) 43 (37–48) West 49 (46–53) 20 (17–23) 80 (76–83) 66 (62–70) 28 (24–31) Abbreviations: CI = confidence interval; FPL = federal poverty level; HS = high school; SSP = syringe services program. * Aggregate estimates are weighted averages of MSA (metropolitan statistical areas)-level percentages. MSA-level percentages were adjusted for differences in recruitment and the size of participant persons who inject drugs, peer networks then proportionally weighted by the size of the persons who inject drugs population in each city. † Participating in an individual or group HIV behavioral intervention (e.g., a one-on-one conversation with a counselor or an organized discussion regarding HIV prevention) did not include counseling received as part of an HIV test or conversations with friends. § Receiving a syringe from a syringe services program (SSP) was defined as reporting receiving a sterile syringe or needles at least once from an SSP or syringe/needle exchange program. Receiving syringes from sterile sources only included reporting receiving syringes from at least one of the following: SSP, pharmacy, or healthcare provider and not any other sources during the previous 12 months. ¶ Aggregate estimates for “Other” race/ethnicity excluded due to insufficient data. “Other” includes American Indian/Alaska Natives, Asians, Native Hawaiian or other Pacific Islanders, and persons of multiple races. ** Persons of Hispanic ethnicity might be of any race or combination of races. †† Poverty level is based on household income and household size. §§ Other drugs injected alone or two or more drugs injected with the same frequency. ¶¶ The Northeast region includes the MSAs of Boston, Massachusetts; Nassau-Suffolk, New York; New York, New York; Newark, New Jersey; and Philadelphia, Pennsylvania. South region includes Atlanta, Georgia; Baltimore, Maryland; Dallas, Texas; Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, District of Columbia. Midwest region includes Chicago, Illinois and Detroit, Michigan. West region includes Denver, Colorado; Los Angeles, California; San Diego, California; San Francisco, California; and Seattle, Washington. San Juan, Puerto Rico was not included. Among persons who inject drugs, a higher percentage of those with health insurance were tested for HIV infection in the previous 12 months (61%) than were those without health insurance (47%) (Table 3). Similarly, more persons who inject drugs with health insurance reported participating in HIV behavioral interventions (28%) or ever testing for HCV infection (85%) than did those without health insurance (15% and 70%, respectively). Discussion This report provides updated prevalence of HIV infection and behaviors since the last NHBS survey among persons who inject drugs in 2012 ( 3 ). In 2015, persons who inject drugs continued to report high levels of injection and sex risk behaviors placing them at increased risk for HIV acquisition, highlighting the need for effective and comprehensive prevention services, including access to sterile injection equipment. The prevalence of HIV infection was 7% (CI = 6%–8%) in 2015, lower than in 2012 (11%; 95% CI = 9%–12%). The change might partially be explained by the differences in the sample composition from 2012 to 2015: the percentage of white persons who inject drugs increased from 30% in 2012 to 39% in 2015, and white persons who inject drugs in 2012 and 2015 had the lowest HIV prevalence (5% and 6%, respectively). Consistent with previous reports ( 3 ), this analysis found a higher prevalence of HIV infection among blacks who inject drugs than among whites who inject drugs, despite fewer reported risk behaviors among blacks. In 2015, when compared with white persons who inject drugs, fewer black persons who inject drugs shared syringes or injection equipment, fewer had condomless vaginal or anal sex, more tested for HIV infection, and more received syringes only from sterile sources in the previous 12 months. Taken together with data from previous reports suggesting that persons who first injected drugs during the 5 years before their interview and young persons who inject drugs are more likely to be white ( 2 ), these findings suggest HIV prevalence among white persons who inject drugs could be lower because they have had less time to acquire HIV infection through injection drug use. Overall, higher percentages of 2015 participants tested for HIV infection in the previous 12 months (51% in 2012, 58% in 2015) and ever tested for HCV (78% in 2012, 82% in 2015) ( 3 ). Increases in HIV and HCV testing could be the result of increased access to health insurance among persons who inject drugs (69% in 2012, 82% in 2015) ( 3 ). In 2015, higher percentages of persons who inject drugs and who have health insurance tested for HIV infection, participated in HIV behavioral interventions, and ever tested for HCV than did those without health insurance. Although these results highlight gains in HIV and HCV testing measures, nearly half of persons who inject drugs did not test for HIV in the previous 12 months as recommended by CDC ( 8 ). Continued activities that expand HIV testing in settings that provide services to persons who inject drugs, such as in syringe services programs, substance use disorder treatment programs and emergency departments, are needed. The findings in this report are subject to at least four limitations. First, because a method of obtaining standard probability samples of persons who inject drugs does not exist, the representativeness of the NHBS sample cannot be determined. Although adjusted for RDS ( 5 ), biases related to participants’ recruitment behavior or their willingness and ability to participate in the interview might have affected the sample. Second, the numbers of participants in some cities were insufficient to include these cities in the aggregate estimates. The number of cities excluded from aggregate estimates varied based on the analysis variable. Third, persons who inject drugs were interviewed in 20 cities with high prevalences of HIV infection; findings from these cities might not be generalizable to all persons who inject drugs including those who reside in rural or nonmetropolitan areas. Finally, behavioral data are self-reported and subject to social desirability bias. This analysis highlights the ongoing need for risk reduction and HIV prevention services among persons who inject drugs. Only half of persons who inject drugs used syringe services programs and only a third obtained their syringes exclusively from sterile sources. Access to sterile injection and drug preparation equipment is critical for the prevention of HIV infections among persons who inject drugs. Although access to syringes through syringe services programs has increased in the United States ( 9 ), the available supply is likely insufficient to meet the demand, and multiple areas continue to lack access to these services. The recent opioid use epidemic increases the potential for HIV outbreaks among persons who inject drugs, particularly in areas with limited prevention services for persons who inject drugs ( 4 ). Thus, failure to respond appropriately to this prevention gap could reverse earlier successes in reducing HIV infection among persons who inject drugs ( 2 ). Comprehensive syringe services programs reduce transmission of HIV and other infections ( 10 ) by providing access to safe syringe disposal; risk reduction education; HIV and viral hepatitis testing; referrals to health services including treatment for HIV, HCV, or substance use disorder (including medication-assisted therapy) and mental health disorders; and preexposure prophylaxis. Recent changes in federal appropriations law †††† permitting the use of federal funding to support syringe services programs present an opportunity to improve access to these critical prevention services to persons who inject drugs. Summary What is already known about this topic? Persons who inject drugs are at increased risk for acquiring human immunodeficiency virus (HIV) infection. In 2012, National HIV Behavioral Surveillance found an overall 11% prevalence of HIV infection of among persons who inject drugs living in 20 large cities. Among HIV-negative persons who inject drugs, 27% shared syringes and 67% had vaginal sex without a condom in the previous 12 months. What is added by this report? In 2015, National HIV Behavioral Surveillance found a 7% prevalence of HIV infection among persons who inject drugs which was lower than in 2012 (11%). Among HIV-negative respondents, 27% reported sharing syringes and 67% reported having vaginal sex without a condom in the previous 12 months; only 52% received syringes from a syringe services program and 34% received all syringes from sterile sources. HIV infection prevalence was higher among blacks (11%) than whites (6%) but more white persons who inject drugs shared syringes (white: 39%; black: 17%) and injection equipment (white: 61%; black: 41%) in the previous 12 months. What are the implications for public health practice? Persons who inject drugs are at risk for acquiring HIV infection because of their drug use practices and sexual behaviors. Approximately half of injection drug users did not receive syringes from a syringe services program in the previous 12 months. Provision of sterile syringes and other community-based strategies can decrease risk for HIV transmission. Persons who inject drugs need access to sterile injection and drug preparation equipment; HIV and viral hepatitis testing; health services that provide treatment for HIV infection, viral hepatitis, substance use disorder and mental health disorders; preexposure prophylaxis; and education on drug- and sex-related risks and risk reduction.
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                Author and article information

                Journal
                JAMA
                JAMA
                American Medical Association (AMA)
                0098-7484
                February 11 2020
                February 11 2020
                : 323
                : 6
                : 568
                Affiliations
                [1 ]Substance Abuse and Mental Health Services Administration, Rockville, Maryland
                [2 ]National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
                Article
                10.1001/jama.2019.20844
                7042840
                32044936
                f24f28da-9641-439e-95a2-0af13d76051a
                © 2020
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