Addressing the HIV/AIDS Epidemic Among Puerto Rican People Who Inject Drugs: The Need for a Multiregion Approach High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemic. Advances in HIV prevention and treatment have reduced HIV among people who inject drugs (PWID) in the United States. We examined HIV-related data for PRPWID in Puerto Rico and the US Northeast to assess whether disparities continue. Injection drug use as a risk for HIV is still overrepresented among Puerto Ricans. Lower availability of syringe exchanges, drug abuse treatment, and antiretroviral treatment for PWID in Puerto Rico contribute to higher HIV risk and incidence. These disparities should be addressed by the development of a federally supported Northeast–Puerto Rico collaboration to facilitate and coordinate efforts throughout both regions. (Am J Public Health. 2014;104:2030–2036. doi:10.2105/AJPH.2014.302114)

Sherry Deren, PhD, Camila Gelpí-Acosta, PhD, Carmen E. Albizu-García, MD, Ángel González, MD, Don C. Des Jarlais, PhD, and Salvador Santiago-Negrón, PhD, MPH

BEHAVIORAL, BIOMEDICAL, and structural interventions have led to significant reductions in HIV incidence in the United States. More than 30 years since HIV was first reported, the possibility of an AIDS-free generation in the United States has recently emerged. Current research and policy efforts focus on identifying those who may be unaware of their infection to engage and maintain them in antiretroviral treatment, and aim to reduce health disparities among racial/ethnic groups. Despite great advances in HIV prevention and care, insufficient progress has been made among Puerto Rican people who inject drugs (PRPWID). Research on the HIV/AIDS epidemic among people who inject drugs (PWID) has documented higher levels of risk behaviors and prevalence among individuals identified as Puerto Rican than among other groups since early in the epidemic, and these disparities persist. Although Puerto Ricans in the island and the continental United States represent about 9% of the US Hispanic population,1 nearly 23% of incident HIV cases among Hispanics in 2006 were among those born in Puerto Rico.2 Injection drug use accounted for the majority of AIDS cases in Puerto Rico early in the epidemic,3 and currently more than 20% of new infections in Puerto Rico are attributed to injection drug use, a higher percentage than for any other region of the United

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States 4 and for any other Hispanic subgroup.5 To meet the challenge of eradicating HIV in the United States, health disparities within subgroups at high risk for HIV must be addressed. Furthermore, the HIV treatment---as---prevention paradigm6 in use to reduce HIV transmission will not suffice in reducing comorbidities associated with injection drug use (e.g., hepatitis C, overdoses), also found at disproportionately high rates among PRPWID. We focused on Puerto Rico and the northeastern United States, where the majority of Puerto Ricans live,1 to examine the history of the epidemic among PRPWID, the current state of the epidemic, and the availability of HIV prevention and treatment services. We also describe other challenges to health for PRPWID and interventions recently adopted in Puerto Rico and provide recommendations to further reduce HIV in this population.

HIV AMONG PUERTO RICAN PEOPLE WHO INJECT DRUGS Beginning in the 1980s, shortly after the identification of injection drug use as a major transmission category for HIV, researchers identified higher seroprevalence and risk behaviors among PRPWID than among other groups.7,8 These findings have been consistent, both in

comparisons of PWID residing in Puerto Rico and in other US locations,9---11 and in comparisons of PRPWID in the mainland United States with other PWID in the same communities.12 Researchers have closely examined HIV risk behaviors among PRPWID who reside in Puerto Rico and those in the northeastern United States, the region with the highest Hispanic PWID prevalence.13 A dual-site study of PRPWID conducted from 1996 to 2004 compared risk behaviors of PWID recruited in Puerto Rico with those of Puerto Rican background recruited in New York City.14 The study found more injection-related risk behaviors (e.g., frequency of injecting, sharing syringes, sharing other injection equipment, and injecting in shooting galleries) in Puerto Rico.15,16 Similar findings were reported in comparisons of PRPWID in Puerto Rico with those recruited in Massachusetts.10,17 The Puerto Rico---New York study also documented higher morbidity18 and mortality19 in Puerto Rico, as well as lack of access to risk reduction resources, such as syringe exchange programs (SEPs)20 and drug treatment.18 A summary of these findings called for increased services and surveillance in Puerto Rico.14 A recent review summarized the higher risk of injection-related transmission among Puerto Ricans and their poorer health outcomes.21 In addition to documenting more risk behaviors among PWID

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in Puerto Rico, studies have shown that PRPWID living in the United States who have a history of injection drug use in Puerto Rico are more likely to engage in injectionrelated risks than PRPWID in the United States who did not inject drugs in Puerto Rico.22 Thus, despite migration from Puerto Rico to New York, where more risk reduction resources are available, higher levels of risk persist.

HIV EPIDEMIOLOGY AMONG PRPWID IN PUERTO RICO As of October 31, 2013, 36 180 persons in the island had been diagnosed with AIDS and 9311 with HIV. Of these, 24 372 had died. Although case fatality for the aggregate US population (2008---2010) was approximately 5 per 100 000 population,23 the rate during the same period in Puerto Rico was nearly 6 times as high (31/100 000 in 2008 and 26/100 000 in 2010).24 Injection drug use became the primary mode of transmission in 1985 and has accounted for nearly half of accumulated AIDS cases in adults and adolescents and nearly 26% of cases diagnosed with HIV between 2005 and 2011.25 Although HIV incidence experienced a downward trend as of 2005, with an estimated 33.37 new cases per 100 000 population, the island remains a major contributor to the epidemic. In 2011, the estimated incidence rate of HIV cases in Puerto Rico was 28.6 per 100 000, ranking eighth among US states and territories.23 In 2010, injection drug use accounted for 8.6% of new HIV infections across the United States, but the proportion in Puerto Rico was more than twice as high (20.4%). A higher percentage of new infections in

Puerto Rico were attributed to heterosexual contact (40.7% vs 22.0% for United States),4 with many of these likely involving intercourse with a person who injects drugs who was HIV infected.26

HIV EPIDEMIOLOGY AMONG PRPWID IN THE US NORTHEAST The Northeast (defined by the Centers for Disease Control and Prevention as comprising Connecticut, Massachusetts, Maine, New Jersey, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont) had an estimated 349 250 AIDS cases as of the end of 2011, approximately 30% of all cases in the United States.23 In 2010 the Northeast reported the highest rates of new AIDS diagnoses.27 During 2010, 27% of people diagnosed with AIDS in the Northeast were Hispanic.27 The Northeast has more new infections attributed to injection drug use than in all the other regions of the United States combined (15.8% vs 8.8%), and 48.7% of Hispanics with a diagnosis of HIV live in the Northeast.4 A recent Centers for Disease Control and Prevention report highlighted the elevated HIV incidence among Hispanic PWID in the Northeast,4 and a study of US metropolitan statistical areas reported that the areas with the highest Hispanic PWID prevalence were in the Northeast.13 Although many reports regarding HIV and Hispanics do not differentiate among Hispanic subgroups, important geographic differences exist. The Hispanic population of the United States is 65% Mexican and 9% Puerto Rican, but Puerto Ricans are primarily concentrated in the Northeast and Mexicans in the Southwest.28

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New York City New York City experienced the largest HIV/AIDS epidemic among PWID in the country, with prevalence reaching about 50% in the mid-1980s.29 Although HIV infections among PWID have significantly declined, with more recent estimated prevalence of about 12%,29 injection-related transmission continues. In the first half of 2012, injection drug use in New York City accounted for 5% and 9.5%, respectively, of overall HIV and AIDS incidence.30 It is estimated that about 50% of all PWID in New York City are of Puerto Rican ancestry (including US-born persons).31,32 One study found that Puerto Rico--born PWID living in New York City were significantly more likely than US-born PWID (including those of Puerto Rican ancestry) to be HIV positive.33 Recent studies of PWID in New York City confirm the continued high prevalence of risk behaviors among persons born in Puerto Rico.32,33 In New York City in 2012, an estimated 45% of newly infected PWID were Hispanic, more than one third of them born in Puerto Rico (A. Neaigus, PhD, New York City Department of Health and Mental Hygiene, written communication, November 2013). Because of the size of the HIV epidemic in New York City, and the academic resources available, more extensive research efforts have been undertaken there than in other northeastern locations. However, the patterns identified are similar across the region.

Other Northeast Locations In New Jersey, as of December 2009, Hispanics accounted for 24% of new diagnoses, and among the state’s Hispanics living with HIV/AIDS, 31% were born in Puerto Rico and 22% were

infected through injection drug use.34 In Connecticut, of the 20 354 cumulative cases of HIV/ AIDS as of 2012, 28% were among Hispanics, and among Hispanics, half of the cases (50%) were attributed to injection drug use.35 Between 2008 and 2010 in Massachusetts, 33% of new HIV diagnoses among Hispanics were among people born in Puerto Rico.36 In Philadelphia, Pennsylvania, in 2012, 40% of Hispanics (including Puerto Ricans) living with HIV/AIDS were infected through injection drug use, a higher percentage than among other race/ethnic groups and the largest risk category among Hispanics.37

HIV PREVENTION AND DRUG TREATMENT SERVICES SEPs and drug treatment (in particular, opiate substitution treatment such as methadone maintenance) are the 2 primary HIV prevention services responsible for reductions in HIV among PWID.38 Numerous studies have documented the effectiveness of SEPs in reducing HIV transmission while not increasing drug use,39 and the effectiveness of drug treatment, particularly opiate substitution therapies, in reducing transmission.40 Combination approaches to HIV prevention among PWID (SEPs and opiate substitution treatment, along with availability of antiretroviral treatment), have been shown to be particularly effective (both in actual and modeling scenarios) in reducing transmission.41 The evidence indicates that these services are much less available in Puerto Rico.

Syringe Exchange Services Studies of SEPs in the 1990s found that the availability of

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syringes was much lower in Puerto Rico than in New York City.20 This was especially troubling because of the high frequency of injection among PWID in Puerto Rico.15 A more recent survey of SEPs in the Northeast serving populations that were at least 50% Hispanic (n = 6; all but 1 located in New York City) and in Puerto Rico (n = 2), although it had sample sizes that were too small for statistical testing, found striking differences in services and resources (D. C. D, unpublished data, 2011). The mean number of weekly service hours was more than 50% greater in the Northeast (48 vs 30.5 hours), and the average annual budgets for the SEPs in the Northeast were more than 5 times those of the SEPs in Puerto Rico (> $ 400 000 vs $80 000). These differences in annual budgets have important implications for reducing HIV transmission and other health problems among PWID. First, larger budgets permit exchange of more syringes, which is associated with a lower rate of HIV transmission.31 Second, exchange of large numbers of syringes usually involves secondary exchange, in which drug users who personally attend the exchange also bring in used syringes for their peers.42 Secondary exchange thus provides opportunities for altruism among PWID and contributes to the development of social norms against sharing needles and syringes. Larger budgets also mean that the programs can provide multiple services in addition to basic exchange. Some of these services, such as HIV and hepatitis C testing, screening and treatment of sexually transmitted diseases, referrals to HIV care, and referrals to drug treatment programs, may directly reduce the likelihood of HIV transmission among SEP

participants. Other services, such as wound care and assistance in obtaining housing, may contribute to the general health and wellbeing of the participants and indirectly reduce HIV transmission.

Drug Treatment Services It is estimated that throughout the US states and territories only 10% to 20% of all individuals in need of it are in treatment for drug use.43 Numerous studies have documented the lower availability and narrower range of drug treatment services in Puerto Rico, where the need is particularly great. In particular, although methadone treatment has been identified as an effective HIV prevention intervention among PWID since the 1990s,44---46 it not been integrated as a strategic objective in HIV prevention plans in Puerto Rico. Robles et al. found that PRPWID recruited in New York City were 5 times as likely to be in drug treatment services, primarily methadone treatment, as those recruited in Puerto Rico.18 Historically, as Hansen has described, the limited drug treatment options in Puerto Rico, aside from state-administered treatment, were mainly provided through faith-based programs.47,48 The prominent role of faith-based treatment was enhanced when the Puerto Rico Mental Health Law of 2000 defined addiction as a spiritual and social problem rather than a mental disorder, promoting an evangelist approach to drug addiction treatment.48 Under this new law, faith-based drug treatment programs were exempted from state regulation, and their involvement in recovery programs influenced legislation that limited the availability of practices supported by scientific evidence (e.g., pharmacotherapy).

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In 2008, the Puerto Rico Mental Health Law was amended to establish drug treatment practices congruent with the professionalization of services.49 Although they recognize the role of pastoral or spiritual advisors in recovery, these programs are part of a broader spectrum of services provided by a multidisciplinary team that includes behavioral health specialists and physicians, all of whom must comply with the law’s definitions of standards of care. Evangelical programs, however, remain an important component of available services. According to national data, more than 85% of admissions of Puerto Ricans to drug treatment took place in the Northeast, primarily in New York.50 Although Puerto Ricans were more likely than other Hispanics to be admitted to a hospital for detoxification, those who were primary heroin users were less likely to receive medication-assisted opioid therapy, indicating that additional efforts may be needed during the transition from detoxification to treatment services.50

Relocating for Drug Treatment The common practice of relocating PRPWID from the island to the United States for drug treatment has encouraged an evangelical approach to drug treatment. PWID and their families in Puerto Rico who seek assistance for drug abuse and are unable to access effective care locally are recruited by organizations that promote themselves as offering effective services in other areas of the country (primarily the Northeast). Decisions regarding treatment program options are often made without information about their quality and licensure status. Relocation for drug

treatment is often urged (and accompanied by a paid 1-way ticket) by Puerto Rican officials, family members, and others. PRPWID arriving in New York are typically taken to a detoxification unit and then to a new home and treatment center overseen by a Christian minister. Residents apply for Medicaid and other assistance, which go to the owner to run the center. Treatment often consists of prayers and shaming techniques. This relocation for drug treatment in New York has been described by Torruella51 and Gelpí-Acosta et al.33 Some other northeastern states have similar treatment destinations for PRPWID. A recent cover article published in a Spanish community newspaper in Philadelphia describes a group of 200 homeless individuals with a substance abuse disorder, including some PWID, who were relocated from Puerto Rico to treatment centers that market their services in Puerto Rico.52 These individuals’ expectations were not met, and they found themselves abandoned, homeless, and unable either to return to Puerto Rico or to access Medicaid or other subsidized care because they lacked required documentation.

HIV Care In Puerto Rico, an estimated 29% of persons with HIV who were aware of their status were not in care (according to the standard definition of having no evidence of viral load testing, CD4 count, or antiretroviral treatment during the past year), and nearly half of those not in HIV care were PWID (consonant with the ;50% of people living with HIV/AIDS in Puerto Rico with injection as the transmission category).53 However, these data may overestimate

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the numbers of PWID in care. For example, treatment statistics from the public specialized clinics providing care in Puerto Rico to people living with HIV/AIDS indicate that in 2013, only 9.2% of registered cases resulted from injection drug use, indicating that PWID were underrepresented among those in HIV care.54 Past reports of the unavailability of HIV medications in Puerto Rico raise other concerns,55 particularly in light of the need for consistent adherence to antiretroviral medications for benefits to be attained. In the Northeast, we examined Ryan White need statements for New York and New Jersey, the 2 northeastern states with the most AIDS cases as of December 2011.23 In New York City, approximately 35% of those infected with HIV and aware of their serostatus were not in care,56 and rates were similar across racial/ ethnic categories. In New Jersey, unmet need among person with HIV (defined as not having a viral load test, CD4 count, or antiretroviral drug in the past year) was estimated at 46% and was higher for Hispanics.57 These data indicate that substantial numbers of HIV-infected individuals are not in care and that increased efforts to enhance care engagement for Hispanics and PWID are particularly needed. Data on maintenance in care and achievement of undetectable viral loads are also important indicators to monitor among people living with HIV/AIDS.

OTHER HEALTH CHALLENGES In addition to HIV-related disparities, PRPWID face many other health challenges. In a study of mortality among PRPWID in New York and Puerto Rico,

mortality was more than 3 times as high in Puerto Rico as in New York.19 Relative to the Hispanic population of New York City, the standardized mortality rate of the New York cohort was 4.4; relative to the population of Puerto Rico, this rate was 16.2 for the study’s Puerto Rico cohort.19 This study also found that the second most frequent cause of death (after HIV/AIDS-related deaths) in both cohorts was drug overdose: 13% of cases in New York and 37% in Puerto Rico. A more recent analysis of HIV-infected PWID in New York City reported that overdose was the major contributing cause of death in 20.5% of cases, a rate 3 to 5 times as high as in other transmission groups.58 Specific comorbid conditions that have been reported at high levels among PRPWID, and that are especially prevalent among those recruited in Puerto Rico, are septicemia,19 hepatitis C and liver disease,59 and bacterial and other soft tissue infections.60 The latter have been related to commensal flora, sharing of injection paraphernalia, use of drug adulterants, and drug preparation, as well as host susceptibility caused by living circumstances.61 Injection of xylazine (a veterinary anesthetic) among PWID has been associated with skin lesions and has been reported in Puerto Rico62---64 and the Northeast.65

REPORTING PRACTICES Reporting practices have contributed to the insufficient attention paid to addressing HIV and other health issues affecting PRPWID. Two types of problems have been identified. The first is combining data across Hispanic populations. National data have long identified Hispanics’ overrepresentation in the

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HIV epidemic. The Hispanic population in the United States is primarily Mexican, but Hispanic PWID are more likely to be Puerto Rican.5 Thus, many of the epidemiological measures of HIV prevalence and incidence and the risk categories among Hispanics have obfuscated the important differences between Hispanic subgroups in risk behaviors and prevalence. Furthermore, although national data on AIDS among Hispanics distinguish by place of birth, showing that those born in Puerto Rico have the highest prevalence of transmission by injection,5 the largest category of Hispanics is persons born in the United States, not stratified by heritage, thus concealing important cultural differences.66 Other investigators have noted the lack of attention to the heterogeneity among US Hispanics in research on HIV, noting that these differences should be taken into account in developing culturally appropriate interventions.67 The second major reporting problem is exclusion of Puerto Rico from regional reports. Although Puerto Rico is part of the Caribbean, reports on this region often exclude it because it is part of the United States (and not an independent country). In addition, reports on HIV in the United States, for a variety of reasons, at times focus only on the 50 states and exclude Puerto Rico,68 resulting in insufficient identification of and attention paid to the magnitude of HIV/AIDS among Puerto Ricans.

ADVANCES Drug treatment and harm reduction services in Puerto Rico have made some promising advances in the wake of the amended Mental Health Law.

Efforts to expand treatment options, supported by the Open Society Foundation’s Closing the Addiction Treatment Gap Program, led to Medicaid’s inclusion of Suboxone (a combination of buprenorphine and naloxone, used to treat opioid dependence) in its formulary in 2010, and new legislation requires all private health insurance plans in Puerto Rico that provide pharmacy benefits to add Suboxone to their formularies.69 A program to initiate integration of services for HIV and substance use disorders has been facilitated by a grant from the Substance Abuse and Mental Health Services Administration to Administración de Servicios de Salud Mental y Contra la Adicción (Mental Health and Anti-addiction Services Administration), whose present administration assumed office in January 2013. Its agenda is guided by the Consensus Statement of the Reference Group to the United Nations on HIV and Injecting Drug Use.70 During its first year in office, this administration supported marijuana decriminalization, initiated expansion of methadone maintenance treatment programs, collaborated with federally qualified health centers to expand buprenorphine treatment in primary care, allocated local funds for SEPs, conducted an analysis of overdose deaths to inform prevention, improved treatment-monitoring indicators and data collection, and revised criteria for licensure of drug treatment programs to ensure compliance with the Mental Health Law and standards of care. Efforts are under way to expand HIV testing to all substance abuse treatment facilities. An initiative is evolving, in collaboration with the Puerto Rico Department of Corrections, to

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significantly expand medicationassisted treatment of opioiddependent inmates, a treatment modality initiated on a small scale in Puerto Rico prisons in 2002 with methadone and in 2007 with buprenorphine (an opioid partial agonist, similar in effectiveness to methadone).71,72 These newly initiated efforts provide an opportunity to make great strides in combating the epidemic among Puerto Rican PWID.

RECOMMENDATIONS Puerto Rican PWID, especially those who reside in Puerto Rico, have experienced disparities in HIV and other health conditions since early in the epidemic. The evidence indicates that these disparities have continued. The migration of Puerto Ricans from the island to the Northeast, including those seeking drug treatment, indicates that a lack of attention to these health concerns on the island will continue to fuel the epidemic and health care disparities both in Puerto Rico and in the Northeast. Although heterosexual transmission has surpassed injection-related transmission of HIV in Puerto Rico, controlling heterosexual transmission of HIV will require controlling HIV infection among PWID. Sexually active PWID will serve as a continuing reservoir for future heterosexual transmission if injection-related HIV transmission is not brought under control. Puerto Rico has an immediate need for expansion of HIV prevention and care interventions, and the Northeast needs more culturally appropriate HIV prevention interventions geared to PRPWID.33,73 Although Puerto Rico has several SEPs, they are not well funded and do not appear to be operating on the public

health scale that is needed to halt the HIV epidemic among PWID. The continuing ban on using federal funds for needle exchange likely remains an impediment to scaling up these programs. We also found that the programs in Puerto Rico generally provided fewer services than did programs in the Northeast. Providing other services not only addresses multiple health needs of PWID, but also creates trust between PWID and health workers that could be critical to the overall effectiveness of efforts to curb HIV transmission. Simply addressing local needs for service expansion or enhancement in Puerto Rico and in the Northeast is not sufficient. Multiregion efforts are needed for this mobile population. A public health, demand reduction approach requires the development of a Northeast---Puerto Rico multiregion initiative that is analogous to the United Nations Office on Drugs and Crime’s supply reduction regional initiatives to counter rising drug traffic. Such an initiative would facilitate collaborations to monitor and coordinate efforts to effectively address the needs of PRPWID throughout these regions. Responses from health authorities and private providers that are contextually and culturally appropriate are required. Multiregion, intercity agreements should promote policy development, networking, and collaborative funding and training. Mechanisms should be established to share information across the Northeast--Puerto Rico regions in a timely way, with data about treatment availability and quality (drug treatment and antiretroviral treatment), and surveillance efforts (e.g., for drug use, HIV and hepatitis C incidence and prevalence, and

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migration patterns between these regions). A partnership between federal, local, and private entities to develop local and cross-regional initiatives is needed to support such collaborations and services. These partnership programs should augment harm reduction measures targeting PRPWID. Implementing these initiatives could be challenging because of the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast; the existence of other major political and economic issues faced by governmental authorities in Puerto Rico74,75; and the ban on using federal funds for SEPs. Nonetheless, the federal commitment to addressing the HIV/ AIDS epidemic through the National HIV/AIDS Strategy, including the Comprehensive HIV Prevention Planning and Implementation Project undertaken by the Centers for Disease Control and Prevention for metropolitan statistical areas most affected by HIV/AIDS, provides funds, authority, and potential mechanisms for supporting a formal collaboration between health departments in Puerto Rico and the Northeast to monitor and address HIV among PWID. These efforts could not only benefit PWID on the island and in the Northeast, but also reduce health disparities in this population. They could be an important component in efforts to end the HIV/AIDS epidemic in the United States. j

About the Authors Sherry Deren is with the Center for Drug Use and HIV Research, College of Nursing, New York University, New York, NY. Camila Gelpí-Acosta is a postdoctoral fellow at National Development and Research Institutes (NDRI), New York, NY. Carmen E. Albizu-García is with the

Graduate School of Public Health, University of Puerto Rico, San Juan. At the time of writing, Ángel González and Salvador Santiago-Negrón were with the Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA; Mental Health and Anti-addiction Services Administration), San Juan. Don C. Des Jarlais is with Mount Sinai Beth Israel, New York, NY. Correspondence should be sent to Sherry Deren, PhD, Center for Drug Use and HIV Research, College of Nursing, New York University, 726 Broadway, 10th floor, New York, NY 10003 (e-mail: [email protected] edu). Reprints can be ordered at http://www. by clicking the “Reprints” link. This article was accepted May 28, 2014.

Contributors S. Deren conceptualized the article. S. Deren, C. Gelpí-Acosta, C. E. AlbizuGarcía, and D. C. Des Jarlais drafted sections of the article. All authors contributed original ideas and reviewed drafts of the article.

Acknowledgments This work was supported by the Center for Drug Use and HIV Research, National Institute on Drug Abuse (grant P30 DA011041 to Sherry Deren). C. GelpíAcosta was supported by Public Health Solutions of New York City Inc and the NDRI, with funding from the National Institute on Drug Abuse (grant 5T32 DA007233). The syringe exchange survey was funded by amfAR, the Foundation for AIDS Research, with support from the Elton John AIDS Foundation. We acknowledge contributions from Charles Cleland and Salaam Semaan. Note. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute on Drug Abuse, ASSMCA, or any other agency or institution.

Human Participant Protection Institutional review board approval was not required because data were obtained from secondary sources.

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6. Cohen MS, Holmes C, Padian N, et al. HIV treatment as prevention: how scientific discovery occurred and translated rapidly into policy for the global response. Health Aff (Millwood). 2012;31(7): 1439---1449. 7. Bakeman R, Lumb JR, Smith DW. AIDS statistics and the risk for minorities. AIDS Res. 1986;2(3):249---252. 8. Friedman SR, Sotheran JL, AbdulQuader A, et al. The AIDS epidemic among Blacks and Hispanics. Milbank Q. 1987;65(suppl 2):455---499. 9. Robles RR, Colon HM, Matos TD, Reyes JC, Marrero CA, Lopez CM. Risk factors and HIV infection among three different cultural groups of injection drug users. In: Brown BS, Beschner GM, eds. Handbook on Risk of AIDS: Injection Drug Users and Sexual Partners. Westport, CT: Greenwood Press; 1993:256---274. 10. López LM, Zerden LD, Fitzgerald TC, Lundgren LM. Puerto Rican injection drug users: prevention implications in Massachusetts and Puerto Rico. Eval Program Plann. 2008;31(1):64---73. 11. Deren S, Kang SY, Colón HM, Andia JF, Robles RR. HIV incidence among high-risk Puerto Rican drug users: a comparison of East Harlem, New York, and Bayamón, Puerto Rico. J Acquir Immune Defic Syndr. 2004;36(5):1067---1074. 12. Singer M, Jia Z. AIDS and Puerto Rican injection drug users in the United States. In: Brown BS, Beschner GM, eds. Handbook on Risk of AIDS: Injection Drug Users and Sexual Practices. Westport, CT: Greenwood Press; 1993:227---255. 13. Pouget ER, Friedman SR, Cleland CM, Tempalski B, Cooper HL. Estimates of the population prevalence of injection drug users among Hispanic residents of large US metropolitan areas. J Urban Health. 2012;89(3):527---564. 14. Mino M, Deren S, Colón HM. HIV and drug use in Puerto Rico: findings from the ARIBBA study. J Int Assoc Physicians AIDS Care. 2011;10(4):248--259. 15. Colón HM, Robles RR, Deren S, et al. Between-city variation in frequency of

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American Journal of Public Health | November 2014, Vol 104, No. 11

AIDS epidemic among Puerto Rican people who inject drugs: the need for a multiregion approach.

High levels of HIV risk behaviors and prevalence have been reported among Puerto Rican people who inject drugs (PRPWID) since early in the HIV epidemi...
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