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Introduction: We analyzed relationships between place characteristics and being HIV-negative among black, Latino, and white people who inject drugs (PWID) in the US. Methods: Data on PWID (N = 9077) were from the Centers for Disease Control and Prevention’s 2009 National HIV Behavioral Surveillance. Administrative data were analyzed to describe the 968 ZIP codes, 51 counties, and 19 metropolitan statistical areas (MSAs) where they lived. Multilevel multivariable models examined relationships between place characteristics and HIV status. Exploratory population attributable risk percents (e-PAR%s) were estimated. Results: Black and Latino PWID were more likely to be HIV-negative if they lived in less economically disadvantaged counties, or in MSAs with less criminal-justice activity (i.e., lower drug-related arrest rates, lower policing/corrections expenditures). Latino PWID were more likely to be HIV-negative in MSAs with more Latino isolation, less black isolation, and less violent crime. E-PAR%s attributed 8–19% of HIV cases among black PWID and 1–15% of cases among Latino PWID to place characteristics. Discussion: Evaluations of structural interventions to improve economic conditions and reduce drug-related criminal justice activity may show evidence that they protect black and Latino PWID from HIV infection. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992–2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations. Methodology: We calculated the number of PWID in the US annually from 1992–2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models. Results: PWID per 10,000 persons aged 15–64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002–2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated – the mean prevalence was 90 to 100 per 10,000 youth in 1992–1996, but increased to >120 PWID per 10,000 youth in 2006–2007. Conclusions: Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes. [ABSTRACT FROM AUTHOR]

Despite the 2010 repeal of the ban on spending federal monies to fund syringe exchange programs (SEPs) in the USA, these interventions-and specifically SEP site locations-remain controversial. To further inform discussions about the location of SEP sites, this longitudinal multilevel study investigates the relationship between spatial access to sterile syringes distributed by SEPs in New York City (NYC) United Hospital Fund (UHF) districts and injecting with an unsterile syringe among injectors over time (1995-2006). Annual measures of spatial access to syringes in each UHF district ( N = 42) were created using data on SEP site locations and site-specific syringe distribution data. Individual-level data on unsterile injecting among injectors ( N = 4,067) living in these districts, and on individual-level covariates, were drawn from the Risk Factors study, an ongoing cross-sectional study of NYC drug users. We used multilevel models to explore the relationship of district-level access to syringes to the odds of injecting with an unsterile syringe in >75% of injection events in the past 6 months, and to test whether this relationship varied by district-level arrest rates (per 1,000 residents) for drug and drug paraphernalia possession. The relationship between district-level access to syringes and the odds of injecting with an unsterile syringe depended on district-level arrest rates. In districts with low baseline arrest rates, better syringe access was associated with a decline in the odds of frequently injecting with an unsterile syringe (AOR, 0.95). In districts with no baseline syringe access, higher arrest rates were associated with increased odds of frequently injecting with an unsterile syringe (AOR, 1.02) When both interventions were present, arrest rates eroded the protective effects of spatial access to syringes. Spatial access to syringes in small geographic areas appears to reduce the odds of injecting with an unsterile syringe among local injectors, and arrest rates elevate these odds. Policies and practices that curtail syringe flow in geographic areas (e.g., restrictions on SEP locations or syringe distribution) or that make it difficult for injectors to use the sterile syringes they have acquired may damage local injectors' efforts to reduce HIV transmission and other injection-related harms. [ABSTRACT FROM AUTHOR]

This research presents estimates of HIV prevalence rates among injection drug users (IDUs) in large US metropolitan statistical areas (MSAs) during 1992–2002. Trend data on HIV prevalence rates in geographic areas over time are important for research on determinants of changes in HIV among IDUs. Such data also provide a foundation for the design and implementation of structural interventions for preventing the spread of HIV among IDUs. Our estimates of HIV prevalence rates among IDUs in 96 US MSAs during 1992–2002 are derived from four independent sets of data: (1) research-based HIV prevalence rate estimates; (2) Centers for Disease Control and Prevention Voluntary HIV Counseling and Testing data (CDC CTS); (3) data on the number of people living with AIDS compiled by the CDC (PLWAs); and (4) estimates of HIV prevalence in the US. From these, we calculated two independent sets of estimates: (1) calculating CTS-based Method (CBM) using regression adjustments to CDC CTS; and (2) calculating the PLWA-based Method (PBM) by taking the ratio of the number of injectors living with HIV to the numbers of injectors living in the MSA. We take the mean of CBM and PBM to calculate over all HIV prevalence rates for 1992–2002. We evaluated trends in IDU HIV prevalence rates by calculating estimated annual percentage changes (EAPCs) for each MSA. During 1992–2002, HIV prevalence rates declined in 85 (88.5%) of the 96 MSAs, with EAPCs ranging from −12.9% to −2.1% (mean EAPC = −6.5%; p < 0.01). Across the 96 MSAs, collectively, the annual mean HIV prevalence rate declined from 11.2% in 1992 to 6.2 in 2002 (EAPC, −6.4%; p < 0.01). Similarly, the median HIV prevalence rate declined from 8.1% to 4.4% (EAPC, −6.5%; p < 0.01). The maximum HIV prevalence rate across the 11 years declined from 43.5% to 22.8% (EAPC, −6.7%; p < 0.01). Declining HIV prevalence rates may reflect high continuing mortality among infected IDUs, as well as primary HIV prevention for non-infected IDUs and self-protection efforts by them. These results warrant further research into the population dynamics of disease progression, access to health services, and the effects of HIV prevention interventions for IDUs. [ABSTRACT FROM AUTHOR]

HIV epidemics among IDUs vary widely across different cities in the USA [American Journal of Public Health 86 (5) (1996) 642]. Few studies have focused on how localities differ in regard to response to the HIV epidemic. While syringe exchange programmes (SEPs) are a response to HIV among IDUs, they are often unwelcome and difficult to set up even in communities hit hardest by the epidemic. It is important to understand what metropolitan area characteristics are related to when and if an SEP opens in a particular locality. Logistic regression models are used to explore how need, political factors, SEP diffusion from Tacoma (the first SEP), and metropolitan socioeconomic characteristics are related to SEP presence. Results indicate that need is not a significant predictor of having an SEP. Predictors were the percentage of the population who are men who have sex with men (AOR=6.95; 95% CI=1.29–37.49), and metropolitan area population (AOR=1.08 per 100,000; 95% CI=1.02–1.14). Predictors of having an SEP in a metropolitan area seem to be political factors and metropolitan area population size, not need among IDUs. Gay political influence and/or support may well facilitate SEP formation, and geographic diffusion may influence where SEPs are established. [Copyright &y& Elsevier]

Purpose: The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period and across a wide range of geographic areas.Methods: This article applies multilevel modeling to data integrated from numerous sources to estimate and validate trajectories of HIV prevalence among MSM from 1992 to 2013 for 86 of the largest metropolitan statistical areas in the United States.Results: Our estimates indicate that HIV prevalence among MSM increased, from an across-metropolitan statistical area mean of 11% in 1992 to 20% in 2013 (S.D. = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among black and Hispanic/Latino MSM than among white MSM across all years and geographic regions.Conclusions: The increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality and perhaps also to increasing HIV incidence among racial/ethnic minority MSM. Future research is needed to confirm this. If true, health care initiatives should focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM. [ABSTRACT FROM AUTHOR]

Purpose: After years of stable or declining HIV prevalence and declining incidence among people who inject drugs (PWID) in the United States, some rapidly emerging outbreaks have recently occurred in new areas (e.g., Scott County, Indiana). However, to our knowledge, trends over time in HIV prevalence among PWID in US metropolitan statistical areas (MSAs) across all major regions of the country have not been systematically estimated beyond 2002, and the extent to which HIV prevalence may be increasing in other areas is largely unknown. This article estimates HIV prevalence among PWID in 89 of the most populated US MSAs, both overall and by geographic region, using more recent surveillance and HIV testing data.Methods: We computed MSA-specific annual estimates of HIV prevalence (both diagnosed and undiagnosed infections) among PWID for these 89 MSAs, for 1992-2013, using several data series from the Centers for Disease Control and Prevention's (CDC) National HIV Surveillance System and National HIV Prevention Monitoring and Evaluation data; Holmberg's (1997) estimates of 1992 PWID population size and of HIV prevalence and incidence among PWID; and research estimates from published literature using 1992-2013 data. A mixed effects model, with time nested within MSAs, was used to regress the literature review estimates on all of the other data series. Multiple imputation was used to address missing data. Resulting estimates were validated using previous 1992-2002 estimates of HIV prevalence and data on antiretroviral (ARV) prescription volumes and examined for patterns based on geographic region, numbers of people tested for HIV, and baseline HIV prevalence.Results: Mean (across all MSAs) trends over time suggested decreases through 2002 (from approximately 11.4% in 1992 to 9.2% in 2002), followed by a period of stability, and steep increases after 2010 (to 10.6% in 2013). Validation analyses found a moderate positive correlation between our estimates and ARV prescription volumes (r = 0.45), and a very strong positive correlation (r = 0.94) between our estimates and previous estimates by Tempalski et al. (2009) for 1992-2002 (which used different methods). Analysis by region and baseline prevalence suggested that mean increases in later years were largely driven by MSAs in the Western United States and by MSAs in the Midwest that had low baseline prevalence. Our estimates suggest that prevalence decreased across all years in the Eastern United States. These trends were particularly clear when MSAs with very low numbers of people tested for HIV were removed from analyses to reduce unexplained variability in mean trajectories.Conclusions: Our estimates suggest a fairly large degree of variation in 1992-2013 trajectories of PWID HIV prevalence among 89 US MSAs, particularly by geographic region. They suggest that public health responses in many MSAs (particularly those with larger HIV prevalence among PWID in the early 1990s) were sufficient to decrease or maintain HIV prevalence over time. However, future research should investigate potential factors driving the estimated increase in prevalence after 2002 MSAs in the West and Midwest. These findings have potentially important implications for program and/or policy decisions, but estimates for MSAs with low HIV testing denominators should be interpreted with caution and verified locally before planning action. [ABSTRACT FROM AUTHOR]

Background: Substantial racial/ethnic disparities exist in HIV infection among people who inject drugs (PWID) in many countries. To strengthen efforts to understand the causes of disparities in HIV-related outcomes and eliminate them, we expand the "Risk Environment Model" to encompass the construct "racialized risk environments," and investigate whether PWID risk environments in the United States are racialized. Specifically, we investigate whether black and Latino PWID are more likely than white PWID to live in places that create vulnerability to adverse HIV-related outcomes.Methods: As part of the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance, 9170 PWID were sampled from 19 metropolitan statistical areas (MSAs) in 2009. Self-reported data were used to ascertain PWID race/ethnicity. Using Census data and other administrative sources, we characterized features of PWID risk environments at four geographic scales (i.e., ZIP codes, counties, MSAs, and states). Means for each feature of the risk environment were computed for each racial/ethnic group of PWID, and were compared across racial/ethnic groups.Results: Almost universally across measures, black PWID were more likely than white PWID to live in environments associated with vulnerability to adverse HIV-related outcomes. Compared to white PWID, black PWID lived in ZIP codes with higher poverty rates and worse spatial access to substance abuse treatment and in counties with higher violent crime rates. Black PWID were less likely to live in states with laws facilitating sterile syringe access (e.g., laws permitting over-the-counter syringe sales). Latino/white differences in risk environments emerged at the MSA level (e.g., Latino PWID lived in MSAs with higher drug-related arrest rates).Conclusion: PWID risk environments in the US are racialized. Future research should explore the implications of this racialization for racial/ethnic disparities in HIV-related outcomes, using appropriate methods. [ABSTRACT FROM AUTHOR]

In the United States, people who inject drugs continue to be at greatly increased risk of HIV infection. To estimate the effectiveness of various prevention scenarios, we modeled HIV transmission in a dynamic network of drug users and people who did not use drugs that was based on the New York Metropolitan Statistical Area population. We compared the projected HIV incidence in 2020 and 2040 if current approaches continue to be used to the incidence if one or more of the following hypothetical interventions were applied: increased HIV testing, improved access to substance abuse treatment, increased use of needle and syringe programs, scaled-up treatment as prevention, and a "high impact" combination scenario, consisting of all of the strategies listed above. No strategy completely eliminated HIV transmission. The high-impact combination strategy produced the largest decrease in HIV incidence-a 62 percent reduction compared to the status quo. Our results suggest that increased resources for and investments in multiple HIV prevention approaches will be required to eliminate HIV transmission among people who inject drugs. [ABSTRACT FROM AUTHOR]

Background: The 2008 Recession was a global event that led to funding cuts for programs and services in the United States; though this recession officially ended in 2009, its aftershocks continued through 2012. We evaluated the relationship between the severity of the Great Recession's aftermath and spatial access to combined prevention services (i.e. HIV testing, syringe service programs, substance use disorder treatment program) for people who inject drugs (PWID) living in 19 metropolitan statistical areas (MSAs) in the United States.Methods: The unit of analysis was the ZIP code; we sampled ZIP codes in these 19 MSAs where ≥1 PWID lived in 2009 and 2012, according to the CDC's National HIV Behavioral Surveillance. We used administrative data to describe the combined prevention environment (i.e., spatial access to HIV testing) for each ZIP code, and measured the severity of the recession's aftermath in each ZIP code, and in the counties and MSAs where these ZIP codes were located. Multilevel modeling estimated associations between changes in the aftermath of the Great Recession and ZIP code-level changes in spatial access to combined prevention services from 2009 to 2012.Results: 675 ZIP codes located in 36 counties and 19 MSAs were included in this analysis. From 2009 to 2012, 21% of ZIP code areas lost access to combined prevention services and 14% gained access. ZIP codes with higher poverty rates relative to their respective MSAs were less likely to lose access (aOR: 0.91; 95% CI: 0.88, 0.95) and more likely to gain access (aOR: 1.05; 95% CI: 1.01, 1.09); there is some evidence to suggest the former association was attenuated for ZIP codes with higher percentages of non-Hispanic white residents.Conclusion: Combined prevention services for PWID living in these 675 ZIP codes demonstrated resilience in the aftermath of the Great Recession. Future research should explore whether community-based and federal HIV prevention initiatives contributed to this resilience, particularly in areas with higher concentrations of people of color. [ABSTRACT FROM AUTHOR]