Richard Garfein, Ph.D., M.P.H., of UC San Diego Department of Medicine, presents "HIV, HCV, and TB Infection among Injection Drug Users in San Diego" at AIDS Clinical Rounds

1. Richard S. Garfein, PhD
Professor
Division of Global Public Health
UCSD School of Medicine
(April 11, 2014)

2. Objectives
 Describe the harms of injection drug use
 Describe an ongoing cohort study of injection drug
users (IDUs) in San Diego
 Share preliminary findings from the study

3. Why talk about injection drug use?
 Health impacts
 HIV/AIDS
 HCV, HBV
 Other STDs
 Bacterial infections
 Tuberculosis
 Overdose
 Social impacts
 Economic costs
 Medical care
 Law enforcement
 Lost productivity
 Crime
 Lost potential

4. Source: UNODC 2013.

5. UNODC and Reference Group to the United Nations on HIV and Injecting Drug Use.

6. Prevalence of HIV among IDUs
Source: Mathers et al., 2008

8. Nature Medicine 19, 850–858 (2013)
Global Prevalence of HCV

9. Lancet. 2011 Aug 13;378(9791):571-83. Jul 27.
Prevalence of HCV among IDUs

10. CIDUS II - HIV, HBV, and HCV Seroprevalence
among 18-30 Year Old IDUs
City
0
10
20
30
40
50
60
70
80
90
100
Prevalence(%)
HCV
HBV
HIV
Garfein, et al.

11. CIDUS II - Prevalence and Incidence of
Viral Infections among 18-30 y.o. IDUs
Prevalence Incidence
N (% pos) N # pos
Rate
/100 PY 95% CI
HIV 2,181 ( 4.7) 1,050 12 1.3 ( 0.6 - 2.0)
HBV 2,071 (22.2) 800 76 11.3 ( 8.9 -13.7)
HCV 2,074 (36.2) 673 83 15.6 (12.6-18.6)
Garfein, et al.

12. Thomas, et al, Nature Medicine 19, 850–858 (2013)

13. HCV Infection Prevalence by Frequency of
Selected Groups in the US Population
Hemophilia
patients
0 5 10 15 20 80 90 100
Percentage
Injection
Drug Users
Dialysis
patients
STD
patients
Healthcare
workers
General
population
HCV
Group
Group
Volunteer
Blood Donors

14. Injection Preparation Table, Pakistan

15. Carefully open sterile water, dissolve medication in sterile vial, fill syringe.

16. Avoid using multidose vials.

17. Clean patient’s skin, inject into anticubital vein, safely discard syringe.

18. Importance of HIV and TB
 Among individuals with latent TB infection (LTBI), the
LIFETIME risk of reactivation is 5%-10%
 Among HIV infected individuals with LTBI, the risk
reactivation is 10% PER YEAR
 TB is a leading cause of death among AIDS patients
worldwide

20. Reported TB Cases, United States, 1982–2009
1985-1992
Resurgence
11,545 cases reported
nationwide in 2009

21. CA
AZ
NM
TX
SON
CHI
COH
TAM
NL
B.C.
NATIONAL
BORDER
Cases
13,142
4,180
Rate*
4.2
6.8
NATIONAL
BORDER
Cases
15,649
4,290
Rate*
14.1
25.7
* Rate = cases per 100,000 population
26.4
17.1
16.5
31.9
40.5
19.9
7.0
3.5
3.0
6.2
Adapted from: Schneider E, et al. Rev Panam Salud Publica. 2004;16(1):23–34.
Mexico and U.S. Tuberculosis Incidence Rates*
By State
San Diego: 8.4
Tijuana: 46.1
CDC, 2008; CDPH, 2008; DGEPI Mexico, 2008; INEGI, 2005; SINAVE, 2007.

22. Seroprevalence among IDUs in
the US/Mexico Border Region
San Diego Tijuana
HIV 4.2%a 4%-10%b
HCV 26.9%a 96%c
Mtb 14.6%d 67%e
a Garfein, et al. J Urban Health. 2013 Jun;90(3):516-28.
b Strathdee, et al. Lancet 2010; 376(9737):268-284
c White, et al., Salud Publica Mex. 2007 May–Jun; 49(3): 165–172
d Among HIV+ IDU, UCSD CFAR 2010
e Garfein, et al. Emerg Infect Dis, 2010 May

23. New Mexican Drug Law
 Aug. 2009 – Mexico passed a law decriminalizing
possession of “personal size” quantities of illicit
drugs
 First two offenses  optional drug treatment
 Third offence  mandatory drug treatment or jail

24. STAHR II: Study of TB, AIDS,
and Hepatitis C Risk
 Design: Longitudinal, mixed-methods, cohort study
 Dates: August 2011 - May 2016
 Study Locations:
 San Diego County
 Hillcrest storefront
 Mobile unit parked in National City and Escondido
 Mobile unit parked at venues around county

25. STAHR II: Specific Aims
 Aim 1: To identify sociodemographic, behavioral, and
health status differences between IDUs in San Diego
who do and do not inject in Mexico.
 Aim 2: To describe changes in San Diegan IDUs’
knowledge, attitudes, and experiences related to drug
policy reforms in Mexico and assess their influences on
decisions about injecting in Mexico.
 Aim 3: To determine whether IDUs from San Diego who
inject in Mexico are at increased risk for incident HCV
and Mtb infection compared to IDUs who do not inject in
Mexico and identify risk factors for infection.

26. STAHR II: Eligibility Criteria
• >18 years old
• Speaks English or Spanish
• San Diego resident planning to stay >24 months
• Injected within the last 30 days
• Agrees to provide contact information
• Agrees to a blood draw for HIV, HCV and Mtb
testing

27. Recruitment
 Street outreach
 Targeted advertising
 Community referrals
 Magazine ads
 Mobile Unit

29. STAHR II Recruitment Sites

30. Procedures
• Eligibility screening (5-10 minutes)
• Obtain written informed consent
• Interviewed about sociodemographics, risk behaviors,
health status, travel to Mexico, knowledge of drug laws
• Serologic testing and counseling for HIV, HCV and Mtb
(QuantiFERON TB Gold [QFT]) infections
• Interviews and serologic testing repeated at 6, 12, 18, and
24 months for those previously tested negative

31. Qualitative Interviews
 Purpose:
 provide insight into the quantitative findings
 explore emerging issues
 inform subsequent rounds of quantitative interviews
 validate interpretations (member checking)
 Occur after each wave of quantitative visits
 N=20 per cycle
 Purposive sampling based on assessment interview
responses (e.g., travel to Mexico)
 Reimbursement: $30

32. Incentives for Participation
 Participants compensated according to the following schedule:
Baseline and 6 Month Assessment: $25
12-month Assessment : $30
18-month Assessment : $35
24-month Assessment : $50
 Plus $10 for result visit after each assessment visit
 Plus $5 for updating their contact information between visits at
3, 9, 15 and 21 months

33. Enrollment June 4, 2012 to January 6, 2014
726 – Screened for eligibility
662 via storefront
64 via mobile unit
579 – Enrolled
40 – Qualitative interviews
STAHR II: Enrollment Status

34. Results: Demographics
 Mean age: 43.4 years (range: 18-70)
 Male: 73%, Transgender: 1.1%
 Race/ethnicity
 Black: 8.8%
 Hispanic: 31%
 White: 51%
 Other: 9.2%
 Born in Mexico: 2.5%
 Ever Homeless: 61%

35. Question 1
What is the prevalence of HIV among IDUs in San
Diego?
1. 0.9%
2. 5.0%
3. 9.5%
4. 12.9%
5. 15.1%

36. HIV+ = 52/545 = 9.5%
HCV+ = 359/545 = 65.9%
QFT+ = 117/500 = 23.4%
Results: Baseline Serostatus

37. Question 2
Is QFT-positivity similar among HIV+ and HIV-
IDUs in San Diego?
1. The same
2. Higher among HIV+
3. Higher among HIV-

38. Results: Co-Infection
HIV+
n (%)
HIV-
n (%)
HCV+ 26 (50.0%) 335 (67.5%)
QFT+ 45 ( 8.2%) 114 (25.6%)
QFT +/- 0 ( 0.0%) 2 ( 0.5%)

39. Results: Travel to Mexico
Ever
Past 6
Months
Traveled to Mexico 87% 28%
Bought drugs in Mexico 50% 19%
Used (not injected) drugs in Mexico 40% 12%
Injected drugs in Mexico 36% 15%

40. Results: Drug Law Differences
in the US
(n=338)
in Mexico
(n=329)
Automatically arrested 266 (78.7%) 86 (26.1%)
Automatically sent to drug treatment 4 ( 1.2%) 3 ( 0.9%)
Given three warnings and then required to
enter drug treatment 14 ( 4.1%) 10 ( 3.0%)
Given three warnings and then sent to jail 12 ( 3.6%) 5 ( 1.5%)
Don't know 42 (12.4%) 225 (68.4%)
What happens if you are caught with drugs for personal use…

41. Question 3
What percentage of IDUs in San Diego have shared a
syringe to inject in the past 6 months?
1. 7%
2. 21%
3. 43%
4. 59%
5. 90%

42. Question 4
Does San Diego have a syringe exchange program?
1. Yes
2. No
3. Don’t know

43. Results: Syringe Source
 Safe sources = syringe exchange program (SEP), pharmacy, clinic
 Unsafe sources = another person, on the street, shooting gallery
 60% any used Safe Sources in past 6 months
 30% reported always injecting with new/sterile syringes
 59% shared a syringe that had been used before.
Factors associated with using safe sources AOR 95% CI
>High school education 1.65 1.08-2.54
Injecting methamphetamine combined with heroin 1.99 1.55-3.44
Aware of the SEP in San Diego 2.65 1.34-5.21
Have own car 3.05 1.76-5.31
Hispanic (ref = white) 0.52 0.33-0.82
Black (ref = white) 0.24 0.11-0.55
Prior police encounters 0.40 0.18-0.84

44. Results: Prefilled Syringe Use
 34% reported ever using prefilled syringes
Factors associated with prefilled syringe use AOR 95% CI
Shared injection paraphernalia in past 6 months 4.45 2.63, 7.53
Ever bought or used drugs in Mexico 1.84 1.24, 2.73
HCV seropositive 1.48 0.99, 2.25

45. Results: Drug Use Class
 Used latent class analysis to examine patterns of drug
use among IDUs
 Classified IDUs based on drug type and route of
administration (injected, smoked, sniffed, swallowed)
 Identified factors associated with class membership
using multivariable logistic regression

46. Results: Drug Use Class
 Class 1 mostly methamphetamine users (multi-route)
 Class 2 mostly heroin by injection
Class 1
51% (SE=0.03)
Class 2
49% (SE = 0.03)
Heroin injecting 28.8% 82.5%
Methamphetamine smoking 71.6% 10.8%
Methamphetamine snorting 34.1% 1.1%
Methamphetamine injecting 81.2% 0.7%
Prescription drug swallowing 15.3% 18.8%
Binge drinking (≥5 drinks in one sitting) 21.9% 19.8%
Marijuana smoking 48.6% 25.4%
Drug/route variables are not mutually exclusive.

47. Results: Drug Use Class (n=431)
Multivariable analysis of factors associated with heroin class membership
AOR* 95% CI p - value
Race/Ethnicity (ref = white) 0.01
Black 3.23 1.53, 6.84
Hispanic 1.84 1.14, 3.01
Other 1.29 0.66, 2.55
Hepatitis C virus Seropositive 2.25 1.37, 3.72 0.01
Ever overdosed on opioids 1.89 1.23, 2.89 <0.001
Age (per 10 year increase) 0.79 0.65, 0.96 0.01
Ever diagnosed with STI (self-report) 0.59 0.38, 0.91 0.02
Homeless, past 6 months 0.42 0.27, 0.65 <0.001
Tested HIV Seropositive 0.17 0.07, 0.44 <0.001
*Ref=Class 1, primarily methamphetamine users multi-routes of administration.
Class 2, primarily heroin injectors.

48. Qualitative Wave 1 Eligibility
• Goal - To describe experiences, attitudes and perceptions of:
1. Drug markets in Mexico & San Diego
2. Safety of traveling to and from Mexico
3. Law enforcement in Mexico & San Diego
4. Drug reform law in Mexico
• Sampling
– Criterion sampling based on two baseline questions:
a. In the last 6 months, have you used drugs while in Mexico (not
injected)? (Y/N)
b. In the last 6 months, have you injected drugs while in Mexico? (Y/N)
– Purposive sampling (e.g., gender, age, race/ethnicity, zip code)
• 4 week window period

49. Qualitative Wave 2 Eligibility
• Goal - Describe behavior changes and decision-making
processes in:
1. Starting travel to Mexico (“Initiators”)
2. Stopping travel to Mexico (“Terminators”)
3. Continuing to travel to Mexico (“Continuers”)
• Sampling:
– Criterion sampling based on comparisons of drug use behavior
in Mexico between Baseline and 6-month Interviews
– All participants meeting criteria were invited to participate
• No Window Period

50. Qualitative Demographics
Wave 1 (n=25)
n (%)
Wave 2 (n=24)
n (%)
Mean Age (range) 37 yrs (21-60 yrs) 46 yrs (23-64 yrs)
Gender (Male) 15 (60%) 22 (92%)
Ethnicity
Hispanic/Latino
Race
Non-Hispanic White
African American/Black
Other
7 (28%)
12 (48%)
4 (16%)
9 (36%)
9 (38%)
14 (58%)
2 ( 8%)
6 (25%)
Country of Origin US 22 (88%) 23 (96%)
Bilingual (Eng & Span) 6 (25%) 9 (39%)
Valid Passport 2 ( 8%) 3 (12%)
Traveled to MX (last 6 months)
Used drugs by injection
Used drugs by other route
18 (72%)
18(100%)
12 (67%)
12 (50%)
7 (58%)
8 (67%)
Initiators
Terminators
Continuers
N/A 5 (21%)
15 (63%)
4 (17%)

51. Qualitative Preliminary Findings
• Motivations to travel to Mexico
“The vacation vibe, the more relaxed setting, the more comfortable, the setting is more
comfortable. It give you more a sense that you there to vacation and relax and have a
good time instead of out here you’re using but you’re on the run, going from place to
place, meeting your friends, picking up money, selling drugs . . .”
Latino Male, Age 36
“Well he told me how much it [methadone dose] costs [in Mexico] and that’s -- $6 every
day, but over here [in San Diego] it’s $25 the first time you go and after that it’s $10 a
day, so it don’t take a rocket scientist ….
African American/Blk female, Age 61
“I started working and started saving up money to get a place and I got my mom and my
brothers and sister over here but I kept going back to see my relative but also to get
you know a little something [drugs]”
Latino Male, Age 31

52. Qualitative Preliminary Findings
• Catering to American IDUs and Drug Use Setting
“Where, where I went to is I got everything I needed right there. . .
I got (chuckles) everything I wanted. I got uh, I got the girl, I got
the dope, I got the needle, I got the room. So then it was like, I
was happy. “
Latino-African American/Blk Male, Age 60
“The places that I had gone, like some of the restaurants, you
know? Um, they would, they would, just bring you everything, they
would bring you whatever you know if you needed foil? Or if you
needed a pipe or you needed a syringe or something, and then
you just go into the bathroom and go handle your business, or you
know, some of the guys they had like little …. like, you know little
like shops with random crap all over the walls, and it’s like all
dusty stuff cause they don’t really sell anything there, (passive
laugh) and they you know, they just have a little back room where
you can go and, go and get high.”
Latino Male, Age 25

53. Qualitative Preliminary Findings
• Knowledge of Mexican Drug Laws
“In between 5 years and now, Mexico came up with an idea that worked.
Alright, the Bush administration was going in. Mexico came up with this
idea, anything under a gram, any kind of dope, heroin, whatever, cocaine,
crack, speed, whatever, under a gram, the Mexican police in Tijuana could
not arrest you and take you to jail. . . . But what it does is that it keeps the
jails open for dangerous criminals, but it keeps the junkies like me go on my
destination. . . .”
Latino-African American/Blk Male, Age 60

54. Qualitative Preliminary Findings
• Policing in Mexico versus US
“ Over here [San Diego] they’ll just throw the cuffs on you, throw you in the jail cell and
wait till you go to court. Over there you go in front of the magistrate of the judge.
He’ll tell you 24 hours, 48 hours, 3 days a week and then you’re gone. Here you’ve
got to wait and go through the whole process. Over there they’ll tell you the same
day. Either you have the fine and you have the money to pay the fine or you’ll have
to do the time.”
Latino Male, Age 36
• Not having a passport is not a barrier
“I don’t have a passport and then I got a criminal record so every time I go I go to
secondary… “
White Male, Age 49
(92% of Wave 1 and 88% of Wave 2 participants did not have a passport)

55. Challenges
• Building rapport with participant
• Establishing trust (overcoming medical distrust)
• Retention among a transient community
• Maintaining the mobile unit
• Mental health of participants

56. Successes
• Building community collaborations
• Established good reputation among IDUs
• Everyone is treated with dignity and respect
• Connecting participants to local services
• Drug treatment
• Counseling
• HIV and health care
• Housing
• Food stamps
• Participants appreciate being heard

57. What is next?
• Finish follow-up interviews by January 2016
• Analyze baseline data
• Analyze follow-up data
• Develop interventions to lower risk among IDUs
• Disseminate findings to participants and the
broader community

58. Contributors
Karla Wagner
Steffanie Strathdee
Peter Davidson
Fatima Muñoz
Lin Liu
Victoria Ojeda
Jose Luis Burgos
Sergio Aguilar-Gaxiola (UCD)
Avelardo Valdez (USC)
Alfredo Velasco (in memorial)
Jazmine Cuevas
Everardo Aguilar
Carlos Vera
Pilar Santamaria
Natasha Ludwig Barron
Richard Armenta
Kelly Collins
SDSU Interns
* This study was funded by the National Institute on Drug Abuse (R01-DA031074)
* Funding also received as gifts from Las Patronas, Rotary Club, and CECO