A total of 514 non-seed IDU were eligible and completed the NYC NHBS study, of whom 26 were foreign-born IDU removed from this analysis, leaving a final analytic sample of 488. As Table shows, the sample was 79% male and 21% female. Fifty-percent were Hispanic (all Puerto Rican IDU in the sample -from the US and from PR- fall within this category), 37% White and 13% Black. The mean age was 40. Two-thirds earned less than $10,000, 62% were homeless, and one-third had been incarcerated in the past year. Two-thirds had unprotected vaginal or anal sex with a heterosexual partner and 22% engaged in this with a casual or exchange partner. Forty-five percent reported binge alcohol use and 66% reported noninjection drug use, with many of those using crack (36%). In terms of risky injection behaviors, 28% reported receptive syringe sharing and 41% shared other injection supplies (cookers, water and cottons) in the past year. Overall, 17% tested positive for HIV and 72% tested positive for HCV.
Sociodemographics, Sexual Risk Factors, Drug Use & Risk, and Disease Outcomes by Puerto Rican Immigration Status, among New York City Injection Drug Users, 2009, n = 488
By migration category, 72% of participants were US-born (36% of whom had PR ancestry), 18% were non-recent PR migrants, and 10% were recent PR migrants. Recent migrants were more likely to be younger (p = 0.03), homeless (p = 0.01), and living in poverty (p < 0.01) in the past year. Recent migrants had significantly higher levels of unprotected sexual intercourse overall (p = 0.01), and specifically of unprotected sexual intercourse with casual/exchange partners (37% vs. 33% for non-recent migrants and 17% for US born, p < 0.01). Noninjection drug use overall (p < 0.01) and specifically noninjection crack use (p < 0.01), was significantly lower among recent migrants. For injection risks, recent migrants were significantly more likely to inject at least daily (p < 0.01) and inject speedball (p < 0.01). With marginal significance, recent migrants were more likely to share syringes (p = 0.08), with a significantly higher number of median sharing partners (p = 0.04). Finally, HIV (31.2%) and HCV (89%) seroprevalence were highest among non-recent PR migrants.
In a subanalysis of recent PR migrants (data not shown), 98% started injecting drugs while still in Puerto Rico (compared with 69% of the non-recent PR migrants). In addition, 67% of recent migrants reported that they moved to NYC to access drug treatment services, compared with 46% of non-recent migrants. Seventy-nine percent were monolingual Spanish speakers.
Table presents factors associated with past-year unprotected sex with a casual/exchange partner and receptive syringe sharing. In bivariate analysis, female IDU, black IDU, and older IDU were all less likely to report unprotected sex with a casual/exchange partner. IDU who were incarcerated in the past year, those who engaged in binge alcohol use, and PR migrants (both recent and non-recent) were all significantly more likely to report this sexual risk. In multiple logistic regression controlling for confounding factors (age and incarceration), both recent migrants (AOR = 2.81; 95% CI = 1.4-5.8) and non-recent migrants (AOR = 2.86; 95% CI = 1.6-5.0) were significantly more likely than US-born IDU to engage in unprotected sex with a casual/exchange partner.
Factors Associated with Past Year Unprotected Sex with a Casual/Exchange Partner and Past Year Receptive Syringe Sharing, among New York City Injection Drug Users, 2009, n = 488
In bivariate analysis, receptive syringe sharing was significantly more likely among female, White or Hispanic, and younger IDU. Syringe sharing was also significantly higher among noninjection crack users and recent PR migrants. In multiple logistic regression controlling for confounding factors (age and noninjection crack use), both recent migrants (AOR = 2.44; 95% CI = 1.2-5.0) and non-recent migrants (AOR = 1.86; 95% CI = 1.04-3.31) were significantly more likely than US-born IDU to share syringes. Noninjection crack use was also significantly associated with syringe sharing (AOR = 3.01; 95% CI = 2.0-4.7).
In qualitative ethnographic research, 61 participants were interviewed in 6 focus groups (8 participants per focus group), 11 individual community key informants (IDU) and 2 key informants (community experts). Of the 61, 12 were recent PR migrants included in this analysis. Eight of these were part of a focus group held with recent PR migrants and 4 more were individually interviewed. At the time of the ethnographic research, most were homeless and living on the street, while others were living in transitional housing institutions (so-called "three-quarter houses"). All were males aged 20 to 43 years old and living in the Bronx. Most participants knew each other, but had met for the first time in NYC. All were monolingual Spanish speakers who had migrated to NYC through faith-based drug treatment programs. All qualitative data collection was carried out in Spanish. All 12 were also recruited into the main survey.
Migration was the first and most heated topic in the focus group. Anger and frustration were palpable in their narratives of moving to the US to attend drug treatment programs. They explained that mayors of several municipalities in Puerto Rico, special police programs and many Pentecostal ministers assist IDU families (and individuals) financially to enroll PR IDU in "drug treatment programs" in NYC. One participant also mentioned that staff at correctional facilities in Puerto Rico sometimes assists the IDU migration process. Other major cities of the US Eastern seaboard were also mentioned as migration destinations for many PR IDU (including Boston and Philadelphia). Once in NYC, many reported being picked up at the airport by Pentecostal ministers or by their church staff.
While in Puerto Rico, they were not made aware that the programs they were volunteering to join were faith-based. One key informant explained, "Before migrating, I was offered drug treatment and a job, a chance to get out of trouble. That's why I came here." Upon arrival, many found themselves enrolled in programs that did not fulfill these expectations. They explained that these programs are a "scam." They complained about the conditions of these facilities and the religious focus of the programs, including "mandated morning praying routines," "bedbugs," "sleeping on church floors," "overcrowding," "the abstinence-only model," and "charging their Medicaid cards for services they never receive." All of the participants had dropped out of these programs by the time of the interview. In fact, most participants reported dropping out of these programs within 3 months of enrollment. Because housing was offered as part of treatment, homelessness followed.
Reasons behind risky sexual behaviors
Most participants were very open about their sexual risks and drug use. Among other things, heterosexual risk was explained in terms of recurring monetary needs (usually to get drugs), getting temporary shelter, and unexpected sexual encounters while using drugs (especially speedball). While all participants admitted they rarely (if ever) used condoms while in Puerto Rico, they also view their current poor material conditions as limiting their ability to refrain from engaging in unprotected sex with casual/exchange partners.
In a key informant interview, a former Bronx-based syringe exchange program employee and a social psychologist who studies PR IDU migration to NYC said that "homeless IDU who have recently migrated from Puerto Rico find people in these programs [syringe exchange programs and other community based organizations] that have housing." Some recent PR IDU migrants who are homeless find themselves in a situation where they may have little choice but to engage in a potentially risky sexual situation in order to avoid (even if temporarily) homelessness. In the focus group, some explained sometimes this is the only way to get shelter.
While lack of condom use might be partly explained by the deeply rooted "macho" sexual identities characteristic of many Hispanic cultures, it is also related to precarious material circumstances that prevent them from using condoms. Sex work patrons often pay more for unprotected sex. Some also mentioned that "speedball" has a twofold effect: (1) it increases their desire to have sex, while (2) it constrains them from using condoms. They report condoms limit the desired sexual sensation already compromised by the pharmacological effects of the drug combination ("speedball"). Craving drugs, being high on drugs, lack of money and homelessness are some of the reasons for unprotected exchange/casual partnerships.
Reasons behind risky injection
Participants also suggested that syringe sharing behaviors have different justifications, explaining that a certain "mentality" developed while injecting drugs in Puerto Rico. "Trust" is also one of the primary reasons for their current sharing of injection supplies. "These are my brothers here," one of the focus group participants asserted, "I'll do anything for them and I know they would do anything for me." For them, "brothers" ("hermanos") are those who also come from Puerto Rico, share the same drug-using norms practiced in Puerto Rico and are immersed in similar material circumstances (homelessness, "three-quarter house" transitional housing, and "faith-based" program drop-outs). The IDU-specific language normally used (i.e., "manteca" (literally, "lard", but here the most common slang term for heroin among this population), "droga" (literally, "drug" but exclusively signified as heroin by this population), "la cura" ("the cure" (for heroin withdrawal)) is another commonality that helps unify them as a group. They will give away their last sterile syringe to their peers in the same way they will share their syringes between them, or share drugs with a peer who is "sick". There is a clear familial bonding in this population. Their treatment of each other displays love, trust, and a deeply rooted connection.
Yet it also seemed that sharing injection supplies is "second nature" among these individuals, an unquestioned, and perhaps unconscious, habit. For instance, while discussing the dangers of injecting in the neck (i.e., hitting an artery could cause a stroke; hitting a nerve can be extremely painful), a focus group participant explained that "this is how I learned to do this", as he held his breath making the veins of his neck swell. Every day, he injects in the neck without any need for assistance, although this is generally considered by IDU to be a risky practice that usually is facilitated by another injector. This risk-taking behavior seemed to follow a natural flow. This participant, appearing almost as if unaware of the risks, continued "It's the best hit", while his peers' body language silently agreed. This is an example of what participants meant when they spoke of a certain "mentality".
For instance, after the ethnographer's questions around continued syringe sharing despite access to free and sterile needles, one recent PR migrant IDU who we interviewed individually as a community key informant explained,
Participant: Because that's the way of doing things in the street [in Puerto Rico]. Since there are no places to exchange syringes, then... that's how it is, you use it first and then I use it.
Interviewer: Even though you have access now? Is this some kind of rule that you bring to here with you?
Participant: "Over there the mentality is different. That's just the way it is. We could take 40 "ganchos" (literally, "pins"; here a slang term for syringes) on Friday, for Saturday and Sunday. But we don't. Nobody does. And then on Saturdays and Sundays they take them from over there, from the shooting [pointing at the "shooting gallery" [injection location] across the street from where we were sitting]. It's just the way it is.
Aside from this PR IDU-specific "mentality", he also mentioned that "being homeless" and feeling "lonely" [in the new setting] may trigger in some a sense of "carelessness", almost as if their lives cannot get any worse than it already has. He used the term "estorbo público" (a public nuisance) to refer to himself. After living in NYC for the past 3 years, he is yet to find structural stability, learn English and to change his PR IDU "mentality". He is 43 years old and runs what seems to be a "temporary" "shooting gallery" (where he also sleeps) located in an abandoned building in the South Bronx. He has a $200/day "speedball" habit that he supports by selling heroin and cocaine. Most (if not all) of his "shooting gallery" patrons and clients are also recently migrated PR IDU. We asked him about the overall makeup of his drug users' network, to which he replied "All injectors from Puerto Rico. These people are abusive over here. The hang-out scene is different here. In Puerto Rico, we didn't allow certain things. We had rules. Over here, a 'snitch' can cop and sell drugs. You don't see that over there." We asked him if that was the reason why he didn't hang out with other PR IDU born in the United States (and usually bilingual) to which he replied affirmatively.
Quasi-familial bonding develops quickly among migrant PR IDU in NYC, because there is a sense of threat to their drug user identity (and their safety) by other street drug users who are unfamiliar with the "Puerto Rican way". The fact that most are Spanish monolingual, homeless IDU converging in NYC allows for this array of signs (e.g. - homelessness, monolingual Spanish, IDU from PR, etc) to be read as family-like and involving bonds of "brotherhood"; trust emerges from this because their everyday struggles in their new setting are very similar.
A focus group participant confirmed part of what the above participant said about risk during weekends. For him, part of the problem is that he gives away his sterile syringes, "especially during the weekends, because nobody has any on them". He also explained that some of his IDU peers are staying in "three-quarter houses", where they cannot have syringes or they will be ejected and will face homelessness again. Other group participants mentioned police harassment around syringe exchange programs and being scared of "syringe arrests" as some of the reasons for not carrying extra syringes on them.
Perceptions of HIV and HCV risks
Upon probing around the risks for HIV and HCV, some said they were "already HCV positive". Although they are "scared" of HIV, trust in their "brothers'" HIV-negative self-reports is apparent. Their trust in their peers, combined with the typical "you don't think of that when you're sick" (which in their case happens often), provide for a powerful mix of social forces that set the stage for continued syringe sharing within this group. Despite ample access to free and sterile injection supplies in NYC, sharing paraphernalia is mostly an action informed by habits, trust and material constraints. Although most met for the first time in NYC, they quickly developed trusting relationships based on shared island-specific drug culture norms, drug injection habits and shared current material conditions (e.g., homelessness and poverty). It is also possible that these "brotherhood" sentiments are a way for these individuals to recreate their own Puerto Rico in a new setting that has proven to be hostile and non-trusting.