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1.  Conducting Peer Outreach to Migrants: Outcomes for Drug Treatment Patients 
Peer outreach models have been successful in addressing HIV risk behaviors of drug users. Patients in methadone maintenance treatment programs who were migrants from Puerto Rico and/or familiar with drug use there were trained to conduct HIV-related peer outreach. A group randomized design was implemented; patients in the Experimental (E) condition (n = 80) received training and conducted 12 weeks of outreach. Half of the patients completed the training and outreach. At follow-up, patients in the E condition who conducted outreach felt they were more helpful to their community, showed a trend for engaging in more vocational activities, and were more likely to talk with others about HIV, compared to those who did not conduct outreach and those in the Control condition (n = 78). Drug treatment patients who are migrants can be trained as peer outreach workers and short-term benefits were found. Longer term maintenance of benefits should be assessed.
PMCID: PMC3178661  PMID: 21479888
Methadone maintenance patients; Peer outreach; Drug users; Migrants; HIV risk; Puerto Rico
2.  Attitudes of Methadone Program Staff toward Provision of Harm Reduction and Other Services 
Journal of addiction medicine  2011;5(4):289-292.
The need for expansion of health services provided in drug treatment programs has been widely discussed since the beginning of the HIV epidemic among drug users. Service expansion has focused on various types of services including medical services (e.g., primary care) and harm reduction services (e.g., provision of sterile syringes).
A staff survey was conducted in eight methadone maintenance clinics in the New York/New Jersey area to assess attitudes towards the provision of harm reduction and other services in methadone clinics, and the relationship of these attitudes to other variables.
A total of 114 staff members in eight methadone maintenance clinics completed the survey.
The majority of staff was supportive of adding services, over 90% supported medical services, and the majority supported harm reduction services such as syringe access and disposal services. Higher education and HIV knowledge levels were significant correlates of favorable attitudes toward service provision.
Support for providing harm reduction services in methadone maintenance clinics was found. Enhancing knowledge of staff regarding various types of health services, and engaging them in how best to institute new services, should be undertaken when new services are planned.
PMCID: PMC3223376  PMID: 22107879
methadone maintenance; HIV; harm reduction; health services
3.  Factors mediating and moderating the relationship between gender and utilization of health care among Puerto Rican drug users in New York 
Drug and alcohol dependence  2009;102(1-3):138-143.
This study examined factors that mediate and moderate the relationship between gender and utilization of mental health and medical services in the past year among Puerto Rican drug users (308 females; 892 males) recruited in New York City. Experience of sexual or physical abuse, injection drug use, relationship variables (e.g., having a sexual partner who is an injection drug user), and serious or chronic mental/medical conditions were used as potential mediators and moderators. Both sexual and physical abuse mediated gender effects on use of mental health services. Having chronic medical problems mediated the relationship between gender and utilization of medical and mental health services. Significant interaction effects of gender by depression, physical abuse, and HIV sero-status on utilization of medical services were found. Health (particularly mental health) care was under-utilized by both women and men, despite high rates of depression and chronic medical conditions. The finding of under-use of medical services by HIV-positive drug users (particularly by HIV-positive women) indicates a need for further efforts to engage all HIV-positive persons in care. The findings also indicate an on-going need for mental and other health services for drug users who have been victims of abuse.
PMCID: PMC2674114  PMID: 19369013
Utilization of health care; Gender; Puerto Rican drug users
4.  Training Drug Treatment Patients to Conduct Peer-Based HIV Outreach: An Ethnographic Perspective on Peers' Experiences 
Substance use & misuse  2010;45(3):414-436.
From 2005 to 2008, the Bienvenidos Project trained Puerto Rican patients of New York City and New Jersey methadone maintenance treatment programs to conduct peer-based community outreach to migrant Puerto Rican drug users to reduce migrants' HIV risk behaviors. Ethnographic research, including focus groups, individual interviews and observations, was conducted with a subset of the patients trained as peers (n=49; 67% male; mean age 40.3 years) to evaluate the self-perceived effects of the intervention. Results of the ethnographic component of this study are summarized. The role of ethnographic methods in implementing and evaluating this kind of intervention is also discussed.
PMCID: PMC2841030  PMID: 20141456
peer outreach; HIV prevention; methadone maintenance treatment; ethnography; qualitative evaluation; intervention evaluation
5.  The Puerto Rico–New York Airbridge for Drug Users: Description and Relationship to HIV Risk Behaviors 
Journal of Urban Health   2007;84(2):243-254.
This study examined mobility on the airbridge between New York (NY) and Puerto Rico (PR) for Puerto Rican drug users and its relationship to HIV risk. Over 1,200 Puerto Rican injection drug users (IDUs) and crack smokers were recruited by outreach workers in NY and PR; interview data included questions on mobility (lifetime residences and recent trips). Two-thirds of the NY sample had lived in PR; one-quarter of the PR sample had lived in NY; the most commonly sited reasons for moving were family-related. Fewer than 10% had visited the other location in the prior 3 years. Variables related to risk were number of moves, recent travel, and having used drugs in PR (all with p < 0.05). Implications included the need to enhance risk reduction efforts for IDUs in PR and address sexual risk among mobile drug users.
PMCID: PMC2231641  PMID: 17216570
HIV risk; Injection drug users; Mobility; New York; Puerto Rican
6.  A Comparative Study of Mortality Among Puerto Rican Injection Drug Users in East Harlem, New York, and Bayamon, Puerto Rico 
Drug users have been found to be at high risk of mortality but the mortality experience of Hispanic drug users remains understudied. This study assessed mortality among Puerto Rican injection drug users (IDUs) in New York City (NY), and in Puerto Rico (PR). Study subjects were 637 IDUs from NY and 319 IDUs from PR. Mortality was ascertained using data from the National Death Index. Annual mortality rate of the NY cohort was 1.3 per 100 person years compared to the PR cohort with a rate of 4.8. Compared to the Hispanic population of New York City, the standardized mortality ratio (SMR) of the NY cohort was 4.4. Compared to the population of Puerto Rico, the SMR of the PR cohort was 16.2. The four principal causes of death were: NY—HIV/AIDS (50.0%), drug overdoses (13.3%), cardiovascular conditions (13.3%), and pulmonary conditions (10.0%); PR—HIV/AIDS (37.0%), drug overdoses (24.1%), sepsis (13.0%), and homicide (11.1%). Modeling time to death using Cox proportional hazards regression, the relative risk of mortality of the PR cohort as compared to the NY cohort was 9.2. The other covariates found to be significantly associated with time to death were age, gender, education, social isolation, intoxication with alcohol, and HIV seropositivity. The large disparity in mortality rates found in this study suggests that health disparities research should be expanded to identify intra-group disparities. Furthermore, these results point to an urgent need to reduce excess mortality among IDUs in Puerto Rico.
PMCID: PMC3261282  PMID: 16977494
Injection drug users; Mortality; New York City; Puerto Rico.
8.  Research challenges to the study of HIV/AIDS among migrant and immigrant hispanic populations in the united states 
Migrant populations have been found to be at risk of HIV/AIDS. The growth in immigrant and migrant Hispanic populations in the United States increases the need to enhance understanding of influences on their HIV-risk behaviors. Four challenges to conducting research among these populations were identified: (1) the need to use multilevel theoretical frameworks; (2) the need to differentiate between Hispanic subgroups; (3) challenges to recruitment and data collection;, and (4) ethical issues. This article describes how two studies of Hispanic immigrants and migrants in the New York area addressed these challenges. One study focused on new immigrants from Mexico, the Dominican Republic, El Salvador, Honduras and Guatemale, and a second study focused on Puerto Rican drug users. Both studies incorporated qualitative and quantitative methods to study these hard-to-reach populations. Continued study of the sociocultural and contextual factors affecting HIV risk for mobile populations, and addressing the research challenges, is crucial to developing effective intervention programs.
PMCID: PMC3455897  PMID: 15933327
Hispanics; HIV/AIDS; Immigrants; Migrants
9.  Impact of the September 11th attacks in New York City on drug users: a preliminary assessment 
An exploratory assessment of the impact of the September 11th attacks in New York City on drug users, including their perceptions of changes in drug use, drug availability, police activities, and access to services, was undertaken. Methods included focus groups with drug users and acquired immunodeficiency syndrome (AIDS) outreach worker supervisors and surveys of service providers. Results indicated that, while there was some immediate concern about the potential impact on drug availability, there was no perceived scarcity, although some drug users did report a decrease in drug purity. Responses included increased use of drugs and increased demand for drug treatment. The wide range of responses indicates that continued monitoring of the impact may be needed to assess long-term effects.
PMCID: PMC3456780  PMID: 12200510
10.  Trends in the AIDS epidemic among New York City’s injection drug users: Localized or citywide? 
The New York City injection drug user acquired immunodeficiency syndrome (IDU AIDS)epidemic accounts for almost one quarter of AIDS cases in IDUs in the United States. Recent studies have reported declines in seroprevalence and risk behaviors among IDUs in New York City during the 1990s. These trends, however, are based on studies primarily conducted in the city’s central borough of Manhattan. This article analyzes data from all five boroughs of New York City to examine trends over phases of the epidemic and to determine the level of prevention services available; an exploratory qualitative study was also conducted to assess access to prevention services and injection practices in areas in the “outer boroughs”. Findings indicated that (1)borough differences in services and behaviors existed from early in the epidemic; (2)services have been concentrated in Manhattan; and (3)declines in seroprevalence were greatest among Manhattan-recruited IDUs. Enhancing access to services for IDUs in the boroughs outside Manhattan may be needed to continue the positive trends in all areas of New York City.
PMCID: PMC3456374  PMID: 11937622
11.  Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis 
Objective To quantify the effect of opiate substitution treatment in relation to HIV transmission among people who inject drugs.
Design Systematic review and meta-analysis of prospective published and unpublished observational studies.
Data sources Search of Medline, Embase, PsychINFO, and the Cochrane Library from the earliest year to 2011 without language restriction.
Review methods We selected studies that directly assessed the impact of opiate substitution treatment in relation to incidence of HIV and studies that assessed incidence of HIV in people who inject drugs and that might have collected data regarding exposure to opiate substitution treatment but not have reported it. Authors of these studies were contacted. Data were extracted by two reviewers and pooled in a meta-analysis with a random effects model.
Results Twelve published studies that examined the impact of opiate substitution treatment on HIV transmission met criteria for inclusion, and unpublished data were obtained from three additional studies. All included studies examined methadone maintenance treatment. Data from nine of these studies could be pooled, including 819 incident HIV infections over 23 608 person years of follow-up. Opiate substitution treatment was associated with a 54% reduction in risk of HIV infection among people who inject drugs (rate ratio 0.46, 95% confidence interval 0.32 to 0.67; P<0.001). There was evidence of heterogeneity between studies (I2=60%, χ2=20.12, P=0.010), which could not be explained by geographical region, site of recruitment, or the provision of incentives. There was weak evidence for greater benefit associated with longer duration of exposure to opiate substitution treatment.
Conclusion Opiate substitution treatment provided as maintenance therapy is associated with a reduction in the risk of HIV infection among people who inject drugs. These findings, however, could reflect comparatively high levels of motivation to change behaviour and reduce injecting risk behaviour among people who inject drugs who are receiving opiate substitution treatment.
PMCID: PMC3489107  PMID: 23038795

Results 1-11 (11)