Injection Practices and Sexual Behaviors Among Persons With Diagnosed HIV Infection Who Inject Drugs — United States, 2015–2017

Sharoda Dasgupta, PhD; Yunfeng Tie, PhD; Ansley Lemons, MPH; Kathleen Wu, MPH; Janet Burnett, MPH; R. Luke Shouse, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(30):653-657. 

In This Article

Introduction

During 2016, 6% of persons in the United States who received a diagnosis of human immunodeficiency virus (HIV) infection had their HIV infection attributed to injection drug use.[1] Injection practices and sexual behaviors among HIV-positive persons who inject drugs, such as injection equipment sharing and condomless sex, can increase HIV transmission risk; nationally representative estimates of the prevalences of these behaviors are lacking. The Medical Monitoring Project (MMP) is an annual, cross-sectional survey that reports nationally representative estimates of clinical and behavioral characteristics among U.S. adults with diagnosed HIV.[2] CDC used MMP data to assess high-risk injection practices and sexual behaviors among HIV-positive persons who injected drugs during the preceding 12 months and compared their HIV transmission risk behaviors with those of HIV-positive persons who did not inject drugs. During 2015–2017, approximately 10% (weighted percentage estimate) of HIV-positive persons who injected drugs engaged in distributive injection equipment sharing (giving used equipment to another person for use); nonsterile syringe acquisition and unsafe disposal methods were common. Overall, among HIV-positive persons who injected drugs, 80% received no treatment, and 57% self-reported needing drug or alcohol treatment. Compared with HIV-positive persons who did not inject drugs, those who injected drugs were more likely to have a detectable viral load (48% versus 35%; p = 0.008) and engage in high-risk sexual behaviors (p<0.001). Focusing on interventions that reduce high-risk injection practices and sexual behaviors and increase rates of viral suppression might decrease HIV transmission risk among HIV-positive persons who inject drugs. Successful substance use treatment could also lower risk for transmission and overdose through reduced injection.

MMP uses a two-stage sampling method. In the first stage, 23 jurisdictions are sampled from all U.S. states, the District of Columbia, and Puerto Rico. Next, simple random samples of adults with diagnosed HIV infection from sampled jurisdictions are selected from the National HIV Surveillance System, a census of persons with diagnosed HIV infection.[1] During June 2015–May 2017, face-to-face or telephone interviews were conducted with participants, during which demographic characteristics, injection practices and sexual behaviors, and need for, and receipt of, medical services were assessed for the preceding 12 months. Response rates for 2 cycle years of data were 100% (jurisdictions) and 40%–44% (adults with diagnosed HIV infection).

Among HIV-positive persons who injected drugs, behaviors during the preceding 12 months were self-reported. Injection practices included distributive sharing of syringes and other injection equipment,* injection before or during sex, and methods for injection syringe acquisition and disposal. Participants self-reported need for, and receipt of, alcohol or drug treatment. Persons who reported receiving, or not receiving but needing, drug or alcohol treatment were considered to have a need for this service. Enrollment in a medication-assisted treatment program for opioid use disorder was also assessed. Sexual behaviors were assessed, including 1) condomless sex; 2) exchange of sex for money or goods; and 3) a dichotomous measure indicative of high risk for sexual HIV transmission (defined as having one or more detectable viral loads in the past 12 months and having high-risk sex). High-risk sex was defined as condomless sex with an HIV-negative partner or a partner whose HIV status was unknown and who was not known to be on preexposure prophylaxis (PrEP). Viral loads from the preceding 12 months were abstracted from medical records.

Weighted percentages of characteristics with corresponding 95% confidence intervals (CIs) were reported to account for complex survey design using standard methodology.[2] Rao-Scott chi-square tests were used to compare characteristics associated with a high risk for sexual HIV transmission between HIV-positive persons who injected drugs (233) and those who did not inject drugs (7,397); p< 0.05 indicated statistical significance. All analyses were conducted using SAS (version 9.4; SAS Institute).

An estimated 3% (95% CI = 2%–3%) of persons with diagnosed HIV infection injected drugs in the preceding 12 months. Among HIV-positive persons who injected drugs, 11% engaged in distributive sharing of syringes, and 10% engaged in distributive sharing of other injection equipment; 61% injected before or during sex (Table). Common sources of injection syringes included a pharmacy or drug store (63%); a friend, relative, or sex partner (50%); a syringe services program (SSP) (32%); or a needle or drug dealer, shooting gallery, or off the street (21%). Common methods for syringe disposal were in the trash, on the street, or in a nonmedical waste container (53%); a medical waste container (50%); an SSP (30%); or keeping the syringe to reuse it (29%). An estimated 57% percent of HIV-positive persons who injected drugs reported needing alcohol or drug use treatment; 80% of HIV-positive persons who injected drugs did not obtain treatment in the preceding year. Eight percent of HIV-positive persons who injected drugs enrolled in a medication-assisted treatment program.

A higher percentage of HIV-positive persons who injected drugs had a detectable viral load than did those who did not inject drugs (48% versus 35%; p = 0.008) (Figure). Condomless sex, exchange sex, and high-risk sex were all more prevalent among HIV-positive persons who injected drugs (63%, 17%, and 18%, respectively), than among those who did not inject drugs (31%, 2%, and 6%, respectively) (p<0.001).

Figure.

Percentage of persons with diagnosed human immunodeficiency virus (HIV) (n = 233) who engaged in high risk sexual behaviors or had a detectable viral load — Medical Monitoring Project, United States, 2015–2017 *,†
* With 95% confidence intervals indicated with error bars; all percentages are weighted.
Exchange sex was defined as exchanging sex for money or goods in the preceding 12 months; high-risk sex was defined as having one or more detectable viral load in the preceding 12 months and having condomless sex with an HIV-negative or HIV-unknown partner who was not known to be on preexposure prophylaxis.

* Includes frontloading/backloading into a syringe, a process in which one syringe is used to prepare a drug solution that is then divided into one or more syringes for injection.
https://www.cdc.gov/hiv/risk/prep/index.html.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....