Georgia HIV Behavioral Surveillance (GHBS): 2012 survey of metro Atlanta injection drug users (IDUs) [2015]

The Georgia Department of Public Health

GEORGIA HIV BEHAVIORAL SURVEILLANCE (GHBS)
2012 Survey of Metro Atlanta Injection Drug Users (IDUs)

What is GHBS?
Each year throughout the United States, 21 health departments serving the cities with the highest HIV prevalence collaborate with the Centers for Disease Control and Prevention (CDC) to implement the National HIV Behavioral Surveillance System (NHBS). NHBS assesses and monitors HIV-related risk behavior, testing behavior and use of prevention programs among three populations at heightened risk for HIV infection: men who have sex with men (MSM), persons who use injection drugs, and heterosexual men and women at increased risk of HIV infection. In 2012, the Georgia Department of Public Health implemented the survey with a focus on IDUs in the Atlanta area. Between August and December of 2012, participants were recruited into the study using response-driven sampling (RDS), a type of peer-driven chain-referral sampling. Men and women received basic information about the survey and were screened for eligibility after providing voluntary consent. Surveys were conducted by trained interviews with hand-held touch-screen computers. If consent was obtained, participants were asked core survey questions followed by a set of local questions of interest to the Atlanta-based researchers. HIV testing and counseling were offered to every participant and was conducted using the OraSure HIV-1 Oral Specimen Collection Device. Two weeks after the test, participants were able to obtain their results anonymously by phone with a personal password.

Counties in the Atlanta Metropolitan Statistical Area

Background: HIV among IDUs
According to the most recently-available CDC Surveillance Report, Georgia ranked 5th in the nation for new HIV diagnoses and for the total number of adults and adolescents living with HIV in 2014, and the Atlanta MSA ranked 7th in the nation for new HIV diagnoses (1). Injection drug use accounted for 3% of new HIV diagnoses among males and 7% of all new HIV diagnoses among females in Georgia in 2013 (2).
1.Centers for Disease Control and Prevention. HIV Surveillance Report,
2014; vol. 26. http://www.cdc.gov/hiv/library/reports/surveillance/
2. Georgia Department of Public Health, HIV/AIDS Epidemiology Section HIV Surveillance Summary, Georgia 2013, https://dph.georgia.gov/data-fact-sheet-summaris,

Research assistants demonstrate use of a handheld touchscreen survey computer

2 Peachtree Street, Atlanta, Ga 30303 | www.dph.georgia.gov

July 2015

Who were the participants?

KEY FINDINGS

A total of 561 injection drug users (IDUs) met the eligibility criteria and consented to completing the survey.
The 561 eligible IDUs who participated in the survey were predominantly male (77%), followed by 22% female, and 1% transgender. More than half (57%) were aged 50 years or older, and 30% were aged 4049 years. Only 11% of participants were aged 30-39 years old, and 2% aged 18-29 years old. The great majority, 87% were Black, 11% were white, and 1% were Hispanic.

Most frequently used drug The most frequently used drugs were Heroin (60%) and speedball (29%). Cocaine was reported by 9%, Methamphetamine by 1%, and crack by less than 1%.
Most often used drug

Methamphetamine (Crystal, meth, tina, crank, ice), 1%

Crack, <1%

Something else, <1%

Injection Drug users by Race

Cocaine, 9%

Speedball, 29%

Heroin, 60%

Highest educational attainment was diverse among participants. Approximately 2% had attained at least a Bachelor's degree, 25% had attained a 2-year degree or some college, and 40% had attained a high school diploma or a General Equivalency Degree (GED) while 34% did not have at least a high school diploma or equivalent.
The majority of respondents (85%) reported earning $0-$19,999 annually. Approximately 11% reported earning $20,000 to $49,999, and 3% reported $50,000$74,000. Additionally, 45% of IDUs said there were currently homeless.
The majority of respondents said they lived in Fulton County (91%), followed by DeKalb (6%), Cobb (2%), and Other (1%) counties.
Most respondents (68%) said they had no health insurance coverage at the present time. Twenty-eight percent of IDUs said their health care expenses were paid for by a publicly-funded program such as Medicaid or Medicare, and 2% said they had private insurance.
Participants described themselves as "heterosexual or straight" (74%), "bisexual" (22%), and "homosexual or gay" (4%).

Injection practices In the last 12 months 41% of respondents used only sterile needles ("never used by anyone, including you"), and 59% used a non-sterile needle at least once. Twenty nine percent of all respondents (161) used needles that someone had already injected with. Of these 161 respondents, 63% responded rarely, 24% about half the time, 13% most of the time or always using needles someone had already injected with. When asked about the last time they injected, 93 respondents used a needle after someone. Of these, 83% did not know that person's HIV status, and 95% did not know if that person had been tested for hepatitis
Use of non-injection drugs Ninety seven percent of respondents indicated they had used non-injection drugs other than those prescribed to them in the last 12 months. When asked which non-injection drugs were used, the most commonly used non-injection drugs were marijuana (60%), crack cocaine (55%), and powdered cocaine (50%), smoked or snorted heroin (47%), and pain killers such as Oxycontin, Vicodin or Percocet (40%).
Heavy alcohol consumption Overall, 42% of male respondents met the criteria for heavy drinking in the past 30 days (two or more drinks, on average, per day during the 30 days preceding the interview). Forty six percent of female respondents met the criteria for heavy drinking (one or more drinks, on average, per day during the 30 days preceding the interview).

Drugs used during last sexual encounter Seventy three percent of males reported using drugs during their last sex encounter. The drugs most commonly used were heroin (56%) followed by crack cocaine (27%), and speedballs (18%). Among females, 70% reported using of drugs at last sex encounter. The drugs most commonly used were heroin (57%), crack cocaine (30%), and speedballs (23%).
Alcohol and drugs during sex Approximately 57% of men said they used both alcohol and drugs during their most recent sex with another female. Forty-four percent of females said they used both alcohol and drugs during their most recent sex with another male. Sixty two percent of the 119 men reporting sex with men said they used both alcohol and drugs during their most recent sex with another male.
Condom use Eighty six percent of heterosexual men and 86% of women reported sex without a condom at their last sexual encounter. Fifty three percent of these men and 39% of these women reported this was with a partner of unknown HIV status. Of the men who reported having anal sex with another man at their last sexual encounter, 100% reported not using a condom, and 77% indicated that this was with a partner whose HIV status was unknown.
Most recent HIV test Eighty eight percent, 8%, and 9%, of respondents reported being HIV-negative, never been tested, respectively, and 9% reported being HIV-positive. Respondents who did not self-report being HIVinfected were asked about the date of their most recent HIV test. Forty six percent of males and 51% of females reported they had been tested in the past 12 months. Only 8% of males and 8% of females reported never being tested for HIV in their lifetime.
Reasons for not having a recent HIV test Among IDUs who said they were not tested for HIV during the past 12 months (n=263), the most common reason was "no particular reason" (35%), followed by "afraid of learning they were infected with HIV" (27%), "thought to be at low risk for HIV infection" (16%), didn't have time" (16%), and some other reason (6%).
Prevalence of HIV infection Among the 554 participants (99%) who consented to HIV testing as part of the survey, 16% (88) had an HIVpositive test result. Of these, 48% indicated they were not aware of their HIV-positive status before taking the survey. The number of men and women unaware of their HIV-positive status might be inflated because some of those who knew their positive status may have described themselves as HIV-negative to the interviewer because of HIV-related stigma.
Sex in exchange for money, sex or drugs Forty-two percent of men with multiple female casual partners (n=290) and 93% of women with multiple male casual partners (n=68) indicated receiving things like

money or drugs in exchange for sex with at least one partner in the past 12 months.
Availability/Use of free condoms Sixty six percent of respondents indicated they had gotten free condoms not counting those given to them by a friend, relative or sex partner in last 12 months. Seventy-four percent of IDUs indicated using free condoms they had received.
Hepatitis Seventy-seven percent of participants said they had never been vaccinated for Hepatitis A or Hepatitis B.
Disclosure of sexual orientation Sixty-eight percent of the men who reported sex with men never told a health care provider about their sexual orientation.
RECOMMENDATIONS
There is a need to promote access to health care among IDUs. Many did not have health insurance (68%) and almost a quarter had not seen a health care provider in the past 12 months (22%).
During the last 12 months, 29% used a needle someone had already injected with. Among those who injected after someone at last injection, only a small percentage knew their injection partner's HIV status or the last time their partner received a Hepatitis C test. Syringe exchange programs should work in collaboration with local health departments offering HIV and Hepatitis C testing.
The majority of male IDU who had sex with men said they have never told a health care provider about their sexual orientation. Health care providers may benefit from training in collecting and assessing HIVrelated patient risk histories with a non-judgmental, open-ended approach.
Because of the association between alcohol, drugs and HIV-related risk behavior, programs for HIV prevention and treatment in metro Atlanta should factor into consideration the prevalence of drug use and heavy alcohol consumption among IDUs.
Approximately one third of IDUs said they had not received free condoms in the community (not including those obtained from friends, family or sex partners). Opportunities should be explored for strengthening and expanding the existing network of condom distribution programs in metro Atlanta.
Limitations
Findings are not representative of all IDUs in metro Atlanta because participants were recruited into the study using response-driven sampling (RDS), a type of peer-driven chain-referral sampling. Also, only sexually-active IDUs were included in this analysis. Findings might not be generalizable to other cities.

Acknowledgments
Special thanks to our storefront locations that made their venues accessible to NHBS surveyors for the 2012 survey: Atlanta Harm Reduction Coalition and Grace United Methodist Church. Grateful recognition is also given to the NHBS 2012 team of research assistants.
Brenda Fitzgerald, MD, Commissioner J. Patrick O'Neal, MD, Director of Health Protection Cherie L. Drenzek, DVM, MS, State Epidemiologist Pascale Wortley, MD, HIV Epidemiology Section Director
Jeffery D. Todd, MA, GHBS Team Lead, Kimi Sato, MPH, GHBS Project Coordinator Sandi Brown, MPH, GHBS Program Consultant
Irene Solomon, GHBS Intern Shaniqua Smith, GHBS Intern
Suggested Citation: Georgia Department of Public Health. (2015). HIV Behavioral Surveillance Fact Sheet: 2012 Survey of Injection Drug Users who Reside in Metropolitan Atlanta. Reported by: Jeff Todd, MA; Kimi Sato, MPH; Sandi Brown, MPH; Irene Solomon, MPH, Shaniqua Smith, MPH. For more information please contact: Jeff Todd, GHBS Team Lead, Georgia Department of Public Health, 2 Peachtree ST NW, Suite 14-464, Atlanta, GA 30303.
http://dph.georgia.gov
For resources related to HIV, syphilis and other infections including screening, treatment and supportive services please call the Georgia AIDS/STD InfoLine at 1-800-551-2728.