Georgia HIV behavioral surveillance (GHBS) : data summary : survey of people who inject drugs (PWID) in Metro Atlanta, 2015

The Georgia Department of Public Health

GEORGIA HIV BEHAVIORAL SURVEILLANCE (GHBS)
Data Summary: Survey of People Who Inject Drugs (PWID) in Metro Atlanta, 2015

What is GHBS?
Each year throughout the United States, 22 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), people who inject drugs (PWID), and heterosexual men and women living in areas of high poverty (HET). In 2015, the Georgia Department of Public Health implemented the NHBS survey with a focus on PWID in the Atlanta area. Between August and December of 2015, participants were recruited into the study using a peer-driven, chain-referral method known as response-driven sampling (RDS). Special efforts were made to include younger PWID ( 35 years) as this group has been underrepresented in previous NHBS cycles. Eligible men and women who consented to participate completed a standardized questionnaire. Surveys were conducted by trained interviewers with handheld computers. All participants were offered anonymous HIV testing and counseling. HIV testing was conducted using the Insti HIV-1/2 Rapid Antibody Test. Reactive rapid tests were confirmed via Western blot assay.
Background: HIV among PWID According to the most recently available CDC HIV Surveillance Report, in 2015, Georgia ranked 5th in the nation for new HIV diagnoses among adults and adolescents (2,381). Georgia also ranked 5th nationally for the total number of adults and adolescents living with HIV (46,870). Similarly, in 2015, the Atlanta MSA ranked 5th in the nation for new HIV diagnoses (1). In Georgia, PWID represented 2% of all new HIV diagnoses among males and 7% of all new HIV diagnoses among females in 2015 (2).
1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015; vol. 27. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html, Published November 2016. [Accessed: December 1, 2016]. 2. Georgia Department of Public Health, HIV/AIDS Epidemiology Section. HIV Surveillance Summary, Georgia 2015. https://dph.georgia.gov/adult-corehivaids-surveillance, Published March 2016. [Accessed: December 1, 2016].

Table 1. Demographic Characteristics,

PWID in Metro Atlanta, 2015 (n=427)

n

%

Age

18-29

88 21%

30-39

73 17%

40-49

92 22%

50+

174 41%

Gender

Male

315 74%

Female

112 26%

Sexual orientation

Heterosexual

375 88%

Bisexual

40 9%

Homosexual

11 3%

Unknown

1 <1%

Race/Ethnicity

Black

222 52%

White

154 36%

Other/multiracial

26 6%

Hispanic

25 6%

County of residence

Fulton

341 80%

Cobb

26 6%

DeKalb

22 5%

Gwinnett

8 2%

Other

30 7%

Education

Less than high school

98 23%

High school diploma/GED

173 41%

More than high school

156 37%

Annual Income

Less than $19,999

307 72%

$20,000-$39,999

77 18%

$40,000 or more

43 10%

Homeless at any time in past 12 months

263 62%

Health insurance at time of interview

146 34%

Detained or arrested in past 12 months

189 44%

Began injecting drugs 10 years ago or lessat time of interview

163 38%

Inclusion criteria: At least 18 years of age, identified as male or female, consented to survey and HIV testing, completed the survey, and provided valid responses.

2 Peachtree Street, Atlanta, Ga 30303 | dph.ga.gov

2017

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2015

Survey of PWID in Metro Atlanta, 2015 A total of 427 participants met the eligibility criteria, consented to and completed the survey and HIV testing, and provided valid responses (Table 1).
Among the 427 participants, most were male (74%). Participants described themselves as "heterosexual or straight" (88%), "bisexual" (9%), and "homosexual or gay" (3%). Approximately 21% of participants were aged 18 to 29 years, 17% were aged 30-39 years, 22% were aged 40-49 years, and 41% were aged 50 years or older. With respect to race/ethnicity, 52% of participants were Black, followed by 36% White, 6% Latino, and 6% other/multiracial.
Most of the participants reported living in Fulton County (80%), followed by Cobb (6%), DeKalb (5%), Gwinnett (2%), Clayton (2%) and Other (5%) Counties.
Educational attainment was diverse among participants. Forty-one percent of participants had attained a high school diploma or a General Equivalency Degree (GED) while 36% had attained at least some college or more. Nearly one out of four (23%) participants attained less than a high school diploma or GED.
Most participants reported earning less than $20,000 annually (72%). Approximately 18% reported earning $20,000 to $39,999 annually and only 10% of participants reported annual earnings greater than $40,000. Additionally, 62% of participants reported being homeless in the past 12 months. Of those, 68% were currently homeless.
Only 34% of participants reported health insurance coverage at the time of interview. Among those, 78% said their health care expenses were paid for by a publicly funded program such as Medicaid or Medicare and only 19% reported private health insurance coverage.
Drug and Alcohol Use Among Those PWID Surveyed Among the 427 eligible participants, the median age at first injection was 22 years of age and 38% began injecting drugs less than 10 years prior to the interview.
Approximately 70% of participants reported injecting more than once a day and 92% reported injecting more than once a week. The most commonly injected drugs were heroin (57%) and speedball (30%), a combination of heroin and cocaine. Methamphetamine was reported by 9%, cocaine/crack by 3%, and painkillers/other by less than 1% (Figure 1).

Four of five participants indicated they had used noninjection drugs other than those prescribed to them in the past 12 months. The most commonly reported noninjection drugs used were cocaine/crack (77%), marijuana (68%), smoked or snorted heroin (61%), and painkillers such as oxycodone, hydrocodone, or morphine (50%). Additionally, one of every three men (31%) and women (33%) reported binge drinking at least once in the past 12 months.

Figure 1. Drugs Injected Most Often by PWID, Metro Atlanta, 2015*

Heroin 57%

Speedball 30%

Painkillers/Other Cocaine/Crack

1%

3%

Methamphetamine 9%

*Data Source: GHBS Survey, 2015

HIV Status and Testing History
Among the 427 participants who consented to HIV testing as part of the survey, 36 (8%) had a confirmed HIV-positive test result. Of the 36 participants who tested HIV-positive, 30 (83%) reported being HIV positive during the interview. Most of the participants with HIV-positive test results were aged 36 years or older (92%).

Nine of every ten participants (92%) had been tested for HIV at least once. Among the 394 participants who reported they were HIV-negative or did not know their status during the interview, 237 (60%) said they had been tested for HIV in the past 12 months.

Of the 155 participants not tested for HIV in the past 12 months, the most common reason was "no particular reason" (51%), followed by "thought to be at low risk for HIV infection" (15%), "afraid of learning they were infected with HIV" (14%), "didn't have time" (10%), and some other reason (10%).

In terms of risk perception, the majority of participants believed they were at low risk of HIV infection at the time of the interview (72%).

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2015

Percent (%) Percent (%)

Drug-related Risk Behaviors
Among the 394 participants who reported they were HIV-negative or did not know their status during the interview, only 28% reported always using a sterile needle to inject with in the past 12 months. Twentyeight percent of younger participants (35 years) reported sharing syringes at least half of the time in the past 12 months compared to only 11% of older participants (Figure 2).

Figure 2. Frequency of Injection Equipment Sharing in the Past 12 Months
by Age, Metro Atlanta, 2015*

Shared syringes 50% of the time

Shared cookers, cottons, water 50% of the time

40

35

30

28

20

10

19 11

0

18-35 years

36+ years

Age Group

*Data Source: GHBS Survey, 2015

Similarly, 35% of younger participants (35 years) reported sharing cookers, cottons, or water at least half of the time in the past 12 months compared to only 19% of older participants. Among those participants who reported sharing any injection equipment in the past 12 months, only 45% and 37% knew their last injecting partner's HIV and HCV status, respectively.
Sexual Risk Behaviors Among the 394 participants who reported they were HIV-negative or did not know their status during the interview, 86% of men and 89% of women reported having at least one sexual partner in the past 12 months. Twenty-eight percent of men and 24% of women reported four or more sexual partners in the past 12 months.
Seventy-two percent of men and 78% of women reported unprotected vaginal or anal sex with an opposite sex partner in past 12 months. Among those who reported unprotected vaginal or anal sex with an opposite sex partner in the past 12 months, 51% of men and 43% of women also reported having unprotected sex with a partner of unknown HIV status in the past 12 months.

Utilization of Prevention Services
Among the 394 participants who reported they were HIV-negative or didn't know their status during the interview, the most commonly cited sources for their syringes in the past 12 months included a syringe service program (28%), a pharmacy (28%), friend/relative/sex partner (21%), or drug dealer/shooting gallery/street (19%) (Figure 3). When asked about the disposal of used syringes, less than half (38%) reported using a syringe service program.

Figure 3. Most Common Source of Syringes in Past 12 Months, Metro Atlanta, 2015*
30 28 28

25

21

20

19

15

10

5

3 1

0

*Data Source: GHBS Survey, 2015
Of the 394 participants, 37% participated in a program to treat drug use in the past 12 months. Approximately one in four participants tried to get into a program to treat drug use but were unable to do so.
Fifty-three percent of participants received free condoms. The three most commonly reported sources of free condoms included a syringe service program (50%), doctor's office/clinic/health center (27%), and community-based organizations (22%).
Additionally, 27% of participants engaged in a counseling session to discuss ways to prevent HIV infection and only 6% heard of pre-exposure prophylaxis, the medication HIV-negative people take to prevent infection.

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2015

Summary

Eight percent of the 427 PWID surveyed in Metro Atlanta had a confirmed HIV-positive test result, of whom 17% were unaware of their infection. Most participants who tested positive were aged 36 years or older.
Almost half (40%) of the participants had not been tested for HIV in the past 12 months.
Most (72%) of the participants believed they were at low risk of infection despite over half (64%) reporting that they shared syringes or injection equipment in the past 12 months.

Sharing of syringes and other injection equipment was more common among younger participants than among older participants.
Almost half (43%) of participants reported commonly obtaining their syringes from potentially unsterile sources such as friends, relatives, sex partners, drug dealers, or shooting galleries.
Most (74%) of the participants reported having unprotected vaginal or anal sex with an opposite sex partner in the past 12 months. Of those, 49% reported having unprotected sex with a partner of unknown HIV status in the past 12 months.

Implications
PWID, especially younger age cohorts and recently initiated drug injectors, are particularly vulnerable to HIV due to risky injection behaviors and unprotected sex. Increasing access to existing HIV prevention services and developing new interventions that are tailored to the needs of the local PWID are critical to reducing transmission of HIV among this population. The CDC recommends that a comprehensive, multicomponent, prevention program is the most effective approach for preventing the acquisition of HIV and other blood-borne infections among PWID.
Limitations
The data presented in this summary are unweighted and findings may not be representative of the entire population of PWID living in Metro Atlanta. Additionally, behavioral questionnaires that rely on self-report are prone to several response biases that might affect data quality.

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2015
Acknowledgments Special thanks to our storefront locations that made their venues accessible to GHBS surveyors for the 2015 survey: Antioch Urban Ministries and The Druid Hills Baptist Church. Grateful recognition is also given to The Atlanta Harm Reduction Coalition and to the GHBS 2015 team of research assistants.
Summary
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 David Melton, MPH, GHBS Project Coordinator Genetha Mustaafa, MFA, GHBS HIV Testing Manager Jonea Shields, BS, GHBS Program Consultant
Tymeckia Kendall, MPH, GHBS Intern
Suggested Citation: Georgia Department of Public Health. (2017). HIV Behavioral Surveillance Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2015. Reported by: David Melton, MPH; Tymeckia Kendall, 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.ga.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.