Data summary : survey of people who inject drugs (PWID) in metro Atlanta, 2018

The Georgia Department of Public Health

GEORGIA HIV BEHAVIORAL SURVEILLANCE (GHBS)
Data Summary: Survey of People Who Inject Drugs (PWID) in Metro Atlanta, 2018

What is GHBS?
Each year throughout the United States, 23 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 2018, the Georgia Department of Public Health implemented the NHBS Round 5 Injection Drug Use (IDU) survey with a focus on PWID in the Atlanta area. Between August and December of 2018, 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 results were confirmed with a Uni-GoldTM Recombigen HIV-1/2 rapid immunoassay.
Background: HIV among PWID
According to the most recently available CDC HIV Surveillance Report, Georgia ranked 5th in the nation for new HIV diagnoses among adults and adolescents (2,588) in 2017. Georgia also ranked 5th nationally for the total number of adults and adolescents living with HIV (51,350). Similarly, in 2017, the Atlanta MSA ranked 5th in the nation for new HIV diagnoses (1). In Georgia, PWID represented 2.1% of all new HIV diagnoses among males and 6.5% of all new HIV diagnoses among females in 2017 (2).
1. Centers for Disease Control and Prevention. HIV Surveillance Report, 2017; vol. 29. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html, Published November 2018. [Accessed: April 2, 2019]. 2. Georgia Department of Public Health, HIV/AIDS Epidemiology Section. HIV Surveillance Summary, Georgia 2017. https://dph.georgia.gov/adult-corehivaids-surveillance, Published February 2019. [Accessed: April 2, 2019].

Table 1. Demographic Characteristics,

GHBS IDU Survey, 2018 (n=382)

n %

Age

18-29

48 13%

30-39

99 26%

40-49

90 24%

50+

145 38%

Gender

Male

280 73%

Female

100 26%

Transgender

2 <1%

Sexual orientation

Heterosexual

329 86%

Bisexual

47 12%

Homosexual

6 2%

Race/Ethnicity

Black

208 54%

White

123 32%

Other/multiracial

34 9%

Hispanic

17 4%

County of residence

Fulton

308 81%

Cobb

25 7%

DeKalb

18 5%

Gwinnett

15 4%

Other

14 4%

Education

Less than high school

104 27%

High school diploma/GED

137 36%

At least some college

141 37%

Annual Income

$9,999 or less

170 45%

$10,000-$19,999

106 28%

$20,000-$39,999

57 15%

$40,000 or more

45 12%

Unknown

4 1%

Homeless at any time in past 12 months

284 74%

Health insurance at time of interview

108 28%

Detained or arrested in past 12 months

172 45%

Began injecting drugs 10 years ago or less

141 37%

Inclusion criteria: At least 18 years of age, injected drugs in the past 12 months, consented to and completed the survey, and provided valid responses.

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

2020

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2018

Survey of PWID in Metro Atlanta, 2018
A total of 382 participants met the eligibility criteria, consented to and completed the survey and HIV testing, and provided valid responses (Table 1).
Among the 382 participants, most were male (73%). Participants described themselves as "heterosexual or straight" (86%), "bisexual" (12%), and "homosexual or gay" (2%). Approximately 13% of participants were aged 18 to 29 years, 26% were aged 30-39 years, 24% were aged 40-49 years, and 38% were aged 50 years or older. With respect to race/ethnicity, 54% of participants were Black, followed by 32% White, 9% other/multiracial, and 4% Latino.
Most of the participants reported living in Fulton County (81%), followed by Cobb (7%), DeKalb (5%), Gwinnett (4%), and Other counties (4%).
Educational attainment was diverse among participants. Thirty-six percent of participants had attained a high school diploma or a General Equivalency Degree (GED) while 37% had attained at least some college or more. Approximately one out of five (27%) participants attained less than a high school diploma or GED.
Most participants reported earning less than $20,000 annually (72%). Approximately 15% reported earning $20,000 to $39,999 annually and 12% of participants reported earning $40,000 or more. Almost three out of every four of participants (74%) reported being homeless in the past 12 months.
Only 28% of participants reported health insurance coverage at the time of interview. Among those, 79% said their health care expenses were paid for by a publicly funded program such as Medicaid or Medicare and only 16% reported private health insurance coverage.
Drug and Alcohol Use Among Those PWID Surveyed
Among the 382 eligible participants, the median age at first injection was 24 years of age and 37% began injecting drugs less than 10 years prior to the interview.
Most participants (72%) reported injecting more than once a day and 96% reported injecting more than once a week. The most commonly injected drugs were speedballs (45%), which is a combination of heroin and a stimulant such as cocaine or methamphetamine, and heroin by itself (42%). Ten percent of participants commonly injected methamphetamine by itself. (Figure 1).

Four out of every five participants indicated they had used non-injection drugs other than those prescribed to them in the past 12 months. The most commonly reported non-injection drugs used were marijuana (60%), crack (49%), painkillers such as oxycodone, hydrocodone, or morphine (46%), smoked or snorted heroin (41%), cocaine (38%), and methamphetamines (32%). Additionally, 33% of males and 27% of females reported binge drinking at least once in the past 30 days.

Figure 1. Drugs Injected Most Often, GHBS IDU Survey, 2018

Speedball 45%

Heroin 42%

Painkillers/Other <1%

Cocaine/Crack 2%

Methamphetamine 10%

HIV Status and Testing History
Among the 377 participants who consented to HIV testing as part of the survey, 42 (11%) had a confirmed HIV-positive test result. Of the 42 participants who tested HIV-positive, 32 (76%) reported being HIV positive during the interview. Most participants (88%) with an HIV-positive test result were 36 years of age or older.
Overall, nine of every ten participants (92%) had been tested for HIV at least once. Among the 348 participants who reported they were HIV-negative or did not know their status during the interview, 199 (57%) reported being tested for HIV in the past 12 months.
Of the 140 participants not tested for HIV in the past 12 months, the most common reason was "no particular reason" (54%), followed by "afraid of learning they were infected with HIV" (19%), "thought to be at low risk for HIV infection" (15%), "didn't have time" (6%), and "some other reason" (6%).

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2018

Drug-related Risk Behaviors
Among the 348 participants who reported they were HIV-negative or did not know their status during the interview, only 123 (35%) reported always using a sterile needle to inject within the past 12 months. Twenty-two percent of younger participants (35 years) reported sharing syringes at least half of the time in the past 12 months compared to 12% of older participants (Figure 2).

Figure 2. Frequency of Injection Equipment Sharing in the Past 12 Months
by Age, GHBS IDU Survey, 2018

Shared syringes 50% of the time Shared cookers, cottons, water 50% of the time

40 30 20 10
0

32 22

21 12

18-35 years

36+ years

Age Group

Similarly, 32% 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 21% of older participants. Among those participants who reported sharing any injection equipment in the past 12 months, only 44% and 41% knew their last injecting partner's HIV and HCV status, respectively.
Sexual Risk Behaviors
Among the 348 participants who reported they were HIV-negative or did not know their status during the interview, 82% of men and 89% of women reported having at least one sexual partner in the past 12 months. Twenty-eight percent of men and 32% of women reported four or more sexual partners in the past 12 months. Additionally, 8% of males reported sexual contact with another male in the past 12 months.
Among the 208 sexually active males, 75% had unprotected vaginal or anal sex with their last sex partner, 44% did not know their last sexual partner's HIV status, 46% were in a concurrent sexual partnership, and 43% reported their last sexual partner "definitely" injected drugs (Figure 3).

Among the 81 sexually active females, 78% had unprotected vaginal or anal sex with their last sex partner, 48% did not know their last sexual partner's HIV status, 44% were in a concurrent sexual partnership, and 62% reported their last sexual partner "definitely" injected drugs (Figure 3).

Figure 3. Last Partner Characteristics Among Sexually Active PWID, GHBS IDU Survey, 2018



100

80

75 78

60

40

Male Female

44 48

46 44

62 43

20

0 Unprotected Patner's HIV Concurrent Last Partner vaginal or Status Partnership PWID anal sex Unknown

Utilization of Prevention Services
Among all 382 participants, the most commonly cited sources for obtaining sterile syringes in the past 12 months included directly from a syringe service program or SSP (64%), a pharmacy (30%), someone else who got them from an SSP (22%), an HIV/AIDS-focused organization (5%), a healthcare provider (3%), or some other source (11%). When asked about the disposal of used syringes, more than half (55%) reported using a syringe service program.
Of the 382 participants, 21% both participated in a program to treat drug use and used medications to treat opioid dependence such as buprenorphine and methadone. Sixteen percent only used medications to treat opioid dependence and 9% only participated in a program to treat drug use.
Additionally, 29% of participants engaged in a counseling session to discuss ways to prevent HIV infection and 58% of participants received free condoms in the past 12 months. Nineteen percent reported awareness of PrEP and no participants reported use of PrEP in the past 12 months.

Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2018
Implications
In Metro Atlanta, people who inject drugs are a vulnerable population that continue to be disproportionately affected by HIV, HCV, and other poor health outcomes. Unsafe injection behaviors are reported by a substantial portion of respondents, particularly among younger age groups. The fact that more participants report sharing equipment than needles highlights the need to increase education related to risks associated with sharing of injection equipment, even in the absence of needle sharing. These findings also underscore the importance of increasing awareness and utilization of existing HIV prevention strategies, such as PrEP, and developing new interventions that are tailored to the needs of PWID in Metro Atlanta. The CDC recommends that a comprehensive, multi-component, prevention program, including syringe service programs (SSP), are the most effective approach for preventing the acquisition of HIV and other bloodborne 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. Behavioral questionnaires that rely on self-report are prone to several response biases that might affect data quality. Additionally, the number of participants unaware of their HIV-positive status might be inflated because some who knew their positive status may have described themselves as HIV-negative to the interviewer due to HIV-related stigma.
Acknowledgments
We would like to thank the Atlanta Harm Reduction Coalition and ANIZ Inc. for their unwavering commitment to providing outreach to underserved populations in Metro Atlanta and for sharing their time and expertise with the GHBS team. A special thanks to the congregations of Antioch Urban Ministries and The Church at Ponce and Highland for making their venues accessible to the GHBS team during the 2018 data collection period. Grateful recognition is also given to the GHBS 2018 team of research assistants and interviewers.
Kathleen E. Toomey, MD, MPH, Commissioner 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 Mustaafaa, MFA, GHBS HIV Testing Manager Christine So, MPH, GHBS Public Heath Care Worker Summary
Suggested Citation: Georgia Department of Public Health. (2020). HIV Behavioral Surveillance Data Summary: Survey of People Who Inject Drugs in Metro Atlanta, 2018.
Reported by: David Melton, MPH; Christine So, 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