Policy Brief

HIV and Safer Drug Consumption Programs in California

March 19, 2018

In 2015, California saw over 4,700 new cases of HIV. Nationally, in the same year, California led the nation for HIV transmissions via injection drug use and among men who have sex with men who inject drugs. Other key groups impacted by both epidemics include women, people of color, those who are homeless and youth. Research has found that people who inject drugs from these subgroups are 4-29 times more likely to have an HIV-positive diagnosis. In California, researchers have estimated that a single safe injection site in San Francisco can prevent 3.3 new HIV transmissions per year and would save the State of California roughly $3.5 million per year in expenses related to healthcare, emergency services and crime.

In 2015, California saw over 4,700 new cases of HIV.1 Nationally, in that same year, California led the nation for HIV transmissions among men who have sex with men who inject drugs (MSM/ IDU). Historically, MSM/IDU account for 14.4% of HIV transmissions among men in California.2 California was the third highest state for HIV transmissions via injection drug use (IDU).

Estimated numbers of HIV diagnoses by transmission category in 2015

Among women, the proportion is greater. Women in California acquired HIV as a result of IDU in 24% of new HIV transmissions. In some jurisdictions, such as San Francisco, transmissions are even higher where over 36% of women seroconverted as a result of IDU.

The ongoing opioid epidemic gives more urgency to focusing on risk factors association with HIV transmission and IDU.3 Given the syndemic nature of HIV, addressing risk factors related to IDU have been and continue to be a central component of addressing HIV prevention and treatment.3 Trends indicate that with increased injection drug use, people who inject drugs (PWID) are at an increased risk of unsafe use of contaminated injection equipment and engage in higher risk sexual behaviors.4 The risk factors presented by the opioid epidemic and increased IDU overlap substantially with risk factors associated with higher rates of HIV transmission.

Proposed in recent California legislation AB 186,7 Safer Drug Consumption Programs build on existing research detailing the efficacy of safe injection sites in the United States, Europe, Canada and Australia.8,9 Research findings have documented how these sites provide supervision by trained personnel, offer safe and sterilized equipment, and safely link people to medical care and substance use treatment. Thus, the scientific consensus is that safer drug consumption programs are effective at reducing risk and incidence of HIV and Hepatitis C (HCV) infection, as well as preventing overdose deaths.8,9 They can help to facilitate continuity of care for both addiction and HIV among people living with HIV who use drugs.10

There are societal and economic benefits to Safer Drug Consumption Programs. Prevention of HIV and HCV transmission significantly reduce the financial burden of costs associated with HIV/HCV-related healthcare.8 One site in Canada prevented 35 new cases of HIV per year.8 Further analysis suggested that closure of that same site could lead to 84 newly HIV-infected people per year.11

In California, researchers have estimated that a single safe injection site in San Francisco could prevent 3.3 new HIV transmissions per year and would save the State of California roughly $3.5 million per year in expenses related to healthcare, emergency services and crime.[12] Other estimates have similarly found that safe injection sites offer net savings—for every dollar spent on the effort, there would be a $2.33 generated in savings.

By focusing on the intersecting nature of the HIV epidemic and the increased IDU resulting from the opioid epidemic, Safer Drug Consumption Programs have the potential to increase access to care and treatment for underserved populations, to prevent HIV transmission, and to leverage opportunities for multiple healthcare interventions early and often.

Risk Factors for HIV and Injection Drug Use

WOMEN – Women who inject drugs that engage in sex work are 5.1 times as likely to contract HIV.14 Women who inject drugs that are under 40 years old are more likely to contract HIV than older women who inject drugs.14

PEOPLE OF COLOR – In California in 2016, Black/African American and Latinx/Hispanic populations combined comprised 53% of all new HIV Infections.2 A 2014 study estimated that Black/African American men who inject drugs were 7-29 times more likely to have an HIV diagnosis than white men who inject drugs. Latinx/Hispanic men who inject drugs are 4-17 times more likely to have an HIV diagnosis than white men who inject drugs. For women, HIV rates are 5-29 times for Black/African American women who inject drugs and 3-8 times for Latinx/Hispanic women who inject drugs when compared to white women who inject drugs.15

SEXUAL MINORITIES – The main risk factor for men who inject drugs is sexual behavior. Together, MSM and MSM/IDUs comprise the largest group at risk for HIV seroconversion.14 MSM/IDUs are almost 9 times as likely to seroconvert as their heterosexual counterparts.14

HOMELESSNESS – While little data is available for homeless populations, one study indicated that 11% of homeless people who inject drugs contracted HIV.16 In Los Angeles County in 2014, 6% of homeless people were living with HIV and 14% were people who inject drugs (PWID).17

YOUTH – Age is a strong predictor of HIV seroconversion as younger people are more likely to engage in higher risk sexual behaviors.18 Young cisgender MSM (ages 13-24) and cisgender women who are sex workers are the most at risk for HIV seroconversion.17

  • References

    1. Estimated Numbers of HIV Diagnoses, Adults and Adolescents, by Transmission Category, State Health Facts, the Henry J. Kaiser Family Foundation, accessed January 31, 2018, https://www.kff.org/statedata/.
    2. California Highlights, California, AIDSVu, accessed January 31, 2018, https://aidsvu.org/state/california/.
    3. Broadhead, R. S., Kerr, T.H., Grund, J.P.C., & Altice, F. L. (2002). Safer injection facilities in North America: their place in public policy and health initiatives. Journal of Drug Issues, 32 (1), 329-355.
    4. Wood, E., Tyndall, M. W., Li, K., Lloyd-Smith, E., Small, W., Montaner, J.S., & Kerr, T. (2005). Do supervised injection facilities attract higher-risk injection drug users?. American Journal of Preventative Medicine, 29(2), 126-130.
    5. Vuong, Zen. “Opioid epidemic may be driving illicit drug users to use needles sooner, USC study finds.” University of Southern California. Accessed February 9, 2018. https://news.usc.edu/121287/opioid-epidemic- may-be-driving-illicit-drug-users-to-use-needles-sooner-usc-study-finds/.
    6. Ehley, Brianna. “From opioids to HIV — a public health threat in Trump country.” Politico. October 21, 2017. https://www.politico.com/story/2017/10/21/opioids-hiv-public-health-threat-red-states-trump-243999.
    7. CALIFORNIA LEGISLATURE— 2017–2018 REGULAR SESSION. “AB-186 Controlled substances: safer drug con- sumption program.” Accessed February 9, 2018. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?-bill_id=201720180AB186.
    8. Andresen, Martin A., et al., A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility. International Journal of Drug Policy, Volume 21, Issue 1, 70 – 76. 2010.
    9. Semaan, Salaam, et al., Potential role of safer injection facilities in reducing HIV and Hepatitis C infections and overdose mortality in the United States. Drug and Alcohol Dependence 118 (2011) 100–110. Elsevier, April 23, 2011.
    10. Kerr, Thomas, Kimber, Jo, DeBeck, Kora, Wood, Evan,. 2007. The Role of Safer Injection Facilities in the Re- sponse to HIV/AIDS Among Injection Drug Users. Current HIV/AIDS Rep (2007) 4: 158. https://doi.org/10.1007/ s11904-007-0023-8.
    11. Pinkerton, Steven D. 2010. Is Vancouver Canada’s supervised injection facility cost-saving?. Society for the Study of Addiction. Addiction, 105 (8), 1429–1436.
    12. Amos, Irwin., Jozaghi, E., Bluthenthal, R.N., Kral, A.H., (2017), A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. Journal of Drug Issues, Vol. 47(2) 164-184.
    13. Lieber, Mark. “Safe injection sites in San Francisco could be first in the US.” CNN. January 2, 2018. https:// www.cnn.com/2018/02/07/health/safe-injection-sites-san-francisco-opioid-epidemic-bn/index.html.
    14. Kral, Alex H., Bluthenthal, R.N., Lorvick, J., Gee, L.; et al., (2001). Sexual transmission of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis. The Lancet. Vol. 357, 9266; Natural Science Collection pg. 1397.
    15. Lansky, Amy, Teresa Finlayson, Christopher Johnson, Deborah Holtzman, and Cyprian Wejnert. “Estimating the Number of Persons Who Inject Drugs in the United States by Meta-Analysis to Calculate National Rates of HIV and Hepatitis C Virus Infections.” PLOS. Accessed May 19, 2014. http://journals.plos.org/plosone/arti- cle?id=10.1371/journal.pone.0097596.
    16. Kral, Alex H., Bluthenthal, R.N., Booth, R.E., Watters, J.K. HIV Seroprevalence among Street-Recruited Injection Drug and Crack Cocaine Users in 16 US Municipalities. American Journal of Public Health, Vol. 88, No.1, Janu- ary 1998.
    17. Los Angeles County Commission on HIV and the Los Angeles County Department of Public Health Division of HIV and STD Programs. Los Angeles County Comprehensive HIV Plan (2017-2021), September 2016:1-165.
    18. Strathdee SA, Galai N, Safaiean M, Celentano DD, Vlahov D, Johnson L, Nelson KE. Sex Differences in Risk
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