Camila Gelpi-Acosta

Background: This study reports outcomes from a pilot test of the Ganchero Intervention, a community-driven, culturally grounded intervention to address disparate rates of HIV, hepatitis C virus (HCV), and overdose in migrant Puerto Rican people who inject drugs (PWID) through empowering Gancheros (PWID who inject others in exchange for drugs or money) to promote risk-reduction practices in their clients. Methods: The intervention was evaluated in a nonrandomized, wait-list control pilot trial in two neighborhoods in New York City from July 2024–October 2025. In Cycle I, Neighborhood A received the intervention and Neighborhood B served as a control; Neighborhood B received the intervention in Cycle II. Fisher’s exact and Mann–Whitney U tests compared baseline characteristics of the two neighborhood samples, and participants who did, versus did not, complete a follow-up. Negative binomial regression models tested group (intervention versus control neighborhood), time, and group by time effects for two outcomes of interest in Cycle I: past-30-day rates of sterile syringe use; and naloxone carriage, both assessed in Ganchero clients. Results: The baseline assessment included 58 participants (clients of Gancheros; 28 in Neighborhood A and 30 in Neighborhood B). Compared to the sample from Neighborhood B, Neighborhood A participants had spent less time living in Puerto Rico, reported more frequent re-use of their own syringes, and reported less frequent visits to brick-and-mortar syringe services programs (SSPs), although there were no significant differences in mobile SSP use, demographics, drug use, injection frequency, overdose, arrest/incarceration, or naloxone training/carriage. In the analysis of rates of sterile syringe use during Cycle I (n=98 observations from 57 participants): compared to the control group (Neighborhood B), the intervention group (Neighborhood A) had a 25% significantly higher relative increase in sterile syringe use from baseline to the end of Cycle I (8 months post-baseline). Increases in reported naloxone carriage (n=99 observations for 57 participants), reported by both groups, did not significantly differ between the intervention and control groups. Conclusions: Community-vetted and culturally appropriate access to sterile syringes, driven by Gancheros, holds promise for reducing HIV and HCV transmission in this culturally distinct population, although naloxone hesitancy challenges overdose prevention efforts. Trial registration: The clinical trial protocol was pre-registered at ClinicalTrials.gov on March 11, 2024 (NCT06316739).

In the United States (US), individuals of Puerto Rican heritage die of drug overdoses at higher rates than other Hispanic groups or non-Hispanic Whites; yet, little is known about the extent to which drug overdose mortality affects island-born, versus US-born, Puerto Ricans. The distinction between Puerto Rican-born and US-born provides a starting point for culturally tailored services and interventions, as place of birth often informs language preferences and cultural identifications. Therefore, this study analyzed 2013–2019 death certificate data from the National Center for Health Statistics for 415,111 US deaths attributed to drug overdose. Drug overdose deaths were compared for island-born Puerto Ricans (N=3516), US-born Puerto Ricans (N=4949), and individuals not of Puerto Rican heritage (N=406,646). Drug overdose mortality rates, including age-specific and directly age-standardized rates, were calculated for each subgroup using population estimates from the US Census Bureau’s American Community Survey. Results indicated that age-adjusted drug overdose mortality rates over the period of 2013–2019 were significantly higher for island-born than US-born Puerto Rican men (46.8 versus 34.6, per 100,000), with rates in both groups significantly higher than for men not of Puerto Rican heritage (24.0 per 100,000). For women, in contrast, drug overdose mortality rates were lower for island-born than US-born Puerto Ricans (8.6 versus 11.1, per 100,000). Within stateside Puerto Rican communities, island-born men experience a disproportionate burden of drug overdose mortality, necessitating targeted, culturally appropriate interventions built around the specific norms, circumstances, and lived experiences shared by Puerto Rican migrants who use drugs.

People who inject drugs (PWID) who migrate from Puerto Rico (PR) to New York City (NYC) are at elevated risk for hepatitis C (HCV), HIV and drug overdose. There is an urgent need to identify a sustainable path toward improving the health outcomes of this population. Peer-driven HIV/HCV prevention interventions for PWID are effective in reducing risk behaviors. Additionally, the concept of intravention—naturally occurring disease prevention activities among PWID (Friedman, 2004)—is a suitable theoretical framework to cast and bolster PWID-indigenous risk reduction norms and practices to achieve positive health outcomes. From 2017–2019, we conducted an ethnographic study in the Bronx, NYC to identify the injection risks of migrant Puerto Rican PWID, institutional barriers to risk reduction and solutions to these barriers. Study components included a longitudinal ethnography with 40 migrant PWID (e.g., baseline and exit interviews and monthly face-to-face follow-ups for 12 months), two institutional ethnographies (IEs) with 10 migrants and six service providers, and three focus groups (FGs) with another 15 migrant PWID. Data were analyzed using a grounded theory approach. In this article, we present findings from the IEs and FGs, specifically regarding a promising intravention pathway to promote health empowerment among these migrants that leverages an existing social role within their networks: the PR-indigenous ganchero. A ganchero is a vein-finding expert who is paid with drugs or cash for providing injection services. Ethnographic evidence from this study suggests that gancheros can occupy harm reduction leadership roles among migrant Puerto Rican PWID, adapting standard overdose and HIV/HCV prevention education to the specific experiences of their community. We conclude by noting the culturally appropriate risk reduction service delivery improvements needed to mitigate the health vulnerabilities of migrants and provide a roadmap for improving service delivery and identifying future research avenues.

American Journal of Public Health (AJPH) from the American Public Health Association (APHA) Puerto Rican Syndemics: Opiates, Overdoses, HIV, and the Hepatitis C Virus in a Context of Ongoing Crises, an article from American Journal of Public Health, Vol 110 Issue 2

Background: While PWID of Puerto Rican origin have been migrating to the US for decades, the range of factors influencing their migration to the US and the resources they draw on to do so are not well understood. This is particularly true for rural Puerto Rican PWID, and the present study is the first empirical research to document migration patterns among this population. The specificities of their migration raise important challenges that need to be documented in order to implement more effective harm reduction policies at home (Puerto Rico) and abroad (US). Methods: This paper draws from data obtained employing a modified NHBS survey which was administered to (N =296) PWID in four rural municipalities of Puerto Rico with participants 18 years or older. The primary dependent variables for this paper are the number of times a person has lived in the continental US, and if they are planning on moving to the continental US in the future. Results: Findings suggest that 65% of the sample reported ever lived in the US and that 49% are planning on moving in the future. The number of times living in the US is associated with higher education and older age, but not with self-reported positive HIV or HCV statuses. Planning to move to the US is associated with knowing PWID who have moved or plan to move, negatively associated with age, and is not associated with HIV or HCV status. Around one third of those that lived in the US reported having some sort of support, with the majority receiving support from family sources. No participant received help to enter HIV/HCV treatment. Conclusions: A multi-region approach to prevention is required to make a dent in curbing HIV/HCV transmission in this population. Understanding PWID migration patterns, risk behaviors, and health care needs in the US is now more important than ever as natural disasters prompted by human-made climate change will only increase in the future, raising demands not only for service providers but also harm reduction policies to cope with an increasing influx of “climate refugees” as PWID move across national borders.

Background: Among people who inject drugs (PWID) in the United States, those who initiated drug injection in Puerto Rico (immigrant Puerto Rican PWID) engage in more injection and sexual risk behaviors, and have higher HIV incidence than non-Hispanic whites. Objective: Understand the persistence of these HIV behaviors. Methods: In a cross-sectional study conducted in New York City (NYC) in 2012 (National HIV Behavioral Surveillance), PWID aged ≥18 years were recruited using Respondent-Driven Sampling, interviewed, and tested for HIV. Participants were categorized into 5 different groups: (1) US-born non-Hispanic PWID, (2) US-born Puerto Rican PWID, (3) recent immigrant Puerto Rican PWID (≤3 years in NYC), (4) medium-term immigrant Puerto Rican PWID (>3 and ≤10 years in NYC), and (5) long-term immigrant Puerto Rican PWID (>10 years in NYC). We examined the relationship between time since migrating on sexual and injection risk behaviors among immigrant Puerto Rican PWID, compared with U.S.-born Puerto Rican PWID and US-born non-Hispanic PWID. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were estimated using logistic regression. Results: A total of 481 PWID were recruited. In adjusted analyses using US-born non-Hispanic PWID as the comparison group, syringe sharing was significantly more likely among medium-term immigrants; and unprotected sex with casual partners was more likely among recent and long-term immigrants. Conclusions: The risk-acculturation process for immigrant Puerto Rican PWID may be nonlinear and may not necessarily lead to risk reduction over time. Research is needed to better understand this process.

Blood contained in needles and injection equipment has been identified as a vector for HIV and HCV transmission among people who inject drugs (PWID). Yet, there is often a wide discrepancy in prevalence for both viruses. While microbiological differences between viruses influence prevalence, other variables associated with the way drugs are acquired and used, also play a role. Respondent-driven sampling (RDS) methods recruited a sample of 315 current intravenous drug users in rural Puerto Rico. Information about type and frequency of use, HIV and HVC risk behaviors (sharing needles, cookers, cotton, and water), sexual behaviors, and alcohol use was collected. HIV and HCV statuses were assessed via rapid antibody tests. T tests compare means of participants who tested positive (reactive) to those who tested negative. Logistic regression analyses were used to validate the association of the risk factors involved. Tests showed a significant difference in HIV (6 %) and HCV (78.4 %) prevalence among a population of current PWID. The main risk behaviors in HCV transmission are the sharing of injection “works”, (e.g., cookers, cotton, and water). Sharing works occurred more than twice as often as the sharing of needles, and HCV+ and HCV− individuals reported the same needle sharing habits. Washing and rinsing injection works with water seems to prevent HIV transmission, but it is unable to prevent HCV infection. While education about the need to clean injection equipment with bleach might be beneficial, equipment sharing—and the subsequent risk of HVC—might be unavoidable in a context where participants are forced to pool resources to acquire and use intravenous drugs.

Community sexual bridging may influence the socio-geographic distribution of heterosexually transmitted HIV. In a cross-sectional study, heterosexual adults at high-risk of HIV were recruited in New York City (NYC) in 2010 for the Centers for Disease Control and Prevention-sponsored National HIV Behavioral Surveillance system. Eligible participants were interviewed about their HIV risk behaviors and sexual partnerships and tested for HIV. Social network analysis of the geographic location of participants’ recent sexual partnerships was used to calculate three sexual bridging measures (non-redundant ties, flow-betweenness and walk-betweenness) for NYC communities (defined as United Hospital Fund neighborhoods), which were plotted against HIV prevalence in each community. The analysis sample comprised 494 participants and 1534 sexual partnerships. Participants were 60.1 % male, 79.6 % non-Hispanic black and 19.6 % Hispanic race/ethnicity; the median age was 40 years (IQR 24–50); 37.7 % had ever been homeless (past 12 months); 16.6 % had ever injected drugs; in the past 12 months 76.7 % used non-injection drugs and 90.1 % engaged in condomless vaginal or anal sex; 9.6 % tested HIV positive (of 481 with positive/negative results). Sexual partnerships were located in 33 (78.6 %) of 42 NYC communities, including 13 “high HIV-spread communities”, 7 “hidden bridging communities”, 0 “contained high HIV prevalence communities”, and 13 “latent HIV bridging communities”. Compared with latent HIV bridging communities, the population racial/ethnic composition was more likely (p < 0.0001) to be black or Hispanic in high HIV-spread communities and to be black in hidden bridging communities. High HIV-spread and hidden bridging communities may facilitate the maintenance and spread of heterosexually transmitted HIV in black and Hispanic populations in NYC.