Ending HIV and Taming HCV and Overdose Among Puerto Rican PWID in New York City: The Ganchero Intervention

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Project Summary/Abstract The threat of HIV among people who inject drugs (PWID) in the United States (US) is not over. Multiple HIV outbreaks among PWID in rural and urban areas of the US have occurred recently, from 2015 in rural Indiana to 2018 in Boston, Massachusetts. PWID who are racial/ethnic minorities continue to be disproportionately infected with HIV. Among these, Puerto Rican (PR) PWID who started injecting drugs in Puerto Rico (PR) and continue to inject drugs in New York City (NYC) remain vulnerable not only to HIV, but also to hepatitis C (HCV) and fatal opioid overdose. Analyses conducted in NYC found PR PWID, especially those who migrated from PR, are the most HIV-vulnerable ethnic group. In 2017, the US overdose mortality rate for US-born and PR-born Puerto Rican PWID exceeded the rate for Non-Hispanic Whites, and the same holds true in NYC. Recent research showed that PR PWID have significantly higher prevalence of HCV than non-PR-PWID, and that PR-born migrant PWID have the highest HCV prevalence (86%) of all three groups. Helping PR-born PWID avoid HIV will help prevent HIV outbreaks in NYC. Lowering their HCV and overdose risk will help reduce overall HCV prevalence (67%) and overdose mortality rates (21.2 per 100,000) in NYC’s PWID. In this 3-year study, we will develop an innovative and culturally tailored HIV, HCV, and overdose risk- reduction intervention for migrant PR PWID in NYC that leverages the key migrant PWID role of the Ganchero, frequently used “injection doctors,” and migrants’ strong social network ties. The intervention will be twofold: 1) it will train Gancheros on the foundational HIV, HCV, and overdose knowledge required to, 2) deploy Gancheros to disseminate evidence-based risk-reduction messages and resources and to implement safer injection practices as they deliver their regular services to migrant PWID clients. The intervention will use a wait-list control design with 10 Gancheros and 60 clients in two Bronx neighborhoods. Across two time-lagged intervention implementation cycles (one per neighborhood, each consisting of a 6-session, small-group Ganchero training and a 4-month deployment period) and five assessment time points, we will measure the intervention’s feasibility (via Ganchero and client participation rates), acceptability (via Ganchero and client Visual Analog Scale [VAS] ratings and qualitative feedback) and preliminary effectiveness in increasing migrant clients’ rates of sterile syringe use (primary effectiveness outcome) and naloxone carriage (secondary effectiveness outcome). Changes in Gancheros’ HIV, HCV, and overdose knowledge and personal drug use behaviors will also be assessed before and after the training component. Ethnographic observations of Gancheros deploying intervention strategies will assess fidelity of implementation, barriers, and Gancheros’ responses to barriers, to inform refinements of the intervention and its implementation strategy. If successful, this intervention will reduce the high rates of HCV and overdose, and the significant potential for an HIV outbreak. We will then evaluate the Ganchero intervention in a hybrid effectiveness-implementation trial (R01).