HIV/AIDS in Puerto Rican People Who Inject Drugs: Policy Considerations

We commend the important work of Deren et al.¹ that underscores the high rates of HIV among Puerto Rican people who inject drugs (PRPWID) and highlights the health, social, and service disparities between Puerto Rico and the Northeast US region. As articulated in their article, HIV/AIDS risk and substance use are not individual problems with individual consequences—the epidemic impacts community and culture, across borders and boundaries. In addition to service disparities, various socioeconomic contextual factors are associated with and may exacerbate the spread of HIV/AIDS in PRPWID, including limited educational and employment opportunities, poverty, and political disenfranchisement. Efforts to reduce the incidence of HIV/AIDS and associated health risks and complications, including other infections, drug overdose, and social stigma, necessitate structural policy intervention in addition to programmatic improvements. Moreover, policy implementation that attends to contextual factors such as incarceration and impediments to culturally appropriate services is needed. We identify two contexts that represent opportunities for improvements in policy implementation that may curb the HIV/AIDS epidemic among PRPWID.

First, the federal ban on funding for syringe exchange programming undermines the public health mission of limiting the spread of blood-borne pathogens. Although President Obama signed a law to lift this ban in 2009, Congress restored it in 2012. Reallocating federal funding to syringe exchange programming may be an effective way to reduce the spread of HIV/AIDS in PRPWID.

Second, the United States has the highest documented incarceration rate in the world, with more than 1.5 million people imprisoned on nonviolent drug charges in 2013.² The federal budget for drug prevention has decreased steadily since 2004, whereas funding for law enforcement and incarceration has increased.³ Although White House Principles of Modern Drug Policy mandate that drug-involved individuals in the criminal justice system be supervised with respect for their basic human rights and provided with substance use treatment, access to these services is limited. The criminal justice system has the potential to play a vital role in breaking the cycle of drug use, crime, incarceration, and rearrest by providing more treatment in correctional facilities and alternatives to incarceration (e.g., drug courts). Resources allocated to drug prevention during reentry may be a viable solution to reducing drug relapse and containing the HIV/AIDS epidemic. Equitable availability and effective implementation of these federal policies, in both Puerto Rico and the US mainland, may contribute to reduce the disproportionate amount of PRPWID with HIV/AIDS and bring much needed services to this population.