Puerto Rican Syndemics: Opiates, Overdoses, HIV, and the Hepatitis C Virus in a Context of Ongoing Crises

Puerto Rico is undergoing serious political and socioeconomic crises. Before the recent political turmoil forcing the resignation of (now former) Governor Ricardo Rosselló, massive government debt had already led to unrest because of unpopular austerity measures (e.g., pension cuts, shrinking public education, and hospital closures). Additionally, a decades-long financial crisis had already triggered large-scale emigration from Puerto Rico (a colony of the United States) to the continental United States, a phenomenon that was significantly augmented by Hurricane Maria in 2017. Puerto Rico’s vulnerability to natural disasters is compounded with its adverse political and socioeconomic conditions to create an exceptionally unstable public health environment.

Although 28 000 people who inject drugs (PWID) call Puerto Rico home,¹ the island hosts only five syringe services programs (SSPs), which are poorly funded, and only six methadone clinics, which are at capacity, to serve 5500 PWID. Because of limited services, needle sharing and cooker sharing are normative behaviors among PWID in Puerto Rico.² In fact, 48% of the 49 476 cumulative HIV/AIDS cases in Puerto Rico are PWID linked (42% injection drug use and 6% male-to-male sexual contact and injection drug use),³ and HIV prevalence among PWID in San Juan, the capital of Puerto Rico, is 13%.⁴

Puerto Rico also hosts one of the most hepatitis C virus (HCV)–vulnerable PWID populations of the United States and its territories. Hepatitis C prevalence among PWID in rural Puerto Rico is 79%, and it is as high as 90% in San Juan.⁵ Puerto Rico’s Department of Corrections and Rehabilitation reports that there were 12 381 people incarcerated in 2015. Data gathered by the Department of Corrections and Rehabilitation from 12 074 of these individuals show that 11.17% suffered from substance use disorders while incarcerated.⁶ Injection drug use is rampant throughout Puerto Rico’s prison system, and access to sterile injection supplies is nonexistent. Among PWID living with HIV in Puerto Rican prisons, many are coinfected with HCV. And yet, because of its outdated abstinence requirement for patients to access HCV treatment, the Puerto Rican government continues to deny HCV treatment to its PWID. It is, then, no mystery why HCV has reached a ubiquitous presence on the island.

Although fentanyl-laced heroin and cocaine fueled the rise of fatal overdoses in post-Maria Puerto Rico, we lack scientific understanding of fentanyl production and distribution in Puerto Rico, and overdose surveillance is not being conducted. Although naloxone (an overdose antidote) is available over the counter, the impoverished circumstances of Puerto Rico’s PWID population likely requires distributing naloxone free of charge. Hence, it may be sound to provide SSPs (and prisons) with naloxone to expand access. Mirroring cities and states with large PWID populations in the United States, Puerto Rico’s Department of Health could fund SSPs across the island. SSPs reduce HIV, HCV, and overdose risks more effectively than do faith-based and abstinence-only programs, which do receive funds from the local government.

By highlighting the overlapping (and interacting) epidemics (i.e., injection drug use, HIV, HCV, and opioid overdoses) fueling Puerto Rico’s syndemic context, we seek to draw attention to structural determinants of disease and mortality that must be modified to save lives. Moreover, weak structural determinants of PWID’s health cement their stigmatization and marginalization, which in turn affects timely uptake and adherence to HIV and HCV care, opioid agonist therapies, and overdose prevention. But we also seek to propose avenues for future research that are aligned with Puerto Rico’s syndemic context.

First, we know fentanyl is present in the island’s drug supplies, but we do not understand its advent and evolution. Although conducting overdose surveillance can help uncover the extent of the problem and also intelligently allocate prevention resources, identifying the structural factors behind the introduction (and maintenance) of fentanyl in Puerto Rico after Hurricane Maria is necessary to build a grounded response to what may be a prolonged problem.

Second, future HIV and HCV research should aim to gauge Puerto Rico’s contextual complexity and assess disease syndemics in tandem with the island’s sustained political, socioeconomic, and environmental (hurricane-prone Caribbean) instability. For example, it remains a mystery why HIV prevalence among PWID is relatively low in San Juan (13%) and in rural Puerto Rico (6%)⁴ when paraphernalia sharing inside and outside prisons is normative. Studies that have compared continental US-born PWID with PWID in Puerto Rico consistently show higher injection risk behaviors among PWID in Puerto Rico and among migrant PWID from Puerto Rico in New York City; these studies typically ascribe these findings to the lack of disease-prevention services, such as opioid agonist therapies and SSPs in Puerto Rico.² These low HIV prevalence numbers among PWID in Puerto Rico may stem from PWID’s everyday practices helping prevent HIV infection despite sustained injection paraphernalia sharing. In a context of increasing poverty, identifying these practices and understanding how they are maintained despite all the contextual disincentives to remain HIV safe may help save lives through their systematic dissemination.

A recent editorial in AJPH addressed the negative impact that the US law Puerto Rico Oversight, Management, and Economic Stability Act (2016) has over the economy and health of Puerto Ricans.⁷ It is also true that the Puerto Rican government could still significantly improve its efforts to prevent disease, death, and the structurally forced US-bound migration of PWID searching for services they lack in Puerto Rico.² Science has conclusively shown that SSPs and opioid agonist therapies save lives (and governmental resources) by preventing infections. To save lives, the Puerto Rican government must start supporting evidence-based interventions: opioid agonist therapies, SSPs and the distribution of naloxone through SSPs, methadone clinics and prisons. Finally, the scientific community concurs that it is no longer medically sound to deny HCV treatment to PWID. We do not need more research on the efficacy of these interventions. They work. The data are conclusive. The political inertia costs lives.