Skip to main content
SpringerLink
Log in

HIV and Hepatitis C Among People Who Inject Drugs in Memphis, Tennessee: an Intersectional Risk Environment Analysis of the Social Determinants of Health

  • Published:
Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

Background

The Southern US is confronting bourgeoning HIV and hepatitis C virus (HCV) epidemics among people who inject drugs (PWID), yet little is known about shared and unique risk factors across the region. We applied an intersectional risk environment framework to understand infectious disease outcomes for sub-groups of PWID that experience multiple axes of social marginalization related to racial and ethnic identity and social and economic vulnerability.

Methods

HIV and HCV prevalence was estimated from the first iteration of the CDC’s National HIV Behavioral Surveillance respondent driven sample of PWID in Shelby County, Tennessee in 2018. We ran adjusted multinomial models to test main and interaction effects of race/ethnicity and structural factors on the prevalence of a three-level outcome: HIV-only, HCV-only, and no infection.

Results

A total of 564 PWID participated, 558 (99%) completed HIV testing, and 540 (96%) HCV testing. Thirty (5%) were HIV-positive, 224 (40%) HCV-positive, and less than 1% were co-infected. Descriptive differences by race/ethnicity and levels of structural vulnerability for HIV and HCV subpopulations were present; however, there was no evidence for statistical interaction. In the final main effects model, HIV status was positively associated with non-Hispanic Black identity (aRR 4.95, 95% CI 1.19, 20.6), whereas HCV status was associated with non-white identity (aRR 0.11 95% CI 0.07, 0.18). Factors associated with HCV infection were higher scores of structural vulnerability (aRR 2.19 95% CI 1.10, 4.35), and criminal legal involvement (aOR 1.99 95% CI 1.18, 3.37).

Conclusion

This is the first study to implement local population-based survey data to evaluate distinctive intersections of ethnic/racial and social factors associated with HIV and HCV status among PWID in the Memphis region. Findings come at an opportune time as harm reduction programs are in development in the South and shed light to the need for socially equitable race conscious resource investment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Center for Disease Control. HIV in the Southern United States [Internet]. Center for Disease Control; 2019. Available from: https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf. Accessed 12 Feb 2022.

  2. Rosenberg ES, Rosenthal EM, Hall EW, Barker L, Hofmeister MG, Sullivan PS, et al. Prevalence of hepatitis C virus infection in US states and the district of Columbia, 2013 to 2016. JAMA Netw Open. 2018;1:e186371.

    Article  PubMed  PubMed Central  Google Scholar 

  3. National HIV Behavioral Surveillance (2018 ) HIV infection, risk, prevention, and testing behaviors among persons who inject drugs. Center Dis Contr. 43.

  4. Van Handel MM, Rose CE, Hallisey EJ, Kolling JL, Zibbell JE, Lewis B, et al. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 1999;2016(73):323–31.

    Google Scholar 

  5. Sizemore L. HIV and Viral hepatitis co-infection(s) and data to action efforts in Tennessee. TN Department of Health; 2019.

  6. Bartholomew TS, Onugha J, Bullock C, Scaramutti C, Patel H, Forrest DW, et al. Baseline prevalence and correlates of HIV and HCV infection among people who inject drugs accessing a syringe services program; Miami. FL Harm Reduct J. 2020;17:40.

    Article  PubMed  Google Scholar 

  7. Tennessee Department of Health. Tennessee Annual Syringe Services Program Highlights, 2021 [Internet]. Nashville, Tennessee: TN Department of Health; 2022. Available from: https://www.tn.gov/content/dam/tn/health/documents/2021-SSP-Annual-Report.pdf. Accessed 12 Feb 2022.

  8. Levitt A, Mermin J, Jones CM, See I, Butler JC. Infectious diseases and injection drug use: public health burden and response. J Infect Dis. 2020;222:S213-7.

    Article  PubMed  Google Scholar 

  9. Tennessee Department of Health. Tennessee HIV Epidemiological Profile, 2020. 2022 Apr.

  10. Tennessee Department of Health. Memphis National HIV Behavioral Surveillance (NHBS) Profile, 2016–2018 [Internet]; 2020. Available from: https://www.tn.gov/content/dam/tn/health/program-areas/std/TDH-Statewide-2022-NHBS-presentation.pdf. Accessed 12 Feb 2022.

  11. Viral Hepatitis Program. Tennessee viral hepatitis epidemiological profile, 2018. Tennessee Department of Health; 2020.

  12. Buot M-LG, Docena JP, Ratemo BK, Bittner MJ, Burlew JT, Nuritdinov AR, et al. Beyond race and place: distal sociological determinants of HIV disparities. PLOS ONE. 2014;9:9e1711.

    Article  Google Scholar 

  13. Platt L, Easterbrook P, Gower E, McDonald B, Sabin K, McGowan C, et al. Prevalence and burden of HCV co-infection in people living with HIV: a global systematic review and meta-analysis. Lancet Infect Dis. 2016;16:797–808.

    Article  PubMed  Google Scholar 

  14. Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health [Internet]. 2018 [cited 2022 Feb 12];108. Available from: https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304187

  15. Rhodes T, Wagner K, Strathdee SA, Shannon K, Davidson P, Bourgois P. Structural violence and structural vulnerability within the risk environment: theoretical and methodological perspectives for a social epidemiology of HIV risk among injection drug users and sex workers. In: O’Campo P, Dunn JR, editors. Rethink Soc Epidemiol Sci Change [Internet]. Dordrecht: Springer, Netherlands; 2012. p. 205–30. https://doi.org/10.1007/978-94-007-2138-8_10.

    Chapter  Google Scholar 

  16. World Health Organization. A conceptual framework for action on the social determinants of health [Internet]. Geneva, Switzerland: World Health Organization; 2010. Available from: https://www.who.int/publications-detail-redirect/9789241500852. Accessed 12 Feb 2022.

  17. Brantley ML, Footer KHA, Lim S, Kerrigan D, Sherman SG. Experiences of structural vulnerability among exotic dancers in Baltimore, Maryland: co-occurring social and economic antecedents of HIV/STI risk. Int J Drug Policy. 2017;50:74–81.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Moen M, German D, Storr C, Friedmann E, Flynn C, Johantgen M. Social stability relates social conditions to the syndemic of sex, drugs, and violence. J Urban Health Bull N Y Acad Med. 2020;97:395–405.

    Google Scholar 

  19. Bayat A-H, Mohammadi R, Moradi-Joo M, Bayani A, Ahounbar E, Higgs P, et al. HIV and drug related stigma and risk-taking behaviors among people who inject drugs: a systematic review and meta-analysis. J Addict Dis. 2020;38:71–83.

    Article  PubMed  Google Scholar 

  20. Adams JW, Lurie MN, King MRF, Brady KA, Galea S, Friedman SR, et al. Potential drivers of HIV acquisition in African-American women related to mass incarceration: an agent-based modelling study. BMC Public Health. 2018;18:1387.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Berkman LF, Kawachi I, Glymour MM. Socioeconomic status and health. Soc Epidemiol. Oxford University Press; 2014. p. 18–22.

  22. American Medical Association. New AMA policies recognize race as a social, not biological, construct [Internet]. Soc. Constr. Race. 2020 [cited 2022 Nov 23]. Available from: https://www.ama-assn.org/press-center/press-releases/new-ama-policies-recognize-race-social-not-biological-construct

  23. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105–25.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the southern United States: sexual networks and social context. Sex Transm Dis. 2006;33:S39-45.

    Article  PubMed  Google Scholar 

  25. Bailey ZD, Feldman JM, Bassett MT. How structural racism works — racist policies as a root cause of U.S. racial health inequities. N Engl J Med. 2021;384:768–73.

  26. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On racism: a new standard for publishing on racial health inequities. Health Aff Forefr [Internet]. 2022 [cited 2022 Sep 3]; Available from: https://www.healthaffairs.org/do/10.1377/forefront.20200630.939347/full/

  27. Des Jarlais DC, Bramson HA, Wong C, Gostnell K, Cepeda J, Arasteh K, et al. Racial/ethnic disparities in HIV infection among people who inject drugs: an international systematic review and meta-analysis. Addiction. 2012;107:2087–95.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ibragimov U, Beane S, Friedman SR, Tempalski B, Williams LD, McKetta S, et al. Evidence for HIV transmission across key populations: a longitudinal analysis of HIV and AIDS rates among Black people who inject drugs and Black heterosexuals in 84 large U.S. metropolitan areas, 2008–2016. Ann Epidemiol. 2021;55:69-77.e5.

    Article  PubMed  Google Scholar 

  29. Strathdee SA, Beletsky L, Kerr T. HIV, drugs and the legal environment. Int J Drug Policy. 2015;26:S27-32.

    Article  PubMed  Google Scholar 

  30. Cooper HLF, Linton S, Kelley ME, Ross Z, Wolfe ME, Chen Y-T, et al. Racialized risk environments in a large sample of people who inject drugs in the United States. Int J Drug Policy. 2016;27:43–55.

    Article  PubMed  Google Scholar 

  31. Friedman SR, Cooper HLF, Osborne AH. Structural and social contexts of HIV risk among African Americans. Am J Public Health. 2009;99:1002–8.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Thompson JR, Creasy SL, Mair CF, Burke JG. Drivers of opioid use in Appalachian Pennsylvania: cross-cutting social and community-level factors. Int J Drug Policy. 2020;78:102706.

    Article  PubMed  PubMed Central  Google Scholar 

  33. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention. HIV Surveillance in Urban and Nonurban Areas [Internet]. Center for Disease Control; 2018 p. 25. Available from: https://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-urban-nonurban-2018.pdf. Accessed 12 Feb 2022.

  34. Suryaprasad AG, White JZ, Xu F, Eichler B-A, Hamilton J, Patel A, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006–2012. Clin Infect Dis Off Publ Infect Dis Soc Am. 2014;59:1411–9.

    Article  CAS  Google Scholar 

  35. Zibbell JE, Iqbal K, Patel RC, Suryaprasad A, Sanders KJ, Moore-Moravian L, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years - Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep. 2015;64:453–8.

    PubMed  PubMed Central  Google Scholar 

  36. U.S. Census Bureau QuickFacts: Shelby County, Tennessee [Internet]. 2020 [cited 2022 Sep 3]. Available from: https://www.census.gov/quickfacts/shelbycountytennessee

  37. Collins AB, Boyd J, Cooper HLF, McNeil R. The intersectional risk environment of people who use drugs. Soc Sci Med. 2019;234:112384.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Jackson JW, Williams DR, VanderWeele TJ. Disparities at the intersection of marginalized groups. Soc Psychiatry Psychiatr Epidemiol. 2016;51:1349–59.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS Lond Engl. 2005;19(Suppl 2):S67-72.

    Article  Google Scholar 

  40. German D, Latkin CA. Social stability and HIV risk behavior: evaluating the role of accumulated vulnerability. AIDS Behav. 2012;16:168–78.

    Article  PubMed  PubMed Central  Google Scholar 

  41. James K, Jordan A. The opioid crisis in Black communities. J Law Med Ethics J Am Soc Law Med Ethics. 2018;46:404–21.

    Google Scholar 

  42. Centers for Disease Control and Prevention. HIV Surveillance Report, 2020 [Internet]. Centers for Disease Control and Prevention; 2022 May. Available from: http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html

  43. McCreesh N, Frost S, Seeley J, Katongole J, Tarsh MN, Ndunguse R, et al. Evaluation of respondent-driven sampling. Epidemiol Camb Mass. 2012;23:138–47.

    Article  Google Scholar 

  44. Estrada AL. Health disparities among African-American and Hispanic drug injectors–HIV, AIDS, hepatitis B virus and hepatitis C virus: a review. AIDS Lond Engl. 2005;19(Suppl 3):S47-52.

    Article  Google Scholar 

  45. Akselrod H, Grau LE, Barbour R, Heimer R. Seroprevalence of HIV, hepatitis B virus, and HCV among injection drug users in Connecticut: understanding infection and coinfection risks in a nonurban population. Am J Public Health. 2014;104:1713–21.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Baker P, Beletsky L, Avalos L, Venegas C, Rivera C, Strathdee SA, et al. Policing practices and risk of HIV infection among people who inject drugs. Epidemiol Rev. 2020;42:27–40.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Beletsky L, Cochrane J, Sawyer AL, Serio-Chapman C, Smelyanskaya M, Han J, et al. Police encounters among needle exchange clients in Baltimore: drug law enforcement as a structural determinant of health. Am J Public Health. 2015;105:1872–9.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Cooper H. The impact of a police drug crackdown on drug injectors’ ability to practice harm reduction: a qualitative study. Soc Sci Med. 2005;61:673–84.

    Article  PubMed  Google Scholar 

  49. Flath N, Tobin K, King K, Lee A, Latkin C. Enduring consequences from the war on drugs: how policing practices impact HIV risk among people who inject drugs in Baltimore City. Subst Use Misuse. 2017;52:1003–10.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Park JN, Rouhani S, Beletsky L, Vincent L, Saloner B, Sherman SG. Situating the continuum of overdose risk in the social determinants of health: a new conceptual framework. Milbank Q. 2020;98:700–46.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Cisneros N, Sears B, Lennon-Dearing R. Enforcement of HIV criminalization in Tennessee [Internet]. Williams Institute: UCLA School of Law; 2022 Jun. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/HIV-Criminalization-TN-Jun-2022.pdf

  52. Tennessee Department of Health. Tennesse HIV Epidemiological Profile, 2019 [Internet]. 2021 [cited 2023 Jul 21]. Available from: https://www.tn.gov/content/dam/tn/health/program-areas/hiv/2019-Tennessee-HIV-Epidemiological-Profile.pdf

  53. del Río-González AM, Holt SL, Bowleg L. Powering and structuring intersectionality: beyond main and interactive associations. Res Child Adolesc Psychopathol. 2021;49:33–7.

    Article  PubMed  Google Scholar 

  54. Rouhani S. Intersectionality-informed quantitative research: a primer [Internet]. Simon Fraser University: The Institute for Intersectionality Research & Policy; 2014. Available from: https://www.ifsee.ulaval.ca/sites/ifsee.ulaval.ca/files/9eba2da23ab70bfadd9ca2e076af4a3a62cc.pdf.

  55. Scott AJ, Wilson RF. Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration. Rural Remote Health. 2011;11:1634.

    CAS  PubMed  Google Scholar 

  56. Reif S, Safley D, McAllaster C, Wilson E, Whetten K. State of HIV in the US Deep South. J Community Health. 2017;42:844–53.

    Article  PubMed  Google Scholar 

  57. SisterReach. Who We Are [Internet]. We are people we serve. 2023 [cited 2023 Oct 28]. Available from: https://www.sisterreach-tn.org/who-we-are.html

  58. Krieger N. Structural racism, health inequities, and the two-edged sword of data: structural problems require structural solutions. Front Public Health. 2021;9: 655447.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Kim BJ, Handcock MS. Population size estimation using multiple respondent-driven sampling surveys. J Surv Stat Methodol. 2021;9:94–120.

    Article  PubMed  Google Scholar 

  60. Ford CL, Airhihenbuwa CO. The public health critical race methodology: praxis for antiracism research. Soc Sci Med. 2010;71:1390–8.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We extend sincere gratitude to Monica Kent, Iran Yarbrough, Bridgette Robinson, the NHBS Memphis field team, and the NHBS-PWID study participants.

Funding

The NHBS surveillance research is sponsored by the CDC grant: P029636. Natalie Flath is supported by the National Institute’s of Drug Abuse grant number: T32DA007292-31A1.

Author information

Authors and Affiliations

  1. Department of Mental Health, School of Public Health, Johns Hopkins Bloomberg, 624 N Broadway, Baltimore, MD, 21205, USA

    Natalie Flath

  2. Tennessee Department of Health, Communicable and Environmental Disease and Emergency Preparedness, 710 James Robertson Parkway, 4th Floor, Nashville, TN, 37243, USA

    Jack H. Marr

  3. Tennessee Department of Health, 710 James Robertson Parkway, 4th Floor, Viral Hepatitis Program, Nashville, TN, 37243, USA

    Lindsey Sizemore

  4. Division of Social and Behavioral Sciences School of Public Health, University of Memphis 209 Robison Hall Memphis, Tennessee, 38152, USA

    Latrice C. Pichon

  5. Tennessee Department of Health, 710 James Robertson Parkway, 4th Floor, Nashville, TN, 37243, USA

    Meredith Brantley

Authors
  1. Natalie Flath
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jack H. Marr
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lindsey Sizemore
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Latrice C. Pichon
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Meredith Brantley
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Natalie Flath: conceptualization, methodology, investigation, formal analysis, writing—original draft; Jack Marr: data curation, resources, investigation, formal analysis, writing—review and editing; Lindsey Sizemore: conceptualization, writing—review and editing; Latrice Pichon: writing—review and editing; Meredith Brantley: funding acquisition, supervision, conceptualization, writing—review and editing.

Corresponding author

Correspondence to Natalie Flath.

Ethics declarations

Ethics Approval

The TN Department of Health IRB approved this study.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Competing Interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Flath, N., Marr, J.H., Sizemore, L. et al. HIV and Hepatitis C Among People Who Inject Drugs in Memphis, Tennessee: an Intersectional Risk Environment Analysis of the Social Determinants of Health. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01878-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40615-023-01878-x

Keywords

Search

Navigation