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Official websites use. Share sensitive information only on official, secure websites. This study identifies the P. Time-location sampling was used to curb possible network bias in recruitment. Over 12 months, migrants completed semi-structured interviews at baseline, monthly follow-ups, and study exit. Analyses were guided by grounded theory. HCV was not a concern. Those who were Gancheros in P. Harm reduction programs should pay closer attention to the rationales behind these injection risks. The Bronx, the poorest of the 5 NYC counties, has the highest number of overdose deaths, and the largest number of Puerto Ricans Paone et al. Yet, when compared to U. PWID in P. Also, there are only 5 inadequately funded syringe exchange programs SEPs in P. Des Jarlais et al. Furthermore, the pervasiveness of injection drug use throughout P. The economic and political crises in P. Since the financial crisis of , the displacement of Puerto Ricans to the U. Among the displaced, many are PWID. Despite U. In this paper, we present findings from our study of the P. For many Latinx immigrants in the U. Latinx immigrants also face acculturative stress from experiencing poverty and discrimination in the U. For them acculturation may be HIV-protective Kang et al. Understanding these risk norms will lay a necessary foundation for the development of culturally appropriate risk-reduction interventions. An aim was to identify the P. Because we sought to capture P. Participants were also required to have injected drugs in P. We employed a combination of purposive sampling PS and time-location sampling TLS to recruit the sample. PS is used to expand existing knowledge of a population and allowed us to recruit a select group of migrants with the characteristics that are the subject matter of our scientific inquiry Patton, To capture the relevance of time after migration for P. Since our study is exploratory, we limited the time after migration of the longer-term group to 6 years to help ensure accurate recollections of P. To populate the sampling frame, we employed TLS, and structured recruitment by a randomized selection of days, times, and locations Magnani et al. Prior to recruitment, for 2 months we conducted observations of venues migrants frequented in the Bronx. To curb network bias, the venue universe contained 26 venues across 4 Bronx neighborhoods. Within the 2. We also identified 5 public drug spots venues where illicit drugs can be purchased , many public drug injection sites parks and street alleys , and businesses where PWID open doors for patrons and panhandle. Study procedures including monthly follow-ups, and an exit interview were explained during consent sessions. We used unique pseudonyms for each participant to protect confidentiality. At baseline, we conducted semi-structured interviews using an interview guide focused on the following domains: 1 sociodemographics; 2 formative years; 3 drug use history; 4 environments where drug use occurred, including access to prevention services; 5 injection norms learned in PR; 6 reasons for risky injection in P. After baseline, we conducted semi-structured monthly face-to-face follow-ups, and asked participants to provide updates on behavioral risks and utilization of HIV and HCV prevention, testing and treatment services, etc. Exit interviews took place 12 months after baseline and used a semi-structured guide. Exit interviews focused on changes in: 1 injection behaviors since baseline ; 2 influences on injection cessation, maintenance, and reduction or maintenance of injection risks; 3 risk networks; 4 experiences with prevention services e. All interviews and follow-ups were conducted in Spanish or English by the Principal Investigator PI or the Research Assistant RA in public parks within the venue universe, in locations where privacy could be maintained. Interviews were audio-recorded and then transcribed verbatim by the RA. Interviews conducted in Spanish were translated into English by the PI. Analyses focused on P. After the PI coded 12 transcripts, she met with 3 additional experienced coders to perform validity and reliability checks of those transcripts. A unified code-list followed and was further examined by 4 coders to insure inter-coder reliability. Two coders proceeded to code the remaining transcripts. Of 40 migrants completing the baseline interview, 20 were recent and 20 were longer-term. Monthly follow-ups were conducted with 35 Results are presented in three sections: A Sociodemographics, B Puerto Rico data drug treatment, prisons and drug dealers , and C New York City data migration and harm reduction access. All except 3 were Spanish-monolingual. A Ganchero is an injection specialist who gets paid for his injection services. Of 9 HIV-positive migrants, 8 were infected in P. All participants had started to inject drugs in P. None reported steady SEP access in P. He knows how to get \[inject\] you. If you have 25 \[units\] of heroin and cocaine, you give him 5. After you get straight, you must leave the shooting \[gallery\]. Everyone in this study injected drugs in shooting galleries in P. The drug treatment program most accessible in P. Although many liked the structure Hogar Crea offered i. Additionally, if caught masturbating, residents had to wear a bracelet with 2 bells and explain to visiting family members the reason for it. Despite these humiliating experiences, some justify this approach. Bonita, one of 4 females all longer-term in the sample, was on buprenorphine maintenance treatment. Bonita: In methadone and Suboxone you just go, take your medication, and leave. Crea is an in-patient \[program\], and a completely different philosophy. They use humiliation and punishment Crea wants you to get clean, period. No methadone, no Suboxone. Interviewer: What kind of structure do migrants need in NYC to help them quit drugs? Bonita: That is an individual journey, you understand? However, Crea is something we know well, and we might feel more comfortable with it. The thing is, you must have the desire to change. If you throw a good apple where there are rotten ones, what do you think will happen? Crea works, but it depends on how you work it. What you want to do, focus on where you want to go. There is no comparison. Here \[in NYC\] you have something that helps you, with that vice you have, a substitute that helps prevent withdrawal pains. Many found the experience too humiliating and left these programs; however, this did not equate to an abandonment of their endorsement of the abstinence-only philosophy. Interviewer- In P. Pedrito: Definitively, there were times there was only one syringe for a cellblock of 48! Pedrito: Yes. I would not wash my syringe 1, 2 or 3 times. Pedrito: If there was no bleach, water-rinsing many times and blowing air through it. The fact is, he is not sure where these infections occurred. Ricky recent : Yes, always. The prison Ganchero gets 2 drops, 2 units. You get straight, and you immediately leave the cell in prison or the shooting \[gallery\] outside prison. You must give him 5 drops, 5 units for the full-service. Ricky: Of course! He must be there, he is the one who knows how to get \[inject\] you. Ricky: Desperation. In prison, the Ganchero secured syringes or made syringes using commissary artifacts such as ear-pumps for suction, or metal spring bars from wristwatches , water, bleach and cookers, injected all PWID in the cellblock and cleaned the syringe usually with bleach from the commissary after each injection. Mateo: Those who sell that on the streets, when they go inside, they will pay for their violation. You can only sell the drugs we approve. Mateo: Yup, if you are wrong, and come inside for raping a girl or whatever, you are going to get what you deserve. Mateo: Yes, even death. Mateo: Both. Mateo: A witness. Prison is entirely Neta. We must give you permission to use drugs, we have norms. Interestingly, just like Hogar Crea, prison-power groups address, often violently, rule breakers. Participants explained that in P. Participants respect their power group leaders and observe their rules to secure order and safety. Interviewer: I see. Did everyone inject on the streets like here in NY? Bebo: Oh no, no. Bebo: Yes. If you inject on the streets, and they get you, they will beat you up. A pound of bread, whatever. In appreciation for your silence, for not snitching. For being a warrior. Throughout the island, Bichotes have a set of norms everyone had to observe: 1 never inject drugs in front of children or the elderly out of respect ; 2 never inject drugs near the drug spot calls for police trouble ; and 3 never throw used needles on the streets to protect kids. Among recent migrants, 5 went directly to a secular residential drug treatment program that recruits PWID on the island through municipal administrations and Christian communities , and one to a Christian drug treatment program. Among longer-term migrants, 5 went to Christian programs. Both types of programs offered immediate Medicaid and Food Stamps enrollment, and inpatient drug treatment using OAT or abstinence-only, prayer-based therapy Christian programs. Of the 5 individuals who arrived directly from P. The promise of housing also evaporated, and at least one migrant was left on the streets during the — Winter season. At the time of this study, most participants were enmeshed in poverty. They started their days accordingly and resumed their income-generating activities: panhandling; opening doors; drug dealing; collecting and redeeming recyclables; and shoplifting. Unlike in P. Despite these circumstances, all participants planned to stay in NYC. In NYC, their anonymity allowed them to do as they pleased without their beloved mothers being adversely affected. They also injected more frequently than they had in P. Despite access to naloxone free-of-charge from local SEPs, none of the participants carried naloxone. SEP utilization is high across the two sub-groups, with 11 recent and 10 longer-term migrants accessing an SEP 6 days a week on average. Also, all 7 active Gancheros in the sample obtained their sterile supplies at these SEPs. Their regular use of SEP may be a steppingstone in the development of safer injection norms. Yet, this process quickly meets resistance for some participants argued that SEPs promote drug use. Melvin recent used SEPs about 3 times a week:. Melvin: It feels good because they help you. Interviewer: But you know they are trying to help you remain HIV-, right? Melvin: Yes and that is a good thing, but on the other end Melvin was not alone in this opinion. Joselito longer-term from Vega Alta, P. Joselito: They serve you everything here in a golden platter. They make it so easy for you to get these services. Like right now, I found you, and you are going to pay me for my time. Joselito: I understand you do it with that in mind. But for us, well you are just making it easier for us to continue doing drugs. While all participants appreciated the public health rationale behind SEP, the ample availability and low-threshold way these services are offered was misread by some as promoting drug use. Forty-five percent of participants regularly used OAT. Unsurprisingly, longer-term migrants injected less frequently than their recent counterparts and attributed this to OAT. Szott, Ricky recent : Yes, sure, we do that over here too. We get the plunger out of the barrel and \[makes blowing sound\] because they say oxygen kills AIDS. We know that so we always do it here too. He added:. I think the bacteria is still there, you know? But not them. And if the person has Hep C then the bacteria could still be there. They really think that getting rid of the blood will do. I see them do it here all the time. Yet, our observations provided data suggesting that this practice is more prevalent than admitted. Of those who disclosed engaging in this practice, 13 of 24 were longer-term migrants. They share because they choose to, they are lazy. When you are sick, you are not going to walk all the way there \[to the SEP\]. This is something that is normal. I even remember once in P. Indeed, this is normative. The other day, I was walking with my husband and we were going to go inject behind the bushes over there \[points to public injection spot in a local park\] and found this guy who asked us for syringes. We will wait for you here. Unlike with water-rinsing and air-blowing, all readily admitted to this behavior. They make sure to keep their used cookers with the cotton inside moist by placing them in tiny clear plastic Ziploc bags. Willie recent , a popular Ganchero, explained,. Payment is in the cooker. We interviewed Willie inside a building where he uses vacant office space as his Ganchero premises. While migrants expressed interest, only 2 participated. At the end of the fieldwork period, one participant had been cured \[Bonita\]. These are health-promoting practices that are helping some prevent disease transmission, and clearly saving the lives of many, judging by the volume of overdose reversals at local SEPs. Yet there are clear limits to these health-promoting practices. Migrants actively preserve injection risk behaviors and norms acquired in P. Although these run counter to the standard gospel of harm reduction e. Also, laboratory tests have shown that water-rinsing may be effective in ridding a used syringe from HIV Abdala et al. For those in this study, it seems that after having engaged in water-rinsing and air-blowing for years, their maintenance of an HIV-negative status might serve as confirmation that this practice works and trump NYC-normative harm reduction narratives that dismiss it as not evidence-based. This binary framework cannot adequately explain the complex processes by which these migrants negotiate the intersection of normative injection practices and logics of their home environment PR with those of their host environment NYC. Acculturation theory would suggest that, after migration to the U. However, our data show that this would be an oversimplification of their reality. These migrants strategically adopt some new drug-related behaviors in NYC i. This suggests that cultural norms and practices, even within the domain of injection drug use, are not monolithic entities to be rejected, retained or adopted in toto, but rather the product of ongoing processes of negotiation. While prevalent, SEP use is mainly an ex post facto event. Their daily activities revolve around securing as many injection sessions as possible. They wake up very early, clean their still-moist, heavily used cookers to curb morning sickness, and begin to engage in income-generating activities. SEP attendance will only take place after they have secured that first speedball injection, after they have engaged in a Caballo session, after they have shared a heavily-used cooker with their Caballo running partner, and after they cleaned a previously used syringe by water-rinsing and air-blowing. Although often within a 2—3-minute walk, the SEP is simply too out of the way from the location where their most intrinsic needs can be met: the drug spots. Hence, they do not perceive a compelling need to change their behavior. Moreover, many are severe in their critique of OAT and refuse to utilize it. While their ambivalence towards SEP does not prevent them from using it, ambivalence towards OAT curtails access among recent migrants. Hansen, , as promoted by Hogar Crea and other programs. For their influence over perceptions of OAT, religious approaches to drug treatment are associated with the very high injection frequency and risks of recent migrants in this study. Hence, their moral approach to OAT augments their disease vulnerability. Also, the absence of Bichotes controlling the drug scene in NYC is important. Their respect stemmed from fear of violence and also from the care they experienced from Bichotes gifted morning bags, gifted their mothers, and nurtured respect for their communities by prohibiting public injection. In NYC, migrants also lack the authority figures prison power groups represented in P. The only native figure who did not disappear with migration is the Ganchero. This is a positive thing. Because drug quality in NYC is experienced as significantly lower than in P. When factoring in that their preferred drug is speedballs, which deteriorates veins faster than heroin-only injections Loyd-Smith et al. The Ganchero figure then emerges as a possible way out of risk for migrants, for he is a figure migrants relate to, and one who organically displays aptitudes for safer injection practices. Given the exploratory nature of this study, relatively small sample size and lack of probabilistic sampling, findings from this study may not be representative of the migrant Puerto Rican PWID population in NYC. However, the rigorous recruitment approach — in particular, the use of time-location sampling techniques to populate our purposive sampling frame — helped to insure geographic and PWID network variance in the sample and may increase the generalizability of the results. Another limitation is that much data stems from self-report and as such should be viewed with caution. While SEP use is normative, sterile syringe use is not a priority. Furthermore, P. Indeed, this may be an opportunity for harm reduction programs to engage the communities they serve in a revitalizing dialogue of their service needs. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. A person who supervises and controls the drug trade in a specific neighborhood of Puerto Rico. Commonly used name for government-assisted housing in Puerto Rico. The syringe man. A person with injection supplies who exchanges his vein-finding expertise for drugs or money. A widely available faith and abstinence-based program for people who use drugs in Puerto Rico. A prison-based power group in Puerto Rico. Known as the largest and most powerful of prison power groups. Conflict of interest statement: The authors declare no conflict of interest. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. As a library, NLM provides access to scientific literature. Int J Drug Policy. Published in final edited form as: Int J Drug Policy. Find articles by H Guarino. Find articles by E Benoit. Find articles by S Deren. Find articles by ER Pouget. Authors contributions Dr. Issue date Jul. PMC Copyright notice. The publisher's version of this article is available at Int J Drug Policy. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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