Research paperRacialized risk environments in a large sample of people who inject drugs in the United States
Introduction
A recent systematic review of international evidence found that HIV prevalence among people who inject drugs (PWID) is twice as high among racial/ethnic minority PWID than among racial/ethnic majority PWID (Des Jarlais et al., 2012). Disparities in HIV prevalence among PWID are particularly stark in the United States (US), where HIV prevalence is six and eleven times higher among Latino and non-Hispanic black PWID, respectively, than among non-Hispanic white PWID (Centers for Disease Control & Prevention, 2006, Laffoon et al., 2011, Lansky et al., 2014). The broad ranges of these disparities reflect geographic variation in the distribution of HIV within and across racial/ethnic groups. These disparities have persisted since the early days of the epidemic in the US (Friedman, Quimby, Sufian, Abdul-Quader, & Des Jarlais, 1997, Kottiri, Friedman, Neaigus, Curtis, & Des Jarlais, 2002). Racial/ethnic differences in risk behaviors do not explain them: Latino and non-Hispanic black PWID are as likely or often less likely to report injection-related and sexual risk behaviors than non-Hispanic white PWID (Centers for Disease Control and Prevention, 2012a, Centers for Disease Control and Prevention, 2012b, Centers for Disease Control and Prevention, 2012c, Cooper et al., 2011, Friedman et al., 1993, Linton et al., 2013, Williams et al., 2013). Racial/ethnic disparities also exist in the progression of HIV infection among HIV-positive PWID in the US (Grigoryan, Hall, Durant, & Wei, 2009). Accordingly, the US Centers for Disease Control and Prevention (CDC), the White House, the Department of Health and Human Services, and investigators have called for research and interventions into the ways in which social factors, including characteristics of the places people live, create and perpetuate these disparities (Centers for Disease Control and Prevention, 2011, Centers for Disease Control and Prevention, 2012a, Centers for Disease Control and Prevention, 2012b, Centers for Disease Control and Prevention, 2012c, Friedman et al., 2009National Institute on Drug Abuse of the National Institutes of Health, 2009, National Minority AIDS Council, 2006, ODP, 2012, The White House Office of National AIDS Policy, 2010).
The Risk Environment Model is a powerful theoretical framework to guide studies of the social determinants of HIV-related outcomes among PWID; a particular strength is its focus on how characteristics of the places where PWID live, work, and engage in drug-related activities shape vulnerability (Rhodes, 2002, Rhodes, 2009, Rhodes et al., 2003, Rhodes et al., 2005, Strathdee et al., 2010). The Risk Environment Model has, however, been underutilized in studies of racial/ethnic disparities in HIV-related outcomes among PWID. This paper develops the concept of “racialized risk environments” and empirically investigates the extent to which PWID who are Latino, non-Hispanic black, and non-Hispanic white (hereafter referred to as black and white, respectively) live in different geographically-defined risk environments in the US. Fundamentally at issue in this analysis is whether black and Latino PWID live in riskier environments than white PWID.
The Risk Environment Model foregrounds the social situations, structures, and places that generate vulnerability to HIV transmission and other drug-and HIV-related harms among PWID (Rhodes, 2002, Rhodes, 2009, Rhodes et al., 2003, Rhodes et al., 2005, Strathdee et al., 2010). The “risk environment” is defined as the “space…[where] factors exogenous to the individual interact to increase the chances of HIV transmission” (Rhodes et al., 2005, p. 1026) and other drug- and HIV-related harms, including HIV-related morbidity and mortality (Milloy et al., 2012). This environment consists of four types of influence: influences that are social, economic, political, or physical (Rhodes, 2002, Rhodes et al., 2005). Some of these influences may be features of places (e.g., neighborhood poverty rates), while others may not be rooted in place (e.g., risk networks, interpersonal discrimination).
The model posits that each type of influence operates at multiple, intersecting levels to affect individual vulnerability (Rhodes, 2002, Rhodes, 2009, Rhodes et al., 2003, Rhodes et al., 2005, Strathdee et al., 2010).
A large body of evidence testifies to the explanatory power of the Risk Environment Model (Rhodes et al., 2005, Degenhardt et al., 2010, Strathdee et al., 2010). Studies have used it to identify policies and other contextual factors that seem to influence HIV acquisition and disease progression among PWID (Strathdee et al., 2010, Milloy et al., 2012); to describe vulnerability to HIV among non-injection drug users (Goldenberg et al., 2011); and to inform mathematical models that explore the relationships between environmental factors and HIV (Strathdee et al., 2010). This model has rarely, however, been applied to study racial/ethnic disparities in HIV-related outcomes among PWID.
To advance research and interventions into disparities in HIV-related outcomes among PWID, we have previously proposed that place-based features of risk environments may be “racialized” in the US (Cooper, Bossak, Tempalski, Friedman, & Des Jarlais, 2009). A risk environment is racialized when racial/ethnic groups of PWID inhabit places that differ systematically in the availability of protective features (e.g., substance abuse treatment programs) and in the presence of harmful features (e.g., police drug crackdowns). In addition to being rooted in the Risk Environment Model, the construct “racialized risk environments” has origins in Critical Race Theory (Bonilla-Silva, 2001). Central to Critical Race Theory is the concept of racialized social systems in which
“… economic, political, social, and ideological [hierarchies] are partially structured by the placement of actors in racial categories … The race placed in the superior position tends to receive greater economic remuneration and access to better occupations and prospects in the labor market, occupies a primary position in the political system, is granted higher social estimation …, often has the license to draw physical (segregation) as well as social (racial etiquette) boundaries … and receives what W.E.B. DuBois called a ‘psychological wage.”’ (Bonilla-Silva, 2001, p. 37).
In the US, racialized social systems can manifest geographically. Within metropolitan areas, racial/ethnic residential segregation sorts members of different racial/ethnic groups into neighborhoods that are both separate and unequal (Logan and Stults, 2011, Massey and Denton, 1989, Massey and Denton, 1993). In US metropolitan areas in 2010, the average black resident lived in a census tract in which 45% of the other residents were black, 35% were white, and 15% were Latino (Logan & Stults, 2011). A parallel pattern existed for Latinos (Logan & Stults, 2011). The average white resident lived in a tract where 75% of the other residents were white and just 8% were black and 11% were Latino (Logan & Stults, 2011). Within segregated metropolitan areas, predominately black neighborhoods (often measured as census tracts) tend to have fewer social, economic, political, and physical resources and more hazards than predominately white neighborhoods; the same is true for predominately Latino neighborhoods, though perhaps to a lesser extent (Massey and Denton, 1989, Massey and Denton, 1993). For example, in urban areas predominately black neighborhoods tend to have higher densities of abandoned buildings, worse municipal services, and poorer housing quality than predominately white neighborhoods (Williams & Collins, 2001).
Members of different racial/ethnic groups may also experience different living environments in larger geographic areas (e.g., counties, municipalities, metropolitan areas). To illustrate, municipalities with higher proportions of black residents invest less in parks (Joassart-Marcelli, 2010).
Racial/ethnic differences in features of the environments where people live are associated with disparities in several health outcomes in the general population (Bleich et al., 2010, Do et al., 2008, Laveist et al., 2011). For example, an analysis of the US National Health Interview Survey data found that differences in neighborhood context explained 38%–76% (depending on the age group) of the black/white disparity in self-rated health among men, after adjusting for individual-level factors (Do et al., 2008); self-rated health strongly predicts mortality (Idler and Benyamini, 1997, Idler and Kasl, 1991, Idler et al., 2000). Conversely, disparities in diabetes and obesity disappear and disparities in hypertension are reduced when black and white adults live in racially integrated neighborhoods (Bleich et al., 2010, Laveist et al., 2011).
Despite the promise of studies on the environments where people live and health disparities in the general population, the prominence of the Risk Environment Model in studies of PWID health, and the magnitude of disparities in HIV infection and HIV disease progression among PWID, research on whether and how place characteristics predict racial/ethnic disparities in HIV-related outcomes among PWID remains rare. To support the development of this line of inquiry and of the Risk Environment Model, this paper describes the extent to which place-based features of risk environments are racialized in a large sample (N = 9170) of PWID living in the US.
Section snippets
Study description and analytic sample
We integrated 2009 surveillance data about PWID living in 19 US metropolitan statistical areas (MSAs) with Census data and data from other existing administrative sources to describe features of the environments where PWID lived. Data on individual PWID were drawn from the 2009 cycle of the CDC's National HIV Behavioral Surveillance (NHBS) (Gallagher, Sullivan, Lansky, & Onorato, 2007). NHBS collects data on HIV serostatus, HIV-related risk behaviors, and health service use among PWID, men who
Results
The 9170 PWID in the analytic sample lived in 15 states, 19 MSAs, 51 counties, and 969 ZIP codes. On average there were 611.33 participants (SD = 308.13) living in each state; 482.63 participants (SD = 93.84) in each MSA; 179.80 participants (SD = 227.23) in each county, and 9.47 participants (SD = 20.05) in each ZIP code area (Table 2). Participants had lived in the MSA where they were sampled for an average of 31.69 years (SD = 19.44). Over half (51.79%) of the participants were black; 30.24% were
Discussion
This analysis of 9170 PWID living in 19 MSAs reveals the extent to which risk environments in the US are “racialized.” Risk environments varied by race/ethnicity, though the extent and nature of this racialization depended on the type of influence, geographic scale, and the racial/ethnic groups compared. Given the extensive literature linking features of the risk environment studied here to vulnerability to HIV and to HIV disease progression among PWID (Cooper et al., 2011, Cooper et al., 2012a
Conclusions
PWID risk environments in the US appear to be racialized, with black PWID living, on average, in environments that past research has found to be associated with increased vulnerability to adverse HIV-related outcomes. Future longitudinal research should assess the extent to which differential exposure to features of risk environments is associated with disparities in these outcomes among PWID, using appropriate methods.
The findings and conclusions in this report are those of the authors and do
Conflict of interest
The authors have no conflicts to disclose.
Acknowledgements
This research was supported by two NIH grants: “Place Characteristics & Disparities in HIV in IDUS: A Multilevel Analysis of NHBS” (DA035101; Cooper, PI) and the Emory Center for AIDS Research (P30 AI050409; Curran, PI). It was also supported by the Centers and Disease Control and Prevention, and the National HIV Behavioral Surveillance Study Group: Atlanta, GA: Jennifer Taussig, Shacara Johnson, Jeff Todd; Baltimore, MD: Colin Flynn, Danielle German; Boston, MA: Debbie Isenberg, Maura
References (94)
- et al.
Distance traveled to outpatient drugtreatment and client retention and client retention
Journal of Substance Abuse Treatment
(2003) - et al.
Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: A longitudinal analysis
Social Science and Medicine
(2006) - et al.
The impact of a police drug crackdown on drug injectors’ ability to practice harm reduction: A qualitative study
Social Science & Medicine
(2005) Medical theories of opiate addiction's aetiology and their relationship to addicts’ perceived social position in the United States: An historical analysis
International Journal of Drug Policy
(2004)- et al.
Drug-related arrest rates and spatial access to syringe exchange programs in New York City health districts: Combined effects on the risk of injection-related infections among injectors
Health & Place
(2012) - et al.
Police drug crackdowns and hospitalization rates for illicit-injection-related infections in New York City
International Journal of Drug Policy
(2005) - et al.
Prevention of HIV infection for people who inject drugs: Why individual, structural, and combination approaches are needed
Lancet
(2010) - et al.
Does place explain racial health disparities? Quantifying the contribution of residential context to the Black/white health gap in the United States
Social Science & Medicine
(2008) - et al.
“Over here, it's just drugs, women and all the madness”: The HIV risk environment of clients of female sex workers in Tijuana, Mexico
Social Science & Medicine
(2011) - et al.
The longitudinal association between homelessness, injection drug use, and injection-related risk behavior among persons with a history of injection drug use in Baltimore, MD
Drug and Alcohol Dependence
(2013)
Neighborhood context and self-rated health in older Mexican Americans
Annals of Epidemiology
The ‘risk environment’: A framework for understanding and reducing drug-related harm
International Journal of Drug Policy
Risk environments and drug harms: A social science for harm reduction approach
International Journal of Drug Policy
Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: A qualitative study of micro risk environment
Social Science & Medicine
The social structural production of HIV risk among injecting drug users
Social Science & Medicine
HIV and risk environment for injecting drug users: The past, present, and future
Lancet
The New Jim Crow: Mass incarceration in the age of colorblindness
Access to social services: The changing urban geography of poverty and service provision
Metropolitan policy program survey series
Interactive spatial data analysis
Racial residential segregation and rates of gonorrhea in the United States, 2003–2007
American Journal of Public Health
Social context explains race disparities in obesity among women
Journal of Epidemiology & Community Health
White supremacy and racism in the post-civil rights era
HIV infection and risk, prevention, and testing behaviors among injecting drug users – National HIV Behavioral Surveillance System, 20 U.S. cities, 2009
MMWR Surveillance Summaries
Racial disparities in injection-related HIV: A case study of toxic law
Temple Law Review
Racial/ethnic disparities in diagnoses of HIV/AIDS – 33 states, 2001–2004
MMWR
Strategic plan: The division of HIV/AIDS prevention 2011 through 2015
Diagnoses of HIV infection among adults and adolescents, by sex and transmission category, 2010 – 46 states and 5 U.S. dependent areas
HIV surveillance report
HIV infection and HIV-associated behaviors among injecting drug users – 20 cities. United States, 2009
MMWR
Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: Summary guidance from CDC and the U.S. Department of Health and Human Services
MMWR Recommendations & Reports
Expanded Testing Initiative
Temporal trends in spatial access to pharmacies that sell over-the-counter syringes in New York City health districts: Relationship to local racial/ethnic composition and need
Journal of Urban Health
Spatial access to syringe exchange programs and pharmacies selling over-the-counter syringes as predictors of drug injectors’ use of sterile syringes
American Journal of Public Health
Spatial access to sterile syringes and the odds of injecting with an unsterile syringe among injectors: A longitudinal multilevel study
Journal of Urban Health
Residential segregation and the prevalence of injection drug use among black adult residents of US metropolitan areas
American Journal of Public Health
Geographic approaches to quantifying the risk environment: Drug-related law enforcement and access to syringe exchange programmes
International Journal of Drug Policy
Dark paradise: A history of opiate addiction in America
Recent evidence on the continuing causes of Black–White residential segregation
Journal of Urban Affairs
Addressing the HIV/AIDS epidemic among Puerto Rican people who inject drugs: The need for a multiregion approach
American Journal of Public Health
Racial and ethnic disparities and implications for the prevention of HIV among persons who inject drugs
Current Opinion in HIV & AIDS
Comparing alternative methods of measuring geographic access to health services
Health Services & Outcomes Research Methodology
Melting pot cities and suburbs: Racial and ethnic change in Metro America in the 2000s
Metropolitan policy program at Brookings
Relationships of deterrence and law enforcement to drug-related harms among drug injectors in US metropolitan areas
AIDS
Structural and social contexts of HIV risk among African Americans [Erratum appears in American Journal of Public Health, 2009 Aug;99(8):1352]
American Journal of Public Health
Laws prohibiting over-the-counter syringe sales to injection drug users: Relations to population density, HIV prevalence, and HIV incidence
American Journal of Public Health
Network and sociohistorical approaches to the HIV epidemic among drug injectors
Racial differences in sexual behaviors related to AIDS in a nineteen city sample of street-recruited drug injectors
AIDS Education and Prevention
Behavioral surveillance among people at risk for HIV infection in the U.S.: The National HIV Behavioral Surveillance System
Public Health Reports
Cited by (52)
Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia
2021, International Journal of Drug PolicyIs the severity of the Great Recession's aftershocks correlated with changes in access to the combined prevention environment among people who inject drugs?
2021, International Journal of Drug PolicyCitation Excerpt :We posit that the Great Recession, a feature of the macro-level economic environment reduced spatial access to local HIV-prevention health care service access for PWID, a feature of the micro-level healthcare service environment. The construct “racialized risk environment” (Cooper et al., 2016) further suggests that declines in spatial access will be attenuated in areas home to higher concentrations of non-Hispanic white residents. To achieve our research aims, we characterized changes in access to the combined prevention environment between 2009 and 2012 by constructing two dichotomous variables at the ZIP code-level: (1) loss in access to combined prevention programs vs. no change, and (2) gain in access vs. no change.
Decision-making by laypersons equipped with an emergency response smartphone app for opioid overdose
2021, International Journal of Drug PolicyAn application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs
2021, International Journal of Drug PolicyCitation Excerpt :These differential findings by MSA and race/ethnicity may reflect the racial/ethnic distribution of the PWID in the five cities of interest. Based on our prior research we also hypothesize exposure to place-based factors may partly influence these findings (H. L. F. Cooper et al., 2016). However, we were unable to model such nuances in the ABM.