AIDS, Sexual Behavior, and Intravenous Drug Use (1989) / Chapter Skim
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3 AIDS and IV Drug Use
3 AIDS and IV Drug Use
Pages 186-256
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From page 186... ...
Although it is not possible at present to predict with certainty the future pattern of heterosexual transmission of HIV in the United States, one aspect of that pattern is gaining sharper focus: it is likely that if heterosexual transmission of the virus becomes self-sustaining, IV drug users will have been the initial source of infection for continued sexual transmission to heterosexuals who c30 not inject drugs (Newmeyer, 1986; Des JarIais, 1987a; Des JarIais et al., 1987~. The threat posed by IV drug use has focused attention on the extent of existing HIV infection among IV drug users; on the current state of knowledge concerning the drug-use and sexual behaviors of this population, inclucling childbearing; and on the number of individuals at risk of acquiring infection through behaviors associated directly or indirectly with IV drug use.
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From page 187... ...
The committee believes that primary prevention of drug use is an important national goal, but questions remain as to whether even substantial improvement in primary prevention would reduce injection behavior. Because many people report smoking marijuana and relatively few go on to inject heroin or other injectable drugs, the efficiency of attempts to stop marijuana use as a way to prevent IV drug use is questionable.
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From page 188... ...
The total number of drug users was a moot issue in many cities; whatever that number was, it exceeded the number who coup be served. Controlling the spread of the AIDS epidemic demands more knowledge about the size of the IV drug-using population and the dynamics of viral transmission in this group.
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From page 189... ...
sexual behaviors that are known to transmit HIV. Sharing Drug Injection Equipment The use of nonsterile injection equipment may account for a range of infections in IV drug users, including bacterial enclocar(litis, hem atitis, malaria, and celluTitis or soft tissue infections (Louria et al., 1967~.
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From page 190... ...
user primariTy by the sharing of bloo~l-contaminatecl injection equipment, which serves as the vector of the virus. IV drug users share injection equipment for a variety of reasons: pragmatically, clean "works" (the collective term for injection paraphernalia)
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From page 191... ...
This ability to adapt to various social and market forces also sustains the belief among many users that they are not addicts but merely visitors to the heroin scene who are still in control of their lives (Fields and Walters, 1985~. Adolescent IV Drug Use.
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From page 192... ...
the iv drug user may continue to inject with those who provided an entree into the drug scene. Needle-sharing is reportedly an integral part of injection and can provide a social bond within the group (Des JarIais, 1988~.
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From page 193... ...
. In cities with relatively few IV drug users, the equivalent of a shooting gallery may be the clearer's apartment, a rented room, or a hotel room in which the deafer makes "house works" available to inject drugs at the time of purchase.
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From page 194... ...
A small piece of cotton is sometimes used to strain out undissolved impurities from the solution in the cooker as it is drawn up into the syringe. Instead of disposing of the cotton after each use, an {V drug user will often "beat the cotton" with a small amount of water to extract one more bit of the cirug.
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From page 195... ...
In addition, for IV drug users who are addicted, the symptoms of drug withdrawal can heighten the sense of urgency or desire for the drug and decrease the likelihood that safer injection practices will be used. Finally, whether an IV drug user did most of his or her injecting prior to 1975 or later will greatly affect his or her risk of HIV infection.
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From page 196... ...
Among 673 IV drug users surveyed in San Francisco, IV cocaine use significantly increased the risk of HIV infection (Chaisson et al., 1988~. Unfortunately, to (late, some forms of drug treatment, including methadone, have not been effective for cocaine dependency.
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From page 197... ...
were people who reported no other risk-associatecT behavior but were born in countries in which heterosexual transmission has played a key role in the spread of the virus. The vast majority of the cases that have been diagnosed among those born in this country is thought to be associated directly with IV drug use or with sexual contact with an IV drug user (Brown, 198~3~.5 Yet less is known about the dynamics of heterosexual HIV transmission from {V drug users than about transmission from index cases in hemophiliac, transfusion recipient, or bisexual mate populations.
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From page 198... ...
of the IV drug users' sexual partners did not inject drugs; however, mate respondents were more likely than female respondents to report a noninjecting sex partner. Only 5 percent of the study participants reported condom use; among this 5 percent, condoms were user!
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From page 199... ...
While some information on female {V drug use is available from women entering drug treatment, little is known about women who are involvecl in intimate relationships with mate {V drug users. Ethnographic studies of female IV drug users at the Stuyvesant Polyclinic and the Montefiore Medical Center in New York City (Wofsy, 1987; Worth, 1988)
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From page 200... ...
Finally, mechanisms to improve collaboration and coordination among those seeking solutions will be required for effective action. The committee thus recommends that high priority be given to studies of the social and societal contexts of IV drug use and IV cirug-use prevention efforts.
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From page 201... ...
Although projected estimates of future HIV infection rates are subject to consi~lerable variation, it is likely that a significant proportion of heterosexually and perinatally acquired infection will come from the IV drug-using population. Therefore, the committee recommends that high priority be given to studies of the sexual and procreative behavior of IV drug users, including methods to reduce sexual and perinatal (mother-infant)
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From page 202... ...
This section traces the history of those studies, summarizes the current state of knowledge, and indicates directions for future research. Changes in Injection Behavior The first risk reduction studies among IV drug users were conducted in New York City, where signs of infection were notes]
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From page 203... ...
More than 85 percent of the vouchers were redeemed by IV drug users for detoxification treatment. In 1987 reports were published on the increasing use of the syringe exchange program in Amsterdam (van den Hoek et al., 1987; Buning et al., in press)
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From page 204... ...
Other studies reported in 1987 indicate some limitations on the AIDS prevention efforts aimed at IV drug users. An evaluation of an ex-addict outreach program in Baltimore showed that {V drug users in the city were changing their behavior to reduce the risk of AIDS; however, the change could not be attributed to the efforts of the outreach workers (McAuliffe et al., 1987~.
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From page 205... ...
Although the studies that support this conclusion tend to rely heavily on selfreported behavioral modifications, there are enough studies in which there is some independent evidence of change to conclude that the self-reports reflect what has actually occurred. Examples of the independent confirmation of change include the increased demand for sterile injection equipment in New York City, increased use of syringe exchange programs, and acceptance of bottles of bleach for decontamination of used injection equipment.
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From page 207... ...
207 D Go oo Go Go ~ .
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From page 208... ...
. During this period, the average age of IV drug users in the city increased, indicating that the group is an aging cohort with little influx of new users.
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From page 209... ...
Although there are as yet no data from Tong-term studies, current data suggest that safer injection programs and drug treatment can be complementary means to reduce the risk of HIV transmission among IV drug users. However, more research is needed to understanc!
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From page 210... ...
More recent studies support these findings. Table 3-2 lists the studies presented at the Fourth International AIDS Conference that were related to heterosexual transmission among IV drug users.
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From page 211... ...
Immediate action is necessary because of the potential for the rapid spread of HIV among IV drug users within short periods. Although the current state of knowledge does not permit permanent or Tong-term solutions to drug-use problems and HIV infection in this population, enough is known now, on the basis of existing research and sound management techniques, to slow the spread of disease.
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From page 212... ...
At a minimum, a system is needed that provides data on the AIDS prevention services being offered throughout the country to IV drug users and their sexual partners, the rates of participation in these programs, and the characteristics of participants. Additional means must be used to reach those vulnerable members of the {V drug-using population who do not come into contact with the treatment system and to assess and serve their needs.
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From page 213... ...
Current studies indicate that safer injection programs are not associates! with increases in IV drug use and do lead to large-scare risk reduction among IV drug users.
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From page 214... ...
behaviors in a population that has been characterized in the past as uncooperative and self-destructive. CONDUCTING RESEARCH ON IV DRUG USE The difficulties involved in conducting research on IV drug use, some of which were discussed in the preceding sections, are only part of the challenge researchers face in this area.
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From page 215... ...
Researchers are only now beginning to collect data on the behaviors associated with HIV transmission in the IV drug-using population. The Heroin Lifestyle Study (Hanson et al., 1985)
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From page 216... ...
In these attempts, they gather data on- daily drug-use and related behaviors, take life histories, and make observations. Despite these promising beginnings, however, there remain certain logistical hurdles and methodological problems that need to be cleared away before we can move more effectively toward the goal of reducing risk-associated behavior among IV drug users.
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From page 217... ...
. Nevertheless, surveys are needed to ascertain the dimensions of the problem: such studies can provide critically needed and statistically sound data on IV drug-using populations.
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From page 218... ...
Finally, two IV drug users, particularly if they are sexual partners or have a very close personal relationship, may consider a single needle and syringe set to be theirs together. Both may use the set without thinking of it as sharing, which for them may refer to letting someone other than one of the joint owners use the equipment.
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From page 219... ...
The major indicator data that are available on injectable illicit drugs primarily cover heroin use; they include the Drug Abuse Warning Network (DAWN) emergency room data,~° medical examiner autopsy reports, state treatment admission reports, and U.S.
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From page 220... ...
It is also important to recognize that, because the initial assignment of a client to a treatment program is not random, samples drawn from the treatment population may not be representative of the larger {V drug-using population or even of the population of those in treatment. Arrestees are another "convenient" population of particular interest because 15-50 percent can be iclentified as drug users (Eckerman et al., 1976)
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From page 221... ...
However, there may be variation by geographic area that will continue to limit the capacity to generalize these findings beyond the local population. Self-Reported Information The manner in which a sample is selected is but one of the factors that affects data quality in studies of IV drug users.
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From page 222... ...
Care must be taken to allow researchers to collect the i2CODAP data for 1981 indicated that 15.6 percent of the drug treatment population had a 9th grade education or less and that an additional 27.8 percent had only a 10th or 11th grade education. The large percentage of Hispanics in the IV drug-using population that seeks treatment suggests that many IV drug users may not have English as a first language.
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From page 223... ...
. Thus, the consistency of association among frequency of injection, use of shared injection equipment, and infection supports the perception that researchers can obtain valid sel£reported data from IV drug users with respect to illicit drug-use behaviors (MadJux and Desmond, 1975~.
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From page 224... ...
The status of IV drug users as members of the heroin community is often secret. These users may or may not be iclentified on the street as addicts, depending on their means of obtaining the drug and the stage of their cirug-use careers.
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From page 225... ...
Estimates of the total number of IV drug users were published in the November 1987 report prepared by the Public Health Service for the White House Domestic Policy Council and in a special supplement to CDC's Morbidity and Mortality Weekly Report (CDC, 1987a,b)
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From page 226... ...
The types and combination of drugs injected and the frequency of needle use vary considerably among users, as do individual drug-use "careers." Hard-core or addicted users may inject many times daily; other IV drug users may inject less frequently and may never become addicted (Ger lo.
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From page 227... ...
. Techniques for Estimating the Total Number of IV Drug Users In general, three kinds of techniques are used to estimate the total number of IV drug users in the United States: (1)
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From page 228... ...
National estimates of this kind i3A recent study of the outcome of HIV infection among IV drug users in New York City found that, of 31 deaths, 6 were attributable to infectious agents that are not categorized as opportunistic agents associated with an AIDS diagnosis (Des Jarlais et al., 1988b)
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From page 229... ...
Overlap in cocaine/heroin use: NIDA, "Demographic Characteristics and Patterns of Drug Use of Clients Admitted to Drug Abuse Treatment Programs in Selected States: Annual Data 1985," analysis of unpublished data; (d) Heavy users of cocaine with a previous history of IV drug use and IV drug users who do not inject heroin or cocaine: NIDA, "National Household Survey on Drug Abuse: Main Findings 1985," analysis of unpublished data.
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From page 230... ...
That is to say, the true number of {V drug users could be as few as half a million or as great as 2 million. Consumption and Turnover Rates Among I V Drug Users A comprehensive, accurate assessment of the prevalence of IV drug use is largely dependent on an adequate un(lerstan(3ing of the (levelopment, maintenance, and cessation of heroin consumption patterns, the diversity of drug-related behaviors, and the movement in and out of the {V drug-using population (turnover)
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From page 231... ...
Modeling the IV Drug- Using Population: Constraints and Limitations There are a number of models to predict drug-use prevalence and drug consumption that attempt to reflect the complex dynamics of drug use. These models are based on sound statistical principles; yet because they require extensive and often elaborate assumptions, for which, unfortunately, there are generally limited supporting data, they do not always produce accurate estimates that can be used with confidence.
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From page 232... ...
use of the New York City narcotics register, Glenn and Hartwell noted that very different estimates were developed. Their conclusion was that, although both methods were theoretically sound, the data bases and key assumptions of the approaches were subject to substantial error.
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From page 233... ...
The committee recognizes the problems inherent in collecting data on IV drug users for modeling efforts. It is difficult to study illicit behavior and to count those who wish to etude the attention of representatives of authority.
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From page 234... ...
Prevalence of AIDS and HIV Infection Among IV Drug Users Approximately one quarter of all AIDS cases cliagnosed in this country among adults and adolescents is related to {V drug use (Schuster, 1988~. However, because of the very strict definition of AIDS that has been established for surveillance purposes, it is thought that the number of reported cases underestimates the size of the problem.
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From page 235... ...
In the United States, there are wide variations in HIV seroprevaTence by region of the country. As shown in Table 3-6, for individuals reporting IV drug use, the rates of HIV infection are highest in the New York City area (typically, 50 percent or higher)
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From page 236... ...
bIV drug users include only heterosexual men and women with a history of IV drug use. SOURCE: Allen and Curran (1988)
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From page 237... ...
Chaisson and coworkers (1987b) found HIV infection among IV drug users in San Francisco to be significantly more prevalent among blacks and Hispanics than among whites.
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From page 238... ...
238 ~ Cal C
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From page 239... ...
239 o _ o ~ _ ~ ~ _ ~ _ en.
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From page 240... ...
Moreover, the knowledge base needed to design, implement, and evaluate measures to change high-risk behavior in IV drug users continues to grow. Opportunities remain to halt the spread of HIV infection among IV drug users.
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From page 241... ...
(1988) The Effectiveness of Methadone Maintenance Treatment in Reducing IV Drug Use and Needle Sharing Among Heroin Addicts at Risk for AIDS.
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From page 242... ...
(1988) Monitoring of HIV Infection Among IV Drug Users in Stockholm.
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From page 243... ...
Women and IV drugs: Parenteral and heterosexual transmission of human immunodeficiency virus. Journal of Drug Issues.
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From page 244... ...
Prepared for the National Institute on Drug Abuse. New York State Division of Substance Abuse, New York City.
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From page 245... ...
Rockville, Md.: National Institute on Drug Abuse.
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From page 246... ...
(1988a) Characteristics and Stated AIDS Risk Behavior of IV Drug Users Attending Drug Treatment Programs in a Medium-Sized U.S.
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From page 247... ...
57. Rockville, Md.: National Institute on Drug Abuse.
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From page 248... ...
NIDA Research Monograph Series. Rockville, Md.: National Institute on Drug Abuse.
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From page 249... ...
ADM 82-1221. Rockville, Md.: National Institute on Drug Abuse.
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From page 250... ...
(1988) Distribution of Sterile Equipment to IV Drug Abusers as Part of an HIV Prevention Program.
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From page 251... ...
Contemporary Drug Problems 14:373-395. National Institute on Drug Abuse (NIDA)
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From page 252... ...
infection among IV drug abusers. British Medical Journal 292:527-529.
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From page 253... ...
50. Rockville, Md.: National Institute on Drug Abuse.
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From page 254... ...
(1988a) Influence of HIV-AB Testing on the Risk Behavior of IV Drug Users in Amsterdam.
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From page 255... ...
Rockville, Md.: National Institute on Drug Abuse. Wiebel, W
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