Preventing HIV Transmission The Role of Sterile Needles and Bleach (1995) / Chapter Skim
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1 THE EPIDEMIOLOGY OF HIV AND AIDS
1 THE EPIDEMIOLOGY OF HIV AND AIDS
Pages 23-56
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is the only complete national population-based data available to monitor the epidemic. Although data are useful in evaluating disease prevalence and incidence, reported AIDS cases are only the clinical tip of the iceberg of effects produced by HIV infection.
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, the risk of transmission is about 3/1,000 exposures (Ippolito et al., 1994~. Direct Needle Sharing The higher rates of HIV infection in injection drug users than in health
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Empirical data on the risk of transmission for the practice of booting are sparse because few injection drug users can report reliably on whether previously used syringes were booted. Nevertheless, in one study, booting was associated with increased HIV seropositivity among injection drug users (Lamothe et al., 1993~.
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Indirect Needle Sharing A separate category of drug injection practices can be termed indirect needle sharing because they do not directly involve passing a contaminated needle and syringe between individuals. Instead, indirect sharing involves common use of other drug preparation or injection equipment that can become contaminated.
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These behaviors have been described in some detail in the professional literature (Inciardi and Page, 1991; Koester et al., 1990; Koester, 1994; Turner et al., 1989; Grund et al., 1990, 1991; Jose et al., 1993; McCoy et al., 1994; Samuels et al., 1991; Zule, 1992; Page et al., 1990; Auerbach et al., 1994~. Risk Behaviors and Interventions Little attention has been given to these risk behaviors in most HIV/ AIDS prevention interventions aimed at injection drug users.
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. The recognition of multiple pathogens that can be transmitted parenterally by injection drug users is important, because development and implementation of prevention programs directed at HIV infection can be viewed more broadly as prevention programs for blood-borne pathogens in general.
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Perinatal Transmission Female injection drug users or partners of male injection drug users represent the largest number of HIV-infected women of childbearing age, constituting a sizable threat for perinatal transmission of HIV. The transmission of HIV from an infected mother to her offspring may occur in utero, during the birth process (intrapartum)
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Additional risk factors in perinatal transmission include high maternal CD8+ T-lymphocyte counts, placental membrane inflammation, and maternal fever. It is likely that many HIV infections in infants are acquired at birth through contact with contaminated blood or secretions.
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Thus, over half of all pediatric AIDS cases are associated with the HIV epidemic among injection drug users. This is likely to be a lower bound estimate because the risk factors for the mother were unknown for an additional 21 percent of pediatric cases.
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In this country and throughout the world, the majority of HIV infections are sexually transmitted (Roper et al., 1993~. In most of the world, over 75 percent of HIV infections are due to heterosexual behavior, approximately 15 percent to homosexual behavior, and a relatively small proportion to injection drug use.
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heterosexual women who use crack. Of these three subepidemics, two are directly linked with drug use, which underscores its catalytic role in the transmission of HIV infection.
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, the number of reported AIDS cases among women increased 167 percent (from 6,295 in 1992 to 16,824 in 1993) , compared with a 120 percent increase among men (from 40,496 in 1992 to 89,165 in 1993~.4 Whereas heterosexual contact accounted for 4 percent of reported AIDS cases among men in 1993, the figure was 37 percent among women.
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. A closer examination of cases by exposure category reveals that 71 percent of the newly reported cases among African American women were related to injection drug use; 52 percent of African American women diagnosed with AIDS in 1993 injected drugs, and an additional 19 percent of those cases were attributed to "sex with injecting drug user" (i.e., heterosexual contact)
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More recent information concerning the prevalence of HIV infection among injection drug users has been consistent with the findings reported by Hahn et al.
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This reported stabilization of seroprevalence rates within geographical areas is comparable to the results of mathematical modeling studies that indicate that HIV incidence among injection drug users has shown a slight to moderate decline since the mid-1980s (Brookmeyer, 1991~. Moreover, Drucker and Vermund (1989)
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Despite the wide variation by geographic location, evidence suggests that, even in areas in which prevalence is low among injection drug users, the risk of HIV infection should not be viewed with complacency. In Milan, Edinburgh, New York City, and Bangkok, once HIV became established in a community of injection drug users (i.e., a prevalence of less than 10 percent)
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were more likely to report needle sharing than their heterosexual counterparts. Bisexual men may also have been important by acting as a conduit for HIV infection between homosexual men and the injection drug user community, at least in some areas.
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, 2 percent of all currently sexually active women in 1990 reported that they knew they had a sexual partner who injected drugs. In another survey of risk factors for HIV infection among female injection drug users in methadone treatment (Schoenbaum et al., 1989)
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, which may in turn facilitate HIV transmission by increasing either infectiousness or susceptibility. Some of the increased rates of transmission from injection drug users to their sexual partners, compared with transmission rates from infected people from other risk groups to their sexual partners, may also be attributed to high-risk sexual practices.
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An improved understanding of the postulated biological mechanisms for heterosexual transmission might shed light on this issue. Perinatal Transmission from Injection Drug Users Several studies have demonstrated an association between HIV infection in newborns and drug use in their mothers.
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In one study that was able to extricate the effects of injection drug use from HIV infection in association with pregnancy among a group of female injection drug users (all of whom were recruited at a methadone treatment clinic) , 24 percent of the 70 who were seropositive and 22 percent of the 115 who were seronegative became pregnant during the course of follow-up (Selwyn et al., 1989~.
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The panel's review of the available epidemiologic data lead to the following specific conclusions and recommendations. Conclusions · The spread of HIV among injection drug users, their sexual partners, and offspring accounts for a major proportion of new HIV infections in the United States, and the resultant propagation of the AIDS epidemic.
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· Given the serious public health threat associated with HIV infection among injection drug users, their sexual partners and offspring, the Assistant Secretary for Health should ensure that AIDS prevention efforts targeted to injection drug users are expanded specifically to include behavioral interventions in order to limit the further spread of HIV infection. · AIDS behavioral prevention efforts need to target direct and indirect needle sharing and the sexual practices of injection drug users and their sex partners.
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Amsel 1991 HIV infection and AIDS risk behaviors among intravenous drug users entering methadone treatment in selected U.S. cities.
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1994 Epidemiology of HIV Among Intravenous Drug Users. Presentation at the meeting of the Panel on Needle Exchange and Bleach Distribution Programs, January 7.
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Jones, and J Dougherty 1989 Prevalence of HIV infection among intravenous drug users in the United States.
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Panel on Injection Drug Users and the HIV Epidemic: Understanding the Regional Differences in Prevalence, Incidence, and Risk Factors for Transmission. Public Health and Diversity: Opportunities for Equity, American Public Health Association's 122nd Annual Meeting and Exhibition, Washington, D.C., November 2.
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1994 Copping, running and paraphernalia laws: Contextual variables and needle risk behavior among injection drug users in Denver. Human Organization 53(3)
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Fauvel 1993 Seroprevalence of and risk factors for HIV-1 inaction in injection drug users in Montreal and Toronto: A collaborative study. Canadian Medical Association Journal 149(7)
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Cohn, and A Munoz in press Temporal trends of incident HIV infection in a cohort of injection drug users in Baltimore, Maryland.
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Gwinn 1995 Trends in HIV Seroprevalence Among Injection Drug Users Entering Drug Treatment Centers, United States, 1988-1993. Paper presented at the Second National Conference on Human Retroviruses and Related Infections, Abstract 312.
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Nelson 1993 Difference in risk factors for human immunodeficiency virus type-1 seroconversion among male and female intravenous drug users. American Journal of Epidemiology 137(8)
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Nelson 1990 Association of drug injection patterns with antibody to human immunodeficiency virus type 1 among intravenous drug users in Baltimore, Maryland. New England Journal of Medicine 123(5)
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