Injecting Drug Users And Hiv

Injecting Drug Users And Hiv

One of the major risk behaviors for infection by the HUMAN IMMUNODEFICIENCY VIRUS (HIV) is injecting drug use; the others are unprotected male homosexual sex (Centers for Disease Control, 1991a) and unprotected heterosexual sex with an HIV-infected partner. The NATIONAL INSTITUTE ON DRUG ABUSE (NIDA) estimated that there were between 1.1 and 1.3 million injecting drug users (IDUs) in the United States in the late 1980s (Centers for Disease Control, 1987). Although the number of IDUs increased between 1990 and 1997, participation in needle exchange programs also increased, as did participation in HIV testing and counseling (Des Jarlais et al., 2000).

In 1990, 30 percent of ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) cases were heterosexual injecting drug users; in addition, 30 to 50 percent of new cases identified were related to IDU (Iguchi et al., 1990). Injecting drug use was also related to most instances of heterosexual transmission of the virus (Centers for Disease Control, 1992). Also, whether directly or indirectly, injecting drug use accounted for 70 percent of AIDS cases among women and children (Centers for Disease Control, 1989). In these cases, either the woman or her sex partner was an IDU (Gayle, Selic, & Chu, 1990). Since 1995 Belarus, Moldova, Kazakhstan, Russia, and Ukraine have seen rapid HIV increases, with at least 50 percent among IDUs (Henderson, 2000a).

The transmission of HIV among IDUs occurs directly through blood transmission of the virus, as when drug users share used, nonsterilized hypodermic needles and syringes, cotton, cookers, rags, and water that has been contaminated with the infected blood of other users. It is also transmitted when bodily fluids (e.g., semen, saliva, blood) are exchanged during sexual acts. The virus can also be transmitted to a fetus by a pregnant, HIV-positive woman. However, the risk of transmission to the fetus can be sharply reduced if the HIV-positive woman takes the antiviral drug AZT during pregnancy. Various studies have found that prior to the HIV epidemic, between 70 and 100 percent of IDUs shared injection paraphernalia (Lange et al., 1988; Des Jarlais et al., 1988). These percentages have been decreasing, since the connection with AIDS has been widely publicized since the 1980s. Still, dirty syringes cause 80,000 to 160,000 HIV infections worldwide annually (Henderson, 2000b).

Historically the most commonly injected drug has been HEROIN; however, the increased availability of COCAINE has resulted in an increased use by IDUs since the late 1980s. Injecting cocaine has elevated the risk of HIV spread because the shorter duration of a cocaine "high" leads to more frequent injecting (Gottlieb & Hutman, 1990). It has also been reported that cocaine injectors, when the number of injections was statistically controlled, were at higher risk than other drug-injecting populations for HIV because cocaine use is associated with increased unprotected sexual activity (Chaisson et al., 1989).

BACKGROUND

The prevalence of HIV/AIDS among injectors varies widely from region to region in the United States. The highest rates of IDU and HIV are found along the east coast and west coast, in the southwest, Florida, Puerto Rico, and in major metropolitan areas. Overall, of the 48,269 new cases of HIV reported in 1998, more than 50 percent were IDU-associated (Centers for Disease Control and Prevention, 1999). The prevalence of HIV infection is also related to the social context of needle sharing. In areas where injectors go to "shooting galleries"—where anyone using a previously used needle may not know who else used the needle—there are generally high rates of HIV infection. Conversely, in areas where the IDU social network is well known and only a limited number share works with one another, the infection rate is lower (Leukefeld et al., 1991).

While IDUs with HIV infection are predominantly males of color (Hispanics and African-Americans) in their late twenties and early thirties, variations and exceptions are noted and reflect dynamics in individual metropolitan areas. In 1989, the highest prevalence of IDUs in drug treatment centers who tested positive for HIV were in the Middle Atlantic states (New York, New Jersey, and Pennsylvania), where the overall rate for HIV-positive intravenous drug using men and women in treatment was 44 percent (Centers for Disease Control, 1990b).

REDUCING RISK-TAKING BEHAVIOR

Drug-abuse treatment and prevention can be effective in controlling the spread of AIDS among IDUs and for reducing the risk of exposure to the HIV virus. The goals of drug treatment and prevention are different. The goal of treatment is to eliminate injecting drug use as a risk factor in the spread of HIV. The goal of prevention is to reduce and eliminate harmful behaviors, like sharing needles, that place the IDU at risk for either becoming infected or infecting others with HIV. Prevention does not necessarily focus on changing drug-seeking and needle-using behavior. Four areas are considered to be of prime importance: (1) increasing the number of drug abusers in treatment, (2) enhancing the effect of treatment, (3) developing outreach and counseling strategies, and (4) developing prevention strategies for reducing the risk-taking behavior among IDUs.

Drug Treatment.

Several organizations and groups have suggested that drug-abuse treatment is important in helping to decrease and prevent the spread of AIDS. These ogranizations include the World Health Organization (WHO), the American Medical Association (AMA), the National Academy of Sciences/Institute of Medicine and the Presidential Commission on the HIV Epidemic.

Drug-abuse treatment can play an important role in preventing HIV transmission. Treatment reduces the number of people engaging in risky behavior. In addition to reducing the number of active drug addicts, treatment can also reduce the number of people out recruiting new drug addicts (Brown, 1991). Barriers to treatment now exist for IDUs with HIV. IDUs themselves avoid people they suspect have HIV or AIDS, and some treatment programs will not allow HIV-infected people to participate in their programs (Brown, 1991). But the most serious barrier to drug-abuse treatment is the lack of treatment availability and programs. More specifically, some IDUs, including those known to be HIV infected, are not admitted into drug treatment for as long as six months due to a lack of available openings in treatment programs (Gotlieb & Hutman, 1990). In some community-outreach programs designed specifically to target IDUs to prevent HIV transmission, the majority of IDUs contacted have never been in treatment (Schrager et al., 1991). There is evidence that drug-abuse treatment reduces needle sharing by eliminating or reducing needle using behaviors.

Drug-abuse treatment incorporates several modalities (approaches), which include: (1) drug-free outpatient services, (2) METHADONE MAINTENANCE PROGRAMS, and (3) therapeutic communities (Leukefeld, 1988), as well as a number of programs that do not fit into these categories. Ideally, HIV and drug treatment should be integrated to increase social supports, which should increase adherence to medication schedules and resistance to drugs (Stein et al., 2000).

Outreach and Counseling.

One way to increase the number of IDUs in treatment is to increase the number of outreach and counseling programs. The National AIDS Drug Abuse Research Demonstration Program is an example of outreach and counseling (National Institute on Drug Abuse, 1988). This demonstration program, initiated in 1987, provided an opportunity to assess the characteristics and risk-taking behaviors of injecting drug abusers not in treatment. Additional purposes included focusing on sexual partners of IDUs at high risk for AIDS, determining and monitoring HIV seroprevalence (rate a given population tests positive) across cities, and evaluating prevention strategies. The overall goal was to reduce the spread of HIV infection by reducing and eliminating drug-use practices and certain high-risk sexual practices. Counseling and outreach approaches were applied, tested, and evaluated at each community site. Projects were targeted on three levels: (1) high-risk individuals, (2) family and social networks of IDUs, and (3) the larger community. Although intervention components varied across sites, the focus and objectives were similar (Chitwood et al., 1991; Leukefeld, 1988). These projects provided information about protective behaviors, and IDUs were encouraged to enroll in drug-abuse treatment programs. Trained indigenous outreach workers distributed and discussed materials using informal groups or through one-on-one interactions. Sixty-three communities were involved in this demonstration project (McCoy & Khoury, 1990; Leukefeld, 1988).

Strategies for community outreach differ between the IDU, their sex partners, and prostitutes. Reaching the IDU means that outreach workers go to places where IDUs hang out and buy their drugs, as well as going into criminal-justice settings (jails, PRISONS, courts), drug-treatment centers, and the health-care system. Although there is inherent danger in many of these settings, recovering drug users—savvy men and women of the same backgrounds as IDUs—have achieved success in contacting IDUs in these settings (Serrano, 1990; Brown, 1990).

Many male IDUs hang out on the street or can be found in places where other IDUs hang out. However, female sex partners of IDUs frequently stay close to home with children and they frequently work (Margolis, 1991). While women may purchase drugs for their partners, they do not generally hang out at those locations. Thus, targeting female partners of IDUs requires different strategies than those used for contacting the IDU. The YES project of San Francisco is an example of a program targeted toward female sex partners of IDUs. It began by supporting high-risk women in meeting their basic needs by helping them get general assistance, food, clothing, and health care. A second strategy was to rent a hotel room, called "A Room of Her Own" in which education, counseling, and service could be provided to the female partner of the IDU. Another project (serving Bridgeport, Connecticut, San Juan, Puerto Rico, and Juarez, Mexico) contacted the female sex partners of male IDUs; it examined an approach that attracted women to a safe setting established by the program—a clothing boutique where women could pick up new clothes and then stay for an AIDS information video. Another strategy as part of this project was to have outreach staff available in the afternoons and evenings, hours when the women were available (Moini, 1991). In another project in Long Beach, California, a drop-in center was established for youth and women (Yankovich, Archuleta, & Simental, 1991).

Prostitutes, another high risk group, require strategies appropriate to their setting. Contacting prostitutes can be difficult, since their pimps can severely restrict contact with social-service workers. In one study, contact was made when the pimp was not around and through the Salvation Army mobile canteen that served coffee to prostitutes in the late night/early morning hours (Moini, 1991). Another study reported that prostitutes are aware of AIDS, know how it is transmitted, and are aware that their drug use and unsafe sexual behavior are putting them at risk (Shedlin, 1990). However, barriers to behavioral changes in prostitutes include low self-esteem and low levels of education, along with POVERTY, addiction, hopelessness, lack of knowledge, and lack of support services.

Prevention Strategies.

Prevention is of central importance in controlling the spread of HIV among IDUs. Abstinence from drug use and needle use is the overall approach for preventing the spread of HIV. Preventing infection is a self-preservation issue (protecting self), while preventing the spread of HIV is an altruistic issue (protecting others) (Moini, 1991). It has been reported that among IDUs there is greater resistance to changing sexual behaviors (using condoms) than drug-use behaviors (sharing needles) (Sorenson, 1990). Thus, it is important to target not only IDUs but also their sex partners and prostitutes who engage in unsafe sex practices. These people may also be exchanging drugs for sex and may be IDUs themselves (Centers for Disease Control, 1991b). Three prevention strategies have been developed: education, NEEDLE-EXCHANGE PROGRAMS, and community-based interventions.

Education. In addition to the community-outreach programs, three overarching prevention-education strategies have been developed: (1) prevention education for HIV-antibody-negative individuals, (2) AIDS pre- and post-test counseling, and (3) prevention and support for HIV-antibody-positive individuals (Schensul & Weeks, 1991). AIDS prevention education involves delivery of information related to HIV spread, risk behaviors, and preventing the spread of the virus. Educational activities have been targeted on the general public, school-aged populations, and populations at risk, like IDUs. The U.S. Centers for Disease Control (CDC) National Public Information Campaign has produced numerous educational materials for the radio, television, and print media. Education targeted to individuals at risk for HIV infection has included counseling, testing, the teaching of behavioral responses to risky behaviors, and providing support for low or no-risk behaviors (Roper, 1991).

Prevention education for IDUs includes several informational components. Of primary importance to active drug users are issues related to needle sharing as a risk behavior for HIV transmission. Also of critical importance to needle-sharing IDUs in preventing HIV transmission are describing ways to effectively sterilize shared paraphernalia. Of importance to IDUs, the sex partners of IDUs, and prostitutes are safe-sex issues and knowledge of HIV transmission through unsafe sex. Of importance to potential partners—both men and women who have relationships with IDUs and who may be IDUs—is knowledge about the transmission of the virus from mother to fetus (Strawn, 1991). Early to mid-1990s research indicates that the use of AZT (an anti-HIV drug) by pregnant women who are HIV-positive sharply reduces the probability that the baby will be infected with the virus.

pre- and post-test AIDS counseling is another strategy for HIV prevention. In the early 1980s, at the beginning of the AIDS epidemic, testing was controversial because of the fear of discrimination, concern about the accuracy of tests, the usefulness of the results, and the psychological distress associated with a positive result. However, with more effective treatment for symptomatic AIDS and early treatment for HIV-infected individuals, the resistance is diminishing (Strawn, 1991).

Generally, individuals seek HIV testing for one of two reasons: (1) an agency or person, (like a plasma center, a penal institution, or a medical professional) requests it, or (2) the individual seeks to be tested because of identified high-risk behaviors (Roggenburg et al., 1991). HIV testing can represent a crisis in the life of an individual being tested. Receiving the results can be difficult due to the anxiety of the situation, even if the results are negative. pre- and posttest counseling is necessary to assess the psychological well-being of the individual being tested. Some people believe that being informed of a positive test result can make some people suicidal (Strawn, 1991).

A controversial prevention approach in the United States for preventing HIV infection is the provision of clean needles to IDUs. In needle-exchange programs, a clean needle and sometimes injection equipment (works) are exchanged for used ones. Proponents of these programs argue that needle exchanges help prevent HIV transmission and offer opportunities for education and referral to drug-treatment programs. It has been reported that in areas where needle-exchange programs have been in operation, the incidence of sharing used needles has diminished (Karpen, 1990). Some needle-exchange programs are conducted illegally by AIDS activists (Karpen, 1990). Occasionally, in the United States, needle exchanges are managed legally by health departments. To conduct a needle-exchange program legally, in many regions the PARAPHERNALIA LAWS related to drug-use equipment would need to be modified (Wood, 1990).

Opponents of needle-exchange programs point out that needles and syringes are only two of the many drug-use implements that can be contaminated with blood and transmit HIV. For example, cotton, cookers, and the water used to rinse out syringes can transmit HIV if they have been contaminated with infected blood. In addition, some injecting rituals can transmit HIV even if a clean needle and syringe are used. Sharing an injection can be part of a ritual between addicts. For example, in a "rinse" or a "geezer" one addict injects another person and then injects him- or herself with the remnant in the syringe (Primm, 1990). Few rigorous U.S. studies have examined needle-exchange programs and their effects on HIV transmission. One group of researchers interviewed IDUs participating in needle-exchange programs to help determine needs for prevention programs (Des Jarlais, 1999). Although some areas showed low rates of HIV, others showed no marked decrease in cases. The researchers believed that more complete reporting of risk behavior was necessary.

As above, one component of the National AIDS Demonstration Project has been to compare the CDC basic outreach and counseling intervention with an enhanced intervention. The CDC basic intervention includes factual information about AIDS transmission, prevention, and self-assessed risk. Enhanced community-based educational-intervention programs have involved several strategies: counseling individuals, couples, and groups; developing behavioral skills; and using applied ethnography with outreach workers to disseminate information (Chitwood et al., 1991). Using these strategies helped the rate of sharing between IDUs to decrease by up to 59 percent in a five-city study. In the same study, IDU condom use increased by up to 16 percent (Iguchi et al., 1990).

CONCLUSION

Preventing the spread of AIDS for IDUs and their sex partners requires a multidisciplinary, multiple-strategy approach. Community-intervention strategies have proven to be partially effective in reducing IDU risk behaviors (Leukefeld, Battjes, & Amsel, 1990). Much remains to be accomplished, however. Targeting HIV-prevention approaches and interventions will receive additional emphasis as the epidemic progresses (Leukefeld & Battjes, 1991). Research needs to continue to examine methods to reduce HIV in IDUs, to reinforce IDU behavior changes, to increase the effectiveness of drug-abuse treatment, and to provide psychosocial and other supports focused on HIV-infected IDUs.

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FAYE E. REILLY

CARL G. LEUKEFELD

REVISED BY REBECCA MARLOW-FERGUSON