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3 AIDS- and IV Drug Use Intravenous (IV) drug users occupy a unique position in the trans- mission chain of HIV: they pose risks not only for each other but also for their sexual partners and offspring. 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 indi- viduals at risk of acquiring infection through behaviors associated directly or indirectly with IV drug use. Unfortunately, information is scanty in many relevant areas. In the United States and Europe, the majority of the cases of heterosexually transmitted AIDS has occurred in IV drug users' sexual partners, who themselves may not be using drugs (Harris et al., 1983; Des Jariais et al., 1985; Fried- man et al., 1986; Newmeyer, 1986~. The majority of cases of AIDS among children has occurred as a result of perinatal transmission from HIV-infected mothers who acquired the infection through drug use (Newmeyer, 1986; Ginzburg et al., 1987; Macks, 1988~. In this chapter the committee reviews what is known about the behaviors associated with HIV transmission among people who inject 186

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AIDS AND IV DRUG USE ~ 187 illicit drugs; these include needle-sharing, sexual behavior, and child- bearing. To highlight data gaps and the research needier] to fill them, the chapter also examines the current state of research methodology and the quality of existing data on risk-associated behaviors ant} on the size of the IV drug-using population. The AIDS epidemic and the role of {V drug use in the transmis- sion of HIV have also focused the nation's attention on the prevention of drug use and the efficacy of drug treatment programs. These issues are of great concern to the Academy complex) and to the nation; yet it is not possible to review the extensive literatures of these topics here. 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. Nevertheless, primary prevention of IV drug use is critical in the light of HIV infection; such prevention requires a better understanding of the complex behaviors and conditions that surround the injection of illicit drugs. Illicit cirug use has been a Tong-standing social problem in this country, and public policies to deal with it have resulted in drug treatment and law enforcement programs. Yet many of the policies establisher! in the past are inadequate for the problems presented by the AIDS epidemic today. For example, much of what is known about {V drug use comes from studies that used samples recruited from heroin treatment programs; little is known about individuals who inject cocaine or amphetamines, about the more prevalent patterns of multiple and concurrent drug use, or about those who have never sought treatment. To make rational decisions about the kinds and amounts of resources to be directed toward drug-use problems, the government needs quantitative information on the size of those problems. As of November 14, 198S, 20,752 cases of AIDS hac! been diagnoses! in indivicluals who reported {V drug use (CDC, 1988~. Although the number of HIV-infecte<1 {V drug users is not known, seroprevaTence data from local convenience samples show rapid growth in infection rates once the virus is introduced into an {V drug-using community 1The Academy complex comprises the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Studies of the efficacy of drug treatment and the capability of existing programs to prevent primary drug use are cur- rently under consideration at the Institute of Medicine.

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188 ~ UNDERSTANDING THE SPREAD OF HIV (Angarano et al., 1985; D. M. Novick et al., 1986; Robertson et al., 1986; Moss, 1987; L. F. Novick et al., 1988~. However, estimates of the total number of individuals at risk of HIV infection from injecting illicit drugs are subject to considerable error; this problem is treated in detail in the last section of this chapter. The quality of existing data is not adequate to answer the diffi- cult questions AIDS poses because the current data collection system is only designed to measure crude trends. In the past, law enforce- ment and other governmental agencies have been more concerned about trends in the number of drug users than about absolute lev- els. For these agencies, increases in the numbers justified calling for more public resources; decreases allowed policy makers to direct resources elsewhere. Unfortunately, resources to meet drug program needs have been persistently scarce. Treatment programs have been so desperately starved for resources that they could not meet the demand for their services. 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. Efforts to control the spread of other viral infections have not produced information on the dynamics of infection that would be helpful in preventing the spread of HIV. The transmission of other blood-borne viral infections among {V drug users, most notably, hepatitis B virus, occurrent rapidly and pervasively (Kreek et al., 1987~; in some communities, in fact, the hepatitis B virus saturated the {V drug-using population before transmission studies could be initiated (Louria et al., 1967; Hessol et al., 1987; Lettau et al., 1987~. Data are still needed on the distribution and variation of behaviors that transmit HIV, the number of IV drug users, and the proportion of users infected with the virus. Such data are critical to planning for future health care needs, targeting prevention programs, counseling the infected, and protecting the uninfected. Yet despite the gaps in the current state of knowledge about {V drug use, enough is now known to slow the spread of infection in this population. As discussed later in this chapter, increasing the capacity to treat IV drug use, expanding innovative programs to provide for safer injection, and creating a system to monitor the efficacy of AIDS prevention efforts shouIcl be undertaken now. The severity of the AIDS epidemic does not permit a "business-as-usual" approach to the problems associated with IV drug use. These problems call

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AIDS AND IV DRUG USE ~ 189 for innovative solutions that take into account the relevant risk- associated behaviors and the complex social networks in which they occur. Because the material inclucled in this chapter is presenter! in some detail, the committee highlights below some major points about IV drug use and HIV infection: . The IV drug-using population is heterogeneous with re- spect to drug use, life-style, and risk-associatec! beliav- iors. . Although the lay press has expressed some skepticism about {V drug users' capacity and motivation for behav- ioral change, existing data indicate that, indeed, much change has already occurred in some groups. Targeting prevention programs to specific at-risk popu- lations will increase the probability of successfully halt- ing the spread of infection while conserving scarce re- sources. . A clearer understanding of the dynamics of viral trans- mission and the prevalence of HIV infection and risk- associated behaviors is needed. HIV seroprevaTence data show tremendous geographical variation. Therefore, considerable opportunities remain to halt the spread of HIV infection in many parts of the country and even in uninfected groups that reside in areas with high rates of infection. The committee has divided its discussion of these issues into four major sections: (1) drug-use behaviors that transmit HIV, (2) risk reduction among IV drug users, (3) conducting research on IV drug use, and (4) measuring the scope of the problem. DRUG-USE BEHAVIORS THAT TRANSMIT HIV Two types of behavior are important in examining the problem of AIDS among IV drug users: (1) sharing contaminates! injection equipment and (2) 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~. As the number of people with whom injection equipment is

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190 ~ UNDERSTANDING THE SPREAD OF HIV shared increases, so does the risk of HIV infection (Chaisson et al., 1987b). As with other blood-borne infections to which TV drug users are prone, HIV spreads from the infected to the uninfected! user pri- mariTy 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 para- phernalia) are scarce; legally, the possession of injection equipment is a criminal offense in many states; socially, sharing represents a form of social bonding among {V drug users (Ffiedman et al., 1986~. Be- fore describing the injection behaviors associates! with transmission, we discuss the setting in which drug use occurs. Social Context of Needle-Sharing Sharing injection equipment is common among {V drug users (Black et al., 1986; Brown et al., 1987~. Indeed, some studies have shown that essentially all {V drug users report needle-sharing during some period of their drug-use careers (Black et al., 1986~. People are not born injectors; they learn this behavior in the presence of others who have already been initiated (Powell, 1973; Harding and Zinberg, 19773. As discussed below, a lack of equipment and injection skills, together with certain social and physiological factors that surround IV cirug use, affect the likelihood of needle-sharing. Initiation into Drug Use. Much like the first sexual experience, the first injection experience may be anticipated or expected but not planned for (Des JarIais et al., 1986c). Curiosity about {V drug use, whether sudden or Tong-standing, and association with people who inject drugs often lead to a moment when the uninitiated is present while drugs are being injected. The desire to join in can result in sharing both drugs and injection equipment. Few people have hypo- dermic injection equipment "around the house," and few are inclined to pierce their own skin with a needle. Therefore, newcomers to the {V cirug-use world are likely to arrive without the proper equipment and to require help in executing the first injection. These circum- stances make it highly probable that a novice will begin injecting in the presence of others and will share the equipment of those teaching the "art" of injection. The sharing of drugs and equipment that occurs during initial and subsequent drug-use episodes leads to the notion that communal or joint use is as natural as sharing alcohol, ice, and glasses at a cocktail party.

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AIDS AND IV DRUG USE I 191 Contrary to popular myth, the first injection of heroin does not necessarily lead to addiction, and not all heroin users are addicts (Powell, 1973; Robins et al., 1975; Gerstein, 1976~. Some individuals experiment with it for a period of time and then quit; others are intermittent users, injecting only on weekends (so-called "weekend! warriors" ~ or on isolated occasions "hippies" ~ (Zinberg et al., 1977~. Indeed, initial IV drug-use experiences are not necessarily pleasur- able. Heroin use involves a combination of pleasure and discomfort. Continued use over time involves both an acquired sense of pleasure and a differential tolerance for heroin's various effects. Popular Tore about heroin users holds that, once they are "hooked," their appetite for the drug is so great that they will run any risk to obtain it. In contrast, research has shown that users adjust their consumption to such external factors as price and avail- ability (Waldorf, 1970; Hanson et al., 1985~. 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. To understand more clearly the process of initiation into heroin use,2 it is helpful to consider the factors that are associated with adolescent drug use. Although studies of drug use among adolescents have not focused on {V use specifically, there are some data indicating that {V drug use among teens is rare. In 1982, adolescents made up only 12 percent of those entering treatment programs, most of which focus on heroin addiction; opiate use accounted for less than 2 percent of adolescents seeking admission to treatment (Polich et al., 1984~. Nevertheless, more information is needed on how this behavior is distributed within the adolescent population. Early initiation into drug use and higher levels of use have been associated with problems in the family environment, inclucling struc- tural factors (e.g., separation, divorce, and single-parent households) and functional factors (e.g., poor communication and the absence of harmony and warmth in the home) (Anhalt and Klein, 1976; Brook et al., 1982; Evans and Raines, 1982; Rachal et al., 1986; Zarek et al., 1987~. In most studies, however, the influence of peers, espe- cially older siblings ant! early sexual partners, was found to be even more powerful than family influences in predicting adolescent (lrug use, although the effects of each kind of influence were nevertheless 2There has been much less research on initiation into the injection of other illicit drugs (e.g., cocaine or amphetamines) than on initiation into heroin use.

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192 ~ UNDERSTANDING THE SPREAD OF HIV significant and independent (Kandel et al., 1978; Brook et al., 1982, 1986~. The impact of peers was also found to be related to the type of drug used and was more closely tied to behavior than to attitudes (Huba and gentler, 1980; Krosnick and Judd, 1982; Kandel et al., 1986; R. E. Johnson et al., 1987~. An ethnographic study (Lourie, 1986, 1988) of mate and female working-cIass adolescents in Lowell' Massachusetts, reported that drugs, sex, and violence were sources of physical stimulation and escape for those teenagers, and became central themes of the peer group-associated life-styTe. The respon- dents in this study perceived society as offering them no access to legitimate work and pleasure. Friendship N~7~:7l1nrt.~ n.nd In f:q~n.n.IP R~l~t,~n chin ~ _ ~ VVV~ ~ TV _ ~~VWVV~ ~ Van VV~V - Once initiated. 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~. Over time, the ties that bind group members may loosen, and individuals may move on to inject with other groups or with another individual in the context of a personal relationship (that may also involve sex); other injection patterns include drug use in more anonymous situations (e.g., "shooting galleries," the communal injection sites often found in large cities) or alone. Pragmatic issues , v . . . .. . .. . foster injection groups: individuals can pool scarce resources, such as money, drugs, and injection equipment, and the group provides some protection against the violence associated with illicit drug use and the threat of discovery by law enforcement officials. Prior to AIDS, sharing was reported to provide "a sense of successful cooperation within a hostile environment" (Des Jarlais. 19881. ~ ~ ~ J The proportion of {V drug users who have an intimate sexual relationship with another drug user is not known. However, Des JarIais and colleagues (1986c) suggest that male and female "running buddies" are likely to share injection equipment and have sexual relations. Sharing injection equipment among friends and injecting each other appear to have strong sexual connotations. Male "running buddies" may share needles and the same women in serial sexual relationships. Shooting Galleries. have to secure both drugs and injection equipment. sanctions against the possession of either, many users may be inclined to "shoot up" shortly after a drug purchase. Those who are addicted and suffering drug hunger or withdrawal symptoms may also want Once they have been initiated, regular users ~ ~ ~ ~ ~ Because of legal

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AIDS AND IV DRUG USE ~ 193 to inject promptly. Even if they are not addicted, some users, out of a classical type of conditioning, will fee! the urge to inject the drug immediately after purchasing it (Wikler, 1973; Des JarIais et al., 1985~. All of these conditions can increase the likelihood of injection with used equipment. In large cities, "shooting galleries" have flourished as communal injection sites, often in apartments or abandoned builclings. The operators of the shooting galleries charge a small fee for use of the site, injection water, and rental of injection equipment. Often, the equipment has been used by other addicts and inadequately sterilized or cleaned to remove contaminating blooc! and infectious pathogens, including HIV (Des Jariais et al., 1986a). 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. The house works are borrowed, used to inject the drugs, and returned to the dealer for the next user again, often without adequate cleaning or sterilization. Renting or borrowing works reduces the risk of arrest for possession of (lrug- related paraphernalia. The use of injection equipment provided in shooting galleries and of house works provided by drug dealers results in syringe- and needle-sharing that involve unknown numbers of afflicts. The blood exchanged in these situations is likely to cut across existing friendship groups. Mechanics of Drug Use and Sources of Contamination Although "needle-sharing" is a convenient shorthand for the practice under discussion, there are at least five elements of the IV drug user's paraphernalia that carry the potential for contamination: the syringe, needle, "cooker," cotton, and rinse water. Collectively, these are known as the "works" (Newmeyer, 1988~. The Syringe. One possible mode of contamination is through infected blood that remains in the syringe between uses. This con- clition frequently occurs when users "boot," that is, when they draw blood back and forth into a syringe multiple times while it is inserted into a vein to ensure that all traces of the drug are removed from the syringe. (Booting does not occur when users practice intramuscular or subcutaneous injection, also referred to as "skin popping.") Decontamination by bleach, alcohol, liquid dish detergent, or

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194 ~ UNDERSTANDING THE SPREAD OF HIV hydrogen peroxide is more likely to be effective if the syringe is flushed to at least the highest level reached by the infected user's injection. Bleach, alcohol, and hydrogen peroxide have been shown to inactivate the virus in vitro (Resnick et al., 1986; Flynn et al., l98Sb). However, the sterilization of injection equipment is not without problems, as some disinfectants may dissolve the silicone lubricant of the syringe plunger, thus making its operation quite stiff. The Needle. Contamination can also occur when a droplet of infected blood remains inside or outside the needle. Decontamination is likely to be effective if the disinfectant is flushed through the needle and the needle is dipped into the disinfectant. The Cooker. A cooker is the small container (e.g., a spoon, a bottle cap) that is used to dissolve the injectable drug, which is usually a powder. Infected blood can be pushed out of the needle or syringe and into the cooker in the process of drawing up a new shot of the drug. Effective sterilization of the needle and syringe would obviate the possibility of contaminating the cooker. Heating the cooker between shots could also kill the virus, but this is not the usual procedure among heroin users; even if the cooker is heated, the temperature may not be high enough to sterilize it and its contents. There is some anecdotal evidence that, in the post-AIDS era, passing the cooker over the flame a few more times may now be more common. (However, amphetamine users generally dissolve their drug in cold water, often simply using the small bag that originally contained the drug and saving this "washbag" for an extra shot.) The Cotton. 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. The cotton thus can become contaminated with the blood of infected users. If the needle and syringe have been sterilized, however, the cotton is less likely to be a source of infection. The Rinse Water. Water is used to rinse out syringes and nee- dles before they are reused not necessarily to decontaminate the equipment but to prevent clotting and therefore unusable works. If there is no effective decontamination step (e.g., multiple rinses with

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AIDS AND IV DRUG USE ~ 195 a bleach solution), the use or reuse of a common rinse water supply can be a source of contamination. The details of injection practices related to sharing, booting, rinsing, and heating the cooker vary greatly; in addition, these be- haviors are constantly evolving in light of the awareness of the risk of HIV transmission. It is difficult to assess the impact of these behavioral changes on stemming the spread of HIV. An interesting variation in injection behavior described recently in Baltimore hi. Newmeyer, Haight-Ashbury Fiee Medical Clinic, San Ffancisco, per- sonal communication, May 25, 1988) enables users to share drugs without sharing the needle or syringe. To ensure that a drug is split equally between users, half of the contents of a single syringe is injected into a second syringe. In fact, there might still be an HIV transmission risk if either syringe were contaminated before the drug-sharing procedure, but the likelihood of contamination is much less because the drug rather than the needle is shared. Frequency of Injection Another factor associated with HIV infection is the frequency of injection: those who inject drugs frequently are more likely to be seropositive than those who inject less often (Blattner et al., 1985; Des JarIais, 1987b). Some IV drug users are har~l-core addicts who inject drugs many times every day; some are otherwise successful micicIle-ciass users who inject less frequently. Still other {V drug users inject many times a (lay for a few months and then stop; some others inject only a few times a year.3 The sharing of injection equipment appears to be common be- havior in both IV drug users who inject frequently and in those who inject less often (~iediand et al., 1985~. However, more frequent injections are likely to mean more episodes with shared equipment, thus increasing the likelihood of HIV infection. 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. Other important 3Data from the Client-Oriented Data Acquisition Process (CODAP; see also footnote 8 in this chapter) indicate a wide range of variability in the frequency of drug use prior to admission to drug treatment (NIDA, 1981~. The range is from no use in the past month to three or more times daily in the past month. Gerstein (1976) also distinguishes between different types of IV drug users, ranging from the hard-core "strung-out" users who inject frequently to situational users who inject only occasionally.

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196 ~ UNDERSTANDING THE SPREAD OF HIV variables in determining the risk of HIV infection include the preva- lence of infection in the local population, the number of people who practice needIe-sharing, the number and frequency of injections, and the injection route (intravenous, intramuscular, or subcutaneous). Polydrug Use One consistent finding with significant implications for treatment and prevention efforts is that of multiple drug use among those who inject drugs. Studies of treatment populations (B. D. Johnson et al., 1985; Ball et al., 1986) suggest that a majority (60-90 percent) of TV heroin users report regular use of at least one other nonopiate. (A survey of approximately 100 former heroin users enrolled in methadone maintenance clinics in the New York City area found that 91 percent also reported {V cocaine use [Brown and Primm, 1988~.) The choice of drugs for injection varies among different drug subcultures and over time. Heroin was the dominant injectec3 drug a few years ago, but today, {V drug users may also inject cocaine, heroin and cocaine in combination, or a variety of other drugs, including amphetamines (Black et al., 1986~. Cocaine has been linked to HIV infection in New York City and San Fiancisco (Chaisson et al., 1988; Ffieciman et al., 1988~. Among 673 IV drug users surveyed in San Francisco, IV cocaine use signif- icantly 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. Indeed, Chaisson and colleagues (1988) found that 26 percent of cocaine users who were aIreacly in Tong-term methadone treatment began injecting cocaine after they entered treatment. Injection practices also appear to vary for different drugs. With cocaine's shorter-lived "high," {V drug users who shoot cocaine may inject themselves repeatedly until their supply is exhausted thus injecting themselves more frequently than if they were using heroin alone.4 Cocaine is associated with HIV infection in several ways. When cocaine is injected! with nonsterile injection equipment, it poses the risk of blood-borne HIV infection. When it is smoked (as "crack"), it can be associated with high-risk sexual activity because crack frequently heightens perceptions of sexual arousal (Ffiedman et al., 1988~. Like heroin, it can be used at or near the site of purchase 4 Gold and coworkers (1986) report that cocaine's desired subjective effects are so rapid and short-lived that administration must be repeated every 2~30 minutes to maintain the high. Siegel (1984) describes individuals who use cocaine 3-20 times per day.

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246 ~ UNDERSTANDING THE SPREAD OF HIV Flavin, D. K., and Frances, R. J. (1987) Risk taking behavior, substance abuse disorders, and the acquired immunodeficiency syndrome. Advances in Alcohol and Substance Abuse 6:23-31. Flynn, N. M., Jain, S., Harper, S., Bailey, V., Anderson, R., Acuna, G., et al. (1987) Sharing of Paraphernalia in Intravenous Drug Users (IVDU): Knowledge of AIDS Is Incomplete and Doesn't Affect Behavior. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Flynn, N. M., Jain, S., Bailey, V., Siegal, B., Bank, V., Nassar, N., Lindo, J., Harper, S., and Ding, D. (1988a) Characteristics and Stated AIDS Risk Behavior of IV Drug Users Attending Drug Treatment Programs in a Medium-Sized U.S. City. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Flynn, N. M., Jain, S., Keddie, E., Harper, S., Carlson, J., and Bailey, V. (1988b) Cleaning IV Paraphernalia: Bleach Was Just the Beginning. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Friedland, G. H., and Klein, R. S. (1987) Transmission of the human immunodeficiency virus. New England Journal of Medicine 347:1125-1135. Friedland, G. H., Harris, C., Butkus-Small, C., Shine, D., Moll, B., Darrow, W., and Klein, R. S. (1985) Intravenous drug users and the acquired immunodeficiency syndrome: Demographic, drug use, and needle sharing patterns. Archives of Internal Medicine 145:1413-1417. Friedman, S. R., and Des Jarlais, D. C. (1988) Dimensions of Prevention Programs Among Intravenous Drug Users. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Friedman, S. R., Des Jarlais, D. C., and Sotheran, J. (1986) AIDS health education for intravenous drug users. Health Education Quarterly 13:383-393. Friedman, S. R., Sotheran, J. L., Abdul-Quader, A., Primm, B. J., Des Jarlais, D. C., Kleinman, P., Mauge, C., Goldsmith, D. S., El-Sadr, W., and Maslansky, R. (1987a) The AIDS epidemic among blacks and Hispanics. 65(Suppl. 2~:455-499. Milbank Quarterly Friedman, S. R., Des Jarlais, D. C., Sotheran, J., Garber, J., Cohen, H., and Smith, D. (1987b) AIDS and self-organization among intravenous drug users. International Journal of the Addictions 22:201-219. Friedman, S. R., Dozier, C., Sterk, C., Williams, T., Sotheran, J. L., Des Jarlais, D. C., et al. (1988) Crack Use Puts Women at Risk for Heterosexual Transmission of HIV from Intravenous Drug Users. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Fuchs, D., Unterweger, B., Hinterhuber, H., Dierich, M. P., Weiss, S. H., Wachter, H., et al. (1988) Successful Preventive Measures in a Community of IV Drug Addicts. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Gerstein, D. R. (1976) The structure of heroin communities in relation to methadone maintenance. American Journal of Drug and Alcohol Abuse 3:571-587. Gibson, D. R., Wermuth, L., Lovelle-Drache, J., Ergas, B., Ham, J., and Sorenson, J. L. (1988) Brief Psychoeducational Counseling to Reduce AIDS Risk in IV Drug Users and Sexual Partners. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Ginzburg, H. M. (1984) Intravenous drug users and the acquired immunodeficiency syndrome. Public Health Reports 99:206-212. Ginzburg, H. M., and MacDonald, M. G. (1986) The epidemiology of human T-cell lymphotropic virus, type-III (HTLV-III diseases). Psychiatric Annals 16:153-157. Ginzburg, H. M., MacDonald, M. G., and Glass, J. W. (1987) AIDS, HTLV-III diseases, minorities, and intravenous drug use. Advances in Alcohol and Substance Ab?lse 6:7-21.

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250 ~ UNDERSTANDING THE SPREAD OF HIV Lettau, L. A., Smith, M. H., Morse, L. J., Bessette, R., Irvine, W. G., Grady, G. F., McCarthy, J. G., Hadler, S. C., Ukena, T., Gurwitz, A., Fields, H. A., and Maynard, J. E. (1987) Outbreak of severe hepatitis due to delta and hepatitis B viruses in parenteral drug abusers and their contacts. New England Journal of Medicine 317:1256-1262. Levin, G., Roberts, E. B., and Hirsch, G. B. (1975) The Persistent Poppy: A Computer-Aided Search for Heroin Policy. Cambridge, Mass.: Ballinger. Ljungberg, B., Andersson, B., Christensson, B., Hug>Persson, M., Tunving, K., and Ursing, B. (1988) Distribution of Sterile Equipment to IV Drug Abusers as Part of an HIV Prevention Program. Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Louria, D., Hensle, T., and Rose, J. (1967) The major medical complications of heroin addiction. Annals of Internal Medicine 67:1-22. Lourie, K. (1986) On the Contradictions of Working Class Drug Subcultures: A Comparative Ethnography. Master's thesis, Brown University. Lourie, K. (1988) Working Class Youth Drug Subculture: An Anthropological Ap- proach to Sexual Meaning. Cited in background material prepared for the CBASSE Committee on AIDS Research and the Behavioral, Social, and Statis- tical Sciences by S. Lindenbaum, New School for Social Research, New York. Lowenstein, W. A., Durand, H., Stern, M., and Tourani, J. M. (1988) Changes of Behavior in French IV Drug Addicts (IVDA). Presented at the Fourth International AIDS Conference, Stockholm, June 12-16. Macks, J. (1988) Women and AIDS: Countertransference issues. Social Casework 69:34~347. Maddux, J., and Desmond, B. (1975) Reliability and validity of information from chronic heroin users. Psychiatrtc Research 12:87-95. Marmor, M., Sanchez, M., Krasinski, K., Cohen, H., Bartelme, S., Weiss, L. R., et al. (1987a) Risk Factors for Human Immunodeficiency Virus Infection Among Heterosexuals in New York City. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Marmor, M., Des Jarlais, D. C., Cohen, H., Friedman, S. R., Beatrice, S. T., Dubin, N., El-Sadr, W., Mildvan, D., Yancovitz, S., Mathur, U., and Holzman, R. (1987b) Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS 1:39-44. Masters, W. H., Johnson, V. E., and Kolodny, R. C. (1988) Cr~sis: Heterosexno~l Behavior in the Age of AIDS. New York: Grove Press. Mata, A. G., and Jorquez, J. S. (In press) Mexican-American Intravenous Drug Users' Needle-Sharing Practices: Implications for AIDS Prevention. NIDA Research Monograph Series. Rockville, Md.: National Institute on Drug Abuse. Mays, V., and Cochran, S. (1987) AIDS and black Americans: Special psychosocial issues. Public Health Repor~ts 102:224-231. McAuliffe, W. E., Doering, S., Breer, P., Silverman, H., Branson, B., and Williams, K. (1987) An Evaluation of Using Ex-Addict Outreach Workers to Educate Intra- venous Drug Users About AIDS Prevention. Presented at the Third International AIDS Conference, Washington, D.C., June 1-5. Miller, J. D., Cisin, I. H., Gardner-Keaton, H., Harrell, A. V., Wirtz, P. W., Abelson, H. I., and Fishburne, P. M. (1983) National Survey on Drug Abuse. Prepared for the National Institute on Drug Abuse by George Washington University, Washington, D.C., and the Response Analysis Corporation, Princeton, N.J. National Institute on Drug Abuse, Rockville, Md.

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