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OCR for page 186
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
OCR for page 187
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
OCR for page 193
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.
OCR for page 246
246 ~ UNDERSTANDING THE SPREAD OF HIV
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and Substance Abuse 6:23-31.
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Flynn, N. M., Jain, S., Keddie, E., Harper, S., Carlson, J., and Bailey, V. (1988b)
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Milbank Quarterly
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Gibson, D. R., Wermuth, L., Lovelle-Drache, J., Ergas, B., Ham, J., and Sorenson,
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Representative terms from entire chapter:
drug users
