Dangerous Intersection of Drug Use and Sexual HIV Transmission Points to Critical Need for Comprehensive HIV Prevention Among Drug Users
Sharing needles for drug injection is a well known route of HIV transmission, yet injection drug use contributes to the epidemic's spread far beyond the circle of those who inject. People who have sex with an injection drug user (IDU) also are at risk for infection through sexual HIV transmission. And, children born to mothers who contracted HIV through injecting drugs or having sex with an IDU may become infected as well.
Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 60,634 new cases of AIDS reported in 1997, 19,463 (32%) were IDU-associated.
76% of these cases were among people whose only reported risk factor was injection drug use.
12% were among male IDUs who also reported having sex with other men.
11% were among men and women whose sex partners were IDUs.
1% were among children born to mothers who were either IDUs or the sex partners of IDUs.
Racial and ethnic minority populations in the United States bear the heaviest burden of HIV disease related to drug injection. In 1997, IDU-associated AIDS cases made up 38% of all cases among African Americans and 37% of all cases among Hispanics, compared with 22% of all cases among whites.
Likewise, IDU-associated AIDS has a greater impact on women than on men. Since 1981, at least 61% of all AIDS cases among women have been attributed to injection drug use or sex with partners who inject drugs, compared with 31% of cases among men.
Noninjection drugs (such as "crack" cocaine) also contribute to the spread of the epidemic when users trade sex for drugs or money, or when they engage in risky sexual behaviors that they might not engage in when sober. One study of over 1,000 young adults in three inner-city neighborhoods found that crack smokers were three times more likely to be infected with HIV than non-smokers.
What Is Needed to Prevent HIV Transmission Among Drug Users?
Comprehensive HIV prevention interventions for substance abusers must provide education on how to prevent transmission through sex.
Numerous studies have documented that drug users are at risk for HIV through both drug-related and sexual behaviors, which places their partners at risk as well. Comprehensive programs must provide the information, skills, and support necessary to reduce both risks. Researchers have found that many interventions aimed at reducing sexual risk behaviors among drug users have significantly increased the practice of safer sex (e.g., using condoms, avoiding unprotected sex) among participants.
Substance abuse treatment is HIV prevention, but lack of drug treatment slots complicates prevention efforts.
In the United States, about half a million drug treatment slots are available at any given time. However, the nation has an estimated 1.5 million active IDUs, and many others who use noninjection drugs or abuse alcohol. Clearly, the need for substance abuse treatment vastly outstrips our capacity to provide it. Effective treatment that helps people stop using drugs not only eliminates the risk of HIV transmission from sharing contaminated syringes, but, for many, reduces the risk of engaging in risky behaviors that might result in sexual transmission.
For injection drug users who cannot or will not stop injecting drugs, the once-only use of sterile needles and syringes remains the safest, most effective approach for limiting HIV transmission.
To minimize the risk of HIV transmission, IDUs must have access to interventions that can help them protect their health. They must be advised to always use sterile injection equipment; warned never to reuse needles, syringes, and other injection equipment; and told that using syringes that have been cleaned with bleach or other disinfectants is not as safe as using new, sterile syringes.
The availability of new, sterile syringes varies across the country. HIV prevention strategies for IDUs who continue to inject have included various approaches to increasing the availability of sterile syringes, reducing the risk of HIV transmission through needle sharing, and increasing access to drug treatment.
In some communities, drug paraphernalia laws have been modified to exclude syringes, syringe prescription laws have been repealed, and pharmacy regulations and practice guidelines restricting the sale of sterile syringes have been changed. Efforts to reduce HIV risk through these types of policy changes have been evaluated and found to be effective. For example, both New York and Connecticut reported significant reductions in the sharing of drug injection equipment after implementation of policies that increased access to sterile injection equipment through pharmacies and other outlets.
In other communities, needle exchange programs have been established to increase the availability of sterile syringes. A review of extensive scientific evidence has shown that needle exchange programs can be an effective part of a comprehensive strategy to reduce HIV transmission. The evidence also demonstrates that these programs do not encourage the use of illegal drugs. Many needle exchange programs also provide drug users with a referral to drug counseling and treatment, medical services, and provide risk-reduction education. The most effective needle exchange programs have had the strong support of their communities, including appropriate state and local public health officials. In addition to offering linkages to appropriate treatment and medical services, effective needle exchange programs make needles available on a replacement basis only.
Having access to sterile injection equipment is important, but it is not enough. Preventing the spread of HIV through injection drug use requires a wide range of approaches, including programs to prevent initiation of drug use, to provide high quality substance abuse treatment options to drug users, to provide outreach services to drug users and their sex partners, to provide prevention services in jails and prisons, and to educate those at risk about preventive options.
Better integration of all prevention and treatment services is critically needed.
HIV prevention and treatment, substance abuse prevention, and sexually transmitted disease treatment and prevention services must be better integrated to take advantage of the multiple opportunities for intervention - first, to help the uninfected stay that way; second, to help infected people stay healthy; and third, to help infected individuals initiate and sustain behaviors that will keep themselves safe and prevent transmission to others.
CDC's Role in HIV Prevention for IDUs
CDC is the lead federal agency responsible for monitoring the epidemic and preventing HIV/AIDS. In cooperation with other federal agencies and offices responsible for addressing drug use - for example, the Center for Substance Abuse Prevention (CSAP) and the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration, the National Institute for Drug Abuse (NIDA) of the National Institutes of Health, and the White House's Office of National Drug Control Policy (ONDCP) - CDC works to address the HIV/AIDS risks presented by illicit drug use.
CDC's role is to provide communities with the best available science to guide comprehensive HIV prevention programs. As part of this process, CDC conducts an ongoing research synthesis process that seeks to identify the most recent and relevant scientific findings from around the world, both published and unpublished, and make them available to prevention program planners. CDC constantly combs the scientific literature, reviews domestic and international scientific databases, and speaks with colleagues around the world to identify effective interventions for all populations at risk, including IDUs.
CDC also provides financial and technical assistance to communities to help them address the unique prevention needs of IDUs, their sex partners, and their children. For example, CDC directly funds 94 community-based HIV prevention programs that provide prevention services in minority communities and other populations at high risk, many of whom are IDUs. Through the HIV Prevention Cooperative Agreements, CDC awards funds to health departments in 50 states, 6 cities, 7 territories, and the District of Columbia. These funds support the provision of services at state and local levels to high-risk populations (including IDUs). Services include health education and risk-reduction activities, such as street outreach programs, as well as HIV counseling, testing, referral, and partner counseling. Prevention needs are prioritized through the HIV Prevention Community Planning process. CDC also funds many national and regional organizations to provide technical assistance to local programs across the country.
In addition, CDC conducts research that provides information used to develop effective prevention programs for IDUs. This includes not only surveillance data on populations at greatest risk, but findings from behavioral and evaluation studies to identify the most effective approaches to prevention.
CDC Presentations Related to IDU
"HIV Testing Behaviors Among High Risk Populations: Why Do Persons Seek, Defer or Avoid Getting Tested for HIV in the United States?" Stan Lehman
"Viral Load and CD4 Cell Count in Injecting Drug Users (IDUs) Newly Infected with HIV-1 Subtypes B' and E, Bangkok," Tim Mastro
"Adherence to Currently Prescribed Antiretroviral Therapies: Results from a Multisite Interview Project," Allyn Nakashima/Jeffrey Jones
"HIV Infection and TB Associated with Injecting Drug Use and Resistant M. tuberculosis, Bangkok, Thailand," Juree Punnotok
"A Meta-Analysis of the Impact of HIV Risk Reduction Intervention on Safer Sex Behaviors of Drug Users," Salaam Semaan
"HIV Risk Through Drug Use and Sexual Behavior in the U.S. Population," John Anderson
"The Need for Improved Reporting of HIV Prevention Intervention Research with Drug Users," Don Des Jarlais/Salaam Semaan
"AIDS Surveillance Trends in the United States: Declines in AIDS Diagnoses and Deaths Direct a Shift to Integrated HIV/AIDS Case Surveillance," Patricia Fleming
"Incarceration as a Continuing HIV Risk Factor Among Injecting Drug Users in Bangkok," Krit Hiranras
"Similar Risk Factors for New Infection with HIV Subtypes B' and E Among Injecting Drug Users (IDUs) in Bangkok, Thailand," Dwip Kitayaporn
"Willingness to Participate in an HIV Vaccine Efficacy Trial Among Injecting Drug Users (IDUs) in Bangkok, Thailand," Kathleen MacQueen
"Who is 'the Community' in Community Collaboration," Kathleen MacQueen
"HIV Serostatus and STD Risks in the Collaborative Injection Drug Users Studies (CIDUS)," Edgar Monterroso
"Effectiveness of HIV Prevention Programs in the Collaborative Injection Drug Users Studies (CIDUS)," Edgar Monterroso
"Acquisition of Sterile Needles Among Injecting Drug Users Admitted to Drug Treatment in Three U.S. Metropolitan Areas," Christopher Murrill/Linda Valleroy
"Substance Use and Sexual Behavior Among HIV-Seropositive Gay Men," David Purcell
"When Worlds Collide: Sex, Needles, and HIV Infection Among Young Injection Drug Using Men Who have Sex with Men," Greg Rebchook/Linda Valleroy
"Development of an HIV Intervention Studies Database for Providers and Researchers," Ellen Sogolow
"Effects of US-Based HIV Interventions on Safer Sex: Meta-Analyses, Overall and for Populations, Age, Groups and Settings," Ellen Sogolow
"Genetic Characterization of Incident HIV-1 Subtype B and E Strains from Injecting Drug Users (IDUs) in Bangkok, Thailand," Shambavi Subbarao
"HIV-1 Incidence, Subtypes, and Follow Up in a Prospective Cohort of Injecting Drug Users (IDUs) in Bangkok, Thailand," Suphak Vanicheseni