1997_2_editorial

Sexual Health Exchange, 1997 - no. 2

HIV/STDs and drug use

Don C. Des Jarlais

Unprotected sexual intercourse and sharing drug injecting equipment are the two major means of HIV transmission among adults. From an evolutionary perspective, sexual intercourse must be one of the oldest methods for transmitting diseases among adults, and sharing equipment for injecting illicit drugs must be one of the most recent methods. Indeed, the hypodermic syringe itself is less than 150 years old. Throughout the first half of the 20th century, illicit narcotic addiction was heavily concentrated in a single country, so much so that it was called "the American disease."

972Editorial In Nigeria, the STOPAIDS Organization produced a brochure called `The Motor Park Story´ in which travellers are warned about the dangers of drug abuse

The second half of the 20th century has seen a tremendous diffusion of illicit drug injection. This has occurred despite strong cultural disapproval of illicit drug injection, health hazards associated with it, and expensive law enforcement efforts, both within and among different nations. Increasing international communication and diversity within nations lead subgroups to engage in behaviours of which traditional leaders strongly disapprove. Good international transportation and communication systems facilitate expansion for both legal and illegal businesses. The cost efficiencies of large scale production and distribution can drive international growth in many legal and illegal businesses.

Transmission of HIV has spread extremely rapidly among some populations of injecting drug users (IDUs). Incidence rates of 10% to almost 50% per year have been observed in both developing and industrialized countries. This rapid

In a WHO study, IDUs who had changed their behaviour were half as likely to be infected with HIV as those who had not changed their behaviour. There are many populations of drug injectors where HIV was introduced but prevention efforts were begun early so that epidemics of HIV infection did not occur.

transmission has occurred through mechanisms for "rapid, efficient mixing" among drug injectors. Not only does needle sharing occur; it occurs among large numbers of injectors within short time periods. "Shooting galleries" (places where injection equipment can be rented to many different injectors) and "dealers' works" (injection equipment that a drug dealer may lend to many different injectors) promote rapid, efficient mixing within an IDU population. Moreover, IDU populations are not closed communities; they may serve as bridges to other populations, contributing to the spread of HIV/STDs through sexual transmission.

Risk reduction among drug injectors

IDUs will change their behaviour to reduce their chances of developing AIDS. In a WHO study of drug injectors in 12 cities on four continents, 82% of the IDUs reported that they had changed their behaviour in response to the threat of AIDS. Drug injectors have reduced their HIVrisk behaviour in response to a wide variety of different prevention programmes, including street outreach, syringe exchange, drug abuse treatment, bleach distribution (for disinfecting used injection equipment), HIV counselling and testing and "education only" programmes. They have even reduced risk behaviour in response to information about AIDS in the mass media and within their own oral communication networks, without any formal prevention efforts.

Analyses of HIV prevention literature suggest that effective prevention programmes provide ongoing and trusted communication links between health workers and IDUs. The programmes also provide good access to the means for behaviour change (e.g., sterile injection equipment for those who continue to inject and drug abuse treatment for those who stop injecting). At the community level, it is clearly preferable to begin prevention efforts early, before HIV infection becomes widespread in the local population.

The changes that IDUs make in their risk behaviour can be very effective in preventing HIV infection. In the WHO study, IDUs who had changed their behaviour were half as likely to be infected with HIV as those who had not changed their behaviour. There are many populations of drug injectors where HIV was introduced but prevention efforts were begun early so that epidemics of HIV infection did not occur.

Indicators of late 20th century commerce and health

There are offices in 91 countries of a single advertising company.

There are outlets in 101 countries of a single fast-food restaurant chain.

Illicit drug injection occurs in 121 countries.

HIV infection has been reported among injecting drug users in 81 countries.

Drugs and sex

The relationships between sexual behaviour and injecting drug use as well as abuse of other substances such as alcohol are quite complex. Female IDUs, who are dependent on men, may fear rejection by their partners if they do not inject drugs. Some people use drugs because they believe the drugs will increase pleasure during sex. Some provide drugs to potential partners to increase the likelihood of engaging in sex. Others engage in sex in order to obtain drugs or money to purchase them. HIV transmission has been associated with exchanging sex for crack cocaine, and noninjected drug use has been a predictor of HIV seroconversion in several studies of men who have sex with men.

Most people, however, seem to be able to modify their drug use so that they are as likely to use condoms when having sex with drugs as when having sex without drugs. Rather than focus prevention efforts on all drugrelated sexual activity, the focus should be on persons who exchange sex to support an addiction, the partners of addicted sex workers (many clients and regular partners do not want to use condoms), and persons who have multiple "problems in living," including unsafe sex, drug dependence, psychiatric conditions such as depression and anxiety, and difficulties in forming supportive interpersonal relationships. Self-empowerment strategies are particularly important for female IDUs.

Drugs and politics

Currently, the most important obstacle in preventing HIV infection among drug users is the behaviour of political leaders. Many leaders either believe they will never have a drug abuse problem in their communities or that, if they do have a problem, they will be able to eradicate it through law enforcement efforts. All recent history suggests that these "national immunity beliefs" are very unlikely to be true. Moreover, some politicians may fear strong opposition from law enforcement groups if they propose substituting harm-reduction strategies for the "war on drugs".

Successful prevention of HIV infection among drug users requires political courage: admitting that drug use exists in the community, that it is likely to persist indefinitely, and that it is necessary to work with drug users to change risk behaviours. The articles in this issue of the Exchange provide examples of such prevention efforts.

Don C. Des Jarlais, Beth Israel Medical Center, Chemical Dependency Institute, 1st Avenue and 16th Street, New York, NY 10003, USA; Tel: 12123873803; Fax: 1212 3873897; email: Dcdesjarla@aol.com