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U.S. Department of Health and Human Services

Archival Content: 1999-2005

A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users

Chapter 1, Section 2: The Context of High-risk Drug and Sexual Practices

The degree of risk associated with injecting drugs is determined in part by the physical setting in which it takes place and the people with whom a user injects. An understanding of the contexts in which drug use occurs is particularly important because they help to explain the ways drug use takes place and they help define individual users and the other people with whom they spend time, buy drugs, inject drugs, and have sex. This knowledge, in turn, illuminates the ways in which infection is transmitted from one individual to another, as well as from small high-seroprevalence groups to the larger community (Des Jarlais et al., 1993; Friedman et al., 1995; Friedman et al., 1997; Needle et al., 1995). Armed with these insights, policy makers and service providers can develop prevention interventions that are tailored to the characteristics and needs of specific groups of injection drug users (AED, 1997; Bourgois, 1998; IOM, 1995). The following sections discuss several key social contexts for drug use.


Drug use takes place in a variety of locations that allow people to inject by themselves or in small groups. These locations include apartments or homes, bars, massage parlors, social clubs, residential hotels, abandoned buildings, public bathrooms, and "shooting galleries" (AED, 1997; Des Jarlais et al., 1993; IOM, 1995; Latkin et al., 1996a). In some settings, users rent out needles and other equipment for a small fee or a portion of the user's drug, which is paid to the dealer operating the gallery. The needles are then returned and used by the next injector. In other settings, sharing drugs or equipment occurs without payment of drugs or money. Key components of this context are the number of drug users in the setting and the riskiness of the behaviors. When a setting brings together multiple individuals who prepare and inject drugs in risky ways (with few syringes and widespread direct and indirect sharing) or who have high-risk sex, transmission of HIV and other blood-born viruses can spread rapidly and efficiently from one user to others (Latkin et al., 1994).


These are groups of users linked by various relationships and bonds. Networks differ based on the number of members and how stable the relationships are, the types of relationships among members, the degree to which the group is open to including new members, the kind of social activity that occurs within it, and the types of drug used and how they are used (Friedman et al., 1997; Needle et al., 1995). In addition, networks may be defined by race or ethnicity, gender, sexual orientation, social class, and the presence of kinship among members.

The nature of the relationships among members and the interpersonal and group dynamics of the network directly affects a member's drug-use and sexual behaviors and therefore are highly influential in determining that person's risk of infection (Friedman et al., 1997; Latkin et al., 1996b; Needle et al., 1995). For example, some networks are small, consisting of a close group of drug-using or sex partners. These individuals may have increased risk because they may be less likely to use condoms or sterile syringes, which may conflict with the intimacy and trust developed in the relationships. Other types of networks are characterized by a larger, more open membership, and the level of risky behavior engaged in by members is influenced by the settings in which drug use takes place and the closeness of the ties that bind members (Trotter, 1995). A member who has close links with other drug injectors in the network is more likely to engage in high-risk practices, such as sharing syringes or injecting in shooting galleries, than are drug injectors who are only peripherally connected to other network members (Friedman et al., 1997). Further more, those members with the most material resources are at the top of the network's hierarchy. When sharing drugs, they will shoot first, which may make it more likely that they will use a sterile syringe and equipment. In contrast, the newest members of the network or those with the fewest material and other resources command the least respect and exist on the margins of the network. They often must engage in the riskiest drug and equipment sharing practices, such as collecting used cottons to extract any drug remaining in them (Bourgois, 1998; Bourgois, unpublished).

Social networks are a critically important context for understanding drug use and its intersection with the transmission of HIV and other blood-borne pathogens because of their role in maintaining an epidemic within the group and in providing a starting point for rapid transmission beyond the group (Friedman et al., 1997). They are also a critically important context when considering prevention efforts because these same dynamics also may be used to introduce and reinforce norms that support risk reduction and to develop effective channels of communication with members (Latkin, 1995).


Certain groups of injection drug users warrant particular attention because their occupations or behaviors lead to drug- and sexually-related transmission risks that appear to be higher than they are for other populations. They can experience considerable societal stigma to begin with because of these occupations and behaviors, and their drug use compounds this problem and contributes to their higher transmission risk. For example, many IDUs have coexisting problems, such as mental illness, physical illness, homelessness, and incarceration. As many as 30 percent of homeless adults may be substance abusers. (NIDA, 1990; Schutt et al., 1992). Overall, homeless adults have higher HIV rates than do the general population, particularly in high prevalence areas. A recent survey of homeless adults using a storefront medical clinic found that more than two-thirds were at risk of HIV infection from various sources, including unprotected sex with multiple partners, injection drug use, sex with an IDU partner, or exchanges of sex for money or drugs (St. Lawrence and Brasfield, 1995). Some homeless also have mental illness and violent and unstable living situations, and because of this they find it dif ficult to form the safe, intimate relationships that could help them reduce their risk. Limited availability of or access to mental health services increases this problem.

Key contexts of
high-risk behaviors Men and women in prisons and jails also suffer disproportionately high rates of drug abuse as well as of HIV infection. Recent data from the National Center on Addiction and Substance Abuse (CASA) show a direct or indirect connection between substance abuse and the incarceration of nearly 80 percent of those in federal, state, and local prisons and jails (Belenko, 1998); 60-80 percent of inmates have serious substance abuse problems (Leshner, 1999). Another recent report, published by the National Institute of Justice, CDC, and the Bureau of Justice Statistics shows that in 1996, 24,881 inmates in state and federal prisons were known to be infected with HIV (Hammett et al., 1999). HIV-positive inmates comprised 2.4 percent of the state prison population in 1996 and 1.0 percent of the federal prison population. Between 1991 and 1996, the number of HIV-positive inmates grew at about the same rate as the overall prison population (both increased by about 42 percent).

Female sex workers and female IDUs who have sex with other women are particularly vulnerable to infection because many are poor and homeless and addicted to alcohol as well as drugs. Female IDUs who trade sex for money or drugs are more likely to share needles than are female injectors who do not engage in sex trading, and are less likely to use new needles or to clean old ones (Kail et al., 1995). Female drug-injecting partners of male IDUs may be more likely to inject after the man and therefore be exposed to greater risk. Regardless of the origin of their risks, these women often exist in a subordinate and physically dependent relationship to the men with whom they interact, and these power imbalances make it difficult for them to change their behaviors in ways that might reduce risk (AED, 1997; Bourgois, unpublished).Young injection drug users are another group who require increased attention because the contexts in which they inject frequently increase their risk of transmission.

Young IDUs may be run aways or peripheral members of drug-using social networks. If they lack money to buy drugs, they may be forced to trade sex for drugs or money. Men who have sex with men (MSM) and inject drugs also face increased risks of transmission. For example, recent evidence from CEWG shows that methamphetamine use, once largely restricted to the West, is now spreading into other parts of the country and gaining in popularity among MSM. Methamphetamines can be administered in several ways but the injection route appears to be increasingly common. This method of administration increases a user's chances for engaging in high-risk sexual and non-sexual behaviors, thus increasing the risk of acquiring or transmitting infection (NIDA, 2000).


Location often influences the types of drugs available, and this in turn dictates the method of administration (e.g., injected, smoked) and the level of risk experienced by users (Sullivan et al., 1998). For example the two major sources of heroin in the United States today are South America and Mexico. South American heroin is distributed primarily to cities on the East Coast and is a high purity, white powder form of the drug. Because of this high purity (60-70 percent), an increasing number of users are resorting to snorting the drug rather than injecting it (CEWG, 1998). In contrast, the major forms of heroin available on the West Coast, Texas, and some Midwestern cities, such as Chicago and St. Louis, are Mexican black tar and brown powdered heroin. Mexican black tar heroin also has recently reappeared in Atlanta (CEWG, 1998). Black tar heroin is less pure than the white powder form (39 percent) and has a consistency somewhere between tar and wax. Its difficult texture makes it hard to snort and users are therefore more likely to inject it, which exposes them to the potential transmission risks associated with injection practices. The combination of the texture and the drug's cost (in San Francisco, it is commonly sold in $20 units about the size of pencil eraser) also increases the chances that IDUs who are short of money will share the drug. This involves dissolving the drug and dividing it into portions equivalent to the money each person contributed to the purchase of the drug. This procedure increases the risk of infection through shared needles and ancillary parapernalia (Bourgois, unpublished; Koester and Hoffer, 1994).


Many IDUs have jobs and health insurance (Eisenhandler and Drucker, 1993; SAMHSA, 1999). Others are less involved in the mainstream economy and must resort to a variety of tactics to support their habits, including panhandling, scavenging, day labor, sex work, and petty theft. As noted already, the relative social status of IDUs has a direct in fluence on the degree of risky behavior necessary for survival. Those who begin with higher social status and more secure income, housing, and support networks may be more able to control their risks of transmission. Poorer IDUs, those with concomitant health or mental problems, and those with unstable living and social circumstances may have difficulty obtaining sterile syringes or be more susceptible to legal penalties for syringe possession, and thus may be more likely to pursue risky behaviors, such as sharing injection equipment (Bluthenthal et al., 1999a; Bluthenthal et al., 1999b; Case et al., 1998). For these IDUs, any change in financial or social circumstances can have a significant impact on their risk profile. A case in point is the 1997 federal decision to cease Supplemental Security Income (SSI) benefit payments to individuals whose drug or alcohol addiction is considered a contributing factor to their disability. Data from a 1995 study of IDUs living in six San Francisco area communities showed that benefits for SSI recipients contributed to the overall stability of their lives and to a lower risk of acquiring or transmitting infection because they were less likely to be homeless, were less reliant on illegal income, used drugs less often, and shared syringes less often than did IDUs who did not receive benefits (Lorvick et al., 1997). A follow-up study showed that those who lost SSI benefits as a result of the ruling were more likely to participate in illegal activities, more likely to share syringes, and injected drugs more often than did those who retained benefits (Bluthenthal et al., 1999b).

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