Archival Content: 1999-2005
HIV Prevention Among Drug Users:
HIV Behavioral Risks Among Drug Users
Drug users face multiple opportunities for HIV exposure through their drug use, sexual, and social behaviors. Understanding these behaviors will allow prevention planners and managers to identify reliable information related to the behaviors, current populations who are at high risk for HIV infection, and populations who are most in need of prevention interventions. Table 2.1 lists these practices and behaviors.
Injection drug users are the second largest subgroup of persons with AIDS in this country (CDC, 1996). Several factors contribute to the IDU's level of risk. These include the type of drug injected, frequency of injection, availability of sterile injecting equipment, method of preparing the drug for injection, and the location chosen for the process. Because each one of these behaviors also presents an opportunity for intervention, it is essential to understand the full constellation of specific injection drug-using behaviors if planning groups are to support successful interventions. For example, if IDUs inject with sterile syringes and do not share equipment, their risk of drug-related HIV infection is low. However, IDUs who use bleach to clean their syringes still incur risk if they continue to use virus-contaminated rinse water in the drug solution. The following section provides a general overview of HIV transmission risks associated with drug use, a discussion of the processes of procuring, mixing, and injecting drugs, and a discussion of high-risk sexual behaviors common among drug users.
Direct and Indirect Transmission of HIV Through Sharing of Injection Equipment
Injecting a drug like cocaine or heroin requires several pieces of equipment that are commonly referred to as a "set of works." Figure 2.1 displays some of the most frequently used components for preparing and injecting drugs. Exhibit D discusses these components in detail.
Through the shared use of drug equipment, HIV can be transmitted from an infected IDU to an uninfected person either "directly" or "indirectly." Transmission may occur directly when someone injects a drug with a syringe that another person has used and contaminated with HIV. Indirect transmission happens when the drug solution in a syringe is contaminated in the process of mixing or distribution.
Even with the advent of AIDS, the use of drug injection equipment by more than one person (multiperson use, or "sharing") continues to be practiced among injection drug users (Koblin et al., 1990; Mandell et al., 1994; Battjes et al., 1994). Sharing syringes occurs among IDU partners and people who regularly inject drugs together (drug networks) (Hartel, 1994; Williams et al., 1995). Anonymous, sequential sharing also can occur at "shooting galleries,"1 where syringes are rented out to one person after another without being disinfected (Murphy et al, 1991).2 Other factors also influence whether or not injection equipment will be shared by IDUs (see Table 2.2).
Not all those who inject drugs do so intravenously, however. For example, injecting a drug underneath the skin ("skin popping") is a method commonly employed by those just beginning to experiment with drug injection (Inciardi et al., 1991; Kaplan, 1983). Novices may incorrectly harbor the notion that drug dependence as well as HIV transmission cannot occur by this practice. Beginners rarely have their own injecting equipment, so they frequently share another IDU's syringe.
The risks of HIV exposure with indirect sharing arise from the processes of preparing the drug for injection and dividing it among several users. After purchasing drugs, one user in the group may use his or her syringe to draw up rinse water to mix with the drug. A plunger may be used to stir the solution as it heats, and the drug may be distributed by using the measurement markers on a syringe. Drug users are at risk of HIV transmission if the water or the syringe used for distribution has been contaminated with HIV-infected blood. Table 2.3 shows the indirect sharing practices that may occur with injection drug use.
Many IDUs are unaware of the risk of transmitting HIV through sharing practices. In one study, only 7 percent of the IDUs interviewed were aware of the risks of indirect sharing, even though more than 70 percent of the injectors observed were currently involved or had already participated in an AIDS intervention (Koester et al., 1994).
Along with the knowledge of practices and risk behaviors related to drug injection, prevention planners and managers need to take into consideration the sexual risk behaviors of drug users. These include unprotected anal, vaginal, or oral sex; multiple partners; trades of money, drugs, and sex; and lack of treatment for STDs, especially those with ulcerative lesions.
Traditionally, most HIV prevention efforts for IDUs have focused primarily on lowering risk of HIV transmission by changing drug injection practices. Less attention, however, has been paid to lowering the sexual risks of HIV transmission among IDUs. In one recent survey of IDUs, at least half reported that they were not sure that condoms are effective in preventing sexual transmission of HIV and less than one-third reported using condoms (Rhodes et al., 1990). Several studies have found a strong correlation between IDUs' unsafe sexual behaviors and their risky injection practices, suggesting that IDUs who engage in one unsafe behavior are more likely to engage in others (Schilling et al., 1991; Vanichseni et al., 1993; Paone et al., 1995). All studies of risk reduction interventions for IDUs that compared changes in injection risk behavior with changes in sexual risk behavior found greater changes in injection risk behavior (Friedman et al., 1993). Overall, condoms have been found to be used more consistently by IDUs in "casual" sexual relationships than in "primary" sexual relationships and with non-injecting sex partners than with injecting sex partners (Friedman et al., 1994).
Powdered cocaine, water, and baking soda are heated, forming a waxy substance known as "crack." Crack is cheaper than other illicit drugs, costing somewhere between $5 and $10 for a small bag of crack "rocks." Typically, a simple glass pipe is filled with one or two "rocks" and then lit. As the crack melts, it vaporizes and makes a crackling sound. The user then inhales the vapor. A water pipe is often used to filter impurities and cool the hot vapor. Figure 2.2 shows two types of pipes commonly used to smoke crack.
The fact that crack is relatively inexpensive, easy to use, and easy to hide makes it extremely popular. However, crack has to be used frequently and repeatedly since its effects are short-lived. As with other forms of cocaine, users can quickly become crack-dependent. Many crack abusers use the substance again and again until their money is gone. Crack users may spend from $50-$500 during a three-to four-day binge, known as a "mission," in which they consume up to 50 rocks of crack each day. During these binges, crack users often do not eat or sleep.
Crack use is associated with high-risk sexual activities as a result of the exchange of sex for crack or money to buy crack. The circumstances under which crack is purchased, prepared, and used can influence the level of these risks. When a crack user is dependent on sex exchange to purchase or use crack, for example, the level of risk for HIV infection increases significantly. Data on the "intersecting epidemics" of crack and HIV are now emerging and help to shed light on these complex behaviors. Case Example 2.1 describes one recent study that explored this linkage in inner-city young adults.
Crack use and the sexual risks of HIV transmission
Considering cocaine's inhibitory effect on sexual functioning, it is still not clear why there is such a close association between crack use and increased sexual activity. Some theories suggest that it is the disinhibiting effect of drug use or the compulsion to use crack that prompts the sexual activity
Three types of sexual exchanges are commonly associated with crack use (Ratner, 1993):
All three of these types of exchanges present risks of HIV transmission, although to varying degrees.3 Since condom use is rare in these circumstances, women are exposed to the potentially infectious semen of all their male partners, who in turn, are also exposed to the semen of the women's previous male partners. In addition, men who abuse crack often have difficulty ejaculating, which leads to prolonged sexual intercourse and possible breaks and tears in the genital skin and mucosal membranes (Ratner, 1993). These breaks provide opportunities for exposure to potentially infectious genital secretions, blood, and semen. Chronic crack users also can burn their lips and tongue while using hot crack pipes, increasing the risk of HIV transmission during oral sex, an activity frequently performed by both male and female crack users during sexual exchanges for crack or money.
The combination of a strong compulsion to use and the power imbalance that occurs during an exchange of sex for drugs or money presents many challenges to prevention planners and program managers who develop and conduct HIV prevention programs for crack users. In particular, prevention programs need to be designed to reach women crack users who exchange sex for drugs.
As discussed, specific behaviors place drug users at risk for HIV infection. However, these behaviors occur between people and often take place in differing settings and under differing social conditions. Drug use often takes place in small groups that meet in apartments, homes, or residential hotel rooms. Still others use drugs at "party houses," consisting of a variety of physical settings where individuals gather to use drugs. Examining the settings and social networks in which drug users interact and influence each other can help program planners and managers understand the social contexts that place drug users at high risk of HIV and can help them select and design more focused and effective HIV prevention interventions.
Injection drug use settings
Some drug-use social settings increase the potential for sharing contaminated equipment or for practicing unsafe sex, and thus influence the risk of HIV transmission. For example, one of the strongest predictors of HIV seroconversion among IDUs is injecting in outdoor settings or abandoned buildings (Friedman et al, 1995). In cities, the most recognized social settings where IDUs gather are "shooting galleries." Shooting galleries, also known as "safe houses" or "get-off houses," can be situated in back rooms, basements, dark hallways, or empty rooms of abandoned buildings in sections of cities where drug use rates are high (Inciardi et al., 1993).
Neighborhood heroin and/or cocaine dealers may operate shooting galleries as a service to customers-providing users, at the cost of just a few dollars, with a nearby location to safely "shoot-up." More often, however, gallery operators are drug users who provide a service for a small fee or a "taste" (sample) of someone else's drugs. For a fee, IDUs rent a set of works and relax while "getting off." After using the syringe and needle, the user generally returns them to a central storage place in the gallery where they are held until someone else rents them. These works also may be passed to another user in the gallery, which may involve an exchange of money, drugs, or sex (Inciardi et al., 1993).
For many IDUs, the use of shooting galleries is commonplace. For users who have no works of their own or their friends or "running partners" have no works, then galleries are their logical recourse. This is also true for those who purchase drugs far from home. In addition, some IDUs prefer local galleries because of the opportunities they provide to socialize with other users (Inciardi et al., 1993).
"Crack houses" are another drug use setting that poses a significant potential risk for HIV. Crack houses are places where users gather not only to purchase and smoke crack, but also to exchange sex for crack or for money to buy crack, or to provide money or drugs for sex (Inciardi et al., 1993). They may also be a place to manufacture or package crack. Crack houses can be located in private houses or apartments, abandoned cars, a vacant building, or a commercial establishment. Depending on the geographical region, crack houses are also known as "hit houses," "smoke houses," and "resorts."
As with shooting galleries, some crack houses charge users admission fees. For additional fees, crack houses may provide crack-smoking equipment, the crack itself as well as other drugs, rooms in which to have sex, and access to sex workers. Crack houses are more likely to be the scene of sex, stealing, bizarre behavior, begging and/or violence than are shooting galleries. Individuals who manage crack houses often recruit chronic crack users, particularly women, to whom they provide crack and sometimes food and shelter, in exchange for the women providing sexual services to male customers (Ratner, 1993).
Shooting galleries and crack houses are not the only settings where risky sexual practices and drug use are linked. For instance, the availability of drugs at social and recreational settings, such as bars, massage parlors, social clubs, or through escort services also is frequently linked to risky sexual behavior.
No matter what drugs are used, however, the key component to social settings is the number of drug users in the setting. When social settings bring together multiple individuals who then either inject drugs in a way that transfers HIV-infected blood among them, or have high-risk sex, HIV transmission can more readily occur. Although popular culture dramatizes the risks of transmission in shooting galleries and crack houses, any gathering of people who use drugs, whether in an apartment or a street corner creates the risk of transmission.
Social networks are characterized by groups of individuals who are linked by various relationships and common bonds. These networks may comprise people whose common link may be friendship, kinship, short-term acquaintances, or anonymous relationships. Social networks among drug users may vary, depending upon the type of drug used and how it is used, the size of the group, the degree in which the group is open to new members, the level of stability of the group, and the kind of social activity that occurs in the group (Needle et al., 1995).
Types of social networks. Networks generally have been characterized as "open" or "closed" systems (Trotter et al., 1995). In "closed networks," drug use takes place in private residences mainly among individuals who know one another. In these kinds of networks, it is uncommon for users to cross social, cultural, economic or geographic boundaries, thereby keeping HIV transmission relatively confined within the network. "Kinship networks" are one type of network where members have close kinship or family-based ties.
In "open networks," HIV may be more easily spread to a greater pool of individuals since the boundaries are not as tight as those in closed networks. Case Example 2.2 describes a type of open network, called an "acquaintance network," in which member turnover is frequent and multiple drug and sex exchanges occur on a regular basis.
Social network webs. Large networks often are composed of smaller "webs" of individuals who may engage in risky drug use and sexual behavior (Trotter et al., 1995). Some of these webs are considered "HIV risk contact networks" whose members are at high risk of HIV infection because of the extent and nature of their connections with HIV-positive people in their own web or in connecting webs. If the personal networks of HIV-positive individuals are small and are not connected to larger webs where there are more interactions, the risk of HIV transmission may be less pronounced.
Familiarity with existing social networks within a community can help determine the most effective channels of communication among network members. For example, it may be useful to identify the key "gatekeepers" or "brokers" within a network, who act as the main link to the network's membership. Interventions designed to reach network gatekeepers can help alter risk behaviors within the network (Friedman, 1995).
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