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By Don Des Jarlais, PhD
Over the last two decades, both the injection of illicit psychoactive drugs and HIV infection among injecting drug users (IDUs) have been spreading throughout the world. HIV infection among IDUs now must be considered a world-wide public health problem. In 1980, 80 countries reported injecting drug use, and 59 had found HIV infection among IDUs (1). By 1998, there were 129 countries with injecting drug use, and 103 with HIV infection among IDUs (2).
The spread of injecting drug use is a reflection of the "globalization" of the world economy. Improvements in communication and transportation and economies of scale in production have led to very large increases in the trade of licit goods; they have also, however, permitted equally large increases in the trade of illicit goods. Despite efforts to control, we must assume that the international trade in illicit psychoactive drugs is likely to increase for the immediate future.
Injecting is the most cost-efficient method of taking psychoactive drugs. It provides an immediate and strong drug effect at the lowest possible dose, and also permits consumption of almost all of the drug that was purchased. The micro-transfusions of blood that occur when two or more drug injectors share the same needles and syringes are an efficient method of transmitting blood-borne viruses such as HIV, hepatitis B, and hepatitis C. Extremely rapid HIV transmission has occurred among populations of injecting drug users, with from 10% to 50% of the IDU population becoming infected with HIV within a single year (3), (4), (1); this has been documented in North America, Europe, and Asia.
While very rapid spread of HIV among IDUs has been observed frequently, it is also known that IDUs will change their injection behavior to avoid HIV infection (5), and there are many examples of highly effective HIV prevention programs for IDUs. Three types of interventions have been shown to be effective: 1-community outreach programs, 2-programs that provide access to sterile injection equipment (such as syringe exchange and pharmacy sales programs), and 3-drug abuse treatment programs (6).
Community outreach and programs providing access to sterile injection equipment exercise their primary effects through encouraging "safer injection" (injection without sharing of needles and syringes). Drug abuse treatment programs, on the other hand, act to prevent HIV infection mainly through reducing the frequency of drug injection itself. Drug abuse treatment was known to be effective in reducing drug use prior to HIV and AIDS (7), so it should not be surprising that such treatment also leads to reductions in the spread of HIV infection – and, in fact, this has been dramatically demonstrated.
For example, in a study conducted in Philadelphia (8), persons in drug abuse treatment were enrolled in a prospective cohort study and asked to recruit "drug users like themselves" who were not in treatment. Both groups were followed to assess the rate of new HIV infections. During the 18 month follow-up period, the rate of new HIV infections (incidence) among the drug users in treatment was 3.5%, while the rate among the drug users who were not in treatment was 22% – more than 6 times higher.
One cautionary note about drug abuse treatment as a method of preventing HIV infection among drug users concerns the scale of the treatment programs. To be effective at the community level, drug abuse treatment needs to be provided on a public health scale. Small "pilot" programs may protect individual drug users from HIV infection, but can do very little to protect the general population of IDUs (and their sexual partners).
A misunderstanding that has greatly hampered HIV prevention efforts for injecting drug users is the false belief that drug abuse treatment programs, with their emphasis on abstaining from illicit drug use, are in conflict with syringe exchange and community outreach programs, which focus on encouraging "safer" drug injection. In some areas this has led to overt hostility between drug abuse treatment programs and syringe exchange programs. In actual practice, drug abuse treatment and safe injection programs have a complementary role in HIV prevention.
The general emphasis on preserving health in the safer injection programs has led many injecting drug users to reconsider their drug use and enter drug abuse treatment. In many cities, the syringe exchange programs and community outreach programs have become important sources of successful referral into drug abuse treatment. On the other hand, some persons who enter drug abuse treatment continue to inject drugs despite their efforts to change their drug use, and others relapse to drug use after leaving treatment; these individuals need access to safer injection programs to lessen the risk of infection with HIV when they resume, or persist in, intravenous drug use.
Drug abuse treatment can be a highly effective method of preventing HIV infection among injecting drug users. The treatment programs need to be implemented on a large (public health) scale, and within a comprehensive HIV prevention program that includes safer injection programs and active outreach efforts.
1. Ball AL, Rana S, Dehne K. HIV prevention among injecting drug users: responses in developing and transitional countries. Public Health Reports 1998;113(supplement 1):170-181.
2. Des Jarlais DC, Friedman SR. AIDS and IV Drug Use. Science 1989;245:578-579.
3. Des Jarlais DC, Friedman SR, Choopanya K, Vanichseni S, Ward TP. International epidemiology of HIV and AIDS among injecting drug users. AIDS 1992;6:1053-1068.
4. Stimson GV, Des Jarlais DC, Ball A, eds. Drug Injecting and HIV Infection: Global Dimensions and Local Responses. London: UCL Press, 1998.
5. Des Jarlais DC, Friedmann P, Hagan H, Friedman SR. The protective effect of AIDS-related behavioral change among injection drug users: a cross-national study. American Journal of Public Health 1996;86(12):1780-1785.
6. National Institutes of Health US. Interventions to Prevent HIV Risk Behaviors. In: NIH Consensus Statement. National Institutes of Health, 1997.
7. Gerstein D, Harwood H, eds. Treating Drug Problems. Washington, DC: National Academy Press, 1990.
8. Metzger D, Woody G, McLellan A, et al. Human immunodeficiency virus seroconversion among in- and out-of-treatment drug users: An 18 month prospective follow-up. Journal of the Acquired Immune Deficiency Syndromes 1993;6:1049-1056.