Dangerous Consequences: Understanding the Link Between Substance Abuse and HIV/AIDS. [The Practical Theorist 8]

2007·0.83 MB·English

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THE PRACTICAL THEORIST
DANGEROUS CONSEQUENCES:
Understanding
Between
the Link
Substance Abuse
and HIV/AIDS
A PUBLICATION OF
Community Anti-Drug Coalitions of America (CADCA)
SUPPORTED IN PART BY THE
National Institute on Drug Abuse (NIDA),
National Institutes of Health (NIH),
U.S. Department of Health and Human Services (DHHS)
•OCADCA
MH07D8179
INTRODUCTION
An
estimated 1 million people in the United States are living
X \ with HIV/AIDS. In this country, annual reported AIDS cases
# \ peaked in 1993 at approximately 80,000. While declining
steadily between 1993 and 1998, since 2001 the incidence of new
AIDS cases has increased slightly each year, with approximately
42,500 new cases reported in 2004.
Early in the HIV/AIDS epidemic, infections In fact, an emerging trend in HIV infection
were mainly seen among White, urban, men is a rise in new infections among MSM after
who have sex with men (MSM) or male experiencing a substantial decline. This
injecdng drug users (IDUs). Today, however, increase has been associated with many
more people have come to recognize the factors, including a resurgence of risky sexual
important role non-injection drug abuse behavior linked to the use of
plays in the spread of HIV and AIDS methamphetamine and other club drugs.
through the dangerous risk behaviors it
engenders. Drug and alcohol intoxication To help coalitions better address HIV/AIDS
affect judgment and can lead to risky sexual in their communities, Community Anti-Drug
behaviors that put people in danger of Coalitions of America (CADCA) in
contracting or transmitting HIV. collaboration with the National Institute on
DrugAbuse (NIDA) have developed
“Dangerous Consequences:
Estimated Number ofAIDS Cases and Deaths among Understanding the Link Between
—
Substance Abuse and HIV/AIDS.”
Adults and Adolescentswith AIDS, 1985-2005 United States
and DependentAreas
This publication, the 8th in CADCA’s Practical
Theoristseries, provides an overview of the
impact of substance abuse on HIV/AIDS. It
summarizes the latest research regarding the
linkages between infectious disease and
substance abuse and highlights real-life
examples of how local coalitions in Detroit,
GA
MI; Berks County, PA; and Atlanta, are
addressing this issue.
Note:Datahovebeenadjustedforreportingdelays
Source:CentersforDiseaseControlandPrevention
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
>
HIV/AIDS AND DRUG ABUSE
SECTION
1
—
Drug abuse has been linked with HIV the virus that causes
—
AIDS since early in the epidemic. Using or sharing unsterile
needles, cotton swabs, rinse water, and cookers, such as when
injecting heroin, cocaine, or other drugs, leaves a drug user
vulnerable to contracting or transmitting HIV.
And, while intravenous drug use is well Among racial and ethnic groups, as of 2004,
known in this regard, less recognized is the 41 percent of cumulative AIDS cases
role that drug abuse plays more generally in reported among adult
the spread of HIV by increasing the and adolescent Did You Know?
likelihood of high-risk sex with infected Hispanic males in
partners. The intoxicating and addictive effect the United States Drug and alcohol intoxication affect
of many drugs can alter judgment and were direcdy or judgment and can lead to risky sexual
inhibition and lead people to engage in indirectly related to behaviors that put people in danger of
impulsive and unsafe behaviors. injection drug use, contracting or transmitting HIV.
as were 42 percent In 2004, nearly 5,000 young people
Drug abuse and addiction can also worsen the among African- were diagnosed with HIV/AIDS.
impact of HIV. It can affect treatment American males. Teens and young adults account for
adherence to HIV medications and it may approximately half of the 19 million
affect the replication of the virus, thereby The percentages new cases of sexually transmitted
influencing the course of the illness. Drug were greater among infections diagnosed each year.
abuse can worsen the consequences of HIV females. Fifty-six
—
in the brain methamphetamine abusers percent of cumulative AIDS cases reported
infected with HIV suffered greater neuronal among adult and adolescent Hispanic females
injury and cognitive impairment than non- were direcdy or indirectly related to injection
drug users. drug use, as were 55 percent of cases
reported amongWhite females and 49
What are the statistics? percent amongAfrican American females.
From 2000 to 2004, almost 60,000 AIDS
We do not have equivalent statistical
diagnoses in the United States were due
information regarding the role of
directly to injection drug use, with males
noninjection drug use in the spread of
accounting for nearly 72 percent of these
HIV/AIDS. However, one CDC study of
cases. Over this same period of time, there
more than 2,000 young adults in three inner-
has been a gradual decline in the number of
new AIDS diagnoses associated with injection city neighborhoods found that crack smokers
were three times more likely to be infected
drug use for both males and females.
with HIV than non-crack smokers.
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
r
SECTION POSITIVE IMPACT OF DRUG TREATMENT
2
ince the late 1980s, research has shown that drug abuse
S
treatment is effective HIV prevention. Drug abusers engaged
in treatment have a higher likelihood of stopping or reducing
their drug use and related risk behaviors, including risky injecdon
practices and unsafe sex. This is particularly true when treatment is
combined with HIV prevention and community-based outreach
programs for at-risk people.
Drug abuse treatment programs can serve an month at 6-month follow up among non-
important role in providing current injection cocaine abusers. Reduction in
information on HIV/AIDS and related cocaine use was associated with an average 40
diseases, counseling and testing services, and percent decrease in HIV risk across gender
referrals for medical and social services. and ethnic groups, mainly as a result of fewer
sexual partners and less unprotected sex.
Combined pharmacological and behavioral Among MSM who abused methamphetamine,
treatments for drug abuse have a comprehensive behavioral treatment reduced
demonstrated impact on reducing HIV risk risky sexual behaviors and sustained those
behaviors. For example, when behavioral reductions for at least one year following
therapies were combined with methadone treatment.
treatment, approximately half of study
participants who reported injection drug use Behavioral treatments have also shown
at intake reported no such use upon exiting promise for enhancing adherence to
the study, and over 90 percent reported no antiretroviral therapy. HIV treatment
needle sharing at the end of the study. adherence is vital to treatment success, but
can require dramatic lifestyle changes.
Drug abuse treatment has also been shown to Effective HIV treatment includes providing a
decrease cocaine use from an average of 10 consistent medical regimen to counter the
days per month at baseline to one day per often chaotic lifestvle created by drug abuse
and addiction.
NIDA
Researchfrom has shown that Drug treatment programs can also help to
HI/ reduce the spread of other blood-borne
comprehensive prevention strategies,
infections, including hepatitis B and C viruses.
including community-based outreach, testing and
counselingfor HI/and other infections, can be Research from NIDA has shown that
comprehensive HIV prevention strategies,
cost-effective and reliable inpreventing new including community-based outreach, testing
HI/ infections among diversepopulations. and counseling for HIV and other infections,
can be cost-effective and reliable in preventing
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
new HIV infections among diverse Early detection of HIV is another cost-
populations of drug abusers and their effective approach. Research indicates that
communities. Short of a vaccine or cure for routine HIV screening in healthcare settings
AIDS, preventing the spread of the virus is among populations with an infection
the most cost-effective approach. Research prevalence rate as low as 1 percent is as cost
has demonstrated that school and effective as screening for other conditions
community-based drug-abuse prevention such as breast cancer and high blood pressure.
programs designed for inner-city African- These findings suggest that HIV screening
American boys can be effective in reducing can lower healthcare costs by identifying
high-risk behaviors, including drug abuse and infection, providing a venue for risk-reduction
risky sexual practices that can lead to HIV counseling, and providing referral for
infection. The research also underscored the appropriate medical follow-up to reduce HIV-
importance of incorporating cultural associated morbidity.
competency for specific populations.
Buprenorphine is playing a key role in getting
more opiate-addicted patients engaged in drug
What is Hepatitis C?
abuse treatment. According to the Substance
Abuse and Mental Health Services
Hepatitis C is a disease of the liver caused
by the hepatitis C virus (HCV). Eighty Administration, nearly 105,000 patients had
percent of infected individuals show no been treated with buprenorphine by March
signs or symptoms. Symptoms that can 2005. An overwhelming majority of patients
appear include jaundice, fatigue, dark have found buprenorphine helpful (99 percent)
urine, abdominal pain, loss of appetite and 97 percentwould recommend
and nausea. Infection can lead to chronic buprenorphine to a friend suffering from
liver disease in 70% of cases, which in 1%- opioid addiction. Buprenorphinewas approved
5% of cases can result in death. for treating opioid addiction by the U.S. Food
Transmission ofthe virus can occur when and DrugAdministration in October 2002.
the blood of an infected person enters the
body of a person who is not infected. HCV A recent study found that 59 percent of
is spread by sharing needles when buprenorphine patients were still abstinent
injecting drugs, through needlesticks or
from all drugs six months later, while 81
sharp exposures on the job, or from an
percentwere abstinent from opioids.
infected mother to her baby during birth.
Most infections are due to illegal injection Buprenorphine also exhibits high treatment
drug use. An estimated 4.1 million retention rates. Notably, needle sharing among
Americans (1.6%) have been infected with a patient sample receiving buprenorphine
HCV, of whom 3.2 million are chronically dropped from 5 percent at baseline to 1
infected. The number of new infections per percent at 30-day follow-up and 2 percent at
year has declined from an average of six-month follow-up. Patients with more than
240,000 in the 1980s to 26,000 in 2004. one sex partner dropped from 7 percent at
There is no vaccine to prevent HCV. The baseline to 6 percent at 30-day follow-up and
virus is detectable by a blood test. 0 percent at six-month follow-up.
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
SECTION PRINCIPLES OF HIV PREVENTION
3
.
A
NIDA
research based guide developed by lists 17 principles
of HIV prevention in drug-using populations. The guide is
available online at http://www.drugabuse.gov/POHP/.
l
NIDA’s 17 principles of HIV prevention are: 5 Prevention programs must be based on a
thorough, continuing assessment of local
1. Reducing the risk of transmitdng and /or community needs, and the effecdveness
acquiring HIV/AIDS among drug users and impact of these programs should be
is an achievable goal. condnually assessed.
2. A community should start HIV/AIDS 6. Prevention services can most effectively
prevention programs as soon as possible. reach drug-using populations when they
are available in a variety of locations and
3. Effective prevention programs require a at a range of operating times.
comprehensive range of coordinated
sendees. 7. Prevention and treatment efforts should
target both HIV+ and HIV- drug users,
4. Prevention programs should work with as well as their sex partners.
the community to plan and implement
interventions and sendees. 8. Prevention efforts should target not only
individuals, but also couples, social
networks, and the broader community of
drug users and their sex partners.
9 Community-based outreach should be
.
directed toward drug users in their own
neighborhoods.
10. Prevention interventions should be
personalized for each person at risk.
11. Drug users and their sex partners should
be treated with dignity and respect and
with sensitivity to cultural, racial/ethnic,
age, and gender-based characteristics.
12 As part of a comprehensive HIV
prevention program, injection drug users
should have ready access to sterile
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
injection equipment to reduce their use of
PSAs Available About Drug Use
previously used injection equipment. and HIV/AIDS
13. Interventions that target injection risk Public service announcements (PSAs) are
should address sharing other injection an effective way to spread the word
equipment in addition to syringes. about the risks associated with alcohol
and drug use. Several PSAs are
14. Risk reduction information alone is often available on NIDA's Web site that can
help increase awareness about
not enough to help drugusers and their
substance abuse and HIV/AIDS. The
sex partners make lasting behavioral
PSAs, available in 15-second, 20-
changes.
second, 30-second and 60-second
spots, can be sent to public service
15. Prevention efforts should address the directors at both radio and TV media
risks of transmitting HIV and other stations. For more information, visit
infections sexually as well as through drug http://hiv.drugabuse.gov/media.html.
injection.
16. HIV/AIDS risk-reduction interventions
should be sustained over time.
17. Community-based prevention is cost-
effective.
Effectivepreventionprograms
require a comprehensive range
of coordinated services.
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
SECTION 4 PREVENTING HIV/AIDS IN DRUG USERS
G
iven the diversity of drug users and their sex partners, no
single HIV/AIDS prevention strategy will work effectively
i
A
for everyone. comprehensive approach that readily adapts
and responds to changing patterns of drug use and HIV/AIDS risk
behaviors, the characteristics of local settings, and the varied service
needs of drug users and their sex partners is the most effective
strategy.
WHAT ARE THE COMPONENTS OF A Effecdve drug abuse treatment helps prevent
COMPREHENSIVE HIV/AIDS HIV. Drug users who enter and continue in
PREVENTION APPROACH? treatment are more likely than those who do
Research has shown that a comprehensive not to reduce risky acdvities such as sharing
HIV/AIDS prevention approach includes needles and injection equipment or engaging
three complementary approaches: in unprotected sex. Drug abuse treatment
community-based outreach, drug abuse can be conducted in a variety of settings
treatment, and sterile syringe access (inpatient, outpatient, residential), can consist
programs. Each of these approaches should of various approaches, including behavioral
include HIV testing and counseling and therapy, medications, or a combination of
referral for appropriate medical care. both, and should include HIV testing,
counseling, and appropriate referral for
Community-based outreach relies on medical follow-up.
coalidons and other grassroots leaders who
typically reside in the local community and
EFFECTIVENESS OF THESE
are familiar with its drug use subculture.
APPROACHES
They are in a unique position to educate and
influence their peers to stop using drugs and The effectiveness of community-based
reduce their risks for HIV and other blood- outreach has been shown through 15 years
borne infecdons. of research on HIV/AIDS prevention
interventions. Cumulative research from a
23-site study that followed 18,144 drug users
(13,164 IDUs and 4,980 non-injecting crack
[Coalitions] are in a uniqueposition to users) showed that 3 to 6 months after
participating in a community outreach
educate and influence theirpeers to
intervention, 72 percent of the IDUs either
stop using drugs and reduce their risksfor stopped injecting drugs or reduced their
HIV frequency of injection. Of those who
and other blood-borne infections.
continued to inject, nearly 60 percent either
stopped or reduced reusing or sharing their
syringes. Twenty-six percent of crack cocaine
users had stopped using crack cocaine at ROLE OF COMMUNITY-BASED
follow-up. Nearly 25 percent of participants LEADERS
in the study had entered treatment at follow- Community-based leaders, such as coalition
up, many for the first time. directors and staff, are on the front line in
the local community and they know where,
Studies have consistently shown that drug when, and how to contact even the most
abuse treatment is associated with lower rates difficult-to-reach drug users in their
A
of drug injection. three-year study of drug neighborhoods. They are a trusted and
use patterns among male IDUs participating recognized source of information and can
in methadone maintenance treatment help drug users understand their personal
reported that 71 percent of 388 patients who risks for HIV and other blood-borne diseases
had remained in treatment for one year or and identify preventive steps they need to
more had stopped injecting drugs. take. As a peer, community leaders can
Conversely, in a second group of 105 IDUs encourage drug users to stop or reduce their
who had dropped out of treatment, 82 using and injecting drugs and enter drug
percent had relapsed to injecting drug use abuse treatment. They are a vital link to
within a year. Another study found that education and can provide referrals for HIV
opiate addicts who were recruited by street testing, treatment, and counseling and other
outreach workers and offered free health, prevention, and social service
methadone maintenance treatment were programs.
significantly more likely to enter and remain
in treatment even if they had never been in
treatment before or claimed not to want COST-EFFECTIVENESS OF HIV
treatment. PREVENTION
Cost-effectiveness studies have reported that,
by preventing HIV infections, community-
based interventions help avert future medical
Bypreventing HIVinfections costs associated with the care and treatment
; of HIV/AIDS. Drug abuse treatment
community-based interventions programs are also cost-effective in reducing
drug use and associated health and social
help avertfuture medical costs
costs, especially when compared to not
associated with the care and treating addicts or incarcerating them.
HIV
AIDS.
treatment of I
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES
NIDA'S COMMUNITY-BASED OUTREACH MODEL
NIDA's Community-Based Outreach Model is based on transmission and drug injection risks. The second session
more than fifteen years of NIDA-funded research and has provides both a review of risk-reduction information and
been tested in 52 communities with more than 60,000 the opportunity to reinforce and support behavior change
injection drug users, 14,000 crack users, and many of efforts. The sessions are designed to occur before and after
their sex partners. The model has been used and tailored HIVtesting, which can be provided directly as part of a
to the needs of specific at-risk subgroups and has been prevention program or indirectly by means of a referral.
found to be effective with multiracial, multiethnic, male
and female, HIV seropositive and seronegative, infected Effective HIV/AIDS prevention requires a range of
and non-infeded drug-using populations residing in low, coordinated services. The NIDA Community-Based
medium, and high HIV prevalence. Outreach Model is designed to complement other
prevention strategies, including HIV prevention case
NIDA's Community-Based Outreach Model includes two management, drug abuse treatment, and access to sterile
interrelated components designed to facilitate behavior syringes through pharmacies or syringe exchange
change among at-risk drug users. These include (1) programs. Because multiple providers will no doubt be
community-based outreach and (2) two sessions of involved in the delivery of services, careful attention must
education and risk-redudion counseling that are organized be given to the coordination of services within a
around testing for HIV, hepatitis B virus (HBV), and hepatitis community.
C virus (HCV), to provide pre-and post-test counseling to
help drug users learn their serostatus and the behavior The NIDA Community-Based Outreach Model is intended
changes needed to reduce transmission risks. to be customized by local communities. This customization
will depend on a careful assessment of local community
In addition to accessing drug users in a variety of needs. There is considerable variation across communities
community settings, outreach workers serve as role in the nature and extent of drug use, the prevalence and
models, educators and advocates who can provide drug course of HIV/AIDS, patterns of risk-taking and the
users with changing and accurate risk-reduction availability of community resources. Resource limitations
information in settings that are familiar to them and at may necessitate that prevention efforts be focused to reach
times of greatest risk. those at greatest risk. Ongoing surveillance of local drug
use and HIV risk-behavior patterns provide important
Specific outreach strategies include: communicating basic information for identifying new populations at risk and
risk-reduction information; presenting a hierarchical tailoring the content of prevention messages.
framework for understanding the relative effectiveness of
different risk-reduction strategies; providing literature and Because oftheir familiarity with the drug-use subcultures
other materials to support behavior change; facilitating and local neighborhoods in their communities, outreach
access to drug treatment, HIV/AIDS testing and counseling workers can access out-of-treatment drug users in their
services, and other medical and social services available in natural environments, including the streets, storefronts,
the local community. parks, shooting galleries, crack houses, soup kitchens,
homeless shelters, abandoned buildings, and syringe
The two sessions of individual HIV risk-reduction exchange programs. Using a converted recreation vehicle
counseling can be held within the context of outreach or van as a mobile home-base for outreach activities when
contacts or can be conducted in an office setting, either by targeting such places can be an effective means of
outreach workers or other staff (counselors, health reaching at-risk populations.
educators). The first session provides basic information
about the transmission and prevention of HIV, HBV, HCV, To download NIDA's Community-Based Outreach Model,
and other sexuallytransmitted diseases, addressing sexual go to http://www.drugabuse.gov/CBOM/lndex.html.
PRACTICAL THEORIST 8: DANGEROUS CONSEQUENCES