Risk Behaviors for HIV Transmission among Intravenous-Drug Users Not in Drug Treatment -- United States, 1987-1989

A major limitation to preventing transmission of human immunodeficiency virus (HIV) among intravenous-drug users (IVDUs) has been that most information about IVDUs' drug use and sexual behavior has been derived from studies of the most accessible subgroup (i.e., persons in drug-treatment programs) and therefore may not be representative of all IVDUs (1,2). Such data have been particularly limited for IVDUs not in drug treatment. This report provides preliminary data from September 1987 through December 1989 about IVDUs not in drug-treatment programs. The data are derived from the National AIDS Outreach Demonstration Research Project, which was initiated in 1987 by the National Institute on Drug Abuse (NIDA) and directed at IVDUs not in drug-treatment programs and their sex partners.

Objectives of the NIDA project included 1) collection of information on drug use and sexual behaviors of IVDUs not in treatment, 2) assessment of knowledge about HIV transmission and acquired immunodeficiency syndrome (AIDS) among IVDUs and their sex partners, and 3) communication of information regarding HIV transmission and AIDS to IVDUs and their sex partners.

From September 1987 to October 1988, outreach demonstration programs were established in 63 sites in 45 cities in the United States and Puerto Rico. IVDUs were recruited from hospital emergency rooms and inpatient settings, jails and prisons, public housing projects, community-based organizations, sexually transmitted disease clinics, and neighborhoods frequented by IVDUs.

Persons recruited for the program must have injected drugs during the 6 months before recruitment and not have been enrolled in a formal drug-treatment program during the 30 days before the intake interview. At recruitment and at 6-month follow-up intervals, trained interviewers used a standardized questionnaire to collect detailed information from participants about knowledge and behaviors related to drug use and sexual activity.

For 16,998 IVDUs not in treatment, preliminary data were obtained on their geographic distribution, demographics, employment status, drug use, and sexual activity. Of these, 5091 (30%) were recruited in the Northeast, 5028 (30%) in the Southeast, 4017 (24%) in the West, 2135 (13%) in the Midwest, and 727 (4%) in Puerto Rico.

Of the 16,998 IVDUs for whom data were obtained, 13,595 (80%) were between the ages of 25 and 44 years; 12,678 (75%) were male; 8585 (51%) were black, and 4498 (26%) were Hispanic; 9077 (53%) were unemployed, and 2620 (15%) worked occasionally; and 6722 (40%) had never been in drug treatment. In addition, 14,067 (83%) reported having been in jail or prison at some time; of these, 11,392 (81%) had never participated in formal drug treatment while incarcerated.

During the 6 months before the intake interview, 16,712 (98%) of IVDUs had injected cocaine or heroin either alone, sequentially, or mixed; 5824 (34%) predominantly injected heroin, 5310 (31%) predominantly injected cocaine, and 5578 (33%) predominantly injected combinations of heroin and cocaine. Two hundred eighty-six (2%) reported injecting amphetamines or other drugs but not heroin or cocaine. Ten thousand seventy-seven (59%) reported injecting drugs daily. In addition, 13,249 (78%) IVDUs reported sharing drug-injection equipment with another IVDU , and 3454 (20%) reported sharing with strangers, (Table 1).

Twenty percent of IVDUs reported always using new injection equipment (Table 2). Of those sharing injection equipment, 14% always cleaned the equipment with bleach before injecting. Sixty percent of IVDUs who reused drug-injection equipment cleaned the equipment with bleach at least some of the time.

In general, IVDUs reported "never using" a condom during sexual activity, although the prevalence of condom use varied by type of sexual activity (Table 3). Almost half of both male and female IVDUs reported having two or more sex partners during the 6 months before recruitment. Reported by: WW Weddington, MD, R Nemeth-Coslett, PhD, Community Research Br, Div of Applied Res, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration. M Anderson, PhD, R Baxter, MEd, S Baxter, P Biernacki, PhD, BS Brown, PhD, L DeNeal, PhD, S Deren, PhD, H Feldman, PhD, D Fleming, MD, S Friedman, PhD, S Gates, P Glider, T Hammett, PhD, D Hunt, L Kotransky, PhD, W McAuliffe, PhD, C McCoy, PhD, S Margolis, J Mondanaro, MD, H Musikoff, PhD, R Needle, PhD, F Rhodes, PhD, R Robles, PhD, R Ross, B Rounsaville, MD, R Rucker, PhD, J Schensul, PhD, H Siegal, PhD, M Singer, PhD, F Snyder, PhD, K South, R Stephens, PhD, S Stevens, PhD, K Vogtsberger, MD, D Watson, MA, W Wiebel, PhD, M Williams, PhD, R Wood, MD, The National AIDS Research Consortium. Office of the Director, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: In 1989, IVDU-associated AIDS cases represented 33% of all reported AIDS cases (3). Sharing of drug-using paraphernalia among IVDUs is a recognized mode of transmitting HIV (4-7). Sexual and perinatal transmission also occurs among this population (8).

Most (about 80%) of IVDUs are not in drug treatment (National Association of State Alcohol and Drug Abuse Directors, unpublished data). This study describes a relatively large population at high risk for transmission of HIV. The findings may not be representative of all IVDUs not in drug treatment in the United States because the study is limited to volunteer participants in selected cities.

The reduction or elimination of HIV transmission among IVDUs and their sex partners will require substantial changes in their drug use and sexual behaviors. Street and community outreach educational programs for IVDUs not in drug treatment can recruit IVDUs for both HIV prevention activities and drug-treatment programs. In this study, 83% of IVDUs had been incarcerated at some time; thus, HIV prevention programs for IVDUs who are incarcerated could reach a substantial proportion of IVDUs who otherwise are not in drug treatment. HIV prevention efforts targeting IVDUs (including those in drug-treatment centers) should be coordinated at the community level (9).

To reduce drug use and associated high-risk behavior (e.g., sharing of injection equipment) drug treatment should be 1) made accessible to those who have never entered drug treatment (e.g., by increasing public funding); 2) made more accessible within the criminal justice system (including prisons, jails, and probation and/or parole systems); and/or 3) used as an alternative to incarceration (10). Additionally, because HIV seroprevalence can be as high as 14% among non-IVDUs who are sex partners of IVDUs (CDC, unpublished data), this group should be targeted for educational and risk-reduction programs.

References

1. CDC. Human immunodeficiency virus infection in the United

States: a review of current knowledge. MMWR 1987;36(no. S-6).

2. Hahn RA, Onorato IM, Jones TS, Dougherty J. Prevalence of HIV infection among intravenous drug users in the United States. JAMA 1989;261:2677-84.

3. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, January 1990:9. 4. Friedland GH, Harris C, Buktus-Small C, et al. Intravenous drug abusers and the acquired immunodeficiency syndrome (AIDS): demographics, drug use, and needle sharing patterns. Arch Intern Med 1985;145:1413-7.

5. Marmor M, des Jarlais DC, Cohen H, et al. Risk factors for infection with human immunodeficiency virus among intravenous drug users in New York City. J AIDS 1987;1:39-44.

6. Chaisson RE, Moss AR, Onishi R, Osmond D, Carlson JR. Human immunodeficiency virus infection in heterosexual drug users in San Francisco. Am J Public Health 1987;77:169-72.

7. Schoenbaum EE, Hartel D, Selwyn PA, et al. Risk factors for human immunodeficiency virus infection in intravenous drug users. N Engl J Med 1989;321:874-9.

8. CDC. Update: acquired immunodeficiency syndrome associated with intravenous drug use--United States, 1988. MMWR 1989;38:165-70.

9. CDC. Coordinated community programs for HIV prevention among intravenous-drug users--California, Massachusetts. MMWR 1989;38:369-74. 10. Public Health Service. Report of the second Public Health Service AIDS Prevention and Control Conference. Public Health Rep 1988;103(suppl 1):66-71.

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