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HIV Prevention for Injecting Drug Users: The First 25 Years and Counting DON C. DES JARLAIS, PHD,

AND

SALAAM SEMAAN, DRPH

During the last three decades, both the injection of illicit psychoactive drugs and HIV infection among injecting drug users (IDUs) have spread throughout industrialized and developing countries. Extremely rapid transmission of HIV has occurred in IDU populations with incidence rates of 10 to 50/100 person-years. In sharp contrast, there are many examples of very effective HIV risk reduction for IDUs, both in preventing initial epidemics and in bringing existing epidemics under control. IDUs are capable of learning basic information about HIV/AIDS and modifying their behavior to protect both themselves and their peers. Effective HIV prevention for IDUs requires programs that treat IDUs with dignity and respect, provide accurate information and the means for behavior change—access to sterile injection equipment, condoms, and drug abuse treatment. Programs that provide these services need to be implemented on a public health scale for IDU populations at risk for HIV infection. Key words: injecting drug use, HIV prevention, HIV/AIDS. IDU ⫽ injecting drug user.

INTRODUCTION ransmission of HIV in persons who use illicit psychoactive drugs remains a major public health challenge in many countries. The purpose of this brief overview is to summarize the epidemiology and transmission of HIV in injecting drug users (IDUs), describe effective prevention efforts, highlight selected societal opportunities and challenges, and provide guidelines for working with IDUs.

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Epidemiology and Transmission of HIV in IDUs AIDS was first observed in IDUs in late 1981 (1). Since then, a considerable amount of research has been conducted on how to prevent HIV infection among IDUs. Many effective prevention programs have been implemented with IDUs, saving hundreds of thousands of lives (2– 4). However, the number of HIV-infected IDUs and the number of IDUs at high risk for becoming infected with HIV have continued to increase globally. The most recent global estimate suggests that there are 13 million persons who inject illicit psychoactive drugs and that 10 million of these IDUs live in developing and transitional countries (5). Although IDUs account globally for about 10% of the estimated 4.3 million new HIV infections that occur each year (5), IDUs account for 30% of these new infections that occur outside of sub-Saharan Africa (6). Transmission of HIV among IDUs has been facilitated by the increase in trade of illicit drugs. Over the last several decades, trade of many illicit drugs has become globalized. Although improvements in transportation and communication systems, including reduction in barriers affecting trade and movement of capital, have led to a massive increase in trade of licit goods (7), these improvements have also led to a massive increase in international trade of illicit drugs (8). In some estimates, the annual international trade in illicit drugs is worth ⬎$400 billion (9). From the Baron Edmond de Rothschild Chemical Dependency Institute (D.C.D.J.), Beth Israel Medical Center, New York, New York; and National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (S.S.), Centers for Disease Control and Prevention, Atlanta, Georgia. Address correspondence and reprint requests to Don C. Des Jarlais, Beth Israel Medical Center/CDI, 160 Water Street—24th Floor, New York, NY 10038. E-mail: [email protected] Dr. Des Jarlais was supported by Grant R01 DA 03574 from the National Institute of Health and the National Institute on Drug Abuse and Grant P30 DA 11041 from the National Institute on Drug Abuse and the Center for Drug Use and HIV Risk. Received for publication June 19, 2007; revision received October 2, 2007. DOI: 10.1097/PSY.0b013e3181772157 606 0033-3174/08/7005-0606 Copyright © 2008 by the American Psychosomatic Society

Although there is variation across cultures in the most commonly used drugs and routes of drug administration, every culture remains vulnerable to psychoactive drug use and misuse. The ability of many psychoactive drugs to short-circuit the reward systems in the human central nervous system creates vulnerability to misuse of both licit and illicit drugs in all societies. Intravenous injection is the most “efficient” route of drug administration. Injecting a drug into a vein leads to a strong drug effect, and putting the drug into a solution and injecting it allows for using almost all the purchased drug. Smoking a drug or inhaling a vaporized drug also leads to a strong drug effect, but smoking or inhaling a drug is associated with a loss of a large percentage of the drug in fumes that are not inhaled. Thus, intravenous injection produces the strongest drug effect at the least cost. Unfortunately, multiperson use (sharing) of needles and syringes for intravenous injection is also an efficient means for transmitting HIV and other blood-borne viruses. Extremely rapid transmission—with incidence rates of 10/100 to 50/100 person-years at risk— have been noted before the initiation of prevention programs, in many IDU populations, including New York City (10), Edinburgh, Scotland (11), Bangkok, Thailand (12), Manipur, India (13), Tallinn, Estonia (14), Togliatti City, Russia (15), Vietnam (16), and China (17). It is critical to note, however, that this extremely rapid transmission is not generated simply by the efficiency of transmission through sharing needles and syringes but rather, there are multiple additional factors associated with extremely rapid transmission (18). These factors include: 1. Lack of information about HIV/AIDS in the local IDU population. 2. Restricted access to sterile needles and syringes for drug users. The restrictions may also come from laws, such as those that require prescriptions for the sale of syringes and drug paraphernalia, or from law enforcement practices, such as those that station police near syringe exchange programs or that arrest drug users for the drug residue in a used syringe. 3. Situations that create rapid risk-partner change—where IDUs may share needles and syringes with many IDUs in a short time period. Examples include “shooting galleries,” in which a gallery operator will rent a single needle and syringe to multiple users; “dealer’s works,” Psychosomatic Medicine 70:606 – 611 (2008)

HIV PREVENTION FOR INJECTING DRUG USERS where a drug dealer may lend the same needle and syringe to many sequential customers; and “hit doctors,” who may use the same needle and syringe to give injections to many clients who may have trouble injecting themselves. 4. People recently infected with HIV tend to be very infectious (19). The first two factors keep IDUs from protecting themselves against HIV infection, and the second two factors increase the likelihood that a newly infected IDU will transmit HIV to a large number of other IDUs within a short time period. Prevention of HIV Among IDUs Whereas there is the potential for extremely rapid transmission of HIV among IDUs, there is also the potential for extremely effective prevention of HIV transmission among IDUs. Thus, with effective prevention programs, it is possible to (1) prevent epidemics of HIV infection in IDUs and (2) to contain emerging and established epidemics. If prevention efforts, such as community outreach and peer outreach to IDUs, and large-scale access to sterile injection equipment, are implemented when HIV prevalence is low, it is possible to prevent epidemics of HIV among IDUs and to keep HIV prevalence at very low levels (⬍5%) indefinitely (20). Notably, HIV prevelance has been kept very low in countries that provide community outreach and access to sterile drug injection equipment, such as the United Kingdom (21) and Australia (22). It is also clear that large-scale implementation of prevention programs—at a public health level, and not a pilot project level—are needed to reverse and contain established HIV epidemics among IDUs. These programs, for example, have been effective in reducing both incidence and prevalence rates by ⱖ75% in New York City (23,24). The HIV epidemic in IDUs in New York City has been the largest HIV epidemic in IDUs in the world. HIV was introduced into the IDU population in New York City during the mid-1970s and it spread very rapidly during the late 1970s and early 1980s. Substantial risk reduction efforts began with IDUs in New York City during the mid-1980s, and HIV prevalence stabilized at approximately 50%. The legalization and large-scale expansion of syringe exchange programs which began in 1992, the provision of HIV prevention, testing, and counseling services, and the implementation of community outreach and peer outreach interventions were associated with drastic reductions in HIV prevalence and incidence rates. These declines were seen in multiple studies, including IDUs recruited from drug detoxification programs, methadone maintenance programs, and through street outreach (23). HIV prevalence declined from approximately 50% in 1990 to the current level of 15% to 20% and HIV incidence declined from an estimated 4/100 person-years at risk to an estimated 1/100 person-years (25,26). Multiple reviews of the research conducted in several other cities and countries on preventing HIV among IDUs have Psychosomatic Medicine 70:606 – 611 (2008)

concluded that community outreach, individual- and grouplevel interventions, access to sterile injection equipment, and drug abuse treatment are effective in reducing HIV transmission among IDUs (27–34). Community-based outreach interventions and peer-based interventions have successfully reached IDUs (35). These interventions provide IDUs with credible risk reduction information and the means for behavior change to enable IDUs to reduce drug use and reuse of syringes and other drug injection equipment, and to increase condom use. As part of these interventions, IDUs have received referrals to substance abuse treatment facilities and to voluntary HIV counseling and testing services. Different combinations of intervention components were included in behavioral intervention studies to address risk behaviors (36,37). Successful interventions used multiple theories and methods for behavioral change derived from the social-cognitive theory (38), the theory of diffusion of innovations (39), and the trans-theoretical model of behavior change (40). In general, behavior change interventions provided a) information on how HIV is transmitted, including information on how to practice safer drug and sex behaviors; b) assessment of personal risk and responsibility; c) risk reduction supplies, including sterile needles and syringes and condoms; d) technical skills training in safer sex and drug behaviors; e) individual and group counseling to address practical and emotional issues in practicing safer sex and drug use behaviors; f) skills training in negotiating safer behaviors with peers and partners; g) voluntary HIV counseling and testing; h) referral to treatment for sexually transmitted diseases or other infections; i) referral to drug treatment; j) education on enhancement of self-esteem and group pride; k) education on enhancement of one’s responsibility to adopt safer behaviors; l) education on enlistment of social support of peers to reinforce positive change; and m) and education on development of intrapersonal and interpersonal skills, such as skills in communication with partners, disclosure of HIV status to partners, problem solving, and self-management. Basic Competencies of IDUs IDUs responded positively to the public health prevention messages and programs they received, as manifested by the reduction in HIV prevalence and incidence rates in IDUs. Thus, the effectiveness of HIV prevention programs for IDUs should be understood in terms of basic competencies of IDUs. 1. IDUs Can Readily Learn and Understand How HIV is Transmitted IDUs in both industrialized and developing countries have quickly learned how HIV is transmitted (sharing of injection equipment, unprotected sex) and is not transmitted (e.g., shaking hands, touching telephone) (41). The ability of IDUs to quickly learn about HIV transmission is not only an individual but also a collective ability. IDUs discuss HIV/AIDS among themselves, and these discussions are an important factor in successful risk reduction (42,43). 607

D. C. DES JARLAIS and S. SEMAAN 2. IDUs Can Reduce HIV Risk Behavior The difficulties in changing addictive behavior have created a stereotype that addicts cannot change their behavior. This is completely inaccurate with respect to reducing HIV risk. The most frequent forms of HIV risk reduction reported by IDUs have been reducing the frequency of sharing needles and syringes, reducing the number of other persons with whom needles and syringes are shared, and reducing unprotected sexual activity. The majority of IDUs, typically 60% to 90%, reported reducing their risk behavior in response to the threat of AIDS (44). The behavioral changes reported by IDUs must be seen as risk reduction and not as complete risk elimination. There is, as of now, no evidence to suggest that IDUs have completely eliminated their risk behaviors. Similarly, there is no evidence to suggest that other population groups at high risk for HIV have eliminated their risk behaviors (45). 3. IDUs Can Manifest Altruism for HIV Prevention Whereas IDUs have clearly changed their behavior to protect themselves from becoming infected with HIV, they have also dramatically changed their behavior to protect their peers from becoming infected with HIV. IDUs have shown multiple types of altruistic responses to HIV/AIDS. The development of new social norms against sharing needles and syringes is one example (46). In some areas, IDUs have also formed “user groups” to advocate for HIV prevention and for other issues that are important to the IDU community (47). Many IDUs have worked as peer educators to educate their peers about the risk of HIV and of other health threats (48,49). Many syringe exchange participants have also conducted “secondary syringe exchange,” where they exchange large numbers of sterile needles and syringes for others who do not personally attend exchange programs (50,51). This secondary exchange greatly increases the coverage of syringe exchange programs, and the great majority of syringe exchange programs in the United States actively encourage secondary exchange (52). IDUs have also practiced “informed altruism” where after they learn their HIV status, HIV-seropositive IDUs reduce dramatically their transmission behaviors, including unprotected sex and passing on used needles and syringes to others (53). Altruistic motivation to prevent others from becoming infected is a critical aspect of this collective response. Sexual Transmission of HIV Among IDUs The effectiveness of HIV prevention efforts for IDUs should not be viewed just in terms of programs influencing individuals, but more as a collective response by the IDU community to reduce HIV risk behavior. This is particularly important as injection-related transmission of HIV decreases and as sexual transmission of HIV poses an additional risk to the health of IDUs and their sex partners. Most IDUs are sexually active (29). Thus, there is the possibility that HIV will spread from IDUs to noninjecting sex partners and that the HIV epidemic will develop into selfsustained heterosexual transmission within the community 608

(54). This heterosexual and self-sustained transmission of HIV seems to have happened between African-Americans IDUs and crack cocaine users in several parts of the United States in conjunction with the crack cocaine epidemic (55). The transition of HIV epidemics from being concentrated in IDUs to generalized heterosexual epidemics seems to be occurring in several Asian and Eastern European countries (56). Programs to reduce sexual risk behavior are effective with IDUs, but the effect sizes are generally modest (57). Changing sexual risk behavior is considerably more difficult than changing injection risk behavior (29). The best strategy for prevention of heterosexual transmission of HIV from IDUs to others is to prevent IDUs from becoming infected through drug risk behaviors. Although behavioral change interventions and effective prevention programs, including syringe exchange programs and substance abuse treatment, have been instrumental in reducing risk behaviors and containing HIV epidemics, it is equally important to address structural (e.g., social, legal) barriers that influence delivery of HIV prevention efforts to IDUs (58).

Social and Legal Concerns and Opportunities An important societal concern relates to whether safer injection programs—syringe exchange in particular—will lead to increases in injection drug use. There is no evidence to support this belief (59,60). The great majority of syringe exchange programs in the United States actively refer drug users to substance abuse treatment programs. Syringe exchange programs have also become a platform for delivering a wide variety of health and social services to IDUs (52). Equally important in prevention activities is support for policies that allow pharmacy sales of sterile syringes to IDUs and repeal of paraphernalia laws, and support for community-based programs for safe disposal of used needles and syringes. These policies and programs are important because they increase access to sterile syringes, reduce high-risk behaviors of syringe reuse, and decrease negative opinions about IDU syringe sales (61). Although there have been numerous successes in HIV prevention for IDUs, it is important to note that the threat of developing AIDS does not cure the disease of addiction. Despite the threat of AIDS, addicts will still have their physiological and psychological drives to continue using drugs. The threat of HIV and AIDS also does not alleviate the problems of homelessness, comorbid psychiatric conditions, unemployment, or other medical and social problems that IDUs face. Thus, provision of anti-retroviral treatment to HIV-infected IDUs may require multiple supportive services, including provision of substance abuse treatment (37). Similarly, the threat of HIV and AIDS does not eliminate stigmatization and discrimination against IDUs or the memories of stigmatization and discrimination against drug users (58). HIV-positive IDUs or IDUs with symptoms of clinical AIDS may experience increased stigmatization and discrimination. Positive actions to overcome past and current stigmatization Psychosomatic Medicine 70:606 – 611 (2008)

HIV PREVENTION FOR INJECTING DRUG USERS are a critical aspect in working to prevent and treat HIV infection among IDUs. The successful HIV prevention efforts with IDUs demonstrate that IDUs are responsive to the HIV risk reduction messages and they do lower their risk for infection with HIV, as shown by national HIV incidence and prevalence rates reported for the United States (62,63). Thus, working with IDUs is feasible and their responsiveness does not support the negative prejudices and myths about drug users. In light of the successes achieved in reducing HIV infection rates among IDUs in the United States and elsewhere, it remains important to continue to devote sufficient research and program resources to keep infection rates under control and to reduce these rates to even lower levels. Decreased attention to this population may cause harm as seen with prior reduced attention and resources to the control of syphilis and tuberculosis (64 – 66). Guidelines for Working With IDUs HIV prevention research has shown that when drug users are treated with dignity and respect, they learn quickly and respond with concern about their own health and the health of others (67). Edlin and colleagues (68,69) have developed a list of 13 principles for managing health care relationships with heroin and cocaine users. Although these guidelines were developed specifically for hepatitis C treatment for drug users, they would also apply to treatment for other medical conditions, including HIV. These principles are: 1. Developing a professional relationship that shows mutual respect and avoids blame or judgment; 2. Educating drug users about health care; 3. Including drug users in decision-making; 4. Establishing a multidisciplinary case management team; 5. Having a primary care provider who coordinates care needs; 6. Developing an agreement on responsibilities; 7. Providing a response to behaviors that violate mutual expectations or limits; 8. Reducing barriers to accessing the health care system; 9. Establishing realistic commitments to more healthful behaviors; 10. Emphasizing the importance of risk-reduction measures; 11. Acknowledging that success requires several attempts; 12. Learning about local resources for drug users; and 13. Avoiding common pitfalls, such as unrealistic expectations, frustration, anger, moralizing, blame, and withholding therapy. Summary The sharing of needles and syringes is a relatively efficient mode for transmitting HIV, and under certain conditions, HIV has spread extremely rapidly in populations of IDUs. Under different conditions, HIV prevention for IDUs has been remarkably successful. The successful conditions include treatPsychosomatic Medicine 70:606 – 611 (2008)

ing IDUs with dignity and respect, and providing information about HIV/AIDS and the means (sterile injection equipment and condoms) for risk reduction. These conditions for prevention success permit IDUs to act on their motivation to protect their own health and the health of their peers. Continued vigilance is needed to build on the successes achieved and to maintain risk levels and infection rates at very low levels. The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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