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SHARING OF DRUG INJECTION EQUIPMENT AND THE AIDS..
AUTHOR: Friedman/ Des Jarlais/ Stoneburner
PUBLISHED ON: April 14, 2003
DOC SOURCE: CCN
PUBLISHED IN: Educational
TAGS: AIDS

THE SHARING OF DRUG INJECTION EQUIPMENT AND THE AIDS EPIDEMIC IN NEW
YORK CITY:  THE FIRST DECADE

Don C. Des Jarlais, Samuel R. Friedman, Jo L. Sotheran, and
Rand Stoneburner

INTRODUCTION

Through April 29, 1987, there were 3,464 cases of AIDS among
intravenous (IV) drug users in New York City.  There were an
additional 201 cases of AIDS among persons who did not inject drugs
themselves but were heterosexual partners of IV drug users, and 154
cases in children of IV drug users (New York City Department of
Health, 1987).  These 3,825 cases in which IV drug use was involved
as a potential source of HIV infection account for 38 percent of the
10,116 cases in the City through that date.  The number of cases of
AIDS among IV drug users in New York City is roughly comparable to
the total number of cases in San Francisco and is approximately three
quarters of the total number of cases in Europe.

In addition to the current cases, approximately 50 percent (Marmor et
al., 1987) of the estimated 200,000 IV drug users in New York City
(New York State Division of Substance Abuse Services, unpublished
data) have been exposed to human immunodefeciency virus (HIV).  Given
the estimates that from 20 to 50 percent of HIV-exposed persons will
develop AIDS (National Academy of Sciences, 1986), the number of new
cases will be increasing for the next several years.

Table 1 shows the (self-reported) sexual orientation and ethnic
composition of the adult IV-drug-use AIDS cases in New York City. 
Male homosexual IV drug users are undoubtedly overrepresented among
the AIDS cases.  Based on our studies in New York, we would estimate
that only 5 percent of IV drug users regularly engage in homosexual
activity (Marmor et al., 1987)

Table 1.  Sexual orientation and ethnicity among IV drug users
                        with AIDS in New York City
———————————————————————
Sexual Orientation/ethnicity                    Number        Percent
———————————————————————
  Sexual Orientation
    Heterosexual Male                            2,365            68
    Female                                        628            18
    Homo/bisexual Male                            469            14
                                                ——————–
            Total                              3,462          100

  Ethnicity
    Black                                      1,540            44
    White                                        626            18
    Hispanic                                    1,289            39
    Other/Unknown                                  7            –
                                                ———————
            Total                              3,462          99

  Ethnicity (Homo/bisexual
  Males Excluded)
    Black                                      1,383            46
    White                                        437            15
    Hispanic                                    1,167            39
    Other/Unknown                                    6              –
                                                ———————

            Total                              2,993            100

Females are under represented among IV-drug-use AIDS cases, even if
the male homosexual cases are removed.  Based on data from heroin
users entering treatment in the City, 27 percent of the IV drug users
are female (Des Jarlais et al., 1984).  After removing male
homosexual IV drug users, females account for only 21 percent of the
AIDS cases among IV drug users in New York.  No studies of HIV
exposure among IV drug users in New York show a significantly lower
seropositivity rate among females, so it is unlikely that the
underrepresentation of females is the result of differences in
exposure.  The underrepresentation of females among the AIDS cases
may be the result of a possible gender-related cofactor in the
progression of HIV infection (Des Jarlais and Friedman, in press).

There is also underrepresentation of non-Hispanic whites among the
IV-drug-use AIDS cases in the City.  Based on the entry-into-
treatment data, non-Hispanic whites comprise 25 percent of the IV
drug users in the City (NYSDSAS, unpublished data).  Two studies
(Schoenbaum et al., 1986; Mamor et al., 1987) have shown higher HIV
seropositivity among blacks and Hispanics in the City, so that the
underrepresentation of whites among the cases probably reflects HIV
exposure rates and underlying patterns of association within the
ethnic groups.

PRE-AIDS SHARING OF INJECTION EQUIPMENT

The social organization of the IV-drug-use subculture in New York is
a good starting point for understanding the economic forces and
interpersonal relationships involved in the sharing of drug injection
equipment.  This social organization contributed to the rapid spread
of HIV among IV drug users in New York and provides the framework in
which AIDS risk reduction among IV drug users will operate.

Because there are very few formal organizations of IV drug users,
there is a common misconception of IV drug users as not organized.  A
multibillion-dollar industry does not persist over time without
social organization.  Sociologists and anthropologists have
conceptualized the organization of IV drug users as a “deviant
subculture” (Des Jarlais et al., 1986; Agar, 1973; Johnson and
DeHovitz, 1986) with shared values, a common argot, and rules for
allocating status.  The primary value is “getting high,” and the
primary basis for having high status within the group is the ability
to obtain and use large quantities of high-quality drugs while
minimizing adverse social, legal, and health consequences of such
drug use.

There is strong, often brutal, competition within the IV-drug-use
subculture.  There is competition for customers among persons
distributing the illicit drugs for injection, and conflict of
interest between dealers and customers over the price and quality of
the drugs being sold.  Among IV drug users, there is competition for
the money needed to purchase drugs, for the very limited supply of
drugs, and sometimes even for the equipment needed to inject the
drugs.  The illegal status of the drugs keep prices high, reinforcing
economic competition and often leading to a reliance on illegal
methods of obtaining money to purchase drugs.  The illegal nature of
IV drug use also leads to a reliance on threatened or actual violence
as a means for resolving disputes.

The IV-drug-use subculture would not be able to persist over time
without some positive social relationships to balance the
mistrusting, often violent, interactions associated with the illegal
nature of IV drug use.  There is some degree of common identity as
persons allied against “straight” (conventional) society.  This
encourages the sharing of information about drug availability,
actions of the police, and new developments that affect the group. 
This sharing of information is almost totally oral, with very little
communication through written or broadcast material.  The oral
information network often spreads inaccurate news but is efficient
enough to maintain the substantial economic scale of IV drug use in
the United States, Europe, and several developing countries.

The primary positive social relationship with the IV-drug-use
subculture is the small friendship group.  The high price/limited
supply of drugs make it effective for many users to work together in
pairs or small groups to obtain money and drugs.  Teamwork provides
more opportunities for obtaining money and protection against others
who might use force against one.  Sharing resources within a
friendship group provides a greater likelihood that an individual
drug user will be able to obtain drugs on any given day.

The social structure of the IV-drug-use subculture promotes the
sharing of equipment for injecting drugs in two ways:  (1) the ethic
of cooperation within small friendship groups is applied to the
sharing of equipment for injecting drugs; and (2) a refusal to share
drug injection equipment within the small friendship group (without a
socially legitimate reason) would call into question the reliability
of the person with respect to other cooperative actions within the
group.

Limited supplies of drug injection equipment can also lead to sharing
between casual acquaintances or complete strangers.  Legal
restrictions on the sale of needles and syringes, refusal of
pharmacists to sell them even when they are permitted to do so, and
laws against the possession of narcotics paraphernalia all serve to
reduce the availability of sterile equipment for injecting illicit
drugs.  Even when there is no legal restrictions on drug injection
equipment, sterile equipment is often not available at the times and
places where IV users want to inject.

Persons who have drugs to inject but do not have injection equipment
readily available may borrow equipment from acquaintances, sometimes
in trade for small quantities of the drug.  Such sharing contains
elements of both social solidarity and economic cooperation.

The widest sharing occurs through the use of “shooting galleries” or
“house works.”  Shooting galleries are places where one can rent drug
injection equipment for a small fee (typically $1 or $2 in New York
City).  After use, the equipment is returned to the proprietor of the
shooting gallery for rental to the next customer.  The needle and
syringe are used until they become clogged or the needle becomes too
dull for further use.  Shooting galleries are typically located in or
near “copping areas” (places where illicit drugs can be easily
purchased).  “House works” are an extra set of drug injection
equipment that a small-scale “dealer” (drug distributor) will
maintain for lending to customers.  These works are then returned to
the dealer for lending to the next customer who may want to borrow
them.

Both shooting galleries and house works provide the opportunity to
inject very soon after the drugs have been obtained.  This temporal
proximity may be a critical obstacle to reducing the sharing of drug
injection equipment.  Addicted heroin users often have entered
withdrawal by the time they obtain their next dose of the drug (the
duration of action of injecting heroin in an addicted person is
typically 4 to 6 hours).  Through classical conditioning, the
possession of heroin can itself trigger withdrawal symptoms in a very
experienced heroin user (Wikler, 1973).  Withdrawal from heroin is
not life threatening but is extremely unpleasant both physically and
psychologically.  Relief from distress is almost instantaneous with
the injection of heroin.  IV drug users report that almost all of
them will use whatever injection equipment is readily available when
possessing heroin and experiencing withdrawal (Des Jarlais et al.,
1986).

Although shooting galleries and house works provide injection
equipment near in time to obtaining drugs, they unfortunately lead to
the sharing of equipment with large numbers of anonymous other IV
drug users.  This breaks the limited protection that would occur if
sharing drug injection equipment were confined to friendship groups.

Prior to concern about AIDS, the sharing of drug injection equipment
was normal behavior among IV drug users.  There were multiple reasons
for sharing, from the social norms within small friendship groups to
greater availability of used equipment when a person had drugs to
inject.  While there were was some concern about hepatitis, there
were no overriding reasons not to share drug injection equipment.

In addition to the social and economic considerations surrounding the
sharing of drug injection equipment, the number of persons who want
to inject drugs and the availability of drugs to be injected
obviously affect the frequency of drug injection, and, prior to
awareness of AIDS, the frequency of sharing drug injection equipment. 
New York City, along with the Unites States as a whole, experienced
an epidemic level increase in heroin injection during the late 1960s
and early 1970s.  During the middle 1970s, there was a general
community reaction against heroin injection that reduced recruitment
into drug injection.  Production was essentially halted in the
Turkish opium fields during this time, leading to very poor quality
heroin available in New York and lower frequencies of drug injection
among persons with histories of drug injection (Des Jarlais and
Uppal, 1980).  Persons who had become confirmed heroin users often
injected heroin on an irregular basis during the middle 1970s,
interspersing a wide variety of non-injected-drug use with their
injections of heroin (Johnson et al., 1985).  During this time, there
was an estimated 200,000 IV drug users in New York City.

During the late 1970s, the production of opium is Southwest Asia
(primarily Iran, Pakistan, and Afghanistan) greatly increased,
leading to much greater availability of heroin in New York City
(Frank, 1980).  There was some recruitment of new heroin users,
maintaining an estimated number of 200,000 heroin injectors in the
city during the early 1980s.  The primary use of this increased
heroin, however, was by previous heroin injectors, who increased
their frequency of injection.

Shortly following this increased availability of heroin, there was a
substantial increase in the popularity and availability of cocaine. 
This was, of course, not confined to New York City, but was a
nationwide phenomenon.  Unfortunately for the coming AIDS situation,
persons in New York with a history of injecting heroin preferred to
use cocaine by injection, often combining with heroin in a
“speedball.”  This cocaine epidemic may have severe consequences for
the spread of HIV since, at present, we have no wide-scale treatment
program to reduce cocaine injection among those addicted to cocaine. 
Additionally, many heroin IV users inject cocaine on an infrequent
basis and see no reason to eliminate this use of the drug.

INTRODUCTION AND SPREAD OF HIV AMONG IV DRUG USERS

HIV was probably introduced into the IV-drug-use group in New York
City during the middle 1970s.  The first physical evidence of HIV
infection comes from three maternal-transmission pediatric AIDS
cases.  In 1977, three children who developed AIDS were born to
mothers who were IV drug users (New York City Department of Health,
1987).  Historically collected sera from IV drug users in New York
show the first seropositive sample from 1978 (Novick et al., 1986). 
Men who engaged in homosexual activity as well as injecting drugs
appear to have been the bridge group to spread the virus from
homosexuals who did not inject drugs to heterosexual IV drug users. 
The first cases of AIDS in New York have been retrospectively
diagnosed as occurring in 1978, with the first cases in IV drug users
appearing in 1980 (Novick et al., 1986).  There were 10 cases of drug
of AIDS among IV drug users in 1980, of whom 4 also reported male
homosexual activity as a risk factor (New York City Department of
Health, 1987).  Approximately 5 percent of male IV drug users in New
York report regular homosexual activity (Des Jarlais, in
preparation), so that 4 of 10 cases is a great overrepresentation. 
Male homosexual activity has also been shown to be associated with
HIV exposure among male IV drug users in Manhattan, independent of
drug use behavior (Marmor et al., 1987)

Once HIV was introduced into the IV-drug-use group in New York, there
was a rapid spread of the virus among active users.  The historically
collected serum samples from Manhattan show over 40 percent
seropositivity in 1980.  In the three studies of risk factors for HIV
seropositivity that have been reported from the New York area (marmor
et al., 1987; Schoenbaum et al., 1986/Selwyn et al., 1986; Weiss et
al. 1985), two factors were often associated with exposure to the
virus.  Frequency of drug injection was associated with
seropositivity in all three studies (the more frequently a drug user
was injecting, the more likely he or she was to share equipment with
someone who could transmit the virus).  The use of shooting galleries
(places where one can rent drug using equipment) was associated with
seropositivity in the Manhattan (Marmor et al., 1987) and Bronx
(Schoenbaum et al., 1987) studies.

The rapid spread of HIV among IV drug users in New York is thus
likely to be a result of three factors.  A relatively large number of
homosexual men who injected drugs and shared equipment with
heterosexual IV drug users provided multiple entry points for the
virus into the IV-drug-use group.  The increasing availability of
heroin and cocaine in the late 1970s led to a general increase in
drug injection–and associated sharing of equipment–just after the
virus had been introduced into the area.  Finally, the use of
shooting galleries permitted rapid dissemination of the virus across
friendship groups.

BEHAVIOR CHANGE IN RESPONSE TO AIDS

Despite the popular conception that IV drug users have no concern for
health, there is consistent evidence that the majority of IV drug
users in NEW York have changed their behavior in order to reduce the
risk of developing AIDS.  Data we collected from IV drug users in
1983 (Des Jarlais et al., 1986) and 1984 (Friedman et. al., 1987)
indicated that essentially all IV drug users in New York City were
aware of AIDS by the middle of 1984, and that over half of them were
reporting some form of risk reduction.  Data collected in 1985 by
Selwyn and colleagues again showed essentially universal knowledge of
AIDS and its transmission through the sharing of injection equipment. 
Over 60 percent of the subjects in the Selwyn study reported changes
in drug injection behavior undertaken to reduce the risk of
developing AIDS (Selwyn et al., 1986).

In both our and the Selwyn et al. studies, the two most commonly
reported forms of risk reduction were increased use of (illicitly
obtained) sterile injection equipment and a reduction in the number
of persons with whom the subject would share injection equipment. 
Approximately one-third of the subjects in the studies reported each
of these methods of AIDS risk reduction.  Reduction of drug injection
was a much less common form of behavior change, reported by less than
20 percent of the subjects in the studies.  The Selwyn study
specifically asked about sterilizing used drug injection equipment. 
Very few subjects–less than 4 percent–reported this type of AIDS
risk reduction.

Evidence for the validity of these self-reported behavior changes
comes from findings of better immune system status in those
seropositives reporting AIDS risk reduction (Friedman et al., in
press(b)) and from studies of the marketing of illicit sterile
injection equipment in New York.  There was a great increase in the
demand for illicitly obtained sterile injection equipment in 1984-85
in New York City (Des Jarlais et al., 1985).  The demand became
strong enough to support a market for “counterfeit” sterile injection
equipment, something that had never occurred prior to AIDS in New
York.  (The counterfeit equipment consisted of used needles and
syringes that were rinsed out and placed in the original packaging,
which was then resealed.  Careful inspection of these needles and
syringes could usually detect the resealing).

These risk reduction efforts by IV drug users occurred prior to any
formal AIDS prevention programs established by health authorities,
and indicated spontaneous change occurring within the IV-drug-use
subculture in New York around the dangers of sharing drug injection
equipment.  The risk reduction reported in these studies should not,
however, be seen as risk elimination.  Increased use of illicitly
obtained sterile equipment does not imply exclusive use of that
equipment–the situation in which an IV drug user is undergoing
withdrawal appears to lead to a willingness to use whatever injection
equipment is handy.  Reduction in the number of persons with whom one
is willing to share equipment will often not be extended to persons
with whom one has a close personal relationship (Des Jarlais et al.,
1986).  The reduction typically involves refusing to share drug
injection equipment with strangers, casual acquaintances, and,
especially, persons who “look sick” (Sotheran et al., 1987).

There is also the possibility that some of the efforts to use “clean
needles” will not be effective.  The methods of cleaning drug
injection equipment prior to AIDS were primarily used to prevent
blood from clogging the needle and syringe.  Thus, they were
associated with extended and likely multiple-person use of the
equipment.  In none of the studies of HIV-exposure risk factors was
cleaning injection equipment associated with avoiding exposure to the
virus.

PRESENT PREVENTION/RISK REDUCTION EFFORTS

At present, there are a number of AIDS prevention efforts aimed at IV
drug users in New York City.  These include telephone hotlines.
pamphlets and posters, education conducted within treatment programs,
additional drug treatment capacity, and face-to-face education
conducted by trained ex-addicts for IV drug users who are currently
not in treatment.  [These, as well as prevention programs in other
areas, are reviewed in Friedman et al. (in press (a))].

It is clearly much too early to assess the effectiveness of these
AIDS prevention programs, but some preliminary observations can be
made.  With respect to informing IV drug users about the basics of
AIDS, the data cited above indicated that this basic information has
been widely disseminated.  The current posters, pamphlets, and basic
education programs should therefore be assessed in terms of their
repetitive effects.  The parallel would be advertising, where
repetition is used to create a persuasive effect rather than
informative effect.

As a response to the AIDS epidemic, 3,000 new drug abuse treatment
positions are being opened.  These are in addition to the 500
additional treatment positions opened over the last few years.  The
500 positions have been filled, and there are still waiting lists of
approximately 1,000 persons seeking drug abuse treatment in the City. 
Nevertheless, it does not appear likely that enough new treatment
programs can be opened in time to have a large-scale effect on the
spread of HIV through the sharing of drug injection equipment in the
City.  (There is currently no treatment for injected cocaine abuse
that could be applied nationally on a large scale.)  This means that
the immediate reduction in IV-drug-use transmission will have to be
made by reducing the sharing of nonsterile drug injection equipment.

The face-to-face education programs and many of the pamphlets being
distributed include information about how to sterilize previously
used drug injection equipment.  This information appears to be well
received and greatly needed by current IV drug users.  Data from a
1986 study of IV drug users in treatment indicate that there is still
considerable ignorance among IV drug users about how to clean drug
injection equipment in a manner that kills HIV (Sotheran et al.,
1987).  When the subjects were asked, “What is the best way to clean
your works?” only 69 percent mentioned ways that might inactivate HIV
if done correctly (boiling, soaking in bleach, or soaking in a high
concentration of alcohol).  Only 8 percent mentioned the use of
bleach, which may be the most effective and convenient method of
sterilizing drug injection equipment.

In addition to the lack of knowledge among these IV drug users, the
subjects who were injecting the most frequently were also those who
were least likely to know proper sterilization techniques. 
Apparently, knowledge of these sterilization techniques were
disseminated primarily from drug abuse treatment personnel to IV drug
users in treatment (Sotheran et al., 1987).  The persons with the
highest level of recent drug injection were those who had been in
treatment for the shortest length of time *Abdul-Quader et al., 1987)
and, perhaps, were those who were less likely to have formed positive
relationships with treatment staff.  Thus, the IV drug users most in
need of the knowledge of how to sterilize drug injection equipment
properly were the least likely to have this information.

The two face-to-face ex-addict AIDS education programs in New York
are currently providing information on how to properly sterilize drug
injection equipment.  One of the programs (ADAPT) has started to
distribute bleach and alcohol in order to provide current IV drug
users with a relatively easy means of sterilizing injection
equipment, and the other program is considering this also. 
(Implementation of this has been delayed by considerations of
liability if Government funds were used to provide for the
distribution of bleach for sterilizing drug injection equipment.) 
The degree to which dissemination of information and/or means for
properly sterilizing drug injection equipment will lead IV drug users
to sterilize used equipment remains to be seen.  The current best
estimate from the ex-addict education programs is that no more than
10 percent of active IV drug users are sterilizing equipment that has
previously been used by another person (Mauge, 1987).  This would
represent a significant improvement over the 4 percent found in the
Selwyn et al. (1986) study, but clearly is not sufficient to halt the
spread of HIV among IV drug users in the City.

Barring a dramatic breakthrough with respect to increased use of
proper sterilization techniques, IV drug users must have easy access
to noncontaminated injection equipment if the spread of HIV among
continuing IV drug users in NEW York is to be contained.  The
difficulties in relying upon an illicit distribution system for a
significant reduction in the spread of HIV have led to calls by a
number of public health officials for increasing the legal
availability of sterile injection equipment.  The New York City
Department of Health has proposed an experimental study of a needle
exchange for IV drug users.  This modeled after the system in
Holland, in which drug users return used injection equipment and then
are given new, sterile equipment at no charge.  This proposal has the
support of the mayor but has not received approval at the State
government level.

CONCLUSION

A final comment on the current AIDS prevention programs in New York
City concerns apparent “contradictions” between the different
efforts.  Teaching IV drug users how to sterilize equipment–and
actually providing sterile equipment to them–have been opposed by
some (often police agencies) as “encouraging” IV drug use.  Based on
current data from the face-to-face education programs, there appears
to be no contradiction between teaching IV drug users how to
sterilize drug injection equipment and reducing IV drug use.  As part
of the AIDS education process, many of the drugs users realize that
they continue to be at risk for AIDS when they are in a state of
strong physical dependence on drugs.  These drug users ask for and
receive referrals for expedited entry into treatment programs (Mauge,
1987).  Thus, nonjudgmental programs for AIDS risk reduction–
programs that do not tell an IV drug user that he or she must stop
injecting drugs–appear to be “discouraging” rather than
“encouraging” IV drug use.

The situation with respect to AIDS prevention among IV drug users is
changing rather rapidly, as the public concern over IV drug users as
a “bridge” to generalized heterosexual transmission grows.  New
prevention efforts are likely to be established.  Attempts will also
be made to evaluate the effectiveness of many of these prevention
efforts, although historical change during the time in which a
prevention program is studied will make interpretation of findings
difficult.

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ACKNOWLEDGMENTS

Preparation of this paper was supported by grant R01-DA03574 from the
National Institute on Drug Abuse.

AUTHORS

Don C. Des Jarlais, Ph.D.            Samuel R. Friedman, Ph.D.
NYSDSAS                              Jo L. Sotheran, M.A.
55 West 125th Street, 10th Floor    Narcotic and Drug Research, Inc.
New York, NY 10027                  55 West 125th Street, 10th fl.
                                    New York, NY 10027

Rand Stoneburner, M.D., M.P.H.
New York City Department of Health
123 Worth Street
New York, NY 10013

This information is in the public domain and may be copied without
permission.  Citation of the source is appreciated.

Needle Sharing Among Intravenous Drug Abusers: National and
International Perspectives
NIDA Research Monograph 80
DHHS Publication No. (ADM)88-1567

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