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Written by: Friedman/ Des Jarlais/ Stoneburner    Posted on: 04/14/2003

Category: Educational

Source: CCN


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


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1987) of the estimated 200,000 IV drug users in New York City (New York State Division of Substance Abuse Services, unpublished data) have been exposed to human immunodefeciency virus (HIV).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.


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.


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.


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.


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.


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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