Multiple, prospective longitudinal studies are needed to keep abreast of problems and changes as they occur. As discussed in Chapter 2, prostitutes are at risk of acquiring HIV infection through both sexual and drug-use behaviors. A 1987 survey of street prostitutes in the New York City area indicated that approximately one half had injected drugs at least once and one third had injected drugs at some time during the previous two years (Des Jarlais et al., 1987).
The need to control the spread of HIV infection has forced a recognition of the underdeveloped state of sex research in the United States. Information about sexual conduct is necessary to understand both the epidemiology of the spread of the disease and the social processes that are involved in behavioral change. Yet current understanding is fragmentary, and the underlying research data are often unreliable. One component of the family of seroprevalence surveys tests blood specimens from newborn babies, and the committee considers this effort to be a very promising enterprise. Key populations at higher risk of HIV include people who sell sex, men who have sex with men, transgender people and people who inject drugs.
Risk Reduction Among IV Drug Users
ART is recommended for everyone with HIV, and people with HIV should start ART as soon as possible. People on ART take a combination of HIV medicines (called an HIV treatment regimen) every day. A person’s initial HIV treatment regimen generally includes three HIV medicines from at least two different HIV drug classes. The following table lists HIV medicines recommended for the treatment of HIV infection in the United States, based on the U.S.
Examples of the independent confirmation of change include the increased demand for sterile injection equipment in New York City, increased use of syringe exchange programs, and acceptance of bottles of bleach for decontamination of used injection equipment. The first risk reduction studies among IV drug users were conducted in New York City, where signs of infection were noted early in the epidemic and where the greatest number of AIDS cases has occurred. Ethnographic interviews conducted in New York in the fall of 1983 among IV drug users who were not in treatment indicated that these drug users were aware of AIDS. Data from this study also indicated that many people knew the virus was transmitted through shared injection equipment, and many recognized the potential benefit of behavioral change in this practice (Des Jarlais et al., 1986b).
The Possible Mechanism behind Intravenous Drug Use
The third generalization concerning risk reduction among IV drug users is an apparently counterintuitive and synergistic relationship between “safer” injection programs and drug treatment to reduce or eliminate injection behavior. The common assumption that providing the means for safer injection will encourage drug use and undermine drug treatment is contradicted by the data collected to date. The Amsterdam syringe exchange program has been collecting data longer than any other program; its results clearly show that syringe exchange has not encouraged drug use. As noted earlier, the program was begun in 1984, during which 25,000 sterile needles and syringes were distributed. The number distributed rose to 700,000 in 1987; it is estimated that 750,000 sterile needles and syringes will be distributed in 1988. During this expansion period, there was no decrease in the number of persons entering either methadone maintenance or drug-free treatment programs.
Barriers may include lack of prescribers, legal and regulatory issues, insurance coverage, and confusion about the use of MAT and MOUD. When possible, for at least each major type of intervention and each major target population, a minimum of two intervention programs should be subjected to rigorous evaluations that are designed to produce research evidence of the highest possible quality. Variants of intervention programs should be developed for and tested in different populations and in different geographic areas using random assignment strategy accompanied by careful evaluation. The role of evaluation is to allow a determination of which strategies actually change people’s behavior and which do not. Making these determinations requires a systematic process that produces a reliable account of a program’s effectiveness. Indeed, preparing for an evaluation can often increase program specificity and quality at the outset.
Sepsis and IV Drug Use
To facilitate such sharing, the committee recommends that a data archive be established to support secondary analyses of these data. The resources of this archive and the documentation accompanying the archived data sets should be sufficient to allow future researchers to understand the limitations of the archived data. The committee recommends that high priority be given to research on the estimation of the current number of IV drug users in the United States and
of seroprevalence rates among different groups of IV drug users. Several factors contribute to the geographic variability of HIV seroprevalence rates among IV drug users in the United States. In addition to limited economic resources, the need for a constant supply of drugs probably reduces their mobility, although they appear to travel some, especially to locations where friends can help them obtain drugs.
Laws, however, can retard the social process of stigmatization by prohibiting some of the behaviors that are inspired by it. Research has shown, for example, that the possibility of legal prosecution can alter discriminatory behaviors in various settings even in the presence of discriminatory attitudes. The law can also protect those who are infected with HIV from discrimination, and the educational message conveyed by such protection can help to reduce the underlying current of stigmatization that pushes those infected with HIV and AIDS to the outskirts of society. The committee recognizes that it may be difficult to attract a sufficient number of senior scientists to Atlanta on a permanent basis. One-or, preferably, two-year visiting scientist appointments might provide quick access to needed personnel and allow CDC management greater flexibility in meeting changing staff needs.
The active and equitable collaboration of persons in the target populations with “outside” scientists and researchers can provide an important safeguard against such failures. Since the early years of the epidemic, CDC has had primary responsibility for AIDS data collection. Some surveys have involved only the collection of physical specimens (e.g., blood) along with a very restricted set of demographic characteristics (e.g., age, sex, residence). The agency’s recent acquisition of the National Center for Health Statistics (NCHS) can provide some of the needed statistical expertise, but the role of NCHS in CDC’s data collection programs is still being defined.
As noted earlier, the first ex-addict outreach program in New Jersey evolved from one that taught sterilization methods into one with expanded treatment capacity (Jackson and Rotkiewicz, 1987; Jackson and Baxter, 1988). The outreach programs in New York and San Francisco that distribute bleach have had to develop referral-to-treatment programs and street counseling components to keep up with the demand for these services (Des Jarlais, 1987b). The details of injection practices related to sharing, booting, rinsing, and heating the cooker vary greatly; in addition, these behaviors are constantly evolving in light of the awareness of the risk of HIV transmission. It is difficult to assess the impact of these behavioral changes on stemming the spread of HIV. An interesting variation in injection behavior described recently in Baltimore (J. Newmeyer, Haight-Ashbury Free Medical Clinic, San Francisco, personal communication, May 25, 1988) enables users to share drugs without sharing the needle or syringe. To ensure that a drug is split equally between users, half of the contents of a single syringe is injected into a second syringe.
Essential for impact: enabling interventions
Skipping HIV medicines allows HIV to multiply and damages your immune system, making it harder for your body to fight infections and certain cancers. Drug interactions between HIV medicines and recreational drugs can also increase the risk of dangerous side effects. Substance use and sexual risk behaviors share some common underlying factors that may predispose teens to these behaviors. Because substance use clusters with other risk behaviors, it iv drug use is important to learn whether precursors can be determined early to help identify youth who are most at risk. Studies conducted among teens have identified an association between substance use and sexual risk behaviors such as ever having sex, having multiple sex partners, not using a condom, and pregnancy before the age of 15 years of age. However, people who inject IV drugs are also at risk of cellulitis from other bacteria and even fungi.
- These programs can also provide comprehensive services such as help with stopping substance misuse; testing and linkage to treatment for HIV, hepatitis B, and hepatitis C; education on what to do for an overdose; and other prevention services.
- Over the past 12 years, ways to prevent yourself from contracting HIV have evolved from using condoms or abstaining from sex to taking medicines in the form of pills, injections and vaginal rings to block the virus from getting a foothold in the first place.
- Problems in interpreting the behavioral change data also arise from a lack of specification of the mechanism or “cause” of the behavioral change.
- In addition, opioid substitution is being used to reduce the prevalence of HIV
infection, thereby causing modest reduction in HIV transmission rates36. - Using such techniques as geographically clustered samples and network samples can help inform the estimation process.