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What Are Substance Abusers’ HIV Prevention Needs?

Are Substance Abusers Who Don’t Inject At High Risk Of Infection?

Yes. Although sharing used needles is a high risk for HIV transmission, substance abuse and HIV goes beyond the issue of needles. People who abuse alcohol, speed, crack cocaine, poppers or other non-injected drugs are more likely than non-substance users to be HIV positive and to become seropositive. People with a history of non-injection substance abuse are also more likely to engage in high-risk sexual activities.

Many injection drug users (IDUs) use other non-injected drugs primarily. When an IDU is HIV-positive, needle sharing may be the primary risk factor, but other non-injected drug use may have a great effect on risk behaviors. For example, a study of high risk clients in a methadone treatment program found that those at highest risk for HIV infection were also crack cocaine users.

A survey of heterosexuals in alcohol treatment programs in San Francisco, CA, found HIV infection rates of 3% for men who were not homosexually active or IDUs and 4% for women who were not IDUs. This was considerably higher than rates of 0.5% for men and 0.2% for women found in a similar population survey.

In Boston, MA, a study of gay men found a strong relationship between use of nitrite inhalants or “poppers” and HIV infection. Men who always used poppers while engaging in unprotected anal sex were 4.2 times more likely to be HIV positive than men who never used poppers and engaged in unprotected anal sex.

Crack cocaine use has been shown to be strongly associated with the transmission of HIV. A study of young adults in three inner-city neighborhoods who smoked crack and had never injected drugs found a 15.7% HIV rate. Women who had recently had unprotected sex in exchange for money or drugs, and men who had anal sex with other men were most likely to be infected.

Why Are They At Higher Risk?

There are probably a lot of reasons why substance abusers are at higher risk for HIV. The reasons most likely vary by drug and social context-crack abusers may have different risks than alcohol abusers, for example. For non-injecting substance abusers, HIV infection is not caused by drug use but by unsafe sexual behavior.

Recently, observers have found an association between HIV infection, heavy crack use and unprotected fellatio among prostitutes. This may be due to poor oral hygiene and oral damage from crack pipes, high frequency of fellatio, and inconsistent condom use.

Gay male substance abusers in San Francisco, CA, identified a number of factors that made safe sex difficult for them, including: perceived disinhibiting effect of alcohol and other drugs, learned patterns of association between substance use and sex (especially methamphetamine use and anal sex), low self-esteem, lack of assertiveness, and perceived powerlessness.

Post Traumatic Stress Disorder (PTSD) may account for high sexual risk-taking activities among female crack users in the South Bronx, NY. In one study, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident.

It is often believed that having unprotected sex while under the influence of drugs or alcohol accounts for substance abusers’ HIV risk. However, sexual networks and sexual mixing might better explain risk. Many people who are in treatment or using drugs or alcohol are primarily selecting sexual partners from similar networks. They might include people who have used needles, have traded sex for money or drugs, have been victims of trauma, or have been incarcerated. All of these populations may have higher rates of HIV infection, making transmission more likely.

What Are Obstacles To Prevention?

In American social culture, drug use and sex have become hopelessly linked. For many people, straight or gay, bars are the main method for meeting people. Ads and commercials portray alcohol as seductive. Honest conversations about sexuality, including homosexuality, are lacking in schools, homes and the media. This can lead to greater sexual inhibitions that might be eased through drinking or using drugs.

The goals of HIV prevention and substance treatment are often conflicting. Many treatment programs focus on stopping substance abuse altogether, and 12 Step programs often advocate sexual abstinence while in recovery. On the other hand, many prevention programs focus on safer sex and harm reduction, acknowledging that relapse could occur. These conflicting cultures may make it difficult to integrate HIV prevention interventions into substance abuse programs.

What’s Being Done?

New Leaf (formerly 18th Street Services) in San Francisco, CA, provides substance abuse treatment for gay/bisexual men, and offers a safer sex intervention. Although evaluation of the intervention showed little difference between men who participated in the safer sex program, and men who only went through treatment, both groups showed significant reductions in sexual risk. Getting and retaining substance abusers in treatment is an effective preventive method; adding a safer sex program may also help.

Some prevention efforts teach safer sex behaviors regardless of drug use. In “Sex, Games, and Videotapes,” a program for homeless mentally ill men in New York City, NY, the men suggested taping condoms to their crack pipes as a reminder for sexual encounters that are often quick and public. They also compete to see which man can put a condom on a banana fastest (without tearing the condom), which teaches important skills for using a condom quickly. The program allows for sex issues to be brought up in a non-judgmental way, and reduced sexual risk behavior threefold.

Many substance abusers receive treatment only after they have been arrested and are offered treatment as an alternative to jail or prison, or while they are incarcerated. The Delaware correctional system has instituted a therapeutic community (TC) treatment program in prison and a transitional TC outside the prison for parolees. The drug-free residential program includes rehabilitation, peer education group counseling and social services. Participants in the TC program had lower rates of drug relapse and re-arrest than non-participants, and reported reduced HIV risk behaviors.

What Still Needs To Be Done?

Gender specific programs are needed that address women’s substance use needs. Women have a higher physical vulnerability to alcohol and higher levels of traumatic events associated with substance use than men. Gay and lesbian-specific treatment is also needed. In addition, specific treatment is needed for drugs such as crack cocaine and new drugs as they arrive on the scene.

Prevention programs for substance abusers need to be integrated into existing services. The HIV epidemic has closely paralleled the epidemics of substance use and incarceration. Substance treatment agencies and prisons and jails need training and authority to incorporate HIV prevention education into their programs. Funders should increase funds and require substance abuse programs to expand treatment to include HIV education.

Prevention programs don’t need to depend on causality-that drug abuse causes risk behaviors. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. Because of high rates of HIV and risk behaviors among substance abusers, programs are urgently needed in this population.

Prepared by Pamela DeCarlo, Ron Stall, PhD, MPH, Robert Fullilove EdD

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Says Who?

1. Leigh BC, Stall R. Substance use and risky sexual behavior for exposure to HIV. American Psychologist. 1993;48:1035-1045.

2. Grella CE, Anglin MD, Wugalter SE. Cocaine and crack use and HIV risk behaviors among high-risk methadone maintenance clients . Drug and Alcohol Dependence. 1995;37:15-21.

3. Avins AL, Woods WJ, Lindan CP, et al . HIV infection and risk behaviors among heterosexuals in alcohol treatment programs . Journal of the American Medical Association. 1994;271:515-518.

4. Seage GR, Mayer KH, Horsburgh CR, et al. The relation between nitrite inhalants, unprotective receptive anal intercourse, and the risk of human immunodeficiency virus infection . American Journal of Epidemiology. 1992;135:1-11.

5. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics – crack cocaine use and HIV infection among inner-city young adults . New England Journal of Medicine. 1994;331:1422-1427.

6. Wallace JI, Bloch D, Whitmore R, et al. Fellatio is a significant risk activity for acquiring AIDS in New York City street walking sex workers. Presented at the Eleventh International Conference on AIDS, Vancouver BC; 1996. Abs #Tu.C.2673.

7. Paul JP, Stall R, Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance-abuse treatment . AIDS Education and Prevention. 1993;5:11-24.

8. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users . Journal of Traumatic Stress. 1993;6:533-543.

9. Renton A, Whitaker L, Ison C, et al. Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings. Journal of Epidemiology and Community Health. 1995;49:205-213.

10. Stall RD, Paul JP, Barrett DC, et al. Substance abuse treatment lowers sexual risk among gay male substance abusers. Presented at Eleventh International Conference on AIDS, Vancouver, BC; 1996. Abs #We.C.3490.

Contact: Ron Stall, 415/597-9155.

11. Susser E, Valencia E, Torres J. Sex, games and videotapes: an HIV-prevention intervention for men who are homeless and mentally ill. Psychosocial Rehabilitation Journal. 1994;17:31-40.

Contact: Ezra Susser, 212/960-5763.

12. Martin SS, Butzin CA, Inciardi JA. Assessment of a multistage therapeutic community for drug-involved offenders . Journal of Psychoactive Drugs. 1995;27:109-116.

Contact: Steve Martin, 302/831-2091-fax.

13. el-Guebaly N. Alcohol and polysubstance abuse among women . Canadian Journal of Psychiatry. 1995;40:73-79.

14. Stall R, Leigh B. Understanding the relationship between drug or alcohol use and high risk sexual activity for HIV transmission: where do we go from here ? Addiction. 1994;89:131-134.


Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.web@ucsf.edu. ©1996, University of California