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Substance abusers
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.
Disclosure
Disclosure of HIV+ status is a complex, difficult and very personal matter. Disclosing one’s HIV+ status entails communication about a potentially life threatening, stigmatized and transmissible illness. Choices people make about this are not only personal but vary across different age groups, in different situations and contexts, and with different partners, and may change with time, depending on one’s experiences. Disclosure may have lifelong implications since more people are living longer, and often asymptomatically, with HIV. Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, some HIV+ persons may choose not to disclose due to fears of rejection or harm, feelings of shame, desires to maintain secrecy, feelings that with safer sex there is no need for disclosure, fatalism, perceived community norms against disclosure, and beliefs that individuals are responsible for protecting themselves. This Fact Sheet primarily focuses on disclosure in the context of sex. Discussing and disclosing HIV status is a two-way street. Be it right or wrong, most people feel that when a person knows that he/she is HIV+ then he/she has an obligation to tell the other person, and counselors are encouraged to help people with this process. Also, laws in some areas require disclosure of HIV+ status prior to sex. However, both partners should be responsible for knowing their own status, disclosing their own status when it seems important, and asking their partner about their status if they want to know. Most HIV+ persons disclose their status to some, but not all, of their partners, friends and family. Disclosure generally becomes easier the longer someone has been living with HIV, as he/she becomes more comfortable with an HIV+ status. Disclosure to sex partners is more likely in longer-term, romantic relationships than in casual relationships (one-night stands, anonymous partners, group scenes, etc.). Disclosure also varies depending on perceived HIV status of partners, level of HIV risk of sex activities, sense of responsibility to protect partners (personal vs. shared responsibility) and alcohol or drug use.