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Resource

Injection drug users (IDUs)

What are injection drug users (IDU) HIV prevention needs?

Are IDUs at risk?

Yes. Injecting drug use accounts for nearly one-third (36%) of cumulative AIDS cases in the US, and for 28% of the 42,156 new AIDS cases reported in 2000. These cases include injecting drug users (IDUs), their sexual partners and children born to them.¹ African Americans and Latinos are disproportionately affected by IDU-associated AIDS. In 2000, the proportion of IDU-associated AIDS cases was 26% for African Americans, 31% for Latinos and 19% for whites.¹ Women are also disproportionately affected. Overall, 62% of AIDS cases among women have been attributed to IDUs and sex with IDU partners, compared with 34% of cases among men.² IDUs are at even greater risk for other serious drug use-related illnesses, including hepatitis C and overdose. Injecting drug use accounts for 60% of hepatitis C infections in the US. Rates of hepatitis C infection among young IDUs are 4 to 100 times higher than rates of HIV infection. Drug overdose is a major cause of death among heroin users, even in areas with high rates of IDU HIV.⁵

What puts IDUs at risk?

Sharing injection equipment to either inject or split drugsincluding syringes, cookers, water and cottonis a high risk factor for IDUs.⁶ Sharing mainly occurs because there are not enough needles and syringes available or they are not affordable to IDUs. Unprotected sexual activity with an HIV+ partner is also a high risk factor for IDUs, especially male IDUs who have sex with men, women IDUs who trade sex for money and women with IDU partners.⁷ Risk varies depending on drug use; for example, speed (methamphetamines) increases sexual desire and has been shown to lead to unsafe sex.⁸ IDUs often struggle with multiple health risks due to social, economic and psychological factors. HIV prevention may not be their top concern since they face other more pressing daily challenges such as addiction, poverty, incarceration, homelessness, stigma, depression, mental illness and past trauma.⁹

What about drug treatment?

Quitting drug use through drug abuse treatment can be an effective HIV prevention intervention. However, only about 15% of IDU are currently in treatment, and there is no medical treatment for speed addiction. Increasing the amount of quality drug treatment alone is not enough. Drug dependence is a chronic, relapsing disease. Some drug users are unwilling to seek treatment and those who do often find there are no treatment services available or affordable. Also, most people who go through drug treatment relapse several times before quitting for good. Because of this, it is important to take a harm reduction approach to HIV prevention for IDUs.¹⁰ A harm reduction approach recognizes that some IDUs are unable or unwilling to stop using drugs; therefore, harm reduction helps IDUs in a nonjudgmental way to reduce negative consequences of drug use. This can be done through promoting safer use, managed use or quitting drug use. In the US, harm reduction methods include street outreach to active drug users, syringe exchange and pharmacy access to sterile syringes.¹¹ Internationally, harm reduction initiatives include safe injecting rooms and medical dispensing of illicit drugs.¹²

What can help?

Peers, such as recovering IDUs, can be effective in motivating behavior change. However, recovering IDUs used as peer educators need support to avoid relapse to drug use. IDUs are more likely to use condoms when members of their social network discuss general health concerns and condom use, and when they have broader financial support.¹³ Access to quality medical care and STD/HIV treatment can help promote safer behaviors. A study in Baltimore, MD, found that informal caregivers were more likely to promote prevention messages in the community when their friends and family had access to HIV treatment, giving them hope for the future.¹⁴

What’s being done?

Methadone maintenance treatment for heroin dependency can help reduce injection risk behavior and HIV seroconversion.¹⁵ In Connecticut, the Department of Mental Health and Addiction Services works with community-based Drug Treatment Advocates (DTAs) to help drug users get into drug abuse and mental health facilities. Each day, the Department faxes the available treatment slots to the DTAs so that their outreach and referrals are guaranteed.¹⁶ Syringe exchange helps reduce the risk of sharing infected needles by exchanging used syringes with new, sterile syringes. It is estimated that the use of a syringe exchange has a two- to six-fold protective effect against HIV risk behaviors.¹⁷ In Oakland, CA, high-risk IDUs who used the syringe exchange were significantly more likely to quit sharing syringes than IDUs who never used the exchange.¹⁸ However, only about 20 million syringes are exchanged annually in the US, equivalent to only about 15 syringes per drug user per year, not nearly enough to meet the number needed for effective HIV prevention.¹⁹ Community-based prevention programs can be effective. These programs address not just individual IDUs needs, but the health and welfare of the entire community. In Harlem, NY, a community advisory board comprised of researchers, health providers and community members identified three public health problems to be addressed: substance use, infectious diseases and asthma. In order to reduce barriers to receiving care and social services, they created a “survival guide” for substance users. They also began a peer training program for IDUs to deliver HIV and hepatitis C prevention interventions at local community-based organizations. The UFO Study in San Francisco, CA, offered a spectrum of services for young IDUs, including HIV and hepatitis B and C testing and counseling and overdose prevention education. The Study had a drop-in site for young IDUs with phones, food and clothes, as well as on-site peer counselors and clinicians. Clients could also receive hepatitis A and B vaccinations. The study also provided a directory of youth-friendly services in several large cities in the US.²⁰ Yet another prevention approach calls for treating HIV+ IDU with highly active antiretroviral therapy and helping them adhere to it. Bringing HIV+ IDUs’ viral loads to undetectable levels could slow transmission of HIV. In San Francisco, CA, Action Point, a storefront drop-in center, offers adherence support for the urban poor with active drug or alcohol addiction. Action Point is open 5 days a week and operates on a harm reduction principle that encourages any positive change in health. The program offers adherence case management, medication dispensing, nursing care, acupuncture and referrals to mental health and substance abuse services.²¹

What still needs to be done?

The biggest barrier to reducing HIV transmission among IDUs is the failure to implement effective prevention programs. Increasing access to quality drug treatment and sterile injection equipment would greatly affect this epidemic among IDUs. However, political attitudes and the criminalization of drug use have hampered prevention efforts in the US.²² Federal and state governments should act quickly to legalize syringe exchange programs and fund more drug treatment. It is often erroneously assumed that IDUs are not comfortable discussing sexual issues. Prevention programs for IDUs need to address sexual behavior as well as injecting behavior. Handing out condoms is not enough; service providers need to initiate discussions about sex. This is especially important for drug use-based interventions, such as syringe exchange programs, drug treatment and 12-step programs. Programs should be multi-faceted and address other non-HIV needs of IDUs. Collaboration between HIV prevention, drug treatment, hepatitis C prevention and mental health services is crucial. Case managers can then give effective referrals to these services, housing or medical care, and help with follow-up and retention. Programs for IDUs should also incorporate a harm reduction approach and be aware that relapse is a common event for IDUs.

Says who? 1. Drug-associated HIV transmission in the United States. Fact Sheet published by the Center for Disease Control https://www.cdc.gov/hiv/risk/substanceuse.html 2. CDC. HIV/AIDS Surveillance Report-cases reported through December 2001. 2002;13:tbl 22,23.https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html 3. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV- related chronic disease. Morbidity and Mortality Weekly Report. 1998;47(RR19):1-39. 4. Garfein RS, Doherty MC, Monterroso ER, et al. Prevalence and incidence of hepatitis C virus infection among young adult injection drug users. Journal of AIDS and Human Retrovirology. 1998;18:S11-19. 5. Darke S, Hall W. Heroin overdose: research and evidence-based intervention. Journal of Urban Health. 2003;80:189-200. 6. Access to sterile syringes. Published by the National Center for HIV, STD and TB Prevention. January 2002. www.cdc.gov/idu/facts/ 7. Kral AH, Bluthenthal RN, Lorvick J, et al. Sexual transmission of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis. Lancet. 2001;357:1397-1401. 8. Bull SS, Piper P, Rietmeijer C. Men who have sex with men and also inject drugs-profiles of risk related to the synergy of sex and drug injection behaviors. Journal of Homosexuality. 2002;42:31-51. 9. Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness and incarceration. Public Health Reports. 2002;117: S135-S145. 10. Day D. Health emergency 2003: the spread of drug-related AIDS and hepatitis C among African Americans and Latinos. Published by Dogwood Center. 2003. www.dogwoodcenter.org/2003/HE2003.pdf 11. Hilton BA, Thompson R, Moore-Dempsey L, et al. Harm reduction theories and strategies for control of HIV: a review of the literature. Journal of Advanced Nursing. 2001;33:357-370. 12. Is there a more effective social policy with respect to the problems of substance misuse in British Columbia? Presentation to the Vancouver Area Network of Drug Users. 2000. www.vandu.org 13. Latkin CA, Forman V, Knowlton A, et al. Norms, social networks, and HIV-related behaviors among urban disadvantaged drug users. Social Science & Medicine. 2003;56:465-476. 14. .Knowlton AR. Social network approaches to HIV prevention and care: theoretical and methodological considerations of intervention. Presented at the 14th International AIDS Conference, Barcelona, Spain. 2002. ThOrE1501. 15. Gibson DR, Flynn NM, McCarthy JJ. Effectiveness of methadone treatment in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS. 1999,13:1807-1818. 16. Alcohol and drug use and HIV. NASTAD HIV Prevention Fact Sheethttps://www.nastad.org/domestic/hepatitis/drug-user-health Gibson DR, Brand R, Anderson K, et al. Two- to six-fold decreased odds of risk behavior associated with use of syringe exchange. Journal of Acquired Immune Deficiencies Syndrome. 2002;31:237-242. 18. Bluthenthal RN, Kral AH, Gee L, et al. The effect of syringe exchange on high-risk injection drug users: a cohort study. AIDS. 2000;14:605-611. 19. Galea S, Factor SH, Bonner S, et al. Collaboration among community members, local health service providers, and researchers in an urban research center in Harlem, New York. Public Health Reports. 2001;116:530-539. 20. The UFO Study. https://ufostudy.ucsf.edu/ 21. Bamberger JD, Unick J, Klein P, et al. Helping the urban poor stay with antiretroviral HIV drug therapy. American Journal of Public Health. 2000;90:699-701. 22. Des Jarlais DC, Friedman SR. Fifteen years of research on preventing HIV infection among injecting drug users: what we have learned, what we have not learned, what we have done, what we have not done. Public Health Reports. 1998;113:182-188.

Prepared by Pamela DeCarlo and David R. Gibson CAPS September 2003. Fact Sheet #51E Special thanks to the following reviewers of this Fact Sheet: Cyril Colonius, Carol Dawson-Rose, Dawn Day, Pam Klein, Alex Kral, Pam Ling, Kim Shafer, Claire Sterk, Karin Tobin.

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 Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2003, University of California

Resource

Methamphetamine

How does methamphetamine use affect HIV prevention?

what is methamphetamine?

Methamphetamine (meth, also called crystal, speed, Tina, ice, crank) is a powerful, illegal stimulant and is similar to amphetamine. It can be taken orally, snorted, smoked, injected and inserted rectally and can affect the user for several hours or more depending on how much is used.¹ Meth is cheap, widely available and has a high potential for abuse and addiction. Meth users describe the positive effects to be feelings of euphoria, loss of appetite, heightened self esteem and increased desire for and intensity of sex. However, meth also has many negative short and long-term effects, including damaging brain neurons, high blood pressure, oral hygiene problems, depression, anxiety, paranoia and psychotic symptoms such as paranoid delusions and hallucinations. Symptoms of overdose include chest pain, elevated body temperature, rapid heart rate and rapid shallow breathing. Meth is widely used, both nationally and internationally, with over one million users in the US.² Although lifetime meth use has increased dramatically since the early 1990s, the number of abusers has remained steady and meth abuse is far less common than cocaine abuse.³ In recent years, meth use has increased in some locales and sub-populations, particularly on the East Coast.

how does meth use affect HIV?

Meth use can heighten one’s HIV risk through unsafe injection and sexual behaviors. If a person injects meth, sharing needles and injection equipment can transmit HIV. Many users consider meth a sexual drug, using it specifically to intensify and prolong sex and increase disinhibition. Meth tends to dry out the skin on the penis, anus and vagina, which may lead to tears and cuts and HIV transmission, especially with extended sex play, multiple partners and more aggressive sex associated with meth use. Meth can both increase sex drive and decrease men’s ability to get and maintain an erection. As a result, some men using meth may choose receptive anal sex (“bottoms”), or may choose to combine meth with erectile dysfunction drugs such as Viagra. Both meth and Viagra use are independently associated with unprotected anal sex.⁴

how does meth use affect HIV risk?

Meth use and abuse is a very real concern among gay men and other men who have sex with men (MSM). Research on meth use in other populations, such as heterosexuals, is limited. Gay and bisexual men report using meth and other stimulants at rates 10 times greater than the general population.⁵ This is particularly concerning because HIV is more common in this population than among heterosexuals. The use of meth for sexual reasons has been found to be more common among HIV+ men.^6,7 The reasons for meth use among MSM vary, and may include strong cultural expectations of sexual prowess in some parts of the gay community.⁸ Several studies of MSM (primarily gay-identified men) have found that users are 2-3 times more likely than non-users to engage in unprotected anal sex, have condoms break or slip off, acquire a sexually transmitted disease, or become infected with HIV.⁹ In fact, these elevated risks occur among frequent and occasional users alike.¹⁰ A study of HIV- MSM found that men using stimulants were twice as likely to become infected as non-users, even when accounting for specific risky sexual behavior like unprotected anal sex with HIV+ partners.¹¹ This suggests that meth use may contribute to HIV infection above and beyond increasing the likelihood that users will engage in risky behavior. While there is ample evidence of the link between HIV risk and meth use among MSM, some studies also show high levels of HIV risk behavior among heterosexuals. In one study, 86% of users reported engaging in “marathon sex” while high on meth. More than a third reported injecting, and of those, 47% had shared and/or borrowed needles.¹²

how does meth affect HIV+ persons?

Meth use and abuse can have negative consequences for HIV+ persons. HIV protease inhibitors (particularly ritonavir) may increase the potential for adverse reactions or overdose. Being high on meth may cause HIV+ persons to forget to take–or be unconcerned with taking–their medications. Meth use may also affect HIV+ persons’ overall health by increasing dehydration, sleeplessness and weight loss.¹³

what’s being done?

The high potential for addiction to meth and the intentional combination of meth and sex pose unique challenges for sexual risk-reduction efforts for meth users. However, a variety of approaches are available. Meth and HIV prevention efforts should focus on: 1) preventing initial use of meth among non-users by influencing community norms, 2) discouraging occasional users from becoming regular users, 3) minimizing health risks for current users, and 4) increasing drug treatment capacity and getting meth abusers into accessible programs. There have been several social marketing campaigns addressing the prevention of meth use. “Crystal Mess” and “Got Meth?” addressed negative consequences of meth use among gay men and youth, respectively. “Silence=Meth” calls for the gay community to take action around meth use.¹⁴ A harm-reduction approach may be better suited to those currently not choosing to cease meth use entirely, such as is offered at the Stonewall Project for MSM in San Francisco, CA.¹⁵ Those injecting meth should be referred to needle exchange programs and provided education and counseling on safer injection and sex practices. Life in the FASTLANE is a harm reduction-based program to reduce sexual risk among heterosexual active meth users. Using four weekly 90-minute one-on-one counseling sessions, FASTLANE increased intentions for safer sex and protected sex acts.¹⁶ For meth users ready to quit using, several programs are available. Some users may benefit from 12-step programs like Crystal Meth Anonymous, Narcotics Anonymous and LifeRing.¹⁷ The Positive Reinforcement Opportunity Project (PROP), uses positive conditioning to help gay and bisexual men stay off meth. Participants get urine tests 3 times a week for 12 weeks. Each time the test is negative for meth, they get positive reinforcement and vouchers good for food, medical bills, personal care items and more.¹⁷ Perhaps the best studied meth treatment approach is the Matrix Model, which is a behavioral intervention using 48 group and individual sessions over 16 weeks.¹⁸ Another study with MSM compared a variation of this model with contingency management (providing vouchers of increasing value for meth-negative urine), a combination of both approaches, and a gay-specific version of Matrix.¹⁹ All groups showed substantial reductions in meth use and sexual risk behavior one year later. While there are no medications currently approved to treat meth dependence, this may prove to be an effective approach. Currently, several studies, such as BUMP, are testing the feasibility of providing the antidepressant bupropion to meth-dependent MSM.²⁰

what are next steps?

The gay community needs to address the very real pressure in some sub-communities to party and be highly sexually active²¹, and to ask the question “is drug use worth the risks men are taking?” It is not enough to attempt to reduce drug and alcohol use and abuse without also addressing the powerful sexual reasons why MSM use drugs, and explore ways to develop a healthy and satisfying sex life without drugs. Research into potentially effective treatment, counseling, medication and harm reduction approaches continues. Counselors and health care providers should be trained on the symptoms and effects of meth use and how to discuss meth and other substance use with clients and patients in a non-judgmental way. Providers can refer users to locally accessible meth harm reduction, treatment and HIV prevention programs when appropriate.

Says who?

1. Cretzmeyer M, Sarrazin MV, Huber DL, Block RI, Hall JA. Treatment of methamphetamine abuse: research findings and clinical directions. Journal of Substance Abuse Treatment. 2003;24:267-277. 2. SAMHSA. Methamphetamine use, abuse and dependence: 2002, 2003 and 2004. The NSDUH Report. September 2005. 3. King RS. The next big thing? Methamphetamine use in the US. Report prepared by The Sentencing Project. June 2006. 4. Mansergh G, Shouse RL, Marks G, et al. Methamphetamine and sildenafil (Viagra) use are linked to unprotected receptive and insertive anal sex, respectively, in a sample of men who have sex with men. Sexually Transmitted Infections. 2006;82:131-134. 5. Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men. Addiction. 2001;96:1589-1601. 6. Semple SJ, Patterson TL, Grant I. Motivations associated with methamphetamine use among HIV+ men who have sex with men. Journal of Substance Abuse and Treatment. 2002;22:149-156. 7. Halkitis PN, Shrem MT, Martin FW. Sexual behavior patterns of methamphetamine-using gay and bisexual men. Substance Use & Misuse. 2005;40:703–719. 8. Diaz RM, Heckert AL, Sanchez J. Reasons for stimulant use among Latino gay men in San Francisco: a comparison between methamphetamine and cocaine users. Journal of Urban Health. 2005;82:i71-78. 9. CDC. Methamphetamine use and HIV risk behaviors among heterosexual menpreliminary results from five northern California counties. Morbidity and Mortality Weekly Report. 2006;55:273-277. 10. Colfax G, Vittinghoff E, Husnik MJ, et al. Substance use and sexual risk: a participant- and episode-level analysis among a cohort of men who have sex with men. American Journal of Epidemiology. 2004;159:1002-1012. 11. Koblin BA, Husnik MJ, Colfax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006;20:731-739. 12. Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addictive Behavior. 2004;29:807-810. 13. New York State Department of Health AIDS Institute. Methamphetamine and HIV: basic facts for service providers. https://www.health.ny.gov/diseases/aids/providers/prevention/harm_reduction/crystalmeth/dearcolleagueletter.htm 14. www.crystalmess.net; https://www.justthinktwice.gov/drugs/methamphetamine; 15. www.tweaker.org 16. Patterson TL, Mausbach B, Semple SJ, et al. Life in the fastlane: testing the efficacy of a behavioral intervention to reduce high risk sexual behaviors among HIV-negative, heterosexual methamphetamine users. Presented at the International AIDS Conference, Toronto, Canada, August 2006. #MOAC0205 17. www.na.org; www.unhooked.com; www.crystalmeth.org; www.propsf.com 18. Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction. 2004;99:708-717. 19. Shoptaw S, Reback CJ, Peck JA, et al. Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug and Alcohol Dependence. 2005;78:125-134. 20. http://www.sfcityclinic.org/providers/dph_speed_brochure.pdf 21. Green IA, Halkitis PN. Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health and Sexuality. 2006;8:317-333. *All websites accessed July 2006

Prepared by Robert Guzman MPH, San Francisco DPH; Pamela DeCarlo, CAPS September 2006 . Fact Sheet #61E Special thanks to the following reviewers of this Fact Sheet: David Celentano, Grant Colfax, Perry Halkitis, Mark Hammer, Jeff Klausner, David Knapp Whittier, Jennifer Lorvick, Alix Lutnick, Jean Malpas, Gordon Mansergh, Tim Matheson, Tracey Packer, Joseph Palamar, Jimmy Palmieri, Jim Peck, Brady Ralston, Cathy Reback, Steve Shoptaw, Michael Siever, Hanne Thiede, Steven Tierney, Chad Upham, Will Wong. 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 Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © September 2006, University of California

Resource

Needle exchange programs (NEP)

Does HIV Needle Exchange Work?

revised 12/98

Why do we need needle exchange?

More than a million people in the US inject drugs frequently, at a cost to society in health care, lost productivity, accidents, and crime of more than $50 billion a year.¹ People who inject drugs imperil their own health. If they contract HIV or hepatitis, their needle-sharing partners, sexual partners and offspring may become infected. It is estimated that half of all new HIV infections in the US are occurring among injection drug users (IDUs)². For women, 61% of all AIDS cases are due to injection drug use or sex with partners who inject drugs. Injection drug use is the source of infection for more than half of all children born with HIV.³ Injection drug use is also the most common risk factor in persons with hepatitis C infection. Up to 90% of IDUs are estimated to be infected with hepatitis C, which is easily transmitted and can cause chronic liver disease. Hepatitis B is also transmitted via injection drug use.⁴ Needle exchange programs (NEPs) distribute clean needles and safely dispose of used ones for IDUs, and also generally offer a variety of related services, including referrals to drug treatment and HIV counseling and testing.

Why do drug users share needles?

The overwhelming majority of IDUs are aware of the risk of the transmission of HIV and other diseases if they share contaminated equipment. However, there are not enough needles and syringes available and even these are often not affordable to IDUs. Getting IDUs into treatment and off drugs would eliminate needle-related HIV transmission. Unfortunately, not all drug injectors are ready or able to quit. Even those who are highly motivated may find few services available. Drug treatment centers frequently have long waiting lists and relapses are common. Most US states have paraphernalia laws that make it a crime to possess or distribute drug paraphernalia “known to be used to introduce illicit drugs into the body.”⁵ In addition, ten states and the District of Columbia have laws or regulations that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. Concern with arrest for carrying drug paraphernalia has been associated with sharing syringes and other injection supplies.⁶ In July 1992, the state of Connecticut passed laws permitting the purchase and possession of up to ten syringes without a prescription and making parallel changes in its paraphernalia law. After the new laws went into effect, the sharing of needles among IDUs decreased substantially, and there was a shift from street needle and syringe purchasing to pharmacy purchasing.⁷ However, even where over-the-counter sales of syringes are permitted by law, pharmacists are often unwilling to sell to IDUs, emphasizing the need for education and outreach to pharmacists.

What’s being done?

Around the world and in more than 80 cities in 38 states in the US, NEPs have sprung up to address drug-injection risks. There are currently 113 NEPs in the US. In Hawaii, the NEP is funded by the state Department of Health. In addition to needle exchange, the program offers a centralized drug treatment referral system and a methadone clinic, as well as a peer-education program to reach IDUs who do not come to the exchange. Rates of HIV among IDUs have dropped from 5% in 1989 to 1.1% in 1994-96. From 1993-96, 74% of NEP clients reported no sharing of needles, and 44% of those who did report sharing reported always cleaning used needles with bleach.⁸ Harm Reduction Central in Hollywood, CA, is a storefront NEP that targets young IDUs aged 24 and under. The program provides needle exchange, arts programming, peer-support groups, HIV testing and case management and is the largest youth NEP in the US. Over 70% of clients reported no needle-sharing in the last 30 days, and young people who used the NEP on a regular basis were more likely not to share needles.⁹

Does needle exchange reduce the spread of HIV? Encourage drug use?

It is possible to significantly limit HIV transmission among IDUs. One study looked at five cities with IDU populations where HIV prevalence had remained low. Glasgow, Scotland; Lund, Sweden; New South Wales, Australia; Tacoma, WA; and Toronto, Ontario, all had the following prevention components: beginning prevention activities when levels of HIV infection were still low; providing sterile injection equipment including through NEPs; and conducting community outreach to IDUs.¹⁰ A study of 81 cities around the world compared HIV infection rates among IDUs in cities that had NEPs with cities that did not have NEPs. In the 52 cities without NEPs, HIV infection rates increased by 5.9% per year on average. In the 29 cities with NEPs, HIV infection rates decreased by 5.8% per year. The study concluded that NEPs appear to lead to lower levels of HIV infection among IDUs.¹¹ In San Francisco, CA, the effects of an NEP were studied over a five-year period. The NEP did not encourage drug use either by increasing drug use among current IDUs, or by recruiting significant numbers of new or young IDUs. On the contrary, from December 1986 through June 1992, injection frequency among IDUs in the community decreased from 1.9 injections per day to 0.7, and the percentage of new initiates into injection drug use decreased from 3% to 1%.¹² Hundreds of other studies of NEPs have been conducted, and all have been summarized in a series of eight federally funded reports dating back to 1991. Each of the eight reports has concluded that NEPs can reduce the number of new HIV infections and do not appear to lead to increased drug use among IDUs or in the general community.^13-15 These were the two criteria that by law had to be met before the federal ban on NEP service funding could be lifted. This is a degree of unanimity on the interpretation of research findings unusual in science. Five of the studies recommended that the federal ban be lifted and two made no recommendations. In the eighth report the Department of Health and Human Services decided that the two criteria had been met, but failed to lift the ban. The Congress has since changed the law, continuing to ban federal funding for NEPs, regardless of whether the criteria are met.

Is needle exchange cost-effective?

Yes. The median annual budget for running a program was $169,000 in 1992. Mathematical models based on those data predict that needle exchanges could prevent HIV infections among clients, their sex partners, and offspring at a cost of about $9,400 per infection averted.¹⁶ This is far below the $195,188 lifetime cost of treating an HIV-infected person at present.¹⁷ A national program of NEPs would have saved up to 10,000 lives by 1995.¹³

What must be done?

Efforts to increase the availability of sterile needles must be a part of a broader strategy to prevent HIV among IDUs, including expanded access to drug treatment and drug-use prevention efforts. Although the US federal government has acknowledged that NEPs¹⁵ reduce rates of HIV infection and do not increase drug use rates, it still refuses to provide funding for NEPs. Therefore, advocacy activity at the state and local community level is critical. However, the federal government should play a more active role in advocating for NEPs publicly, even if it doesn’t fund them. States with prescription laws should repeal them; those with paraphernalia laws should revise them insofar as they restrict access to needles and syringes. Local governments, Community Planning Groups and public health officials should work with community groups to develop comprehensive approaches to HIV prevention among IDUs and their sexual partners, including NEPs and programs to increase access to sterile syringes through pharmacies.

Says who?

1. Rice DP, Kelman S, Miller LS. Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988 . Public Health Reports. 1991;106:280-92. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. CDC. HIV/AIDS Surveillance Report . 1998;9:12. 4. Alter MJ, Moyer LA. The importance of preventing hepatitis C virus infection among injection drug users in the United States . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998; 18(Suppl 1):S6-10. 5. Gostin LO, Lazzarini Z, Jones TS, et al. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: a national survey on the regulation of syringes and needles . Journal of the American Medical Association. 1997;277:53-62. 6. Bluthenthal RN, Kral AH, Erringer EA, et al. Drug paraphernalia laws and injection-related infectious disease risk among drug injectors. Journal of Drug Issues. (in press). 7. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993 . Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89. 8. Vogt RL, Breda MC, Des Jarlais DC, et al. Hawaii’s statewide syringe exchange program . American Journal of Public Health. 1998;88:1403-1404. 9. Kipke MD, Edgington R, Weiker RL, et al. HIV prevention for adolescent IDUs at a storefront needle exchange program in Hollywood, CA. Presented at 12th World AIDS Conference, Geneva, Switzer-land. 1998. Abstract #23204. 10. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231. 11. Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection . Lancet. 1997;349:1797-1800. 12. Watters JK, Estilo MJ, Clark GL, et al. Syringe and needle exchange as HIV/AIDS prevention for injection drug users . Journal of the American Medical Association. 1994; 271:115-120. 13. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA . Lancet. 1997;349:604-608. 14. Report from the NIH Consensus Development Conference. February 1997. 15. Goldstein A. Clinton supports needle exchanges but not funding. Washington Post. April 21, 1998:A1. 16. Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle Exchange Programs in the United States and Abroad . Prepared for the Centers for Disease Control and Prevention. October 1993. 17. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1997;16:54-62.

Prepared by Peter Lurie, MD MPH*,** and Pamela DeCarlo** *Public Citizen’s Health Research Group **CAPS Updated December 1998. Fact Sheet #5Er

Resource

Substance abusers

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.¹ 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.² 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.³ 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.⁴ 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.⁵

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.⁶ 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.⁷ 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.⁹ 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.⁹ 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.¹⁰ 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.¹¹ 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.¹²

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.¹³ 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.¹⁴ 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 **********

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 [email protected]. ©1996, University of California

Resource

Drogas de club o discoteca

¿Cuál es el impacto de las drogas de club en la prevención del VIH?

¿cuáles son éstas drogas?

Entre las llamadas drogas de club o fiesta se incluyen la MDMA (éxtasis), la metanfetamina (cristal, speed), el GHB (X líquido o ácido gammahidroxibutirato), la ketamina (K especial), y a veces también los nitratos de amilo (poppers) y la Viagra¹. Con frecuencia estas drogas se consumen (aunque no exclusivamente) en clubes nocturnos/discotecas, en las fiestas rave y en las de circuito. Los raves son fiestas grandes con música house o tecno acompañada de efectos visuales; la mayoría de los asistentes son jóvenes. Las fiestas de circuito son una serie de fiestas grandes que duran varios días y noches y se organizan anualmente en diferentes ciudades². Sus asistentes son predominantemente hombres gay blancos de la clase media, tanto jóvenes como mayores. Entre los efectos físicos y psicológicos de las drogas de club se encuentran: estado de ánimo elevado; mayor empatía, alteración en las percepciones visuales, sensuales y emocionales; agudeza mental; disminución del apetito; relajamiento; mayor energía física y autoestima elevada. Muchas personas consumen drogas recreativamente con pocas o ninguna consecuencia inmediata. El mal uso de las drogas de club puede producir toxicidad (por las drogas mismas o por sus interacciones con otras drogas o fármacos), problemas legales y a veces problemas de adicción. Muchas personas que usan una o más de estas drogas en las relaciones sexuales mencionan haber participado en conductas que aumentan considerablemente su riesgo de VIH. Las drogas de club plantean otros riesgos para la salud, pero aquí sólo comentaremos sus posibles efectos sobre las prácticas que facilitan el contagio del VIH.

¿quiénes las usan?

Gran parte de las investigaciones sobre las drogas de club se ha realizado entre hombres homosexuales, principalmente por la alta prevalencia del VIH y riesgo de infección que existen en esta población. El consumo de drogas de club varía según la población y el área geográfica³. Un estudio de fiestas rave en Chicago encontró que el 48.9% de los asistentes había consumido alguna droga de club, el 29.8% LSD, el 27.7% éxtasis y el 8.5% metanfetamina. Ellos consumieron drogas de club junto con otras drogas tales como marihuana (el 87%), alcohol (el 65.2%) y cocaína/crack (el 26.1%).⁴ Una encuesta de hombres homosexuales que asistían a fiestas de circuito en San Francisco demostró que el 80% consumió éxtasis, el 66% ketamina, el 43% metanfetaminas, el 29% GHB, el 14% Viagra y el 12% poppers. La mitad (el 53%) consumió cuatro drogas o más.⁵

¿cuál es el riesgo?

Estas drogas tienen muchas consecuencias físicas y psicológicas que aumentan el riesgo de contraer el VIH: pueden disminuir las inhibiciones, afectar el juicio, incrementar la resistencia sexual y promover conductas riesgosas durante el sexo. El consumo de drogas inyectables también puede aumentar el riesgo de VIH si los equipos de inyección se comparten. El riesgo de VIH ocurre principalmente cuando el consumo de drogas coincide con el contacto sexual. Por ejemplo, la metanfetamina (speed) se usa a menudo para iniciar, intensificar y prolongar los encuentros sexuales, de modo que es posible tener relaciones sexuales con varias parejas. Las drogas inhaladas poppers se usan para relajar el esfínter anal durante el sexo anal receptivo. Por ser deshidratante, la metanfetamina también puede promover desgarros en los tejidos del ano, vagina o boca, aumentando así el riesgo de contraer el VIH/ITS.^6,7 En un estudio, consumidores heterosexuales VIH- reportaron un promedio de 9.4 parejas sexuales durante dos meses. El promedio de actos sexuales desprotegidos durante este lapso era de 21.5 para el sexo vaginal, de 6.3 para el sexo anal y de 41.7 para el sexo oral. El 86% de los participantes mencionaron haber tenido sexo maratónico mientras estaban bajo los efectos de la metanfetamina. El 37% dijo que se había inyectado la droga; casi la mitad compartió jeringas o las pidió prestadas.⁷ El sexo desprotegido con una pareja sexual cuya condición de VIH se desconoce es una actividad de alto riesgo. Una encuesta de hombres homosexuales encontró que el 21% de los hombres VIH+ y el 9% de los VIH- reportaron sexo anal desprotegido en la fiesta de circuito más reciente sin conocer la condición de VIH de su pareja.⁵ Un estudio de hombres homosexuales en fiestas rave en la Ciudad de Nueva York reveló que el 34% consumía éxtasis por lo menos una vez al mes. Los consumidores de éxtasis mencionaron más incidentes de sexo anal desprotegido que los consumidores de otras drogas y de alcohol.⁸

¿por qué se consumen?

Para muchas personas, tanto homosexuales como heterosexuales, el consumo de drogas y el sexo son una parte integral y un atractivo principal de las fiestas rave y de circuito. Estas actividades sociales son importantes para algunos grupos de jóvenes y hombres homosexuales, quienes pueden sentirse presionados por sus compañeros a consumir drogas y a tener sexo en este ambiente. Las fiestas rave y de circuito en sí tal vez no producen el consumo de drogas, pero pueden atraer a personas más propensas a consumirlas.⁹ Las drogas de club se consumen por varias razones: para divertirse, bailar, disminuir las inhibiciones, escaparse de los problemas y combatir la depresión o la ansiedad, entre otras. Algunos factores que pueden llevar al consumo de drogas son la depresión, el consumo de drogas de los padres y el abuso sexual infantil.¹⁰

¿qué se está haciendo al respecto?

Un programa de tratamiento de drogas para consumidores gay de metanfetamina en Los Ángeles, CA, buscó reducir el consumo de drogas y las prácticas sexuales arriesgadas relacionadas con el VIH. Ofreció terapia conductual cognitiva (una sesión grupal de 90 minutos tres veces por semana), ayuda para el manejo de contingencias (intervención conductual que ofrece bonos cuyo valor incrementa al abstenerse de las drogas) y terapia conductual cognitiva diseñada especialmente para la cultura gay. Todos los hombres redujeron su consumo de drogas, y quienes participaron en el manejo de contingencias mantuvieron la reducción por más tiempo. La mayor reducción de prácticas sexuales riesgosas ocurrió entre los participantes de la terapia dirigida a la cultura gay.¹¹ “DanceSafe” capacita a voluntarios que sirven como promotores de salud y de prevención del consumo de drogas en las fiestas rave y clubes nocturnos en todo EE.UU. y Canadá. Estos programas emplean un método de reducción de daños y dirigen sus servicios principalmente a consumidores recreacionales de drogas que no son adictos. DanceSafe ofrece información sobre las drogas, el sexo protegido y cómo mantenerse sano; en algunos clubes y fiestas ofrecen examinar las pastillas para comprobar que no contengan sustitutos peligrosos.¹² Por medio de reuniones regulares, los programas de 12 pasos como “Crystal Meth Anonymous,” “Narcotics Anonymous” y “Alcoholics Anonymous” promueven la abstención entre personas con problemas causados por el consumo de alcohol, metanfetamina y otras drogas.¹³ El proyecto “PROTECT” del South Florida Regional Prevention Center pretende reducir el consumo de drogas de club entre homosexuales jóvenes. PROTECT capacita a policías, maestros y otros actores comunitarios sobre las drogas de club, particularmente el éxtasis. Su sitio web incluye una sala de conversación monitoreada por consejeros jóvenes.¹⁴ “Stepping Stone,” en San Diego, CA, es un programa residencial de tratamiento de drogas para homosexuales y lesbianas; la mayoría son policonsumidores (que combinan drogas) con algún trastorno psiquiátrico. Las conductas sexuales y las necesidades de salud mental se abordan en el contexto del tratamiento para dejar las drogas. Stepping Stone auspicia una campaña de mercadotecnia social sobre la reducción de daños para concientizar al público sobre los peligros de las drogas de club y el alcohol.¹⁵

¿qué queda hacer?

Varias organizaciones están respondiendo a los efectos perjudiciales de las drogas de club en fiestas en EE.UU. Se necesita más sensibilización sobre la toxicidad de estas drogas, el policonsumo y la relación entre el consumo de drogas y la falta de protección en el sexo. En estas fiestas también se deben ofrecer recomendaciones a servicios de salud mental. La comunidad homosexual necesita responder a las presiones reales que existen en algunos subgrupos sobre consumir drogas y ser muy activos sexualmente y debe preguntarse “si el consumo de drogas vale el riesgo que estos hombres corren.” No es suficiente intentar reducir el uso y abuso de drogas en las fiestas de circuito sin abordar simultáneamente las poderosas motivaciones sexuales de su consumo.⁶ Al recetarles Viagra, los médicos deben informar a los hombres sobre los efectos dañinos de combinar el Viagra con metanfetaminas, poppers y éxtasis. También deben preguntar a sus pacientes VIH+ si ellos usan drogas de club, y explicarles sobre los peligros de combinarlas con los medicamentos contra el VIH.¹⁶ Los médicos necesitan saber que el consumo de drogas de club puede afectar la adherencia (apego) al tratamiento del VIH.

¿Quién Lo Dice?

1. Freese TE, Miotto K et al. The effects and consequences of selected club drugs. Journal of Substance Abuse Treatment. 2002;23:151-156. 2. Swanson J, Cooper A. Dangerous liaison: club drug use and HIV/AIDS. IAPAC Monthly. 2002;8:1-15. 3. Halkitis PN, Parsons JT, Stirratt MJ. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. Journal of Homosexuality. 2001;41:17-35. 4. Stall R, Paul JP, Greenwood G et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96:1589-1601. 5. Colfax GN, Mansergh G, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. Journal of Acquired Immune Deficiency Syndromes. 2001;28:373-379. 6. Fendrich M, Wislar JS, Johnson TP et al. A contextual profile of club drug use among adults in Chicago. Addiction. 2003;98:1693-1703. 7. Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addictive Behavior. 2004;29:807-810. 8. Klitzman RL, Pope HG, Hudson JI. MDMA (“ecstacy”) abuse and high-risk sexual behaviors among 169 gay and bisexual men. American Journal of Psychiatry. 2000;157:1162-1164. 9. Task Force on Crystal, Syphilis and HIV. Confronting crystal methamphetamine use in New York City. Public policy recommendations. Gay Men’s Health Crisis, New York, NY. July 2004. https://www.gmhc.org/files/editor/file/ti_0609.pdf 10. Adlaf EM, Smart RG. Party subculture or dens of doom? An epidemiological study of rave attendance and drug use patterns among adolescent students. Journal of Psychoactive Drugs. 1997;29:193-198. 11. Shoptaw S, Reback CJ. Drug and sex risk behavior reductions with behavioral treatments for methamphetamine dependence among gay/bisexual men. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. Abstract #T3-D1004. 12. www.dancesafe.org 13. www.crystalmeth.org, www.na.org, www.aa.org 14. Rothaus S. Workshop targets young gays with a penchant for club drugs. Miami Herald. July 16, 2003. 15. Johnson SB. Stepping Stone: a catalyst for change. Presented at Methamphetamine Use and Gay Men Meeting. Sacramento, CA. April 24, 2003. 16. Romanelli F, Smith KS, Pomeroy C. Use of club drugs by HIV-seropositive and HIV-seronegative gay and bisexual men. Topics in HIV Medicine. 2003;11:25-32. Otros recursos en español: Drogas de club, NIDA AZ libre de drogas Otros recursos en inglés: www.crystalrecovery.com www.drugabuse.com www.freevibe.com www.crystalneon.org

Preparado por Mike Pendo*, Pamela DeCarlo** *SF Dept of Public Health, **CAPS Traducción Rocky Schnaath Enero 2005. Hoja Informativa 55S