Substance Abuse and HIV/AIDS in the United States
The spread of HIV disease in the United States is fueled in part by the use of illicit drugs. Injection drug use (IDU) is directly related to HIV transmission because it may involve the sharing of drug equipment. The use of both injected and noninjected illicit drugs impairs decision making and increases sexual risk-taking behavior, which increases the risk for acquiring HIV.1
Surveillance
In 2004, the exposure category for an estimated 21.5 percent of new AIDS cases among adolescents and adults was IDU.2
Men
- Among men, IDU was the exposure category in an estimated 19.2 percent of new AIDS cases in 2004; another estimated 6.2 percent of cases resulted from sexual contact with men who have sex with men (MSM) and inject drugs.2
- Among all men living with AIDS at the end of 2004, an estimated 21.1 percent contracted HIV through IDU, but the estimated rate was higher among Black and Hispanic men (29.2 and 28.3 percent, respectively).3
- AIDS mortality estimates among men for whom the HIV exposure category was IDU declined by 18.7 percent from 2000 to 2004; mortality decreased by 8.5 percent for MSM.4
Women
Among women, an estimated 27.8 percent of new AIDS cases were attributed to IDU in 2004.2 At the end of 2004, IDU was the HIV exposure category for an estimated 33.6 percent of women living with AIDS, ranging from 39.7 percent among White women and 38.8 percent among American Indian/Alaska Natives to 32.2 percent for Blacks, 32.6 percent for Hispanics, and just 15.8 percent among Asian/Pacific Islanders.3
Among women infected through IDU, the AIDS mortality rate actually increased by 7.8 percent from 2000 to 2004.4
CRITICAL ISSUES
In 2004, the National Survey on Drug Use and Health reported that an estimated 22.5 million Americans were either substance dependent or substance abusers. People considered to be substance dependent rely on an illicit drug and cannot physically or psychologically cope without it in their system; they need addiction treatment. Substance abusers are people who abuse a drug regularly but have not become physically or psychologically addicted to it.5
The risk for HIV associated with substance abuse involves more than simply the sharing of IDU paraphernalia. Use of drugs and alcohol interferes with judgment about sexual and other behavior. As a result, substance users may be more likely to have unplanned and unprotected sex.1
Even though substance abuse treatment is crucial for staying in HIV care and adhering to a treatment regimen, it is in short supply. The introduction of buprenorphine, a treatment for opiate addiction that may be given in a primary care setting, offers hope for improved access to treatment for addiction. Special training, however, is required to administer buprenorphine, and the training may not be readily available in all health care environments. This state of affairs needs to be remedied: Research shows that “one in three people living with HIV continue engaging in high-risk behavior after learning they are HIV positive.”6
Recent studies have found that trauma, substance abuse, and sexual risk factors are interconnected. For example, women who have experienced sexual abuse, whether as a child or in adulthood, may be more likely than other women to use drugs as a coping mechanism, have difficulty refusing unwanted sex, or engage in sexual activities with strangers. Women who have experienced trauma also may be less assertive about birth control and have a greater number of lifetime partners, increasing their risk for HIV infection.7 In addition, research has found that people who suffer from mental illness are more likely to use injection drugs.8
Substance Abuse and the Ryan White CARE Act
A special issue of HRSA CAREAction (available at www.hab.hrsa.gov) and an initiative under the Special Projects of National Significance program are among the Health Resources and Services Administration's (HRSA's) activities to increase access to buprenorphine.
Users of illicit substances may receive HIV services through all Ryan White Comprehensive AIDS Resources Emergency (CARE) Act programs. The lack of drug treatment services in the United States has placed increased pressure on CARE Act providers because they must address substance abuse issues to sustain individuals in care over time.
Substance Abuse and Infectious Disease: Cross-Training for Collaborative Systems of Prevention, Treatment, and Care is an initiative that provides training and technical assistance to State and local public health agencies and to mental health and substance abuse health care delivery systems so that they can more effectively serve people with substance abuse problems and infectious diseases such as HIV/AIDS, other sexually transmitted infections, viral hepatitis, and tuberculosis.
A HRSA report, Investigation of the Adequacy of the Community Planning Process to Meet the HIV Care Needs of Active Substance Users, provides recommendations on how to more effectively use CARE Act Title I funds to meet the needs of the substance-using population.
INSPIRE, a 5-year cooperative agreement jointly funded by HRSA and the CDC, is a randomized controlled trial to test a 10-session intervention developed by a multisite research team. The primary objectives of the study are to reduce high-risk behaviors, increase access to medical care, and improve adherence to HIV antiretroviral medication regimens among HIV-positive IDUs.
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References
1 National Institute on Drug Abuse (NIDA). HIV/AIDS: How Does Drug Abuse Impact the HIV/AIDS Epidemic? Research Report Series. Bethesda, MD: NIDA; 2005. Available at: www.nida.nih.gov/PDF/
RRhiv.pdf.
2 Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report. 2004;16:12. Table 3.
3 CDC. HIV/AIDS Surveillance Report. 2004;16: 21. Table 11.
4 CDC. HIV/AIDS Surveillance Report. 2004;16:16. Table 7.
5 Substance Abuse and Mental Health Services Administration (SAMHSA). Illicit drug use. In: SAMHSA. Results From the 2004 National Survey on Drug Use and Health: National Findings (DHHS Publication No. SMA 05-4062). Rockville, MD: SAMHSA; 2005. Available at: www.oas.samhsa.gov/NSDUH/
2k4NSDUH/2k4results/
2k4results.htm#ch2. Accessed December 21, 2005.
6 Kalichman SC. The other side of the healthy relationships intervention: mental health outcomes and correlates of sexual risk behavior change. AIDS EducPrev. 2005;17(suppl A):66-75.
7 Simoni J, et al. Triangle of risk: urban American Indian women’s sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS Behav. 2004;8(1): 33-45.
8 Weiser SD, et al. The HIV epidemic among individuals with mental illness in the United States. Curr HIV/AIDS Rep. 2004;1: 186-92.
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