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AIDS may not be front-page news anymore, but it is still considered an epidemic. Since the first case was identified in 1981, according to the Centers for Disease Control and Prevention (CDC), close to 800,000 AIDS cases have been reported in the United States, approximately 450,000 Americans have died, and at least 40,000 new infections occur each year. More than one third of AIDS cases reported to the CDC are directly associated with injection drug use. A little-known link between injection drug use and heterosexual transmission of the virus that causes AIDS (human immunodeficiency virus or HIV) may be alcohol consumption. A study in the October issue of Alcoholism: Clinical & Experimental Research examines what role alcohol consumption may play among drug injectors who have unsafe sex.
"The average person has become complacent about AIDS," said Michael D. Stein, associate professor of medicine at Brown University School of Medicine and lead author of the paper. "In fact, certain groups impacted by the epidemic, such as gay men in certain cities, have clearly become complacent. Risk behavior surveillance studies suggest these groups have recently increased their risk. Among another at-risk group, injection drug users, alcohol may not be considered an ?important' drug, or even a drug at all, yet it is likely to reduce certain inhibitions and lead to unsafe sex." Indeed, most reported cases of heterosexual transmission of HIV occur through unprotected sexual contact with injection drug users (IDUs).
The ?drugs of choice' among the 1.2 million IDUs in the U.S. are heroin and cocaine. Previous studies have shown that IDUs frequently have multiple sex partners, give money or drugs for sex, and infrequently use condoms. Less is known about their drinking behavior. Stein and his colleagues interviewed a "high-risk group" of IDUs ? individuals not receiving formal substance abuse treatment ?recruited from a syringe exchange program (SEP) in Providence, Rhode Island. SEPs were created to reduce HIV transmission primarily by encouraging IDUs to use only sterile injection equipment. More than 100 SEPs currently operate in the United States.
"We found that among active injectors," said Stein, "alcohol consumption is associated with unsafe sex." Of the total days analyzed (5610), 1054 (18.8%) were considered days of unprotected sexual contact. On 549 (52%) of these days, drinking also occurred. These findings indicate that drinking days were 1.76 times more likely to involve risky sexual behavior than days on which alcohol was not consumed. In other words, drinking appears to be one of several risky behaviors engaged in by IDUs.
"Many, many people have pointed out over the past 20 years that without a cure or vaccine for AIDS," said Ron Stall, chief of the Behavioral Interventions Research Branch at the CDC, "the only way of protecting ourselves and our country is through prevention. Fewer people have remarked upon the fact that prevention works. One of the necessary conditions for HIV prevention to work, however, is for rigorous data to be collected regarding the conditions under which risk-taking behaviors occur." Which means that even though it seems intuitive that people who drink may have risky sex ? research data needs to support this association before preventive measures can be developed.
"One of the challenges in HIV prevention," Stall continued, "has to do with the way that risk categorizations are used. If someone is identified as an intravenous drug user, then many people think only of modifying their drug use patterns so that HIV infection will not be transmitted. However, people are not always completely described by single risk categories. This study's data show that several health challenges exist among intravenous drug users. These include addiction (along with other probable mental health problems), intravenous drug use, heavy alcohol consumption, and sexual risk-taking, among other possible problems. Two of these health problems ? intravenous drug use and high-risk sex ? are transmitters of not only HIV infection, but also other dangerous viral and bacterial STD infections. If we are to prevent the spread of HIV infection among populations that have some level of intravenous drug use, we will have to find ways to promote safe sex among intravenous drug users and their sexual partners."
In addition to the finding that alcohol seems to contribute to IDUs engaging in risky sex, Stein noted another reason for concern. "Because so many drug injectors carry the hepatitis C virus," he said, "and alcohol worsens the disease course of hepatitis C, attention to alcohol is particularly important for injectors." Yet little attention is currently paid to alcohol use or disorders among drug injectors who are in medical or drug-treatment settings, he noted.
"[This situation needs to change dramatically,]" he said. "Given the high rates of alcohol abuse and dependence in this sample, referrals to alcohol treatment should be available at needle exchanges. Health care providers need to pay attention to alcohol use when they are addressing the complications of drug use, as well as the behaviors of drug users."
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