AIDS and Behavior An Integrated Approach (1994) / Chapter Skim
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2 UNDERSTANDING HIV TRANSMISSION
2 UNDERSTANDING HIV TRANSMISSION
Pages 47-77
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From page 47... ...
Yet, in orcler to clevelop effective prevention and treatment strategies, it is crucial to understand the specific behaviors involved. A review of knowIedge gained to date from biological, epidemiological, psychological, and social research on HIV transmission much of it supported by NIAAA, NIDA, and NIMH-has helped to elucidate relevant behaviors.
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From page 48... ...
In major studies of prevalent HIV infection among gay men, receptive anal intercourse has been the primary mode of transmission when researchers controlled for other risk factors, including number of sex partners {Winkelstein et al., 1987~. Similarly, receptive anal intercourse has been shown to be the primary mode of transmission of HIV among gay men in cohort studies in which seroconversion has been analyzed during follow-up {Kingsley et al., 1987; Winkelstein et al., 1989~.
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From page 49... ...
However, alcohol and other mood-altering drugs popular among a broader range of people may be just as likely to influence highrisk sexual behaviors, although the evidence of this is mixed jBolton et al., 1992; Leigh and Stall, 1993J. The biological variables that determine HIV infectivity ithe tendency to spread from host to hostJ and susceptibility The tendency for a host to become infected are incompletely understood.
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From page 50... ...
Important findings in this regard came from the California Partners' Study, an investigation that surveyed the opposite-sex partners of individuals infected with HIV or diagnosed with AIDS {Padian et al., 1990J. Of 150 female partners of infected men recruited for the study during the second half of the 1980s, 48 percent were partners of bisexual men, 15 percent were partners of injection drug users, 23 percent were partners of hemophiliacs, 5 percent were partners of men infected
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From page 51... ...
One of the more comprehensive studies of heterosexual transmission to examine the full range of risk behaviors was concluctecl by the Italian Study Group on HIV Heterosexual Transmission (Lazzarin et al., 1991~. The sample included 368 women whose only potential exposure to HIV was having a male sex partner who was HIV positive, and 27.7 percent of these women were seropositive.
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From page 52... ...
Several explanations have been offered for the differences in female-to-male transmission rates between the United States and certain countries in Africa. A number of researchers have suggested that the documentation of infrequent heterosexual transmission from women to men in this country may be a function of the history of the epidemic, since the initial phase was largely confined to men who have sex with men and injection drug users, so that during that time the number of infected women was low, and the possibility of female-to-male transmission was small.
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From page 53... ...
HIV RISK AND INJECTION DRUG USE The sharing of hypodermic needles, syringes, and other injection paraphernalia is the most likely route of HIV transmission among intravenous and other injection drug users. When the blood of the previous user is lodged in the needle, the syringe, or some other part of the works {drug paraphernalia)
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From page 54... ...
The user then repeats this process with a larger amount of the drug until all of the drug is mixed with blood and injected and no cocaine is left in the syringe {Ouellet et al., l991J. Although most injection drug users are generally aware of the risks associated with booting, jacking, and needle sharing, they may be less aware of risks associated with other aspects of the injection process.
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From page 55... ...
Backloading has been found to be a risk factor for HIV transmission among injection drug users in New York City {Iose et al., 1993J. Frontioading seems to be the preferred mixing/ sharing method; backloading is substituted when syringes with detachable needles are unavailable.
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From page 56... ...
. Shooting galleries occupy a functional niche in the world of injection drug use, where for a fee of two or three dollars users can rent an injection kit and relax while getting off.
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From page 57... ...
For many drug injectors, however, the use of shooting galleries is routine and commonplace. Moreover, there are repeated occasions in the lives of all injection drug users, including the most hygienically fastidious, when galleries become necessary.
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From page 58... ...
By contrast, 20 percent of the needle and syringe combinations containing visible blood were found to be HIV positive. This study indicated a clearly significant relationship between the appearance of a needle and syringe and the presence of HIV antibodies.
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From page 59... ...
During these cyclical binges, crack users neglect food, sleep, and basic hygiene, severely compromising their physical health. In a~ldition, mouth ulcerations and burned lips and tongues from the hot stems of the pipes are not uncommon, and many smokers have reported and have been observed to have untreated STDs {Inciardi, Tims, and Fletcher, 1993; McCoy and Miles, 1992; Ratner, 1993~.
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From page 60... ...
The association between crack use and apparent excessive sexual behavior has been evident in numerous ethnographic analyses of the crack scene {Ratner, 1993J. Indeed, the tendency of crack users to engage in high-frequency sex with numerous, anonymous partners is a feature of crack dependence and crack house life in many locales {Bourgois, 1989; Hamid, 1990; Inciardi, 1992, 1993; Treaster, 1991; Williams, 1992~.
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From page 61... ...
including sexual behavior. ~, ~ ~, ~, The d~isinhibiting effect of cocaine is markedly stronger than that of depressants such as alcohol, Valium, or heroin.
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From page 62... ...
However, one of the difficulties in assessing the nature of HIV risks associated with crack use remained the fact that most crack users engage in multiple risk behaviors. A stucly of risk factors for HIV infection was conducted at an STD clinic in an area of New York City where the cumulative incidence of AIDS among adults through mic3-1990 was 9.1 per 1,000 population and where the use of illicit drugs, including crack smoking, was common (Chiasson et al., 1991)
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From page 63... ...
Crack use was significantly related to both traditional AIDS risk behaviors {injecting drugs ant! having sex with an injection drug userJ and other unsafe sexual behaviors {exchanging sex for money or drugs and having casual sex partnersJ.
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From page 64... ...
In a recent stucly of HIV seroprevalence rates among heterosexual alcoholics in treatment, researchers in San Francisco found that, after controlling for injection drug use, the rate of HIV infection was 3 percent in men and 4 percent in women {it was 5 percent overall, including injection drug users)
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From page 65... ...
For all markers, there is no claim that such characteristics cause risky sexual behaviors, only that the correlation is useful in designing public health and information efforts {Leigh and Stall, 1993; Stall and Leigh, 1994~. Because HIV infection is transmitted by intimate acts, the epidemic spread of the virus through social and sexual networks has illuminated the personal connections that link the disparate parts of the world together.
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From page 66... ...
However, this stereotype has been challenged as the list of groups at risk for contracting HIV has expanded to include injection drug users, their sexual partners, infants born to mothers infected with HIV and, in very rare cases, those exposed to blood or blood products by occupational activities or transfusion.
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From page 67... ...
There was a larger proportion of cases attributable to heterosexual transmission in the second 100,000 than there was in the first 100,000. The proportion of cases among African American and Hispanics/Latinos increased from 42 percent to 48 percent of cases.
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From page 68... ...
AIDS also spread within the commuting field of each of the affected cities, extending outward from local epicenters {spatial contagions. Within a particular area, AIDS has been transmitted within the social and sexual networks of infected people isocial diffusions.
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From page 69... ...
These seroprevalence studies demonstrate that HIV infection spread rapidly through the large, tightly knit, geographically concentrated networks of gay men and injection drug users that occurred in certain cities. The San Francisco Cohort, a study that began in the 1970s as a study of the hepatitis vaccine, was able to document retrospectively that substantial spread of HIV had transpired before the first cases were officially recognized in 1981.
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From page 70... ...
In fact, rates of risk behavior may provide a more accurate window to the future than that offered by AIDS case rates or HIV seroprevalence. With respect to injection drug users, numerous HIV seroprevalence studies have been conducted in many cities around the world, and have generated prevalence estimates ranging from 0 percent to greater than 50 percent of the relevant populations.
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From page 71... ...
Among injection drug users, in particular, it is also critical to develop effective epidemiologic surveillance mechanisms for iclentifying new drug injectors within populations, to be able to track trends in drug injection over time. Due in part to difficulties in identifying and gaining access to the population groups initiating or relapsing into drug injection, most of the HIV epidemiologic studies among drug users to date have focused on long-term, chronic injectors.
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From page 72... ...
Only very recently has the seriously mentally ill population been considered a group of people at risk of contracting or transmitting HIV, even though it is generally assumed that cognitive impairments, problems in judgment, affective instability, and impulsivity increase the likelihood that people will engage in unsafe sexual behavior and drug use (Brady and Carmen, 1990~. Indeed, comorbidity of substance abuse and psychiatric illness has been recognized for quite some time (Cournos et al., 1991)
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From page 73... ...
Moreover, substance abuse often is a cofactor in risky sexual behavior among the mentally ill (as well as other populations)
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From page 74... ...
For example, sharing of drug injection equipment is concentrated among those who use illicit drugs, particularly heroin, cocaine, and amphetamines. Because of the illegal nature of drug use, drug users are forced to live in hidden subcultures, mostly located in poor communities in urban centers (Drucker, l991J.
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From page 75... ...
Social settings and networks are also implicated in efforts to reduce HIV risk. In a recent study of injection drug users in Brooklyn, consistent condom use was shown to be a characteristic of social relationships rather than an individual attribute "Friedman et al., 1994~.
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From page 76... ...
2.3 The committee recommends that NIAAA, NIDA, and NIMH develop studies of the high-risk settings, such as shooting galleries and crack houses, that may contribute to epidemic spread and implement prevention efforts in those settings. 2.4 The committee recommends that NIAAA, NIDA, and NIMH support research that integrates basic biological, epi
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From page 77... ...
Such research should be conducted in a range of geographic locations. 2.6 The committee recommends that the Public Health Service coordinate interagency efforts to monitor and respond to concurrent epidemics {such as drug use, violence, and infectious diseases)
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