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Recreational Drug Use & HIV

Drug use continues to have a major impact on the global HIV/AIDS pandemic. HIV is transmitted very efficiently through blood transfer, making needle sharing among injecting drug users (IDUs) extremely risky. But it is not only IDUs who are at higher risk of HIV exposure: although non-IDUs are overlooked by most harm reduction strategies, research indicates that crack-cocaine, alcohol and many other drugs lower inhibition and increase sexual desire, leading to ‘high risk’ behaviour such as unprotected sex.

Global overview of recreational drug use and HIV

There are many types of recreational drug available and the popularity of each varies around the world, as does the popularity of injecting. Many people who use non-injected drugs are also at high risk of exposure to HIV, not through the use of the drugs themselves but through unsafe sexual behaviour.

It is estimated that around 200 million people (4.9% of all adults) use illicit drugs at least once per year. The most popular drug is cannabis, followed by amphetamines, cocaine and opiates. Some 110 million people use illicit drugs at least once a month, and 25 million (0.6% of adults) more than once a month. ¹ The 25 million people who use illegal drugs frequently are usually known as “problem” drug users.

Roughly one tenth of new HIV infections result from needle sharing. ² It is estimated that there are 13.2 million IDUs worldwide, with around 80% living in developing and transitional countries. ³ This breaks down to an estimated:

• 8.8 million in Eastern and Central Europe, South and South-East Asia
• 1.4 million in North America
• 1 million in Latin America

In some countries, needle sharing is the dominant route of HIV transmission. In Russia, for example, 80% of HIV positive people were infected in this way. ⁴ Sharing needles and other injection paraphernalia is a highly efficient way of spreading blood-borne viruses such as HIV and hepatitis quickly among drug injecting communities, as discussed in our injecting drug use page.

Sex, drugs and HIV

Recreational drug use and its effects on sexual behaviour

Some recreational drugs act as sexual stimulants, lowering inhibition and increasing sexual drive. ^{5 6} This often leads to risky sexual behaviour and increased likelihood of HIV infection.

Methamphetamine (also known as ‘speed’ or ‘crystal’) releases dopamine into the brain, which can heighten arousal and enhance and prolong often-unprotected sexual encounters. Cocaine is used to increase sexual stamina and to counteract erectile dysfunction caused by regular use of other recreational drugs. Some gay men frequently use poppers (amyl nitrate) before receptive anal sex to relax the anal sphincter. ⁷ A series of studies on the use of methamphetamines and poppers among gay men found that users of these popular party drugs were twice as likely to become infected with HIV through unprotected sex. ^{8 9}

Speed can be dehydrating, which may make men and women more prone to tears in the anus, vagina or mouth, and therefore more prone to becoming infected when exposed to HIV during sex. ¹⁰

Crack use and HIV

An underestimated route of HIV transmission is the use of cocaine, particularly crack-cocaine. Around 13.4 million people use cocaine worldwide, nearly half of whom live in North America. ¹¹ Although HIV prevalence among crack cocaine users is lower than among IDUs, studies are now revealing that infection rates are on the rise. ¹²

Some crack smokers suffer from burns, blisters and cuts on the lips and inside the mouth caused by the intense heat from the vaporising smoke being conducted through poorly constructed smoking devices. Blood from these wounds can contaminate the ‘stem’ - usually a small metal pipe - and be passed along to the next smoker. If two smokers both have open sores then there is a risk of HIV or hepatitis C transmission. Oral sex may also be risky for heavy crack-cocaine smokers who have open oral sores due to the potential for blood transfer through frequent fellatio. ¹³

A study in Canada found that 37% of 550 enrolled drug users reported sharing smoking equipment every time they took the drug. ¹⁴ The programme supplied clean crack-smoking apparatus for 12 months and sharing fell to 13%. This study emphasised the need for better harm reduction strategies as more evidence reveals the extent of this overlooked route of HIV transmission.

Alcohol

Another recreational drug that presents a major, and often overlooked, challenge to HIV prevention is alcohol. Excessive alcohol use, know as ‘binge’ drinking, is a big problem in many countries; getting drunk has gained a cultural and social importance, especially among young people. ¹⁵ Like many other recreational drugs, alcohol lowers inhibition and has a moderate affect on sexual drive, although it can also make drinkers unable to perform sex.

“Nobody really pays attention to the fact that alcohol really has a higher odds ratio for being a risk factor for transmission of HIV” ¹⁶ - Dr. Kevin Fenton of the U.S. Centers for Disease Control and Prevention

It has been found that alcohol affects judgement and increases the likelihood of reckless sexual behaviour. ¹⁷ Yet because alcohol is legal in most countries, it is often overlooked as a factor in the transmission of HIV and other sexually transmitted diseases.

Injecting drug use

Transmission through injection drug use accounts for just less than one third of new HIV infections outside sub-Saharan Africa. ¹⁸ Needle sharing carries a very high risk of transmitting HIV from an infected user to an uninfected user. In much of Eastern Europe, Asia, the Middle East and the Southern cone of Latin America, the sharing of injecting equipment is the primary route of HIV transmission. ¹⁹

More information on injecting drug use be can be found on our HIV & injecting drug use page.

Recreational drug use and the immune system

Scientific research is beginning to suggest that use of non-injected recreational drugs, such as alcohol or methamphetamine, may affect the immune system and hasten disease progression in people infected with HIV. A study involving monkeys infected with Simian Immunodeficiency Virus (SIV) found that consuming large amounts of alcohol (‘binge’ drinking) was associated with a weaker immune system and higher levels of virus. ²⁰ Among humans living with HIV and not receiving treatment, heavy drinkers have been found to have lower concentrations of CD4 immune cells. ²¹

A study into methamphetamine use found that the addictive party drug “increases production of a docking protein that promotes the spread of the HIV-1 virus in infected users.” ²²

ARV treatment for drug users

Recreational drug users face many problems with antiretroviral (ARV) treatment, mainly in two areas: access to ARVs, and drug interactions between ARVs and recreational drugs.

Access to anti-HIV treatment for drug users is surrounded by controversy and stigma in most parts of the world, with many governments favouring policies that require absolute abstinence from illegal drug use before ARV treatment is provided. Many physicians believe that drug users cannot properly adhere to anti-HIV treatment, and will thus develop resistance to the medication. Indeed, there is evidence that current users of heroin and cocaine/crack are less likely to do well on ARVs, for various reasons including delayed access to treatment and interruptions to medical care, as well as lower adherence.²³ However, studies have also found that former heroin users are just as likely to achieve good outcomes as people who have never used heroin.²⁴

Although around 10% of all HIV infections are a direct result of transmission through sharing needles, many of these drug users are unable to access anti-HIV treatment. ²⁵ Data collected from 46 low- and middle-income countries found that only 36,000 former or current IDUs were receiving ARV treatment at the end of 2004, most of whom lived in Brazil. ²⁶ In Eastern Europe and Central Asia, IDUs account for more than 70 percent of HIV cases but represent only 24 percent of people receiving antiretroviral treatment. ²⁷

In countries that have little or no harm reduction services, outreach work is minimal so many drug users do not get the opportunity to get treatment or make contact with health officials.

The second problem that drug users face is the interactions between recreational drugs and antiretroviral drugs. The health risks associated with recreational drugs such as heroin or MDMA (ecstasy) are widely known, but the risks of taking recreational drugs whilst on ARVs are unclear. There has been limited clinical research carried out on potential drug interactions, mainly because laboratories are not prepared to test illegal drugs. The information that does exist on drug interactions is largely based on predictions rather than actual tests, or extrapolated from tests in the laboratory. ²⁸

Most drugs are metabolised by the liver and it is here that adverse reactions usually occur. The critical factor is often the effect that the drug has on the efficiency of the liver’s enzyme system.

Some recreational drugs act as ‘inducers’, increasing the activity of liver enzymes and making the liver work faster. When an ARV drug is metabolised faster than normal, the ARV’s HIV suppressing effects will be exhausted sooner than intended, leading to periods when HIV is not under control, and increasing the likelihood of drug resistance.

Other recreational drugs that have the opposite effect on the liver; known as ‘inhibitors’, they slow down the rate at which the liver metabolises. This means that an ARV drug cannot be broken down fast enough, which again can lead to periods when more HIV replication can occur.

Antiretroviral drugs can also act as inducers or inhibitors, or sometimes both. This makes it difficult to predict interactions between ARVs and recreational drugs, and to maintain the correct level of medicine in the body. ²⁹

A more immediate risk with complex drug interactions is the presence of toxins that remain unprocessed. Alongside the kidneys (which are also affected by drug use), the liver works to filter out toxins. If the liver metabolises more slowly then there is a greater chance of drug toxicity. This is especially dangerous with recreational drugs, which because of their illegal nature contain unknown and varying quantities of toxins. Recreational drugs are often impure, meaning they are cut or padded out with other substances that may interact with ARVs or other drugs. ^{30 31} These toxins can potentially poison the drug user, and in some cases result in death.

What needs to happen?

Generally when there is discussion of HIV and drug use, there is a focus on injecting and harm reduction. Although this continues to be very important, and there is a need for continued progress on injecting drug use and harm reduction, there is also a need for non-injecting drug use to be much more widely considered. This is particularly because of its association with unsafe sex and the sexual transmission of HIV.

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• The global AIDS epidemic
• HIV prevention, harm reduction and injecting drug users
• AIDS and prostitution
• Global HIV/AIDS statistics