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Injecting Drug Users and HIV/AIDS
Millions of people worldwide are injecting drug users (IDUs), and blood transfer through the sharing of drug taking equipment, particularly infected needles, carries a high risk of transmitting HIV. Around 30 percent of global HIV infections outside of sub-Saharan Africa are caused by the use of injecting drugs, and it accounts for an ever growing proportion of those living with the virus.1
The illegal nature of injection drug use can also create barriers to accessing adequate treatment and prevention services making IDUs more vulnerable to HIV and its effects. Without adequate access to HIV testing and prevention services, there is a high risk that HIV will also be transmitted to the sexual partners of people who inject drugs. The crossover of drug use with sex work further means that HIV is likely to be transmitted to other at risk populations and their partners.
Why do people take drugs?
People take drugs, both legal and illegal, for a variety of reasons that will differ from person to person and from drug to drug. Individuals may enjoy the sense of detachment or euphoria that drugs create, their relaxing or energy-inducing properties, the heightened alertness or sensitivity they produce, and their medicinal qualities. Peer pressure or habit may be other reasons, and if they are chemically dependent, addicts will feel they cannot operate without them. These reasons will depend on an individual’s own background and socio-economic circumstances.
Drugs can be taken in a variety of ways including drinking, smoking, snorting and rubbing, but it is the injection of drugs that creates the biggest risk of HIV transmission.
What is injected?
The most commonly injected drugs are heroin and other opiates, cocaine and amphetamines, and the prevalence of each is likely to vary according to location and population group. In Western European nations, heroin is the most commonly injected drug amongst older users, whilst amphetamine-type stimulants (ATS) are favoured amongst younger people. ATS are also the most commonly injected drugs in Thailand, Laos, South Korea, Cambodia and Japan, whilst across Latin America, with the exception of Mexico, cocaine is the most prevalent injected drug.2 3
Within and between North American countries usage patterns differ widely. US figures for 2002-05 show injection was a method of intake for a higher proportion of past year heroin users (42%) than for methamphetamine (9%), stimulant (5%) or cocaine users (3%). However, the percentage of the Northeast’s population, as a whole, who had injected heroin in the previous year (0.13%) is roughly similar to the percentage of people in the West who injected stimulants (0.14%).4
The Canadian AIDS Society argues heroin has been the focus of discussion when talking about injection drug use and HIV but that cocaine is the bigger problem in many cities.5 This is validated by studies of Vancouver and Montreal which find cocaine is the most widely used injecting drug.6 7 The latter study also highlights the fact that cocaine injections occur more frequently among users due to the drug’s shorter lasting effect, thereby increasing the risk of HIV transmission.
It is also important to point out another type of drugs that can be injected - image and performance enhancing drugs (IPEs). These are drugs used to change one’s image, and increase one’s level of performance. A specific study in the UK found that HIV prevalence among men who inject IPEs was similar to those who inject drugs like heroin and cocaine. This highlights that it is the injecting practice that is important to monitor, rather than the type of substance injected.8
Why are drugs injected?
There are several possible reasons as to why drugs are injected rather than taken in other forms. The UNDP HIV and Development Programme suggests these include the availability of drugs that can be injected, linked to production locations and trafficking routes; that it is a cheaper and more rapidly acting method; the sharing of knowledge about such techniques that comes from migrating drug users; and so none of the drug becomes lost in smoke, especially when drug control efforts reduce its availability.9 10
The UNDP estimates that the most common change in drug consumption patterns is the move from the smoking of opium to the injecting of heroin and other drugs as a result of law enforcement.11 Populations in developing nations have become more exposed to new methods of drug taking, including injecting, as refinement of drugs into injectable forms has been forced from more developed nations and closer to production areas.
In Pakistan, for example, the last 10 to 15 years has seen a shift from the inhalation and smoking of heroin, to the injecting of heroin and synthetic drugs. Injectors of heroin are an ever growing proportion of total heroin users rising from less than 2 percent in 1993 to 15 percent in 2000 to more than a quarter in 2007. This is largely attributed to aggessive drug control measures that have reduced supply, boosted the cost, and made injecting a more economically viable method of consumption.12
One HIV-positive IDU in Pakistan described the scarcity and growing cost of heroin as the primary reason for switching from inhaling to injecting:
"Good-quality heroin is not available in the market anymore. There is low-quality heroin available at unaffordable prices. If we inject the low-quality heroin, its effects are immediate and prolonged."
A number of factors can be associated with, though will not necessarily cause, injecting drug use. These could include an individual’s involvement in crime, family breakdown, social upheaval, poor healthcare, low income, homelessness, use of other drugs, depression, alienation or other personality traits.
It is estimated that there are around 15.9 million IDUs worldwide; 47 percent of this population are from just five countries: China, Vietnam, Malaysia, Russia and Ukraine.13 The number of IDUs by region are as follows:14 15
4.5 million in South, East, and South-East Asia
3.7 million in Russia, Eastern Europe and Central Asia
2.27 million in North America
1 million in Western Europe
300,000 - 1 million in the Middle East and North Africa
2 million in Latin America
170,000 in Oceania
1.78 million in Sub-Saharan Africa
186,000 in the Caribbean
Why do people share needles?
Many factors specific to individual IDUs and countries influence or cause needle sharing. For many users sterile syringes are not readily available and drug paraphernalia laws in some countries make it an offence to distribute or possess syringes for non-medical purposes. In Mexico, a link has been found between arrests for carrying used or unused syringes, despite this being legal, with incidences of recent syringe sharing.16 Higher rates of needle sharing among Russian IDUs have similarly been associated with arrests for drug offences.17 One IDU in the Indian state of Manipur – where police can stop and search any suspected drug user – described fear of the law as a factor in needle sharing:
“When we [inject] drugs we need to be quick. Police might come at any time. For that reason... we don’t mind sharing with others."18
A lack of awareness or education about safe injecting can also lead to needle sharing. For example, fewer than half of IDUs surveyed in Afghanistan in 2005-06, who were aware of HIV, knew that using a new needle for each injection reduces the risk of transmission.19 Other possible reasons are that it is a social and cultural norm, and that it can act as a form of bonding.
The effect of injection drug use on HIV rates
Roughly one tenth of new HIV infections result from needle sharing, with this figure rising to just under a third outside of sub-Saharan Africa.20 It is estimated that globally, around 3 million IDUs are living with HIV, however only 4 percent of these people are receiving antiretroviral treatment.21 Among the regions where injecting drug use accounts for a majority or highly significant share of HIV prevalence are:22
- Eastern Europe and Central Asia
- Russia: 83%
- Kyrgyzstan: 75%
- Kazakhstan: 73.6%
- Ukraine: 64.1%
- East and South-East Asia
- Malaysia: 72%
- Indonesia: 54%
- Vietnam: 52%
- China: 44.3%
In many other parts of Asia, the Middle East and the Southern cone of Latin America, the sharing of injecting equipment is the primary route of HIV transmission.23
Injecting drugs and marginalisation
People who inject drugs are perhaps the most marginalised group at risk of HIV infection. This is because of a number of laws which restrict IDU access to HIV services; prohibiting ARV treatment for HIV-positive IDUs, prohibiting the provision of sterile injecting equipment or the criminalisation of drug use all prevent IDUs accessing necessary services. Only 97 countries currently support some form of harm reduction approach, involving initiatives such as opioid substitution therapy (OST), needle and syringe exchange programmes (NSPs) or decriminalising drug posession.24
Injecting drugs for purposes not prescribed by a doctor is illegal worldwide, and the criminalisation of drug use and possession can hinder attempts to engage IDUs with available HIV services. There have been documented incidences of Ukrainian police arresting and beating IDUs near needle exchanges for possessing used and sterile syringes.25 Police in Thailand have reportedly acted similarly despite possession of syringes being legal in the country.26 It is estimated that 40% of countries have laws that interfere with their ability to reach injecting drug users.27
IDUs who find themselves on the wrong side of the law and in confrontation with the police may be mistrustful of the authorities in general and hesitate to seek treatment or take advantage of prevention initiatives in the first place. Following a major drug operation by Vancouver police in the Downtown Eastside district, in which there were reported cases of unnecessary force and illegal search and seizure, the number of sterile syringes provided nightly by a local needle exchange program dropped by a third.28
A report by the UNAIDS Inter-Agency Task Team on HIV and Young People found that although an estimated 70 percent of the world's drug users are under 25, and at least half in urban areas start injecting in their teens, very few programmes target young people at risk of injecting drug use.29 In particular, few reach out to vulnerable youth to prevent them from starting to inject or help them to end their addiction if they have already started. Moreover, prevention programmes do not specifically address the issues that vulnerable young people face, such as peer pressure, unstable family homes or exclusion from school. Some HIV prevention initiatives like opioid substitution may even deter young people because they require registration or parental consent.
Crack use and HIV
Though crack, which is derived from cocaine, is normally smoked, it too presents a range of risk factors related to HIV. Although prevalence among crack cocaine users is lower than among IDUs, studies are now revealing that infection rates are on the rise.30 According to the 2010 US National Survey on Drug Use and Health, 9.2 million Americans 12 years and older (3.6%) had used crack at least once in their lifetime with 871 (0.3%) having used it in the year prior to interview.31
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.32
Like many drugs crack cocaine usage can lead to risky sexual behaviour. When surveyed, crack users in Campinas, Brazil, said they were more likely to have unprotected sex than injecting cocaine users.33
Crack cocaine is also more associated with marginal and at-risk groups including those who have turned to sex work to fund their addiction. In a group of drug users in South Florida, 48% of women who smoked crack, and 54% of women who both smoked crack and injected drugs, had traded sex for money or drugs, compared with 29% who only injected. The authors of this study even argue that due to its higher prevalence in the US, “crack smoking presents a greater population risk of HIV transmission than does injection drug use”.34
Drug users and sex work
Although injecting drug users constitute a risk group in themselves, there is also an overlap between drug addiction and those involved in sex work. Individuals who fall into both categories are therefore particularly vulnerable to HIV and are perhaps doubly stigmatised. The link between substance abuse and sex work is hard to pinpoint though there are a variety of factors that are common to both including homelessness, unstable family lives, socio-economic deprivation, disrupted schooling, local authority care and confidence and esteem issues.35
One study of UK cities found 63% of people who sold sex outdoors did so mainly to pay for drugs. Heroin was the most commonly used drug, with 78% having used it, and just under half the sample had injected drugs in the previous month.36 UNAIDS believes that the spread of HIV in several North African and Middle Eastern countries is being facilitated by a combination of injecting drug use and sex work with one third of IDUs having paid for or sold sex. In Syria 53% of drug users have sold sex, with 40% of these saying they had never used condoms.37 One study of Sichuan province, China, reported similar rates, around 56%, of female IDUs who sell sex.38
IDUs who are sex workers put themselves at risk and also facilitate the transmission of HIV between population groups. Looking at the spread of HIV among the two risk groups in Jakarta, Indonesia, the Commission on AIDS in Asia found that infection levels began to increase within commercial sex networks only after the epidemic among injecting drug users had reached significant levels.39
Sexual risk behaviour related to drug use should not just be considered within the bounds of sex work. While the impact of drugs on sexual behaviour may vary by drug, length of use, sexual identity, and other factors, there are a number of effects related to drug use that could influence unsafe sexual behaviour. HIV transmission may be facilitated among drug users and their sexual partners if the user is sexually stimulated or disinhibited by drugs.
ARV treatment for drug users
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. There are questions over whether heroin and cocaine/crack users will respond to treatment as well as other patients with studies both affirming and contradicting this view.40 41
The second problem that drug users face is the interaction between recreational drugs and antiretroviral drugs. Recreational drugs can either speed up or slow activity of the liver which breaks down ARV drugs. This means the HIV suppressing effect of ARV treatment can be exhausted sooner than expected or will not work as rapidly as possible. Unknown impurities in illegal drugs may also interfere with the efficacy of the treatment.42
What needs to happen?
With injecting drug use accounting for a very significant proportion of people living with HIV, the overwhelming majority in some regions, harm reduction measures including needle exchange schemes, should be implemented widely and sufficiently. Furthermore, stigma and discrimination against drug users need to be tackled so they can access treatment and reduce the risk of being exposed to HIV. This would also lessen the chance of transmitting HIV to other population groups through the overlap with sex work and unsafe sex in general.
- 1. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 2. International Harm Reduction Association (2008), ‘Global State of Harm Reduction 2008: Mapping the response to drug-related HIV and hepatitis C epidemics’
- 3. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 4. Substance Abuse and Mental Health Services Administration (2007, 19th July), ‘Demographic and Geographic Variations in Injection Drug Use’, The NSDUH Report
- 5. Canadian AIDS Society (2007, 27th July), ‘Drug Injecting and the Spread of HIV/AIDS’, accessed 29th November 2011
- 6. Tyndall M.W. et al (2003, 19th May), ‘Intensive Injection Cocaine Use as the Primary Risk Factor in the Vancouver HIV-1 Epidemic’, AIDS 17(6)
- 7. Leri F. et al (2004, January), ‘Heroin and cocaine co-use in a group of injection drug users in Montréal’ Journal of Psychiatry & Neuroscience 29(1)
- 8. Hope. V. et al (2013) 'Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study' BMJ
- 9. Deany P. for UNDP HIV and Development Programme and UNDP Asia-Pacific Regional Programme on HIV and Development (2000, December), ‘HIV and Injecting Drug Use: A New Challenge to Sustainable Human Development’
- 10. European Monitoring Centre for Drugs and Drug Addiction (2010) 'Trends in injecting drug use in Europe'
- 11. Deany P. for UNDP HIV and Development Programme and UNDP Asia-Pacific Regional Programme on HIV and Development (2000, December), ‘HIV and Injecting Drug Use: A New Challenge to Sustainable Human Development’
- 12. Shamim, Gul, 'Twin Epidemics - Drug Use and HIV/AIDS in Pakistan' from International Harm Reduction Development Program, Open Society Institute (2009, March), 'At What Cost?: HIV and Human Rights Consequences of the Global War on Drugs'
- 13. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 14. Mathers, B.M. et al (2008, September), 'Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review', The Lancet, September 24th, 2008
- 15. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 16. Pollini R.A. et al, (2008, January), ‘Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities’, Addiction 103(1)
- 17. Rhodes T. et al (2004), ‘Injecting equipment sharing among injecting drug users in Togliatti City, Russian Federation: maximizing the protective effects of syringe distribution’, Journal of Acquired Immune Deficiency Syndromes 35(3)
- 18. Chakrapani V. Kh. Kumar Kh. J. 'Drug Control Policies and HIV Prevention Among Injection Drug Users in Imphal, India', from International Harm Reduction Development Program, Open Society Institute (2009, March), 'At What Cost?: HIV and Rights Consequences of the Global War on Drugs'
- 19. Todd C. et al (2007, 21st March) ‘Association between expatriation and HIV awareness and knowledge among injecting drug users in Kabul, Afghanistan: A cross-sectional comparison of former refugees to those remaining during conflict’, Conflict and Health 1(5)
- 20. UNAIDS (2007, May 11th), ‘Injecting drug use: focused HIV prevention works’
- 21. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 22. International Harm Reduction Development Program, Open Society Institute (2008, March) ‘Harm Reduction Developments 2008: Countries with Injection-Driven HIV Epidemics’, Figures: Eastern Europe and Central Asia as of 2007 (Russia: 2006); Indonesia and Malaysia: 2006; China and Vietnam: 2005,
- 23. World Health Organization and UNAIDS (2004), ‘HIV/AIDS prevention among injecting users’ (pdf)
- 24. IHRA (2012) 'The Global State of Harm Reduction 2012: Towards an Integrated Response'
- 25. Human Rights Watch (2006, March), ‘Rhetoric and Risk: Human Rights Abuses Impeding Ukraine’s Fight against HIV/AIDS’, Human Rights Watch 18(2(D))
- 26. Human Rights Watch (2007, March), ‘Deadly Denial: Barriers to HIV/AIDS Treatment for People Who Use Drugs in Thailand’, Human Rights Watch 19 (17(C))
- 27. UNAIDS (2008) ‘2008 Report on the global AIDS epidemic’
- 28. Human Rights Watch (2003, May), ‘Abusing the User: Police Misconduct, Harm Reduction and HIV/AIDS in Vancouver’, Human Rights Watch, 15(2)(B)),
- 29. Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team on HIV and Young People, and FHI (2010) 'Young People Most at Risk of HIV: A Meeting Report and Discussion Paper'
- 30. Collins C. L. et al (2005, September), ‘Rationale to evaluate medically supervised safer smoking facilities for non-injection illicit drug users’, Canadian Journal of Public Health 96(5)
- 31. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) (2010), '2010 National Survey on Drug Use and Health - Detailed Tables
- 32. Faruque S., et al (1996), ‘Crack cocaine smoking and oral sores in three inner-city neighbours’, Journal of Acquired Immune Deficiency Syndromes 13(1).
- 33. Azevedo R.C.S. et al (2006) ‘Crack users, sexual behavior and risk of HIV infection’
- 34. McCoy C.B. et al (2004, September), ‘Injection Drug Use and Crack Cocaine Smoking: Independent and Dual Risk Behaviors for HIV Infection’, Annals of Epidemiology 14(8)
- 35. Tiggey May and Gillian Hunter (2006), ‘Sex work and problem drug use in the UK: the links, problems and possible solutions’, in Sex Work Now, eds Rosie Campbell and Maggie O’Neill, Willan Publishing
- 36. Church S et al (2001, 3rd March), ‘Violence by clients towards female prostitutes in different work settings: questionnaire survey’, British Medical Journal 322 (7285)
- 37. UNAIDS ‘2008 Report on the global AIDS epidemic’
- 38. Choi S.Y.P., Cheung Y.W., Chen K. (2006), ‘Gender and HIV risk behaviour among intravenous drug users in Sichuan province, China’, Social Science and Medicine 62(7), cited in UNAIDS, ‘2008 Report on the global AIDS epidemic’
- 39. Commission on AIDS in Asia (2008, March), ‘Redefining AIDS in Asia: Crafting an Effective Response’
- 40. Lert F. and Kazatchkine M.D. (2007, August), ‘Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview’, International Journal of Drug Policy 18(4)
- 41. Cofrancesco J. et al (2008, 30th January), ‘Illicit drug use and HIV treatment outcomes in a US cohort’, AIDS 22(3)
- 42. AETC (2006, July), ‘Recreational Drugs and Antiretroviral Therapy’, Clinical Manual For Management Of The HIV-Infected Adult, AIDS Education and Training Center