RiskRisk ReductionReduction StrategiesStrategies ManualManual
A Healthcare Provider’s Guide to Reducing HIV Transmission Risk University of Connecticut Center for Health, Intervention, and Prevention Among PLWHA
OPTIONS RISK REDUCTION STRATEGIES MANUAL A Healthcare Provider’s Guide to Reducing HIV Transmission Risk Among PLWHA
Content Developed for New York State Department of Health AIDS Institute by Center for Health, Intervention, and Prevention (CHIP) University of Connecticut
Content Developed and Written by: Stacy Cruess, Ph.D. Deborah Cornman, Ph.D. K. Rivet Amico, Ph.D. Sarah Christie, M.P.H. Lindsay Shepherd, B.S. Roberta Glaros, M.A. NYS Department of Health AIDS Institute
For information on Options, contact: Deborah H. Cornman, Ph.D., Associate Director Center for Health, Intervention, and Prevention (CHIP) 2006 Hillside Road, Unit 1248 University of Connecticut Storrs, CT 06269–1248 Phone: 860–486–4645 Fax: 860–486–4876 E-mail: [email protected]
Welfare Research, Inc. (WRI) provided editorial and design assistance. © 2007 University of Connecticut. All rights reserved. Funding provided by New York State Department of Health AIDS Institute and Centers for Disease Control (CDC). II Contents
How to Use the Risk Reduction Strategies Manual...... VI
CHAPTER 1. Introduction...... 1
CHAPTER 2. Quick Reference Guide to HIV Risk Reduction Strategies...... 13
CHAPTER 3. Predictors of HIV Risk Behavior...... 19
CHAPTER 4. Assisting Patients with HIV Disclosure...... 29
CHAPTER 5. Sexual Transmission of HIV...... 45
CHAPTER 6. Sexual Behaviors, Relative Risk, and Safer Alternatives...... 55
CHAPTER 7. Identifying Risk Triggers for Safer Sex and Drug Use Lapses...... 71
CHAPTER 8. Safer Sex Communication Skills...... 79
CHAPTER 9. Condoms and Lubricants...... 89
III Contents (cont’d)
CHAPTER 10. Strategies for Dealing with Negative Attitudes About Condoms..... 101
CHAPTER 11. Other Barrier Methods: Oral Barriers, Cots, and Gloves...... 109
CHAPTER 12. Microbicides...... 113
CHAPTER 13. Commonly Abused Drugs and Effective Risk Reduction Strategies..... 119
CHAPTER 14. HIV and Injection Drug Use...... 131
CHAPTER 15. New York State Resources for Healthcare Providers...... 147
CHAPTER 16. Internet Resources for Healthcare Providers...... 155
APPENDICES...... 161
The goal of the Options intervention is to frame the healthcare provider and patient as a team. The Options Risk Reduction Strategies Manual and accompanying patient handouts are tools to support both the provider and the patient.
IV Appendices
A. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV (Centers for Disease Control and Prevention)
B. HIV and its Transmission (Centers for Disease Control and Prevention)
C. What you Should Know About Oral Sex (Centers for Disease Control and Prevention)
D. Female Condom FAQ (Female Health Company)
E. What is FC Female Condom? (Female Health Company)
F. What is FC2 Female Condom? (Female Health Company)
G. FAQ about Microbicides (Global Campaign for Microbicides)
H. Drug Fact Sheets (Office of National Drug Control Policy and New York State Department of Health AIDS Institute)
I. Drug-Associated HIV Transmission Continues in the U.S. (Centers for Disease Control and Prevention)
J. Viral Hepatitis and Injection Drug Users (Centers for Disease Control and Prevention)
K. Coinfection with HIV and Hepatitis C Virus (Centers for Disease Control and Prevention)
L. Syringe Disinfection for Injection Drug Users (Centers for Disease Control and Prevention)
M. Physician Prescription of Sterile Syringes to Injection Drug Users (Centers for Disease Control and Prevention)
N. Syringe Exchange Programs (Centers for Disease Control and Prevention)
How to Use the Risk Reduction Strategies Manual
he Options Risk Reduction Strategies Manual is a reference tool and is divided into chapters based on the type of risk reduction information T presented, such as safer sex and drug use strategies, HIV transmission information, and communication skills.
Providers can take several steps to use the Options Risk Reduction Strategies Manual as a tool when working with their HIV-positive patients: 1. Become familiar with the manual before implementing the Options intervention with patients. Healthcare providers who plan to use the Options intervention with their HIV-positive patients should review this manual before implementing the intervention to become familiar with the information, motivation, and skills development material that may be relevant for their patients. 2. Refer to the manual as needed when working with patients to reduce their risk behaviors. The Options intervention can help the providers uncover barriers to safer sex and drug use behavior when working with a patient. Once specific barriers have been identified, providers can then refer to the appropriate section(s) of this manual as a reference tool to help them most effectively work with the patient to address those barriers.
— For example, if during an Options intervention session a provider discovers that the patient often has unprotected sex because he doesn’t like to wear condoms, the provider can refer to Chapter 10, Strategies for Dealing with Negative Attitudes about Condoms, for suggestions on how to help the patient be more open to using condoms. 3. Use relevant patient handouts to reinforce information provided during meetings with patients.
VI Target Risk Behaviors for Interventions—Sexual Risk The majority of research conducted to date on prevalence of sexual risk behaviors among individuals living with HIV has been with men who have sex with men (MSM).
Research suggests that although many HIV-positive MSM attempt to make some behavioral changes to reduce the risk of transmitting HIV, a significant number continue to engage in at least some forms of risky sexual behavior after a diagnosis of HIV.
• In a study of recently diagnosed HIV+ MSM, although men appeared to make efforts to reduce transmission risks after diagnosis, many continued to engage in some risky behaviors. For example, unprotected anal intercourse with unknown status or one-time partners was less frequent after diagnosis, but rates of unprotected anal intercourse with last sex partner did not change.4
• In a study of more than 1,000 HIV+ MSM in New York City and San Francisco, 47.3% reported engaging in unprotected anal sex during the past 3 months with an HIV-negative or status unknown non-main partner, while 21.3% reported unprotected anal sex with HIV-negative and status unknown main partners (see Table 1). 5
VII VIII Chapter 1
Introduction
Overview he Options Risk Reduction Strategies Manual is a supplement to the Options Intervention Protocol Manual and is intended for physicians and Tother healthcare providers who work with HIV-positive patients. This manual is a resource for information and risk reduction strategies that providers can use to help patients reduce their HIV transmission risk behaviors. It presents information on HIV risk reduction in a practical and nonjudgmental way to help providers effectively incorporate prevention counseling into clinical care with their HIV-positive patients.
Rationale for Prevention in the HIV Clinical Setting Although HIV prevention efforts have historically focused on “at-risk” populations (i.e., uninfected individuals at-risk for acquiring HIV due to risky sex or drug use behaviors), recently the focus of prevention has broadened to include individuals already infected with the virus. While many HIV-positive individuals attempt to practice safer behaviors to protect themselves and their partners, they may find it difficult to maintain the behavioral changes. In addition, efforts at reducing HIV transmission risks may be inconsistent. Helping HIV-positive patients reduce sexual and drug use risk behaviors and maintain behavior changes has significant implications for three main reasons: 1. Reducing the Risk of HIV Transmission to Uninfected Partners HIV-infected individuals represent a source from which future infections may be generated. If HIV-positive individuals continue to practice unprotected sex, they put their uninfected partners at risk for acquiring HIV. In addition, even if they engage in unprotected sex with other known HIV-positive individuals, they and their partners are at risk for acquisition of other STIs and HIV dual infection (see next page).
2. Reducing the Risk of STI Acquisition HIV-infected individuals who engage in unprotected sex put themselves at risk of acquiring other sexually transmitted infections (STIs) that may accelerate their HIV disease progression. 3. Reducing the Risk of HIV Dual Infection Dual infection occurs when an HIV-positive individual is infected with two different strains of HIV from different sources; it can be due to coinfection or superinfection. The frequency of HIV dual infection has not been well-documented: most of the available information is from a handful of case reports, though coinfection appears to be more common than superinfection.1 The clinical consequences of HIV dual infection have not been well documented in longitudinal studies, but clinical observations suggest dual infection is associated with faster disease progression (including decreased CD4 count and increased viral load) as well as drug resistance and complications in antiretroviral therapy.1 Individuals also put themselves at risk for acquiring a drug-resistant strain of HIV.
Coinfection occurs when an individual is infected “with two heterologous strains either simultaneously or within a brief period of time before infection with the first strain has been established and an immune response has developed.” 1
Superinfection occurs when an individual is infected “with a second strain after the initial infection and the immune response to it has been established.” 1
Support for Prevention in the Clinical Care Setting Prevention interventions for people living with HIV/AIDS have been shown to be effective at decreasing HIV transmission risk behaviors and sexually transmitted infection rates.2 Specific characteristics of interventions that have been found to reduce rates of unprotected sexual behaviors2 include many of the elements of the Options intervention:
CHAPTER 1 Guided by behavioral theory. Specifically focused on HIV transmission behaviors. Provides skills building. Delivered one-on-one, by healthcare providers, and in the clinical care setting.
Recent recommendations from the CDC and other agencies3 (Appendix A) reinforce the need for prevention interventions for people living with HIV/ AIDS and support the routine incorporation of prevention interventions into existing clinical practice as an emerging standard of care.
Recommendations for Prevention in the Clinical Care Setting According to recent recommendations from the CDC and others,3 clinicians providing care to people with HIV/AIDS are uniquely positioned to play a “key role in helping their patients reduce risk behaviors and maintain safer practices, and can do so with a feasible level of effort, even in constrained practice settings.”
Key Components of Recommended Prevention Interventions Recommended clinician-delivered prevention interventions that can be incorporated into routine office visits include:3 Performing a brief screening for HIV transmission risk behaviors. Communicating prevention messages. Discussing sexual and drug use behavior. Positively reinforcing changes to safer behavior. Referring patients for services such as substance abuse treatment. Facilitating partner notification, counseling, and testing. Identifying and treating other STDs.
Furthermore, other clinic staff (e.g., nurses, social workers, health educators) can reinforce the prevention messages and interventions delivered by physicians.
The Importance of Referrals HIV providers are uniquely positioned to assist patients with sexual and drug- use risk reduction. However, it is critical that providers be aware of and use the resources within their care organization and community to support both themselves and their patients.
CHAPTER 1 Providers should have a referral guide of available local resources, including:
Substance abuse treatment Mental health services Syringe exchange programs & locations to purchase clean needles Domestic violence services Case management services (if not offered through the medical care clinic) Nutrition counseling Reproductive medicine specialists Individual or group HIV prevention interventions (e.g., Healthy Relationships)
CHAPTER 1 Topics that can be successfully addressed by clinicians and clinic support staff: • Lack of knowledge about HIV transmission risks • Misconceptions about risk of specific types of sexual and drug-use practices • Misconceptions about viral load and transmission of HIV • How to disclose HIV-seropositive status to a sex partner, family member, or friend • Importance of using condoms or not exchanging fluids with partners • Ways to reduce number of sex or drug partners • Ways to keep condoms accessible • Ways to remember to use condoms • How to persuade a sex partner to use a condom • Ways to obtain support (e.g., emotional, financial) from family, friends, and lovers • Ways to clean/disinfect injection equipment • Ways to obtain clean needles • Ways to avoid sharing injection equipment • Ways to deal with mild psychological distress stemming from situational circumstances
Issues that might need referral to outside agencies • Need for intensive HIV prevention intervention • Excessive use of alcohol or recreational drug use • Drug addiction, including injection drug use • Depression, anger, guilt, fear, or other mental health needs • Need for social support • Sexual compulsivity • Sexual or physical abuse (victim or perpetrator) • Desire to have children, contraceptive counseling • Housing or transportation needs • Nutritional needs • Financial emergencies • Child custody, parole, or other legal matters • Insurance coverage
Table reproduced from the Centers for Disease Control and Prevention 3 New York State Resources A regional directory of New York State HIV/AIDS Service Programs is available at: http://www.health.state.ny.us/diseases/aids/resources/index.htm For information on licensed domestic violence service providers in NYS, contact the NYS Coalition against Domestic Violence 24-hour hotlines: 800–942–6906 (English) 800–942–6908 (Spanish)
For a directory of syringe exchange (ESAP) providers in New York State: http://www.health.state.ny.us/diseases/aids/harm_reduction/needles_ syringes/esap/provdirect.htm For a referral to a drug abuse treatment program, contact the New York State Office of Alcohol and Substance Abuse Services (800–522–5353).
HIV Clinical Guidelines and other provider materials from the New York State Department of Health AIDS Institute is available at: http://www.hivguidelines.org For more information, visit the New York State Department of Health HIV/ AIDS website: http://www.health.state.ny.us/diseases/aids/
Target Risk Behaviors for Interventions—Sexual Risk The majority of research conducted to date on prevalence of sexual risk behaviors among individuals living with HIV has been with men who have sex with men (MSM). Research suggests that although many HIV-positive MSM attempt to make some behavioral changes to reduce the risk of transmitting HIV, a significant number continue to engage in at least some forms of risky sexual behavior after a diagnosis of HIV. In a study of recently diagnosed HIV+ MSM, although men appeared to make efforts to reduce transmission risks after diagnosis, many continued to engage in some risky behaviors. For example, unprotected anal intercourse with unknown status or one-time partners was less frequent after diagnosis, but overall rates of unprotected anal intercourse (with last sex partner) did not change.4 In a study of over 1,000 HIV+ MSM in New York City and San Francisco, 47% reported engaging in unprotected anal sex during the past 3 months with an HIV-negative or status unknown non-main partner, while 21% reported unprotected anal sex with HIV-negative and status unknown main partners (see Table 1).5
CHAPTER 1 Table 1 Summary of MSM Sexual Behaviors from Parsons et al. (2005)5 Unknown HIV-Positive HIV-Negative Status Partners Partners Partners Any insertive oral sex Main Partners (n=435) 47% – 55% 45% – 47% 59% – 72% Non-Main Partners (n=840) 57% – 63% 53% – 62% 33% – 35% Unprotected insertive oral sex Main Partners 45% – 47% 65% – 76% 49% – 68% Non-Main Partners 53% – 62% 40% – 51% 29% – 33% Any receptive oral sex Main Partners 84% 69% – 75% 83% – 87% Non-Main Partners 64% – 68% 41% – 50% 36% – 42% Unprotected receptive oral sex Main Partners 73% – 79% 64% – 71% 73% – 83% Non-Main Partners 60% – 66% 38% – 49% 33% – 41% Any insertive anal sex Main Partners 21% – 39% 55% – 61% 31% – 51% Non-Main Partners 33% – 38% 32% – 33% 19% – 20% Unprotected insertive anal sex Main Partners 5% – 20% 47% 11% – 12% Non-Main Partners 19% – 22% 21% – 27% 7% – 10% Any receptive anal sex Main Partners 58% – 69% 52% – 54% 59% – 62% Non-Main Partners 39% – 42% 30% – 35% 22% – 26% Unprotected receptive anal sex Main Partners 26% – 47% 38% – 45% 24% – 45% Non-Main Partners 21% – 27% 21% – 28% 11% – 17%
In previous work implementing the Options intervention in a clinical care setting with a predominantly heterosexual population (79% of the total sample), approximately one quarter of the sample reported sexual risk behavior (unprotected vaginal, anal, or insertive oral sex) in the preceding three months.6 The aggregate number of such unprotected sexual events was substantial: HIV-infected study participants reported a total of 2,408 unprotected vaginal, anal, or insertive oral sexual events during the past 3 months, with 1,785 of these being unprotected vaginal or anal sexual events.6 The aggregate number of partners involved in unprotected vaginal, anal, or insertive oral sexual events over the past 3 months was also substantial: HIV-infected study participants reported engaging in such unprotected sexual acts with a total of 351 partners during this interval.6
CHAPTER 1 Target Risk Behaviors for Interventions—IDU risk Most providers and patients are familiar with the risks of needle/syringe sharing. However, syringe sharing is not the only concern among injection drug users (IDUs). Although syringe sharing continues to be a problem among IDUs, sharing of drug solution and other drug equipment appears to be a more common behavior and also carries a significant risk of HIV transmission.7–11 In a study of IDUs in the Baltimore area from 1988 to 1998, reported rates of sharing cottons or cookers among IDUs declined significantly over time (from over 70% to less than 50%) but remained significantly higher than rates of needle-sharing (from approximately 20–30% in 1998 to approximately 10% in 1998).7 A follow-up study of the same cohort found similar trends from 1998 to 2004.8
A 2004 study of IDUs in the Philadelphia area found high rates of HIV transmission risk behaviors.9
— 34% had shared needles in the past month.
— 67% had shared works in the past month.
— 60% had attended a shooting gallery at least once in the past month.
— 35% had traded sex for drugs or money in the past month. Similarly, a 2006 study also observed high rates of transmission risk behaviors among IDUs in Needle Exchange Programs (NEP) and those not in a NEP.10 Specifically, in a 6-month period:
— 31% of NEP users & 53% of non-NEP users engaged in receptive needle sharing.
— 40% of NEP users & 55% of non-NEP users reported sharing their used needle.
— 21% of NEP users & 40% of non-NEP users reported back- loading.
— 61% of NEP users & 75% of non-NEP users reported sharing a cooker.
— 52% of NEP users & 65% of non-NEP users reported sharing a cotton.
— 42% of NEP users & 56% of non-NEP users reported sharing rinse water.
CHAPTER 1 Injection drug users who report transmission risk behaviors may also harbor drug resistant strains of HIV. A study of 180 HIV-infected injection drug users found that 31% reported using injection drugs in the past month and 40% of those active users reported sharing needles/works 148 times with 296 partners.12 Furthermore, 31% (55) of the injection drug users harbored resistant HIV, including 3% (5 individuals) who also shared needles/works 27 times with 44 partners, thus exposing a substantial number of people to drug resistant HIV.12
Research shows that while many HIV-positive individuals attempt to practice safer sex and drug use behaviors, a significant number of individuals continue to engage in high-risk behavior—putting themselves, and their sex and drug use partners, at risk.
HIV prevention for people living with HIV/AIDS is emerging as a standard of care that can be effectively integrated into ongoing medical services to help reduce these risk behaviors.
CHAPTER 1 References 1. Smith DM, Richman DD, Little SJ. HIV superinfection. J Infect Dis. 2005;192:438–444. 2. Crepaz N, Lyles CM, Wolitski RJ, et al. Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta- analytic review of controlled trials. AIDS. 2006;20:143–157. 3. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2003; 52(RR-12):1–24. 4. Even after diagnosis, risky behaviors persist. AIDS Alert. 2005;20:54–55. 5. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S26. 6. Fisher JD, Fisher WA, Cornman DH, Amico KR, Bryan A, Friedland GH. Clinician-delivered intervention during routine clinical care reduces unprotected sexual behavior among HIV-infected patients. J Acquir Immune Defic Syndr. 2006;41:44–52. 7. Nelson KE, Galai N, Safaeian M, Strathdee SA, Celentano DD, Vlahov D. Temporal trends in the incidence of human immunodeficiency virus infection and risk behavior among injection drug users in Baltimore, Maryland, 1988–1998. Am J Epidemiol. 2002;156:641–653. 8. Mehta SH, Galai N, Astemborski J, et al. HIV incidence among injection drug users in Baltimore, Maryland (1988–2004). J Acquir Immune Defic Syndr. 2006;43:368–372. 9. Ouellet L, Huo D, Bailey SL. HIV risk practices among needle exchange users and nonusers in Chicago. J Acquir Immune Defic Syndr. 2004;37:1187–1196. 10. Mark HD, Nanda J, Davis-Vogel A, et al. Profiles of self-reported HIV- risk behaviors among injection drug users in methadone maintenance treatment, detoxification, and needle exchange programs.Public Health Nurs. 2006;23:11–19. 11. Santibanez SS, Gargein RS, Swartzendruber A, Purcell DW, Paxton LA, Greenberg AE. Update and overview of practical epidemiologic aspects of HIV/AIDS among injection drug users in the United States. J Urban Health. 2006;83:86–100. 12. Kozal MJ, Amico KR, Chiarella J, Cornman D, Fisher W, Fisher J, Friedland G. HIV drug resistance and HIV transmission risk behaviors among active injection drug users. J Acquir Immune Defic Syndr. 2005;40:106–109.
10 CHAPTER 1 Recommended Reading Centers for Disease Control and Prevention. Trends in HIV/AIDS Diagnoses— 33 States, 2001–2004. MMWR. 2005;54:1149–1153. Centers for Disease Control and Prevention. High-risk sexual behavior by HIV-positive men who have sex with men: 16 sites, United States, 2000–2002. MMWR. 2004;53(38):891–894. Coates T, Szekeres G. HIV prevention in the clinical setting. Global AIDS Learning and Evaluation Network, International Association of Physicians in AIDS Care. 2005. Available at http://www.iapac.org/home.asp?pid=184. Accessed May 3, 2007. Colfax G, Dawson-Rose C. Integrating HIV prevention into the care of people with HIV. HIV InSite Knowledge Base Chapter. March 2006. Available at http://www.hivinsite.org/InSite?page=kb-07–04–17. Accessed May 3, 2007 DeCarlo P, Coates T. Does HIV prevention work on different levels? CAPS Fact Sheet # 1Er. Available at http://www.caps.ucsf.edu/pubs/FS/levels.php. DeCarlo P, Gergert B, and the Center for Health Improvement and Prevention Studies. Can healthcare workers help in HIV prevention? CAPS Fact Sheet #6ER. Available at http://www.caps.ucsf.edu/pubs/FS/healthcarerev.php. Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock KM. The serostatus approach to fighting the HIV epidemic: prevention strategies for infected individuals. Am J Public Health. 2001;91:1019–1024. Johnson WD, Hedges LV, Ramirez G, et al. HIV prevention research for men who have sex with men: a systematic review and meta-analysis. J Acquir Immune Defic Syndr. 2002;30:S118-S129. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS epidemic update: December 2005. November 21, 2005. Available at http://www.who.int/hiv/epi-update2005_en.pdf. Accessed May 3, 2007.
CHAPTER 1 11 12 Chapter 2 Quick Reference Guide To HIV Risk Reduction Strategies
Understanding the Sexual Transmission of HIV and the Continuum of Sexual Risk Behaviors number of factors may influence the likelihood of HIV transmission among partners during sexual activity: viral load, antiretroviral A treatment status, stage of HIV infection, presence of other STIs, circumcision, and others. However, all patients with HIV are at risk for transmitting HIV to others, or becoming reinfected with a different strain of HIV. The type of sexual behavior an individual engages in also affects the risk of HIV transmission. For example, unprotected vaginal intercourse and receptive anal intercourse are considered very high-risk behaviors. The transmission risk of insertive anal intercourse is somewhat less than receptive anal intercourse, but this behavior still poses a significant transmission risk. The risk of oral sex is less clear, and although it is considered to be relatively low risk as compared to vaginal or anal sex, documented cases of HIV transmission through oral sex do exist. Other sexual behaviors also carry some risk for HIV transmission that patients need to be aware of.
Providers should be knowledgeable about the relative risks of different behaviors and the factors that promote and inhibit HIV transmission. Providers should assist patients in making informed decisions about engaging in different sexual behaviors and the relative risks of each.
Relevant Chapters: Chapter 5—Sexual Transmission of HIV Chapter 6—Sexual Behaviors, Relative Risk, and Safer Alternatives
13 HIV Risk Reduction Strategies for Sexual Behaviors Eliminating HIV Sexual Transmission Risk Abstaining from vaginal, anal, and oral sex. Engaging in sexual behaviors that do not involve penetration or exposure to genitals or genital secretions (e.g., massage, fantasy, phone/Internet sex).
Reducing HIV Sexual Transmission Risk (Harm Reduction) Engaging in vaginal or anal sex with a latex or polyurethane condom (following procedures to correctly use the condom and minimize likelihood of breakage or slippage). Using a water-based lubricant inside and outside of a condom to minimize the likelihood of condom breakage and trauma to the mucosal wall of the receptive partner. (Avoiding oil-based lubricants which can break down latex.) Engaging in vaginal sex using a female condom (with correct usage procedures). Avoiding use of the spermicide nonoxynol-9 (N-9), which may actually increase the risk of HIV transmission. However, using a condom with N-9 is preferable to not using a condom at all during intercourse. Engaging in oral sex with a cut-up nonlubricated condom or a dental/ Glyde dam. If neither a condom nor a dam is available, using a piece of plastic wrap may be the next best option. Engaging in relatively lower-risk sexual behaviors (e.g., mutual masturbation). Encouraging regular screening and treatment for STIs, which may increase the risk of HIV transmission. Avoiding use of drugs or alcohol when sex may occur, as these substances often impair the user’s judgment and may increase the likelihood of risky sexual behaviors.
Relevant Chapters: Chapter 9—Condoms and Lubricants Chapter 10—Strategies for Dealing with Negative Attitudes about Condoms Chapter 11—Other Barrier Methods: Oral Barriers, Cots, and Gloves Chapter 12—Microbicides
14 CHAPTER 2 HIV Risk Reduction Strategies for Injection Drug Use (IDU) Behaviors Eliminating HIV IDU Transmission Risk Abstaining from injection drug use. Using new, sterile syringes purchased from participating ESAP (Expanded Syringe Access Demonstration Program) pharmacies or NYS-approved Syringe Exchange Programs. Never sharing syringes or injection drug “works” (e.g., cottons, filters, water, spoons, or other drug use paraphernalia).
Reducing HIV IDU Transmission Risk (Harm Reduction) Cleaning syringes (if a new syringe is not available) with bleach or boiling water. Reducing injection drug use (thereby reducing transmission risk by decreasing the number of times the person is injecting). Consuming drugs in alternative form (e.g., snorting or smoking) instead of injecting. Practicing safer injection behaviors.
Relevant Chapters: Chapter 13—Commonly Abused Drugs and Effective Risk Reduction Strategies Chapter 14—HIV and Injection Drug Use
Helping Patients Identify Challenges for Consistent Safer Sex and Drug Use Once a person is motivated to reduce their HIV transmission risk behavior and begins to make a change, it can be a significant challenge to maintain that behavior change over time. Behavior change is a process, not an all-or-nothing event. By recognizing that lapses are common, and encouraging patients to use their lapses as learning experiences, providers will be better able to facilitate long-term behavior change.
CHAPTER 2 15 The Relapse Prevention model can be applied to the reduction of HIV transmission risk behaviors to give providers and patients strategies for understanding the challenges that patients face in long-term behavior change and tools to deal with those challenges. These strategies include: Identifying high-risk situations for relapse. Developing adaptive behavioral responses and problem-solving skills to cope with high-risk situations. Changing maladaptive thought patterns to better deal with high-risk situations, urges, and lapses. Learning from safer sex and drug use lapses. Reinforcing safer behaviors.
Relevant Chapters: Chapter 7—Identifying Triggers for Safer Sex and Drug Use Lapses
Helping Patients Acquire Adaptive Communication Skills Although motivation to consistently practice safer sex and drug use behaviors is critical for patients to engage in these risk reduction behaviors, certain skills–– such as the ability to communicate assertively––are also essential. Because practicing safer sex and drug use typically involves other people, the development of assertiveness skills can be a very effective tool for people living with HIV/AIDS. Assertive communication––which must be differentiated from passive, aggressive, and passive-aggressive communication styles––involves a person expressing their feelings, thoughts, and desires in a clear manner that is respectful and does not violate the rights of the other person. In assertive communication a person . . . Clearly states their thoughts, feelings, and/or request. Uses “I” statements. Listens to what their partner is saying. Is respectful, and acknowledges their partner’s feelings/opinions.
16 Explains the reason for their position or request. Refuses to be coerced into something they don’t want. Matches their verbal and nonverbal communication.
Relevant Chapters: Chapter 8—Safer Sex Communication Skills.
Facilitating HIV Status Disclosure to Partners For many men and women with HIV, deciding when and how to disclose their HIV status can be an extremely stressful process. Disclosure to all sex partners is important to encourage, as it allows both partners to make informed decisions about HIV risk reduction.
In New York State, partner notification is mandated, and providers are required to talk with HIV-infected patients about their options for informing sexual and needle-sharing partners of possible HIV exposure. The three options for partner notification in New York include: 1. The counselor from the Health Department’s PartNer Assistance Program (PNAP) or Contact Notification Assistance Program (CNAP in New York City) tells the partner(s) without ever revealing the patient’s identity. 2. The patient tells their partner(s) with the help of their doctor or PNAP/CNAP. 3. The patient tells their partner(s) themselves.
When making decisions about HIV status disclosure, patients will want to consider: Who do they want to tell, and why? How much are they ready to share? How much is the person being told ready to hear? How will the disclosure affect your client? How will the disclosure affect the person being told? What are the risks and benefits of disclosure? When and where do they want to disclose their status? Do they have the skills to effectively disclose and cope with the other person’s reaction?
CHAPTER 2 17 The New York State brochure There’s Something I Need to Tell You is a valuable resource for helping patients address HIV disclosure with their partners. It is included in the Options patient handouts and is available at: http://www. health.state.ny.us/disease/aids/publications.
Relevant Chapters: Chapter 4—Assisting Patients with HIV Disclosure Tip Providers should use appropriate patient handouts provided with the Risk Reduction Strategies Manual to reinforce risk reduction information and strategies discussed during the clinic visit.
Providers should also rely on available support and referral services within their care organization and community to support the patient in their efforts to reduce their sexual and drug-use risk behaviors.
18 CHAPTER 2 Chapter 3 Predictors of HIV Risk Behaviors
lthough many men and women living with HIV/AIDS attempt to reduce their HIV transmission risk behaviors, a substantial number Aof individuals continue to engage in some forms of sexual or drug use risk behaviors.
Estimates of the proportion of infected individuals who continue to engage in unsafe sex vary across populations and studies, but overall approximately 33% of HIV-positive individuals continue to practice unprotected sex despite their HIV status (including men who have sex with men [MSM], injection drug users [IDUs], and clinical/community samples). 1
Similarly, rates of injection drug use risk behaviors––especially sharing “works”– –are relatively high among both HIV-positive and HIV-negative IDUs (see Chapter 1, Introduction). There is no way to predict with complete accuracy who will practice unsafe sexual or drug use behavior after an HIV diagnosis, and no assumptions should be made. Each patient’s risk behaviors should be assessed individually. However, research has shown that some factors may place some HIV-positive individuals particularly at risk.
Risk Factors for Unsafe Sexual Behaviors Factors associated with engaging in sexual risk behavior(s)1–3 include: Lack of sufficient information about HIV/AIDS, its transmission, and health risks. Belief that safer sex decreases sexual pleasure. Lack of confidence in one’s ability to engage in safer sex practices. Perception that one has little behavioral control over condom use, especially among women. Lack of assertiveness, especially among women. Problems communicating to partners about safer sex.
19 Lack of (or low) commitment to self or others to practice safer sex. Low socioeconomic status. Alcohol and drug abuse (especially hard drug use). Low self-esteem.
Other factors that may have implications for a person’s likelihood of engaging in unsafe sexual behaviors 1,2 include: Partner HIV Status HIV-positive men and women are generally more likely to have unprotected sex with partners they believe are also HIV-positive than those thought to be HIV- negative. This suggests many HIV-positive individuals are concerned about transmitting the virus to uninfected individuals However, they may not realize the potential risks of getting or giving a different strain of HIV or other secondary infections that may accelerate their or their partner’s HIV disease progression. MSM “POZ Parties” have been reported in several urban areas, providing venues for HIV-positive MSM to feel relieved of HIV status disclosure pressures and engage in high rates of unprotected sex with multiple partners.4 It is also important to explore the manner in which patients determine a partner’s HIV status. False assumptions or quick but inaccurate decision-making rules may lead to the belief that a potential partner is HIV-positive when in fact they are not.
Type of Partner (Primary vs. Casual) Results from studies looking at rates of unprotected sex with primary versus casual partners (often in MSM populations) have been mixed. Unprotected sex may depend more on presumed serostatus than primary vs. casual partner. For example, several studies suggest that unprotected sex is more common with seroconcordant partners, regardless of whether they are primary or causal partners. However, the type of partner (primary vs. casual) may interact with HIV status to influence sexual behaviors. Among primary partner sexual relationships, evidence suggests that HIV- positive men with HIV-negative or unknown status primary partners are less likely to practice some forms of risky sexual behavior (e.g., insertive oral and anal sex) than those with HIV-positive main partners.5
20 CHAPTER 3 Among casual partner sexual relationships, evidence suggests that HIV- positive men are most likely to have unknown status partners, followed by HIV-positive and then HIV-negative partners. Men appear most likely to practice risky sexual behaviors with HIV status unknown casual partners, followed by HIV-positive casual partners.5
In addition, having a partner who is willing to engage in unprotected sex has been shown to increase the likelihood of it occurring.
HIV Serostatus Disclosure Although there is inconsistent support for a relation between nondisclosure of HIV serostatus and sexual risk, some research does suggest that patterns of disclosure and nondisclosure may be important risk factors Consistency of HIV status disclosure may be a particularly important factor. In a study of HIV-positive MSM, individuals who inconsistently disclosed their HIV status to partners were most likely to engage in risky sexual behaviors, followed by nondisclosers. MSM who consistently disclosed their HIV status were the least likely to engage in risky behavior.6
These inconsistent disclosers and nondisclosers may represent important targets for HIV risk reduction counseling.
Negative and Positive Emotions There is conflicting evidence about whether negative emotional states such as depression, anxiety, and anger are associated with unprotected sex. Importantly, positive emotions may sometimes play a role as well: some HIV- positive individuals report positive mood states (e.g., affection and excitement) associated with incidents of unprotected sex.
Misperceptions of HIV/AIDS Infectivity Because of Low Viral Load Some HIV-positive individuals may continue to practice unsafe sex because of misperceptions that an undetectable plasma viral load may lead to decreased infectivity.7 This is problematic because of the instability of plasma viral load measures and uncertainty of exactly how plasma viral load translates to infectivity (i.e., viral load in semen and genital tract/anal mucosa).
Impact of ART on Perceptions of HIV as a Treatable Disease and Infectivity Some MSM have reported being less concerned about becoming HIV-positive because the availability of new treatments has changed their perception from HIV as a terminal disease to a treatable disease, and also because they believe newer HIV treatments will reduce the likelihood of HIV transmission.
CHAPTER 3 21 A recent meta-analysis7 suggests that it is not being on antiretroviral therapy (ART) or having an undetectable viral load per se that puts an individual more at risk for practicing unsafe sex, but rather an individual’s beliefs about ART and viral load. Specifically, individuals on ART or with an undetectable viral load are not necessarily more likely to engage in unprotected sex, but individuals who believe that receiving ART or having an undetectable viral load protects against transmitting HIV, or who had reduced concerns about engaging in unsafe sex given the availability of ART are at increased risk for practicing unsafe sex.
Risk Factors for Injection Drug Use Risk Behaviors Less is known about risk factors for continued injection drug use risk behaviors, but longitudinal research suggests that the best predictor of IDU risk behavior is past IDU risk behavior. For example, in a 6-year prospective study of IDUs, the users least likely to stop sharing needles were those who had a previous history of either needle-sharing or use of shooting galleries.8 Other factors associated with sharing injection drug paraphernalia8–17 include: Homelessness. Having an IDU sex partner (especially if that partner shares equipment with others, or if one partner relies on the other to inject them). Nonparticipation in a Syringe Exchange Program (SEP participation also reduces likelihood of sharing drug paraphernalia other than syringes). Engaging in drug-splitting and/or joint purchasing of drugs. Attendance at shooting galleries. Unemployment. Being female. Young age. Incarceration. Regular use of injection drugs (3 or more times per week). Depression. Family history of injection drug use. Use of amphetamines and/or cocaine.
22 CHAPTER 3 Risk Factors for Initiation of Injection Drug Use In addition to understanding which IDUs may be at particular risk for engaging in risky drug use behaviors, it is also useful for HIV care providers to be familiar with factors that may be associated with non-injection drug users eventually transitioning to injection drug use (and possibly risky injection behaviors). Research suggests the following18–25 may be associated with initiating injection drug use: Previous drug use (especially non-injection use of heroin and cocaine). Homelessness. Young age (<18 years). Parental divorce or separation. Dropping out of high school. Unemployment. Have traded sex for drugs or money. Parental substance abuse. Use of injection drugs by family members. Comfort with needles (which may be correlated with a greater likelihood of a history of needle use, such as having one or more tattoos). Social network acceptance of injection drug use (e.g., friends, sex partners, and community members).
— For example, IDUs with early onset (ages 12–16) often first inject with friends, relying on others to administer the drug and provide the needle.19
— Crack cocaine smokers who transition to injecting drugs are more likely to have a sex partner who injects drugs.20
CHAPTER 3 23 Implications for HIV Care Providers Many factors may potentially increase the likelihood that someone will engage in risky sexual or drug use behavior. By being familiar with factors that may be associated with engaging in HIV transmission risk behaviors, providers may be better prepared to identify those individuals who may be at greatest risk, and potentially help patients avoid establishing those behaviors early on. At the same time, although research can provide group-level observations and trends that suggest who may be at highest risk, all individuals should be considered as potentially at risk and thus appropriate targets for HIV prevention interventions. Therefore, because there are many types of factors associated with risk behavior, and all patients are unique, the prevention net must be cast widely. With prevention, one size does not fit all. Each patient should be assessed for their unique needs and barriers to safer sex and IDU behavior, and the appropriate targeted intervention must then be implemented.
24 CHAPTER 3 References 1. Kalichman S. HIV transmission risk behaviors of men and women living with HIV-AIDS: prevalence, predictors, and emerging clinical interventions. Clin Psychol Sci Prac. 2000;7:32–47. 2. Crepaz N, Marks G. Towards an understanding of sexual risk behavior in people living with HIV: a review of social, psychological, and medical findings.AIDS . 2002;16:135–149. 3. Stein JA, Rotheram-Borus MJ, Swendeman D, Milburn NG. Predictors of sexual transmission risk behaviors among HIV-positive young men. AIDS Care. 2005;17:433–442. 4. Clatts MC, Goldsamt LA, Yi H. An emerging HIV risk environment: a preliminary epidemiological profile of an MSM POZ party in New York City. Sex Transm Infect. 2005;81:373–376. 5. Parsons JT, Schrimshaw EW, Wolitski RJ, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19:S13-S26. 6. Parsons JT, Schrimshaw EW, Bimbi DS, Wolitski RJ, Gomez CA, Halkitis PN. Consistent, inconsistent, and non-disclosure to casual sexual partners among HIV-seropositive gay and bisexual men. AIDS. 2005;19:S87-S97. 7. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. JAMA. 2004;292:224–236. 8. Celentano DD, Munoz A, Cohn S, Vlahov D. Dynamics of behavioral risk factors for HIV/AIDS: a 6-year prospective study of injection drug users. Drug Alcohol Depend. 2001;61:315–322. 9. Belanger D, Godin G, Alardy M, Noel L, Cote N, Claessens C. Prediction of needle sharing among injection drug users. J App Soc Psychol, 2002;32:1361–1378. 10. Huo D, Bailey SL, Garfein RS, Ouellet LJ. Changes in the sharing of drug injection equipment among street-recruited injection drug users in Chicago, Illinois, 1994–1996. Subst Use Misuse. 2005;40:63–76. 11. Pouget EP, Deren S, Fuller CM, et al. Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State Expanded Syringe Access Demonstration Program. J Acquir Immune Defic Syndr. 2005;39:471–477. 12. Lum PJ, Sears C, Guydish J. Injection risk behavior among women syringe exchangers in San Francisco. Subst Use Misuse. 2005;40:1681–1696. 13. Braine N, Des Jarlais DC, Ahmad S, Purchase D, Turner C. Long-term effects of syringe exchange on risk behavior and HIV prevention. AIDS Educ Prev. 2004;16:264–275.
CHAPTER 3 25 14. Unger JB, Kipke MD, De Rosa CJ, Hyde J, Ritt-Olson A, Montogomery S. Needle-sharing among young IV drug users and their social network members: the influence of the injection partner’s characteristics on HIV risk behavior. Addict Behav. 2006;31:1607–1618. 15. Longshore D, Bluthenthal RN, Stein MD. Needle exchange program attendance and injection risk in Providence, Rhode Island. AIDS Educ Prev. 2001;13:78–90. 16. Fernando D, Schilling RF, Fontdevila J, El-Bassel N. Predictors of sharing drugs among injection drug users in the South Bronx: implications for HIV transmission. J Psychoactive Drugs. 2003;35:227–236. 17. Klein H, Levy JA. Shooting gallery users and HIV risk. J Drug Issues. 2003;33:751–768. 18. Crofts N, Louie R, Rosenthal D, Jolley D. The first hit: circumstances surrounding initiation into injecting. Addiction. 1996;91:1187–1196. 19. Abelson J, Treloar C, Crawford J, Kippax S, van Beek I, Howard J. Some characteristics of early-onset injection drug users prior to and at the time of their first injection.Addiction . 2006;101:548–555. 20. Irwin KL, Edlin BR, Faruque S, et al. Crack cocaine smokers who turn to drug injection: characteristics, factors associated with injection, and implications for HIV transmission. Drug Alcohol Depend. 1996;42:85–92. 21. Neisen JH. Parental substance abuse and divorce as predictors of injection drug use and high risk sexual behaviors known to transmit HIV. J Psychol Hum Sex. 1993;6:29–49. 22. Fuller CM, Vlahov D, Ompad DC, Shah N, Arria A, Strathdee SA. High-risk behaviors associated with transition from illicit non-injection to injection drug use among adolescent and young adult drug users: a case- control study. Drug Alcohol Depend, 2002;66:189–198. 23. Neaigus A, Miller M, Friedman SR, et al. Potential risk factors for the transition to injecting among non-injecting heroin users: a comparison of former injectors and never injectors. Addiction. 2001;96:847–860. 24. Roy E, Haley N, Leclerc P, Cedras L, Blais L, Boivin JF. Drug injection among street youths in Montreal: predictors of initiation. J Urban Health. 2003;80:92–105. 25. Neaigus A, Gyarmathy VA, Miller M, Frajzyngier VM, Friedman SR, Des Jarlais DC. Transitions to injecting drug use among noninjecting heroin users. J Acquir Immune Defic Syndr. 2006;41:493–503.
26 CHAPTER 3 Recommended Reading Halkitis PN, Parsons JT, Wilton L. Barebacking among gay and bisexual men in New York City: explanations for the emergence of intentional unsafe behavior. Arch Sex Behav. 2003;32:351–357. Kalichman SC, Rompa D, Luke W, Austin J. HIV transmission risk behaviours among HIV-positive persons in serodiscordant relationships. Int J STD AIDS. 2002;13:677–682. Lightfoot M, Song J, Rotheram-Borus MJ, Newman P. The influence of partner type and risk status on the sexual behavior of young men who have sex with men living with HIV/AIDS. J Acquir Immune Defic Syndr. 2005;38:61–68. Mackellar DA, Valleroy LA, Secura GM, et al. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/ AIDS. J Acquir Immune Defic Syndr. 2005;38:603–614. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446–453. Reilly T, Woo G. Predictors of high-risk sexual behavior among people living with HIV/AIDS. AIDS Beh. 2001;5:205–217. Suarez T, Miller J. Negotiating risks in context: a perspective on unprotected anal intercourse and barebacking among men who have sex with men—where do we go from here? Arch Sexual Behav. 2001;30:287–300. Van der Straten A, Gomez CA, Saul J, Quan J, Padian N. Sexual risk behaviors among heterosexual HIV serodiscordant couples in the era of post-exposure prevention and viral suppressive therapy. AIDS. 2000;14:F47-F54.
CHAPTER 3 27 28 Chapter 4 Assisting Patients with HIV Disclosure
or many men and women with HIV, deciding when and how to disclose their HIV status can be extremely stressful. F There is no best way for a person to tell someone else that he or she is HIV-positive, and there is no way to be sure how another person will react to hearing the news. However, there are some things that you can do to help your patients be better prepared to decide who to disclose their HIV status to and how to best tell them. The healthcare provider is often the first person the patient talks to about disclosure and, as such, it is important that providers who care for HIV-positive patients be familiar with common concerns surrounding disclosure. New York State has specific resources that HIV-positive patients can use to help them with disclosure.
Ethical and Legal Issues in Partner Disclosure Disclosure to current, past, and potential sexual partners can be a particularly challenging situation, and it involves additional ethical, legal, and safety considerations for both healthcare providers and their patients. Many people living with HIV do not disclose their HIV status to their current sexual partners (an estimated 10%–50% of HIV-infected individuals), and even fewer disclose their HIV status to past partners.1 It is important to encourage disclosure to all partners, as this facilitates informed decisions about HIV risk reduction. In one study of HIV-infected gay men,2 48% of the total sample withheld disclosure from their sex partner, and 13% withheld disclosure and engaged in unsafe sex. Inconsistent disclosers and nondisclosers may be more likely to engage in risky sexual behaviors than individuals who consistently disclose their HIV status.
29 For example, a study of HIV-positive MSM found that individuals who consistently disclosed their HIV status to their casual sexual partners (29%) were more likely than inconsistent disclosers (38%) and nondisclosers (33%) to practice safer sex.3 HIV-infected men and women are more likely to disclose their status to steady sexual partners than to casual partners.4
Some people may assume that if their sex partner (or potential partner) doesn’t ask if they are infected, the partner is infected or doesn’t care, and thus is unlikely to disclose.
New York State Partner Notification Laws In New York State, partner notification is mandated, and providers are required to talk with HIV-infected patients about their options for letting sexual and needle-sharing partners know they may have been exposed to HIV. Partner notification in New York State can occur in three ways: 1. The counselor from the Health Department’s PartNer Assistance Program (PNAP) or Contact Notification Assistance Program (CNAP in New York City) tells the patient’s partner(s) without ever revealing the patient’s identity. 2. The patient tells the partner(s) with the help of his/her doctor or a PNAP or CNAP counselor. 3. The patient tells the partner(s) without support. A PNAP/CNAP counselor will work with the doctor to confirm that the partner(s) was told. If PNAP/CNAP cannot confirm this, the counselor may follow up with the patient or the partner(s) directly.
Healthcare providers who are aware of the name of the patient’s partner(s) must report the name to the Department of Health. Partner notification will proceed unless deferred because of the potential for domestic violence. In New York, patients are not required to disclose their partners, and no civil or criminal liability arises for nondisclosure of partners by the patient. For more information about New York regulations and resources, see the NYS Department of Health website: http://www.health.state.ny.us/diseases/aids/regulations/notification/ summary.htm
30 CHAPTER 4 Addressing Disclosure with Patients HIV status disclosure issues may come up with your patients in different ways.
Patients may spontaneously say that they have concerns about HIV disclosure (either in general or to someone specifically). If this occurs, you can normalize their concerns and help them make appropriate decisions about disclosure by talking about the considerations. Example: A lot of my patients have told me that deciding who to tell about their HIV status and how to tell them can be a hard thing to figure out. In working with lots of people living with HIV over the years, I’ve found that there are some important things that can be helpful to think through when you’re trying to sort it all out. Would it be helpful to talk about some of these things together? If patients say they are not ready to talk about a specific plan for disclosure, let them know that is fine and that you will be happy to talk about it when they are ready. Note: This may not apply to partner nondisclosure (see the first section in this chapter, Ethical and Legal Issues in Partner Disclosure).
Patients may not say anything specifically about disclosure, but you may get a sense from talking with them that disclosure is something they may be concerned about. In this case, you may decide to bring up the subject of disclosure in a nonthreatening, supportive manner. Example: Some of my patients have told me how hard it is to decide who to tell about their HIV status, and what the best way is to tell someone. I was wondering if you are concerned about this? If a patient acknowledges that this is a struggle for him/her, you can follow up by normalizing their concerns and offering to discuss helpful strategies (see example above). If a patient does not seem ready to address this, let them know that is fine and if they decide later on they want to talk about it, you’ll be happy to help them. Note: This may not apply to partner nondisclosure (see the first section in this chapter, Ethical and Legal Issues in Partner Disclosure).
You may be concerned (ethically and/or legally) that a patient has not disclosed their HIV status to their sexual partner(s), even if the patient has not expressed this concern. In this case, it is important to bring up the issue of partner notification in a nonjudgmental, nonthreatening manner. Example: You’ve mentioned your partner several times in our discussions. I was wondering if your partner is aware of your HIV status?
CHAPTER 4 31 If a patient indicates that he or she has not disclosed their HIV status to their partner(s), you will need to explore this issue further according to state laws and the requirements of your institution (be sure you are clear on both). Most importantly, you want to give your patient the clear but nonjudgmental message that it is very important that their sexual partners are aware of their HIV status. Example: It is important that your partners know your HIV status so that they can get tested to see if they have HIV. If they do, then they can get the health care they need and learn how to prevent spreading the virus to other people. If they do not have HIV, you and your partner can learn how to try to keep it that way.
Exploring Concerns About Partner Disclosure Depending on your relationship with the patient (i.e., whether this is a new patient to you or someone who you have a strong trusting relationship with) and how much time you have available to talk with them, you will need to decide how much you can practically explore about disclosure with them. If you have very limited time available with the patient, you can use that time to express the importance of disclosure to sexual partners and to discuss the options for disclosure (i.e., disclosure by the patient, disclosure through a partner notification system, or physician disclosure). If you sense the patient is having a difficult time with disclosure and you do not have time to extensively explore their perceived barriers to disclosure, consider a referral to a counselor to help the patient address their disclosure concerns more in depth. If you have more time available with the patient and have the opportunity to explore your patient’s disclosure concerns more extensively, it can be helpful to determine if your patient has not disclosed because they do not want to tell their partner (a motivation deficiency), or because they not feel they have the skills to disclose to tell their partner (a behavioral skills deficiency). Example: Have you not told your partner because you don’t want him to know, or because you don’t know how to tell him? Addressing a Motivation Barrier If a patient does not want his/her partner to know their HIV status, it can be helpful to explore the reasons. For example, are they concerned about being rejected? Are they worried that other people will find out too? Do they think it’s the partner’s responsibility to ask? Once the patient’s concerns become clearer, you will be better prepared to address them. Remember, simply giving advice and/or adopting a confrontational style usually do not work.
32 CHAPTER 4 To move the patient closer to the decision to disclose, it can help to:5 use open-ended questions to explore the patient’s concerns. listen to and encourage the patient with verbal and nonverbal prompts. seek to understand the patient’s frame of reference. express acceptance and understanding. clarify and summarize what the patient has told you. elicit and selectively reinforce the patient’s own self-motivational statements about disclosure. remain nonjudgmental and supportive.
Regardless of the laws of your state regarding partner notification, patients should always first be encouraged to disclose their HIV status to their partner(s) themselves unless there is a risk of potential violence. However, if the patient remains unwilling to disclose to his/her partner(s), and partner notification is required by law in your state, you must discuss your obligation with the patient and jointly consider the options.
See the section in this chapter on Ethical and Legal Issues in Disclosure for more information.
Addressing a Behavioral Skills Barrier Behavioral skills barriers can sometimes be more straightforward to address than motivational barriers.
If your patient wants to tell their partner(s) about their HIV status, but lacks confidence in their ability to do so, you can use the steps outlined in the sections that follow to help your patient feel better prepared and confident in their ability to disclose.
Assisting Patients With Disclosure When making decisions about HIV status disclosure, it may be helpful for patients to consider: Who do they want to tell, and why? How much are they ready to share? How much is the person being told ready to hear? How will the disclosure affect your patient? How will the disclosure affect the person being told? What are the risks and benefits of disclosure?
CHAPTER 4 33 When and where do they want to disclose their status? Do they have the skills to effectively disclose and cope with the other person’s reaction?
Deciding Who Needs to Know When deciding whether or not to disclose, your patient may want to think about who needs to know, who does not necessarily need to know, and who they may want to know. Your patient may also want to consider whom to disclose to first: it may be easier to first disclose to close friends and relatives before disclosing to a sexual partner.
Helping your patient clarify why they want a specific person to know can also help them decide what they want to say and to make sure their expectations are realistic.
Who Should Be Informed? People who may have been exposed to HIV so that they can be tested and seek medical attention if required (e.g., sexual contacts, needle-sharing partners). Doctors and other healthcare providers to ensure that your patient receives appropriate care.
Who Does the Patient Not Have an Obligation to Inform? Patient’s employer (though they are protected from job discrimination under ADA). Anyone not at risk of acquiring HIV from your patient.
Who May Your Patient Want to Tell? Close family and friends Children
How Much Is Your Patient Ready to Share? Patients need to think about how much they are ready to share before disclosing. Remember, even though they are disclosing their status, they still have a right to privacy and are not obligated to share anything they don’t want to share. The patient should anticipate possible questions and responses to those questions. For example, people may ask how they became infected. If they don’t want to share this information, they should have a reply ready such as . . . “Does it really matter?” “I’m not ready to talk about that.”
34 CHAPTER 4 How Much Is the Person Being Told Ready to Hear? Some people are open to hearing anything, while other people actively avoid discussing issues they perceive as negative or stress-inducing. It can be helpful for your patient to anticipate how ready the person is to hear this information. For example, if an HIV-infected gay man would like to disclose his HIV status to another male friend who is part of an active gay community, he may not have to worry much about his friend being unprepared and overwhelmed. He may feel that his friend will be emotionally able to receive this news. The same may not be true for other people who are not used to dealing with such news or who do not generally deal well with stressful situations; your patient may want to prepare how much they want to share accordingly.
How Will Disclosure Affect Your Patient and the Person Receiving the Information? People react differently to hearing that someone is HIV-positive: some may immediately embrace the patient while others may react negatively or need time to process the news and overcome preconceived notions about HIV. For example, the patient may think that the person they want to disclose to may react by rejecting the patient or getting angry. The patient can then prepare for each of these possible reactions so that they will feel confident in their ability to handle the other person’s reaction, whatever it is. Tip Although it is impossible to accurately predict how another person will react to disclosure, it can be helpful for the patient to think about how the person has reacted in other situations, how they may react to this situation, and what the patient can do to deal with the reaction.
It may be helpful to provide resources and support to the person being told. The patient may want to provide informational brochures or books on HIV, telephone numbers of support groups in the area, and/or names of others who are aware of the patient’s status and can be available for support. Possible sources of support include family, friends, a doctor, a social worker, a counselor, community AIDS organizations, etc.
CHAPTER 4 35 Tip
The patient also needs to anticipate how the disclosure, and the other person’s reaction, may affect them. Patients should make sure that they have support networks in place to help them deal with the process of disclosure.
Concerns About Violence If your patient has concerns that the person they are planning to tell may become violent, you can discuss their options, such as having someone with them when they disclose, disclosing with a counselor or physician present, or using a partner notification program.
If the patient is in a violent relationship, a referral to a social worker or counselor for assistance in getting out of the abusive situation is very important. Also, advise the patient to disclose through a partner notification program. The patient should not disclose to the partner alone.
What Are The Risks and Benefits of Disclosure? Research suggests that there are a number of concerns that people with HIV commonly have about disclosing their HIV status to others.6 These common concerns include fears about: Abandonment, closely tied to fear of loss of economic support from partners. Rejection/discrimination. Violence. Upsetting family members. Accusations of infidelity. It is important for your patients to consider the realistic potential for each of these risks (and any others), and to weigh the risks and benefits of disclosure when deciding whether or not to tell someone about their HIV status. Helping your patients anticipate how they could best handle these potential concerns may help them feel better prepared to deal with them. Considering the possible benefits of disclosure is also important when trying to motivate patients to disclose, or when helping them weigh the risks against the benefits.
36 CHAPTER 4 Possible benefits of disclosure include: Increased social support, acceptance. Decreased anxiety, depression, and stress of having to keep a secret. Strengthening of relationships. Ability to make informed decisions with partner (which facilitates HIV- preventive behavior). Increased feeling of control and self-responsibility when informing sexual and needle-sharing partners. Avoiding legal consequences.
Creating a continuum of disclosure risks/benefits can help patients establish a personal plan for disclosure. Ask the patient to rank order people they would find least difficult to most difficult to tell about their HIV status. This activity helps patients think about whom they may want to disclose their status to first and how to plan ahead and reduce their stress.
When and Where Should the Patient Disclose? Where to Disclose? When preparing for disclosure, it is important to consider where the disclosure will occur. For example, would it be better to have the conversation at the patient’s home, a friend’s home, a healthcare setting (especially important if there is a risk of the person becoming violent), or somewhere else? Tip When possible, it is best for the patient to plan for the disclosure to occur in a place that is comfortable and safe, where they will not be disturbed while they talk, and while they are both sober.
When to Disclose? When to disclose can also be a challenging issue for patients, particularly for disclosure to sexual, or potential sexual, partners.
Generally speaking, there is no ideal time to disclose. Unless legally required, the patient should disclose when they feel ready to do so, but they should consider the potential ramifications of their decision about when to disclose.
CHAPTER 4 37 Options for when to disclose to (potential) sexual partners include: Disclosure upon meeting a potential sexual partner Advantage: Less emotional attachment before possible rejection Disadvantage: Possibility of more people in community knowing about HIV status
Disclosure after several “dates” but before sexual contact Advantage: More privacy, don’t have to disclose to every date Disadvantage: Possible angry/hurt reaction about not being told previously Disclosure after a sexual encounter Rationale: Patient hopes that partner will be emotionally involved and won’t reject patient. Disadvantages: Most people lose their trust in partners who conceal important information. If patient had unprotected sex, will expose partner to HIV Studies indicate that telling after sex can lead to increased risk of violence. There may be legal repercussions.
Skills Needed for Disclosure There is no best way to disclose one’s HIV status to another person, but becoming an effective communicator can help a person reduce their stress and make better decisions about disclosure. If done skillfully, disclosure can empower your patient, the other person, and their relationship. To effectively communicate about their HIV status, your patient needs: Confidence in their ability to manage disclosure situations (self-efficacy) Confidence can be increased bypreparing for disclosure, getting feedback from other people who have gone through disclosure themselves or with a physician/ counselor, and through role-plays and practice. Role-playing and/or rehearsing different ways to disclose can be a very helpful preparation tool. Practicing and saying the words out loud will certainly help the patient be more confident.
38 CHAPTER 4 When practicing, the patient should consider:
— How will the topic be introduced?
— How will they respond to the person’s questions?
— What will the patient say and do if the person responds negatively? Availability of support from others for disclosing The patient should have support available before the disclosure (to help prepare) and after the disclosure (to help cope with the other person’s reaction, if needed). Ability to determine the potential consequences for disclosing one’s HIV status See previous section in this chapter, What are the Risks and Benefits of Disclosing? Skills for managing disclosure situations, such as the. . .
— ability to communicate assertively
(expressing personal thoughts, feelings and needs using “I” statements)
Example: I am telling you this because I care about and respect you, and I want be honest in our relationship. I understand you may need some time to process this information, but I hope that we can continue our relationship.
— ability to use active listening
(listening for both the thoughts and feelings of the other person, then summarizing back to them what they said)
Example: From what you are saying, it sounds like you are concerned about the risks of getting HIV if we have sex, and you are feeling a little hurt and angry that I didn’t tell you sooner. Is that right?
— ability to identify aspects of situations that facilitate or impede disclosure
(i.e., availability of a private place and time to talk, both sober)
CHAPTER 4 39 — ability to manage one’s own emotional reactions
The patient should plan for the possibilities of how the person they are disclosing to may react, and then plan for how they will deal with those possible reactions.
For example, if the person your patient tells becomes angry, how will the patient de-escalate the situation and manage their own emotional reactions? If the person rejects or pulls away from the patient, how will they handle that? Support and preparation are critical here.
Summary The most effective way to help your patients with disclosure is to teach them the skills to: evaluate the risks and benefits of disclosing. communicate effectively to others about their HIV. cope with the positive and negative consequences of disclosing their HIV status.
Seven Steps to Notifying Partners Patients can use the strategies discussed in the previous sections, and may also refer to the brochure, There’s Something I Need to Tell You, a step-by-step guide to disclosing to partners that is published by the New York Department of Health.7 It is included in the Options patient handouts and is available at: http://www.health.state.ny.us/disease/aids/publications. This guide follows 7 steps to notifying partners that they may have HIV: 1. Weigh the pros and cons of telling your partner yourself. 2. Get ready to share the facts about HIV. 3. Decide if you want help telling your partner and who will help you. 4. Find the right time and place. 5. Plan what you will say. 6. Prepare for how your partner will react. 7. Get extra support after telling your partner.
40 CHAPTER 4 Planning What to Say In planning what to say to their partner, the patient should make sure that they get 3 basic messages across: 1. The patient has HIV. 2. Their partner may also have HIV. 3. Their partner should get an HIV test.
What else the patient may want to say: Why the patient is telling their partner Example: “I care about you and want you to stay healthy, so you need to know about this.” Why it is important the partner gets tested Example: “There are medicines that help people with HIV stay healthier. You should get tested right away so that if you have HIV, you can get treatment and support.” How the patient will support the partner Example: “Getting an HIV test can be stressful. I am here for you if you need help.” That they will share information about their medical condition Example: “My doctor says I will probably need to start taking HIV medicine soon. That will help keep me healthier. I plan to be around for a long time.” Tip
Helpful Hint for the Patient: Think about how you felt when you first tested positive for HIV. What did people say that helped you? Remembering these things will help you plan what to say to your partner(s).
Things for the patient to think about when preparing for their partner’s reaction: Remember how you felt when you were told that you have HIV. How did you react? Your partner may feel the same way. Bring phone numbers with you to share with your partner. Helpful numbers might be an HIV/AIDS hotline, the number of your counselor or clergy, or the number for PNAP/CNAP.
CHAPTER 4 41 Telling a partner may change your relationship. Sometimes people stay together and work through this. Sometimes they don’t. Your partner may want some time and space to see how they feel. Be understanding and let your partner know that you care and are there to help. Get the support you need to help you through changes in the relationship. No matter how your partner reacts, remember that you are sharing important information to protect their health. Telling is an act of caring and concern. Let the person know why you are telling them: you respect them, you want to protect them, you want to be honest with them, etc.
42 CHAPTER 4 References 1. Kalichman S. HIV transmission risk behaviors of men and women living with HIV-AIDS: prevalence, predictors, and emerging clinical interventions. Clin Psychol Sci Prac. 2000;7:32–47. 2. Marks G, Crepaz N. HIV-positive men’s sexual practices in the context of self-disclosure of HIV status. J Acquir Immune Defic Syndr. 2001;27:79–85. 3. Parsons JT, Schrimshaw EW, Bimbi DS, Wolitski RJ, Gomez CA, Halkitis PN. Consistent, inconsistent, and non-disclosure to casual sexual partners among HIV-seropositive gay and bisexual men. AIDS. 2005;19:S87-S97. 4. Sullivan KM. Male self-disclosure of HIV-positive serostatus to sex partners: a review of the literature. J Assoc Nurses AIDS Care. 2005;16:33–47. 5. Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. Edinburgh: Churchill Livingstone; 1999. 6. World Health Organization. HIV status disclosure to sexual partners: rates, barriers and outcomes for women. WHO Document Summary; 2004. Available at: http://www.who.int/gender/documents/en/. Accessed April 18, 2006. 7. New York State Department of Health. There’s Something I Need to Tell You: A Step-by-Step Guide to Telling Your Partners That They May Have HIV 2003. Available at: http://www.health.state.ny.us/diseases/aids/ publications/#partner_notification. Accessed April 18, 2006.
CHAPTER 4 43 44 Chapter 5 Sexual Transmission of HIV
he largest proportion of HIV/AIDS diagnoses in the United States continues to be attributable to sexual contact. For men, male-to-male Tsexual contact is by far the biggest transmission category, and for women, heterosexual contact accounts for the majority of HIV/AIDS cases (see Figure 1).
Figure 1 Transmission Categories of Adults/Adolescents with HIV/AIDS Diagnosed in 20041 (Based on data from 35 areas with long-term, confidential name-based reporting.)
Given that many HIV-positive individuals continue to be sexually active after their diagnosis, it is critical for health care providers to understand and convey to their patients the relative risks of different types of sexual behaviors and the factors that may increase the likelihood of HIV transmission through sexual contact.
Infectivity Estimates of Various Sexual Practices HIV-positive individuals, like uninfected individuals, may engage in a variety of sexual behaviors that fall along the continuum of transmission risk. Some HIV- positive individuals engage in unprotected sexual behaviors under the mistaken impression that certain behaviors (e.g., receptive anal sex or oral sex) carry little
45 or no risk of HIV transmission. While patients need to understand the relative risk of different sexual behaviors, they also need to know that all unprotected sexual behaviors carry some degree of transmission risk. Table 2 shows estimates from the CDC about the per-act risk for acquisition of HIV for different unprotected sexual behaviors.2 Risk estimates of exposure by transfusion and injection drug use are provided as a reference.
Table 2 Estimated Per-Act Risk for Acquisition of HIV, by Exposure Route2
Risk per 10,000 exposures to Exposure Route* an infected source Blood transfusion 9,000 Needle-sharing injection-drug use 67 Receptive anal intercourse 50 Percutaneous needle stick 30 Receptive penile-vaginal intercourse 10 Insertive anal intercourse 6.5 Insertive penile-vaginal intercourse 5 Receptive oral intercourse** 1 Insertive oral intercourse** 0.5
* Estimates of risk for transmission from sexual exposures assume no condom use. ** Refers to oral intercourse performed on a man.
Heterosexual Intercourse (penile vaginal sex) 3 Heterosexual intercourse is the most common route of HIV acquisition for females in the United States, and the most common mode of HIV infection for males and females worldwide. Heterosexual intercourse during menstruation may increase the risk of transmission from an infected female to an uninfected male. In the U.S., infectivity estimates are higher for male-to-female transmission than female-to-male transmission (in some areas of the developing world estimates of female-to-male transmission are higher than in developed countries, though the reasons for this are unclear). Anal Intercourse (penile anal sex) 3 The risk of HIV infectivity is higher for the receptive partner in penile anal sex than for the insertive partner, but it is critical for patients to be aware that both behaviors carry a risk of HIV transmission.
46 CHAPTER 5 HIV transmission to the receptive partner most likely occurs as a result of HIV-infected semen coming into contact with traumatized rectal mucosa. “Pulling out” prior to ejaculation is also unsafe—exposure to pre-ejaculate may also carry a significant risk of transmission. Rectal Douching and Rectal Fisting3 Rectal douching and rectal fisting have been shown to increase risk of HIV infection in studies of MSM—this is likely due to rectal mucosa trauma which then facilitates entry of HIV into the bloodstream during subsequent anal sex post-douching or fisting.
Oral Sex See Appendix C for in-depth information from the Centers for Disease Control and Prevention on the HIV transmission risks associated with oral sex. Oral Penile Sex3 Exact estimates of the risk of oral penile sex are difficult to obtain given that so few people practice oral sex to the exclusion of other, higher risk sexual activities. Generally, the risk of oral-penile sex is believed to be very low, but not necessarily risk-free (there have been reports of suspected transmission due to oral sex). Importantly, regardless of its relatively lower risk for HIV transmission, oral sex is clearly a risk factor for other STIs such as herpes and gonorrhea that may play a role in the acceleration of HIV disease-progression in co- infected patients. Oral Vaginal Sex3 The transmission risk associated with oral vaginal sex has received very little attention. There are case reports of female-to-male and female-to-female HIV transmission via oral-vaginal sex, but studies generally conclude that the risk is extremely low. However, like oral penile sex, oral vaginal sex is a risk factor for other STIs that may play a role in HIV disease-progression acceleration in co-infected patients. Oral Anal Sex3 Oral anal sex has not been shown to be an independent risk factor for HIV infection based on studies with MSM. However, oral anal sex is an effective route of transmission for other harmful pathogens, such as Hepatitis A and B and parasitic infections (e.g., giardiasis and amebiasis).
CHAPTER 5 47 An Important Note about Oral Sex . . . Some patients believe that using mouthwash after oral sex will help minimize the risk of acquiring HIV or another STI. There is no scientific evidence that this practice has any effect on likelihood of HIV/STI transmission.
Other Factors Affecting Sexual Transmission of HIV Viral Load4,5,6 Generally, research suggests that individuals with low blood plasma viral loads are less infectious than individuals with high levels of blood plasma viral load. However, low levels of plasma HIV viral load are generally relevant for transmission only to the degree to which they mirror low levels of HIV present within the rectal tissues, the female genital tract, and the semen of HIV-infected men. One study5 of HIV-positive women found that although more women with detectable plasma viral load had concurrent HIV-1 genital tract shedding (80%), a significant minority of women (33%) with less than 500 copies/mL plasma RNA also had genital tract shedding. A similar study found genital shedding in 25% of women with undetectable plasma viral loads.6 Therefore, while risk of transmissibility may be highest among patients with higher levels of plasma viral load, a significant number of patients with low or undetectable plasma viral load remain potentially infectious. Antiretroviral Therapy4,7,8 Antiretroviral therapy (ART) has been shown to be effective in reducing the mortality and morbidity associated with HIV. The impact of ART on HIV transmissibility is less defined. While ART has been shown to reduce plasma viral load, the extent to which it decreases the likelihood of HIV transmission depends in part on the impact of ART on the amount of HIV present in semen, the genital tract, and rectal mucosa. Studies have demonstrated that even among individuals on ART with fully suppressed plasma viral load, seminal shedding may still occur. For example, one study of 7 men on ART with no detectable plasma viral RNA (<50 copies/mL) demonstrated proviral DNA in seminal cells of 4 of the men, suggesting “that the genital tract can be a reservoir for HIV-1 replication in men.” 7 The penetration of a given antiretroviral drug into the male genital tract is not consistent across drugs: it is highly drug-specific (see Taylor et al.8 for an in-depth description of drug concentrations). Although very few studies have evaluated drug concentrations in the female genital tract, variation also has been observed.
48 CHAPTER 5 Overall, current evidence suggests ART may have a role in reducing the sexual transmissibility of HIV, but the impact remains to be definitively demonstrated. Even if infectivity is reduced via ART for some patients, this is not necessarily true for all patients.
Similarly, the extent to which low plasma viral loads are mirrored within the male and female genital tracts also appear to depend upon the drug regimen given. Generally, combination therapy is more effective at reducing genital shedding than monotherapy; suboptimal regimens tend to be less effective. Stage of HIV Infection4 Primary HIV-1 infection is a stage of disease in which individuals may be particularly infectious, as plasma viral load and genital HIV secretions tend to be very high during this stage. Similarly, advanced disease may also be a stage of increased risk for transmissibility, possibly related to increased viremia during this stage as well. Presence of Other Sexually Transmitted Infections4 The presence of genital ulcer disease (e.g., herpes, syphilis, chancroid) in either sexual partner appears to increase risk of HIV transmission. Specifically, STIs with genital ulcers in an HIV-infected individual may increase the likelihood that that person may transmit the virus to a partner. Similarly, presence of genital ulcers in an uninfected person may also make them more susceptible to acquiring HIV. Even individuals with asymptomatic genital ulcer disease may be more at risk for transmitting or acquiring HIV given that reactivation of these diseases is often sub-clinical. Non-ulcerative STIs may also impact upon the transmissibility of HIV, but they appear to do so primarily by increasing the risk of HIV acquisition for the receptive partner. Other Active Illnesses4 Systemic illnesses (e.g., active TB) and opportunistic infections may increase the likelihood of HIV transmission via their impact on viral load.
CHAPTER 5 49 Use of Hormonal Contraception4 Use of hormonal contraception in women also appears to increase a woman’s risk of acquiring and transmitting HIV. While the mechanism is unclear, it may include effects on cell-mediated and humoral immunity, increased risk of cervical ectropion, and/or increased HIV shedding. Microbicide Use4 Clinical studies suggest that nonoxynol-9 may facilitate HIV transmission vaginally and rectally, as well as other STIs (despite its anti-HIV properties in vitro), and the CDC has recommended that all individuals discontinue use of nonoxynol-9 for HIV prevention. Studies investigating the utility of other microbicides in protecting against HIV and STIs in women are currently under way. Circumcision4 The risk of HIV transmission from females to males is higher in uncircumcised men, and there is some suggestion from studies that HIV- positive uncircumcised men may also be more infectious to their partners.
Increasing Accurate Information about Sexual Trans- mission of HIV/What your Patients Need to Know 1. An “undetectable” viral load does not mean you do not have HIV in your body: you can still transmit HIV even when you have an “undetectable” viral load.
2. Use of ART may reduce viral load and may make transmission of HIV less likely, but some people on ART with low or undetectable viral loads in their blood may still have high levels of the virus present in their semen or genital tracts and, therefore, still have a chance of transmitting the virus to others. 3. You can get reinfected with HIV if you have unprotected sex with partners who also have HIV. Getting reinfected may make your HIV progress faster, and/or you may get reinfected with a strain of HIV that is not responsive to medication. 4. If you acquire a sexually transmitted infection, it may make your HIV worse (or make you more likely to transmit HIV to your partners). 5. Use of nonoxynol-9 is not recommended, as it can actually make transmission of HIV more likely to occur. 6. Uncircumcised men may be at increased risk of acquiring or transmitting HIV. 7. People who have recently acquired HIV or who have advanced HIV
50 CHAPTER 5 disease may be more likely to transmit the virus to others, as they may have particularly high levels of the virus present. 8. Relatively speaking, oral sex (oral-genital or oral-anal) is comparatively lower-risk behavior, but there have been case reports of people who appear to have acquired HIV through oral sex. Oral-anal sex is also a risky practice for acquiring other illnesses, such as hepatitis. 9. There is no evidence that using mouthwash after oral sex will minimize the risk of acquiring HIV or another STI. 10. Rectal douching and rectal fisting may increase the likelihood of HIV transmission during subsequent anal sex, as both practices may damage the lining of the rectum and facilitate HIV entry. 11. Receptive anal sex appears to be more risky than insertive anal sex, but both carry a significant risk of HIV transmission. 12. Heterosexual intercourse while a woman is having her period may increase the risk that she will transmit HIV to her male partner.
Medication Adherence, Viral Load, and the Options Intervention Studies have demonstrated that patients with low or undetectable plasma viral load tend to be less infectious to others through sexual contact (i.e., they tend to have less HIV present in their semen or genital tract). Therefore, strategies to increase patients’ adherence to medication regimens and other medical care recommendations may also have important implications for decreasing the risk of HIV transmissibility. It is important to note, however, that plasma viral load measures do not always correlate with the amount of viral load in semen or the genital tract (see above sections on Viral Load and Antiretroviral Adherence). Therefore all individuals with HIV, regardless of their viral load, should be considered infectious. In addition to encouraging HIV risk reduction, the Options intervention also may be beneficial to patients and their providers in promoting medication and medical care adherence. By facilitating open and honest discussions between patients and healthcare providers about barriers and challenges for safer sex and drug use, providers may observe that their patients are more open to discussing other HIV-related challenges (such as adherence) as well as strategies for improvement. Any intervention that strengthens the provider-patient relationship (as the Motivational Interviewing-based Options intervention is designed to do) may be useful for promoting a patient’s willingness to work as a team with their provider and follow care recommendations.
CHAPTER 5 51 References 1. CDC HIV/AIDS Fact Sheet: A Glance at the HIV/AIDS Epidemic. April 2006. Available at http://www.cdc.gov/hiv/resources/factsheets/At-A- Glance.htm. Accessed May 5, 2006. 2. Centers for Disease Control and Prevention. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR. 2005;54:1–19. 3. Lane T, Palacio H. Safer sex methods. HIV InSite Knowledge Base Chapter, December 2003. Available at http://www.hivinsite.org/ InSite?page=kb-07&doc=kb-07–02–02. Accessed December 23, 2005. 4. Chan D. Factors affecting sexual transmission of HIV-1: current evidence and implications for prevention. Curr HIV Res. 2005;3:223–241. 5. Kovacs A, Wasserman SS, Burns D, et al. Determinants of HIV-1 shedding in the genital tract of women. Lancet. 2001;358:1593–1601. 6. Fióre JR, Suligio B, Saracino A, et al. Correlates of HIV-1 shedding in cervicovaginal secretions and effects of antiretroviral therapies. AIDS. 2003;17:2169–2176. 7. Zhang H, Dornadula G, Beumont M, et al. Human immunodeficiency virus type 1 in the semen of men receiving highly active antiretroviral therapy. N Engl J Med. 1998;339:1803–1809. 8. Taylor S, Boffito M, Vernazza PL. Antiretroviral therapy to reduce the sexual transmission of HIV. J HIV Ther. 2003;8:55–66.
52 CHAPTER 5 Recommended Reading Buchbinder SP, Hecht FM, Klausner JD, Osmond D, Page Shafer K, Vittinghoff E, Peiperl L (convener), Coates T (moderator). Risk of HIV infection through receptive oral sex. HIV InSite Roundtable Discussion March 14, 2003. Available at http://www.hivinsite.com/InSite?page=pr-rr-05. Accessed May 3, 2007. del Romero J, Marincovich B, Castilla J. Evaluating the risk of HIV transmission through unprotected orogenital sex. AIDS. 2002;16:1296–1297. Fethers K, Marks C, Mindel A, Estcourt CS. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Inf. 2000;76:345–349. Grulich AE, Hendry O, Clark E, Kippax S, Kaldor JM. Circumcision and male- to-male sexual transmission of HIV. AIDS. 2001;15:1188–1189. Merchant RC, Mayer KH. Perspectives on new recommendations for nonoccupational HIV postexposure prophylaxis. JAMA. 2005;293:2407–2409. Page-Shafer K, Shiboski CH, Osmond DH, et al. Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men. AIDS. 2002;16:2350–2352. Richters J, Grulich A, Ellard J, Hendry O, Kippax S. HIV transmission among gay men through oral sex and other uncommon routes: case series of HIV sero- converters. AIDS. 2003;17:2269–2271. Royce RA, Sena A, Cates W, Cohen MS. Sexual transmission of HIV. N Engl J Med. 1997;336:1072–1078.
CHAPTER 5 53 54 Chapter 6 Sexual Behaviors, Relative Risk, And Safer Alternatives
here are many different types of sexual behaviors, all of which carry their own associated levels of HIV transmission risk and recommendations for Trisk reduction. People living with HIV/AIDS can engage in a number of sexual behaviors that are safe, sexually satisfying, and do not involve penetration. To assist providers in becoming familiar with the variety of sexual behaviors available and practiced, this chapter includes: Different types of sexual behaviors. Definitions of the different behaviors when appropriate. Information about relative risk for transmission of HIV and STIs for each behavior. Risk reduction strategies to make each behavior safer (as appropriate). Tip
Becoming familiar with the different kinds of sexual behaviors commonly practiced within different populations can assist providers in working with their HIV-positive patients and their diverse risk reduction needs.
Harm Reduction Options for Sexual Behavior Patients who are interested in learning about, trying, or adopting sexual behaviors that carry no or lowered transmission risk may consider the alternatives to penetrative sex listed in this chapter. The risks associated with each sexual behavior are listed as well as methods of reducing those risks. It is important to work toward risk reduction rather than elimination of a risk behavior when the patient reports intending to continue the behavior. 55 Phone Sex HIV Transmission Risk: None Description: Talking sexually over the phone with a known partner or a consenting stranger while masturbating. Using phone sex services including listening to recorded messages of people talking sexually, listening to recorded ads left by people who want to be called, calling a professional sex worker, and calling live party-line connections where it is possible to talk with one or more people at a time. HIV Transmission Risk: There is no risk of HIV transmission from phone sex because there is no physical contact between partners. Other Risks: Phone sex services can be expensive (i.e., as much as $3 a minute) and addictive.
Cyber Sex (sex on the Internet) HIV Transmission Risk: None Description: Viewing provocative websites on the Internet or talking sexually to others via chat rooms or instant messaging programs while masturbating. HIV Transmission Risk: There is no risk of HIV transmission from sex on the Internet because there is no physical contact between partners. Other Risks: Not knowing the identity of the other person is risky. To avoid unnecessary social risks, the relationship should be confined to the Internet.
Fantasy HIV Transmission Risk: None (may be higher if it includes sexual contact) Description: Talking about or enacting sexual fantasies with partners, including taking on different roles, playing different parts, and dressing up in different clothes. HIV Transmission Risk: While fantasy itself does not carry any risk of HIV transmission, other sexual behavior included in the enactment may carry risk. Appropriate precautions need to be taken to prevent transmission of HIV or other STIs.
56 CHAPTER 6 Reducing Risk: When enacting fantasies that lead to sexual contact, condoms or other barrier methods should be used to minimize exposure to HIV and other STIs. Individuals who engage in sexual contact during their fantasy enactment may benefit from planning and developing strategies to incorporate prevention into their fantasy enactments.
Massage HIV Transmission Risk: None (may be higher if it includes sexual contact) Description: Massage (with or without oil) used both as a form of foreplay and by itself as a form of safer sex. HIV Transmission Risk: Massage itself poses no risk of HIV transmission. If a massage leads to intercourse, any oil used during the massage will weaken latex condoms and may cause them to break. Reducing Risk: If oil is used, it should be kept away from the vagina and penis if intercourse follows, and should be cleaned off one’s hands before putting on a condom.
Frottage (external body rubbing to orgasm) HIV Transmission Risk: None Description: Rubbing one’s body against his/her partner’s body to achieve orgasm. HIV Transmission Risk: Frottage poses no risk of HIV transmission because there is no penetration.
Kissing HIV Transmission Risk: Low Description: Romantic or sexual mouth-to-mouth contact. Often French or deep kissing which involves stimulating the lips, tongue, and mouth and the exchange of saliva.
CHAPTER 6 57 HIV Transmission Risk: There is a low risk for HIV to be transmitted through kissing—researchers have found infectious HIV in the saliva but only in extremely low titers. It is very difficult to transmit HIV through kissing unless both people have open wounds in the mouth. There has been no evidence of HIV transfer via saliva alone; blood appears to be a necessary component. There is one documented case where HIV was thought to be transmitted from one person to another through kissing, but the transmission of HIV was found to be associated with blood in the saliva of both individuals.1 This was a unique case in which gum disease in both people caused excessive bleeding. Other Risks: There is some risk of acquiring an STI during kissing, but generally the risk is low. The risk increases if one or both partners have bleeding gums, cuts, or sores in the mouth. Reducing Risk: Taking good care of teeth and gums will help reduce any risk from kissing.
Mutual Masturbation HIV Transmission Risk: Low Description: Each partner self-masturbating in the presence of the other, or each partner stimulating or masturbating the other. HIV Transmission Risk: There is no risk of HIV transmission if each partner self-masturbates in the presence of each other because there is no exchange of or contact with fluid. If each partner is stimulating/masturbating the other, the behavior carries a minimal risk because there is a possibility that blood, semen, or vaginal secretions can enter the body through any cuts on the hands. Reducing Risk: The use of finger cots or gloves will reduce the risk by protecting any cuts, cracks, or scratches on one’s hands.
Finger Play HIV Transmission Risk: Low Description: Inserting one’s finger(s) into the vagina or anus of his/her partner.
58 CHAPTER 6 HIV Transmission Risk: There is a relatively low risk for HIV transmission during finger play. Transmission of HIV may occur if vaginal secretions or blood from inside the vagina or anus gets into any cuts or scratches that are on the fingers of the person who is inserting his/her fingers. Other Risks: Fingers can carry other infections that can be transmitted from the fingers to the vagina or anus. Reducing Risk: To minimize risk of HIV transmission, the person inserting their fingers may want to wear a condom, finger cot (i.e., a piece of latex that covers a single finger), or disposable glove, especially if there are cuts, cracks, or scratches on their fingers. One should keep fingernails short and smooth and remove rings prior to insertion to prevent damage to the delicate membrane of the vaginal or anal wall. Sufficient water-based lubricant should be used to reduce the risk of tearing the membrane of the vaginal or anal wall. The person inserting their fingers should always wash their hands before insertion, especially if one has their own semen or vaginal secretion on them. Hands should be cleaned using hot water and antibacterial soap. If a person is putting their fingers inside multiple vaginas or anuses in one setting, they must clean their fingers or change gloves between partners, as HIV and other STIs can be transferred from one person to another. Gloves should be worn if the person has warts on their fingers or hands because warts can spread to others. If gloves are not worn, the person needs to clean their hands before touching their eyes, mouth, or anyone else’s genitals.
Nipple Play HIV Transmission Risk: Low Description: Manual and oral nipple stimulation and use of items such as nipple clamps, nipple suction devices, rubber bands, and hot wax. HIV Transmission Risk: Most behaviors involved in nipple play have no or very low risk for HIV transmission. Nipple clamps with teeth that can cut the skin may allow the transfer of blood, vaginal secretions, or semen that may be infected with HIV or an STI.
CHAPTER 6 59 Reducing Risk: “Spring-type” clothespins should be used in the place of nipple clamps that have teeth because they are less likely to cut the skin and inexpensive enough to throw away if they get dirty (i.e., with blood, vaginal secretions, or semen).
Shaving HIV Transmission Risk: Low (may be higher if sharing razors) Description: Shaving one’s genitals or their partner’s genitals as part of sex play. HIV Transmission Risk: Shaving is a relatively low-risk activity but carries more risk if razors are shared or if bleeding occurs. Reducing Risks: Clean, disposable razors should be used, and neither the razor nor the shaving cream used should be shared. Bleeding may occur after shaving, especially if one has sensitive skin. Therefore, sexual contact should be avoided if bleeding is present. It is recommended that people not have sex immediately after shaving either or both partner’s genitals. If they do have sex, condoms should be used.
Bondage HIV Transmission Risk: Low (may be higher if skin is broken) Description: Being tied up or restrained as part of sex play. Often used in S&M (sadomasochism) activities. HIV Transmission Risk: Bondage has an increased risk of HIV transmission when the skin is broken. Cuts can allow HIV and other STIs into the body via blood, vaginal secretions, or semen. Reducing Risk To avoid abrasions and cuts, cuffs and straps should be used rather than ropes, which are more likely to damage the skin.
60 CHAPTER 6 Whipping/Spanking HIV Transmission Risk: Low (may be higher if skin is broken) Description: Hitting or being hit with a hand or other object including bullwhips, cat o’nines tails, and paddles as part of sex play. Often used in S&M (sadomasochism) activities. HIV Transmission Risk: Whipping and spanking have an increased risk of HIV transmission when the skin is broken. Cuts can allow HIV and other STIs into the body via blood, vaginal secretions, or semen. Reducing Risk: To avoid cutting the skin, cat-o-nine tails and crops should be used in place of paddles with sharp edges or whips with metal tips that are more likely to damage the skin. It is necessary to clean whips, paddles, and other tools after using them to remove any blood, vaginal secretions, or semen. To disinfect these items (especially those made of metal, plastic, or other nonporous materials), wash with hot soapy water, soak for 2 or 3 minutes in a 10% bleach–90% water solution, rinse well with hot water, and air-dry. For items made of leather or suede, which could be damaged by bleach, refer patients to the book Leather and Latex Care by Kelly J. Thibault.
Rimming (analingus) HIV Transmission Risk: Low Description: Mouth-to-anus sexual play. HIV Transmission Risk: The risk for HIV transmission during rimming is relatively low if no blood is involved. The risk increases if open fissures or sores are present in the mouth or rectum. Other risks: The risk of transmitting parasites, hepatitis, and various forms of dysentery during rimming is very high. Acquiring an STI or an intestinal disease can weaken the immune system and make it more difficult for HIV-positive individuals to fight off opportunistic infections.
CHAPTER 6 61 Reducing Risk: Risk can be reduced by using a dental dam, glyde dam, or plastic wrap while engaging in rimming. Only one side of the barrier should be used so that any infection will not enter the mouth. Showering prior to engaging in rimming may help reduce risk of transmitting infections.
Golden Showers (water sports) or Scat HIV Transmission Risk: Low Description: Using urine or fecal matter, respectively, during sexual activity. HIV Transmission Risk: Sex play with urine or fecal matter has a relatively low risk of transmitting HIV unless blood is present. Infectious HIV exists in urine but at extremely low titers, and there have been no reports of HIV transmission via urine. HIV is not found in feces though blood is more commonly found in fecal matter than in urine. Other Risks: Because urine and fecal matter are both bodily fluids, they can transmit hepatitis as well as intestinal infections. Reducing Risk: Urine and fecal matter should be kept away from cuts, open sores, and eyes. Neither urine nor fecal matter should be ingested. Individuals engaging in these behaviors should thoroughly wash their hands or other contacted areas with disinfecting soap.
Fisting HIV Transmission Risk: Low (but may increase transmission vulnerability without precautions) Description: Inserting one’s hand/fist into a partner’s vagina or anus. Anal fisting or handballing refers specifically to inserting a hand/fist into an anus. HIV Transmission Risk: There is a relatively low risk of transmission of HIV and other STIs during fisting if appropriate precautions are taken.
62 CHAPTER 6 It can take up to two or three days for the anal/rectal membranes to fully recover after deep anal fisting, making a person more vulnerable to transmitting or acquiring HIV or other STIs. The most commonly used lubricants for anal fisting are oil-based, which can weaken the latex in gloves and condoms making them more likely to break. Reducing Risk: To minimize damage to the vaginal or anal wall, one should keep his/her nails short and smooth, not wear any jewelry on one’s fingers or hands, and use plenty of water-based lubricant. Gloves should be worn to cover any cuts on the hand. If any blood is noticed, fisting should cease and intercourse should be avoided. The use of mind-altering substances should be avoided with anal fisting as they can block pain sensations for the receiving partner that would signal the need to stop. Oil-based lubricants such as Crisco have traditionally been popular for anal fisting because the anal passageway needs to be well-lubricated for long periods of time during fisting, and water-based lubricants need to be reapplied or reconstituted often. However, because oil-based lubricants break down latex gloves, silicone-based lubricants should be used in place of traditional oil-based lubricants. A small number of advanced anal fisters have penetrated through the rectum to near the transverse colon, with the person’s arm doing the penetration inserted to near the elbow. Some healthcare professionals feel that unless there are visible cuts on the arm, it is okay to penetrate to beyond the base of the glove. Because oil-based lubricants are most commonly used in anal fisting, latex condoms are not recommended for use following fisting. If one is going to engage in anal intercourse after using an oil-based lubricant for fisting, a polyurethane condom should be used and extreme care taken to maintain the integrity of the barrier. If a person chooses to put their ungloved fingers, hands, or fists in someone’s vagina or anus/rectum, they should thoroughly clean their hands using hot water and antibacterial soap, with particular attention to beneath the fingernails before putting them in or near their own mouth or eyes or on anyone else’s genitals.
Use of Sexual Toys HIV Transmission Risk: Low Description: Using sexual toys including vibrators, dildos, butt plugs, and cock rings.
CHAPTER 6 63 HIV Transmission Risk: The use of sexual ‘toys’ has a relatively low risk of transmitting HIV if the items are used safely and not shared between partners without thorough cleaning and changing of the protective condom used on them. The linings of the vagina and anus/rectum are easily damaged by objects inserted into them, which means that traces of HIV- or STI-infected blood can end up on the toys and be transferred if used again without cleaning. Reducing Risk: When sharing toys, it is critical to cover the toys with a condom (or glove or finger cot), and then change the condom between partners, or clean the sex toys between partners by washing them thoroughly. Toys can be cleaned by washing them with hot water and disinfectant soap, or they can be disinfected with bleach and then rinsed well with water. (Note: Over time, bleach can cause cracks to develop in the rubber or plastic). Toys that are made of silicone, such as some dildos and butt plugs, can be boiled up to 3 minutes, cleaned with a bleach solution, or run through a dishwasher. Toys that are made of rubber are porous and difficult to completely sterilize. With rubber toys, it is best not to share them at all; they should be used with condoms if shared. Toys with batteries cannot be submerged in water and should be used with condoms if shared. Dildos, butt plugs, and vibrators that are made of smooth, pliable soft rubber or plastic should be used to minimize damage to the vagina and anus/rectum. Objects that are sharp, breakable, pointy, rough, hard, or inflexible should not be used as a sexual toy, and any toy that develops holes or cracks should be replaced. Toys with a string or handle should be used, or part of the toy left outside the body, to remove easily. Cock rings should not be used continuously for prolonged periods of time (longer than 24 hours) as the rings can cause tissue damage.
Piercing HIV Transmission Risk: Low to moderate Description: Piercing one’s genitals or nipples as part of sex play or having intercourse with a pierced penis. HIV Transmission Risk: There is some risk of acquiring HIV when getting pierced if the equipment hasn’t been sterilized.
64 CHAPTER 6 The vaginal or anal wall can be damaged by a pierced penis, which increases the risk of transmission of HIV and other STIs. Condoms are more likely to break when worn over a pierced penis, increasing the risk of transmission of HIV and other STIs. Other Risks: There is a risk of acquiring Hepatitis C when getting pierced if the equipment has not been sterilized. Reducing Risk: To minimize the risk of acquiring blood-borne diseases, permanent piercings should only be done by an experienced piercer. Piercings under 2 months old should be treated as open wounds that can transfer or acquire diseases and should be protected from contact with other people. If a person gives or receives play piercings, it is important that the site to be pierced is first disinfected with one or more of the following: Betadine, Benzalkonium Chloride, or 70% rubbing alcohol; and applied by using pre-packaged cleansing towelettes. Sterile, disposable needles, which can be purchased from a medical or scientific supply shop, should then be used for the piercing. Needles should not be shared. Used needles should be disposed of carefully in a sharps container, which is a sealed, unbreakable container. Sharps containers should not be disposed of in the trash—individuals should contact their local health department or ask their physician about where sharps containers may be dropped off.
Oral Sex HIV Transmission Risk: Low to moderate Description: Using the mouth to stimulate the genitalia. Known as fellatio when performed on a man and as cunnilingus when performed on a woman. May be performed as its own sex act or as foreplay. HIV Transmission Risk: The risk of transmitting HIV during unprotected oral sex is controversial. While there have been documented cases of HIV transmission via oral sex, it is difficult to assess the actual risk because most people who have oral sex also engage in vaginal or anal intercourse. Oral sex is relatively less risky than anal and vaginal sex.
CHAPTER 6 65 HIV can enter the bloodstream of the receptive partner through chapped lips, gum disease, sores, or scrapes. Other STIs can be transmitted which can seriously compromise or complicate the health of HIV-positive individuals. Other risks: Herpes can be transmitted from mouth to genitals or genitals to mouth. Gonorrhea, syphilis, and genital warts can be transmitted from genitals to mouth. Yeast infections may also be transmitted from unprotected oral sex. Reducing Risk: One oral sex risk reduction strategy is to use a condom or dental dam. When performing oral sex on a woman, dental dams, plastic wrap, and cut-up condoms may offer protection against HIV, STIs, and yeast infections. Only one side of the barrier should be used so that the vaginal secretions do not enter the mouth. Unprotected oral sex on a woman should be avoided when she is menstruating because blood is involved. If a barrier method (e.g., cut-up condom, dental dam) is not used during oral sex, the risk of transmission of HIV and other STIs may be reduced by:
— not brushing or flossing teeth for an hour before having oral sex, as this can cause small cuts or tears in gums, increasing HIV/STI transmission risk.
— avoiding oral sex if one has periodontal disease.
— avoiding aggressive oral sex with a man’s penis as it can do damage to the back of the throat and thus increase the risk of transmission.
— removing the penis from the mouth before ejaculation so that semen does not enter the mouth. However, many men emit pre- ejaculate fluid during oral sex, so removing one’s mouth before orgasm does not guarantee that there is no contact with HIV- infected (or STI-infected) semen.
— spitting the semen out immediately rather than waiting or swallowing if one’s partner does ejaculate in one’s mouth.
Vaginal Intercourse HIV Transmission Risk: High (without condom use) Description: Insertion of the penis into the vagina.
66 CHAPTER 6 HIV Transmission Risk: Vaginal intercourse without a condom is one of the most risky sexual behaviors for the transmission of HIV and STIs. It is estimated that women are more likely to acquire HIV during a single episode of unprotected vaginal intercourse than are men.2 The risk of transmitting HIV is greater when a woman is menstruating because blood is present. Other factors can increase the likelihood of transmitting HIV through unprotected sex, such as the presence of ulcerative STIs and a high viral load. Other Risks: Unprotected vaginal sex can also result in the transmission of yeast infections and STIs. Reducing Risk: The safest protection against HIV and STI transmission during vaginal sex is using a condom (a male condom or female condom) correctly and consistently.
Anal Intercourse HIV Transmission Risk: Very high (without condom use) Description: Insertion of the penis into the rectum. HIV Transmission Risk: Anal intercourse without a condom is the most risky sexual behavior for the transmission of HIV.2 The partner of an HIV-infected individual is at risk of acquiring HIV if a condom is not used, and HIV-infected individuals are at risk of acquiring other STIs and possibly being reinfected with another strain of HIV. Because rectal walls are very thin, tiny or invisible blood capillary breaks or abrasions can occur during anal intercourse. Semen can enter the microscopic rectal blood capillary breaks and infect/reinfect the individual with HIV or other STIs. Breaks in the mucosal lining of the rectum are not necessary for transmission to occur. Direct infection of bowel mucosal cells has been observed. The risk of HIV transmission is still present even if the man withdraws before he ejaculates because there is a possibility of pre-ejaculate fluids being released into his partner’s rectum. The risk of transmission is greater for the receptive anal sex partner than the insertive partner2; however practicing only receptive anal intercourse is not an effective risk-removal strategy for HIV-positive individuals.
CHAPTER 6 67 The insertive partner is still at risk for HIV and other STIs because his partner’s rectal blood can enter his penis through microscopic breaks in the skin of his penis. Reducing Risk: If one chooses to have unprotected anal intercourse, the risk of HIV transmission may be slightly reduced by practicing receptive anal sex only or avoiding ejaculation into the partner’s anal cavity. Condoms are the safest protection again HIV and STI transmission; use of condoms is strongly encouraged for anal intercourse.
Group Sex HIV Transmission Risk: Very high (without condom use) Description: Any sex act performed by more than 2 participants at a time. HIV Transmission Risk: Engaging in group sex is a very risky behavior for transmitting HIV or other STIs because it involves the riskiest sexual behaviors (vaginal and anal sex) with multiple partners. All risks of HIV transmission of vaginal and/or anal sex are present in group sex, with the additional risk of passing HIV and other STIs from one partner to another. Reducing Risk: The correct and consistent use of condoms is the safest protection against HIV and STI transmission and acquisition. To reduce spreading disease from one’s partner to another partner, men need to change condoms between partners, and women using the female condom need to insert a new condom with each partner. One partner should wear the male or female condom. Using both condoms will cause friction and may lead to tears in one or both condoms, slipping of one or both condoms, or displacing the ring inside the female condom. If group oral sex is performed on women and dental dams are being used, barriers need to be changed between partners so that one woman’s vaginal secretions will not be transferred to another woman.
68 CHAPTER 6 References 1. Centers for Disease Control and Prevention. HIV and its transmission. Fact sheet available at: http://www.cdc.gov/HIV/pubs/facts/transmission. htm. Accessed June 28, 2006. 2. Centers for Disease Control and Prevention. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR. 2005;54:1–19.
CHAPTER 6 69 70 Chapter 7 Identifying Risk Triggers For Safer Sex and Drug Use Lapses
The Challenge of Maintaining Behavior Change nce a person is motivated to reduce their HIV transmission risk behavior and begins to make a change, it can be a significant challenge Oto maintain that behavior change over time. As with any health behavior (e.g., exercise, eating right, smoking cessation), individuals who wish to practice safer sex, stop using drugs, or practice safer drug use will often experience “slips” or “lapses,” or will at least be tempted to give in and forego safer behavior at some time.
Note the use of the word “lapse” or “slip” instead of “relapse.” The term relapse reinforces the mistaken all-or-nothing view of behavior change where a single slip is often interpreted as a failure that one can do nothing about. The term lapse or slip emphasizes the incident as a single occurrence and not as indicative of a full-scale return to consistently practicing the less safe behavior (i.e., relapse). It is important for providers to understand that behavior change is a process, not an all-or-nothing event. By recognizing that lapses are common, and encouraging patients to use their lapses as learning experiences, providers will be able to facilitate long-term behavior change and help patients avoid the guilt, dismay, and self-blame that often accompany a lapse (often referred to as the Abstinence Violation Effect).
The Relapse Prevention Model Applied to HIV Prevention The Relapse Prevention (RP) model1 is based on a cognitive-behavioral framework that focuses on preventing and managing lapses in individuals who are in the process of a health behavior change. The RP model has been most widely applied to substance abuse but has also been successfully applied to other health behaviors and mental health problems as well.2 The RP model can be applied to the reduction of HIV transmission risk behaviors to give providers and patients strategies for understanding the challenges patients face in long-term behavior change, and tools to deal with those challenges.
71 The goal of RP is to help individuals who have made a health behavior change to anticipate and prevent a full-blown relapse. RP strategies help patients (1) identify high-risk situations for lapses, and (2) provide skills to effectively manage those situations, cope with urges and cravings, and reframe their negative reactions to lapses. Although RP is often used by mental health providers with patients in ongoing therapy for the target behavior, RP strategies can be useful for HIV physicians and other clinical care providers helping their patients maintain safer sex and drug use behaviors. These strategies1 include: 1. Identifying high-risk situations for relapse. 2. Developing adaptive behavioral responses and problem-solving skills to cope with high-risk situations. 3. Changing maladaptive thought patterns to better deal with high-risk situations, urges, and lapses. 4. Learning from safer sex and drug use lapses. 5. Reinforcing safer behaviors.
Identifying High-Risk Situations The Context of Safer Sex and Drug Use Lapses Many people who are trying to change a behavior will experience one or more lapses in the process. These lapses can be seen as important learning opportunities for maintaining behavior change in the future. Lapses typically do not occur “out of the blue.” Often they are triggered by one or more psychological, interpersonal, or social factors. High-risk situations vary from person to person and also within a given person at different times. Aspects of high-risk situations that may be triggers include: People Places Events Social pressure (either direct or indirect) Interpersonal conflict Negative emotional states
High-risk situations may appear to arise without warning, often the result of a series of “apparently irrelevant decisions” 1 that people make without realizing the implications of their choices.
72 CHAPTER 7 For example, an HIV-positive man decides to walk to the store without his “safer sex kit” because he plans to come right home. He decides to go to a store down the street from a popular nightclub and bumps into a friend, who persuades him to go to the club for just one drink. Eventually, he goes home with another man he meets in the club and has unsafe sex.
Identifying High-Risk Triggers For a person to change their sex or drug use behavior (or maintain healthy behavior changes), they need to identify the circumstances––or triggers–– that are high-risk for them, as well as “apparently irrelevant decisions” that sometimes set up the high-risk situation. Each person has a unique set of challenges or triggers. That is, certain situations may be challenging to one person but not to another. Some patients who experience lapses find it difficult to identify their own unique high-risk triggers. Encourage a period of self-monitoring of safer sex/drug use lapses using a written record of psychological and environmental circumstances surrounding the lapse to review together. Once a person is able to identify the situations that are challenging for them personally, they can anticipate these situations and learn to handle them differently. Knowing what an individual’s own challenges are can help them have more control over their behavior. Encourage the patient to look at several factors to understand which situations are personally challenging for them: Different settings or environments (e.g., bars, dance clubs, parties). Different people (e.g., casual partners, primary partners, specific drug-using friends). Mood or feeling states (e.g., depressed, lonely, angry). Use of alcohol and/or drugs.
Adaptive Behavioral Responses and Problem- Solving Skills Once you have worked with a patient to identify and anticipate their own high-risk situations for unsafe sexual and/or drug use behaviors, help the patient develop skills for dealing with those situations. One of the most important skills is the ability to detect early warning signals for a lapse. In recognizing their own personal risk triggers for unsafe behavior, the patient will be better prepared to identify signs of a lapse and intervene early in the process, rather than later when it may be much more difficult to do so.
CHAPTER 7 73 For example, an IDU who is trying to avoid sharing his works with other users may find that he is most likely to do so when he is low on cash and needs to go in on a purchase with other users. It will be much easier for this person to intervene early in the process––when he realizes he is low on cash but before he jointly purchases the drugs––rather than later on, after he has spent his money to buy the drugs. Skills needed to prevent future lapses may vary from patient to patient and should apply to one’s specific psychological and environmental risk triggers.
Behavioral Skills Behavioral skills for coping with situations that are high-risk for lapses in safer behavior include: Assertiveness
— A patient may need to learn how to assert their desire to use condoms with their partner or to separate prepared drugs with clean needles. Stress management skills
— A patient who is more likely to engage in unprotected sexual behavior when feeling stressed or lonely may need to learn skills for managing those emotions. Relaxation training
— Patients can learn how to deal with high levels of stress, anxiety, or anger, and therefore avoid poor choices (such as unsafe sex or drug use) associated with those feelings. Communication skills
— An injection drug user may need help finding ways to tell his IDU partners that he is unwilling to share works anymore.
Social and/or dating skills
— An HIV-positive woman may need help developing skills for meeting new men so that she feels less trapped in relationships where she is pressured to engage in risky sexual behaviors. General problem-solving skills
— All patients can benefit from learning a set of highly flexible and generalizable skills for approaching and managing problems in their lives; this helps develop confidence and increases the likelihood that they will be able to deal with new situations as they arise.
74 CHAPTER 7 Urge surfing
— Patients can learn how to ride out the urge to engage in a risky behavior, as urges will inevitably peak and then subside with time. Urge-surfing is a concept that has been largely applied to alcohol and drug users who are dealing with psychological and physiological urges to use, but the concept can also be applied to safer sex and drug use behavior. Practice is very important for the development of these behavioral skills. As a person’s ability to use these skills to deal with high-risk situations increases, their confidence about their capacity to cope effectively will also increase, and their risk for lapse will decrease. Sometimes it is not practical to implement/rehearse these new skills in real life situations. Patients should be encouraged to rehearse them through imagining and role-playing possible and likely high-risk situations.
Stimulus Control Stimulus control is another important tool for helping patients mitigate their risk for unsafe sexual and/or drug use behavior lapses. Stimulus control refers to helping patients change their environment to reduce the likelihood that they will be exposed to high-risk triggers.
For example, an IDU who is trying to stop using drugs would avoid people and places previously associated with shooting drugs. An HIV-positive gay man who is trying to consistently practice safer sex with his partners would avoid MSM “Poz Parties” where unprotected sex is common. An HIV-positive woman who is more likely to engage in risky sex when she drinks or uses drugs would be encouraged to not drink or use drugs when there is any possibility she might have sex. While stimulus control can be a very important tool for patients to use in promoting maintenance of healthy behavior changes, it is typically not possible to fully control a patient’s present or future environment. Therefore, in addition to useful stimulus control strategies, patients should be encouraged to develop and practice the behavioral skills described previously for dealing with high-risk situations.
CHAPTER 7 75 Facilitating Adaptive Cognitive Responses In addition to developing more adaptive behavioral skills for dealing with high- risk situations, patients need to develop adaptive cognitive skills as well. Adaptive cognitive skills for relapse prevention refer to patterns of thinking about high-risk situations, urges, and lapses that are more likely to help the person, rather than hurt them, in their attempt to maintain healthy behavior changes. Central to this strategy is the idea that it is not a situation or event that determines a person’s emotional or behavioral response, but their appraisal (or perception) of that situation. Examples of maladaptive cognitive patterns include: Believing that there is no way to change a situation to facilitate safer behavior. Looking at a lapse in safer behavior as proof that a person really is a failure, or doomed to never change (the Abstinence Violation Effect). Feeling that an urge to have unprotected sex with a given partner is so strong that a person could never fight it. Seeing situational or personal factors as insurmountable to reach safer injection drug use goals. Patients should be encouraged to look at situations realistically and to avoid common maladaptive thought patterns that detract from behavior-change efforts, such as seeing things in all-or-nothing terms, “catastrophizing,” focusing only on the negative while ignoring the positive. (For more information about maladaptive thought patterns, see Feeling Good: The New Mood Therapy by David Burns.)
Learning From a Lapse Maladaptive cognitive appraisals are common when people experience a lapse. Some people use denial and rationalization to avoid exploring, excuse, or justify their lapses. Alternatively, some people start to ”catastrophize,” or think the worst, when they have had a lapse. These are not productive and can make the lapse more likely to happen again.
When your patient slips (lapses), they, and you, can regard the situation as a unique and specific event. A lapse should not be generalized to all situations, nor should it be interpreted as meaning that your patient is a failure at practicing safer behavior. Slipping does not mean that someone is a failure, has lost control, or is lacking in willpower. It just means that the person needs to learn from the slip and try a different strategy.
76 CHAPTER 7 Lapses should be dealt with constructively; they should be viewed as opportunities for learning rather than indications of total failure: for example, “I slipped in this situation, but I can learn from it. What can I do differently next time the situation arises?”
Unless your patient can look at the trigger situation and understand what happened, they are likely to make the same mistake again and feel even worse about themselves. To the extent that your patient can learn from their slip, even though they are feeling badly about it, the more likely they are to stay safer for the long term.
Factors to Consider in Evaluating a Lapse To reduce the likelihood that a lapse will happen again, when examining the lapse with your patient it is important to evaluate:
What was the sequence of events (thoughts, feelings, behaviors) that led up to the lapse?
Was the patient’s motivation level affected by things outside the situation, such as fatigue and stress?
Was the patient missing an important skill (or skills) to effectively cope with the situation?
Once you and your patient understand the individual-level and environmental circumstances that contributed to the lapse in safer sex or drug use behavior, you can determine what the patient needs to reduce the likelihood of future lapses.
Reinforcing Safer Behavior Knowing how challenging it is to consistently practice safer behavior, praise your patients when they do engage in safer behavior. Every time a patient practices safer behavior, they are helping themselves and their partner(s) stay healthy. If you and the patient want this behavior to continue, it is critical that you reinforce this behavior and not take it for granted. Often, because of time pressures and the orientation of the healthcare system to fix what is broken, it can become all too easy to focus on the mistakes patients make and to ignore their healthy choices. Just like everyone else, patients need encouragement, support, and acknowledgment of all their positive efforts. Positive reinforcement can be an extremely effective tool for behavior change. As a healthcare provider, you are an important figure in your patients’ lives; your encouragement and support may go a long way in helping your patients make long-lasting healthy behavior choices.
CHAPTER 7 77 References 1. Marlatt GA, George WH. Relapse prevention: introduction and overview of the model. Br J Addict. 1984;79:261–273. 2. Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychol. 2004;59:224–235.
78 CHAPTER 7 Chapter 8 Safer Sex Communication Skills
Safer Sex and the Role of Assertiveness ne of the most important skills individuals with HIV can use to consistently practice safer sex is the ability to communicate clearly, Oeffectively, and assertively with their partners. When encouraging patients to practice safer sex, providers may incorrectly assume that their patients already have these skills. In fact, in many situations, individuals may feel committed to safer sex (i.e., they have the motivation) but feel incapable of actually making that happen in the context of their particular relationships (i.e., they lack the behavioral skills). In the context of the Options protocol, providers may see weaknesses in this skill manifested as very high importance ratings for safer sex and very low confidence ratings. Tip While patients may be motivated to perform safer sex, they may not necessarily possess the skills to negotiate the use of condoms or other risk reduction strategies.
The following sections describe the difference between assertiveness and other types of communication, as well as strategies to help patients build their assertiveness skills.
Role of the HIV Care Provider in Building Assertiveness To the extent that time and comfort level allow, providers can work with their patients on building communication skills by:
providing guidance about the content of safer sex communications.
giving them support for asserting themselves.
offering some examples of strategies they could try to become more assertive. 79 Referral sources should also be used if the patient is having a particularly difficult time with assertiveness or is interested in working more in-depth on building effective communication strategies.
Considering the Risk of Domestic Violence Assertiveness may be potentially dangerous in the context of relationships that are currently violent or that have been violent in the past.
Who Is at Risk for Domestic Violence? While women are more likely than men to be victims of violence within intimate relationships,1 it is important to acknowledge that gay/bisexual men and heterosexual men are at risk for domestic violence as well.
Approximately 20% of HIV-infected women, 8%–24% of HIV-infected heterosexual men, and 12%–17% of HIV-infected gay/bisexual men report having experienced intimate partner violence within the past 6 months.1,2
These prevalence rates may underestimate the lifetime experience of intimate partner violence, especially among HIV-positive women. One study of women residing in low income, urban neighborhoods found that 65% of both HIV-positive and HIV-negative women had experienced intimate partner violence as an adult.3 Risk factors for victimization in relationships are fairly similar to risk for HIV, and include:
Poverty1
Unemployment1
History of childhood abuse1
Homelessness1
Younger age1,4
Ethnic minority status4
History of psychiatric illness4
Current binge drinking or drug dependency4 Sometimes issues related to HIV can also be a trigger for abuse in relationships when there is a history of intimate partner violence.1
80 CHAPTER 8 The Impact of Domestic Violence in the Context of HIV Victims of physical abuse may be more likely than non-victims to engage in unprotected sexual behaviors.2 There is some evidence that women who are victims of domestic violence may have an increased risk of being verbally abused or threatened with physical abuse and/or abandonment when they attempt to negotiate condom use.5 For some women, disclosing an HIV-positive test result to their partner may also be a trigger for violence, especially for women who are already in an abusive relationship.5 Tip
It is important to assess the risk of violence when working with patients who are having difficulty asserting their desire to use condoms or engage in other risk reduction strategies with their partner(s).
As with any situation where you suspect that your patient may be in danger, use referral sources and take steps to ensure safety when violence is an issue.
The Right to Be Assertive about HIV Risk Reduction Everyone has the right to be in control of what happens to their bodies. Often people forget this and feel that they do not have the right to be assertive. Patients often fear that condom use demonstrates a lack of commitment to their partner. It is not uncommon to hear HIV-positive patients talk about their partner’s annoyance over not being able to fully share everything about that patient when condoms are used. Such perceptions must be addressed by exploring whether there are other ways to confirm commitment and acceptance that would not involve risk of HIV transmission. Exploring these issues with partners who are insistent on having unsafe sex is extremely difficult and requires solid assertiveness and communication skills. Assertiveness skills require time and effort to develop, but patients can be encouraged to develop them by recognizing the possible consequences of being assertive about safer sex and emphasizing the consequences of not being assertive.
CHAPTER 8 81 Types of Communication Assertive communication allows a person to express their feelings, thoughts, and desires in a clear manner that is respectful and does not violate the rights of the other person. Being assertive is different from being aggressive, passive, or passive-aggressive, all of which can be quite destructive to a relationship.
Aggressive Communication What It Is: When a person is verbally aggressive, they state their goal, need, or view in a way that does not show respect for their partner’s rights.
Example: When a man’s partner tells him that he doesn’t want to use a condom because he doesn’t like the way it feels, the man responds by saying “Look, I’m using condoms whether you like it or not. I’ve already decided, and it doesn’t matter what you have to say about it.” Disadvantage: Aggressive communication often causes the person hearing the message to get defensive and makes them less likely to hear the other person. It can be very destructive: a person may get their way when they are aggressive but probably at the expense of the relationship.
Passive Communication What It Is: When a person is passive, they fail to state their goal, need, or view, ignoring their own needs and wishes.
Example: A woman wants to use condoms with her partner but never says anything when they have sex, fearing what he might think of her if she brings it up. Disadvantage: Being passive, or avoiding an issue, is rarely effective. In fact, passivity can lead to resentment, depression, anger, or other problems within the relationship.
Passive-Aggressive Communication What It Is: When a person is passive-aggressive, they fail to state their goal, need, or view but express their frustration with having an unmet need in other unproductive, sometimes destructive ways.
Example: A woman who wants to use condoms with her partner but never says anything when they have sex because she knows her partner doesn’t like the way they feel. She expresses her frustration by giving him the silent treatment after sex, without explaining why.
82 CHAPTER 8 Disadvantage: Being passive-aggressive doesn’t solve the problem, often leaves both people feeling hurt, and can eventually be quite destructive.
Assertive Communication and Safer Sex What to Communicate When negotiating with a partner about safer sex, a person needs to convey the following:
Communicating their wish to be safe.
Communicating that they are unwilling to be unsafe.
Communicating what specific behaviors they consider to be safe for themselves and their partner.
Negotiating or determining what kinds of sex are acceptable both to them and their partner.
How to Communicate The following guidelines will help increase the odds that your patient’s message will be heard by their partner(s): Clearly State Thoughts, Feelings, and/or Requests Assertive: It’s important to me that we use a condom. So if we have sex, I want us to have sex that is protected with a condom. Unassertive: I’d been thinking that, well, it might be good to, you know, take precautions of some kind, if that’s OK.
Use “I” Statements Assertive: I feel that it is very important for me to take care of my health, so I always practice safer sex. Aggressive: You have to wear a condom, because who knows where you have put that thing of yours.
Listen to What the Partner Is Saying This can be difficult. While the other person is talking, we are often deciding what we’re going to say next, rather than concentrating on what the other person is trying to tell us. One way to make sure we are listening is to think about how we would reflect back what has been said. Reflecting back is when we paraphrase what we just heard in our own words and check in to see if we understood what was shared. Encourage the patient to listen closely to what
CHAPTER 8 83 a partner is saying and think about how they would put what was shared into their own words. That can help keep the focus on the content of the communication.
Be Respectful—Acknowledge the Partner’s Feelings/Opinions This is important if the individual wants their partner to respect their feelings and opinions. Assertive: I know that you think it feels better without a condom, but I made a promise to myself before I met you to only have sex with a condom. Aggressive: I don’t care what you think. We’re going to do it with a condom or not at all.
Explain the Reason for the Position or Request The person should use reasons that are about them, not their partner. Assertive: I care about your health and my health so I want to be safe. Aggressive: I have no idea who you’ve been sleeping with, so we are going to be safe.
Check in with the Other Person Seek agreement or concurrence from the other individual or at least his/her acceptance with one’s own position. Assertive: Do you feel the same way? Assertive: Can you accept that this is important to me?
Refuse to Be Coerced into Something Not Wanted Refuse the unreasonable request or coercive behavior of the other person, especially when being pressured to behave in a manner that is inconsistent with one’s wishes. Assertive: I understand how you feel. But I feel just as strongly that the way to show we care about each other is to use condoms. I care about your feelings, but I won’t have sex unless we use a condom. Passive: Okay, if that’s what you want, we don’t have to use one . . . but I’d prefer to use one.
Match Nonverbal and Verbal Communication Make sure that one’s tone of voice, emotional expression, and body language are consistent with the content of one’s message and are appropriate to the situation.
84 CHAPTER 8 Tip Patients cannot make another person feel or behave in a certain way, regardless of how effectively and assertively they communicate. They can only take responsibility for what they say and do, not how the other person ultimately reacts.
Some Strategies for Establishing Safer Sex It is easier to set the stage for safer sex at the beginning of a physical relationship. Once a person starts engaging in unsafe or risky sex in a relationship, it may be more difficult to make the shift to safer sex. Any of the strategies listed below can help a patient establish their commitment to safer sex at the beginning of a relationship. When the ground rules for sexual contact are set early on, they are easier to maintain over time. Many of the strategies can also be used at any point in a relationship. It is never too late to make a change in the sexual dynamics of a relationship. It is very important to couple these strategies with assertiveness. Effective assertive communication often involves repeating one’s message multiple times. Research has found that when people are asked to do something they don’t want to do (such as using condoms), it is often easier for them to say no the first time, but they are more likely to give in when asked repeatedly. Any strategy––such as those illustrated below––has to be supported with assertiveness and other effective communication strategies. Inform patients that a single strategy may not make the request or pressure for unsafe sex stop entirely.
Examples of Verbal Strategies for Safer Sex Talking is the clearest and most direct way that an individual can let someone know what they want or don’t want. Below are some suggestions of what people practicing safe/safer sex have said or done to effectively communicate that commitment to their partners:
Before going home or before any sexual activity starts, a person might say, “I only have sex with condoms.” or “Guys who wear rubbers turn me on. Let me put one on you.”
If a person’s partner is going to put his uncovered penis in the person’s mouth and that person doesn’t want him to cum in their mouth, they can simply say, “Don’t cum in my mouth,” or they can request that their partner ejaculate elsewhere because it would be exciting for them to see/watch.
CHAPTER 8 85 Phrases such as “I’m not into that” or “I like this better” are ways of saying “No” that are less likely to bring about defensiveness in partners.
People should always be encouraged to clearly state “No.” No means no, and no one should feel guilty about saying it. Everyone has the right to say no when it comes to their body.
A person can communicate safer sex desires in a manner that emphasizes how desirable and sexy a partner is. When safe/safer sex behaviors are framed as sexy or sexually stimulating, they are often responded to in- kind, and the mood of the moment is seldom compromised.
Examples of Nonverbal Strategies for Safer Sex Nonverbal communication, or body language, can be a very powerful tool for communicating a person’s desires or feelings. Examples of ways to use nonverbal strategies to communicate about safer sex include:
Without uttering a word, a man can put a condom on himself as a way to communicate his desire to use a condom during sex.
A woman can insert a female condom up to 8 hours before having sex. With sufficient lubrication, the condom may go unnoticed by partners, leaving it completely up to her as to whether she wants to say anything to her partner.
Handing one’s partner a condom sends a simple and direct message of the intention to use one.
A person can put a condom in their mouth and then use their mouth to put the condom on their partner’s penis (i.e., “cheeking”).
A person can keep condoms in visible places for a sex partner to see. Some people keep condoms on a table right next to their beds, on their beds, on the floor next to their beds, or in other obvious places so that they can send a message to their sex partner that they practice safer sex.
One way to communicate the intention to use a condom is to do a striptease, where the person puts the condom on their own or their partner’s penis as part of the striptease.
A person can interest their partner in another sexual activity if they are being asked to do something they don’t want to. This gives a clear message about what one does and does not want to do without getting into a discussion about it. For example, if a woman’s partner moves their head down towards the woman’s vagina to perform oral sex on her without a dental dam, the woman can gently lift her partner’s head and start kissing them instead. This is a nonconfrontational way of conveying that she does not want oral sex right now.
A person can simply stop the behavior if something happens that they don’t like or feel comfortable with. 86 CHAPTER 8 References 1. Zierler S, Cunningham WE, Anderson R, et al. Violence victimization after HIV infection in a US probability sample of adult patients in primary care. Am J Public Health. 2000;90:208–215. 2. Bogart LM, Collins RL, Cunningham W, et al. The association of partner abuse with risky sexual behaviors among women and men with HIV/AIDS. AIDS Behav. 2005;9:325–333. 3. Burke JG, Thieman LK, Gielen AC, O’Campo P, McDonnell KA. Intimate partner violence, substance use, and HIV among low-income women. Violence Against Women. 2005;11:1140–1161. 4. Galvan FH, Collins R, Kanouse DE, et al. Abuse in the close relationships of people with HIV. AIDS Behav. 2004;8:441–451. 5. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Soc Sci Med. 2000;50:459–478.
CHAPTER 8 87 88 Chapter 9
Condoms and Lubricants
any men and women continue to engage in sexual behavior after being diagnosed with HIV. While the only way to guarantee 100% Mprotection against transmitting HIV and other STIs is to abstain from sexual behavior, male and female condoms, as well as other barrier methods, are highly effective at preventing transmission when used properly.
Male Condoms The male condom is a thin sheath of latex, polyurethane, or animal membrane (e.g., lambskin) that fits over the man’s penis and acts as a mechanical barrier to prevent pregnancy and reduce or prevent the spread of many sexually transmitted infections (STIs). Lambskin condoms are not effective in the prevention of STIs (including HIV) and should not be used for disease prevention.
Effectiveness of the Male Condom Used correctly and consistently, condoms are highly effective in preventing the transmission of HIV and most other STIs, including discharge and genital ulcer diseases.1 Laboratory studies have demonstrated that latex condoms provide an impermeable barrier to particles that are the size of sexually transmitted pathogens, including HIV.1 Epidemiological studies provide strong support for the effectiveness of male latex condoms in preventing HIV transmission, though evidence for protection against other STIs (including discharge and genital ulcer infections) is mixed, likely due to methodological shortcomings of studies to date.1 Although male latex condoms should be impermeable to genital ulcer diseases (e.g., HPV, herpes, chancroid), condoms can only provide protection against these infections when the infected area or area coming in contact with a partner’s infected area is covered by the condom, which is not always the case. Condoms lubricated with spermicides are not more effective than other lubricated condoms in protecting against HIV and other STIs, and nonoxynol- 9 (N-9) should not be used when trying to prevent HIV/STI transmission, as it may actually increase risk of transmission.2 89 Condom Failure Condom use can not guarantee 100% protection against transmission of HIV and other STIs, but most condom failures result from improper use and/or storage, so it is critical that users are informed of appropriate storage and usage methods. Condom slippage and breakage are two of the most commonly reported problems with condoms. Recent studies that have examined slippage and breakage in recent years (therefore representing the higher quality condoms manufactured today), estimate that condom failure due to slippage or breakage is between 1.6% and 3.6%.2 Factors related to slippage and breakage include user familiarity and knowledge, selection of proper condom size, and proper use of additional lubricant.2
Storage and Care of the Male Condom Remind patients to always check the condom expiration date and not to use expired condoms. If someone is unsure of how old a condom is, they should discard it and replace it with a new unexpired one. If a condom package is damaged, the condom may also be damaged and therefore should not be used. Condoms should not be carried in a wallet for long periods of time, as this can damage the condom. Condoms should be stored in a cool, dry place. Exposure to sunlight, heat, or humidity can break down latex, causing it to tear more easily.
How to Properly Use a Male Condom Condom effectiveness can be greatly enhanced by ensuring proper use. To be most effective, the condom should be put on the penis prior to any contact with the vagina (or anus, in anal sex), and carefully removed immediately after ejaculation. The following steps4 should be followed for proper condom use: 1. The expiration (EXP) date should be checked to make sure the condom has not expired. 2. The condom package should be opened carefully with fingers––not with teeth, scissors, knives, or other sharp objects. Care should be taken when opening a condom package that teeth, nails, or rings do not tear or nick the latex. (There is usually a little indentation in the packet that shows where to open it.) If the condom gets torn, it should be thrown out. 3. Lubricant should be applied to the inside tip of the condom.
90 CHAPTER 9 4. The penis foreskin should be pulled back and the rolled-up condom put on the head of the penis (right side up). 5. The tip of condom should be pinched between thumb and forefinger, and the condom rolled down over the penis. Unrolling the condom before putting it on can weaken the latex and make it difficult to use. The rolled up condom should be placed over the tip of the erect penis. The penis should be erect or the condom might fall off. The condom should be placed on the penis in the right direction. The condom should unroll onto the penis. If it is placed on the penis upside down, it won’t unroll. The receptacle or reservoir end of the condom is held between the thumb and forefinger against the head of the penis. If the penis is uncircumcised, the foreskin should be pulled back first. A space at the tip should be made so the semen will not leak out the side of the condom. The condom should be rolled over the entire length of the penis while the tip of the condom is squeezed. The condom must be unrolled all the way. 6. Space should be left at the tip of the condom. Some condoms are manufactured with built-in reservoirs, and some are not. If there is no built-in reservoir in the condom, one can be created by leaving some space at the tip of the condom. The reservoir is important because it leaves room for the semen and thus decreases the chance of breakage. Excess air should be removed to prevent the condom from bursting. (Friction against air bubbles is the cause of most condom breakage). 7. Once the condom is on, plenty of water-based lubricant should be applied. The lubricant makes movement easier and decreases the chances of breakage due to friction. Putting a drop of lubricant inside the tip of the condom (before the condom is put on) can increase both sensation and safety. Oil-based products such as Crisco, lotion, Vaseline, or baby oil should never be used as they will weaken the latex and cause it to break. (Oil-based lubricants can be used with polyurethane condoms but using water-based lubricants is recommended to prevent accidental use of oil- base products on latex condoms.) 8. After ejaculation, the condom should be held at the base of the penis and the penis withdrawn from the partner. After ejaculation, the penis should be withdrawn while still erect, and the base of the condom should be held onto to prevent it from falling off. If the penis is not withdrawn before the erection is lost, the condom might come off while inside the partner.
CHAPTER 9 91 9. The condom should be removed from the penis and disposed of. To remove, the condom should be gently rolled toward the tip of the penis to remove. Condoms should not be flushed down the toilet because they can clog plumbing. Condoms should be wrapped in a tissue and thrown away. Condoms cannot be reused. For added safety, some people choose to withdraw right before ejaculating in order to ensure that the condom doesn’t slip off or break.
Female Condoms The female condom is a transparent polyurethane condom that is intended to be used by the female partner in heterosexual intercourse. The female condom is approximately 6.5 inches in length (similar to a male condom), with a flexible ring at each end. It is inserted into the vagina prior to sexual intercourse and forms a barrier between the penis and the vagina, cervix, and external genitalia of the female. Thus the female condom provides protection against pregnancy and most sexually transmitted infections (including HIV). The female condom is soft but also very strong. It is stronger than latex, has no odor, causes no known allergic reactions, and has no serious side effects.5 It contains no spermicide and is lubricated with a water-based, silicone lubricant. Unlike latex condoms, it can be used with additional oil-based or silicone lubricants. The female condom is FDA-approved for a single use. The World Health Organization (WHO) has convened several consultations to address reuse of the female condom. Based on these consultations, the WHO recommends against reuse of the female condom.6-7 Specifically, WHO suggests that a new female condom be used for each act of intercourse where there is a risk of unplanned pregnancy or sexually transmitted infection.
The female condom is FDA-approved for use during vaginal intercourse. It has not received approval for use during anal intercourse, although some men do use the female condom during anal sex. It is FDA- approved for a single use.
92 CHAPTER 9 Effectiveness of the Female Condom The female condom has been found to be effective in the prevention of pregnancy and sexually transmitted infections. No clinical trials have been conducted to evaluate the effectiveness of the female condom in preventing HIV transmission. However, laboratory studies demonstrate that the female condom is impermeable to most STIs and HIV.5 The estimated annual accidental pregnancy rate for the female condom is 5% (when used correctly and consistently during vaginal intercourse), as compared to the estimated 3% estimated pregnancy rate for the conventional male condom (when used correctly and consistently).5
How to Properly Use a Female Condom The following steps should be followed for proper use of a female condom:8 1. The expiration date (EXP) should be checked to make sure the condom has not expired. 2. The package should be opened carefully by tearing at the notch on the top right of the package. Scissors and knives should not be used. 3. Lubrication should be spread evenly on the condom. 4. The flexible inner ring at the closed end of the sheath should be squeezed with the thumb and middle finger so it becomes long and narrow. 5. A comfortable position (i.e., squatting, with one leg raised, sitting, or lying down) should be chosen and the inner ring should be gently inserted into the vagina. 6. The index finger should be inserted inside of the condom to push the inner ring back as far as possible. 7. The sheath should not be twisted, and approximately 1 inch of the sheath and the outer ring should remain outside the vagina. 8. The female partner should then guide the penis into the sheath’s opening to ensure it enters properly. The penis should not enter between the sheath and the vaginal wall. 9. After intercourse, the condom should be removed by grasping the outer ring, twisting it to seal in the fluid, and gently pulling the condom out. 10. The condom should be properly disposed of. The condom should be wrapped in the package or in a tissue and thrown in the garbage. Condoms should not be put in the toilet.
CHAPTER 9 93 Tips for Female Condom Use Although polyurethane is strong, sharp objects like finger rings, pierced penises, and sharp or gagged nails can still tear it—therefore users should be careful. If your patient has sharp or jagged nails, he/she should consider wearing gloves when inserting the condom.
If the female condom gets pushed in accidentally and your patient is having trouble getting it out, he/she should bend his/her knees and squat down. From this position, it will be easier to remove the condom.
If your patient or partner is wearing the female condom, the other person should not wear a conventional male condom. This will cause friction leading to tears in one or both condoms, slipping of one or both condoms, and/or displacing the ring of the female condom inside the vagina.
If it is noisy when using the female condom, adding more lubricant should help.
Current recommendations are to use a new condom for each occurrence of intercourse. The female condom should be discarded once a person has ejaculated in it.
The female condom should be discarded in the trash and not flushed down the toilet.
Practice is very important before using the female condom for the first time. Users should anticipate that using the female condom may be awkward until they become accustomed to it, but practice will help.
The inner ring is removable but must be in when the female condom is used for vaginal sex. Although not FDA-approved for anal sex, some men do use the female condom during anal sex, either with the inner ring in the condom, or removing it before sex.
Benefits of the Female Condom The female condom has a number of benefits5 including:
The polyurethane material of the female condom is stronger than the latex of the conventional male condom.
The polyurethane material of the female condom is thinner than latex, so it conducts heat better and provides increased sensation.
Because the female condom has a larger diameter than the conventional male condom, it does not feel as tight or constricting on the penis.
The female condom can be inserted ahead of time and therefore does not interrupt sexual spontaneity.
There are no serious side effects associated with using the female condom.
94 CHAPTER 9 Both oil-based and water-based lubricants can be used with the female condom (unlike latex, which deteriorates when exposed to oil-based lubricants).
An erect penis is not required for its use.
It provides coverage for both the woman’s internal and external genitalia (as well as the base of the penis).
Acceptability of the Female Condom Studies suggest the female condom is acceptable to many men and women. However, practice appears to be important in enhancing acceptance of the female condom and as such, many programs that promote the use of the female condom suggest that women try it three times before deciding if they will continue to use it or not.5 According to the World Health Organization:5 Studies in numerous countries and in many different settings show that, on average, 50% to 70% of male and female participants found the female condom to be acceptable. Satisfied couples reported that use of the female condom did not interfere with sexual sensitivity and pleasure. Women and men of all ages can use the female condom. It is particularly attractive to women who experience side effects from hormonal methods; people who want to protect themselves from both STIs, including HIV/AIDS, and unwanted pregnancy; people who do not like (or whose partners do not like) the male condom; and people who are allergic to latex.
Use of the Female Condom by Men Having Sex with Men The female condom has not been approved by the FDA for use during anal sex. Men sometimes use the female condom during anal sex because it is thinner than traditional male condoms (resulting in increased sensation), much less constricting on the penis, and stronger than latex condoms. The failure rate of the female condom during anal sex is not known
Availability of the Female Condom Samples of the female condom are available free of charge from some AIDS service organizations and health departments. Female condoms are often difficult to find in stores, but they are readily available online. The cost from Internet retailers ranges from $2.00 each to over $4.00.
The female condom is Medicaid-reimbursable in many states in the U.S. Local Medicaid offices can provide specific information about the process of reimbursement.
CHAPTER 9 95 Sexual Lubricants Sexual lubricants can be used during sexual activity to reduce friction within the vagina, anus, or other body parts. Using lubricants inside and outside a condom helps prevent rips and tears, and also increases sensitivity. Lubricants are typically used to enhance sexual pleasure, but not to provide protection. Products marketed as lubricants do not provide protection against pregnancy, HIV, or other sexually transmitted infections (unless they specifically say they contain a spermicide). There are 3 primary types of non-spermicidal sexual lubricants: 1. Water-based lubricants 2. Silicone-based lubricants 3. Oil-based lubricants Tip
Water-based and silicone-based lubricants are safe to use with latex condoms. Oil-based lubricants weaken latex and are not safe to use with male latex condoms.
Water-based Lubricants Water-based personal lubricants are water-soluble and are safe to use with latex condoms. Many are made with glycerine (and therefore may be referred to as glycerine-based lubricants). One primary advantage of water-based lubricants is they rarely cause irritation. Also, they do not stain and are easy to clean up with water. However, water-based lubricants tend to dry out during use, so reapplication may be necessary. Examples of water-based lubricants include: Astroglide Wet Light and Wet Original Formula Aqua Lube Frixion K-Y Jelly Sliquid Probe Classic 96 CHAPTER 9 Silicone-based Lubricants Silicone-based personal lubricants are made with silicone and are also safe to use with latex condoms. The primary difference between water-based and silicone-based lubricants is that silicone-based lubricants retain their lubrication longer and are waterproof (i.e., they do not typically require reapplication during sex and can be used in water). Because they are waterproof, silicone-based lubricants tend to be somewhat more difficult to clean off than water-based lubricants. Silicone-based lubricants should not be used with silicone sex toys, as they can cause damage to the sex toy. Examples of silicone-based lubricants include: Eros Sliquid Silver Wet Platinum ID Millenium
Oil-based Lubricants Oil-based personal lubricants are typically made with natural products such as vegetable oils, nut oils, and butter that weaken latex, thereby reducing the effectiveness of condoms. Because oil-based lubricants reduce the effectiveness of latex, they are not recommended for use. Oil-based lubricants are also difficult to clean off the body after sexual activity and may stain fabrics. Examples of oil-based lubricants include Vaseline and Crisco. The following are examples of oil-based lubricants and other products that are unsafe for use with latex condoms: Vaseline and petroleum jelly products Bag Balm hand and body lotions butter baby oil and massage oils mineral oil
CHAPTER 9 97 peanut butter petroleum jelly cold creams edible oils (olive, peanut, corn) rubbing alcohol shortening suntan oil and lotions whipped cream vaginal yeast infection medications
98 CHAPTER 9 References 1. Centers for Disease Control and Prevention. Fact sheet for public health personnel: male latex condoms and sexually transmitted diseases. January 23, 2003. Available at http://www.cdc.gov/nchstp/od/latex.htm. Accessed on June 28, 2006 2. National Institute of Allergy and Infectious Diseases. Workshop summary: scientific evidence on condom effectiveness for sexually transmitted disease (STD) prevention. July 20, 2001. Available at http://www.niaid.nih.gov/ dmid/stds/condomreport.pdf. Accessed on June 28, 2006. 3. Van Damme L, Ramjee G, Alary M. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomized controlled trial. Lancet. 2002;360:971-977. 4. Condomania. All about condoms. Available at http://secure.condomania. com/SaferSex/Manual/Condoms/#howto. Accessed on June 28, 2006. 5. World Health Organization and UNAIDS. The female condom: a guide for planning and programming. 2000. Available at: http://www.who. int/reproductive-health/publications/RHR_00_8/PDF/female_condom_ guide_planning_programming.pdf. Accessed June 7, 2006. 6. World Health Organization. WHO information update: considerations regarding reuse of the female condom. July, 2002. Available at: http://www. who.int/reproductive-health/stis/reuse.en.html. Accessed June 7, 2006. 7. World Health Organization. The Safety and feasibility of female condom reuse: report of a WHO consultation. January, 2002. Available at http:// www.who.int/reproductive-health/stis/docs/report_reuse.pdf. Accessed June 28, 2006. 8. The Female Health Company. What is FC female condom? Available at: http://www.femalehealth.com/pdf/PR_pack_2_whatisfc.pdf. Accessed on June 5, 2007.
CHAPTER 9 99 Recommended Reading Joanis C. Latka M. Glover LH, Hamel S. Structural integrity of the female condom after a single use, washing, and disinfection. Contraception. 2000;62:63–72. Philpott A. Re-use of the female condom: now for the practical realities. Reprod Health Matters. 2003;11:185–186. Potter B, Gerofi J, Pope M, Farley T. Structural integrity of the polyurethane female condom after multiple cycles of disinfection, washing, drying and relubrication. Contraception. 2003;67:65–72.
100 CHAPTER 9 Chapter 10 Strategies for Dealing with Negative Attitudes about Condoms
our role as a healthcare provider is not only to educate your patients about the risks associated with various sexual practices, but also to help Ythem incorporate HIV transmission risk reduction into their sex lives so that sex remains fun and satisfying as well as safe. The most effective way to prevent the transmission of HIV during sex is through the use of condoms, but, unfortunately, many people have very negative attitudes about condoms. Realistically, we know that many people will never learn to regard condoms as erotic, but there are strategies that you can offer, which can help them view condoms more positively.
Common Complaints about Condoms Listed below are some of the common complaints voiced by individuals about condoms, as well as suggestions for how to respond to those complaints. “Condoms Are Uncomfortable” or “Condoms Don’t Fit Me (or My Partner) Right” With the variety of condoms currently available, recommend to your patient that they experiment until they (or their partner) find the one that is most comfortable and pleasurable for them. Condoms come in different sizes, colors, and textures so they can search for the condom (or condoms) that is right for them. Some condoms, such as InSpiral, Pleasure Plus, Lifestyles Xtra Pleasure, Lifestyles Lubricated, and Durex Enhanced Pleasure Condom, have large bulbous ends on them to provide more headroom and less constriction of the head of the penis. As an alternative to the conventional male condom, your patients can also try the female condom, which is inserted into the vagina and allows the penis to move more freely.
Larger Size Condoms Condoms that are larger and roomier include Maxx, Trojan-Enz Large, Trojan Magnum, and Avanti. (Some men complain that their penises are too large for condoms, but the reality is that most men fit quite easily into the majority of available condoms.) 101 Smaller Size Condoms Smaller condoms include Lifestyles Snugger Fit and Beyond Seven, both of which are smaller, lubricated condoms.
“Condoms Don’t Taste Good” A common complaint when condoms are used during oral sex is that they taste bad. However, condoms now come in a variety of flavors and scents: mint is a standard flavor, but there are many others including fruit flavors. Another option is to use a flavored lubricant with a nonlubricated condom. The flavored lubricant should mask the taste of the latex.
“Condoms Make Me (Or My Partner) Itch” If your patient, or your patient’s partner, is experiencing itching while using condoms, they may be having an allergic reaction to nonoxynol-9, a spermicide used in some condoms. Patients attempting to reduce the risk of HIV transmission should not use nonoxynol-9. Recommend that patients use a condom that does not have nonoxynol-9 in it.
If your patient (or patient’s partner) reports itching, and the condoms being used do not have nonoxynol-9, suggest that they try using a different brand or type of condom, or a condom that is not lubricated. Have them experiment with different lubricants. It may be the lubricant––not the condom––that is making them (or their partner) itch.
One other possibility is that your patient (or their partner) is allergic to latex. If that is the case, they should consider switching to polyurethane condoms, or trying the female condom.
“I Can’t Feel as Much When I Wear a Condom” or “It Decreases the Sensation” Suggest to your patient that they try putting some lubricant inside the tip of the condom before they (or their partner) put it on, as this will increase the sensation. Putting lubricant inside the condom also helps to prevent the condom from breaking. In addition, they may want to experiment with different condoms, as condoms vary in terms of how thin or thick they are and thus in how much can be felt when they are worn. Thinner condoms include Avanti, Crown (Skinless and Skinless Plus), Beyond Seven (Regular and Plus), Kimono MicroThin (Regular and Plus), Durex Extra Sensitive, Lifestyles Ultra- Thin, Contempo Bareback, and Trojan Very Thin. Another perspective that some users of condoms have expressed is that although condoms may decrease sensation slightly, this can be a benefit because it increases the duration of arousal, leading to stronger orgasms.
102 CHAPTER 10 “It Takes Too Long to Put On a Condom” or “Condoms are Difficult to Put On” Patients who struggle with putting on a condom may want to practice putting one on. They can practice while alone, without the pressure of someone watching them. Another option is for the man’s partner to put the condom on him rather than the man putting it on himself; this can make it more exciting and arousing.
“I Lose My Erection When I Wear a Condom” If a patient (or their partner) has difficulty maintaining an erection while wearing a condom, it might be because they are too focused on the presence of the condom itself and are unable to relax during sex. You can suggest to your patient that they (or the patient’s partner) practice ejaculating in a condom while masturbating alone without the pressure of performing. It is important to try to relax while wearing the condom and not focus on the condom. While masturbating with the condom on, they can try visualizing a highly erotic scene, using focused fantasy to get their mind off the condom and onto arousal. When the patient is able to comfortably masturbate with a condom on, it will likely be easier to remain erect during sex with a partner.
If the patient’s partner is having difficulty maintaining an erection during condom use, the patient may want to put the condom on their partner in an erotic manner so that it becomes incorporated into their foreplay. The patient can masturbate their partner’s penis while putting on the condom, or they can put on the condom with their mouth. The patient can also distract the partner by talking erotically or saying that men who wear condoms turn them on. If wearing a condom is viewed as sexy and erotic, then the condom can enhance the erection rather than diminish it. Also, for penile-vaginal sex, a woman can try using the female condom as an alternative to the male condom.
“I (or My Partner) Can’t Cum in a Condom” This is similar to “I lose my erection” above. The difference is that whereas some people can’t keep their erections while wearing a condom, others can keep their erections but can’t ejaculate. It may take practice to learn to ejaculate in a condom, particularly if the individual has become used to ejaculating without one. You can suggest that the patient (or the patient’s partner) practice ejaculating in a condom while masturbating alone without the pressure of performing. If that doesn’t help, the patient has the option of pulling his penis and the condom out of his partner prior to orgasm and then ejaculating outside of their partner. For penile-vaginal sex, a woman can try using the female condom as an alternative to the male condom.
CHAPTER 10 103 “Condoms Spoil the Mood (Wreck the Moment)” Suggest to your patient that they find a creative way to incorporate condoms into their sex life. Putting on a condom can be as erotic as taking off one’s clothes before having sex. A man can put a condom on himself or, or a person could put one on their partner in a highly erotic manner, if they choose to. For example, a person could put a condom on their partner with their mouth (called “cheeking”), masturbate their partner or themselves while putting a condom on the partner, do a striptease for the partner that incorporates putting on the condom, or tell their partner that the condom is hidden somewhere on them and their partner has to find it. The bottom line is that condom use can be fun and erotic when it becomes a natural part of sex.
“Condoms Aren’t Always Available When You Need Them” Encourage your patients to always be prepared. Condoms will not be used unless they are nearby and readily available. Some people keep condoms in every room in their house, including the kitchen, so they can spontaneously have sex should the opportunity arise. Patients should anticipate situations and carry unexpired condoms with them if there is any possibility of sex occurring. They can carry condoms in a handbag, fanny pack, pocket, backpack, briefcase, or suitcase, wherever they can get to them easily. Some people actually have a little bag that they use just for carrying condoms and lubricant––their “Safer Sex Bag.” If a patient finds him or herself in a situation where neither the patient nor their partner has a condom, encourage him/her to consider a form of sex that doesn’t involve the risk of transmission of HIV or other STIs (see examples in Chapter 6, Sexual Behaviors, Relative Risk, and Safer Alternatives).
“Condoms Don’t Allow for Spontaneity” Point out to your patient that if they always have condoms available, they can be as spontaneous as the moment allows. Having condoms in many rooms of their house, or having condoms with them whenever they go out, will always allow for spontaneous encounters. Putting condoms on is no less spontaneous than a person taking off their shoes or their pants. The patient just needs to incorporate using condoms into their sexual repertoire.
“Condoms Stifle My Creativity” Rather than looking at condom use as something that stifles creativity, your patient can be encouraged to view condom use as a creative challenge. How can they bring condoms into the situation in a seductive, erotic manner? Have them explore creative ways for integrating condoms into their sex life. For example, what if they put on the condom as part of a striptease?
104 CHAPTER 10 “Sex With Condoms Is Impersonal” Present a different perspective: whether a person uses a condom is only one aspect of a sexual encounter. Sex consists of numerous behaviors, and a person can make any of them as personal or impersonal as they wish. It is actually very personal for someone to wear a condom to protect their partner from HIV. It means that that the person cares enough about their partner to want to avoid infecting (or reinfecting) him or her.
“Using Condoms Prevents a Couple from Achieving True Intimacy” Most individuals make sexual choices based on meaning and pleasure, in addition to considering risk. For many individuals, one of the most intimate forms of bonding involves the ejaculation of semen from one person into another person, whether that is into a person’s mouth, vagina, or anus. Some people feel that unless you ejaculate inside a person or take a person’s semen inside of you, you haven’t given all of yourself to your partner. Accepting semen may be regarded as a way of showing devotion and belonging. Thus, sex without a condom is regarded as more intimate. As healthcare providers and health educators, we are asking people who live with HIV to give up this form of bonding because it is potentially dangerous for both them and their partners. It is important to realize that this is a true loss of intimacy for many and to acknowledge this with patients:
“For many people, bonding and intimacy has been defined as exchanging semen. It is sad to have to give that up, but that loss will keep you and your partner healthy. If you truly care about yourself and your partner, you need to find new ways to bond and show devotion. I know that that is not an easy task.”
“Some Men Won’t Have Sex with Me If I Want to Use a Condom” Another expression of this attitude is “I am afraid that I will be rejected if I insist on a condom being used.” As discussed in Chapter 8, Safer Sex Communication Skills, some people will have tremendous difficulty in asserting their desires to have safer sex when they believe that their partner will respond negatively. Ask the patient to consider whether a partner who refuses to be safe after being specifically asked is really a partner they want in their lives. Gently support the patient in recognizing their right to make these kinds of requests. Provide them with some ideas for working condoms into the sexual encounter in a nonconfrontational manner or role-play strategies that could help them assertively communicate their desires. Again, recognize the need and desire for physical contact, but also remind the patient that they deserve to be respected. You can also present a different perspective: Ask the patient if having sex with someone without a condom is worth the risk of compromising their health.
CHAPTER 10 105 “Using Condoms Implies That I Am Dirty or Diseased in Some Way” Encourage your patient to think of alternative perspectives. Ask them if there might be other reasons that people use condoms. Using condoms can be seen as making sex healthier, and using them may actually show that a person is proud of him or herself. Alternatively, the patient can tell their heterosexual partners that condoms are excellent for pregnancy prevention, regardless of STI prevention.
“If I Insist On Using A Condom, I Am Afraid That My Partner May Ask If I Am HIV+” You have an excellent opportunity to open a discussion on HIV status disclosure if your patient expresses this concern. Encourage your patient to think through the issue of disclosure by asking about their specific concerns. Disclosing HIV status can be terrifying, and, whenever possible, provide referrals to counselors or advocates who can assist your patient in either preparing for disclosure or actually disclosing to their partners (see Chapter 4, Assisting Patients with HIV Disclosure). As previously noted, there are many advantages to using condoms, only one of which is STI prevention.
“Using Condoms Implies That I Don’t Trust My Partner” Present a different perspective: using condoms allows the patient to convey their desire to protect their partner. In reality, your patient also needs protection against re-infection or other STIs, but this does not need to be the main rationale presented to partners. If the patient emphasizes their investment in keeping their partner safe, then distrust is not conveyed or implied. Alternative strategies to incorporate condoms into sex could be considered. If the partner is unaware of the patient’s HIV status, disclosure issues would need to be addressed.
“Condoms Are Expensive to Buy” Inform your patient that free condoms are available at a variety of places, including AIDS service organizations. Most public health departments, health clinics, STI clinics, and family planning clinics make condoms available free of charge. Many outreach workers who are in the community carry condoms. If your patient is a gay man, tell him that he will find bowls of condoms in many of the gay bars and clubs. Your patients should not have to buy condoms if they know where to get them for free.
106 CHAPTER 10 Women: “Since Men Wear the Condoms, I Have No Control Over Whether or Not Condoms Are Used” It is true that men ultimately control whether or not male condoms are worn, but women control whether or not sex occurs. The exception to this is if the man uses force to have sex or threatens the woman with violence if she doesn’t have sex. Barring that, women should have a fair amount of influence in sexual negotiations but are often unaware of just how much. Ask your patient to consider some of the communication strategies discussed in Chapter 8, Safer Sex Communication Skills, or to consider using the female condom. Work with your female patients to gain a sense of control and power in sexual negotiations. If you have any concerns about violence (or potential violence) in your patients’ relationships––for either your female or male patients––consider a referral to a social worker or domestic violence program to help the patient finds ways to stay safe.
Potential Concerns and Advantages of the Female Condom The female condom is an alternative to traditional male condoms for heterosexual couples. (Currently, female condoms are FDA-approved only for male-female vaginal intercourse.) Because it is worn by the female, the female condom provides women with more control over HIV/STI protection during sexual intercourse and is less constricting to the man’s penis, and therefore may prove to be a more pleasurable alternative to the male condom. For more information about the female condom, including advantages and common concerns/questions, see the following: Chapter 9, Condoms and Lubricants Appendix D, Female Condom FAQ
CHAPTER 10 107 108 Chapter 11 Other Barrier Methods: Oral Barriers, Cots, and Gloves
Oral Sex and the Use of Oral Barriers he CDC recommends that, for protection against HIV and other STIs, barrier methods be used during oral sex. Specifically, CDC recommends that condoms be used during oral-penile sex and oral barriers be used T 1 during oral-anal and oral-vaginal sex. Oral barriers are flat pieces of virus-impermeable material used for protection against sexually transmitted infections during oral-anal and oral-vaginal sex. Options for oral barriers include dental dams, Glyde dams, plastic wrap, and modified condoms and latex gloves.
Important Tips for Oral Barrier Use All barriers should be used only once and should not be shared. Once in place, the oral barrier should always be kept on the same side against the body to prevent STI transmission. As with condoms, careful storage of oral barriers is important to preserve their effectiveness. They should not be stored in hot places, near sharp objects, or in areas that allow for constant friction.
Dental Dams Dental dams are small squares of latex material that can be used for protection during oral-vaginal or oral-anal sex. Dental dams were originally designed for use during dental procedures and have not specifically been tested or FDA- approved for use during oral sex. Made in different sizes and flavors, dental dams are placed over the area where oral sex will occur. To increase sensation and pleasure, a small amount of water- based lubricant may be placed on the receiver’s side of the dam. The dam should be held in place by either partner and should cover the entire anal or vaginal area.
109 Glyde Dams Glyde dams are the only FDA-approved oral sex barrier permitted to claim the ability to protect against sexually transmitted infections. Glyde dams are similar to dental dams but are thinner and thus often experienced by users as able to provide more sensation than dental dams. They also come in a variety of flavors.
Plastic Wrap (Saran™ Wrap) As an alternative to dental dams or Glyde dams, plastic wrap may be used for protection during oral sex,1 although its efficacy in HIV and STI prevention has not been fully evaluated. Nonetheless, in situations where your patient may not have access to other barrier methods, plastic wrap may be a viable alternative and safer than not using any barrier at all. As with dental dams and Glyde dams, the plastic wrap should be large enough to cover the entire vaginal or anal area and should be held firmly in place during use.
Modified Latex Condoms and Gloves Nonlubricated latex condoms and latex gloves can also be modified for protective use during oral sex. To create an oral barrier from a nonlubricated condom, the user can cut the condom up the middle and then cut off the tip to create a rectangular barrier. To create an oral barrier from a latex glove, there are several options. The user may cut off all the fingers and then cut a slit up the middle creating a traditional oral barrier. Another alternative is to leave the thumb to provide a space where the user’s tongue may go.
Finger Cots and Gloves Latex finger cots and latex gloves can be used during sexual activity that involves hand-genital contact (i.e., insertion of fingers or the hand into the vagina or anus). Use of latex cots and gloves can provide protection for broken or severely chapped skin and torn cuticles. It is important for users not to share or reuse finger cots or gloves, and to dispose of them after each use. Finger cots resemble mini-condoms and are convenient barriers when one finger is being used for penetration, or for small sex toys. Finger cots can either be purchased or made by cutting the fingers off latex gloves. For added protection, it is important for the user to remove rings, keep fingernails trimmed and smooth, and use sufficient water-based lubricant (oil-based lubricant should be avoided, as it will weaken latex). Gloves made of a substance called Nitrile (a synthetic latex substitute that does not degrade in the presence of oils) are also available. Nitrile gloves may be used for individuals who are allergic to latex or if a person is engaging in anal fisting where oil-based lubricants are often used and penetration can be relatively deep. 110 CHAPTER 11 References 1. Centers for Disease Control and Prevention. Preventing the sexual transmission of HIV, the virus that causes AIDS: what you should know about oral sex. Available at: http://www.cdc.gov/HIV/pubs/facts/oralsex. pdf. Accessed on June 28, 2006.
CHAPTER 11 111 112 Chapter 12
Microbicides
Overview of Microbicides he term microbicide refers to a range of different substances that can be applied inside the vagina or rectum to reduce the risk of sexually Ttransmitted infections (including HIV).1 Microbicides can be formulated as gels, creams, suppositories, films, lubricants, or a sponge or vaginal ring that slowly releases the active ingredient.2 Some microbicides also have a contraceptive effect, while others do not.1
Availability of Microbicides Currently, there is no effective microbicide available to the general public.1 There are approximately 60 potential microbicides under investigation, and as of January 2006, 20 of these microbicides were in various stages of clinical testing. (For the most recent update on the microbicide pipeline, see http://www. microbicide.org/publications/digest.shtml.) The majority of the microbicides being tested are for vaginal use, and given the differences in the physiology of the vagina and the rectum, it is not clear which products may be acceptable for rectal use.
Why Microbicides Are Important Microbicides are important because they offer women the opportunity to make STI prevention decisions more directly. They also allow them to initiate prevention behaviors as opposed to negotiating with or persuading their partners to enact the behaviors (e.g., putting a male condom on), and they allow for women to do so discreetly. Despite existing HIV prevention efforts (e.g., condoms, mutual monogamy, and STI treatment), HIV continues to spread rapidly, especially among women in developing countries.1 Due to gender inequalities, many women in these settings often do not have the power to negotiate condom use with their partners. For these women, microbicides are empowering given that they offer an alternative to condoms that they can control. Microbicides can be applied prior to sexual intercourse and do not require the cooperation, or even the knowledge, of the partner.1 113 How Microbicides Work Microbicides can protect against HIV and other sexually transmitted infections (STIs) in several ways:1,2 1. By providing a physical barrier between the pathogen and the cells of the vagina or rectum. 2. By enhancing natural vaginal defenses. 3. By disabling or killing pathogens. 4. By prohibiting viral entry into a cell or preventing viral replication of the pathogen once it has entered the cell. Because STIs are caused by different pathogens, microbicides will not necessarily provide protection against all STIs. Many of the microbicides in development work against HIV and at least one other STI.2
Microbicides are substances that may be applied inside the vagina or rectum to prevent HIV and/or other sexually transmitted infections. Currently, there are no effective microbicides.
Nonoxynol-9 Because nonoxynol-9 (N-9) may be available to your patients, it is important to be aware of the history of N-9 and current recommendations concerning its use. Nonoxynol-9 (N-9) is a spermicide that was used in a variety of contraceptive products that were available in the U.S. for many years, either as a stand-alone product or with other protective methods such as condoms and diaphragms1. N-9 was also used in some sexual lubricant products. Products containing N-9 may still be available commercially.
While N-9 demonstrated activity against HIV and several other STIs in vitro (and thus was considered as a potential microbicide), a large-scale human study of nearly 900 HIV-negative sex workers showed that N-9 use actually increased a woman’s likelihood of becoming infected with HIV and had no protective effect against gonorrhea or chlamydia.3 Women who used N-9 in the study had more vaginal lesions in a dose response manner––that is, as frequency of N-9 gel use increased, so did frequency of vaginal lesions––therefore increasing the users’ susceptibility to HIV transmission3. Nonxynol-9 has also been found to cause significant sloughing of rectal epithelium in humans and animals (even more so than vaginal use of N-9), which may also increase risk of HIV transmission.4
114 CHAPTER 12 As a result of this and other studies, the Centers for Disease Control,5 the World Health Organization,6 and others have recommended that nonoxynol-9 should not be used for HIV prevention and should not be used rectally.
The Centers for Disease Control, the World Health Organization, and others recommend that N-9 should not be used for HIV prevention, nor should it be used rectally.
CHAPTER 12 115 References 1. World Health Organization. Microbicides. Available at http://www.who. int/hiv/topics/microbicides/microbicides/en/. Accessed on June 2, 2006. 2. Global Campaign for Microbicides website. Available at http://www.global- campaign.org/. Accessed on June 2, 2006. 3. Van Damme L, Ramjee G, Alary M. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomized controlled trial. Lancet. 2002;360:971–977. 4. Philips DM, Taylor CL, Zacharopoulos VR, Maguire RA. Nonoxynol- 9 causes rapid exfoliation of sheets of rectal epithelium. Contraception. 2000;62:149–154. 5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(no.RR-6):1–84. 6. World Health Organization. WHO/CONRAD technical consultation on nonoxynol-9. Meeting held at the World Health Organization, October 2001. Geneva Switzerland. Available at http://www.who.int/reproductive- health/publications/rhr_03_8/Nonoxynol_9.pdf. Accessed June 2, 2006.
116 CHAPTER 12 Recommended Reading Balzarini J, Van Damme L. Intravaginal and intrarectal microbicides to prevent HIV infection. CMAJ. 2005;172:461–464. Centers for Disease Control and Prevention. Nonoxynol-9 spermicide contraception use—United States, 1999. MMWR. 2002;51:389–392. Mayer KH, Karim SA, Kelly C, et al. Safety and tolerability of vaginal PRO 2000 gel in sexually active HIV-uninfected and abstinent HIV-infected women. AIDS. 2003;17:321–329. Weber J, Desai K, Darbyshire J, on behalf of the Microbicides Development Programme. The development of vaginal microbicides for the prevention of HIV transmission. PLoS Med. 2005;2:e142.
CHAPTER 12 117 118 Chapter 13 Commonly Abused Drugs and Effective Risk Reduction Strategies*
Drugs and HIV any drugs are associated with risk of HIV transmission (or co-infection with other pathogens) either directly through the sharing of used Mneedles (or other contamination hazards involved in drug use), or indirectly through their association with risky sex. Many drugs (as well as alcohol) are disinhibiting and may impair the user’s judgment, making it less likely that the user will practice safer sex behaviors. Similarly, some drugs, especially stimulant drugs, may be experienced as sexually stimulating to the user, potentially increasing the likelihood of engaging in sexual behavior (perhaps unprotected sexual behavior) while high. This chapter includes basic information about commonly used and abused drugs that healthcare providers may encounter when discussing sexual and drug use risk behaviors with their HIV-positive patients. Tip Drug use places users at risk for HIV and other pathogens beyond risks of shared injection equipment. Many drugs are disinhibiting and some are sexually stimulating, putting users at increased risk for engaging in risky sexual behaviors.
Heroin HIV Transmission Risk: Shared needles/works. Disinhibition may increase risk of unprotected sex. Heroin is a highly addictive drug that is a derivative of morphine. Pure heroin is a white powder with a bitter taste. Street heroin typically varies in color from white to dark brown, depending on additives or impurities. “Black tar” heroin is a form of heroin from Mexico that is typically sticky and dark brown or black, used often in West Coast cities in the U.S. (South-American-produced “white”
*The information presented in this chapter comes from many sources that are referenced in full at the end of the chapter. 119 powder heroin is more common in East Coast U.S. cities). Heroin is often injected, but it can also be snorted or smoked. Street names for heroin include called Smack, H, Skag, Silk, Horse, Junk, Bags, Blue-Steel, China White, and P-Dope.
The Effects of Heroin Soon after taking heroin, the user typically feels a very quick feeling of euphoria (a “rush”). One of the reasons heroin is so addictive is because it enters the brain quickly and produces a rapid euphoria. The rush is usually accompanied by a warm flushing of the skin, dry mouth, a heavy feeling in the arms and legs, and sometimes nausea, vomiting, and itchiness. After the initial euphoria, heroin often leads to other symptoms that may last for several hours, including drowsiness, difficulty thinking clearly, and slowed breathing/heart-rate, sometimes so extreme that it causes death. Withdrawal symptoms (which usually occur once a person is addicted) can last from a week to several months and include restlessness, muscle and bone pain, trouble sleeping, diarrhea and vomiting, cold flashes and goose bumps, and leg movements.
Risks of heroin use include addiction (heroin is highly addictive); overdose; infection with HIV, hepatitis, or other pathogens when the user shares needles or works; collapsed veins; abscesses; infections of the heart; arthritis; and liver or kidney disease.
Cocaine HIV Transmission Risk: Shared needles/works if injected. Disinhibition may increase risk of unprotected sex. Cocaine is a highly addictive stimulant drug usually in the form of a white to light brown powder. The powdered form of cocaine can be snorted or dissolved in water and injected. Crack cocaine comes in a rock crystal that is heated and then smoked. Some users mix cocaine powder or crack with heroin (called a “speedball”). Cocaine is sometimes called Coke, Snow, Flake, Blow, Cane, Dust, Shake, Toot, Nose Candy, and White Lady. Crack is sometimes referred to as Crack, Rock, or Free-Base.
The Effects of Cocaine The effects of cocaine are typically felt almost immediately, and disappear within a few minutes or hours, depending on the route of administration. Snorting cocaine produces a relatively slower-onset high that usually lasts 15–30 minutes, while the high from smoking crack may last 5–10 minutes. In small amounts (up to 100 mg.), cocaine induces euphoria, a feeling of energy, talkativeness, and a sense of mental alertness. Physiologically, cocaine induces constricted blood vessels, dilated pupils, increased temperature, increased heart rate, and elevated blood pressure. Large amounts of cocaine will intensify the
120 CHAPTER 13 experienced “high” but may also lead to bizarre or violent behavior. Cocaine- related deaths are often due to cardiac arrest or seizures followed by respiratory arrest. Cocaine may cause a strong physiological addiction, and long-term effects of cocaine may include addiction, irritability and mood disturbances, restlessness, paranoia, and hallucinations. Common medical complications of use include heart rhythm disturbances, heart attacks, chest pain, respiratory failure, strokes, seizures, headaches, abdominal pain, and nausea.
Club Drugs “Club drugs” are those that are frequently used at dance parties or all night “raves.” Drugs commonly referred to as “club drugs” include methamphetamine, MDMA (Ecstasy), ketamine, GHB, inhaled nitrates (poppers), and rohypnol. Club drug use is more prevalent in the MSM population than in the general population.1 Numerous studies have demonstrated an association between club drug use and increased sexual risk behavior and HIV/STI infection.1 Although there is little literature on club drug use and HIV medication adherence, available reports suggest that some club drug users are at risk for decreased medication adherence, which may have implications for their HIV disease.1 In addition, significant risks may be associated with club drug-ART medication interactions.1 All providers should ask their HIV-positive patients about club drug use and potential associations with risky sexual or drug use behaviors. Patients who use club drugs should also be informed of acute and long-term risks and information about risk reduction, such as adequate (but not excessive) hydration, avoidance of mixing club drugs with alcohol, and possible drug interactions.1
Methamphetamine HIV Transmission Risk: Shared needles/works if injected. Disinhibition may increase risk of unprotected sex. May be experienced as sexually stimulating. Methamphetamine is an addictive stimulant drug created in illegal laboratories. Methamphetamine is related to amphetamine but causes more pronounced central nervous system effects than amphetamine. Methamphetamine is produced as clear chunky crystals that resemble ice. Methamphetamine can be taken orally, snorted, injected intravenously, smoked, or inserted rectally. Street names for methamphetamine include Ice, Crystal, Glass, Chalk, and Tina.
The Effects of Methamphetamine Similar to amphetamine, methamphetamine causes increased activity, decreased appetite, and a general sense of well-being lasting 6–8 hours. When smoked or taken intravenously, methamphetamine may cause an intense “rush” that lasts
CHAPTER 13 121 for several minutes and is described as extremely pleasurable. Following the initial euphoria associated with use, methamphetamine may lead to agitation and sometimes violent behavior. The CNS effects of methamphetamine use include increased wakefulness, increased physical activity, decreased appetite, increased respiration, hyperthermia, and euphoria. Methamphetamine use also often leads to irritability, insomnia, confusion, tremors, convulsions, anxiety, paranoia, and aggressiveness. Methamphetamine appears to have a neurotoxic effect, damaging brain cells that contain dopamine and serotonin, and over time may cause Parkinson-like symptoms. Methamphetamine use may also cause irregular heartbeat, extreme anorexia, cardiovascular collapse, and even death.
MDMA (Ecstasy) HIV Transmission Risk: Shared needles/works if injected disinhibition. May increase risk of unprotected sex. MDMA is a synthetic drug that is chemically similar to methamphetamine and mescaline (a hallucinogenic). MDMA is most commonly taken by ingestion (in tablet form), but may also be dissolved and injected, crushed and snorted, or taken in suppository form. MDMA pills sold on the street may often be cut with other substances or drugs, potentially increasing the risk to users. Street names for MDMA include Ecstasy, Adam, Candy Canes, Disco Biscuit, Doves, E, Eckie, Essence, Hug Drug, Love Drug, M&M, Rolls, White Doves, X, and XTC. The Effects of MDMA MDMA induces a sense of well-being, openness, empathy, energy, and euphoria among users. It may also enhance tactile sensations. Heavy doses of MDMA may cause visual hallucinations. MDMA may also interfere with the body’s ability to regulate temperature, and can cause increases in heart rate and blood pressure, muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating. Often used at all-night dancing parties, MDMA can lead to severe dehydration and heat stroke. However, MDMA has been associated with hyponatremia when users ingest excessive amounts of water.2 MDMA users who exert themselves physically, such as dancing all evening, may benefit from rehydration with electrolyte-containing fluids such as sport drinks.2 Psychological effects may include confusion, depression, sleep problems, and severe anxiety. Long-term effects of MDMA use are unclear, but animal research suggests MDMA may be damaging to neurons involved in mood, thinking, and judgment.
122 CHAPTER 13 Other “Club Drugs” (Poppers, Ghb, Ketamine, Rohypnol) Poppers (Amyl and Butyl Nitrate) HIV Transmission Risk: Disinhibition may increase risk of unprotected sex. May be experienced as sexually stimulating. Amyl nitrate and butyl nitrate––often referred to as “poppers”––are a type of inhalant drug that are often considered “club drugs” because of their frequent use among people at nightclubs. Poppers dilate blood vessels and relax the muscles but are used primarily as sexual enhancers to heighten stimulation. Amyl and butyl nitrate come as a clear or yellow liquid in small bottles or vials and is inhaled from the bottle or cloth. The effects of nitrates are immediate and last only several minutes. Users may experience light-headedness, giddiness, a feeling of blood rushing to the head, a warm flush, and heightened sensual awareness. Side effects include headache, nausea, vomiting, and coughing. Excessive use can cause severe vomiting, unconsciousness, increased eye pressure (especially dangerous to users with glaucoma), and death. Poppers are also sometimes referred to as Rush, Ram, Thrust, and Locker Room.
GHB HIV Transmission Risk: Disinhibition may increase risk of unprotected sex. GHB (gamma hydroxy-butyrate) is a central nervous system depressant that, along with rohypnol and ketamine, is sometimes referred to as a “date rape drug.” GHB is often used in liquid form (it is colorless, tasteless, odorless and therefore easily added to a drink and ingested by an unknowing individual) or sometimes as a powder. In lower doses GHB causes drowsiness, dizziness, nausea, and visual disturbances. At higher doses, GHB can induce unconsciousness, seizures, severe respiratory depression, and even coma. Withdrawal effects can include insomnia, anxiety, tremors, and sweating. Street names include Liquid Ecstasy, Soap, Easy Lay, Vita-G, and Georgia Home Boy. Ketamine HIV Transmission Risk: Shared needles/works if injected. Disinhibition may increase risk of unprotected sex. Ketamine is an anesthetic drug sometimes used legally for veterinary use. As an illegal, recreational drug, ketamine comes in a clear liquid or a white (or off-white) powder form that can be injected, consumed in drinks, or added to smokable materials. Certain doses of ketamine can cause dream-like states and hallucinations, and at high doses it can induce delirium, amnesia, impaired motor function, depression, elevated blood pressure, potentially fatal respiratory problems, and long-term memory and cognitive difficulties. Because of its dissociative effects, ketamine (like GHB and rohypnol) is also sometimes used as a “date rape drug.” Street names for ketamine include Special K, Vitamin K, Jet, Super Acid, Green, K, and Cat Valium. CHAPTER 13 123 Rohypnol HIV Transmission Risk: Disinhibition may increase risk of unprotected sex. Rohypnol––the drug most commonly referred to as the “date rape drug”––is a benzodiazepine that, when used with alcohol, can incapacitate users and produce anterograde amnesia (i.e., individuals may not remember events experienced while under the effects of the drug). Rohypnol is manufactured in a pill form and is usually taken orally but can also be crushed and snorted. In addition to chemically induced amnesia, rohypnol often causes decreased blood pressure, drowsiness, visual disturbances, dizziness, confusion, gastrointestinal disturbance, and urinary retention. The generic name for rohypnol is flunitrazepam.Street names for rohypnol include R-2, Mexican Valium, Rophies, Roofies, and Circles.
Risk Reduction Strategies And Drug Use When discussing HIV risk reduction with patients, it is important for providers to assess whether the patient is using any illicit drugs, and, if so, whether that drug use is contributing to HIV transmission risk (either due to shared injection equipment or increased likelihood of risky sex when high). Framing the Discussion It is critical that questions about drug use are framed in a nonjudgmental, non- threatening manner that allows patients to feel comfortable discussing their drug use behaviors. Once the issue of drug use and its importance for HIV risk reduction has been broached, then you can probe gently to get a clearer picture of the extent of the patient’s drug use.
Example: One thing that comes up with many of my patients when we’re talking about challenges in reducing risk with HIV is drug use. Most people know that sharing needles or works is risky, but even if people aren’t injecting, when they use drugs often they are less careful about making sure they practice safer sex. I was wondering if this is ever an issue for you. Remember, Risk Reduction Is the Primary Goal The most important goal is to reduce the patient’s HIV risk behaviors. If in the process you are able to work with the patient to decrease (or stop) their drug use, that is an important achievement. But if the patient does not seem willing (or able) to stop using drugs at this time, it is appropriate to adopt a harm reduction perspective to minimize their HIV transmission risk within the context of their drug use.
Addressing Drug Use with Patients You can use the strategies outlined in the Options intervention protocol regarding safer sex behaviors to address the issue of drug use behavior change. Based in motivational interviewing theory, these strategies are generalizable to many target behaviors.
124 CHAPTER 13 For example, questions about importance of and confidence in changing drug use behavior can help clarify weaknesses in motivation and/or behavioral skills needed for change. If you choose to address your patient’s drug use (especially if abuse and/or dependence is evident), express your concern in a non- threatening manner that seeks their permission to discuss the issue further. If the patient is not open to discussing their drug use any further, you can express your concern in a caring manner that respects their wishes. By respecting the patient, you are less likely to alienate them and are more likely to maintain the integrity of your relationship. This makes it more likely that you will be able to help them reduce their HIV transmission and drug-related risks over time. Example: I am concerned about your meth use. You mentioned that you are using at least every weekend and sometimes have unprotected sex when you’re high. I’m concerned about the negative effects that meth could have on your health. By having unprotected sex when you’re high, you can put yourself at risk for getting reinfected with HIV, or passing it on to your partner. Ultimately it’s your choice to decide whether you use or not, and I will respect that. But, I want you to know that there are ways to reduce the risks involved, and I would like your permission to talk about some of those. Attempt to understand the patient’s perspective. Asking the patient to describe what they perceive as the pros and cons of their drug use (and the pros and cons of not using) may be useful in eliciting information from the patient that can be used to build motivation for change. It also conveys that you are interested in the patient as a person. Patients who are motivated to change their drug use but lack the necessary skills to do so may benefit from referral to an outpatient or inpatient drug abuse clinic. Patients receiving treatment for drug abuse are more likely to be successful in stopping their drug use than patients who do not receive treatment. Remember, however, that pushing patients into drug treatment when they are not yet ready to make a change in their use is typically not effective and may actually have negative consequences for your relationship with them. For patients not yet in the “preparation” or “action” stage of change, you may choose to provide the contact information of a drug treatment clinic without pushing them into treatment. Assure them that if and when they are ready to consider treatment, you will be there to help. Behavior change does not happen overnight. If you choose to address drug use with your patient, your primary goal is to move them along the continuum of change, which often happens in small steps. Just opening the discussion and allowing the patient to openly express their thoughts can be a good first step.
CHAPTER 13 125 If your patient chooses to continue their drug use, encourage them to practice risk reduction strategies to reduce the risk of transmission of HIV or other STIs, such as: Consider using drugs (or alcohol) only when there is little or no chance that they will engage in risky or unprotected sexual behaviors. Practice consistent safer sex behaviors when not using drugs to increase the likelihood that these behaviors will become habits and therefore easier to engage in when under the influence of drugs (or alcohol). For patients who use injection drugs, encourage use of the strategies outlined in Chapter 14, HIV and Injection Drug Use, to help reduce their HIV transmission risk.
126 CHAPTER 13 Sources 1. Colfax G, Guzman R. Club drugs and HIV infection: a review. Clin Infect Dis. 2006;42:1463–1469. 2. Hall AP, Henry JA. Acute toxic effects of ‘Ecstasy’ (MDMA) and related compounds: overview of pathophysiology and clinical management. Br J Anaesth.2006;96:678–685. 3. National Institute on Drug Abuse. NIDA InfoFacts: club drugs. March, 2005. Available at: http://www.drugabuse.gov/DrugPages/Clubdrugs. html. Accessed on June 28, 2006. 4. National Institute on Drug Abuse. NIDA InfoFacts: crack and cocaine. March, 2005. Available at: http://www.drugabuse.gov/infofacts/cocaine. html. Accessed on June 28, 2006. 5. National Institute on Drug Abuse. NIDA InfoFacts: heroin. February, 2005. Available at: http://www.drugabuse.gov/infofacts/heroin.html. Accessed on June 28, 2006. 6. National Institute on Drug Abuse. NIDA InfoFacts: inhalants. December, 2004. Available at: http://www.drugabuse.gov/infofacts/inhalants.html. Accessed on June 28, 2006. 7. National Institute on Drug Abuse. NIDA InfoFacts: MDMA (ecstasy). March, 2005. Available at: http://www.drugabuse.gov/infofacts/ecstasy. html. Accessed on June 28, 2006. 8. National Institute on Drug Abuse. NIDA InfoFacts: methamphetamine. May, 2005. Available at: http://www.drugabuse.gov/infofacts/ methamphetamine.html. Accessed on June 28, 2006. 9. National Institute on Drug Abuse. NIDA research report: cocaine abuse and addiction. Available at: http://www.drugabuse.gov/ResearchReports/ Cocaine/Cocaine.html. Accessed on June 28, 2006. 10. National Institute on Drug Abuse. NIDA research report: heroin abuse and addiction. Available at: http://www.drugabuse.gov/ResearchReports/ Heroin/Heroin.html. Accessed on June 28, 2006. 11. National Institute on Drug Abuse. NIDA research report: inhalant abuse. Available at: http://www.drugabuse.gov/ResearchReports/Inhalants/ Inhalants.html. Accessed on June 28, 2006. 12. National Institute on Drug Abuse. NIDA research report: methamphetamine abuse and addiction. Available at: http://www. drugabuse.gov/ResearchReports/methamph/methamph.html. Accessed on June 28, 2006. 13. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: heroin. June, 2003. Available at http://www. whitehousedrugpolicy.gov/publications/factsht/heroin/index.html. Accessed on June 15, 2006.
CHAPTER 13 127 14. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: cocaine. November, 2003. Available at http:// www.whitehousedrugpolicy.gov/publications/factsht/cocaine/index.html. Accessed on June 15, 2006. 15. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: methamphetamine. November, 2003. Available at http://www.whitehousedrugpolicy.gov/publications/factsht/methamph/ index.html. Accessed on June 15, 2006. 16. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: MDMA (ecstasy). February, 2004. Available at http://www.whitehousedrugpolicy.gov/publications/factsht/mdma/index. html. Accessed on June 15, 2006. 17. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: gamma hydroxybutyrate (GHB). November, 2002. Available at http://www.whitehousedrugpolicy.gov/publications/ factsht/gamma/index.html. Accessed on June 15, 2006. 18. Office of National Drug Control Policy. Drug policy information clearinghouse fact sheet: rohypnol. February, 2003. Available at http:// www.whitehousedrugpolicy.gov/publications/factsht/rohypnol/index.html. Accessed on June 15, 2006. 19. Psychiatry 24x7. Poppers (amyl and butyl nitrate). Published by Janssen- Pharmaceutica NV. Available at http://www.psychiatry24x7.com/bgdisplay. jhtml?itemname=substance_inhalants. Accessed on September 6, 2006. 20. U.S. Drug Enforcement Administration. Cocaine. Available at http://www. dea.gov/concern/cocaine_factsheet.html. Accessed on June 28, 2006. 21. U.S. Drug Enforcement Administration. GHB (gamma hydroxybutyric acid). Available at http://www.dea.gov/concern/ghb_factsheet.html. Accessed on June 28, 2006. 22. U.S. Drug Enforcement Administration. Ketamine. Available at http:// www.dea.gov/concern/ketamine_factsheet.html. Accessed on June 28, 2006. 23. U.S. Drug Enforcement Administration. MDMA (Ecstasy). Available at http://www.dea.gov/concern/mdma/mdma_factsheet.html. Accessed on June 28, 2006. 24. U.S. Drug Enforcement Administration. Rohypnol (flunitrazepam). Available at http://www.dea.gov/concern/flunitrazepam.html. Accessed on June 28, 2006. 25. Wikipedia. Black tar heroin. Available at http://en.wikipedia.org/wiki/ Black_tar_heroin. Accessed on June 15, 2006. 26. Wikipedia. Methylenedioxymethamphetamine. Available at http:// en.wikipedia.org/wiki/Methylenedioxymethamphetamine. Accessed on June 15, 2006
128 CHAPTER 13 Recommended Reading Arnsten JH, Demas PA, Grant RW, et al. Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. J Gen Intern Med. 2002;17:377–381. Boddiger D. Methamphetamine use linked to rising HIV transmission. Lancet. 2005;365:1217–1218. Buchacz K, McFarland W, Kellogg TA, et al. Amphetamine use is associated with increased HIV incidence among men who have sex with men in San Francisco. AIDS. 2005;19:1423–1424. Clatts MC, Goldsamt LA, Yi H. Club drug use among young men who have sex with men in NYC: a preliminary epidemiological profile.Subst Use Misuse. 2005;40:1317–1330. Colfax G. Methamphetamine: important clinical guidance for healthcare providers. Available at http://www.medscape.com/viewarticle/514193. Accessed June 28, 2006. Colfax G, Coates TJ, Husnik MJ, et al. Longitudinal patterns of methamphetamine, popper (amly nitrate), and cocaine use and high-risk sexual behavior among a cohort of San Francisco men who have sex with men. J Urban Health. 2005;82:i62-i70. Colfax GN, Mansergh G, Guzman R, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. J Acquir Immune Defic Syndr. 2001;28:373–379. Colfax G, Shoptaw S. The methamphetamine epidemic: implications for HIV prevention and treatment. Curr HIV/AIDS Rep. 2005;2:194–199. Chu PL, McFarland W, Gibson S, et al. Viagra use in a community-recruited sample of men who have sex with men, San Francisco. J Acquir Immune Defic Syndr. 2003;33:191–193. Halkitis PN, Green KA, Mourgues P. Longitudinal investigation of methamphetamine use among gay and bisexual men in New York City: findings from project BUMPS. J Urban Health. 2005;82:i18-i25. Klitzman RL, Greenberg JD, Pollack LM, Dolezal C. MDMA (‘ecstasy’) use, and its association with high risk behaviors, mental health, and other factors among gay/bisexual men in New York City. Drug Alcohol Depen. 2002;66:115– 125. Klitzman RL, Pope HG, Hudson JI. MDMA (‘ecstasy’) abuse and high- risk sexual behaviors among 169 gay and bisexual men. Am J Psychiatry. 2000;157:1162–1164. Mansergh G, Purcell DW, Stall R, et al. CDC consultation on methamphetamine use and sexual risk behavior for HIV/STD infection: summary and suggestions. Public Health Rep. 2006;121:127–132.
CHAPTER 13 129 Nath A, Hauser KF, Wojna V, et al. Molecular basis for interactions of HIV and drugs of abuse. J Acquir Immune Defic Syndr. 2002;31:S62-S69. Patterson TL, Semple SJ, Zians JK, Strathdee SA. Methamphetamine-using HIV-positive men who have sex with men: correlates of polydrug use. J Urban Health. 2005; 82:i120-i126.
130 CHAPTER 13 Chapter 14 HIV and Injection Drug Use
Injection Drug Use and Risk of HIV Transmission njection drug use presents multiple risks for potential HIV transmission. Research suggests that HIV-infected injection drug users (IDUs) often Idemonstrate a broad array of risky sexual and drug use behaviors, not only needle sharing. Risk behaviors associated with injection drug use include1: Syringe-sharing (one of the most efficient methods of transmitting HIV2) Sharing injection equipment, such as cookers, water, drug solutions, and cottons Increased likelihood of unsafe sexual behaviors by impairing users’ judgment, decreasing inhibitions, and opportunities to trade sex for drugs/money HIV-infected IDUs who share needles or works are at risk for: Transmitting HIV to other users Acquiring or transmitting hepatitis and other blood-borne pathogens Acquiring or transmitting additional strains of HIV to partners
— Transmission or acquisition of drug-resistant HIV is a particular concern for all HIV-infected individuals.
— One study of HIV-infected IDUs found that 14% of participants reporting high-risk sexual and/or drug behavior at study visits also demonstrated clinically significant drug-resistant HIV.3
Who Is at Risk? Although the incidence of HIV among IDU decreased from 1994–20004 (CDC 2003) and again from 2001–2005, injection drug users continued to account for at least 14% of all new HIV cases in 2005.5
131 All injection drug users (IDUs) who share needles or works are at risk, even if they are already HIV-positive. IDUs may be at particular risk for sharing needles if they3: are homeless. have a lower income. have a sexual partner that is also an injection drug user. inject daily. trade sex for drugs. Women injection drug users may be at particular risk for transmission risk factors beyond the injection drug use itself. In one study of high-risk behaviors among IDUs, among those who were sexually active, women were almost twice as likely to have unprotected sex than men (even controlling for other variables such as alcohol use, trading sex for drugs, and frequency of sex). 3
Factors Associated with the Decline in HIV Prevalence Among IDUs Factors that may be contributing to the decline in new HIV diagnoses among IDUs include: Syringe Exchange Programs (SEPs) Since SEPs were legalized and expanded in New York City, rates of distributed sharing (passing on used needles to others) and receptive sharing (injecting with a needle used by someone else) have both decreased significantly.6 In a study of global cities with and without programs that distributed clean needles and syringes, cities with needle–distributing programs had annual decreases in HIV seroprevalence of IDUs while cities with no distribution programs had an increase in HIV seroprevalence among IDUs.7 Substance Abuse Treatment Entering and remaining in substance abuse treatment reduces drug use and HIV transmission risk behaviors.8 Prevention Norms of IDUs Some IDUs report that when using drugs in a group without enough needles for each person, they engage in “informed altruism” (disclosing their HIV status) and “ordered sharing” (having HIV-negative users use a needle first) to reduce transmission risks.6
132 CHAPTER 14 Similarly, many IDUs encourage other users in their communities to engage in self-protective behaviors, helping to facilitate a norm of HIV transmission risk reduction (termed “intraventions).9
Injection Drug Use and Risk of Hepatitis C Coinfection IDUs are at particular risk for being infected not only with HIV but with the Hepatitis C virus as well. It is estimated that 50%–90% of HIV-infected IDUs are infected with Hepatitis C.10 Injection drug use is the main risk factor for acquisition of Hepatitis C, and the virus is rapidly acquired among IDUs. Between 50% and 80% of users become infected within 5 years of starting injection drug use, and 60% of new cases in 2000 occurred among IDUs.11 The primary risk factor for Hepatitis C transmission is when blood from an infected person enters the body of an uninfected person—for example through shared injection drug equipment or shared needles in other activities (e.g., piercings, tattooing).11 There is also a small risk of Hepatitis C transmission through other body fluids such as semen or vaginal fluid.11 Many patients with Hepatitis C are unaware that they are infected because symptoms in newly acquired cases are mild or nonexistent.11 Hepatitis C infection is more serious in HIV-infected patients and can lead to liver damage more quickly and affect the treatment of HIV infection.11 Tip
HIV transmission risk reduction strategies also apply to Hepatitis C risk reduction. Prevention messages to IDUs should include reducing the risk of Hepatitis C acquisition and transmission.
Sources of Risk for Injection Drug Users Possible Sources of Risk during Injection Drug Use Although much attention has been paid to the risks of needle sharing during injection drug use, there are other drug-sharing behaviors that present risk for transmission of HIV, including the sharing of cookers, cotton filters, and water. Sharing of these “works” may actually be more common than needle sharing and poses a significant risk of HIV and hepatitis transmission. For example, in a study of drug use behaviors among IDUs,12 it was found that direct sharing of syringes occurred relatively infrequently (reported by only 22% of users during their last injection episode). High-risk drug preparation
CHAPTER 14 133 practices, however, were quite common among IDUs (ranging from 58%–86% of users during their last injection episode).12
Research suggests needle sharing may be relatively infrequent among some injection drug users, whereas other risky drug-sharing behaviors (such as sharing cookers and using common syringes to partition drugs) may actually be more common among IDUs.
Injection drug use practices that may facilitate the transmission of HIV, Hepatitis B, and Hepatitis C often occur during the preparation and distribution of drugs for injection that are purchased jointly. These practices commonly include:
Sharing “cookers” or “spoons” An IDU may use a syringe to pull their portion of a drug from a communal cooker, or they may squirt some of the drug solution from their syringe back into the cooker (e.g., if too much is taken or a single “shot” is further divided and shared).
Sharing or reusing cotton filters An IDU may share or reuse a filter, or they may use a filter that has been saturated with shared drug solution to get more of the drug (a practice referred to as “beating the cotton,” “a rinse,” “cotton shot” or “a wash”). During this practice, the user puts water on the filter, puts it in the cooker, then draws up the solution and injects it.
Sharing water IDUs may share water for mixing drugs into solution or for rinsing their syringe or other drug paraphernalia.
Partitioning drugs When injection drugs are purchased for joint use, the drug is typically heated in a cooker and then drawn back into the preparer’s syringe to measure each participant’s share using the calibrations on the syringe barrel. This can be done in several ways:
Frontloading Frontloading is a method of distributing shared drugs through a needle with a detachable syringe. The drug solution is drawn up into a “donor” syringe and then measured out into one or more
134 CHAPTER 14 other syringes.13 It is referred to as “frontloading” because the drug solution is squirted through the front of the syringe.
Backloading Backloading is a method of distributing shared drugs from one syringe into the barrel of another. It differs from frontloading in that the syringes used have fixed needles: the recipient syringe plunger is removed, and the drug solution is squirted in from the donor syringe through the back opening.13
Squirting the drugs back into the cooker to be drawn up by the other users
These indirect sharing practices appear to be quite common among IDUS. In a study of IDUs and the people they used drugs with (their drug-sharing “network”), at least one member in many networks participated in risky drug use behaviors:12 82% of the drug-sharing networks divided the drug as a liquid. 86% used a common cooker. 35% reported use of a used, unbleached syringe to prepare the drug solution. 67% reported use of water that syringes had been rinsed in for mixing drugs. 58% beat a cotton. 5% reported backloading. Indirect sharing may be particularly common among users who do not have a safe place to use. That is, they want to prepare and inject their drugs as quickly as possible and prefer to use the least amount of equipment possible to avoid getting caught.12 Sexual Risk for IDUs IDUs may be at additional risk for sexual transmission of HIV given that individuals under the influence of some substances are more likely to engage in sexual risk-taking behavior and some drug users eventually exchange sex for drugs or money.14 HIV prevention interventions for IDUs must be comprehensive. Interventions need to provide information on how to prevent HIV transmission through sexual behavior risk reduction strategies as well as IDU risk reduction strategies.11
CHAPTER 14 135 Specifically, HIV providers need to address use of condoms and other barrier methods, disclosure of HIV status to sexual partners, triggers for high-risk sexual behavior, and other issues related to sexual behavior risk reduction for all patients, regardless of whether or not they are injection drug users.14
Discussing IDU Risks with Patients While one’s own personal style of interacting with patients will set the tone of discussions about IDU behavior, several kinds of questions should be avoided since they do not facilitate open discussions. When talking with your patients about injection drug use:
Avoid close-ended questions like “Do you share needles?” Most patients are aware that sharing needles is “bad” and may be reluctant to admit to such behaviors when questions are framed that way. It is easy to say “no” and avoid the discussion. Instead, try open-ended questions like “What situations have been most difficult for you in terms of lending or borrowing needles or works?” “Can you describe a situation where you might feel like you’d have to borrow or lend works or needles?”
Avoid leading questions like “You’re not sharing, are you?” Instead, ask questions that allow the patient to answer openly, like “What have you been able to try in terms of lending or borrowing needles? What has worked for you and what doesn’t?”
Use the Motivational Interviewing (MI) techniques of the Options intervention to elicit your patient’s perspective and understand the motivation and/or behavioral skills barriers involved. The fundamental components of the Options intervention can be implemented in conversations about IDU to minimize resistance to discussing risk behaviors. Often patients who use drugs expect their healthcare providers to be unable to understand them, and, therefore, of no potential use or help. It is critical to challenge that belief through MI techniques, open listening, and nonjudgmental discussion.
Safer Injection Drug Use Strategies Encouraging Patients to Stop Using Injection Drugs There is no “safe” drug use. Stopping use of injection (and other) drugs is the safest strategy in preventing HIV transmission.
How the topic of drug use and potentially “quitting” is approached has important implications for determining how productive the ensuing conversation between provider and patient will be. Patients often anticipate that their providers will simply instruct them to quit using and may even lecture or chastise them for using. As such, an open dialogue with a patient who is using may be difficult to achieve.
136 CHAPTER 14 The provider must first earn the trust of the patient and “prove” that they are interested in exploring options and working with the patient “where they are at.” Lecturing, oversimplifying, or issuing prescriptive advice to simply quit is rarely effective and can in fact be damaging to an otherwise collaborative relationship. Thus, when providers discuss the possibility of quitting use, it is best to present it as an option, one of many. Framing the discussion in terms of the patient’s thoughts on the issue can provide an opportunity for the provider to tell the patient about local resources and support, but not as a directive. For those patients who are ready to get “clean,” be knowledgeable about community resources for drug abuse and relapse prevention treatment referral.
See Chapter 13, Commonly Abused Drugs and Effective Risk Reduction Strategies, for more information about strategies to help patients overcome drug abuse. The Harm Reduction Approach While stopping drug use is the safest prevention strategy, patients sometimes do not view this as a viable option. When patients indicate to you, either verbally or nonverbally, that they are not in a position to consider stopping their drug use at this point, it is critical that a harm reduction approach be adopted. Harm reduction strategies are commonly used in medical and public health practices to reduce the risk of transmitting HIV or acquiring other infections for patients who are not ready to enter treatment or to stop using injection drugs. If your patient is not ready or currently interested in entering treatment or stopping IDU, there are a number of strategies he/she can use to reduce the risk of transmitting HIV or acquiring other infections (such as hepatitis).
Harm Reduction Options for IDUs:14–15 Use an alternate (non-injection) method of taking drugs. Reduce frequency of injection drug use. When possible, use a new, sterile syringe to prepare and inject drugs. The patient should use only sterile syringes obtained from a reliable source (e.g., a pharmacy or a syringe access program) and should not lend or borrow syringes. Options for obtaining syringes include Syringe Exchange Programs and Expanded Syringe Access Demonstration Programs (i.e., pharmacies). Use bleach as an alternative if no new syringe is available.
CHAPTER 14 137 If it is not possible to use a new, unused, sterile syringe, the syringe should be cleaned and disinfected with full-strength bleach. However, inform patients that a disinfected syringe is not a sterile syringe: even the best disinfection procedure can not guarantee that all viruses have been killed.6 Avoid reusing, lending or borrowing syringes. Avoid reusing or sharing water or other drug preparation equipment. If possible, use sterile water to prepare drugs. If this is not possible, use clean water from a reliable source (e.g., fresh tap water). Any leftover water should be discarded. Once the sterile water has been opened, it should be thrown out because once opened it may contain bacteria from the air or end up being used by another person. Make every effort to use a new or disinfected container (“cooker”) and a new filter (“cotton”) to prepare drugs. IDUs should mark their spoons (or other “cookers”) for easier identification, keep them in a place where other people do not have access to them, clean them with bleach, and rinse them thoroughly before use.13 (Use the same procedure for any other receptacle used for mixing drugs.) Avoid contamination of other materials used during drug use, including the drug preparation site and other items (e.g., knives). Safely dispose of syringes after one use. See suggestions below in “Safe Syringe Disposal” Follow other harm reduction procedures during injection drug use, such as:
— Always wash hands and arms before preparing to inject.
— Use a clean surface to prepare drugs or spread out a piece of clean paper.
— Use an alcohol pad to clean the skin where the user is going to inject.
— After injecting, use a gauze pad to stop the bleeding.
— Put a bandage on the place where the user injected.
— Throw away the used alcohol pad, gauze, and all other drug preparation equipment.
— Clean anything else blood might have touched (such as the tourniquet, the injection space, or clothes).
— Wash hands again to clean off dirt, blood and viruses.
138 CHAPTER 14 Syringe Disinfection Below are instructions for syringe disinfection from the Centers for Disease Control and Prevention:16 1. Fill the syringe with clean water (such as water right from a tap or a new bottle of water), and shake or tap. Squirt out the water and throw it away. Repeat until you don’t see any blood in the syringe. 2. Completely fill the syringe with fresh, full-strength household bleach. Keep it in the syringe for 30 seconds or more. Squirt it out and throw the bleach away. 3. Fill the syringe with clean water and shake or tap. Squirt it out and throw the water away. 4. If you don’t have any bleach, use clean water to vigorously flush out the syringe: fill the syringe with water and shake or tap it. Squirt out the water and throw it away. Do this several times.
Safe Syringe Disposal There are several ways your injection drug using patients can safely store, and then dispose of, used syringes. Encourage your IDU patients to follow these strategies17 for their own safety and for the safety of others. Do put used syringes in a sharps container or a puncture-resistant, plastic bottle (for example, a bleach or laundry detergent bottle). Close the screw- on top tightly. You may want to tape it as well. Label the bottle, “Contains Sharps.” Do keep sharps containers away from children and pets. Don’t put sharps in soda cans, milk cartons, glass bottles, or in any containers that are not puncture resistant. Coffee cans are not recommended because the plastic lids come off too easily and may leak. Don’t flush sharps down the toilet or drop them into a storm sewer. Don’t put sharps containers out with the recycling. Loose needles, syringes, or lancets should never be thrown into a recycling bin. Once the sharps container is ready for disposal, there are several safe disposal options that patients can use to help protect themselves, others, and the environment. For example:
— You (or your healthcare organization) can prepare a handout about local sharps disposal options to give to your injection drug-using patients.
— You can help your patient find out the days and times that local hospitals or nursing homes accept sharps for disposal.
CHAPTER 14 139 — Your patient can call their local public works department or trash collector. (Check the blue pages of the telephone book for their numbers.) Some communities have special household medical waste collection or drop-off days.
— Your patient can call their local health department and ask the health educator on staff about sharps collection programs in their county.
Overdose Prevention The risk of overdose due to heroin use may be as high as 2% per year.14 Death usually occurs 1 to 3 hours after injection, is more common when opioids are mixed with alcohol or benzodiazepines, and is often witnessed by someone who does not recognize the danger.14 Clinicians should discuss harm-reduction topics related to opioid overdose including: The risk of using alone. The risk of using after a period of abstinence. The danger of mixing other depressants with heroin. Signs of possible heroin overdose in another user. Learning mouth-to-mouth breathing or CPR. Calling 911 to report someone who is unconscious or not breathing. Be prepared for possible police involvement. When the ambulance comes, report exactly what the person took. Use of naloxone (Narcan) to help reduce an opiod overdose.
— A law that took effect in April 2006 in New York State allows for the use of injectable naloxone as first aid if administered in good faith by a nonprofessional intending to reverse an opioid overdose. Unlicensed individuals are permitted to carry and administer naloxone without fear of prosecution. Syringe exchange programs and some drug treatment programs train users in overdose prevention, recognition, and response including the use of naloxone. Clinicians can refer patients to these services and cooperate by prescribing naloxone to patients who have been trained in its use.
140 CHAPTER 14 The Importance of Multidisciplinary Care Comprehensive care for HIV-infected substance users often requires the services of providers from multiple disciplines.14 Clinicians should be familiar with community resources available and should coordinate the care of their substance using patients. Services may be colocated at one site linked across several sites: Colocated Services Colocated services offer interdisciplinary care to patients in a single-site treatment. Primary care centers augmented by staff such as psychologists, social workers, and addiction counselors are examples of colocated programs. Services in New York provide HIV primary care to substance users within drug treatment programs. Organizations in New York that provide colocated HIV care within drug treatment facilities include:14 Addiction Research & Treatment Corporation Beth Israel Medical Center Center for Comprehensive Health Practice Greenwich House Lower Eastside Service Center Narco Freedom Promesa St. Vincent’s Catholic Medical Center West Midtown Medical Group Albert Einstein College of Medicine Bronx Lebanon Hospital Center Daytop Village Interfaith Medical Center Montefiore Medical Center Project Samaritan Health Services Staten Island University Hospital VIP Community Services
CHAPTER 14 141 Interagency Services When a patient receives services from multiple agencies, exchange of information should be well coordinated. The primary care clinician should clearly assign responsibilities for important elements of the patient’s care including making referrals to social services, following up with the patient and other members of the healthcare team if the patient drops out of treatment, and notifying other members of the healthcare team if a major change in status occurs. Case Management A case manager should coordinate care for patients receiving services in more than one setting. Providers should work with the case management team to coordinate medical care, referrals, and ongoing services. Appropriate Drug Treatment Referrals Drug treatment programs may be available through hospitals or community- based programs, and providers should work with social workers and other mental health providers (when available) to refer the patient to the most appropriate drug treatment program to best meet the patient’s needs.
142 CHAPTER 14 References 1. Doherty MC, Garfein RS, Monterroso E, Brown D, Vlahov D. Correlates of HIV infection among young adult short-term injection drug users. AIDS. 2000;14:717–726. 2. Centers for Disease Control and Prevention. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR. 2005;54:1–19. 3. Sethi AK, Celentano DD, Gange SJ, Gallant JE, Vlahov D, Farzadegan H. High-risk behavior and potential transmission of drug-resistant HIV among injection drug users. J Acquir Immune Defic Syndr. 2004;35:503– 510. 4. Centers for Disease Control and Prevention. HIV diagnoses among injection-drug users in states with HIV surveillance—25 states, 1994– 2000. JAMA. 2003;290:743–744. 5. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005. Vol. 17. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention;2006:1–54. Also available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. 6. Des Jarlais DC, Perlis T, Arasteh K, et al. “Informed altruism” and “partner restriction” in the reduction of HIV infection drug users entering detoxification treatment in New York City, 1990–2001.J Acquir Immune Defic Syndr.2004;35:158–166. 7. MacDonald M, Law M, Kaldor J, Hales J, Dore GJ. Effectiveness of needle and syringe programmes for preventing HIV transmission. Int J Drug Policy. 2003;14:353–357. 8. Santibanez SS, Garfein RS, Swartzenruber AS, Purcell DW, Paxton LA, Greenberg AE. Update and overview of practical epidemiologic aspects of HIV/AIDS among injection drug users in the United States. J Urban Health. 2006;83:86–100. 9. Friedman SR, Maslow C, Bolyard M, Sandoval M, Mateu-Gelabert P, Neaigus A. Urging others to be healthy: “intravention” by injection drug users as a community prevention goal. AIDS Educ Prev. 2004;16:250–263. 10. Centers for Disease Control and Prevention. Coinfection with HIV and hepatitis C virus. November 2005. 11. Centers for Disease Control and Prevention. Viral hepatitis and injection drug users. September 2002. 12. Koester S, Glanz J, Baron A. Drug sharing among heroin networks: implications for HIV and hepatitis B and C prevention. AIDS Behav. 2005;9:27–39.
CHAPTER 14 143 13. Derricott J, Preston A, Hunt N. The safer injecting briefing: an easy to use comprehensie reference guide to promoting safer injection. Available at: http://www.exchangesupplies.org/publications/safer_injecting_briefing/ section_cover.html. Accessed on June 29, 2006. 14. New York State Department of Health AIDS Institute. Working with the active user. October 2006. Available at: http://www.hivguidelines.org/ GuideLine.aspx?pageID=262&guideLineID=78. Accessed on November 7, 2006. 15. National Institute on Drug Abuse. Principles of HIV prevention in drug- using populations: a research-based guide. March, 2002. Available at: http://www.drugabuse.gov/POHP/. Accessed on June 29, 2006. 16. Centers for Disease Control and Prevention. Syringe disinfection for injection drug users. July, 2004. Available at: http://www.cdc.gov/IDU/ facts/disinfection.pdf. Accessed on June 29, 2006. 17. State of New York Department of Health. How to safely dispose of household sharps. Updated January, 2006. Available at http://www.health. state.ny.us/diseases/aids/harm_reduction/needles_syringes/esap/docs/ sharpseng.pdf. Accessed on June 29, 2006.
144 CHAPTER 14 Recommended Reading Burack JH, Bangsberg D. Epidemiology and HIV transmission in injection drug users. HIV InSite Knowledge Base Chapter. May, 1998. Available at http://www.hivinsite.org/InSite?page=kb-07&doc=kb-07–04–01. Accessed May 3, 2007. Carey J, Perlman DC, Friedmann P, et al. Knowledge of hepatitis among active drug injectors at a syringe exchange program. J Subst Abuse Treat. 2005;29:47–53. Centers for Disease Control and Prevention. Drug-associated HIV transmission continues in the United States. May 2002. Des Jarlais DC, Perlis T, Arasteh K, et al. HIV incidence among injection drug users in New York City, 1990 to 2002: use of serologic test algorithm to assess expansion of HIV prevention services. Am J Public Health. 2005;95:1439–1444. Doherty MC, Gargein RS, Monterroso E, Latkin C, Vlahov D. Gender differences in the initiation of injection drug use among young adults. J Urban Health. 2000;77: 396–414. Finlinson HA, Colon HM, Lopez MS, Robles RR, Cant JG. Injecting shared drugs: an observational study of the process of drug acquisition, preparation, and injection by Puerto Rican drug users. J Psychoactive Drugs. 2005;37:37–49. Friedman SR, Ompad DC, Maslow C, et al. HIV prevalence, risk behaviors, and high-risk sexual and injection networks among young women injectors who have sex with women. Am J Public Health. 2003;93:902–906. Gibson DR. HIV prevention in injection drug users. HIV InSite Knowledge Base Chapter. November, 1998. Available at http://www.hivinsite.org/ InSite?page=kb-07&doc=kb-07–04–01–01. Accessed May 3, 2007. Moatti JP, Vlahov D, Feroni I, Perrin V, Obadia Y. Multiple access to sterile syringes for injection drug users: vending machines, needle exchange programs and legal pharmacy sales in Marseille, France. Eur Addict Res. 2001;7:40–5. Pouget ER, Deren S, Fuller CM, et al. Receptive syringe sharing among injection drug users in Harlem and the Bronx during the New York State expanded syringe access demonstration program. J Acquir Immune Defic Syndr. 2005;39:471–477. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. Am J Epidemiol. 2001;154:S70-S77.
CHAPTER 14 145 146 Chapter 15 New York State Resources for Healthcare Providers
HIV Counseling & Testing Directory HIV Counseling & Testing Resource Directory—2004 Edition (Oct. 2006 Update) or HIV information, referrals, or information on how to obtain a free HIV test without having to give the client’s name and without waiting Ffor an appointment, call the regional program closest to the county where the client lives:
Region Toll Free #
Albany 800–962–5065 Buffalo 800–962–5064 Nassau 800–462–6785 New Rochelle 800–828–0064 Queens 800–462–6785 Rochester 800–962–5063 Suffolk 800–462–6786 Syracuse 800–562–9423 New York State DOH AIDS Hotline 800–541-AIDS SIDA Hotline (Spanish) 800–233–7432 New York City DOH AIDS 800-TALK-HIV Hotline 800–825–5448
HIV Counseling Hotline: 800–872–2777 (M-F: 4pm–8pm; S/S: 10am–6pm) Full Provider List: http://www.health.state.ny.us/diseases/aids/testing/ directory/index.htm
147 Testing is anonymous—clients do not have to provide names to obtain HIV tests. Each client is given a code number that is used to keep track of their test record. Written on a return appointment card, this number enables clients to receive their results. Methods include rapid testing, oral fluid testing (no needles) and blood testing for HIV antibodies. Results are provided in-person during the same session if rapid testing is selected or at a post-test appointment. Clients with positive test results have the option to convert their test records to confidential—benefits of this include avoiding the need for retesting and allowing more immediate access to care.
PNAP & CNAP Partner Assistance Program (PNAP) and Contact Notification Assistance Program (CNAP) for HIV-positive Individuals PNAP and CNAP help individuals with HIV or AIDS inform their partners or contacts that they may have been exposed to HIV. PNAP or CNAP services are free of charge and completely confidential.
Area Telephone # Buffalo 716–858–7853 Western New York Southern Tier 716–661–8111 Rochester 800–757–5803 315–477–8116 Syracuse 800–878–3827 Onondaga County 315–435–3236 Oneida/Herkimer 315–798–5747 Central New York Southern Tier 800–878–3827 Central New York Northern Tier 315–785–2277 Albany/Schenectady 518–402–7411 Dutchess 845–486–3558 Orange 845–568–5333 Westchester 914–813–5115 Nassau 516–571–0216 Suffolk 631–853–2255 Rockland 845–364–2992 Ulster, Sullivan, Putnam Counties 914–654–7158 New York City (CNAP) 212–693–1419
148 CHAPTER 15 Syringe Exchange Expanded Syringe Access Demonstration Program (ESAP) For full list of ESAP providers, see: http://www.health.state.ny.us/diseases/aids/ harm_reduction/needles_syringes/esap/provdirect.htm Questions concerning ESAP can be directed as follows: ESAP Registration Process: Bureau of Controlled Substances at (518) 402–0707. Other program information: AIDS Institute at (212) 417–4770 By e-mail: [email protected] NYS Department of Health-Approved Syringe Exchange Programs (SEPs)
New York City AIDS Center of Queens County 4257 Hunter Street Long Island City, NY 11101 718–869–2500 Family Services Network of NY 1639 Broadway Brooklyn, NY 11207 718–573–3358 CitiWide Harm Reduction Program 250 E. 143rd St., 3rd Floor Bronx, NY 10451 718–292–7718 FROST’D 369 8th Avenue New York, NY 10001 212–924–3733 Housing Works (SEP open to Housing Works’ clients only) 130 Crosby Street New York, NY 10012 347–473–7404 Lower East Side Harm Reduction Center 25 Allen Street New York, NY 10002 212–226–6333 NY Harm Reduction Educators (Bronx-Harlem) 903 Dawson Street Bronx, NY 10459 718–842–6050
CHAPTER 15 149 Positive Health Project 301 W. 37th St., 2nd Floor New York, NY 10018 212–465–8304 Queens Hospital Center 166–10 Archer Avenue Jamaica, NY 11433 718–883–4027 St. Ann’s Corner of Harm Reduction 310 Walton Avenue, Ste. 201 Bronx, NY 10451 718–585–5544 The After Hours Project 1232 Broadway Brooklyn, NY 11221 718–249–0755
Outside of New York City AIDS Rochester 844 N. Clinton Avenue Rochester, NY 14605 716–454–5556 Southern Tier AIDS Program (STAP) 501 South Meadow Street, Rt. 13 Ithaca, NY 14850 607–272–4098 Kaleida Health/PROJECT REACH 206 S. Elmwood Avenue Buffalo, NY 14201 716–845–0172 Urban League of Westchester 10 Fiske Place Mount Vernon, NY 10550 914–667–1010
Information about the above programs may also be located at: http://www.harmreduction.org/usnep/newyork/hours.html (Note: Go to “Resources,” then “Syringe Exchange,” then to “US Needle Exchange Locations and Hours,” then “New York (State and City).”) http://www.hivpositive.com/f-Resources/f-19-NeedleExPgms/19- NYexchange.html
150 CHAPTER 15 Sharps Disposal For information on days and times for sharps disposal by region, call 800–522–5006 (TTY: 800–655–1789) To find places with sharps disposal kiosks call 800–541–2437 For a list of disposal sites by county, see: http://www.health.state. ny.us/diseases/aids/harm_reduction/needles_syringes/sharps/directory_ sharpscollection.htm For information from the CDC about safe community needle disposal in New York State, see: http://www.cdc.gov/needledisposal For information about sharps disposal from the American Diabetes Association, call 888–232–2737 or see http://www.BDdiabetes.com to learn about their mail-in sharps disposal program.
Drug Treatment Referrals New York State Office of Alcohol and Substance Abuse Services (OASAS): 800–522–5353 In New York City, call 800-LIFENET (543–3638) LIFENET is an anonymous help line run by the Mental Health Association of New York City for persons seeking treatment for drugs, alcohol or emotional problems. To find a drug treatment center near you, visit:http://oasasapps.oasas. state.ny.us/portal/pls/portal/OASASREP.DYN_PROV_SEARCH.show
Other Resources Clinical Resources for HIV New York State Department of Health AIDS Institute http://www.hivguidelines.org
Clinical Trials AIDS Community Research Initiative of America (ACRIA) http://www.acria.org 212–924–3934
AIDS Clinical Trials Information Service 800–TRIALS–A [email protected]
CHAPTER 15 151 Confidentiality New York State Confidentiality 800–962–5065 Legal Action Center 212–243–1313
Day Treatment Programs NYS Department of Health, Division of HIV Health Care, Chronic Care Unit 518–474–8162
Designated AIDS Centers New York State Department of Health, Division of HIV Health Care 518–486–1383
Domestic Violence Services New York State Domestic Violence Hotline 800–621-HOPE
Educational Materials about HIV/AIDS Order Forms for Free HIV/AIDS Education and Prevention Materials http://www.health.state.ny.us/diseases/aids/publications/index.htm 518–474–9866 [email protected]
General Information about HIV/AIDS New York State Department of Health, HIV/AIDS Hotline 800–541-AIDS (2437)—English 800–233-SIDA (7432)—Spanish New York City Department of Health 800–825–5448 Centers for Disease Control and Prevention (CDC) 800–342–2437 (English) 800–344–7432 (Spanish) Monday–Friday, 8am–2am New York State Department of Health TTY HIV/AIDS Information Line 212–925–9560 Voice callers can use the New York Relay System, 711 or 800–421–1220 (ask the operator for 212–925–9560)
152 CHAPTER 15 Home Care NYS Department of Health, Division of HIV Health Care, Chronic Care Unit 518–474–8162
Human Rights/Discrimination New York State Division of Human Rights 800–523–2437 New York City Commission on Human Rights 212–306–7500
Incarcerated Persons NYS Prison HIV Hotline 718–854–5469 Monday–Friday, 12–8pm; Saturday–Sunday, 10am–6pm; collect calls are accepted from inmates in NYS Correctional Facilities.
Insurance Regulations New York State Insurance Department 800–342–3736 Medical Care HIV Uninsured Care Program 800–542–2437 518–459–0121 (TDD) AIDS Drug Assistance Program (ADAP) 800–542–2437
Newborn Regulations and Testing Regulations and Guidance on DNA PCR Testing 518–869–4568 Specimen Tracking 518–474–4543 HIV Antibody Test Interpretation 518–474–2163 PCR Test Interpretation 518–869–4568
Nursing Facilities New York State AIDS Institute, Chronic Care Section 518–474–8162
CHAPTER 15 153 Postexposure Prophylaxis (PEP) NYS Department of Health 212–417–4536 Monday–Friday, 9am–5pm 917–453–0488 Evenings and Weekends
Sexual Abuse NYSDOH Rape Crisis Program For general information on the NYSDOH protocol for the management of sexual abuse victims. 518–474–3664
Sexually Transmitted Diseases Centers for Disease Control (CDC) National STD Hotline 800–227–8922 (English) 800–344–7432 (Spanish) New York State Department of Health, Bureau of STD Control 518–474–3598 NYC Department of Health, STD Education Office 212–427–5120
Special Needs Plans (SNPs) New York Medicaid CHOICE HelpLine 800–505–5678 888–329–1541 TTY/TDD
Training Information for HIV/AIDS General HIV/AIDS Training Information and Calendar of Events 518–474–3045 Clinical HIV/AIDS Education (clinicians only) 518–473–8815
154 CHAPTER 15 Chapter 16 Internet Resources for Healthcare Providers
General HIV/AIDS Resources AIDS Education and Treatment Center (AETC) Resource Center http://www.aids-ed.org/ CDC HIV/AIDS Prevention http://www.cdc.gov/hiv/dhap.htm HIV Clinical Resource (Office of the Medical Director— New York AIDS Institute) http://www.hivguidelines.org/ UNAIDS: The Joint United Nations Programme on HIV/AIDS www.unaids.org World Health Organization—HIV/AIDS Programme http://www.who.int/hiv/en/ National Institute of Allergy and Infectious Diseases http://www.niaid.nih.gov/publications/aids.htm UCSF Center for AIDS Prevention Studies http://www.caps.ucsf.edu/ AIDS Treatment Data Network http://www.atdn.org
Glossaries and Dictionaires General HIV/AIDS AIDSinfo Glossary (U.S. Department of Health and Human Services) http://aidsinfo.nih.gov/Glossary/GlossaryDefaultCenterPage.aspx?MenuItem= AIDSinfoTools Gay Men’s Health Crisis (GMHC)— AIDS Medical Glossary and Drug Chart http://www.gmhc.org/health/glossary.html
155 Sexual Behavior The Lounge—Gay, Lesbian, Bisexual and Transgender Slang Dictionary http://andrejkoymasky.com/lou/dic/dic00.html Gay City USA—Gay Slang Dictionary http://www.gaycityusa.com/GaySlangDictionary.htm
Drug Use Street Drug Slang Dictionary (Indiana Prevention Resource Center) http://www.drugs.indiana.edu/slang/SearchSlang.aspx Street Terms: Drugs and Drug Trade (U.S. Office of National Drug Control Policy) http://www.whitehousedrugpolicy.gov/streetterms/Default.asp
Prevention for People Living with HIV General Integrating HIV Prevention into the Care of People with HIV (HIV InSite) http://hivinsite.ucsf.edu/InSite?page=kb-07–04–17 Incorporating HIV Prevention into the Medical Care of Persons Living with HIV http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm
CDC Resources On Behavioral Modification CDC REP+ (Replicating Effective Programs Plus) http://www.cdc.gov/hiv/projects/rep/default.htm CDC Compendium of HIV Prevention Interventions with Evidence of Effectiveness http://www.cdc.gov/hiv/pubs/hivcompendium/hivcompendium.htm
HIV Infection Rates General CDC HIV/AIDS Surveillance Report: 2004 http://www.cdc.gov/hiv/stats/2004SurveillanceReport.pdf HIV/AIDS Epidemic Update: December, 2005—WHO and UNAIDS http://w3.whosea.org/LinkFiles/Facts_and_Figures_PDFepi-update2005.pdf
By Demographics List of all CDC HIV Fact Sheets http://www.cdc.gov/hiv/pubs/facts.htm 156 CHAPTER 16 CDC HIV/AIDS Surveillance Supplemental Report (Race/Ethnicity) http://www.cdc.gov/hiv/stats/hasrsuppV0110N01.htm CDC Fact Sheet: HIV/AIDS Among African Americans http://www.cdc.gov/hiv/pubs/Facts/afam.htm CDC Fact Sheet: HIV/AIDS Among Hispanics http://www.cdc.gov/hiv/pubs/Facts/hispanic.htm CDC Fact Sheet: HIV/AIDS Among Asians and Pacific Islanders http://www.cdc.gov/hiv/pubs/Facts/API.htm CDC Fact Sheet: HIV/AIDS Among Women http://www.cdc.gov/hiv/pubs/facts/women.htm CDC Fact Sheet: HIV/AIDS & U.S. Women Who Have Sex With Women (WSW) http://www.cdc.gov/hiv/pubs/facts/wsw.htm CDC Fact Sheet: HIV/AIDS & U.S. Men who have Sex with Men (MSM) http://www.cdc.gov/hiv/pubs/facts/msm.htm CDC: AIDS Cases by Exposure Category http://www.cdc.gov/hiv/stats.htm#exposure
By State Cumulative AIDS Cases by Age, Race and Exposure (Kaiser Family Foundation) http://www.statehealthfacts.kff.org/cgi-bin/healthfacts.cgi?action=compare&w elcome=1&category=HIV%2fAIDS
State Facts and Health Agencies State Health Agencies from the U.S. Food and Drug Administration: http://www.fda.gov/oca/sthealth.htm Kaiser Family Foundation: State Health Facts http://www.statehealthfacts.kff.org
Guide To Sexual and Drug Histories Guide to Sexual History Taking (California STD/HIV Prevention Training Center) http://www.stdhivtraining.org/pdf/A_Guide_to_Sex_Hx_Taking.pdf The Clinical Approach to the STD Patient (National Network of STD and HIV Prevention Training Centers) http://www.stdhivtraining.org/pdf/ClinicalApproach2004.pdf
CHAPTER 16 157 Sexual History Taking (Association of Reproductive Health Professionals) http://www.arhp.org/healthcareproviders/cme/onlinecme/maturecmecp/ sexualhistory.cfm?ID=44
HIV Transmission and Safer Sex Options Male Latex Condoms and Sexually Transmitted Diseases (CDC) http://www.cdc.gov/hiv/pubs/facts/condoms.htm Safer Sex Methods (HIV InSite) http://hivinsite.ucsf.edu/InSite?page=kb-07&doc=kb-07–02–02 What You Should Know About Oral Sex (CDC) http://www.cdc.gov/hiv/pubs/Facts/oralsex.pdf Women Who Have Sex With Women (CDC) http://www.cdc.gov/hiv/pubs/facts/wsw.htm Resources for HIV Transmission & Prevention in Transgender People (HIV InSite) http://hivinsite.ucsf.edu/InSite?page=kbr-07–04–16 Resources for Sexual Transmission of HIV (HIV InSite) http://hivinsite.ucsf.edu/InSite?page=kbr-07–02–01 Resources for HIV Transmission and Prevention in Gay Men (HIV InSite) http://hivinsite.ucsf.edu/InSite?page=kbr-07–04–04
Drug Use Resources General Index of NIDA InfoFacts http://www.nida.nih.gov/Infofacts/Infofaxindex.html How do Club Drugs Impact HIV Prevention? (Center for AIDS Prevention Studies) http://www.caps.ucsf.edu/pdfs/ClubDrugsFS.pdf SAMHSA Center for Substance Abuse Prevention (CSAP) http://www.prevention.samhsa.gov/ SAMHSA Center for Substance Abuse Treatment http://www.csat.samhsa.gov/ National Clearinghouse for Alcohol and Drug Information http://www.health.org NIDA National Institute on Drug Abuse http://www.drugabuse.gov/
158 CHAPTER 16 Injection Drug Use CDC Fact Sheets for HIV Prevention Among IDUs http://www.cdc.gov/idu/ Syringe Disinfection for Injection Drug Users (CDC) http://www.cdc.gov/idu/facts/disinfection.htm Access to Sterile Syringes (CDC) http://www.cdc.gov/idu/facts/aed_idu_acc.htm Syringe Exchange Programs (CDC) http://www.cdc.gov/idu/facts/aed_idu_syr.htm Viral Hepatitis and Injection Drug Users (CDC) http://www.cdc.gov/idu/hepatitis/index.htm IDU HIV Prevention Needs (Center for AIDS Prevention Studies—CAPS) http://www.caps.ucsf.edu/IDU.html North American Syringe Exchange Network http://www.nasen.org/ U.S.—Based Needle Exchange and Needle Access Programs (thebody.com) http://www.thebody.com/whatis/druguse_needle_programs.html
Recreational Drug Interactions with Antiretrovirals HIV Drug Interactions (University of Liverpool) http://www.hiv-druginteractions.org/ Interactions with Illegal and Recreational Drugs (NAM—AIDSmap.com) http://www.aidsmap.com/en/docs/79D69369–262C-44AE-82DB- B8123B7210DC.asp?type=preview
HIV Testing Resources CDC National HIV Testing Resources http://www.hivtest.org/index.htm
CHAPTER 16 159 Appendices
© 2007 University of Connecticut. All rights reserved. Funding provided by New York State Department of Health AIDS Institute and Centers for Disease Control (CDC). Appendix A:
Incorporating HIV Prevention into the Medical Care of Persons Living with HIV
(Centers for Disease Control and Prevention) Morbidity and Mortality Weekly Report
Recommendations and Reports July 18, 2003 / Vol. 52 / No. RR-12
Incorporating HIV Prevention into the Medical Care of Persons Living with HIV
Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America
INSIDE: Continuing Education Examination
department of health and human services Centers for Disease Control and Prevention MMWR
CONTENTS
The MMWR series of publications is published by the Introduction ...... 1 Epidemiology Program Office, Centers for Disease Risk Screening ...... 3 Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Screening for Behavioral Risk Factors...... 3 Screening for Clinical Risk Factors ...... 5 Behavioral Interventions ...... 7 SUGGESTED CITATION Structural Approaches To Support and Enhance Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of Prevention ...... 7 persons living with HIV: recommendations of CDC, Interventions Delivered On-Site ...... 8 the Health Resources and Services Administration, the Referrals for Additional Prevention Interventions National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of and Other Services ...... 13 America. MMWR 2003;52(No. RR-12):[inclusive Examples of Case Situations for Prevention Counseling ... 14 page numbers]. Partner Counseling And Referral Services, Including Partner Notification ...... 15 Centers for Disease Control and Prevention Laws and Regulations Related to Informing Partners ...... 16 Julie L. Gerberding, M.D., M.P.H. Approaches to Notifying Partners ...... 16 Director Acknowledgments...... 17 Dixie E. Snider, Jr., M.D., M.P.H. References ...... 17 (Acting) Deputy Director for Public Health Science Donna F. Stroup, Ph.D., M.Sc. (Acting) Associate Director for Science Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc. Director Office of Scientific and Health Communications John W. Ward, M.D. Director Editor, MMWR Series Suzanne M. Hewitt, M.P.A. Managing Editor, MMWR Series C. Kay Smith-Akin, M.Ed. Lead Technical Writer/Editor Lynne McIntyre, M.A.L.S. Project Editor Beverly J. Holland Lead Visual Information Specialist Lynda G. Cupell Malbea A. Heilman Visual Information Specialists
Quang M. Doan Disclosure of Relationship Erica R. Shaver The preparers of this report have no conflict of interest with the manufacturers Information Technology Specialists or products discussed herein. Vol. 52 / RR-12 Recommendations and Reports 1
Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America
Summary Reducing transmission of human immunodeficiency virus (HIV) in the United States requires new strategies, including empha- sis on prevention of transmission by HIV-infected persons. Through ongoing attention to prevention, risky sexual and needle- sharing behaviors among persons with HIV infection can be reduced and transmission of HIV infection prevented. Medical care providers can substantially affect HIV transmission by screening their HIV-infected patients for risk behaviors; communicating prevention messages; discussing sexual and drug-use behavior; positively reinforcing changes to safer behavior; referring patients for services such as substance abuse treatment; facilitating partner notification, counseling, and testing; and identifying and treating other sexually transmitted diseases (STDs). To help incorporate HIV prevention into the medical care of HIV-infected persons, CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America developed these recommendations. The recommendations are general and apply to incorporating HIV prevention into the medical care of all HIV-infected adolescents and adults, regardless of age, sex, or race/ethnicity. They are intended for all persons who provide medical care to HIV-infected persons (e.g., physicians, nurse practitioners, nurses, physician assistants); they might also be useful to those who deliver prevention messages (e.g., case managers, social workers, health educators). The recommendations were developed by using an evidence-based approach. For each recommendation, the strength of the recommendation, the quality of available evidence supporting the recommendation, and the outcome for which the recommenda- tion is rated are provided. The recommendations are categorized into three major components: screening for HIV transmission risk behaviors and STDs, providing brief behavioral risk-reduction interventions in the office setting and referring selected patients for additional prevention interventions and other related services, and facilitating notification and counseling of sex and needle- sharing partners of infected persons.
Introduction by HIV-infected persons (2,3). HIV-infected persons who are aware of their HIV infection tend to reduce behaviors that Despite substantial advances in the treatment of human might transmit HIV to others (4–7). Nonetheless, recent immunodeficiency virus (HIV) infection, the estimated num- reports suggest that such behavioral changes often are not main- ber of annual new HIV infections in the United States has tained and that a substantial number of HIV-infected persons remained at 40,000 for over 10 years (1). HIV prevention in continue to engage in behaviors that place others at risk for this country has largely focused on persons who are not HIV HIV infection (8–13). infected, to help them avoid becoming infected. However, fur- Reversion to risky sexual behavior might be as important in ther reduction of HIV transmission will require new strate- HIV transmission as failure to adopt safer sexual behavior gies, including increased emphasis on preventing transmission immediately after receiving a diagnosis of HIV (14). Unpro- tected anal sex appears to be occurring more frequently in some urban centers, particularly among young men who have sex The material in this report originated in the National Center for HIV, with men (MSM) (15). Bacterial and viral sexually transmit- STD and TB Prevention, Harold W. Jaffe, M.D., Director; Division of HIV/AIDS Prevention — Surveillance and Epidemiology, Robert S. ted diseases (STDs) in HIV-infected men and women receiv- Janssen, Director; Division of HIV/AIDS Prevention — Intervention, ing outpatient care have been increasingly noted (16,17), Research, and Support, Robert S. Janssen, M.D., Acting Director. indicating ongoing risky behaviors and opportunities for HIV 2 MMWR July 18, 2003 transmission. Further, despite declining syphilis prevalence in (36,37). These measures may also decrease patients’ risks of the general U.S. population, sustained outbreaks of syphilis acquiring other STDs and bloodborne infections (e.g., viral among MSM, many of whom are HIV infected, continue to hepatitis). Managed care plans can play an important role in occur in some areas; rates of gonorrhea and chlamydial infec- HIV prevention by incorporating these recommendations into tion have also risen for this population (18–21). Rising STD their practice guidelines, educating their providers and enroll- rates among MSM indicate increased potential for HIV trans- ees, and providing condoms and educational materials. In the mission, both because these rates suggest ongoing risky behav- context of care, prevention services might be delivered in clinic ior and because STDs have a synergistic effect on HIV or office environments or through referral to community-based infectivity and susceptibility (22). Studies suggest that opti- programs. Some clinicians have expressed concern that reim- mism about the effectiveness of highly active antiretroviral bursement is often not provided for prevention services and therapy (HAART) for HIV may be contributing to relaxed note that improving reimbursement for such services might attitudes toward safer sex practices and increased sexual risk- enhance the adoption and implementation of these guidelines. taking by some HIV-infected persons (12,23–27). This report provides general recommendations for incorpo- Injection drug use also continues to play a key role in the rating HIV prevention into the medical care of all HIV- HIV epidemic; at least 28% of AIDS cases among adults and infected adolescents and adults, regardless of age, sex, or race/ adolescents with known HIV risk category reported to CDC ethnicity. The recommendations are intended for all persons in 2000 were associated with injection drug use (28). In some who provide medical care to HIV-infected persons (e.g., phy- large drug-using communities, HIV seroincidence and sicians, nurse practitioners, nurses, physician assistants). They seroprevalence among injection drug users (IDUs) have may also be useful to those who deliver prevention messages declined in recent years (29,30). This decline has been attrib- (e.g., case managers, social workers, health educators). Special uted to several factors, including increased use of sterile injec- considerations may be needed for some subgroups (e.g., ado- tion equipment, declines in needle-sharing, shifts from lescents, for whom laws and regulations might exist governing injection to noninjection methods of using drugs, and cessa- providing of services to minors, the need to obtain parental tion of drug use (31–33). However, injection-drug use among consent, or duty to inform). However, it is beyond the scope young adult heroin users has increased substantially in some of this report to address special considerations of subgroups. areas (34,35), a reminder that, as with sexual behaviors, changes Furthermore, the recommendations focus on sexual and drug- to less risky behaviors may be difficult to sustain. injection behaviors, since these behaviors are responsible for Clinicians providing medical care to HIV-infected persons nearly all HIV transmission in the United States. Separate can play a key role in helping their patients reduce risk behav- guidelines have been published for preventing perinatal trans- iors and maintain safer practices and can do so with a feasible mission (38–40). level of effort, even in constrained practice settings. Clinicians These recommendations were developed by using an can greatly affect patients’ risks for transmission of HIV to evidence-based approach (Table 1). The strength of each rec- others by performing a brief screening for HIV transmission ommendation is indicated on a scale of A (strongest recom- risk behaviors; communicating prevention messages; discuss- mendation for) to E (recommendation against); the quality of ing sexual and drug-use behavior; positively reinforcing changes available evidence supporting the recommendation is indicated to safer behavior; referring patients for such services as sub- on a scale of I (strongest evidence for) to III (weakest evidence stance abuse treatment; facilitating partner notification, coun- for), and the outcome for which the recommendation is rated seling, and testing; and identifying and treating other STDs is provided. The recommendations are categorized into three
TABLE 1. Rating systems for strength of recommendations and quality of evidence supporting the recommendations Rating Strength of the Recommendation A Should always be offered. Both strong evidence for efficacy and substantial benefit support recommendation for use. B Should generally be offered. Moderate evidence for efficacy — or strong evidence for efficacy but only limited benefit — supports recommenda- tion for use. C Optional. Evidence for efficacy is insufficient to support a recommendation for use. D Should generally not be offered. Moderate evidence for lack of efficacy or for adverse outcome supports a recommendation against use. E Should never be offered. Good evidence for lack of efficacy or for adverse outcome supports a recommendation against use. Quality of Evidence Supporting the Recommendation I Evidence from at least one properly randomized, controlled trial. II Evidence from at least one well-designed clinical trial without randomization, from cohort or case-controlled analytic studies (preferably from more than one center), or from multiple time-series studies. Or dramatic results from uncontrolled experiments. III Evidence from opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees. Vol. 52 / RR-12 Recommendations and Reports 3 major components: 1) screening for HIV transmission risk STDs, eliciting patient reports of symptoms of other STDs, behaviors and STDs, 2) providing brief behavioral risk- and laboratory testing for other STDs. Although each of these reduction interventions in the office setting and referring methods has limitations, a combination of methods should selected patients for additional prevention interventions and increase the sensitivity and effectiveness of screening. In con- other related services, and 3) facilitating notification and coun- ducting risk screening, clinicians should recognize that risk is seling of sex and needle-sharing partners of infected persons. not static. Patients’ lives and circumstances change, and a This report was developed by CDC, the Health Resources patient’s risk of transmitting HIV may change from one medical and Services Administration (HRSA), the National Institutes encounter to another. Also, clinicians should recognize that of Health (NIH), and the HIV Medicine Association working with adolescents may require special approaches and (HIVMA) of the Infectious Diseases Society of America should be aware of and adhere to all laws and regulations (IDSA). The recommendations will evolve as results from related to providing services to minors. ongoing behavioral intervention trials become available. Screening for Behavioral Risk Factors Risk Screening Clinicians frequently believe that patients are uncomfort- able disclosing personal risks and hesitant to respond to ques- Risk screening is a brief assessment of behavioral and clini- tions about sensitive issues, such as sexual behaviors and illicit cal factors associated with transmission of HIV and other STDs drug use. However, available evidence suggests that patients, (Table 2). Risk screening can be used to identify patients who when asked, will often disclose their risks (41,42) and that should receive more in-depth risk assessment and HIV risk- some patients have reported greater confidence in their reduction counseling, other risk-reduction interventions, or clinician’s ability to provide high-quality care if asked about referral for other services (e.g., substance abuse treatment). Risk sexual and STD history during the initial visits (43). screening identifies patients at greatest risk for transmitting Screening for behavioral risk factors can be done with brief HIV so that prevention and referral recommendations can be self-administered written questionnaires; computer-, audio-, focused on these patients. Screening methods include probing and video-assisted questionnaires; structured face-to-face for behaviors associated with transmission of HIV and other
TABLE 2. Recommendations for screening of human immunodeficiency virus (HIV)-infected persons for HIV transmission risk Recommendation Rating HIV-infected patients should be screened for behaviors associated with HIV transmission by using a straightforward, A-II (for identifying nonjudgmental approach. This should be done at the initial visit and subsequent routine visits or periodically, as the transmission risk) clinician feels necessary, but at a minimum of yearly. Any indication of risky behavior should prompt a more thorough assessment of HIV transmission risks.
At the initial and each subsequent routine visit, HIV-infected patients should be questioned about symptoms of STDs A-I (for identifying and (e.g., urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal ulcers; anal pruritus, burning, or treating STDs) discharge; and, for women, lower abdominal pain with or without fever). Regardless of reported sexual behavior or other epidemiologic risk information, the presence of such signs or symptoms should always prompt diagnostic testing and, when appropriate, treatment.
At the initial visit • All HIV-infected women and men should be screened for laboratory evidence of syphilis. Women should also be A-II (for identifying STDs) screened for trichomoniasis. Sexually active women aged <25 years and other women at increased risk, even if asymptomatic, should be screened for cervical chlamydial infection.
• Consideration should be given to screening all HIV-infected men and women for gonorrhea and chlamydial B-II (for identifying STDs) infections. However, because of the cost of screening and the variability of prevalence of these infections, decisions about routine screening for these infections should be based on epidemiologic factors (including prevalence of infection in the community or the population being served), availability of tests, and cost. (Some HIV specialists also recommend type-specific serologic testing for herpes simplex virus type 2 for both men and women.). B-III (for identifying Screening for STDs should be repeated periodically (i.e., at least annually) if the patient is sexually active or if earlier STDs) screening revealed STDs. Screening should be done more frequently (e.g., at 3–6-month intervals) for asymptomatic persons at higher risk (see Box 2). A-I (for preventing At the initial and each subsequent routine visit, HIV-infected women of childbearing age should be questioned to identify perinatal HIV possible current pregnancy, interest in future pregnancy, or sexual activity without reliable contraception. They should transmission) be referred for appropriate counseling, reproductive health care, or prenatal care, as indicated. Women should be asked whether they suspect pregnancy or have missed their menses and, if so, should be tested for pregnancy. 4 MMWR July 18, 2003 interviews; and personalized discussions (41,44–53). Screen- or anal sex) and whether condoms are used; and barriers to ing questions can be either open-ended or closed (directed) abstinence or correct condom use (e.g., difficulty talking with (Box 1). Use of open-ended questions avoids simple “yes” or partners about or disclosing HIV serostatus, alcohol and other “no” responses and encourages patients to discuss personal risks drug use before or during sex). Also, because the risk for peri- and the circumstances in which risks occur (15,44,54). Open- natal HIV transmission is high without appropriate interven- ended questions also help the clinician gather enough detail tion, clinicians are advised to assess whether women of to understand potential transmission risks and make more childbearing age might be pregnant, are interested in becom- meaningful recommendations. However, although well ing pregnant, or are not specifically considering pregnancy but received by patients, the open-ended approach may initially are sexually active and not using reliable contraception be difficult for clinicians schooled in directed questioning, who (39,56,57). Women who are unable to become pregnant tend to prefer directed screening questions. Directed questions because of elective sterilization, hysterectomy, salpingo- are probably useful for identifying patients with problems that oophorectomy, or other medical reasons might be less likely to should be more thoroughly discussed. Among directed use condoms because of a lack of concern for contraception; approaches, technical tools like computer-, audio-, and video- these women should be counseled regarding the need for use assisted interviews have been found to elicit more self-reported of condoms to prevent transmission of HIV. Patients who wish risk behaviors than did interviewer-administered question- to conceive and whose partner is not infected also might naires, particularly among younger patients (41,51–53,55). engage in risky behavior. Patients interested in pregnancy, for Studies suggest that clinicians who receive some training, par- themselves or their partner, should be referred to a reproduc- ticularly that including role-play and feedback concerning clini- tive health specialist (58). cal performance, are more likely to perform effective risk Injection-drug–related behaviors important to address in screening (46–49). screening include whether the patient has been injecting illicit Sex-related behaviors important to address in risk screening drugs; whether the patient has been sharing needles and include whether the patient has been engaging in sex; number syringes or other injection equipment; how many partners the and sex of partners; partners’ HIV serostatus (infected, not patient has shared needles with; whether needle-sharing part- infected, or unknown); types of sexual activity (oral, vaginal, ners are known to be HIV infected, not infected, or of
BOX 1. Examples of screening strategies to elicit patient-reported risk for human immunodeficiency virus (HIV) transmission* Open-ended question by clinician, similar to one of the following: • “What are you doing now that you think may be a risk for transmitting HIV to a partner?” • “Tell me about the people you’ve had sex with recently.” • “Tell me about your sex life.” Screening questions (checklist) for use with a self-administered questionnaire; computer-, audio-, or video-assisted questionnaire; or a face-to-face interview: †§ “Since your last checkup here,” or, if first visit, “Since you found out you were infected with HIV,”: • “Have you been sexually active; that is, have you had vaginal, anal, or oral sex with a partner?” If yes — “Have you had vaginal or anal intercourse without a condom with anyone?” If yes — “Were any of these people HIV-negative, or are you unsure about their HIV status?” — “Have you had oral sex with someone?” If yes — (For a male patient) “Did you ejaculate into your partner’s mouth?” • “Have you had a genital sore or discharge, discomfort when you urinate, or anal burning or itching?” • “Have you been diagnosed or treated for a sexually transmitted disease (STD), or do you know if any of your sex partners have been diagnosed or treated for an STD?” • “Have you shared drug-injection equipment (needles, syringes, cotton, cooker, water) with others?” If yes — “Were any of these people HIV negative, or are you unsure about their HIV status?” * Source: Adapted from CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50(No. RR-19). † This checklist can be administered by the patient or clinician and should take approximately 4 minutes. § A positive response to any of the screening questions should cue the clinician to have a more in-depth discussion to ensure that specific risks are clearly understood. Vol. 52 / RR-12 Recommendations and Reports 5 unknown HIV serostatus; whether the patient has been using help ensure that recommended procedures are done regularly. new or sterilized needles and syringes; and what barriers exist Multicomponent health-care system interventions that include to ceasing illicit drug use or, failing that, to adopting safer a provider reminder system and a provider education program injection practices (e.g., lack of access to sterile needles and are effective in increasing delivery of certain prevention ser- syringes). vices (59). Risk screening might be more likely to occur in managed care settings if the managed care organization Approaches to Screening for Behavioral Risk specifically calls for it (60). Factors The most effective manner for screening for behavioral risk Screening for Clinical Risk Factors factors is not well defined; however, simple approaches are more acceptable to both patients and health-care providers (53). Screening for STDs Screening tools should be designed to be as sensitive as pos- Recommendations for preventive measures, including medi- sible for identifying behavioral risks; a more detailed, person- cal screening and vaccinations, that should be included in the alized assessment can then be used to improve specificity and care of HIV-infected persons (16,21,39,44,54,61–69) have provide additional detail. The sensitivity of screening instru- been published previously. This report is not intended to ments depends on obtaining accurate information. However, duplicate existing recommendations; it addresses screening spe- accuracy of information can be influenced by a variety of fac- cifically to identify clinical factors associated with increased tors: recall, misunderstanding about risk, legal concerns, con- risk for transmission of HIV from infected to noninfected cern about confidentiality of the information and how the persons. In this context, STDs are the primary infections of information will be used, concern that answers may affect abil- concern for three reasons. First, the presence of STDs often ity to receive services, concern that answers may affect social suggests recent or ongoing sexual behaviors that may result in desirability (i.e., the tendency to provide responses that will HIV transmission. Second, many STDs enhance the risk for avoid criticism), and the desire for social approval (the ten- HIV transmission or acquisition (22,70–73). Early detection dency to seek praise) (45,55). Interviewer factors also influ- and treatment of bacterial STDs might reduce the risk for HIV ence the accuracy of information. Surveys indicate that patients transmission. Third, identification and treatment of STDs can are more likely to discuss risk behaviors if they perceive their reduce the potential for spread of these infections among high- clinicians are comfortable talking about stigmatized topics such risk groups (i.e., sex or drug-using networks). as sex and drug use (46–49) and are nonjudgmental, Screening and diagnostic testing serve distinctly different empathetic, knowledgeable, and comfortable counseling purposes. By definition, screening means testing on the basis patients about sexual risk factors (41,46–50). These factors of risk estimation, regardless of clinical indications for testing, need to be considered when interpreting responses to screen- and is a cornerstone of identifying persons at risk for transmit- ing questions. To the extent possible, screening and interven- ting HIV to others. Clinicians should routinely ask about STD tions should be individualized to meet patient needs. Examples symptoms, including urethral or vaginal discharge; dysuria; of two screening approaches are provided (Box 1). intermenstrual bleeding; genital or anal ulcers or other lesions; Incorporating Screening for Behavioral Risk anal pain, pruritus, burning, discharge, or bleeding; and, for Factors into the Office Visit women, lower abdominal pain with or without fever. Regard- less of reported sexual behavior or other epidemiologic risk Before the patient is seen by the clinician, screening for information, the presence of such symptoms should always behavioral risks can be done with a self-administered ques- prompt diagnostic testing and, when appropriate, treatment. tionnaire; a computer-, audio-, or video-assisted questionnaire; However, clinical symptoms are not sensitive for identifying or a brief interview with ancillary staff; the clinician can then many infections because most STDs are asymptomatic review the results on the patient’s medical record. Alternatively, (74–81); therefore, laboratory screening of HIV-infected behavioral risk screening can be done during the medical persons is an essential tool for identifying persons at risk for encounter (e.g., as part of the history); either open-ended ques- transmitting HIV and other STDs. tions or a checklist approach with in-depth discussion about positive responses can be used (Box 1). Because, given patients’ Laboratory Testing for STDs immediate health needs, it can be difficult in the clinical care Identification of syphilis requires direct bacteriologic (i.e., setting to remember less urgent matters such as risk screening dark-field microscopy) or serologic testing. However, and harm reduction, provider reminder systems (e.g., com- noninvasive, urine-based nucleic acid amplification tests puterized reminders) have been used by health-care systems to 6 MMWR July 18, 2003
(NAATs) have greatly simplified testing for Neisseria gonorrhoeae diagnostic tests for detecting asymptomatic STDs are described and Chlamydia trachomatis. Although they are more costly than (Box 2, Table3). other screening tests, their ease of use and sensitivity—similar Local and state health departments have reporting require- to the sensitivity of culture for detection of N. gonorrhoeae ments, which vary among states, for HIV and other STDs. and substantially higher than the sensitivity of all other tests Clinicians need to be aware of and comply with requirements for C. trachomatis (including culture)—for detecting genital for the areas in which they practice; information on reporting infection are great advantages. Detection of rectal or pharyn- requirements can be obtained from health departments. geal gonorrhea still requires culture. Pharyngeal infection with Screening for Pregnancy C. trachomatis is uncommon, and routine screening for it is not recommended (63,82). NAATs have not been approved Women of childbearing age should be questioned during for use with specimens collected from sites other than the ure- routine visits about the possibility of pregnancy. Women who thra, cervix, or urine. Recommended screening strategies and state that they suspect pregnancy or have missed their menses
BOX 2. Examples of laboratory screening strategies to detect asymptomatic sexually transmitted diseases* First Visit For all patients • Test for syphilis: nontreponemal serologic test (e.g., rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL] test). • Consider testing for urogenital gonorrhea: urethral (men) or cervical (women) specimen for culture, or urethral/cervi- cal specimen or first-catch urine† (men and women) nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae.§ • Consider testing for urogenital chlamydial infection: urethral (men) or cervical (women) specimen or first-catch urine† (men and women) specimen for NAAT for Chlamydia trachomatis.§ For women • Test for trichomoniasis: wet mount examination or culture of vaginal secretions for Trichomonas vaginalis. • Test for urogenital chlamydia: cervical specimen for NAAT for C. trachomatis§ for all sexually active women aged <25 years and other women at increased risk, even if asymptomatic. For patients reporting receptive anal sex • Test for rectal gonorrhea: anal swab culture for N. gonorrhoeae.§ • Test for rectal chlamydia: anal swab culture for C. trachomatis,§ if available. For patients reporting receptive oral sex • Test for pharyngeal gonococcal infection: culture for N. gonorrhoeae.§ Subsequent Routine Visits • The tests described here should be repeated periodically (i.e., at least annually) for all patients who are sexually active. More frequent periodic screening (e.g., at 3-month to 6-month intervals) may be indicated for asymptomatic persons at higher risk. Presence of any of the following factors may support more frequent than annual periodic screening: 1) multiple or anonymous sex partners; 2) past history of any STD; 3) identification of other behaviors associated with transmission of HIV and other STDs; 4) sex or needle-sharing partner(s) with any of the above-mentioned risks; 5) developmental changes in life that may lead to behavioral change with increased risky behaviors (e.g., dissolution of a relationship); or 6) high prevalence of STDs in the area or in the patient population. * These recommendations apply to persons without symptoms or signs of STDs. Patients with symptoms (e.g., urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal lesions; anal pruritus, burning, or discharge; and lower abdominal pain with or without fever) or known exposure should have appropriate diagnostic testing regardless of reported sexual behavior or other risk factors. † First-catch urine (i.e., the first 10–30 mL of urine voided after initiating the stream) should be used. § The yield of testing for N. gonorrhoeae and C. trachomatis is likely to vary, and screening for these pathogens should be based on consideration of patient’s risk behaviors, local epidemiology of these infections, availability of tests (e.g., culture for C. trachomatis), and cost. Appropriate diagnostic tests for different pathogens causing STDs are described (Table 3). Note: Testing or vaccination for hepatitis, pneumococcal disease, influenza, and other infectious diseases (e.g., screening pregnant women for syphilis, gonorrhea, chlamydia, and hepatitis B surface antigen) should be incorporated into the routine care of HIV-infected persons as recommended elsewhere (16,21,39,44,54,61–67). Note: Symptomatic and asymptomatic herpes simplex virus (HSV) infection, especially with HSV type 2, is prevalent among HIV-infected persons and might increase the risk of transmitting and acquiring HIV. Therefore, some HIV specialists recommend routine, type-specific serologic testing for HSV-2. Patients with positive results should be informed of the increased risk of transmitting HIV and counseled regarding recognition of associated symptoms (16,54,67). Only tests for detection of HSV glycoprotein G are truly type- specific and suitable for HSV-2 serologic screening. Note: Local and state health departments have reporting requirements for HIV and other STDs, which vary among states. Clinicians should be aware of and comply with requirements for the areas in which they practice; information on reporting requirements can be obtained from health departments. Vol. 52 / RR-12 Recommendations and Reports 7
TABLE 3. Available diagnostic testing for detection of sexually transmitted diseases (STDs)* STD Diagnostic test† Syphilis Dark-field examination or direct fluorescent antibody test of exudate of lesion Serum nontreponemal tests, rapid plasma reagin (RPR), or Venereal Disease Research Laboratory (VDRL) for screening followed by serum treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS] or Treponema pallidum particle agglutination [TP-PA])
Trichonomiasis Microscopic examination of wet mount or culture of vaginal secretions
Herpes Viral culture of genital or other mucocutaneous ulcers Herpes simplex virus type-specific serologic tests
Gonorrhea Female Culture of endocervical swab specimen genitourinary Nucleic acid amplification tests (NAAT) of endocervical swab specimen [GU] tract NAAT of urine§
Male GU tract Culture of intraurethral swab NAAT of intraurethral swab NAAT of urine§
Rectum/pharynx Culture of rectal or pharyngeal swab specimen with selective medium specimen
Chlamydia Female GU tract NAAT of endocervical swab specimen NAAT of urine§ Unamplified nucleic acid hybridization test, enzyme immunoassay, or direct fluorescent antibody test of endocervical swab specimen Culture of endocervical swab specimen
Male GU tract NAAT of intraurethral swab specimen NAAT of urine§ Non-NAAT or culture of intraurethral swab specimen
Rectum/pharynx Culture of rectal or pharyngeal swab specimen¶ Direct fluorescent antibody test performed on rectal or pharyngeal swab specimen¶ * Source: CDC. Sexually transmitted diseases treatment guidelines, 2002. MMWR 2002;51(No. RR-6). CDC Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections—2002. MMWR 2002;51(No. RR-15). † Diagnostic tests are listed in order of preference for recommendation, with the most highly recommended test listed first. Alternative tests should be performed if a specimen cannot be obtained or if the preferred test is not available. § NAAT of urine is less sensitive than that of an endocervical or intraurethral swab specimen. ¶ Chlamydia trachomatis-major outer membrane protein (MOMP)–specific stain should be used. should be tested for pregnancy. Early pregnancy diagnosis conducted at each clinic visit could result in patients, over would benefit even women not receiving antiretroviral treat- time, adopting and maintaining safer practices. Behavioral ment because they could be offered treatment to decrease the interventions should be appropriate for the patient’s culture, risk for perinatal HIV transmission. language, sex, sexual orientation, age, and developmental level (44). In settings where care is delivered to HIV-infected ado- lescents, for example, approaches need to be specifically tai- Behavioral Interventions lored for this age group (83). Also, clinicians should be aware Behavioral interventions are strategies designed to change of and adhere to all laws and regulations related to providing persons’ knowledge, attitudes, behaviors, or practices in order services to minors. to reduce their personal health risks or their risk of transmitting HIV to others (Table 4). Behavioral change can Structural Approaches To Support be facilitated by environmental cues in the clinic or office set- and Enhance Prevention ting, messages delivered to patients by clinicians or other quali- Clinic or office environments can be structured to support fied staff on-site, or referral to other persons or organizations and enhance prevention. All patients, especially new patients, providing prevention services. Because behavior change often should be provided printed information about HIV transmis- occurs in incremental steps, a brief behavioral intervention sion risks, preventing transmission of HIV to others, and 8 MMWR July 18, 2003
TABLE 4. Recommendations for behavioral interventions to reduce human immunodeficiency virus (HIV) transmission risk Recommendation Rating Clinics or office environments where patients with HIV infection receive care should be structured to support and B-III (for enhancing patient enhance HIV prevention. recall of prevention messages)
Within the context of HIV care, brief general HIV prevention messages should be regularly provided to HIV- A-III (for efficacy in promoting infected patients at each visit or periodically, as determined by the clinician, and at a minimum of twice yearly. safer behaviors) These messages should emphasize the need for safer behaviors to protect their own health and the health of their sex or needle-sharing partners, regardless of perceived risk. Messages should be tailored to the patient’s needs and circumstances. A-III (for using brief clinician- Patients should have adequate, accurate information regarding factors that influence HIV transmission and delivered messages to methods for reducing the risk for transmission to others, emphasizing that the most effective methods for prevent- influence patient behavior) ing transmission are those that protect noninfected persons against exposure to HIV (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same HIV status). HIV-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly. A-III (for using brief clinician- Patients’ misconceptions regarding HIV transmission and methods for reducing risk for transmission should be delivered messages to identified and corrected. For example, ensure that patients know that 1) per-act estimates of HIV transmission risk influence patient behavior) for an individual patient vary according to behavioral, biologic, and viral factors; 2) highly active antiretroviral therapy (HAART) cannot be relied upon to eliminate the risk of transmitting HIV to others; and 3) nonoccupational postexposure prophylaxis is of uncertain effectiveness for preventing infection in HIV-exposed partners. A-III (for efficacy in promoting Tailored HIV prevention interventions, using a risk-reduction approach, should be delivered to patients at highest safer behaviors) risk for transmitting HIV. A-I (for efficacy of multisession, After initial prevention messages are delivered, subsequent longer or more intensive interventions in the clinic or clinic-based interventions in office should be delivered, if feasible. promoting safer behaviors)
A-I (for efficacy of HIV pre- HIV-infected patients should be referred to appropriate services for issues related to HIV transmission that cannot vention interventions con- be adequately addressed during the clinic visit. ducted in nonclinic settings)
A-II (for reducing risky drug Persons who inject illicit drugs should be strongly encouraged to cease injecting and enter into substance abuse use and associated sexual treatment programs (e.g., methadone maintenance) and should be provided referrals to such programs. behaviors)
A-II (for reducing risk for HIV Persons who continue to inject drugs should be advised to always use sterile injection equipment and to never transmission) reuse or share needles, syringes, or other injection equipment and should be provided information regarding how to obtain new, sterile syringes and needles (e.g., syringe exchange program). preventing acquisition of other STDs. Information can be dis- both their own health and the health of their sex or needle- seminated at various locations in the clinic; for example, post- sharing partners. These messages can be delivered by clini- ers and other visual cues containing prevention messages can cians, nurses, social workers, case managers, or health educators. be displayed in examination rooms and waiting rooms. These They include discussion of the patient’s responsibility for materials usually can be obtained through local or state health appropriate disclosure of HIV serostatus to sex and needle- department HIV/AIDS and STD programs or from the sharing partners. Brief clinician-delivered approaches have been National Prevention Information Network (NPIN) effective with a variety of health issues, including depression (1-800-458-5231; http://www.cdcnpin.org). Additionally, (84), smoking (85–90), alcohol abuse (91,92), weight and diet condoms should be readily accessible at the clinic. Repeating (93), and physical inactivity (94). This diverse experience with prevention messages throughout the patient’s clinic visit rein- other health behaviors suggests that similar approaches may forces their importance, increasing the likelihood that they will be effective in reducing HIV-infected patients’ transmission be remembered (68). risk behaviors. For patients already taking steps to reduce their risk of transmitting HIV, hearing the messages can reinforce Interventions Delivered On-Site continued risk-reduction behaviors. These patients should be commended and encouraged to continue these behaviors. Prevention Messages for All Patients General HIV Prevention Messages All HIV-infected patients can benefit from brief prevention messages emphasizing the need for safer behaviors to protect Patients frequently have inadequate information regarding factors that influence HIV transmission and methods for Vol. 52 / RR-12 Recommendations and Reports 9 preventing transmission. The clinician should ensure that pa- perspective of a person not infected with HIV, might vary tients understand that the most effective methods for prevent- greatly according to the various choices related to sexual ing HIV transmission remain those that protect noninfected behavior (Table 5) (115,116). persons against exposure to HIV. For sexual transmission, the Effect of Antiretroviral Therapy on HIV Transmission. only certain means for HIV-infected persons to prevent sexual High viral load is a major risk factor for HIV transmission transmission to noninfected persons are sexual abstinence or (117–125). Among untreated patients, the risk for HIV trans- sex with only a partner known to be already infected with mission through heterosexual contact has been shown to HIV. However, restricting sex to partners of the same serostatus increase approximately 2.5-fold for each 10-fold increase in does not protect against transmission of other STDs or the plasma viral load (126) (Table 6). By lowering viral load, possibility of HIV superinfection unless condoms of latex, poly- antiretroviral therapy might reduce risk for HIV transmission, urethane, or other synthetic materials are consistently and cor- as has been demonstrated with perinatal transmission (127,128) rectly used. Superinfection with HIV has been reported and and indirectly suggested for transmission via genital secretions appears to be rare, but its clinical consequences are not known (semen and cervicovaginal fluid) (2,129–133). However, (95,96). For injection-related transmission, the only certain because HIV can be detected in the semen, rectal secretions, means for HIV-infected persons to prevent transmission to female genital secretions, and pharynx of HIV-infected noninfected persons are abstaining from injection drug use or, patients with undetectable plasma viral loads (16,134–137) for IDUs who are unable or unwilling to stop injecting drugs, and because consistent reduction of viral load depends on high refraining from sharing injection equipment (e.g., syringes, needles, cookers, cottons, water) with other persons. Neither TABLE 5. Estimated per-act relative risk for a person without antiretroviral therapy for HIV-infected persons nor human immunodeficiency virus (HIV) infection acquiring HIV infection, based on sex act* and condom use† postexposure prophylaxis for partners is a reliable substitute Relative risk for a person without HIV for adopting and maintaining behaviors that guard against HIV Risk factor infection of acquiring HIV infection exposure (97). Sex act Insertive fellatio§ 1 Identifying and Correcting Misconceptions Receptive fellatio§ 2 Insertive vaginal sex¶ 10 Patients might have misconceptions about HIV transmis- Receptive vaginal sex¶ 20 sion (98), particularly with regard to the risk for HIV trans- Insertive anal sex¶ 13 mission associated with specific behaviors, the effect of Receptive anal sex¶ 100 antiretroviral therapy on HIV transmission, or the effective- Condom use Yes** 1 ness of postexposure prophylaxis for nonoccupational No** 20 exposure to HIV. Note: This table quantifies the relative risk for HIV transmission in a way Risk for HIV Transmission Associated with Specific that can help compare the effects of a person’s choices of sex act and con- Sexual Behaviors. Patients often ask their clinicians about the dom use. It is presented from the point of view of a person without HIV infection and should be used to educate the HIV-infected patient degree of HIV transmission risk associated with specific sexual regarding risks for transmission to partners who are not HIV infected or activities. Numerous studies have examined the risk for HIV have unknown HIV serostatus. These risks are estimated from available data. Risks can vary depending on several factors, including presence of transmission associated with various sex acts (99–113). These STDs in either partner and the HIV-infected partner’s viral load. In addition, studies indicate that some sexual behaviors do have a lower the relative frequency of performance of higher- and lower-risk sex acts will average per-act risk for transmission than others and that affect risk for transmission (see Prevention Messages for All Patients). Note: The risks of these choices are multiplicative. Compared with the low- replacing a higher-risk behavior with a relatively lower-risk est relative risk (performing insertive fellatio using a condom; referent group, behavior might reduce the likelihood that HIV transmission RR = 1), the overall relative risk increases to 2,000 when performing recep- tive anal sex (RR = 100) without a condom (RR = 20). will occur. However, risk for HIV transmission is affected by * Data regarding risk for transmission from sharing drug injection equip- numerous biological factors (e.g., host genetics, stage of infec- ment are too limited to be included in this table. tion, viral load, coexisting STDs) and behavioral factors (e.g., † Source: Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. Reducing the risk of sexual HIV transmission: quantifying the per-act patterns of sexual and drug-injection partnering) (105,114), risk for HIV infection based on choice of partner, sex act, and condom and per-act risk estimates based on models that assume a con- use. Sex Transm Dis 2002;29:38–43. stant per-contact infectivity could be inaccurate (110,113). § Best guess estimate, from Varghese et al. ¶ Source: European Study Group. Comparison of female-to-male and Thus, estimates of the absolute per-episode risk for transmis- male-to-female transmision of HIV in 563 stable couples. BMJ sion associated with different activities could be highly mis- 1992;304:809–13. leading when applied to a specific patient or situation. Further ** Source: Macaluso JM, Kelaghan J, Artz L, et al. Mechanical failure of the latex condom in a cohort of women at high STD risk. Sex Transm Dis the relative risks of becoming infected with HIV, from the 1999;26:450–8. 10 MMWR July 18, 2003
TABLE 6. Adjusted rate ratios of the risk for transmission and infection and for acquiring new STDs. This includes patients acquisition of human immunodeficiency virus type 1 (HIV-1) among discordant partners* whose risk screening indicates current sex or drug-injection Risk for transmission practices that may lead to transmission, who have a current or Serum viral load to partners not infected recent STD, or who have mentioned items of concern in dis- of HIV-infected partners with HIV (adjusted rate ratio; cussions with the clinician (149,150). Any positive results of † (copies/mL) 95% confidence interval) screening for behavioral risks or STDs should be addressed in <3500 Referent 3500–9999 5.80 (2.26–17.80) more detail with the patient so a more thorough risk assess- 10,000–49,999 6.91 (2.96–20.15) ment can be done and an appropriate risk-reduction plan can >50,000 11.87 (5.02–34.88) be discussed and agreed upon. Per log increment viral load 2.45 (1.85–3.26) Although the efficacy of brief clinician-delivered interven- * Source: Quinn TC, Wawer MJ Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1 from tions with HIV-infected patients has not been studied exten- mother to infant. N Engl J Med 1996;335:1621–9. sively, substantial evidence exists for the efficacy of † Patients in this study did not receive antiretroviral medications, and those provider-delivered, tailored messages for other health concerns with low viral loads might have been long-term nonprogressors. Risks might not be equivalent for treated persons with low viral loads.Viral load (151–155). An attempt should be made to determine which in the blood may not be predictive of viral load in the genital tract; therefore, of the patient’s risk behaviors and underlying concerns can be risks may vary with genital tract viral load. addressed during clinic visits and which might require referral adherence to antiretroviral regimens, the clinician should (Box 3). assume that all patients who are receiving therapy, even those At a minimum, an appropriate referral should be made and with undetectable plasma HIV levels, can still transmit HIV. the patient should be informed of the risks involved in con- Patients who have treatment interruptions, whether scheduled tinuing the behavior. HIV-infected persons who remain sexu- or not, should be advised that this will likely lead to a rise in ally active should be reminded that the only certain means for plasma viral load and increased risk for transmission. Another preventing transmission to noninfected persons is to restrict concern related to adherence to antiretroviral therapy is the sex to partners known to be already infected with HIV and development of drug-resistant mutations with subsequent that they have a responsibility for disclosure of HIV serostatus transmission of drug-resistant viral strains. Several reports sug- to prospective sex partners. For mutually consensual sex with gest that transmission of drug-resistant HIV occurs in the a person of unknown or discordant HIV serostatus, consistent United States (138–141). Recent reports suggest that drug- and correct use of condoms made of latex, polyurethane, or resistant HIV strains might be less easily transmitted than wild- other synthetic materials can substantially reduce the risk type virus (142), but these data are limited and their significance for HIV transmission. Also, some sex acts have relatively less is unclear. risk for HIV transmission than others (Table 5). For HIV- Effectiveness of Postexposure Prophylaxis for Non infected patients who continue injection drug use, the pro- occupational Exposure to HIV. Although the U.S. Public vider should emphasize the risks associated with sharing needles Health Service recommends using antiretroviral drugs to and should provide information regarding substance abuse reduce the likelihood of acquiring HIV infection from occu- treatment and access to clean needles (Box 4) (156–158). pational exposure (e.g., accidental needle sticks received by Examples of targeted motivational messages on condom use health care workers) (143), limited data are available on and needle sharing are provided (Figures 1 and 2), and pro- efficacy of prophylaxis for nonoccupational exposure viders can individualize their own messages using these as a (97,143–147). Observational data suggesting effectiveness have guide. been reported (148); however, postexposure prophylaxis might Clinician Training not protect against infection in all cases, and effectiveness of Clinicians can prepare themselves to deliver HIV preven- these regimens might be further hindered by lack of tolerabil- tion messages and brief behavioral interventions to their ity, potential toxicity, or viral resistance. Thus, avoiding expo- patients by 1) developing strategies for incorporating HIV risk- sure remains the best approach to preventing transmission, reduction interventions into patients’ clinic visits (159); and the potential availability of postexposure prophylaxis 2) obtaining training on speaking with patients about sex and should not be used as justification for engaging in risky behavior. drug-use behaviors and on giving explanations in simple, Tailored Interventions for Patients at High everyday language (68,87,160,161); 3) becoming familiar with Risk for Transmitting HIV interventions that have demonstrated effectiveness (162); Interventions tailored to the individual patient’s risks can be 4) becoming familiar with the underlying causes of and con- delivered to patients at highest risk for transmitting HIV cerns related to risk behaviors among HIV-infected persons Vol. 52 / RR-12 Recommendations and Reports 11
BOX 3. Examples of which concerns to address and which to refer BOX 4. Examples of messages that should be communicated to drug users who continue to inject* Topics that can be successfully addressed by clinicians and clinic support staff: Persons who inject drugs should be regularly • lack of knowledge about HIV transmission risks; counseled to do the following: • misconceptions about risk of specific types of sexual and • Stop using and injecting drugs. drug-use practices; • Enter and complete substance abuse treatment, • misconceptions about viral load and transmission of including relapse prevention. HIV; • Take the following steps to reduce personal and public • how to disclose HIV-seropositive status to a sex partner, health risks, if they continue to inject drugs: family member, or friend; — Never reuse or share syringes, water, or drug prepa- • importance of using condoms or not exchanging fluids ration equipment. with partners; — Use only syringes obtained from a reliable source • ways to reduce number of sex or drug partners; (e.g., pharmacies). — Use a new, sterile syringe to prepare and inject • ways to keep condoms accessible; † • ways to remember to use condoms; drugs. — If possible, use sterile water to prepare drugs; oth- • how to persuade a sex partner to use a condom; erwise, use clean water from a reliable source (such • ways to obtain support (e.g., emotional, financial) from as fresh tap water). family, friends, and lovers; — Use a new or disinfected container (cooker) and a • ways to clean/disinfect injection equipment; new filter (cotton) to prepare drugs. • ways to obtain clean needles; — Clean the injection site with a new alcohol swab • ways to avoid sharing injection equipment; or before injection. • ways to deal with mild psychological distress stemming — Safely dispose of syringes after one use. from situational circumstances. In addition, drug users should be provided informa- Issues that might need referral to outside agencies tion regarding how to prevent HIV transmission through • need for intensive HIV prevention intervention; sexual contact and, for women, information regarding • excessive use of alcohol or recreational drug use; reducing the risk of mother-to-infant HIV transmission. • drug addiction, including injection drug use; * Source: US Department of Health and Human Services. Medical advice for persons • depression, anger, guilt, fear, or other mental health who inject illicit drugs. HIV Prevention Bulletin. CDC; Health Resources and needs; Services Administration; National Institute on Drug Abuse, National Institutes of • need for social support; Health; Center for Substance Abuse and Mental Health Services Administration. May 1997. Available at http://www.cdc.gov/idu/pubs/hiv_prev.htm. • sexual compulsivity; † If new, sterile syringes and other drug preparation and injection equipment are not • sexual or physical abuse (victim or perpetrator); available, previously used equipment should be boiled or disinfected with bleach by • desire to have children, contraceptive counseling; using the methods recommended by CDC (Source: CDC National Prevention Information Network. HIV connect. Vol. 11, No.8. Available at http:// • housing or transportation needs; www.cdcnpin.org). • nutritional needs; • financial emergencies; • child custody, parole, or other legal matters; or Ongoing Delivery of Prevention Messages • insurance coverage. Prevention messages can be reinforced by subsequent longer or more intensive interventions in clinic or office environments by nurses, social workers, or health educators. Advantages of a (e.g., domestic violence) (13,163); and 5) becoming familiar multidisciplinary approach are that skill sets vary among staff with community resources that address risk reduction. Free members from various disciplines and that a patient may be training on risk screening and prevention can be obtained at more receptive to discussing prevention-related issues with one CDC-funded STD/HIV Prevention Training Centers (http:// team member than with another. For HIV-negative persons depts.washington.edu/nnptc) and HRSA-funded AIDS or persons of unknown HIV serostatus, randomized controlled Education and Training Centers (http://www.aids-ed.org), trials provide strong evidence for the efficacy of short, one- or which also offer continuing medical education credit for this two-session interventions (164–170) and for longer or training. Ongoing training will help clinicians refine their multisession interventions in clinics for individuals and groups counseling skills as well as keep current with prevention con- (164,171–173). For example, for persons who continue to cerns at the community level, thus increasing their ability to engage in risky behaviors, CDC recommends client-centered appropriately counsel and provide support to patients. counseling, a specific model of HIV prevention counseling 12 MMWR July 18, 2003
FIGURE 1. Example of tailoring messages regarding condom use for sexually active, HIV-infected persons
“How often do you use condoms when you have sex?”
Never/Sometimes Always
“What do you plan to do about using condoms in the future? “How long have you been using condoms?”
No plans Undecided Has plan <1 month 1–6 months >6 months
“Do you know that “How do you think not “What problems do you “What problems have “How do you “You’ve done great! you could catch an using condoms affects anticipate when you start you encountered as handle a How do you feel STD that way, and you and the people you using condoms? How do you started using situation when about yourself now?” it could make your are having sex with?” you plan to deal with condoms? How are you want to use or HIV infection worse?” these problems?” you dealing with condoms but “You’ve done great! these problems?” think your Have you ever partner doesn’t?” thought of changing anything else?”
* This is an example, not a comprehensive list of all questions that could be asked
FIGURE 2. Example of tailoring messages regarding needle sharing for HIV-infected persons who continue to inject drugs
“How often do you borrow or share a needle or works?”
Sometimes/Always Never
“What do you plan to do about sharing needles in the future? “How long have you been using your own and not sharing?”
No plans Undecided Has plan <1 month 1–6 months >6 months
“Have you heard “How do you think “How do you think your “What problems have “How do you “You’ve done great! that HIV can survive sharing needles and friends will deal with you you encountered as handle a How do you feel in the cotton and works affects you and when you don’t share you stopped sharing situation when about not sharing?” rinse water?” the people you’re needles or works?” needles or works?” you don’t want or or shooting with?” or or to share but your “You’ve done great! “Can you tell me or “What are some of the “What are some of the friend is begging What do you do to something about “Does anyone close good things that might good things that have you to?” reward yourself?” sharing needles?” to you ever talk to you happen if you started happened since you about bleaching? bleaching needles stopped sharing What do they say?” before you share?” needles or works?”
* This is an example, not a comprehensive list of all questions that could be asked Vol. 52 / RR-12 Recommendations and Reports 13
(44,164). Evidence for the efficacy of multisession interven- Referrals for IDUs tions for HIV-infected patients, individually or in groups, in For IDUs, ceasing injection-drug use is the only reliable way clinical settings is limited to a few randomized, controlled to eliminate the risk of injection-associated HIV transmission; trials (69,174,175) and other studies that might not have however, most IDUs are unable to sustain long-term absti- assessed behavioral outcomes (6,176–180). The studies of nence without substance abuse treatment. Several studies have single-session interventions for individual HIV-infected examined the effect of substance abuse treatment, particularly patients in clinical settings have not been randomized methadone maintenance treatment, on HIV risk behaviors controlled trials (181–187). among IDUs (208–210). These include controlled (211–217) and noncontrolled (218–221) cohort studies, case-control stud- Referrals for Additional Prevention ies (222), and observational studies with controls (223,224), Interventions and Other Services and collectively they provide evidence that methadone main- tenance treatment reduces risky injection and sexual behav- Types of Referrals iors and HIV seroconversion. Thus, early entry into substance Certain patients need more intensive or ongoing behavioral abuse treatment programs, maintenance of treatment, and interventions than can feasibly be provided in medical care sustained abstinence from injecting are crucial for reducing settings (44). Many have underlying problems that impede the risk for HIV transmission from infected IDUs. For those adoption of safer behaviors (e.g., homelessness, substance abuse, IDUs not able or willing to stop injecting drugs, once-only mental illness), and achieving behavioral change is often use of sterile syringes can greatly reduce the risk for injection- dependent on addressing these concerns. Clinicians will usu- related HIV transmission. Substantial evidence from cohort, ally not have time or resources to fully address these issues, case-control, and observational studies (225) indicates that many of which can best be addressed through referrals for ser- access to sterile syringes through syringe exchange programs vices such as intensive HIV prevention interventions (e.g., reduces HIV risk behavior and HIV seroconversion among multisession risk-reduction counseling, support groups), medi- IDUs. Physician prescribing and pharmacy programs can also cal services (e.g., family planning and contraceptive counsel- increase access to sterile syringes (226–231). Disinfecting ing, substance abuse treatment), mental health services (e.g., syringes and other injection equipment by boiling or flushing treatment of depression, counseling for sexual compulsivity), with bleach when new, sterile equipment is not available has and social services (e.g., housing, child care and custody, pro- been suggested to reduce the risk for HIV transmission (156); tection from domestic violence). For example, all patients however, it is difficult to reliably disinfect syringes, and this should be made aware of their responsibility for appropriate practice is not as safe as using a new, sterile syringe (232–234). disclosure of HIV serostatus to sex and needle-sharing part- Information on access to sterile syringes and safe syringe dis- ners; however, full consideration of the complexities of disclo- posal can be obtained through local health departments or sure, including benefits and potential risks, may not be possible state HIV/AIDS prevention programs. in the time available during medical visits (188). Patients who Engaging the Patient in the Referral Process are having, or are likely to have, difficulty initiating or sustain- ing behaviors that reduce or prevent HIV transmission might When referrals are made, the patient’s willingness and abil- benefit from prevention case management. Prevention case ity to accept and complete a referral should be assessed. Refer- management provides ongoing, intensive, one-on-one, client- rals that match the patient’s self-identified priorities are more centered risk assessment and prevention counseling, and assis- likely to be successful than those that do not; the services need tance accessing other services to address concerns that affect to be responsive to the patient’s needs and appropriate for the patients’ health and ability to change HIV-related risk-taking patient’s culture, language, sex, sexual orientation, age, and behavior. For HIV-seronegative persons, randomized controlled developmental level. For example, adolescents should be trials provide evidence for the efficacy of HIV prevention referred to behavioral intervention programs and services that interventions delivered by health departments and community- work specifically with this population. Discussion with the based organizations (164,189–198). For HIV-infected persons, patient can identify barriers to the patient’s completing the efficacy studies of such interventions are limited to a few referral (e.g., lack of transportation or child care, work schedule, randomized controlled trials (199–201), only one of which cost). Accessibility and convenience of services predict whether documented change in risk-related behavior (199), and to other a referral will be completed. The patient should be given studies, the majority of which did not assess behavioral specific information regarding accessing referral services and outcomes (7,202–207). might need assistance (e.g., scheduling appointments, obtain- ing transportation) in completing referrals. The likelihood that 14 MMWR July 18, 2003 referrals will be completed successfully could possibly be BOX 5. Referral resource guide, suggested contents increased if clinicians or other health-care staff assist patients For each resource, the referral resource guide should with making appointments to referral services. When a clini- specify cian does not have the capacity to make all appropriate refer- • name of the provider or agency; rals, or when needs are especially complex, a case manager can • range of services provided; help make referrals and coordinate care. Outreach workers, • target population(s); peer counselors or educators, treatment advocates, and treat- • service area(s); ment educators can also help patients identify needs and com- • contact names and telephone and fax numbers, street plete referrals successfully. Health department HIV/AIDS addresses, e-mail addresses; prevention and care programs can provide information on • hours of operation; accessing these services. Assessing the success of referrals by • location; documenting referrals made, the status of those referrals, and • competence in providing services appropriate to the patient satisfaction with referrals will further assist clinicians patient’s culture, language, sex, sexual orientation, age, in meeting patient needs. Information obtained through follow- and developmental level; up of referrals can identify barriers to completing the referral, • cost for services; • eligibility; responsiveness of referral services to patient needs, and gaps in • application materials; the referral system, and can be used to develop strategies for • admission policies and procedures; removing the barriers. • directions, transportation information, and accessibility Referral Guides and Information to public transportation; and • patient satisfaction with services. Preparation for making patient referrals includes 1) learning about local HIV prevention and supportive social services, including those supported by the Ryan White CARE Act; already done]), how does one address prevention? What is 2) learning about available resources and having a referral guide the minimum that should be done, and how can it be listing such resources; and 3) contacting staff in local programs incorporated into this visit? to facilitate subsequent referrals. Referral guides and other Assuming no emergent issues preclude a complete history information usually can be obtained from local and state health and physical examination during this visit, the following should department HIV/AIDS prevention and care programs, which be done: are key sources of information about services available locally. • During the history, question how the patient might have Health departments and some managed care organizations are acquired HIV, current risk behaviors, current partners and also a source of educational materials, posters, and other pre- whether they have been notified and tested for HIV, and vention-related material. Health departments can provide or current or past STDs. suggest sources of training and technical assistance on behav- • During the physical examination, include genital and rec- ioral interventions. A complete listing of state AIDS directors tal examinations, evaluation and treatment of any current and contact information is available from the National Alli- STD, or, if asymptomatic, appropriate screening for STDs. ance of State and Territorial AIDS Directors (NASTAD) at • Discuss current risk behavior, at least briefly. Emphasize http://www.nastad.org. In addition, information can be the importance of using condoms; address active injection- obtained from local health planning councils, consortia, and drug use. community planning groups; local, state, and national HIV/ • Discuss the need for disclosure of HIV serostatus to sex AIDS information hotlines and Internet websites; and and needle-sharing partners, and discuss potential community-based health and human service providers (Box 5). barriers to disclosure. • Note issues that will require follow-up; e.g., risk behavior Examples of Case Situations for that will require continuing counseling and referral and Prevention Counseling partners who will need to be notified by either the patient or a health department. 1. A patient with newly diagnosed HIV infection comes 2. A patient with chronic, stable HIV comes to you with to your office for initial evaluation. Of the many things a new STD. What prevention considerations should be that must be addressed during this initial visit (e.g., any covered in this visit? emergent medical or psychiatric problems, education about For the patient who has had a stable course of disease, a new HIV, history, physical, initial laboratory work [if not STD can be a sign of emerging social, emotional, or substance Vol. 52 / RR-12 Recommendations and Reports 15 abuse problems. These potential problems should be addressed • Inform the patient that upon stopping HAART, CD4+ in addition to the STD. count and viral load will likely return to pretreatment lev- • During the history, cover topics related to acquisition of els with risk for opportunistic infections and progression the new STD—number of new partners, number of of immune deficiency. episodes of unsafe sex, and types of unsafe sex. • Inform the patient that increase in viral load to pretreat- • Address the personal risks associated with high-risk ment levels will likely result in increased infectiousness behavior, e.g., viral superinfection and HIV/STD inter- and risk for transmission of HIV to sex or needle-sharing actions. partners. • Address personal or social problems (including substance • Counsel the patient regarding the option of changing the abuse and domestic violence) that might have led to a HAART regimen to limit progression of metabolic side change in behavior resulting in the acquisition of the new effects. STD; refer to social services, if necessary. • Address other issues (e.g., adherence to HAART) that may be affected by personal or social problems. Check viral Partner Counseling and Referral load if nonadherence is evident or is suspected. Services, Including Partner • During the physical examination, include a careful geni- Notification tal and rectal examination and screen for additional STDs, such as syphilis, trichomoniasis, (for women), chlamydial HIV-infected persons are often not yet aware of their infec- infection (for sexually active women aged <25 years and tion; thus, they cannot benefit from early medical evaluation selected populations of men and women), and gonorrhea and treatment and do not know that they may be transmitting (for selected populations of men and women). HIV to others. Reaching such persons as early after infection • Discuss the need for partner notification and referral for as possible is important for their own health and is a critical counseling and testing. strategy for reducing HIV transmission in the community. • Note in the chart that risk behavior should be addressed Furthermore, interviews of HIV-infected persons in various in future visits and that tailored counseling may be needed settings suggest that >70% are sexually active after receiving for the patient. their diagnosis, and many have not told their partners about 3. A patient with chronic, stable HIV has been seen regu- their infection (188). Partner counseling and referral services larly in a health care setting. What should be included in (PCRS), including partner notification, are intended to this patient’s routine clinical care? address these problems by 1) providing services to HIV- Discussion of sexual and needle-sharing practices should be infected persons and their sex and needle-sharing partners so integrated into a routine part of clinical care. the partners can take steps to avoid becoming infected or, if • Periodically (e.g., annually) screen for STDs. STDs to be already infected, to avoid infecting others and 2) helping included in screening should be determined by patient’s infected partners gain earlier access to medical evaluation, treat- sex, history of high-risk behavior, and local epidemiology ment, and other services (Table 7). A key element of PCRS of selected STDs. involves informing current partners (and past partners who • Reiterate general prevention messages and patient educa- may have been exposed) that a person who is HIV infected tion regarding partner notification, high-risk behaviors has identified them as a sex or needle-sharing partner and associated with transmission, prevention of transmission, advising them to have HIV counseling and testing (235–238). or condom use, as deemed appropriate by the clinician. Informing partners of their exposure to HIV is confidential; 4. A patient who has been treated with HAART for 2 i.e., partners are not told who reported their name or when years comes to you. At the time of treatment initiation, the reported exposure occurred. It is voluntary in that the CD4+count was 200 cells/µL and the viral load was 50,000 infected person decides which names to reveal to the inter- copies/ml. The response to therapy was prompt; CD4+ viewer. Studies have indicated that infected persons are more count increased to 500 cells/µL, and the viral load has been likely to name their close partners than their more casual part- undetectable since soon after treatment began. The patient ners (204,239,240). Limited reports of partner violence after now has mildly elevated cholesterol, some mild lipodys- notification suggest a need for caution, but such violence seems trophy, and facial wasting. He states that he would like to to be rare (241–2). When asked, 92% of notified partners stop HAART because of the side effects. What should you reported that they believe the health department should con- tell this patient? tinue partner notification services (243). No studies have directly shown that PCRS prevents disease in a community. 16 MMWR July 18, 2003
TABLE 7. Recommendations for partner counseling and referral, including partner notification Recommendation Rating In HIV health-care settings, all applicable requirements for reporting sex A-III (for identifying patients who should be referred for partner counseling and needle-sharing partners of HIV-infected patients to the appropriate and referral services [PCRS]) health department should be followed.
At the initial visit, patients should be asked if all of their sex and needle- A-III (for identifying patients who should be referred for PCRS) sharing partners have been informed of their exposure to HIV.
At routine follow-up visits, patients should be asked if they have had any A-III (for identifying patients who should be referred for PCRS) new sex or needle-sharing partners who have not been informed of their exposure to HIV.
All patients should be referred to the appropriate health department to A-I (for increasing partner counseling and referral and voluntary testing discuss sex and needle-sharing partners who have not been informed of of partners) their exposure and to arrange for their notification and referral for HIV testing.
In HIV health-care settings, access to available community partner A-III (for establishing a working relationship and increasing understanding counseling and referral resources should be established. about partner counseling and referral procedures)
However, studies have demonstrated that quality HIV pre- partners were notified. Another 39 HIV-infected persons vention counseling can reduce the risk of acquiring a new STD were assigned to health department referral; and for these, 78 (164) and that persons who become aware of their HIV infec- partners were notified. Thus, notification by the health tion can take steps to protect their health and prevent further department appears to be substantially more effective than transmission (244); in addition, before–after studies have notification by the infected person. Other studies, with less suggested that partners change their behavior after they are rigorous designs, have demonstrated similar results (247,248). notified (245). Finally, compelling arguments have been Some persons, when asked, prefer to inform their partners offered regarding partners’ rights to know this information themselves. This could have a benefit if partners provide sup- that is important to their health. port to the infected person. However, patients frequently find that informing their partners is more difficult than they Laws and Regulations Related anticipated. Certain health departments offer contract refer- to Informing Partners ral, in which the infected person has a few days to notify his or her partners. If by the contract date the partners have not had The majority of states and some cities or localities have laws a visit for counseling and testing, they are then contacted by and regulations related to informing partners that they have the health department. In practice, patients’ difficulties in been exposed to HIV. Certain health departments require that, informing their partners usually means notification is done by even if a patient refuses to report a partner, the clinician report the health department. to the health department any partner of whom he or she is Although clinicians might wish to take on the responsibility aware. Many states also have laws regarding disclosure by for informing partners, one observational study has indicated clinicians to third parties known to be at high risk for future that health department specialists were more successful than HIV transmission from patients known to be infected (i.e., physicians in interviewing patients and locating partners (249). duty to warn) (246). Clinicians should know and comply with Health departments have staff who are trained to do partner any such requirements in the areas in which they practice. With notification and skilled at providing this free, confidential ser- regard to PCRS, clinicians should also be aware of and adhere vice. These disease intervention specialists can work closely to all laws and regulations related to providing services to with public and private sector clinicians who treat persons with minors. other STDs. With regard to partner notification, the clinician should be sensitive to concerns of domestic violence or abuse Approaches to Notifying Partners by the informed partner. Partners can be reached and informed of their exposure by All partners should be notified at least once. Persons who health department staff, clinicians in the private sector, or the continue to have sex with an HIV-infected person despite an infected person. In the only randomized controlled trial that earlier notification may have erroneously concluded that some- has been conducted to date (175), 35 HIV-infected persons one else was the infected partner. Thus, renotification might were asked to notify their partners themselves, and 10 be important, although no research is available on renotification. Vol. 52 / RR-12 Recommendations and Reports 17
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Summary of recommendations for human immunodeficiency virus (HIV) prevention among HIV-infected persons in clinical care settings Recommendation Rating* HIV-infected patients should be screened for behaviors associated with HIV transmission by using a straightforward, nonjudgmental approach. This A-II should be done at the initial visit and subsequent routine visits or periodically, as the clinician feels necessary, but at a minimum of yearly. Any indication of risky behavior should prompt a more thorough assessment of HIV transmission risks. At the initial and each subsequent routine visit, HIV-infected patients should be questioned about symptoms of sexually transmitted diseases (STDs) (e.g., A-I urethral or vaginal discharge; dysuria; intermenstrual bleeding; genital or anal ulcers; anal pruritus, burning, or discharge; and, for women, lower abdomi- nal pain with or without fever). Regardless of reported sexual behavior or other epidemiologic risk information, the presence of such signs or symptoms should always prompt diagnostic testing and, when appropriate, treatment. At the initial visit • All HIV-infected women and men should be screened for laboratory evidence of syphilis. Women should also be screened for trichomoniasis. A-II Sexually active women aged <25 years and other women at increased risk, even if asymptomatic, should be screened for cervical chlamydial infection. • Consideration should be given to screening all HIV-infected men and women for gonorrhea and chlamydial infections. However, because of the cost B-II of screening and the variability of prevalence of these infections, decisions about routine screening for these infections should be based on epidemio- logic factors (including prevalence of infection in the community or the population being served), availability of tests, and cost. (Some HIV specialists also recommend type-specific serologic testing for herpes simplex virus type 2 for both men and women.) Screening for STDs should be repeated periodically (i.e., at least annually) if the patient is sexually active or if earlier screening revealed STDs. Screening B-III should be done more frequently (e.g., at 3–6-month intervals) for asymptomatic persons at higher risk. At the initial and each subsequent routine visit, HIV-infected women of childbearing age should be questioned to identify possible current pregnancy, A-I interest in future pregnancy, or sexual activity without reliable contraception. They should be referred for appropriate counseling, reproductive health care, or prenatal care, as indicated. Women should be asked whether they suspect pregnancy or have missed their menses and, if so, should be tested for pregnancy. Clinics or office environments where patients with HIV infection receive care should be structured to support and enhance HIV prevention. B-III Within the context of HIV care, brief general HIV prevention messages should be regularly provided to HIV-infected patients at each visit, or periodically, A-III as determined by the clinician, and at a minimum of twice yearly. These messages should emphasize the need for safer behaviors to protect their own health and the health of their sex or needle-sharing partners, regardless of perceived risk. Messages should be tailored to the patient’s needs and circumstances. Patients should have adequate, accurate information regarding factors that influence HIV transmission and methods for reducing the risk for transmission A-III to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to HIV (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same HIV serostatus). HIV-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly. Patients’ misconceptions regarding HIV transmission and methods for reducing risk for transmission should be identified and corrected. For example, A-III ensure that patients know that 1) per-act estimates of HIV transmission risk for an individual patient vary according to behavioral, biologic, and viral factors; 2) highly active antiretroviral therapy (HAART) cannot be relied upon to eliminate the risk of transmitting HIV to others; and 3) nonoccupational postexposure prophylaxis is of uncertain effectiveness for preventing infection in HIV-exposed partners. Tailored HIV prevention interventions, using a risk-reduction approach, should be delivered to patients at highest risk for transmitting HIV. A-III After initial prevention messages are delivered, subsequent longer or more intensive interventions in the clinic or office should be delivered, if feasible. A-I HIV-infected patients should be referred to appropriate services for issues related to HIV transmission that cannot be adequately addressed during the A-I clinic visit. Persons who inject illicit drugs should be strongly encouraged to cease injecting and enter into substance abuse treatment programs (e.g., methadone A-II maintenance) and should be provided referrals to such programs. Persons who continue to inject drugs should be advised to always use sterile injection equipment and to never reuse or share needles, syringes, or other A-II injection equipment and should be provided information regarding how to obtain new, sterile syringes and needles (e.g., syringe exchange programs). In HIV health-care settings, all applicable requirements for reporting sex and needle-sharing partners of HIV-infected patients to the appropriate health A-III department should be followed. At the initial visit, patients should be asked if all of their sex and needle-sharing partners have been informed of their exposure to HIV. A-III At routine follow-up visits, patients should be asked if they have had any new sex or needle-sharing partners who have not been informed of their exposure A-III to HIV. All patients should be referred to the appropriate health department to discuss sex and needle-sharing partners who have not been informed of their A-I exposure and to arrange for their notification and referral for HIV testing. In HIV health-care settings, access to available community partner counseling and referral resources should be established. A-III
* Letters indicate the strength of the recommendation, and roman numerals indicate the quality of evidence supporting it, respectively (see Table 1). Appendix B:
HIV and Its Transmission
(Centers for Disease Control and Prevention) HIV Prevention HIV and Its Transmission
Research has revealed a great deal of valuable medical, scientific, and public health information about the human immunodeficiency virus (HIV) and acquired immuno- deficiency syndrome (AIDS). The ways in which HIV can be transmitted have been clearly identified. Unfortunately, false information or statements that are not supported by scientific findings continue to be shared widely through the Internet or popular press. Therefore, the Centers for Disease Control and Prevention (CDC) has prepared this fact sheet to correct a few misperceptions about HIV.
How HIV is Transmitted
HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes (primarily for drug injection) with someone who is infected, or, less com- monly (and now very rarely in countries where blood is screened for HIV antibod- ies), through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breast-feeding after birth. In the health care setting, workers have been infected with HIV after being stuck with needles containing HIV-infected blood or, less frequently, after infected blood gets into a worker’s open cut or a mucous membrane (for example, the eyes or inside of the nose). There has been only one instance of patients being infected by a health care worker in the United States; this involved HIV transmission from one infected dentist to six patients. Investigations have been completed involving more than 22,000 patients of 63 HIV-infected physicians, surgeons, and dentists, and no other cases of this type of transmission have been identified in the United States. Some people fear that HIV might be transmitted in other ways; however, no scientific evidence to support any of these fears has been found. If HIV were being transmitted through other routes (such as through air, water, or insects), the pattern of reported AIDS cases would be much different from what has been observed. For example, if mosquitoes could transmit HIV infection, many more young chil- dren and preadolescents would have been diagnosed with AIDS. All reported cases suggesting new or potentially unknown routes of transmission are thoroughly investigated by state and local health departments with the assis- tance, guidance, and laboratory support from CDC. No additional routes of transmission have been recorded, despite a national sentinel system designed to detect just such an occurrence. The following paragraphs specifically address some of the common misperceptions about HIV transmission. HIV in the Environment Scientists and medical authorities agree that HIV does not survive well in the environment, making the possibility of environmental transmission remote. HIV is
found in varying concentrations or amounts in blood, semen, vaginal fluid, breast
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ HIV and it’s Transmission, July 1999 milk, saliva, and tears. (See page 3, Saliva, Tears, and Sweat.) To obtain data on the survival of HIV, labora- tory studies have required the use of artificially high concentrations of laboratory-grown virus. Although these unnatural concentrations of HIV can be kept alive for days or even weeks under precisely controlled and limited laboratory conditions, CDC studies have shown that drying of even these high concentrations of HIV reduces the amount of infectious virus by 90 to 99 percent within several hours. Since the HIV concentrations used in laboratory studies are much higher than those actually found in blood or other specimens, drying of HIV- infected human blood or other body fluids reduces the theoretical risk of environmental transmission to that which has been observed—essentially zero. Incorrect interpretation of conclusions drawn from laboratory studies have unnecessarily alarmed some people. Results from laboratory studies should not be used to assess specific personal risk of infection because (1) the amount of virus studied is not found in human specimens or elsewhere in nature, and (2) no one has been identified as infected with HIV due to contact with an environmental surface. Additionally, HIV is unable to reproduce outside its living host (unlike many bacteria or fungi, which may do so under suitable conditions), except under laboratory conditions, therefore, it does not spread or maintain infectiousness outside its host. Households Although HIV has been transmitted between family members in a household setting, this type of transmission is very rare. These transmissions are believed to have resulted from contact between skin or mucous membranes and infected blood. To prevent even such rare occurrences, precautions, as described in previously published guidelines, should be taken in all settings—including the home—to prevent exposures to the blood of persons who are HIV infected, at risk for HIV infection, or whose infection and risk status are unknown. For example, ❖ Gloves should be worn during contact with blood or other body fluids that could possibly contain visible blood, such as urine, feces, or vomit. ❖ Cuts, sores, or breaks on both the care giver’s and patient’s exposed skin should be covered with ban- dages. ❖ Hands and other parts of the body should be washed immediately after contact with blood or other body fluids, and surfaces soiled with blood should be disinfected appropriately. ❖ Practices that increase the likelihood of blood contact, such as sharing of razors and toothbrushes, should be avoided. ❖ Needles and other sharp instruments should be used only when medically necessary and handled according to recommendations for health-care settings. (Do not put caps back on needles by hand or remove needles from syringes. Dispose of needles in puncture-proof containers out of the reach of children and visitors.) Businesses and Other Settings There is no known risk of HIV transmission to co-workers, clients, or consumers from contact in industries such as food-service establishments (see information on survival of HIV in the environment). Food-service workers known to be infected with HIV need not be restricted from work unless they have other infections or illnesses (such as diarrhea or hepatitis A) for which any food-service worker, regardless of HIV infection status, should be restricted. CDC recommends that all food-service workers follow recommended standards and practices of good personal hygiene and food sanitation. In 1985, CDC issued routine precautions that all personal-service workers (such as hairdressers, barbers, cosmetologists, and massage therapists) should follow, even though there is no evidence of transmission from a personal-service worker to a client or vice versa. Instruments that are intended to penetrate the skin (such as tattooing and acupuncture needles, ear piercing devices) should be used once and disposed of or thoroughly
cleaned and sterilized. Instruments not intended to penetrate the skin but which may become contaminated with
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 2 HIV and it’s Transmission, July 1999 blood (for example, razors) should be used for only one client and disposed of or thoroughly cleaned and disinfected after each use. Personal-service workers can use the same cleaning procedures that are recom- mended for health care institutions. CDC knows of no instances of HIV transmission through tattooing or body piercing, although hepatitis B virus has been transmitted during some of these practices. One case of HIV transmission from acupuncture has been documented. Body piercing (other than ear piercing) is relatively new in the United States, and the medical complications for body piercing appear to be greater than for tattoos. Healing of piercings generally will take weeks, and sometimes even months, and the pierced tissue could conceivably be abraded (torn or cut) or inflamed even after healing. Therefore, a theoretical HIV transmission risk does exist if the unhealed or abraded tissues come into contact with an infected person’s blood or other infectious body fluid. Additionally, HIV could be transmitted if instruments contaminated with blood are not sterilized or disinfected between clients. Kissing Casual contact through closed-mouth or “social” kissing is not a risk for transmission of HIV. Because of the potential for contact with blood during “French” or open-mouth kissing, CDC recommends against engaging in this activity with a person known to be infected. However, the risk of acquiring HIV during open-mouth kissing is believed to be very low. CDC has investigated only one case of HIV infection that may be attributed to contact with blood during open-mouth kissing. Biting In 1997, CDC published findings from a state health department investigation of an incident that suggested blood-to-blood transmission of HIV by a human bite. There have been other reports in the medical literature in which HIV appeared to have been transmitted by a bite. Severe trauma with extensive tissue tearing and damage and presence of blood were reported in each of these instances. Biting is not a common way of trans- mitting HIV. In fact, there are numerous reports of bites that did not result in HIV infection. Saliva, Tears, and Sweat HIV has been found in saliva and tears in very low quantities from some AIDS patients. It is important to understand that finding a small amount of HIV in a body fluid does not necessarily mean that HIV can be transmitted by that body fluid. HIV has not been recovered from the sweat of HIV-infected persons. Contact with saliva, tears, or sweat has never been shown to result in transmission of HIV. Insects From the onset of the HIV epidemic, there has been concern about transmission of the virus by biting and bloodsucking insects. However, studies conducted by researchers at CDC and elsewhere have shown no evidence of HIV transmission through insects—even in areas where there are many cases of AIDS and large populations of insects such as mosquitoes. Lack of such outbreaks, despite intense efforts to detect them, supports the conclusion that HIV is not transmitted by insects. The results of experiments and observations of insect biting behavior indicate that when an insect bites a person, it does not inject its own or a previously bitten person’s or animal’s blood into the next person bitten. Rather, it injects saliva, which acts as a lubricant or anticoagulant so the insect can feed efficiently. Such diseases as yellow fever and malaria are transmitted through the saliva of specific species of mosquitoes. However, HIV lives for only a short time inside an insect and, unlike organisms that are transmitted via insect bites, HIV does not reproduce (and does not survive) in insects. Thus, even if the virus enters a mosquito or another sucking or biting insect, the insect does not become infected and cannot transmit HIV to the next human it feeds on or
bites. HIV is not found in insect feces.
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 3 HIV and it’s Transmission, July 1999 There is also no reason to fear that a biting or bloodsucking insect, such as a mosquito, could transmit HIV from one person to another through HIV-infected blood left on its mouth parts. Two factors serve to explain why this is so—first, infected people do not have constant, high levels of HIV in their bloodstreams and, second, insect mouth parts do not retain large amounts of blood on their surfaces. Further, scientists who study insects have determined that biting insects normally do not travel from one person to the next immediately after ingesting blood. Rather, they fly to a resting place to digest this blood meal. Effectiveness of Condoms Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). Condom manufacturers in the United States test each latex condom for defects, including holes, before it is packaged. The proper and consistent use of latex or polyurethane (a type of plastic) condoms when engaging in sexual intercourse—vaginal, anal, or oral—can greatly reduce a person’s risk of acquiring or transmitting sexually transmitted diseases, including HIV infection. There are many different types and brands of condoms available—however, only latex or polyurethane condoms provide a highly effective mechanical barrier to HIV. In laboratories, viruses occasionally have been shown to pass through natural membrane (“skin” or lambskin) condoms, which may contain natural pores and are therefore not recommended for disease prevention (they are documented to be effective for contraception). Women may wish to consider using the female condom when a male condom cannot be used. For condoms to provide maximum protection, they must be used consistently (every time) and correctly. Several studies of correct and consistent condom use clearly show that latex condom breakage rates in this country are less than 2 percent. Even when condoms do break, one study showed that more than half of such breaks occurred prior to ejaculation. When condoms are used reliably, they have been shown to prevent pregnancy up to 98 percent of the time among couples using them as their only method of contraception. Similarly, numerous studies among sexually active people have demonstrated that a properly used latex condom provides a high degree of protection against a variety of sexually transmitted diseases, including HIV infection. For more detailed information about condoms, see the CDC publication “Male Latex Condoms and Sexually Transmitted Diseases.” CDC’s Response CDC is committed to providing the scientific community and the public with accurate and objective information about HIV infection and AIDS. It is vital that clear information on HIV infection and AIDS be readily available to help prevent further transmission of the virus and to allay fears and prejudices caused by misinformation. For a complete description of CDC’s HIV/AIDS prevention programs, see “Facts about CDC’s Role in HIV and AIDS Prevention.”
For more information...
CDC National AIDS Hotline: 1-800-342-AIDS (2437) Spanish: 1-800-344-SIDA (7432) (HIV and STDs) Deaf: 1-800-243-7889
CDC National Prevention Information Network: Internet Resources: P.O. Box 6003 DHAP: http://www.cdc.gov/hiv Rockville, Maryland 20849-6003 NCHSTP: http://www.cdc.gov/nchstp/od/nchstp.html
1-800-458-5231 NPIN: http://www.cdcnpin.org
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 4 HIV and it’s Transmission, July 1999 Appendix C:
What You Should Know About Oral Sex
(Centers for Disease Control and Prevention) December 2000
Preventing the Sexual Transmission of HIV, the Virus that Causes AIDS What You Should Know about Oral Sex
Oral Sex Is Not Considered Safe Sex Like all sexual activity, oral sex carries some risk, particularly when one partner or the other is known to be infected with HIV, when either partner’s HIV status is not known, and/or when one or the other partner is not monogamous or injects drugs. Numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases (STDs). Abstaining from oral, anal, and vaginal sex all together or having sex only with a mutually monogamous, uninfected partner are the only ways that individuals can be completely protected from the sexual transmission of HIV.
Oral Sex is a Common Practice Oral sex involves giving or receiving oral stimulation (i.e. sucking or licking) to the penis, the vagina, and/or the anus. Fellatio is the technical term used to describe oral contact with the penis. Cunnilingus is the technical term which describes oral-vaginal sex. Anilingus (sometimes called “rimming”) refers to oral-anal contact. Studies indicate that oral sex is commonly practiced by sexually active male-female and same-gender couples of various ages, including adolescents. Although there are only limited national data about how often adolescents engage in oral sex, some data suggest that many adolescents who engage in oral sex do not consider it to be sex; therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent. Moreover, many consider oral sex to be a safe or no risk sexual practice. In a recent national survey of teens conducted for The Kaiser Family Foundation, 26% of sexually active 15 to 17 year olds surveyedresponded that one “cannot become infected with HIV by having unprotected oral sex”, and an additional 15% didn’t know whether or not one could become infected in that manner.
Oral Sex and the Risk of HIV Transmission The risk of HIV transmission from an infected partner through oral sex is much smaller than the risk of HIV transmission from anal or vaginal sex. Because of this, measuring the exact risk of HIV transmission as a result of oral sex is very difficult. In addition, since most sexually active individuals practice oral sex in addition to other forms of sex, such as vaginal and/or anal sex, when transmission occurs, it is difficult to determine whether or not it occurred as a result of oral sex or other more risky sexual activities. Finally, several co-factors can increase the risk of HIV transmission through oral sex, including: oral ulcers, bleeding gums, genital sores, and the presence of other STDs. When scientists describe the risk of transmitting an infectious disease, like HIV, the term “theoretical risk” is often used. Very simply, “theoretical risk” means that passing an infection from one person to another is possible, even though there may not yet be any actual documented cases. “Theoretical risk” is not the same as likelihood. In other words, stating that HIV infection is “theoretically possible” does not necessarily mean it is likely to happen—only that it might. Documented risk, on the other hand, is used to describe transmission that has actually occurred, been investigated, and documented in the scientific literature. Theoretical and Documented Theoretical and Documented Risk Theoretical and Documented Risk Risk of HIV Transmission During of HIV Transmission During of HIV Transmission During Oral-Penile Contact Oral-Vaginal Contact Oral-Anal Contact
Theoretical: Theoretical: Theoretical: In fellatio, there is a theoretical Cunnilingus carries a theoretical Anilingus carries a theoretical risk of transmission for the risk of HIV transmission for the risk of transmission for the receptive partner (the person insertive partner (the person who insertive partner (the person who who is sucking) because infected is licking or sucking the vaginal is licking or sucking the anus) if pre-ejaculate ("pre-cum") fluid or area) because infected vaginal there is exposure to infected semen can get into the mouth. fluids and blood can get into the blood, either through bloody For the insertive partner (the mouth. (This includes, but is not fecal matter (bodily waste) or person who is being sucked), limited to, menstrual blood). cuts/sores in the anal area. there is a theoretical risk of Likewise, there is a theoretical Anilingus carries a theoretical infection because infected blood risk of HIV transmission during risk to the receptive partner (the from a partner's bleeding gums cunnilingus for the receptive person who is being or an open sore could come in partner (the person who is licked/sucked) if infected blood contact with a scratch, cut, or having her vagina licked or in saliva comes in contact with sore on the penis. sucked) if infected blood from anal/rectal lining. oral sores or bleeding gums comes in contact with vulvar or vaginal cuts or sores.
Documented: Documented: Documented: Although the risk is many times The risk of HIV transmission There has been one published smaller than anal or vaginal sex, during cunnilingus is extremely case of HIV transmission HIV has been transmitted to low compared to vaginal and associated with oral-anal sexual receptive partners through anal sex. However, there have contact. fellatio, even in cases when been a few cases of HIV insertive partners didn't transmission most likely ejaculate ("cum"). resulting from oral-vaginal sex.
Other STDs Can Also Be Transmitted From Oral Sex Scientists have documented a number of other sexually transmitted diseases that have also been transmitted through oral sex. Herpes, syphilis, gonorrhea, genital warts (HPV), intestinal parasites (amebiasis), and hepatitis A are examples of STDs which can be transmitted during oral sex with an infected partner. For more information see Oral Sex and STDs Fact Sheet.
Reducing the Risk of HIV Transmission Through Oral Sex The consequences of HIV infection are life-long, life-threatening, and extremely serious. You can lower any already low risk of getting HIV from oral sex by using latex condoms each and every time. For cunnilingus or anilingus, plastic food wrap, a condom cut open, or a dental dam can serve as a physical barrier to prevent transmission of HIV and many other STDs. Because anal and vaginal sex are much riskier and because most individuals who engage in unprotected (i.e. without a condom) oral sex also engage in unprotected anal and/or vaginal sex, the exact proportion of HIV infections attributable to oral sex alone is unknown, but is likely to be very small. This has led some people to believe that oral sex is completely safe. It is not. Appendix D:
Female Condom FAQ
(Female Health Company) Frequently Asked Questions About FC Female Condoms From the Female Health Company
1. How easy to use are FC female condoms? FC female condoms are not difficult to use, but you may want to practice to get used to them. Women should practice putting it in and removing it, prior to using it for the first time during sexual intercourse. Research has indicated that FC may need to be tried up to three times before users become confident and comfortable using it. New users should try to insert the device several times, and each time with the body in a different position (e.g. lying down, crouching, sitting) to find which is the most comfortable for you. While individual counseling and personal fitting may help to reassure women, group sessions and peer groups may overcome early abandonment, as women can share anxieties, ideas and laughter with each other. 2. Are any precautions necessary for correctly using FC female condoms? It is important that the penis is guided into the centre of an FC female condom, taking care not to insert between the vaginal wall and the outer side of the condom—you are not protected if that happens. Diagrams and/or anatomical models should be referenced to illustrate this problem. If the penis does enter incorrectly, the man should withdraw his penis and the couple should start over. 3. Can a lubricant be used with FC female condoms and, if so, what kind of lubricant can be used? FC female condoms come pre-lubricated with a silicone-based, non-spermicidal lubricant. This lubrication helps assist in the insertion of the device and allows easy movement during intercourse. The lubricant may make FC a little slippery at first. If the outer ring of FC gets pushed in or pulled out of the vagina, more lubricant may be needed. Also, if FC makes noise during sex, simply add more lubricant. FC female condoms can be used with both water-based and oil-based lubricants. 4. Can FC female condoms be used more than once? Both FC and FC2 are approved for a single use only. For the original FC female condom, re-use has been reported in several countries. WHO, UNAIDS and USAID among others have conducted studies to investigate the safety of disinfection, washing, drying, storage and re-lubrication, followed by re-use, and WHO has convened two technical consultations to review data from these studies.
Continued on next page WHO recommends use of a new male or female condom for every act of intercourse, where there is a risk of unintended pregnancy and/or STI/HIV infection. Recognizing the urgent need for risk-reduction strategies for women who cannot or do not access new condoms, WHO has developed a protocol for the safe handling and preparation of a used (original) FC female condom that is intended for re-use. WHO does not recommend or promote re-use, but has made available the protocol, together with guidelines on programmatic issues, to programme managers who intend to evaluate the feasibility of re-use and application in local settings. WHO’s Information Update on re-use is available on-line at www.who.int/ reproductive-health/rtis/reuse.en.html 5. What if I find that the inner ring is uncomfortable for me or my partner? Some people have reported that both the inner and outer rings add to both a man’s and a woman’s sexual pleasure. However, some women do report that the inner ring can be uncomfortable. If this happens to you, you can try to place FC differently (i.e. reinsert or re- position the device) so that the inner ring is tucked back behind the cervix and out of the way. 6. What size are FC female condoms? If you compare FC female condoms with an unrolled male condom you will find that they are the same length but wider than the male condom. It is important to note that, due to size, FCs provide added protection because the base of the penis and the external female genitalia are partly covered during use. Although the initial reaction to their size may be negative, this feeling diminishes with use. To reduce potential negative reactions, some programmes have introduced FC rolled up to minimise the size; and have suggested that the female insert FC before the initiation of sexual activity. It is also significant to reinforce the advantages of the wider diameter, since many men complain that male condoms can be constricting.
7. How do I dispose of FC female condoms? FC female condoms do not need to be removed immediately after a man ejaculates, unlike the male condom. But they should be taken out before the woman stands up to avoid having the semen spill out. 1. The outer ring of FC should be twisted (clockwise) to seal the condom so that no semen comes out. 2. FC can be pulled out and wrapped in the package it came in and/or in tissue. 3. FC should be disposed of in waste containers and not in the toilet. Also, since in many countries women dispose of sanitary napkins in a clean and private way, the same procedures can be promoted for the disposal of FC. 8. Can FC female condoms be used in different sexual positions? FC female condoms can be used in any sexual position; however, additional lubricant may be needed. Some women may feel more comfortable learning to use FC in the missionary position, and then adding other positions after that. Group counseling sessions are often ideal for women to learn from each other how to use the device while having sex in different positions.
Continued on next page FC female condoms are not specifically approved or recommended for anal sex. There are reports from all over the world, however, that the original FC has been used for anal sex. Several studies have been done and published and others are on-going. 9. Can an FC female condom and a male condom be used at the same time? You should not use two condoms at the same time. Using the condoms simultaneously may cause friction resulting in either or both condoms slipping or tearing, and/or the displacing of the outer ring of FC to the inside of the vagina. 10. How long can FC female condoms be kept, and are there any special storage requirements? Both FC and FC2 have a shelf life of 5 years from the date of manufacture. There are no special storage requirements. 11. Who can and/or should use FC female condoms?
People who want to protect themselves and their partners from unintended pregnancy and STIs, including HIV/AIDS, and show their partners that they care.
People whose partners cannot or will not use the male condom.
Women who are menstruating.
Women who have recently given birth.
Women who have had a hysterectomy.
Women who are in perimenopause or post-menopause.
People who are allergic or sensitive to latex should use FC as an alternative to the male latex condom.
People who are HIV+ or have HIV+ partners.
Reproduced with permission from The Female Health Company. Available online at: http://www.femalehealth.com.
July 2006 Appendix E:
What is FC Female Condom?
(Female Health Company) What is FC female condom?
FC female condom is a strong, soft, transparent polyurethane sheath that is 17 centimetres long (about 6.5 inches, the same length as a male condom) with a flexible ring at each end. It is inserted into the vagina prior to sexual intercourse and provides protection against both pregnancy and sexually transmitted infections (STIs) including HIV/AIDS. The inner ring aids insertion and secures the device in place during intercourse while the softer outer ring remains outside the vagina.
FC female condom: • can be inserted up to 8 hours before • provides both men and women with an intercourse so will not interrupt sexual additional choice to prevent unintended spontaneity; is not dependent on the pregnancies and protect themselves male erection and does not require from STIs, including HIV/AIDS immediate withdrawal after ejaculation • forms a barrier between the penis and • conducts/retains heat, so sexual the vagina, cervix and external genitalia, intercourse can feel very sensitive thereby providing additional protection and natural • is stronger than latex, odourless and • is not tight or constricting causes no allergic reactions and, unlike • is the only new prevention technology latex, may be used with both oil and invented and approved since the advent The Female Health Company water based lubricants 515 North State Street, Suite 2225 of the HIV/AIDS epidemic and the sole Chicago, Illinois 60610 female initiated protective method Tel: +1 312 595 9123 currently available. Fax: +1 312 595 9122 Email: [email protected] www.femalehealth.com FC female condom is not difficult to use but it may take some practice to become comfortable with it. Women should practice putting it in and removing it prior to using it for the first time during sexual intercourse. Insertion becomes easier with time – try it at least 3 times before making any decisions.
Outer ring
Inner ring
1 Open the package carefully; tear the notch on 2 The outer ring covers the area around the opening of the vagina. 3 Hold the sheath at the closed end; grasp the flexible inner ring the top right of the package. Do not use scissors The inner ring is used for insertion and to hold the sheath in place and squeeze it with the thumb and middle finger so it becomes long or a knife to open. during intercourse. and narrow.
Pubic bone Pubic bone
4 Choose a position that is comfortable for insertion – squat, raise 5 Place the index finger on the inside of the condom, and push the 6 The female condom is now in place and ready for use with your one leg, sit or lie down. Gently insert the inner ring into the vagina. inner ring up as far as it will go. Be sure the sheath is not twisted. partner. Feel the inner ring go up and move into place. The outer ring should remain on the outside of the vagina.
OK
OK OK
OK
Not OK – STOP!
7 Gently guide your partner’s penis into the sheath’s opening using 8 Be sure that the penis is not entering on the side, between the 9 To remove the condom, twist the outer ring and gently pull the your hand to make sure that it enters properly. sheath and the vaginal wall. condom out.Wrap the condom in the package or in a tissue and throw it in the garbage. Do not put it in the toilet . Appendix F:
What is FC2 Female Condom?
(Female Health Company) What is FC2 Female Condom?
FC2 female condom has the same design and instructions for use as the FC female condom. The material has been changed to improve affordability, while maintaining the high quality, reliability and features of FC. FC2’s sheath, with its outer ring, is made from a synthetic nitrile. Insert FC2 prior to sexual intercourse to provide protection against HIV/AIDS, other STIs and unintended pregnancies. The inner ring aids insertion and helps to secure the device in place during intercourse while the softer outer ring remains outside the vagina.
FC2 female condom • is a new second generation female •forms a barrier between the penis and condom made of synthetic nitrile. It the vagina, cervix and external genitalia, was designed to improve affordability, thereby providing additional protection. particularly in large volumes, while • is strong, hypoallergenic and, unlike maintaining the high quality, reliability and latex, may be used with both oil and features of the original FC female condom. water-based lubricants. • has been shown in studies to be as • can be inserted up to 8 hours before effective as FC. These assessments intercourse, to allow for sexual include preclinical safety studies of the spontaneity. new material and a direct comparison •is not dependent on the male erection, study evaluating efficacy in terms of rips, does not require immediate withdrawal tears and slippage. and is not tight or constricting. The Female Health Company 515 North State Street, Suite 2225 Like FC, FC2 •is the sole female-initiated protection Chicago, Illinois 60610 • provides women and men with an method invented and approved since Tel: +1 312 595 9123 additional choice to protect themselves Fax: +1 312 595 9122 the advent of the HIV/AIDS epidemic. Email: [email protected] against HIV/AIDS, other STIs and www.femalehealth.com unintended pregnancies. FC2 female condom is not difficult to use but it may take some practice to become comfortable with it. Women should practice inserting and removing it prior to using it for the first time during sexual intercourse. Insertion becomes easier with practice — try it at least 3 times before making any decisions about future use.
Outer ring
Inner ring
1 Open the package carefully by tearing the notch on the top right 2 The outer ring covers the area around the opening of the vagina. 3 Hold the sheath at the closed end, grasp the flexible inner ring of the package. Do not use scissors or a knife to open. The inner ring is used for insertion and to hold the sheath in place and squeeze it with the thumb and middle finger so it becomes long during intercourse. and narrow.
Pubic bone Pubic bone
4 Choose a position that is comfortable for insertion – squat, raise 5 Place the index finger on the inside of the condom, and push the 6 FC2 female condom is now in place and ready for use with your one leg, sit or lie down. Gently insert the inner ring into the vagina. inner ring up as far as it will go. Be sure the sheath is not twisted. partner. Feel the inner ring go up and move into place. The outer ring should remain on the outside of the vagina.
OK
OK OK
OK
Not OK – STOP!
7 Gently guide your partner’s penis into the sheath’s opening using 8 Be sure that the penis is not entering on the side, between the 9 To remove the condom, twist the outer ring and gently pull the your hand to make sure that it enters properly. sheath and the vaginal wall. condom. Wrap the condom in the package or in a tissue and throw it in the garbage. Do not put it in the toilet. Appendix G:
FAQ About Microbicides
(Global Campaign for Microbicides) Fact Sheet #2 Frequently Asked Questions About Microbicides
What is a microbicide? A microbicide (m-KRO-b-sd) is a substance that can substantially reduce transmission of sexually transmitted diseases (STIs) when applied either in the vagina or rectum. A microbicide could be produced in many forms, including gels, creams, suppositories, films, lubricants, or in the form of a sponge or a vaginal ring that slowly releases the active ingredient. The word “microbicides” refers to a range of different products that share one common characteristic: the ability to prevent the sexual transmission of HIV and other STI pathogens when applied topically.
Are microbicides currently available? No. Scientists are currently testing many substances to see whether they help protect against HIV and/or other STIs, but no safe and effective microbicide is currently available to the public. However, scientists are seriously pursuing dozens of product leads, including 16 that have proven safe and effective in animals and are now being tested in people. If one of these leads proves successful and with sufficient investment, a successful microbicide could be on the market by the end of the decade.
How would a microbicide work? A microbicide could prevent HIV and STIs by: 1) killing or otherwise immobilizing pathogens 2) blocking infection by creating a barrier between the pathogen and the cells of the vagina or rectum; or 3) preventing the infection from taking hold after it has entered the body. Ideally, a microbicide would combine these mechanisms for extra effectiveness.
Would a microbicide eliminate the need for condoms? No. When used consistently and correctly, male or female condoms are likely to provide better protection against HIV and STIs than microbicides, so they will still be the preferred option. But for people who cannot or will not use condoms, and particularly for women whose partners refuse condoms, using microbicides can save lives and have a substantial impact on the spread of HIV. In fact, researchers developed a mathematical model that shows that if even a small proportion of women in lower income countries used a 60% efficacious microbicide in half the sexual encounters where condoms are not used, 2.5 million HIV infections could be averted over 3 years.
Would a microbicide protect against all sexually transmitted infections? Since STIs are caused by different pathogens (some viral, some bacterial), a microbicide that works against one STI pathogen would not necessarily protect against another. Many of the microbicides currently being tested work against HIV and at least one other STI. Eventually, a product that combines different microbicides and mechanisms of action may offer a protection from a wide range of sexually transmitted infections, including HIV.
What if a woman wants to get pregnant? Some of the microbicides being investigated prevent pregnancy and some do not. It is important to have both non-contraceptive microbicides and “dual-action” microbicides that prevent pregnancy and infection, so that women and couples can protect their health and still have children. This is not possible with condoms.
Global Campaign for Microbicides. May 2005. Reproduction encouraged. For info contact: [email protected] Updates available at: www.global-campaign.org/download.htm
Would microbicides be safe? Any new product must go through rigorous safety testing before becoming available to consumers. Women’s health activists and researchers are working closely together to ensure that the clinical testing of microbicides is thorough and ethical. Fortunately, many of the substances and mechanisms of action under investigation are already commonly used in over the counter products.
Would men benefit from microbicides as well? Current clinical trials are evaluating whether microbicides could protect HIV negative women from infection, but there is hope that some products may eventually be shown to protect men if their female partner is HIV positive. Evaluating whether a microbicide protects male partners, however, will require separate clinical trials.
Who is working on microbicide research and development? Virtually all microbicide research to date has been conducted by non-profit and academic institutions or small biotech companies. Studies are funded by charitable foundations and government grants. These public funds also support basic science, social and behavioural research, and clinical trial infrastructure that contribute to microbicide research and development. Large pharmaceutical companies have not invested significantly in this field, primarily because microbicides are a classic “public health good” which would yield tremendous benefits to society but for which the profit incentive to private investment is low.
Why do we need microbicides if we will eventually have an HIV-vaccine? No one strategy or technology will “solve” the AIDS pandemic. We must employ all existing prevention strategies-- such as behaviour change, voluntary counselling and testing, STI diagnosis and treatment, broad access to male and female condoms, access to sterile syringes, and anti-retroviral interventions—as well as expand our repertoire of tools and technologies. Microbicides will likely be available and accessible sooner than an HIV-vaccine. Even after a safe and effective vaccine is discovered, vaccines and microbicides will have different, complementary roles to play in an integrated, multi-faceted global HIV prevention strategy.
How much will microbicides cost, and will people be able to afford them? It is essential that microbicides get into the hands of women and men who need it at a price they can afford. In the past, new health technologies have rarely become widely available in developing countries until more than a decade after their approval in the US and Europe, an unacceptable delay for this life-saving technology developed primarily with public funds. Advocates are working with researchers and policy makers now to emphasize the need to address issues of access and affordability up front, in order to be prepared to deliver a microbicide rapidly as soon as one is proven safe and effective.
How can you get involved? Visit the Global Campaign for Microbicides website: www.global-campaign.org to sign a petition, sign up for our electronic newsletter, write to your legislators, meet up with local advocacy groups in your region, and learn more about microbicides. We need your help to make a safe and effective microbicide available as soon as possible.
The Global Campaign for Microbicides c/o PATH, 1800 K Street NW, Suite 800, Washington, DC 20006 USA Phone: +1 (202) 822-0033 Fax: +1 (202) 457-1466 Email: [email protected] or Rebekah Webb, 7th Floor, 98 rue du Trone, Brussels 1050, Belgium Phone: +32 (0)2 507 1221 Fax: +32 (0)2 507 1222 Email: [email protected]
Global Campaign for Microbicides. May 2005. Reproduction encouraged. For info contact: [email protected] Updates available at: www.global-campaign.org/download.htm
Appendix H:
Drug Fact Sheets
(Office of National Drug Control Policy & NYS Department of Health AIDS Institute) Executive Office of the President Office of National Drug Control Policy
OONDCPNDCP June 2003 Drug Policy Information Clearinghouse FACT SHEET John P. Walters, Director www.whitehousedrugpolicy.gov 1–800–666–3332
Heroin
Background enters the brain and binds to the natural opioid recep- Heroin was first synthesized in 1874 from morphine, tors. The rush is usually accompanied by a warm flush- anaturally occurring substance extracted from the seed ing of the skin, dry mouth, and a heavy feeling in the pod of certain varieties of poppy plants. It was com- user’s arms and legs. The user may also experience nau- mercially marketed in 1898 as a new pain remedy and sea, vomiting, and severe itching. Following the initial became widely used in medicine in the early 1900s effects, the user will be drowsy for several hours with until it became a controlled substance in 1914 under clouded mental function and slow cardiac function. the Harrison Narcotic Act. Heroin is a highly addictive Breathing is slowed, possibly to the point of death. drug and is considered the most abused and most rap- Repeated heroin use produces tolerance and physical idly acting opiate. dependence. Physical dependence causes the user’s Heroin comes in various forms, but pure heroin is a body to adapt to the presence of the drug and with- white powder with a bitter taste. Most illicit heroin drawal symptoms occur if use is reduced. Withdrawal comes in powder form in colors ranging from white to symptoms begin within a few hours of last use and can dark brown. The colors are due to the impurities left include restlessness, muscle and bone pain, insomnia, from the manufacturing process or the presence of diarrhea, vomiting, cold flashes with goose bumps, and additives. “Black tar” is another form of heroin that involuntary leg movements. These symptoms peak resembles roofing tar or is hard like coal. Color varies between 24 and 48 hours after the last dose and sub- from dark brown to black. side after about a week, but may persist for up to a month. Heroin withdrawal is not usually fatal in an Effects otherwise healthy adult, but can cause death to the fetus of a pregnant addict. Heroin can be injected, smoked, or snorted. Intra- venous injection produces the greatest intensity and Prevalence Estimates most rapid onset of euphoria. Effects are felt in 7 to 8 seconds. Even though effects for sniffing or smoking Although it is difficult to obtain an exact number of develop more slowly, beginning in 10 to 15 minutes, heroin users because of the transient nature of this sniffing or smoking heroin has increased in popularity population, several surveys have attempted to provide because of the availability of high-purity heroin and estimates. A rough estimate of the hardcore addict pop- the fear of sharing needles. Also, users tend to mistak- ulation in the United States places the number between enly believe that sniffing or smoking heroin will not 750,000 and 1,000,000 users. lead to addiction. The U.S. Department of Health and Human Services’ After ingestion, heroin crosses the blood-brain barrier. National Household Survey on Drug Abuse found that, While in the brain, heroin converts to morphine and in 2001, approximately 3.1 million Americans (1.4%) binds rapidly to opioid receptors. Users tend to report 12 years old and older had used heroin at least once in feeling a “rush” or a surge of pleasurable sensations. their lifetime. Persons ages 18 to 25 reported the high- The feeling varies in intensity depending on how much est percentage of lifetime heroin use with 1.6% in of the drug was ingested and how rapidly the drug 2001 (see table 1). NCJ 197335 According to the Community Epidemiology Work Ta b le 1. Percentage of Americans reporting lifetime Group (CEWG), as of December 2002, heroin use use of heroin, by age group, 1999–2001 indicators increased in four CEWG sites, decreased in Age 1999 2000 2001 one, were stable in seven, and were mixed in nine. 12–17 0.4% 0.4% 0.3% Despite mixed patterns, heroin abuse indicators remain 18–25 1.8 1.4 1.6 high in many CEWG areas. The sites where heroin in- 26–34 1.3 1.1 1.3 dicators increased were Atlanta, Boston, Detroit, and 35 and older 1.5 1.4 1.5 Washington, D.C. Total population 1.4 1.2 1.4
Source: National Household Survey on Drug Abuse. The Arrestee Drug Abuse Monitoring Program (ADAM) collects data on male arrestees testing posi- tive for opiates at the time of arrest in 36 ADAM sites. According to the University of Michigan’s Monitoring During 2002, the percentage of adult male arrestees the Future Study in 2002, 1.6% of 8th graders, 1.8% of testing positive ranged from 0% in Woodbury, Iowa, 10th graders, and 1.7% of 12th graders surveyed to 26% in Chicago. Of the 28 ADAM sites collecting reported using heroin at least once during their life- female arrestee data, the percentage of female arrestees time. That study also showed that 0.9% of 8th graders, testing positive for opiates at the time of arrest ranged 1.1% of 10th graders, and 1% of 12th graders reported from 0% in Woodbury, Iowa, to 18% in Portland, using heroin in the past year. Oregon, and Washington, D.C. The ADAM program also collects data on reported drug use by arrestees in Among college students surveyed in 2001, 1.2% the past 30 days. For adult male arrestees during 2002, reported using heroin during their lifetime and 0.1% the average number of days that arrestees reported reported using heroin in the 30 days before being sur- using heroin ranged from 0.7 days in Omaha to 21.5 veyed. Of those young adults surveyed between ages days in Woodbury, Iowa. The average number of days 19 and 28, 2% reported using heroin during their life- reported by adult female arrestees ranged from zero time and 0.3% reported using heroin within the 30 days in Woodbury, Iowa, to 16 days in New York City. days before being surveyed.
In another study, of those high school students sur- Availability veyed in 2001 as part of the Youth Risk Behavior According to What America’s Users Spend on Illegal Surveillance System, 3.1% reported using heroin at Drugs, heroin expenditures were an estimated $22 bil- least once during their lifetime. Male students (3.8%) lion in 1990, and decreased to $10 billion in 2000. were more likely than female students (2.5%) to report During 1990, Americans consumed 13.6 metric tons lifetime heroin use. of heroin. Current estimates of heroin consumption remain relatively unchanged and show that 13.3 metric Regional Observations tons of heroin were consumed in 2000. According to Pulse Check: Trends in Drug Abuse, during Production and Trafficking the first half of 2002, heroin was perceived to be the drug associated with the most serious consequences According to the National Drug Intelligence Center’s (medical, legal, and societal) in 15 of the 20 Pulse National Drug Threat Assessment 2003, heroin is culti- Check sites across the United States. Heroin users are vated from opium poppies in four source areas: South predominantly white males, over age 30, who live in America, Mexico, and Southeast and Southwest Asia. central city areas. Most heroin sellers tend to be young Opium cultivation decreased from 5,082 metric tons adults between the ages of 18 and 30. during 2000 to 1,255 metric tons during 2001. This led to a reduction in heroin production from 482.2 metric The different forms of heroin vary in availability tons during 2000 to 109.3 metric tons during 2001. across the Pulse Check sites in the United States. High-purity, South American (Colombian) white hero- South American heroin is the most prevalent type of in is widely available across the Northeast, South, and heroin in the United States. Colombian criminal Midwest. Mexican black tar, a less pure form of hero- groups, operating independently of major cocaine car- in, is more commonly found in the West. Southeast tels, dominate the smuggling of South American heroin Asian heroin is considered widely available in New into the United States. Others involved in the trans- Orleans, Portland, Maine, and Washington, D.C., and portation of South American heroin include Bahamian, Southwest Asian heroin (the least common form of Dominican, Guatemalan, Haitian, Jamaican, and heroin) is only considered widely available in Chicago Puerto Rican criminal groups. and New Orleans.
2 Heroin is smuggled into the United States through the Adjudication air, sea, land, and mail services. Once in the United During FY 2001, 1,757 Federal drug offenders were States, heroin is distributed at the wholesale level, convicted of committing an offense involving heroin. most frequently by Columbian, Dominican, Mexican, Of those convicted of a Federal drug offense for Nigerian, and Chinese criminal groups described as heroin, 61.3% were Hispanic, 23% were black, 14% small, independent, and loosely structured. Retail- or were white, and 1.7% were of another race. street-level distribution of heroin is handled by a larger array of criminal groups. Gangs also are involved in the Corrections wholesale and retail distribution of heroin. Many mem- In FY 2001, the average length of sentence received by bers of national gangs, such as the Gangster Disciples, Federal heroin offenders was 63.4 months, compared Vice Lords, and Latin Kings, keep links to heroin traf- to 115 months for crack cocaine offenders, 88.5 months fickers to guarantee a constant supply of the drug. for methamphetamine offenders, 77 months for powder cocaine offenders, 38 months for marijuana offenders, Price and Purity and 41.1 months for other drug offenders. According to During 2001, wholesale prices for South American a 1997 Bureau of Justice Statistics survey of Federal heroin ranged from $50,000 to $250,000 per kilogram. and State prisoners, approximately 10% of Federal and Southeast and Southwest Asian heroin wholesale 12.8% of State drug offenders were incarcerated for an prices ranged from $35,000 to $120,000 per kilogram, offense involving heroin or other opiates. and Mexican heroin ranged from $15,000 to $65,000 per kilogram. Street-level heroin usually sells for $10 Consequences of Use per dose, although prices vary throughout the country. Chronic heroin use can lead to medical consequences According to the Drug Enforcement Administration such as scarred and/or collapsed veins, bacterial infec- (DEA), during 2000, retail purity levels of heroin ranged tions of the blood vessels and heart valves, abscesses from 48.1% for South American heroin, to 34.6% for and other soft-tissue infections, and liver or kidney dis- Southwest Asian heroin, to 20.8% for Mexican heroin. ease. Poor health conditions and depressed respiration The national average purity for retail heroin from all from heroin use can cause lung complications, includ- sources was 36.8%. ing various types of pneumonia and tuberculosis.
Enforcement Addiction is the most detrimental long-term effect of heroin use because it is a chronic, relapsing disease char- Arrests acterized by compulsive drug seeking and use, as well as The Federal Bureau of Investigation estimates that, neurochemical and molecular changes in the brain. during 2001, heroin or cocaine and their derivatives accounted for 9.7% of drug arrests for sale and manu- Long-term effects of heroin use also can include arthri- facturing and 23.1% of drug arrests for possession tis and other rheumatologic problems and infection of (estimates of heroin arrests alone are not available). bloodborne pathogens such as HIV/AIDS and hepatitis B and C (which are contracted by sharing and reusing From October 1, 1999, to September 30, 2000, there syringes and other injection paraphernalia). It is esti- were 3,557 arrests by DEA for opiates out of 38,411 mated that injection drug use has been a factor in one- total drug arrests. These figures represent only DEA’s third of all HIV and more than half of all hepatitis C portion of heroin arrests nationwide during 2000. cases in the United States.
Seizures Heroin use by a pregnant woman can result in a mis- carriage or premature delivery. Heroin exposure in According to the Federal-wide Drug Seizures System utero can increase a newborns’ risk of SIDS (sudden (FDSS), 1,587 kilograms of heroin were seized from infant death syndrome). January to September 2002 by U.S. Federal law en- forcement authorities, a decline from 2,493 kilograms Street heroin is often cut with substances such as in 2001. FDSS comprises information about drug sugar, starch, powdered milk, strychnine and other seizures made within the jurisdiction of the United poisons, and other drugs. These additives may not dis- States by DEA, the Federal Bureau of Investigation, solve when injected in a user’s system and can clog the U.S. Customs Service, and the U.S. Border Patrol, the blood vessels that lead to the lungs, liver, kidneys, as well as maritime seizures made by the U.S. Coast or brain, infecting or killing patches of cells in vital Guard. FDSS eliminates duplicate reporting of seizures organs. In addition, many users do not know their involving more than one Federal agency.
3 heroin’s actual strength or its true contents and are at Detoxification relieves the withdrawal symptoms expe- an elevated risk of overdose or death. rienced when substance use is discontinued. Detox- ification is not a treatment for addiction, although it can According to Drug Abuse Warning Network (DAWN) be used to aid in the transition to long-term treatment. emergency department (ED) data, there were 93,064 reported mentions of heroin in 2001, an increase of Naloxone and naltrexone are medications that inhibit 47.4% since 1994 (see table 2). Preliminary ED data the effects of opiates such as morphine and heroin. for the first half of 2002 revealed that there were 42,571 LAAM, a synthetic opiate similar to methadone, is mentions of heroin. A drug mention refers to a substance used to treat heroin addiction. This treatment’s long that was recorded (mentioned) during a visit to the ED. duration of action (up to 72 hours) allows patients to Heroin represented 15% of 638,484 total ED episodes administer their dosage three times a week instead of in 2001. Approximately 56% of heroin ED mentions daily. Buprenorphine, another opiate treatment, causes were for people ages 35 and older. Almost half (43%) weaker opiate effects and is not as likely to cause over- of heroin ED mentions were for whites. dose. Buprenorphine creates a lower level of physical dependence and makes it easier for patients to discon- According to DAWN’s 2001 mortality data, of the 42 tinue medication. metropolitan areas studied, 19 areas saw a decrease in the number of heroin/morphine mentions, while 9 areas Scheduling and Legislation reported an increase in heroin/morphine mentions. Heroin was first controlled in the United States under the Harrison Narcotic Act of 1914. Currently, heroin falls under Schedule I of the Controlled Substances Ta b le 2. Number of emergency department mentions of heroin, 1994–2001 Act. A Schedule I Controlled Substance has a high potential for abuse, is not currently accepted for medical 1994 1995 1996 1997 1998 1999 2000 2001 use in treatment in the United States, and lacks accept- 63,158 69,556 72,980 70,712 75,688 82,192 94,804 93,064 ed safety for use under medical supervision.
Source: Drug Abuse Warning Network. Street Terms
Treatment Street terms for heroin According to Treatment Episode Data Set, heroin accounted for 15.2% of all treatment admissions in Al Capone Isda 2000 (243,523 admissions). Males accounted for Antifreeze Jee gee 66.9% of heroin treatment admissions. Treatment Ballot Joy admissions by race/ethnicity ranged from 47.3% white, Bart Simpson Junk to 24.7% Hispanic, to 24.2% black. Big bag Lemonade Big H Mexican brown Eighty-one percent of heroin treatment admissions Brown sugar Nice and easy reported daily use of the drug. Almost 80% of heroin Capital H Noise admissions had been in treatment before the current Cheese Ogoy episode and 25% had been in treatment five or more Chip Old Steve times. Methadone treatment was planned to be used Crank Orange line for 40% of primary heroin admissions. Dead on arrival P-dope Methadone has been used to treat opioid addiction for Dirt Pangonadalot more than 30 years. This synthetic narcotic suppresses Dr. Feelgood Peg opioid withdrawal symptoms for 24 to 36 hours. Al- Ferry dust Perfect high though the patient remains physically dependent on the George smack Poison opioid, the craving from heroin use is reduced and the Golden girl Pure highs and lows are blocked. This permits the patient to Good horse Rawhide be free from the uncontrolled, compulsive, and disrup- Hard candy Ready rock tive behavior associated with heroin addiction. Hazel Salt Hero Sweet dreams Other pharmaceutical approaches to heroin treatment Hombre Train include detoxification, naloxone and naltrexone, LAAM Horse White boy (levo-alpha-acetyl-methadol), and buprenorphine. HRN Zoquete
4 Resource University of Michigan, Monitoring the Future National Drug Policy Information Clearinghouse, Methadone, Survey Results on Drug Use, 1975–2001, Volume II: April 2000. College School Students and Adults Ages 19–40, 2002. www.whitehousedrugpolicy.gov/publications/factsht/ http://monitoringthefuture.org/pubs/monographs/ methadone/index.htm vol2_2001.pdf Zickler, Patrick, “High-Dose Methadone Improves Sources Treatment Outcomes,” NIDA Notes, 14 (5), Executive Office of the President: December 1999. http://165.112.78.61/NIDA_Notes/NNVol14N5/ Office of National Drug Control Policy HighDose.html
Drug Availability Estimates in the United States, Substance Abuse and Mental Health Services December 2002. Administration www.whitehousedrugpolicy.gov/publications/pdf/ drugavailability.pdf Emergency Department Trends From the Drug Abuse Warning Network, Preliminary Estimates Drug Policy Information Clearinghouse, Street Terms: January–June 2002, December 2002. Drugs and the Drug Trade, 2002. www.samhsa.gov/oas/DAWN/Prelim2k2EDtrends/ www.whitehousedrugpolicy.gov/streetterms/default.asp text/EDTrendPrelim02text.pdf
National Drug Control Strategy: Data Supplement, Mortality Data From the Drug Abuse Warning February 2003. Network, 2001, January 2003. www.whitehousedrugpolicy.gov/publications/policy/ http://dawninfo.samhsa.gov/pubs_94_02/mepubs/files/ ndcs03/ndcs_suppl03.pdf DAWN2001/DAWN2001.pdf
Pulse Check: Trends in Drug Abuse, November 2002. Summary of Findings From the 2000 National www.whitehousedrugpolicy.gov/publications/drugfact/ Household Survey on Drug Abuse, September 2001. pulsechk/nov02 www.samhsa.gov/oas/NHSDA/2kNHSDA/2kNHSDA.htm
What America’s Users Spend on Illegal Drugs, 1988– Results From the 2001 National Household Survey on 2000, December 2001. Drug Abuse: Volume I. Summary of National www.whitehousedrugpolicy.gov/publications/pdf/ Findings, August 2002. american_users_spend_2002.pdf www.samhsa.gov/oas/nhsda/2k1nhsda/PDF/cover.pdf
U.S. Department of Health and Human Services: Results From the 2001 National Household Survey on Drug Abuse: Volume II. Technical Appendices and Centers for Disease Control and Prevention Selected Data Tables, August 2002. www.samhsa.gov/oas/nhsda/2k1nhsda/PDF/vol2cover.pdf Youth Risk Behavior Surveillance—United States, 2001, June 2002. Treatment Episode Data Set (TEDS) 1992–2000: www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm National Admissions to Substance Abuse Treatment Services, December 2002. National Institute on Drug Abuse www.samhsa.gov/oas/dasis.htm#teds2 Epidemiologic Trends in Drug Abuse Advance Report, U.S. Department of Justice: December 2002. www.drugabuse.gov/about/organization/CEWG/Advance Drug Enforcement Administration dRep/1202adv/1202adv.html Drugs of Abuse, February 2003. Research Report, Heroin Abuse and Addiction, www.usdoj.gov/dea/pubs/abuse/index.html September 2000. www.drugabuse.gov/ResearchReports/Heroin/Heroin.html Drug Trafficking in the United States. www.usdoj.gov/dea/concern/drug_trafficking.html University of Michigan, Monitoring the Future 2002 Data From In-School Surveys of 8th, 10th, and 12th Federal Bureau of Investigation Grade Students, December 2002. http://monitoringthefuture.org/data/ Crime in the United States–2001, October 2002. 02data.html#2002data-drugs www.fbi.gov/ucr/01cius.htm
5 National Drug Intelligence Center National Institute of Justice, Preliminary Data on Drug Use and Related Matters Among Adult Arrestees National Drug Threat Assessment 2003, January 2003. and Juvenile Detainees, 2002. www.usdoj.gov/ndic/pubs3/3300/index.htm www.adam-nij.net/files/2002_Preliminary_Data.pdf
Office of Justice Programs Other Source:
Bureau of Justice Statistics, Compendium of Federal U.S. Sentencing Commission, 2001 Sourcebook of Justice Statistics, 2000, August 2002. Federal Sentencing Statistics, 2002. www.ojp.usdoj.gov/bjs/abstract/cfjs00.htm www.ussc.gov/ANNRPT/2001/SBTOC01.htm Bureau of Justice Statistics, Sourcebook of Criminal Justice Statistics Online, 2001. www.albany.edu/sourcebook
Bureau of Justice Statistics, Substance Abuse and Treatment of State and Federal Prisoners, 1997, January 1999. www.ojp.usdoj.gov/bjs/abstract/satsfp97.htm
This fact sheet was prepared by Jennifer Lloyd of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849–6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
*NCJ~197335* Executive Office of the President Office of National Drug Control Policy
November 2003
John P. Walters, Director
Cocaine
Background Users often feel euphoric, energetic, talkative, and Cocaine, the most potent stimulant of natural origin, is mentally alert after taking small amounts of cocaine. extracted from the leaves of the coca plant (Erythro- Cocaine use can also temporarily lessen a user’s need xylon). It was originally used in South America in the for food or sleep. Short-term physiological effects mid-19th century by natives of the region to relieve include constricted blood vessels, dilated pupils, and fatigue. Pure cocaine (cocaine hydrochloride) was first increased temperature, heart rate, and blood pressure. used as a local anesthetic for surgeries in the 1880s and Ingesting large amounts of cocaine can intensify the was the main stimulant drug used in tonics and elixirs user’s high, but can also lead to bizarre, erratic, and vio- for treatment of various illnesses in the early 1900s. lent behavior. Users who ingest large amounts may Crack, the freebase form of cocaine, derives its name experience tremors, vertigo, muscle twitches, and para- from the crackling sound made when heating the sodi- noia. Other possible effects of cocaine use include irri- um bicarbonate (baking soda) or ammonia used during tability, anxiety, and restlessness. production. Crack became popular in the mid-1980s Cocaine is a powerfully addictive drug. A tolerance is because of its immediate high and its inexpensive pro- often developed when a user, seeking to achieve the ini- duction cost. tial pleasure received from first use, increases the Cocaine most often appears as a white crystalline pow- dosage to intensify and prolong the euphoric effects. der or an off-white chunky material. Powder cocaine is commonly diluted with other substances such as lac- Prevalence Estimates tose, inositol, mannitol, and local anesthetics such as During 2000, there were an estimated 2,707,000 chron- lidocaine to increase the volume of the substance and ic cocaine users and 3,035,000 occasional cocaine users the profits of the drug dealer. Powder cocaine is usually in the United States. snorted or dissolved in water and injected. Crack, or “rock,” is most often smoked. According to What America’s Users Spend on Illegal Drugs, users spent $35.3 billion on cocaine in 2000, a Effects decrease from the $69.9 billion spent in 1990. Ameri- cans consumed 259 metric tons of cocaine in 2000, a The effects of cocaine normally occur immediately after decrease from the 447 metric tons consumed in 1990. ingestion and can last from a few minutes to a few hours. The duration of the drug’s effects depends on The U.S. Department of Health and Human Services’ how it is ingested. Snorting cocaine produces a slow Results From the 2002 National Survey on Drug Use onset of effects that can last from 15 to 30 minutes, and Health: National Findings found that more than 33 while the effects of smoking cocaine last from 5 to 10 million people age 12 and older (14.4%) in 2002 report- minutes and produce a more intense high. Cocaine pro- ed that they had used cocaine at least once in their life- duces euphoric effects by building up dopamine in the time (see table 1). More than 8 million Americans brain, causing the continuous stimulation of neurons. NCJ 198582 Ta b le 1. Percentage of Americans reporting lifetime use Ta b le 4. Percentage of students reporting crack use, of cocaine, by age group, 2002 2001–2002
Age Group Lifetime Past Year Past Month Lifetime Past year Past month 12Ð17 2.7% 2.1% 0.6% Grade 2001 2002 2001 2002 2001 2002 18Ð25 15.4 6.7 2.0 8th grade 3.0% 2.5% 1.7% 1.6% 0.8% 0.8% 26 and older 15.9 1.8 0.7 10th grade 3.1 3.6 1.8 2.3 0.7 1.0 Total population 14.4 2.5 0.9 12th grade 3.7 3.8 2.1 2.3 1.1 1.2
Source: National Survey on Drug Use and Health. Source: Monitoring the Future Study.
followed by white students (9.9%), and black students Ta b le 2. Percentage of Americans reporting lifetime use (2.1%). Male students (10.3%) were more likely than of crack, by age group, 2002 female students (8.4%) to report lifetime cocaine use. Age Group Lifetime Past Year Past Month 12Ð17 0.7% 0.4% 0.1% Regional Observations 18Ð25 3.8 0.9 0.2 According to Pulse Check: Trends in Drug Abuse, dur- 26 and older 3.9 0.7 0.3 ing the first half of 2002 powder and crack cocaine Total population 3.6 0.7 0.2 were widely to somewhat available in the 20 Pulse Check sites across the United States. Among powder Source: National Survey on Drug Use and Health. cocaine users, the predominant group consisted of white males who were older than 30 and lived in the central (3.6%) age 12 and older had used crack cocaine at least city. Crack cocaine users tended to be young adults once in their lifetime (see table 2). between the ages of 18 and 30 who lived in the central city and were usually from low socioeconomic back- According to the University of Michigan’s Monitoring grounds. Blacks were twice as likely as whites to be the Future Study, in 2002, 3.6% of 8th graders, 6.1% of reported as the predominant crack cocaine user group by 10th graders, and 7.8% of 12th graders surveyed report- Pulse Check sites. ed using cocaine at least once during their lifetime (see table 3). Of the students surveyed, 2.5% of 8th graders, In December 2002, the 21 Community Epidemiology 3.6% of 10th graders, and 3.8% of 12th graders report- Work Group (CEWG) sites reported that cocaine/crack ed using crack within their lifetime (see table 4). indicators showed mixed patterns of stabilization or decline in 10 sites, while 8 sites remained stable, 1 The study also showed that, in 2002, 8.2% of college reported an increase, and 2 reported decreases. students and 13.5% of young adults (ages 19 to 28) reported using cocaine during their lifetime. Almost 2% The Arrestee Drug Abuse Monitoring (ADAM) Program of college students and 4.3% of young adults reported collects data on male arrestees testing positive for cocaine using crack cocaine during their lifetime. at the time of arrest in 36 ADAM sites. According to pre- liminary 2002 data, the percentage of adult male arrestees In another study, among the high school students sur- testing positive ranged from 9.1% in Honolulu to 49.4% veyed in 2001 as part of the Youth Risk Behavior in Atlanta. Of the 23 ADAM sites collecting female- Surveillance System, 9.4% reported using cocaine in arrestee data, the percentage of female arrestees testing their lifetime and 4.2% reported using cocaine in the 30 positive for cocaine at the time of arrest ranged from days before the survey. Hispanic students reported the 7.4% in Honolulu to 55.2% in Indianapolis. highest percentage of lifetime cocaine use (14.9%), Availability
Ta b le 3. Percentage of students reporting cocaine use, Production and Trafficking 2001–2002 According to the National Drug Intelligence Center’s National Drug Threat Assessment 2003, cocaine is the Lifetime Past year Past month primary drug threat in the United States because of its Grade 2001 2002 2001 2002 2001 2002 high demand and availability, its expanding distribution 8th grade 4.3% 3.6% 2.5% 2.3% 1.2% 1.1% to new markets, the high rate of overdose associated 10th grade 5.7 6.1 3.6 4.0 1.3 1.6 with it, and its relation to violence. Cocaine consumed 12th grade 8.2 7.8 4.8 5.0 2.1 2.3 in the United States originates from coca plants grown Source: Monitoring the Future Study. in South America. In 2002, there was the potential for 550 metric tons of cocaine production. Some 352
2 metric tons of export-quality cocaine was available in Federal agents for cocaine, 40% were white and 59% U.S. markets. were black.
Approximately 75% of the coca cultivated for process- Seizures ing into cocaine is currently grown in Colombia, and According to the Federal-wide Drug Seizure System Colombian drug trafficking organizations (DTOs) are (FDSS), U.S. Federal law enforcement authorities seized responsible for most of the cocaine production, trans- 105,885 kilograms of cocaine in 2001 and 60,874 kilo- portation, and distribution. Bahamian, Dominican, grams from January to September 2002. FDSS consoli- Haitian, Jamaican, and Puerto Rican criminal groups dates information about drug seizures made within the transport cocaine, usually under the supervision of jurisdiction of the United States by DEA, the Federal Colombian DTOs. Mexican DTOs are involved in Bureau of Investigation, and U.S. Customs and Border wholesale cocaine distribution in the United States. Protection, as well as maritime seizures made by the Gangs control retail distribution of powder and crack U.S. Coast Guard. FDSS eliminates duplicate reporting cocaine in urban areas, while local independent dealers of seizures involving more than one Federal agency. are the primary distributors in suburban and rural areas. According to U.S. Customs and Border Protection, more Of the cocaine that enters the United States, 72% passes than 171,000 pounds of cocaine were seized nationally through the Mexico/Central America corridor. Another during fiscal year (FY) 2002. Large amounts of cocaine 27% moves through the Caribbean and 1% comes were seized at the Southwest border and in South directly from South America. Florida—a total of more than 30,000 pounds at each Cocaine is readily available in most major cities in the location. United States. Powder cocaine is typically shipped to one of six main transportation hubs—Central Arizona Adjudication (Phoenix/Tulsa), El Paso, Houston, Los Angeles, Miami, During FY 2001, 5,356 Federal drug offenders were and Puerto Rico. New York City also is becoming a convicted of committing an offense involving powder main transportation hub. Powder cocaine is then distrib- cocaine and 4,999 were convicted of committing a uted through one of the primary distribution centers— crack cocaine offense. Of those convicted of a Federal Atlanta, Chicago, Dallas, Detroit, New York City, and drug offense for powder cocaine, 50.2% were Hispanic, Philadelphia. 30.5% were black, 18.1% were white, and 1.2% were of another race. Of those convicted of a Federal drug Crack cocaine is not usually transported in large quan- offense involving crack cocaine, 82.8% were black, tities or over long distances due to the more severe 9.3% were Hispanic, 7% were white, and 0.9% fell mandatory sentencing for possession and distribution into another race category. of the drug. Retail distributors often convert powder cocaine into crack closer to the marketing areas. Corrections Federal drug offenders received longer sentences for Price and Purity crack cocaine than for any other drug. In FY 2001, the In 2001, the wholesale price for powder cocaine ranged average length of sentence received by Federal crack from $10,000 to $36,000 per kilogram, $400 to $1,800 cocaine offenders was 115 months, compared with per ounce, and $20 to $200 per gram. Prices for crack 88.5 months for methamphetamine offenders, 77 cocaine ranged from $3 to $50 per rock, with prices months for powder cocaine offenders, 63.4 months for usually ranging from $10 to $20. In 2001, the average heroin offenders, 38 months for marijuana offenders, nationwide purity of powder cocaine was 69% for kilo- and 41.1 months for other drug offenders. According gram quantities and 56% for gram quantities. to a 1997 Bureau of Justice Statistics survey of Federal and State prisoners, approximately 65.5% of Federal Enforcement and 72.1% of State drug offenders were incarcerated for a cocaine offense. Arrests The Federal Bureau of Investigation estimates that, Consequences of Use during 2001, cocaine and heroin and their derivatives Cocaine use can lead to medical complications such as accounted for 9.7% of drug abuse violation arrests for cardiovascular effects (disturbances in heart rhythm, sale and manufacturing and 23.1% for possession arrests heart attacks), respiratory failure, neurological effects (estimates of cocaine arrests alone are not available). (strokes, seizure, and headaches), and gastrointestinal From October 1, 2000, to September 30, 2001, there complications such as abdominal pain and nausea. were 12,457 Federal drug arrests for cocaine, represent- Cocaine use has been linked to heart disease, has ing 37% of all Federal drug arrests. Of those arrested by been found to trigger ventricular fibrillation (chaotic
3 heart rhythms), can accelerate a user’s heart beat and Ta b le 5. Number of emergency department mentions breathing, and can increase a user’s blood pressure and of cocaine, 1995–2002 body temperature. Additional physical symptoms of cocaine use include blurred vision, fever, muscle spasms, 1995 1996 1997 1998 1999 2000 2001 2002 convulsions, and coma. In rare instances, sudden death 135,711 152,420 161,083 172,011 168,751 174,881 193,034 199,198 can occur on the first use of cocaine or unexpectedly Source: Drug Abuse Warning Network. thereafter. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest. Medical treatments are also being developed to deal Other medical complications are related to the method with cocaine overdose. of ingestion. For example, users who snort cocaine may lose their sense of smell, have nose bleeds, have prob- Treatments such as cognitive-behavioral coping skills lems swallowing, and have an overall irritation of their have been shown to be effective in addressing cocaine nasal septum that leads to a chronic runny nose. addiction but are a short-term approach that focuses on the learning processes. Behavioral treatment attempts to Combined cocaine and alcohol use converts in the body help patients recognize, avoid, and cope with situations to cocaethylene and causes a longer duration of effects in which they are most likely to use cocaine. in the brain that is more toxic than each drug used alone. This mixture results in more drug-related deaths According to the Treatment Episode Data Set, cocaine than any other combination of drugs. was the third most common illicit drug responsible for treatment admissions in 2000, accounting for 13.6% of Although the effects of prenatal cocaine exposure are all drug treatment admissions. There were 158,524 total not completely understood, scientific studies have admissions for smoked cocaine, accounting for 9.9% shown that such afflicted babies are often born prema- of all drug treatment admissions (73% of all cocaine turely, have low birth weights and smaller head circum- admissions), and 59,787 total admissions for non- ferences, and are shorter in length. Originally thought smoked cocaine, accounting for 3.7% of all drug treat- to suffer irreversible neurological damage, these “crack ment admissions. babies” now appear to recover from the drug exposure. This is not to underestimate the many subtle but signif- Those admitted for smoking crack cocaine were pre- icant effects such babies later experience because of dominantly black (59%), followed by whites (32%) and their exposure to cocaine, including impairment in Hispanics (6.3%). Approximately 42% of those admit- behaviors that are crucial to concentrating in school. ted for smoking crack were female. Of all individuals admitted for smoking crack, most (59%) did not use the According to emergency department (ED) data collect- drug until age 21 or older and 41% reported daily use. ed by the Drug Abuse Warning Network (DAWN), there were 135,711 reported mentions of cocaine in Those admitted for nonsmoked cocaine were predomi- 1995 (see table 5). A drug mention refers to a substance nantly white males (29%), followed by black males that was recorded (mentioned) during a visit to the ED. (23%), white females (18%), and black females (12%). This number increased to 199,198 in 2002. More than 40% of those admitted for nonsmoked cocaine reported first using the drug by the age of 18. The more According to DAWN’s 2001 mortality data, of the 42 common form of nonsmoked cocaine ingestion was by metropolitan areas studied, 14 reported a decrease in inhalation (70%), followed by injection (15%). cocaine mentions and 14 saw an overall increase since 2000. The remaining metropolitan areas had stable Scheduling and Legislation cocaine mentions. Cocaine was first controlled in the United States under Treatment the Harrison Narcotic Act of 1914. Currently, cocaine falls under Schedule II of the Controlled Substances Medications to treat cocaine addiction are not available, Act. A Schedule II Controlled Substance has a high although researchers are working to identify and test potential for abuse, is currently accepted for medical new options. The most promising experimental medica- use in treatment in the United States, and may lead to tion is selegiline, which still needs an appropriate severe psychological or physical dependence. Currently, method of administration. Disulfiram, a medication cocaine can be administered by a doctor for legitimate that has been used to treat alcoholism, has been shown medical uses, such as for a local anesthetic for some to be effective in treating cocaine abuse in clinical tri- eye, ear, and throat surgeries. als. Antidepressants are usually prescribed to deal with mood changes that come with cocaine withdrawal.
4 Street Terms U.S. Department of Homeland Security:
U.S. Customs Service, Seizure Data, FY 2002. Street terms for cocaine www.cbp.gov/xp/cgov/toolbox/about/accomplish/ drug_seizure_data.xml All American drug Icing Aspirin (powder cocaine) Jelly U.S. Department of Health and Human Services: Barbs Lady Basa (crack cocaine) Mama coca Centers for Disease Control and Prevention Base (crack cocaine) Mojo Youth Risk Behavior Surveillance—United States, 2001, Bernie Nose stuff June 2002. Big C Oyster stew www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm Black rock (crack cocaine) Paradise CDs (crack cocaine) Pariba (powder cocaine) National Institute on Drug Abuse Candy sugar (powder cocaine) Pearl Coca Real tops (crack cocaine) Epidemiologic Trends in Drug Abuse Advance Report, Crack Rocks (crack cocaine) December 2002. Double bubble Roxanne (crack cocaine) www.drugabuse.gov/about/organization/CEWG/ Electric Kool-Aid (crack cocaine) Scorpion AdvancedRep/1202adv/1202adv.html Flave (powder cocaine) Sevenup Florida snow Snow white Monitoring the Future: 2002 Data From In-School Surveys of 8th, 10th, and 12th Grade Students, December 2002. Foo foo Sugar boogers (powder cocaine) http://monitoringthefuture.org/data/ Gin Twinkie (crack cocaine) 02data.html#2002data-drugs Gold dust Yam (crack cocaine) Happy dust Zip Monitoring the Future: National Survey Results on Drug Use, 1975Ð2002, Volume II: College Students and Adults Ages 19Ð40, September 2003. Sources http://monitoringthefuture.org/pubs/monographs/ Executive Office of the President: vol2_2002.pdf
Office of National Drug Control Policy Research Report: Cocaine Abuse and Addiction, May 1999. www.drugabuse.gov/ResearchReports/Cocaine/ 2002 Annual Assessment of Cocaine Movement, Cocaine.html March 2003. Substance Abuse and Mental Health Services Drug Policy Information Clearinghouse, Street Terms: Drugs Administration and the Drug Trade, 2002. www.whitehousedrugpolicy.gov/streetterms/default.asp Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates 1995Ð2002, July 2003. National Drug Control Strategy: Data Supplement, February http://dawninfo.samhsa.gov/pubs_94_02/edpubs/ 2003. 2002final/files/EDTrendFinal02AllText.pdf www.whitehousedrugpolicy.gov/publications/policy/ ndcs03/ndcs_suppl03.pdf Mortality Data From the Drug Abuse Warning Network, 2001, January 2003. Pulse Check: Trends in Drug Abuse, November 2002. http://dawninfo.samhsa.gov/pubs_94_02/mepubs/files/ www.whitehousedrugpolicy.gov/publications/drugfact/ DAWN2001/DAWN2001.pdf pulsechk/nov02/pulse_nov02.pdf. Results From the 2002 National Survey on Drug Use and What America’s Users Spend on Illegal Drugs, 1988Ð2000, Health: National Findings, September 2003. December 2001. www.samhsa.gov/oas/nhsda/2k2nsduh/2k2SoFW.pdf www.whitehousedrugpolicy.gov/publications/pdf/ american_users_spend_2002.pdf Treatment Episode Data Set (TEDS) 1992Ð2000: National Admissions to Substance Abuse Treatment Services, December 2002. www.samhsa.gov/oas/dasis.htm#teds2
5 U.S. Department of Justice: Bureau of Justice Statistics, Substance Abuse and Treatment of State and Federal Prisoners, 1997, January 1999. Drug Enforcement Administration www.ojp.usdoj.gov/bjs/abstract/satsfp97.htm
Drugs of Abuse, February 2003. National Institute of Justice, Preliminary Data on Drug Use & Related Matters Among Adult Arrestees & Juvenile Data from the Federal-wide Drug Seizure System, as found Detainees, 2002. in the Sourcebook of Criminal Justice Statistics Online. www.adam-nij.net/files/2002_Preliminary_Data.pdf www.albany.edu/sourcebook National Drug Intelligence Center Drug Trafficking in the United States. www.usdoj.gov/dea/concern/drug_trafficking.html National Drug Threat Assessment 2002, December 2001. www.usdoj.gov/ndic/pubs07/716/index.htm Federal Bureau of Investigation National Drug Threat Assessment 2003, January 2003. Crime in the United States—2001, October 2002. www.usdoj.gov/ndic/pubs3/3300/index.htm www.fbi.gov/ucr/01cius.htm U.S. Sentencing Commission: Office of Justice Programs 2001 Sourcebook of Federal Sentencing Statistics, 2002. Bureau of Justice Statistics, Compendium of Federal Justice www.ussc.gov/ANNRPT/2001/SBTOC01.htm Statistics, 2001, November 2003. www.ojp.usdoj.gov/bjs/abstract/cfjs01.htm
This fact sheet was prepared by Jennifer Lloyd of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849Ð6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
*NCJ~198582* Executive Office of the President Office of National Drug Control Policy
OONDCPNDCP NoNovvemberember 20032003 Drug Policy Information Clearinghouse FACT SHEET John P. Walters, Director www.whitehousedrugpolicy.gov 1–800–666–3332
Methamphetamine
Background “run,” on methamphetamine. During these binges, Methamphetamine, a derivative of amphetamine, is a users will inject as much as a gram of methampheta- powerful stimulant that affects the central nervous sys- mine every 2 to 3 hours over several days until they tem. Amphetamines were originally intended for use in run out of the drug or are too dazed to continue use. nasal decongestants and bronchial inhalers and have Chronic methamphetamine abuse can lead to psychotic limited medical applications, which include the treat- behavior including intense paranoia, visual and audito- ment of narcolepsy, weight control, and attention ry hallucinations, and out-of-control rages that can re- deficit disorder. Methamphetamine can be smoked, sult in violent episodes. Chronic users at times develop snorted, orally ingested, and injected. It is accessible in sores on their bodies from scratching at “crank bugs,” many different forms and may be identified by color, which describes the common delusion that bugs are which ranges from white to yellow to darker colors crawling under the skin. Long-term use of methamphet- such as red and brown. Methamphetamine comes in a amine may result in anxiety, insomnia, and addiction. powder form that resembles granulated crystals and in a rock form known as “ice,” which is the smokeable After methamphetamine use is stopped, several with- version of methamphetamine that came into use during drawal symptoms can occur, including depression, the 1980s. anxiety, fatigue, paranoia, aggression, and an intense craving for the drug. Psychotic symptoms can some- Effects times persist for months or years after use has ceased. Methamphetamine use increases energy and alertness and decreases appetite. An intense rush is felt, almost Prevalence Estimates instantaneously, when a user smokes or injects meth- According to the U.S. Department of Health and amphetamine. Snorting methamphetamine affects the Human Services’ Results From the 2002 National user in approximately 5 minutes, whereas oral inges- Survey on Drug Use and Health: National Findings, tion takes about 20 minutes for the user to feel the more than 12 million people age 12 and older (5.3%) effects. The intense rush and high felt from metham- reported that they had used methamphetamine at least phetamine results from the release of high levels of once in their lifetime (see table 1). Of those surveyed, dopamine into the section of the brain that controls the 597,000 persons age 12 and older (0.3%) reported past feeling of pleasure. The effects of methamphetamine month use of methamphetamine. can last up to 12 hours. Side effects include convul- sions, dangerously high body temperature, stroke, car- Since 1999, methamphetamine has been included in diac arrhythmia, stomach cramps, and shaking. the University of Michigan’s Monitoring the Future survey questionnaire. Survey results indicate that annu- Chronic use of methamphetamine can result in a tol- al methamphetamine use (use within the past year) by erance for the drug. Consequently, users may try to secondary school students in 1999 ranged from 3.2% intensify the desired effects by taking higher doses of among 8th graders, to 4.6% among 10th graders, to the drug, taking it more frequently, or changing their 4.7% among 12th graders (see table 2). In 2002, method of ingestion. Some abusers, while refraining estimates of annual methamphetamine use ranged from from eating and sleeping, will binge, also known as NCJ 197534 2.2% among 8th graders, to 3.9% among 10th graders, to 3.6% among 12th graders. Ta b le 1. Percentage of lifetime methamphetamine use among U.S. population by age group, 2002
The study also collected data on methamphetamine use Age Group Lifetime Past Year Past Month by college students and young adults ages 19 to 28. 12Ð17 1.5% 0.9% 0.3% During 1999, 3.3% of college students and 2.8% of 18Ð25 5.7 1.7 0.5 young adults tried methamphetamine in the past year 26 and older 5.7 0.4 0.2 (see table 3). In 2002, annual use of methamphetamine Total population 5.3 0.7 0.3 declined to 1.2% for college students and 2.5% for Source: National Survey on Drug Use and Health. young adults.
According to the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance—United Ta b le 2. Percentage of methamphetamine use by States, 2001 study, 9.8% of high school students had secondary school students, by grade, 1999–2002 used methamphetamine within their lifetime. Overall, white (11.4%) and Hispanic (9.1%) students were Lifetime Grade 1999 2000 2001 2002 more likely than black students (2.1%) to report life- 8th graders 4.5% 4.2% 4.4% 3.5% time methamphetamine use. 10th graders 7.3 6.9 6.4 6.1 12th graders 8.2 7.9 6.9 6.7 Regional Observations Annual The widespread availability of methamphetamine is Grade 1999 2000 2001 2002 illustrated by increasing numbers of methamphetamine 8th graders 3.2% 2.5% 2.8% 2.2% seizures, arrests, indictments, and sentences. According 10th graders 4.6 4.0 3.7 3.9 to the National Drug Intelligence Center (NDIC), 12th graders 4.7 4.3 3.9 3.6
methamphetamine is widely available throughout the Past 30 Days Pacific, Southwest, and West Central regions and is Grade 1999 2000 2001 2002 increasingly available in the Great Lakes and Southeast. 8th graders 1.1% 0.8% 1.3% 1.1% 10th graders 1.8 2.0 1.5 1.8 Similarly, the National Institute on Drug Abuse’s 12th graders 1.7 1.9 1.5 1.7 Community Epidemiology Work Group (CEWG) reports that, in 2002, methamphetamine indicators Source: Monitoring the Future Study. remained highest in West Coast areas and parts of the Southwest, as well as Hawaii. Methamphetamine abuse Miami, New York, and Sioux Falls (South Dakota). is spreading in areas such as Atlanta, Chicago, Detroit, The remaining 12 Pulse Check sites reported stable St. Louis, and Texas. Relatively low indicators were methamphetamine availability. There were no reported found in East Coast and Mid-Atlantic CEWG areas, decreases in availability. although abuse is increasing.
According to the Arrestee Drug Abuse Monitoring Availability Program sites, during 2002, methamphetamine use by Yaba, the Thai name for a tablet form of methampheta- adult arrestees was concentrated in the Western region mine mixed with caffeine, is appearing in Asian com- of the United States. Out of 36 sites, the highest per- munities in California. These tablets are popular in centages of adult male arrestees testing positive for Southeast and East Asia where they are produced. The methamphetamine were located in Honolulu (44.8%), tablets are small enough to fit in the end of a drinking Sacramento (33.5%), San Diego (31.7%), and Phoenix straw and are usually reddish-orange or green with var- (31.2%). Out of 23 sites, the highest percentages of ious logos. There are indications that methampheta- adult female arrestees testing positive for methamphet- mine tablets are becoming more popular in the rave amine were located in Honolulu (50%), San Jose scene because their appearance is similar to club drugs (42.8%), Phoenix (41.7%), Salt Lake City (37.7%), such as Ecstasy. and San Diego (36.8%). Production and Trafficking According to Pulse Check: Trends in Drug Abuse,law Methamphetamine trafficking and abuse have changed enforcement agencies and epidemiologic/ethnographic in the United States during the past 10 years. Mexican sources surveyed in 2002 reported that methampheta- drug trafficking organizations have become the dominant mine availability increased in the following sites: manufacturing and distribution group in cities in the Boston, Billings, Chicago, Columbia (South Carolina), Midwest and the West. Methamphetamine production Denver, Detroit, Honolulu, Los Angeles, Memphis,
2 Ta b le 3. Percentage of methamphetamine use by college students and young adults, 1999–2002
Lifetime Annual Past 30 Days Age Groups 1999 2000 2001 2002 1999 2000 2001 2002 1999 2000 2001 2002 College students 7.1% 5.1% 5.3% 5.0% 3.3% 1.6% 2.4% 1.2% 1.2% 0.2% 0.5% 0.2% Young adults 8.8 9.3 9.0 9.1 2.8 2.5 2.8 2.5 0.8 0.7 1.0 1.0
Source: Monitoring the Future Study. and abuse were previously controlled by independent lab- made by the U.S. Coast Guard. FDSS eliminates dupli- oratory operators, such as outlaw motorcycle gangs, cate reporting of seizures involving more than one which continue to operate but to a smaller extent. The Federal agency. Mexican criminal organizations are able to manufac- ture in excess of 10 pounds of methamphetamine in In addition, Federal authorities seized 301,697 Southeast a 24-hour period, producing high-purity, low-cost Asian methamphetamine tablets in U.S. Postal Service methamphetamine. facilities in Oakland, Los Angeles, and Honolulu in 2000, representing a 656% increase from the 1999 Methamphetamine precursor chemicals usually include seizures of 39,917 tablets. pseudoephedrine and ephedrine drug products. Mexican organizations sometimes use methylsulfonylmethane According to the El Paso Intelligence Center’s (MSM) to “cut” the methamphetamine in the production National Clandestine Laboratory Seizure System, cycle. MSM is legitimately used as a dietary supplement 8,290 methamphetamine labs were seized in 2001. In for horses and humans. The supplement is readily 2001, there were 303 “superlabs” with the capacity to available at feed/livestock stores and in health/nutrition produce 10 or more pounds of methamphetamine in stores. By adding MSM, the volume of methampheta- one production cycle seized in the United States. mine produced is increased, which in turn increases the profits for the dealer. Adjudication During FY 2001, 3,404 Federal drug offenders were Price and Purity convicted of committing an offense involving metham- According to the Drug Enforcement Administration phetamine. Of those convicted of a Federal drug (DEA), during 2001, the price of methamphetamine offense for methamphetamine, 59% were white, 35.2% ranged nationally from $3,500 to $23,000 per pound, were Hispanic, 4.2% were of another race, and 1.6% $350 to $2,200 per ounce, and $20 to $300 per gram. were black. The average purity of methamphetamine decreased from 71.9% in 1994 to 40.1% in 2001. International Corrections controls have reduced the availability of chemicals In FY 2001, the average length of sentence received by used to produce high-purity methamphetamine and Federal methamphetamine offenders was 88.5 months, may have contributed to the decrease in purity levels. compared with 115 months for crack cocaine offend- ers, 77 months for powder cocaine offenders, 63.4 Enforcement months for heroin offenders, 38 months for marijuana offenders, and 41.1 months for other drug offenders. Arrests From October 1, 2000, to September 30, 2001, there were Consequences of Use 3,932 Federal drug arrests for amphetamine/methamphet- amine, representing 12% of all Federal drug arrests. Chronic methamphetamine abuse can result in inflam- mation of the heart lining and, for injecting drug users, Seizures damaged blood vessels and skin abscesses. Social and occupational connections progressively deteriorate for According to the Federal-wide Drug Seizure System chronic methamphetamine users. Acute lead poisoning (FDSS), 2,807 kilograms of methamphetamine were is another potential risk for methamphetamine abusers seized in 2001 by U.S. Federal law enforcement because of a common method of production that uses authorities, down from 3,373 kilograms in 2000. FDSS lead acetate as a reagent. consolidates information about drug seizures made within the jurisdiction of the United States by DEA, Medical consequences of methamphetamine use can the Federal Bureau of Investigation, and U.S. Customs include cardiovascular problems such as rapid heart and Border Protection, as well as maritime seizures rate, irregular heartbeat, increased blood pressure, and
3 There are no pharmacological treatments for metham- Ta b le 4. Number of emergency department phetamine dependence. Antidepressant medications methamphetamine mentions, 1995–2002 can be used to combat the depressive symptoms of 1995 1996 1997 1998 1999 2000 2001 2002 withdrawal. The most effective treatment for metham- 15,933 11,002 17,154 11,486 10,447 13,505 14,923 17,696 phetamine addiction is cognitive behavioral interven- tions, which modify a patient’s thinking, expectancies, Source: Drug Abuse Warning Network. and behavior while increasing coping skills to deal with life stressors. stroke-producing damage to small blood vessels in the Clandestine Laboratories brain. Hyperthermia and convulsions can occur when a user overdoses and, if not treated immediately, can result Methamphetamine can be easily manufactured in in death. Research has shown that as much as 50% of clandestine laboratories (meth labs) using ingredients the dopamine-producing cells in the brain can be dam- purchased in local stores. Over-the-counter cold medi- aged by prolonged exposure to relatively low levels of cines containing ephedrine or pseudoephedrine and methamphetamine and that serotonin-containing nerve other materials are “cooked” in meth labs to make cells may be damaged even more extensively. methamphetamine.
Methamphetamine abuse during pregnancy can cause The manufacture of methamphetamine has a severe prenatal complications such as increased rates of pre- impact on the environment. The production of one mature delivery and altered neonatal behavior patterns, pound of methamphetamine releases poisonous gas such as abnormal reflexes and extreme irritability, and into the atmosphere and creates 5 to 7 pounds of toxic may be linked to congenital deformities. Methamphet- waste. Many laboratory operators dump the toxic waste amine abuse, particularly by those who inject the drug down household drains, in fields and yards, or on rural and share needles, can increase users’ risks of contract- roads. ing HIV/AIDS and hepatitis B and C. Due to the creation of toxic waste at methamphetamine During 1995, hospitals participating in the Drug Abuse production sites, many first response personnel incur Warning Network (DAWN) reported 15,933 mentions injury when dealing with the hazardous substances. of methamphetamine (see table 4). A drug mention The most common symptoms suffered by first respond- refers to a substance that was recorded (mentioned) ers when they raid meth labs are respiratory and eye during a drug-related visit to the emergency depart- irritations, headaches, dizziness, nausea, and shortness ment (ED). By 1999, the number of methamphetamine of breath. ED mentions decreased to 10,447. This number Meth labs can be portable and so are easily dismantled, increased to 17,696 in 2002. stored, or moved. This portability helps methampheta- In 2001, DAWN’s mortality data for methamphetamine mine manufacturers avoid law enforcement authorities. mentions to medical examiners remained concentrated Meth labs have been found in many different types of in the Midwest and West regions of the United States. locations, including apartments, hotel rooms, rented The metropolitan areas reporting the most metham- storage spaces, and trucks. Methamphetamine labs phetamine mentions were Phoenix (122), San Diego have been known to be boobytrapped and lab operators (94), and Las Vegas (53). The East Coast area that are often well armed. reported the highest number of methamphetamine According to DEA, in 2001 there were 12,715 meth- mentions was Long Island (49). Out of 42 metropolitan amphetamine laboratory incidents reported in 46 States. areas studied, 15 areas reported fewer than 5 metham- The West Coast accounted for most of the laboratory phetamine mentions. incidents. On the East Coast, the following States reported the highest incident rates: Georgia (51), North Treatment Carolina (31), and Florida (29). Nationally, the high- According to the Treatment Episode Data Set, during est rate of lab activity took place in Missouri, which 2000 methamphetamine treatment admissions account- reported 2,207 incidents. California and Washington ed for 4.1% of total admissions or 66,052 admissions. also had high incident rates with 1,847 and 1,477, Those admitted for methamphetamine/amphetamine respectively. were primarily white (79%) and male (53%). In 1994, there were half as many admissions for methampheta- Scheduling and Legislation mine, 33,432 or about 2% of all admissions for Methamphetamine is a Schedule II drug under the treatment. Controlled Substance Act of 1970. A Schedule II
4 Controlled Substance has high potential for abuse, is Pulse Check: Trends in Drug Abuse, November 2002. currently accepted for medical use in treatment in the www.whitehousedrugpolicy.gov/publications/drugfact/ United States, and may lead to severe psychological pulsechk/nov02 or physical dependence. U.S. Department of Health and Human Services: The chemicals that are used to produce methampheta- mine also are controlled under the Comprehensive Centers for Disease Control and Prevention Methamphetamine Control Act of 1996 (MCA). This legislation broadened the restrictions on listed chemi- Public Health Consequences Among First Responders to cals used in the production of methamphetamine, Emergency Events Associated With Illicit Metham- increased penalties for the trafficking and manufacturing phetamine Laboratories—Selected States, 1996Ð1999, of methamphetamine and listed chemicals, and November 2000. expanded the controls of products containing the www.cdc.gov/mmwr/preview/mmwrhtml/mm4945a1.htm licit chemicals ephedrine, pseudoephedrine, and Youth Risk Behavior Surveillance—United States, 2001, phenylpropanolamine (PPA). June 28, 2002. The Methamphetamine Anti-Proliferation Act was www.cdc.gov/mmwr/preview/mmwrhtml/ss5104a1.htm passed in July 2000. The act strengthens sentencing National Institute on Drug Abuse guidelines and provides training for Federal and State law enforcement officers on methamphetamine inves- Epidemiologic Trends in Drug Abuse Advance Report, tigations and the handling of the chemicals used in December 2002, January 2003. clandestine meth labs. It also puts in place controls on www.drugabuse.gov/about/organization/CEWG/ the distribution of the chemical ingredients used in AdvancedRep/1202adv/1202adv.html methamphetamine production and expands substance abuse prevention efforts. Monitoring the Future: 2002 Data From In-School Surveys of 8th, 10th, and 12th Grade Students, December 2002. Street Terms http://monitoringthefuture.org/data/ 02data.html#2002data-drugs
Street terms for methamphetamine Monitoring the Future: National Survey Results on Drug Use, 1975Ð2002, Volume II: College Students and Adults Blue meth Meth Ages 19Ð40, September 2003. Chicken feed OZs http://monitoringthefuture.org/pubs/monographs/ Cinnamon Peanut butter vol2_2002.pdf Crink Sketch Crystal meth Spoosh Research Reports: Methamphetamine Abuse and Addiction, Desocsins Stove top January 2002. Geep Super ice www.drugabuse.gov/ResearchReports/methamph/ Granulated orange Tick tick methamph.html Hot ice Trash Ice Wash Substance Abuse and Mental Health Services Kaksonjae Working man’s cocaine Administration L.A. glass Yellow barn Emergency Department Trends From the Drug Abuse Lemon drop Yellow powder Warning Network, Final Estimates 1995Ð2002, July 2003. http://dawninfo.samhsa.gov/pubs_94_02/edpubs/ 2002final/files/EDTrendFinal02AllText.pdf Sources Executive Office of the President: Mortality Data From the Drug Abuse Warning Network, 2001, January 2003. Office of National Drug Control Policy dawninfo.samhsa.gov/pubs_94_02/mepubs/files/ DAWN2001/DAWN2001.pdf Drug Policy Information Clearinghouse, Street Terms: Drugs and the Drug Trade, 2002. Results From the 2002 National Survey on Drug Use and www.whitehousedrugpolicy.gov/streetterms/default.asp Health: National Findings, September 2003. www.samhsa.gov/oas/nhsda/2k2nsduh/2k2sofw.pdf
5 Treatment Episode Data Set (TEDS) 1992Ð2000: National National Drug Intelligence Center (NDIC) Admissions to Substance Abuse Treatment Services, December 2002. National Drug Threat Assessment 2002, December 2001. www.samhsa.gov/oas/dasis.htm#teds2 www.usdoj.gov/ndic/pubs07/716/index.htm
U.S. Department of Justice: National Drug Threat Assessment 2003, January 2003. www.usdoj.gov/ndic/pubs3/3300/index.htm Drug Enforcement Administration Office of Justice Programs Congressional Testimony before the House Committee on Government Reform Subcommittee on Criminal Justice, Bureau of Justice Statistics, Compendium of Federal Justice Drug Policy and Human Resources, July 12, 2001. Statistics, 2001, November 2003. www.usdoj.gov/dea/pubs/cngrtest/ct071201.htm www.ojp.usdoj.gov/bjs/abstract/cfjs01.htm
Diversion Control Web Site, Provisions of the National Institute of Justice, Preliminary Data on Drug Use Comprehensive Methamphetamine Control Act of 1996. and Related Matters Among Adult Arrestees and Juvenile www.deadiversion.usdoj.gov/fed_regs/rules/2002/fr0328.htm Detainees, 2002, 2003. www.adam-nij.net/files/2002_Preliminary_Data.pdf Drug Descriptions: Methamphetamine & Amphetamines www.usdoj.gov/dea/concern/amphetamines.html Other Sources:
Drug Intelligence Brief: The Forms of Methamphetamine, Congressman Chris Cannon’s Web site, Cannon Announces April 2002. House Anti-Meth Bill (H.R. 2987), Press Release, www.usdoj.gov/dea/pubs/intel/02016 September 27, 1999. www.house.gov/cannon/meth_press.html Drugs of Abuse, February 2003. Methamphetamine Anti-Proliferation Act of 1999 Drug Trafficking in the United States. H.R. 2987. www.usdoj.gov/dea/concern/drug_trafficking.html www.house.gov/cannon/meth_text.html
Meth in America: Not in Our Town, 2002. U.S. Sentencing Commission, 2001 Sourcebook of Federal www.usdoj.gov/dea/pubs/pressrel/methmap.html Sentencing Statistics, 2002. www.ussc.gov/ANNRPT/2001/SBTOC01.htm
This fact sheet was prepared by Jennifer Lloyd of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849Ð6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
*NCJ~197534* New York State Department of Health AIDS Institute March 2006 Methamphetamine and HIV: Basic Facts for Service Providers
Methamphetamine use is a serious public health concern in New York State. New cases of HIV and other sexually transmitted diseases (STDs), particularly among gay men and other men who have sex with men (MSM), may be related to methamphetamine use. Other people are affected as well. Although methamphetamine does not directly cause new HIV infections, research has shown that people who use the drug are more likely to have high-risk sex that increases their chances of HIV and STD infection. HIV-positive methamphetamine users may also harm themsleves by not taking their medications on schedule and neglecting important aspects of their health. This fact sheet explains the physical and psychological effects of methamphetamine on users. It also details the short-term and long-term adverse effects of this dangerous, illegal drug.
What is methamphetamine and Short-term adverse effects include: how is it taken? • An increase in blood pressure, heart rate, and body temperature, sometimes to dangerous levels, which Methamphetamine — often called “crystal meth” — can lead to a heart attack or stroke. is a powerful drug that stimulates the central nervous • A “crash” period often occurs after several straight system and lasts for many hours. It generally comes days of using methamphetamine. When they crash, in a white powder or solid crystal-like chunks, but users have little energy and feel depressed and its color may vary. It can be snorted, swallowed, isolated. smoked, injected into a vein, or inserted into the rectum. Some people call injection “slamming.” Longer-range adverse effects include: The slang terms “booty bumping” and “keistering” • Intense craving for methamphetamine when not are used to describe inserting methamphetamine into taking it. Users are likely to develop tolerance for the rectum. Compared with other illegal drugs, it is the drug (more and more is needed to get high) rather inexpensive and provides a strong high that and become dependent on it or addicted to it. lasts 6 to 12 hours. It is fairly simple to manufacture, However, some people can use methamphetamine, but the process is dangerous because it involves even for long periods, and not become addicted. heating chemicals that can explode. • Deterioration of teeth and gums is common and What are the effects of methamphetamine? often severe. • Reduced appetite, weight loss, and poor eating Some of the desired effects include: habits can be harmful, especially to people with • A great boost in energy and mental focus that HIV or AIDS. allows users to work or play for long periods • Potentially serious damage to nerve cells in without getting tired. the brain. The person may need to stop using • A stronger sense of self-confidence and self-worth. the drug entirely for the brain to heal — but • Lower sexual inhibitions and increased sex drive. the damage may be permanent and cannot However, men who use methamphetamine may be reversed. be less able to get and keep an erection without • Impaired memory, reasoning, and ability to ® using erectile dysfunction drugs, such as Viagra process information. ® ® (sildenafil), Levitra (vardenafil), and Cialis • Psychological problems: depression, psychosis, (tadalafil). aggressive behavior, hallucinations, and paranoia. • Damage to the cardiovascular system, lungs, liver, muscles, and nerve cells; skin lesions. Continued on next page Methamphetamine and HIV (continued)
How does methamphetamine increase the they experience in everyday life. risk of transmitting HIV and other STDs? • HIV-positive gay men and MSM may be more • It lowers sexual inhibitions and affects personal vulnerable to using methamphetamine as a judgment, making users more likely to have way to deal with their illness and the stigma unprotected sex. of having HIV. • Users who cannot keep an erection may switch What are the specific risks of to receptive anal intercourse (“bottoming”), which can raise their risk of getting infected injection and rectal use? with HIV. Although methamphetamine can be swallowed, • Some methamphetamine users also take drugs smoked, or snorted, injection and rectal use carry to treat the erectile dysfunction (not able to get specific risks for disease transmission. or keep an erection) that results from using methamphetamine. This may lead to having • Injecting the drug into the bloodstream increases longer, more aggressive periods of sex, especially the risk of transmitting blood-borne infections — anal sex. When this occurs, condoms can break HIV, hepatitis B, and hepatitis C — if syringes and tears can occur in the skin of the penis, anus, and other drug injection equipment (“works”) and rectum, which can cause bleeding and are shared. Users can greatly lower the risk HIV transmission. The drug also causes skin of transmission by not sharing drug injection tissues to dry out and be more likely to tear. equipment. • Methamphetamine increases the likelihood of having unprotected sex. Its use is probably a • Inserting crystal meth into the rectum can damage factor in higher rates of new syphilis cases in this delicate tissue, making it more likely to tear the New York City area. and possibly transmit HIV by exchanging blood. How does methamphetamine affect Why do gay men/MSM use people who are HIV-positive? methamphetamine? Some research studies that used animals found that Like other users, many gay men and MSM use methamphetamine can damage the immune system. methamphetamine because it allows them to Other research also suggests that methamphetamine work longer and party longer. It lowers sexual quickens the progress of HIV-related dementia (loss inhibitions and gives them the energy, confidence, of mental function) in humans. and stimulation to engage in sexual activities for long periods of time — sometimes for hours or Methamphetamine is not known to have an effect on even days. They may engage in specific types of HIV medications. However, some protease inhibitors sex they would only have while under the influence (a type of anti-HIV medication) cause the body to of methamphetamine, especially unprotected anal absorb methamphetamine at a much faster rate — sex (“barebacking”). which may cause severe reactions or possible overdose. • Many methamphetamine users say the drug provides an escape from stress, depression, Methamphetamine can affect the health and well- alienation, and loneliness. being of HIV-positive persons in less direct ways. • Gay men and MSM may find the drug helps When users are high, they may forget to take their them cope with the homophobia and prejudice 2 Continued on next page Methamphetamine and HIV (continued)
HIV medications or lose their motivation to stay What types of help can people get to on their treatment schedule. This can lead to drug quit using methamphetamine? resistance (anti-HIV drugs fail to work properly); For some users, quitting methamphetamine is very users would then have fewer treatment options difficult, even with professional help. Many users and possibly develop AIDS more quickly. HIV- have withdrawal symptoms that include intense positive users also may not take proper care cravings, anxiety, depression, and possible psychosis. of their health, such as getting enough sleep Relapse is common. There is no specific medical and eating well. treatment for methamphetamine use. Treatment options include: What should service providers tell their clients about methamphetamine? • Supportive individual and group counseling sessions. Health care and supportive service providers • Cognitive behavioral therapy. should educate clients about the effects and risks of methamphetamine use and the advantages • Motivational interviewing. of prevention and harm reduction. Clients may • 12-step programs, including Crystal Meth or may not feel comfortable talking about their Anonymous in places where it is available. substance use at a particular time. Ask clients • Medical support to handle the symptoms of about their substance use — including their quitting methamphetamine use, including methamphetamine use — during intake. Try withdrawal and depression. to maintain an ongoing dialogue with clients about substance use during routine visits. Here How can service providers help prevent are suggested key messages for clients: or reduce methamphetamine use? Prevention messages for non-users Being on the front lines of HIV/AIDS counseling • Avoid or limit the use of methamphetamine. and treatment, service providers can help prevent or This may greatly improve your ability to reduce methamphetamine use by taking these steps: prevent HIV infection and live a healthy life with HIV. If you can’t stay within your • Monitor the specific impact of methamphetamine limits, it may be a sign you need help. on the communities you serve. • To prevent HIV infection, always use a latex • Include methamphetamine education and prevention condom correctly each time you have sex. in programs that target gay men, MSM, and • Avoid sharing syringes and other drug people who have HIV/AIDS. injection equipment. • Identify other populations in your community • Be aware that many people become addicted (college students, rural residents, etc.) that use to using methamphetamine. methamphetamine or who seem most vulnerable to the drug so they can receive education and Harm reduction messages for users services. • Share ideas and “best practices” with other service • Make a plan to protect yourself BEFORE providers for reducing methamphetamine use and using methamphetamine. HIV/STD transmission. • Have plenty of condoms and water-based • Learn about treatment providers in the community lubricant ready before having sex. who can help methamphetamine users and create • Try to eat some food, drink plenty of fluids, referral relationships with them. and get sleep while taking methamphetamine. Continued on next page 3 Methamphetamine and HIV (continued) Resources for information and client treatment
New York State Department of Health Callen-Lorde Community Health Center AIDS Institute www.callen-lorde.org For more information on methamphetamine and 212-271-7200 HIV, visit the New York State Department of Health Greenwich House website at: www. health.state.ny.us/diseases/aids www.greenwichhouse.org harm_reduction/crystalmeth/index.htm. The site 212-242-4140 also has a methamphetamine-related literature base. Addiction Institute of New York (formerly Smithers) For information on treatment programs: www.addictionresourcesguide.com/listings/ addictioninstitute.html New York State Office of Substance Abuse 212-523-6491 Services (OASAS) Electronic Methamphetamine LIFENET Clearinghouse 1-800-LIFENET (New York City only) www.oasas.state.ny.us/meth/index.htm 1-800-522-5353 How to get new syringes and dispose LIFENET 1-800-LIFENET (New York City only) of used ones The New York State Expanded Syringe Access For counseling and treatment: Demonstration Program (ESAP) allows drug stores to sell new syringes to persons aged 18 Crystal Meth Anonymous years or older without a prescription. You can www.crystalmeth.org also go to Syringe Exchange Programs to trade New York City Crystal Meth Anonymous in a used syringe for a new one. To find ESAP www.nycma.org drug stores, Syringe Exchange Programs, or 212-642-5029 disposal sites for used syringes, call: Gay Men’s Health Crisis (GMHC) 1-800-541-AIDS (English) or 1-800-233-SIDA www.gmhc.org (Spanish). These are toll-free calls within New 1-800-AIDS-NYC (1-800-243-7692) York State. The Lesbian, Gay, Bisexual, and Transgender Community Center For more information, visit the New York State www.gaycenter.org Department of Health website: 212-620-7310 www.nyhealth/diseases/aids/harm_reduction/ needles_syringes/index.htm.
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John P. Walters, Director
MDMA (Ecstasy)
Background nausea, blurred vision, feeling faint, tremors, rapid eye The designer drug MDMA (3,4-methylenedioxymeth- movement, and sweating or chills. Because of MDMA’s amphetamine) or “ecstasy” is a synthetic drug with ability to increase heart rate and blood pressure, an extra both psychedelic and stimulant effects. In the past, risk is involved with MDMA ingestion for people with some therapists in the United States used the drug to circulatory problems or heart disease. facilitate psychotherapy. In 1988, however, MDMA Rave party attendees who ingest MDMA are at risk of became a Schedule I substance under the Controlled dehydration, hyperthermia, and heart or kidney failure. Substances Act. These risks are due to a combination of the drug’s In response to the Ecstasy Anti-Proliferation Act of stimulant effect, which allows the user to dance for 2000, the U.S. Sentencing Commission increased the long periods of time, and the hot, crowded atmosphere guideline sentences for trafficking ecstasy. The new of rave parties. The combination of crowded all-night amendment, which became effective in May 2001 on an dance parties and MDMA use has been reported to emergency basis, increases the sentence for trafficking cause fatalities. 800 pills (approximately 200 grams) of ecstasy by Research shows that MDMA causes damage to the 300%, from 15 months to 5 years. It also increases the parts of the brain that are critical to thought and penalty for trafficking 8,000 pills by almost 200%, memory. MDMA increases the activity levels of neu- from 41 months to 10 years. This new increase will rotransmitters such as serotonin, dopamine, and nor- affect the upper middle-level distributors. The amend- epinephrine. The drug causes the release of the ment became permanent on November 1, 2001. neurotransmitters from their storage sites, which Currently, MDMA is predominantly a “club drug” and increases brain activity. By releasing large amounts of is commonly used at all-night dance parties known as the neurotransmitters and also interfering with neuro- “raves.” However, recent research indicates that the use transmitter synthesis, MDMA causes a significant of MDMA is moving to settings other than nightclubs, depletion in the neurotransmitters. It takes the brain a such as private homes, high schools, college dorms, significant length of time to rebuild the amount of and shopping malls. serotonin and other neurotransmitters needed to per- form important functions.
Effects In addition to the dangers associated with MDMA it- MDMA is a stimulant whose psychedelic effects can self, users are also at risk of being given a substitute last between 4 and 6 hours and it is usually taken orally drug. For example, PMA (paramethoxyamphetamine) in pill form. The psychological effects of MDMA is an illicit, synthetic hallucinogen that has stimulant include confusion, depression, anxiety, sleeplessness, effects similar to MDMA. However, when users take drug craving, and paranoia. Adverse physical effects PMA believing they are ingesting MDMA, they often include muscle tension, involuntary teeth clenching, think they have taken weak ecstasy because PMA’s
NCJ 201387 effects take longer to appear. They then ingest more of 3% among 10th graders and 4.5% among 12th graders the substance to attain a better high, which can result (see table 2). in death by overdose. Data on MDMA use by college students and young Adulterants may be added to ecstasy without the user’s adults from 19 to 28 years old is also captured in the knowledge, resulting in additional danger to the user. Monitoring the Future Study. In 2002, 12.7% of col- According to the November 2002 Pulse Check report, lege students and 14.6% of young adults reported hav- ecstasy adulterants in Memphis included mescaline ing used MDMA at least once. Approximately 6.8% of and methamphetamine, while in Los Angeles adulter- college students and 6.2% of young adults reported ants included codeine, dextromethorphan (DXM), and past year MDMA use (see table 2). PMA.
In 1995, hospitals participating in the Drug Abuse Ta b le 2. Percentage of students and young adults Warning Network (DAWN) reported 421 mentions of reporting past year MDMA use, 1996–2003 MDMA. These mentions document the number of 8th 10th 12th College Young times a reference to MDMA was made during a drug- Year Grade Grade Grade Students Adults related emergency department (ED) visit. The number 1996 2.3% 4.6% 4.6% 2.8% 1.7% of ED MDMA mentions reported in 2002 reached 1997 2.3 3.9 4.0 2.4 2.1 4,026 out of more than 1 million total drug mentions. 1998 1.8 3.3 3.6 3.9 2.9 During 2002, approximately 75% of the ED MDMA 1999 1.7 4.4 5.6 5.5 3.6 mentions were attributed to ED patients age 25 and 2000 3.1 5.4 8.2 9.1 7.2 under. The primary reason for going to the ED after 2001 3.5 6.2 9.2 9.2 7.5 using MDMA was “unexpected reaction,” cited in 2002 2.9 4.9 7.4 6.8 6.2 1,578 of the ED visits involving MDMA. Another 2003 2.1 3.0 4.5 NA NA 1,215 MDMA-related ED visits were the result of an NA: Not available. overdose. Source: Monitoring the Future Study.
Prevalence Estimates The number of new MDMA users has risen since The Monitoring the Future Study also measures per- 1993, when there were 168,000 initiates. By 2001, the ceived harmfulness and disapproval of use by students. number of MDMA initiates reached 1.8 million. The The 2003 study found that 41.9% of 8th graders, National Survey on Drug Use and Health found that 49.7% of 10th graders, and 56.3% of 12th graders 15.1% of 18- to 25-year-olds surveyed in 2002 had thought that trying MDMA once or twice was a great used MDMA at least once in their lifetime (see table risk. This is up from 38.9%, 43.5%, and 52.2%, 1). There were 676,000 current MDMA users in 2002, respectively, in 2002. Approximately 22% of 8th meaning that they had used the drug within the month graders, 36% of 10th graders, and 58% of 12th graders before being surveyed. surveyed in 2003 felt that MDMA was “fairly easy” or “very easy” to obtain.
Ta b le 1. MDMA use among U.S. population, 2002 Ecstasy was emerging, or was continuing to emerge, as a drug of abuse in all but five Pulse Check sites in Age Group Lifetime Past Year Past Month 2002: Detroit, Miami, New Orleans, New York City, 12–17 3.3% 2.2% 0.5% and Portland, Maine. In these five sites, ecstasy has 18–25 15.1 5.8 1.1 either leveled off or is now considered an established 26 and older 2.6 0.5 0.1 drug of abuse. In 25 of the 40 Pulse Check sites, ecsta- Total population 4.3 1.3 0.3 sy is considered widely available by enforcement and epidemiologic/ethnographic sources. Source: National Survey on Drug Use and Health. Most ED visits involving club drugs also involve other drugs. In 2002, other drugs were found in 72% of the The University of Michigan’s Monitoring the Future ED visits involving MDMA. Ecstasy continues to Study found that MDMA use among high school stu- be taken with alcohol or marijuana, or both. It is also dents declined from 2002 to 2003. Among 10th and sometimes taken in combination or sequentially with 12th graders surveyed in 1996, annual prevalence of various other legal and illegal drugs including LSD, MDMA use (use in the past year) was 4.6% in both GHB, ketamine, heroin, prescription pills (benzodi- grades. By 2003, annual prevalence had decreased to azepines or antidepressants), cough syrup, Viagra, and nitrous oxide.
2 Raves in their efforts to prevent chemical diversion. The MDMA is often found at nightclubs and raves. Raves United States and other governments use the annual first appeared in the United States in the late 1980s in meetings of the United Nations Commission on cities such as San Francisco and Los Angeles. By the Narcotic Drugs to promote international acceptance early 1990s, rave parties and clubs were present in of chemical control and to highlight emerging chemi- most American metropolitan areas. cal control concerns. During 1999, the International Criminal Police Organization (Interpol) reported sever- Raves are characterized by high entrance fees, exten- al seizures of precursor chemicals in areas such as sive drug use, and overcrowded dance floors. Club Spain, the Slovak Republic, and the Netherlands. owners often seem to promote the use of MDMA at their clubs. They sell overpriced bottled water and The majority of the MDMA produced in other coun- sports drinks to try to manage the hyperthermia and tries is trafficked to the United States by Israeli and dehydration effects of MDMA use; pacifiers to prevent Russian organized crime syndicates that have forged involuntary teeth clenching; and menthol nasal inhalers relationships with Western European drug traffickers and neon glowsticks to enhance some of the other and gained control over most of the European market. effects of MDMA. These groups recruit American, Israeli, and Western European nationals as couriers. In addition, traffickers Raves often are promoted as alcohol-free events, which use express mail services, commercial flights, and air- gives parents a false sense of security that their chil- freight shipments to deliver their merchandise. All dren will be safe attending these parties. In reality, major airports in Europe act as shipping points for raves may be havens for the illicit sale and abuse MDMA destined for the United States. Currently, Los of club drugs. Angeles, Miami, and New York are the major gateway cities for the influx of MDMA from abroad. Cities and communities throughout the United States have attempted to reduce the number of raves in their According to DEA data, the national wholesale price areas and to curb the use of club drugs in these raves. range for MDMA tablets was $5 to $17 per dosage Several cities have passed new ordinances designed to unit during 2001. The national retail price range during regulate rave activity. Other cities have reduced rave the year was $10 to $60 per tablet. activity through enforcement of juvenile curfews, fire codes, health and safety ordinances, liquor laws, and Domestically, DEA seized 196 MDMA tablets in 1993, licensing requirements for large public gatherings. 174,278 tablets in 1998, more than 1 million in 1999, more than 3 million in 2000, and more than 5.5 million Production,Trafficking, and in 2001. The U.S. Customs Service (USCS), now part of U.S. Customs and Border Protection, also reported a Enforcement large increase in the number of MDMA tablets seized. MDMA is most often manufactured clandestinely in USCS seized approximately 3.5 million MDMA Western Europe, primarily in Belgium and the Nether- tablets in 1999 and 9.3 million tablets in 2000. lands. These countries produce 80% of the MDMA consumed worldwide. This is primarily because of the According to Interpol, more than 14.1 million MDMA availability of precursor and essential chemicals and tablets were seized in Europe during 1999. This is international transportation hubs in this area of the nearly triple the amount seized in 1998 (5 million world. tablets). During the first half of 2000, more than 8.4 million MDMA tablets were seized in Europe. In 1999, In the United States, the Drug Enforcement Admin- global MDMA seizures totaled approximately 22 mil- istration’s (DEA’s) Chemical Control Program is work- lion tablets, up from 5.6 million in 1998. ing to disrupt the production of MDMA and other controlled substances by preventing the diversion of Prevention and Enforcement Initiatives the precursor chemicals used to produce these sub- In recent years, some initiatives have been developed stances. DEA registration, recordkeeping, and suspi- to curb the use of MDMA and other club drugs. In cious order reporting requirements apply to those who 1999, the National Institute on Drug Abuse (NIDA) import, export, manufacture, and distribute the chemi- and its partners (American Academy of Child and cals being monitored by DEA. Adolescent Psychiatry, Community Anti-Drug The United States works with other countries to pre- Coalitions of America, Join Together, and National vent the diversion of precursor chemicals. As a result Families in Action) launched a national research and of the 1988 United Nations Drug Convention, parties education initiative, “Club Drugs: Raves, Risks, and to the convention became obligated to control their Research,” to combat the increased use of club drugs. chemical commerce and to cooperate with each other Through this initiative, NIDA increased funding for
3 club drug research and launched a multimedia public Sources education strategy to alert teens, young adults, parents, Executive Office of the President: educators, and others about the dangers associated with MDMA and other club drugs. Office of National Drug Control Policy
In February 2002, the Partnership for a Drug-Free Pulse Check: Trends in Drug Abuse, November 2002. America (PDFA) launched a national MDMA educa- www.whitehousedrugpolicy.gov/publications/drugfact/ tion campaign. The campaign consists of television and pulsechk/nov02 print advertising and an MDMA microsite found with- in PDFA’s Web site. The campaign is aimed at teens Drug Policy Information Clearinghouse, Street Terms: Drugs and their parents. and the Drug Trade, 2004. www.whitehousedrugpolicy.gov/streetterms/default.asp In 2002, DEA began Operation X-Out, a multifaceted, year-long initiative that focuses on identifying and dis- National Institutes of Health: mantling organizations that produce and distribute MDMA and similar drugs in the United States and National Institute on Drug Abuse abroad. Some results of Operation X-Out include increasing the number of DEA investigations involving “Club Drugs Take Center Stage in New National Education MDMA and other club drugs, enhancing airport inter- and Prevention Initiative by NIDA and National diction task forces, creating new task forces in cities Partners,” December 2, 1999. such as Miami and New York, creating a task force on www.drugabuse.gov/MedAdv/99/NR-122.html Internet drug trafficking, and expanding cooperation Ecstasy: What We Know and Don’t Know About MDMA with international law enforcement. www.drugabuse.gov/PDF/MDMAConf.pdf Street Terms Monitoring the Future 2003 Data From In-School Surveys of 8th-, 10th-, and 12th-Grade Students, December 2003. Street terms for MDMA http://monitoringthefuture.org/data/ 03data.html#2003data-drugs Adam Ecstasy Morning shot B-bombs E Pollutants Monitoring the Future: National Survey Results on Drug Bens Essence Scooby snacks Use, 1975–2002, Volume II: College Students & Adults Clarity Eve Speed for lovers Ages 19–40, 2003b. Cristal Go Sweeties http://monitoringthefuture.org/pubs/monographs/ Decadence Hug drug Wheels vol2_2002.pdf Dex Iboga X U.S. Department of Health and Human Services: Disco biscuit Love drug XTC Substance Abuse and Mental Health Services Administration Conclusion The synthetic drug MDMA is commonly found at rave The DAWN Report: Club Drugs, 2001 Update, October parties, nightclubs, and, more recently, other settings 2002. such as schools, malls, and private homes that are www.samhsa.gov/oas/2k2/DAWN/clubdrugs2k1.pdf frequented by youth and young adults. The damaging Emergency Department Trends From the Drug Abuse effects of the drug can be long lasting and are possible Warning Network: Final Estimates 1995–2002, July 2003. after only a small number of uses. The trafficking of http://dawninfo.samhsa.gov/pubs_94_02/edpubs/2002final/ MDMA is increasing at an alarming rate, and multiple files/EDTrendFinal02AllText.pdf agencies have reported large seizures of the drug. Results From the 2002 National Survey on Drug Use and Health: National Findings, September 2003. www.samhsa.gov/oas/nhsda/2k2nsduh/2k2SoFW.pdf
4 U.S. Department of Homeland Security: National Drug Intelligence Center
Customs and Border Protection Raves, Information Bulletin, April 2001. www.usdoj.gov/ndic/pubs/656/656p.pdf Ecstasy News www.cbp.gov/xp/cgov/newsroom/highlights/ U.S. Department of State: ecstasy_news.xml International Narcotics Control Strategy Report, 2002, U.S. Department of Justice: March 2003. www.state.gov/g/inl/rls/nrcrpt/2002/html Drug Enforcement Administration U.S. Sentencing Commission: Drug Intelligence Brief. Club Drugs: An Update, September 2001. MDMA Drug Offenses: Explanation of Recent Guideline www.dea.gov/pubs/intel/01026/index.html Amendments, May 2001. www.ussc.gov/r_congress/mdma_final2.PDF Drugs of Abuse, February 2003. “Sentencing Commission Increases Penalties for High- Drug Trafficking in the United States, September 2001. Dollar Fraud Offenders, Sexual Predators, and Ecstasy www.dea.gov/pubs/intel/01020/index.html Traffickers,” April 16, 2001. www.ussc.gov/PRESS/rel0401.htm Ecstasy and Predatory Drugs, February 2003. www.dea.gov/pubs/ecstasy/predatory_drugs-4.pdf “Statement of Diana E. Murphy, Chair of the United States Sentencing Commission, Before the Senate Caucus on Ecstasy: Rolling Across Europe, August 2001. International Narcotics Control,” March 21, 2001. www.dea.gov/pubs/intel/01008/index.html www.ussc.gov/testimony/ecstasytestimony2.pdf The Hallucinogen PMA: Dancing With Death, October Other Source: 2000. www.dea.gov/pubs/intel/20025intellbrief.pdf Partnership for a Drug-Free America
Illegal Drug Price and Purity Report, April 2003. “National Survey: Ecstasy Use Continues Rising Among www.dea.gov/pubs/intel/02058/02058.pdf Teens,” February 11, 2002. Office of Diversion Control, Chemical Control Program www.drugfreeamerica.org Web site. www.deadiversion.usdoj.gov/chem_prog/index.html
This fact sheet was prepared by Michele Spiess of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849–6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
5 Executive Office of the President Office of National Drug Control Policy
OONDCPNDCP November 2002 Drug Policy Information Clearinghouse FACT SHEET John P. Walters, Director www.whitehousedrugpolicy.gov 1-800-666-3332
Gamma Hydroxybutyrate (GHB)
Background liquid packaged in vials or small bottles. In liquid form, Gamma hydroxybutyrate (GHB) is a powerful, rapidly it is clear, odorless, tasteless, and almost undetectable acting central nervous system depressant. It was first when mixed in a drink. GHB is typically consumed by synthesized in the 1920s and was under development as the capful or teaspoonful at a cost of $5 to $10 per dose. an anesthetic agent in the 1960s. GHB is produced nat- The average dose is 1 to 5 grams and takes effect in 15 urally by the body in small amounts but its physiologi- to 30 minutes, depending on the dosage and purity of cal function is unclear. the drug. Its effects last from 3 to 6 hours.
GHB was sold in health food stores as a performance- Consumption of less than 1 gram of GHB acts as a enhancing additive in bodybuilding formulas until the relaxant, causing a loss of muscle tone and reduced Food and Drug Administration (FDA) banned it in inhibitions. Consumption of 1 to 2 grams causes a 1990. It is currently marketed in some European coun- strong feeling of relaxation and slows the heart rate tries as an adjunct to anesthesia. GHB is abused for its and respiration. At this dosage level, GHB also inter- ability to produce euphoric and hallucinogenic states feres with blood circulation, motor coordination, and and for its alleged function as a growth hormone that balance. In stronger doses, 2 to 4 grams, pronounced releases agents to stimulate muscle growth. GHB interference with motor and speech control occurs. A became a Schedule I Controlled Substance in March coma-like sleep may be induced, requiring intubation 2000. to wake the user. When mixed with alcohol, the depressant effects of GHB are enhanced. This can In the United States, GHB is produced in clandestine lead to respiratory depression, unconsciousness, laboratories with no guarantee of quality or purity, coma, and overdose. making its effects less predictable and more difficult to diagnose. GHB can be manufactured with inex- Side effects associated with GHB may include nausea, pensive ingredients and using recipes on the Internet. vomiting, delusions, depression, vertigo, hallucinations, Gamma butyrolactone (GBL) and 1,4-butanediol are seizures, respiratory distress, loss of consciousness, analogs of GHB that can be substituted for it. Once slowed heart rate, lowered blood pressure, amnesia, and ingested, these analogs convert to GHB and produce coma. GHB can become addictive with sustained use. identical effects. GBL, an industrial solvent, is used as Patients with a history of around-the-clock use of GHB an immediate precursor in the clandestine production of (every 2 to 4 hours) exhibit withdrawal symptoms GHB. The FDA has issued warnings for both GBL and including anxiety, insomnia, tremors, and episodes of 1,4-butanediol, stating that the drugs have a potential for tachycardia (abnormally fast heart rates), and may abuse and are a public health danger. progress to delirium and agitation. Because GHB has a short duration of action and quickly leaves the user’s Effects system, withdrawal symptoms may occur within 1 to 6 GHB is usually taken orally. It is sold as a light-colored hours of the last dose. These symptoms may last for powder that easily dissolves in liquids or as a pure many months.
NCJ 194881 According to the Drug Abuse Warning Network In 2000, according to the National Drug Intelligence (DAWN), GHB emergency department (ED) mentions Center (NDIC), GHB availability was stable or increas- have increased from 56 in 1994 to 3,340 in 2001 (see ing in nearly every DEA Field Division and High In- table). tensity Drug Trafficking Area. Many areas reported that the increased availability of GHB occurred in concert with a rise in rave activity. Law enforcement also Estimated number of emergency department GHB mentions, 1994–2001 reported increases in the number of cases involving GHB analogs. 1994 1995 1996 1997 1998 1999 2000 2001 56 145 638 762 1,282 3,178 4,969 3,340 According to Pulse Check: Trends in Drug Abuse, GHB users and sellers tend to be between the ages of 18 and Source: Drug Abuse Warning Network. 30. Most users are middle-class white males. GHB is typically packaged in plastic bottles (mostly water or sports drink bottles) and distributed by the capful for GHB-related deaths have occurred in several Com- $5Ð$20 per dose. Additional packaging includes eye- munity Epidemiology Work Group (CEWG) sites. In dropper bottles, glass vials, and mouthwash bottles. 1999, there were three reported deaths involving GHB in Texas and two in Minnesota. Missouri has reported five GHB-related deaths and two near deaths in which Drug-Facilitated Rape GHB was used to facilitate rapes. In Florida, during Drug-facilitated rape is defined as sexual assault made 2000, GHB was detected in 23 deaths and identified easier by the offender’s use of an anesthetic-type drug as the cause of death in 6 cases. Since 1990, the U.S. that renders the victim physically incapacitated or help- Drug Enforcement Administration (DEA) has docu- less and unable to consent to sexual activity. Whether mented more than 15,600 overdoses and law enforce- the victim is unwittingly administered the drug or ment encounters and 72 deaths relating to GHB. willingly ingests it for recreational use is irrelevant— the person is victimized because of their inability to Prevalence Estimates consciously consent to sexual acts. GHB is often ingested with alcohol by young adults and According to NDIC, GHB has surpassed Rohypnol teens at nightclubs and parties. It is used as a pleasure (flunitrazepam) as the most common substance used in enhancer that depresses the central nervous system and drug-facilitated sexual assaults. GHB can mentally and induces intoxication. It also can be used as a sedative to physically paralyze an individual, and these effects are reduce the effects of stimulants (cocaine, methampheta- intensified when the drug is combined with alcohol. To mine, ephedrine) or hallucinogens (LSD, mescaline) date, DEA has documented 15 sexual assaults involving and to prevent physical withdrawal symptoms. 30 victims who were under the influence of GHB. Of the 711 drug-positive urinalysis samples submitted from Since 2000, GHB has been included in the University victims of alleged sexual assault, 48 tested positive for of Michigan’s Monitoring the Future Survey question- GHB. naire. Survey results indicate that annual GHB use by secondary school students in 2000 ranged from 1.1% It is difficult to estimate the incidence of drug-facilitated among 10th graders to 1.2% among 8th graders and rape involving GHB. Victims may not seek help until 1.9% among 12th graders. In 2001, estimates of annual days after the assault, in part because the drug impairs GHB use ranged from 1.0% among 10th graders to their memory and in part because they may not identify 1.1% among 8th graders and 1.6% among 12th graders. signs of sexual assault. GHB is only detectable in a person’s system for a limited amount of time and, if the Regional Observations victim does not seek immediate help, the opportunity to According to CEWG, as of 2001, 15 CEWG areas detect the drug can quickly pass. Also, law enforce- reported increases in GHB indicators. They were ment agencies may not be trained to gather necessary Boston, Chicago, Dallas/Houston, Denver, Los evidence and may not be using equipment that is sensi- Angeles, Miami, Minneapolis/St. Paul, Newark, New tive enough to test for the drug. York, Philadelphia, Phoenix, St. Louis, San Diego, San Francisco, and Seattle. Atlanta, Baltimore, and Scheduling and Legislation Washington, D.C., reported stable GHB indicators. In response to the use of drugs in sexual assaults, Con- Only two CEWG sites, Detroit and New Orleans, gress passed the Drug-Induced Rape Prevention and reported declines in GHB indicators. Most CEWG Punishment Act of 1996 to combat drug-facilitated areas report that GHB is frequently used in combina- crimes of violence, including sexual assaults. The act tion with alcohol, causing users to overdose.
2 imposes harsh penalties for distribution of a controlled Resources substance to an individual without the individual’s ClubDrugs.org. National Institute on Drug Abuse. knowledge and consent with intent to commit a crime www.clubdrugs.org of violence, including rape. Club Drugs. INFOFAX, National Institute on Drug Abuse. On February 18, 2000, the Hillory J. Farias and www.nida.nih.gov/Infofax/Clubdrugs.html Samantha Reid Date-Rape Prevention Act of 2000 (Public Law 106-72) became law. It made GBL a List I GHB Analogs: GBL, BD, GHV, and GVL. National Drug chemical subject to the criminal, civil, and administra- Intelligence Center, August 2002. tive sanctions of the Federal Controlled Substances www.usdoj.gov/ndic/pubs/1621/1621p.pdf Act of 1970. As a result of the law, GHB became a Schedule I Controlled Substance. A Schedule I drug has The Prosecution of Rohypnol and GHB Related Sexual a high potential for abuse, is not currently accepted for Assaults. American Prosecutors Research Institute, 1999. medical use in treatment in the United States, and lacks www.ndaa.org/publications.apri/violence_against_ accepted safety for use under medical supervision. women.html
On March 20, 2001, the Commission on Narcotic Drugs Rapists Are Using a New Weapon to Overpower Their placed GHB in Schedule IV of the 1971 Convention Victims. Santa Monica Hospital Medical Center, Rape of Psychotropic Substances. This placement affects Treatment Center, 1997. international drug control laws with which countries www.911rape.org/request/blowouts/brochure.html that are a part of the convention must comply. Schedule IV mandates international requirements on Sources licensing for manufacture, trade, and distribution of the Executive Office of the President: drug. It also requires parties to comply with prohibition of and restrictions on export and import of the drug and Office of National Drug Control Policy to adopt measures for the repression of acts contrary to these laws and regulations. Pulse Check: Trends in Drug Abuse, April 2002, NCJ 193398. On July 17, 2002, Xyrem, a drug with an active ingredi- www.whitehousedrugpolicy.gov/publications/drugfact/ ent of sodium oxybate or GHB, was approved by the pulsechk/2001/index.html FDA to treat cataplexy attacks in patients with nar- colepsy. Cataplexy is a condition characterized by weak Street Terms: Drugs and the Drug Trade. or paralyzed muscles. Xyrem, when used as medically www.whitehousedrugpolicy.gov/streetterms/default.asp prescribed, is a Schedule III Controlled Substance. A Schedule III Controlled Substance has less potential for U.S. Department of Health and Human Services: abuse than Schedule I and II categories, is currently accepted for medical use in treatment in the United National Institute on Drug Abuse States, and may lead to moderate or low physical dependence. Illicit use of Xyrem is subject to Schedule Epidemiologic Trends in Drug Abuse, Volume I: Highlights I penalties. and Executive Summary, June 2001, Community Epidemiology Work Group. Street Terms www.drugabuse.gov/PDF/CEWG/EXSUMJune01.pdf
Street terms for GHB Epidemiologic Trends in Drug Abuse, Volume I: Highlights and Executive Summary, December 2001, Community Cherry Meth Liquid X Epidemiology Work Group. Fantasy Organic quaalude www.drugabuse.gov/PDF/CEWG/EXSUMDec01.pdf GBH Salty water Georgia home boy Scoop Monitoring the Future: National Results on Adolescent Great hormones at bedtime Sleep-500 Drug Use, Overview of Key Findings, 2001, 2002. Grievous bodily harm Soap monitoringthefuture.org/pubs/monographs/ Liquid E Somatomaz overview2001.pdf Liquid Ecstasy Vita-G Substance Abuse and Mental Health Services Administration
“Detailed Emergency Department Tables From the Drug Abuse Warning Network, 2001,” Emergency Department
3 Trends From the Drug Abuse Warning Network, Final National Institute of Justice Estimates 1994Ð2001. www.samhsa.gov/oas/DAWN/DetEDAnnual/2001/Text/ “Drug-Facilitated Rape: Looking for the Missing Pieces,” DetEDtext.pdf NIJ Journal, April 2000. www.ncjrs.org/pdfflies1/jr000243c.pdf U.S. Department of Justice: Office of Justice Programs, National Criminal Justice Drug Enforcement Administration Reference Service
Diversion Control Program, Drugs and Chemicals of In the Spotlight: Club Drugs. Concern: Gamma Hydroxybutyric Acid. www.ncjrs.org/club_drugs/club_drugs.html www.deadiversions.usdoj.gov/drugs-concern/ghb/ summary.html U.S. Food and Drug Administration:
Gamma Hydroxybutyric Acid (GHB, Liquid X, Goop, FDA Talk Paper, “FDA Approves Xyrem for Cataplexy Georgia Home Boy), November 27, 2000. Attacks in Patients With Narcolepsy,” July 17, 2002. www.fda.gov/bbs/topics/ANSWERS/2002/ANS01157.html Gamma Hydroxybutyric Acid. www.usdoj.gov/dea/concern/ghb.html Other Source:
National Drug Intelligence Center Texas Department of Health, Texas Commission on Alcohol and Drug Abuse, GHB Withdrawal Syndrome, National Drug Threat Assessment 2002, December 2001. March 2001. www.usdoj.gov/ndic/pubs/716/index.htm www.tcada.state.tx.us/research/ghb_withdrawal.pdf
This fact sheet was prepared by Jennifer Lloyd of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849Ð6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
*NCJ~194881* 4
Executive Office of the President Office of National Drug Control Policy
ONDCPONDCP February 2003 Drug Policy Information Clearinghouse FACT SHEET John P. Walters, Director www.whitehousedrugpolicy.gov 1–800–666–3332
Rohypnol
Background Information Under Rohypnol, individuals may experience a slowing Rohypnol is the trade name for the drug flunitrazepam, of psychomotor performance, muscle relaxation, de- a benzodiazepine (central nervous system depressant) creased blood pressure, sleepiness, and/or amnesia. like Valium, yet 10 times more potent. Outside the Some of the adverse side effects associated with the United States, Rohypnol is legally manufactured by drug’s use are drowsiness, headaches, memory impair- Hoffman-LaRoche, Inc., and is available by prescrip- ment, dizziness, nightmares, confusion, and tremors. tion for the short-term treatment of severe sleep disor- Although classified as a depressant, Rohypnol can ders. It is widely available in Europe, Mexico, and induce aggression and/or excitability. Colombia, but is neither manufactured nor approved for sale in the United States. Prevalence Estimates Rohypnol is popular with youth because of its low cost, Illicit use of Rohypnol began in the 1970s in Europe which is usually less than $5 per tablet. It has been and appeared in the United States in the early 1990s. used throughout the United States by high school and Much of the concern surrounding Rohypnol is its abuse college students, street gang members, rave and night- as a “date rape” drug. Rohypnol is a tasteless and odor- club attendees, drug addicts, and alcohol abusers. less drug and, until recent manufacturer efforts, dis- Rohypnol is used in combination with alcohol, mari- solved clear in liquid, which masked its presence. juana, cocaine, heroin, ecstasy, and LSD. The predom- Rohypnol comes in pill form and is usually sold in the inant user age group is 13- to 30-years-old and users manufacturer’s bubble packaging, which can mislead tend to be male. users in the United States into believing the drug is safe and legal. Since February 1999, reformulated A questionnaire about Rohypnol use was included in Rohypnol tablets, which turn blue in a drink to increase the Monitoring the Future Survey for the first time in visibility, have been approved and marketed in 20 1996. Lifetime Rohypnol use by secondary school stu- countries. The old noncolored tablets are still available, dents in 1996 ranged from 1.5% among 8th and 10th however. In response to the reformulated blue tablets, graders to 1.2% among 12th graders (table 1). Current people who intend to commit a sexual assault facilitat- estimates of lifetime Rohypnol use range from 1.1% ed by Rohypnol are now serving blue tropical drinks among 8th graders, to 1.5% among 10th graders, to and punches in which the blue dye can be disguised. 1.7% among 12th graders.
Effects Availability,Trafficking, and Seizures Rohypnol can be ingested orally, snorted, or injected. It Because Rohypnol is not manufactured nor approved is often combined with alcohol or used as a remedy for for medical use in the United States, distributors must the depression that follows a stimulant high. The effects obtain their supply from other countries. Colombian of Rohypnol begin within 15 to 20 minutes of adminis- traffickers ship Rohypnol to the United States via mail tration and, depending on the amount ingested, may services and/or couriers using commercial airlines. persist for more than 12 hours. The drug’s metabolic properties are detectable in urine for up to 72 hours after ingestion. NCJ 193976
report that the drug is widely available. The remaining Table 1: Rohypnol use by secondary school students, 1996–2001 Pulse Check sites report it as somewhat, not very, or not at all available. 1996 1997 1998 1999 2000 2001 8th grade In El Paso, speedball (a combination of heroin and Lifetime 1.5 1.1 1.4 1.3 1.0 1.1 cocaine) users often use Rohypnol to “soften the fall Annual 1.0 0.8 0.8 0.5 0.5 0.7 when coming down.” El Paso treatment centers also 30-Day 0.5 0.3 0.4 0.3 0.3 0.4 report clients using “roche,” which is presumed to be 10th grade Rohypnol smuggled in from Mexico. Lifetime 1.5 1.7 2.0 1.8 1.3 1.5 Annual 1.1 1.3 1.2 1.0 0.8 1.0 30-Day 0.5 0.5 0.4 0.5 0.4 0.2 According to the Community Epidemiology Work 12th grade Group (CEWG), reports of Rohypnol use have been Lifetime 1.2 1.8 3.0 2.0 1.5 1.7 declining since recent legislation and its use is very low Annual 1.1 1.2 1.4 1.0 0.8 0.9 or nonexistent in the majority of CEWG areas. Cities 30-Day 0.5 0.3 0.3 0.3 0.4 0.3 that are exceptions to this decline in use include Atlanta Source: Monitoring the Future, 2001 and New Orleans. Poison control calls involving Rohyp- nol in combination with other drugs have increased in Atlanta where Rohypnol sells for $5 to $10 per pill. In Distributors also travel to Mexico to obtain supplies New Orleans, Rohypnol is common in nightclubs and of the drug and smuggle it into the United States. private rave parties. In the late 1980s, Rohypnol abuse and distribution were Texas has experienced increases in poison control calls occasionally reported in Florida and in the border areas and treatment admissions for Rohypnol, especially of Arizona, California, and Texas. Beginning around among Hispanic youth close to the Mexican border. In 1993, the abuse and distribution of Rohypnol began to the first quarter of 2000, DEA reported increases in spread, with the vast majority of Rohypnol-related law Rohypnol seizures in Laredo, Beaumont, and Austin. enforcement cases occurring between January 1993 and December 1996. The two largest Rohypnol seizures occurred in February 1995. At that time, more than Drug-Facilitated Rape 52,000 tablets were seized in Louisiana and 57,000 Drug-facilitated rape can be defined as sexual assault tablets were seized in Texas. By June 1996, the Drug made easier by the offender’s use of an “anesthesia” Enforcement Administration (DEA) had documented type drug that can render the victim physically incapac- more than 2,700 Federal, State, and local law enforce- itated or helpless and unable to give consent to sexual ment encounters with Rohypnol. activity. Whether the victim is unwittingly administered the drug or willingly ingests it for recreational use is On March 5, 1996, the U.S. Customs Service began irrelevant. The person is victimized because of an seizing Rohypnol at United States borders on advice inability to consciously consent to sexual acts. from DEA and the U.S. Food and Drug Administration. By December 1997, Customs Service efforts had sub- Rohypnol is one of the drugs most commonly implicat- stantially reduced the availability of the drug. ed in drug-facilitated rape. It can mentally and physi- cally paralyze an individual. Effects of the drug are of In May 2000, DEA, along with the U.S. Border Patrol, particular concern in combination with alcohol and can seized 900 Rohypnol tablets in Texas. In July 2000, lead to anterograde amnesia, where events that occurred multiagency investigations led to the closure of a phar- during the time the drug was in effect are forgotten. macy in Mexico that used the mail to distribute Ro- hypnol to California. During 2000, some 261,000 rapes/sexual assaults occurred, but it is unknown how many were drug- According to DEA’s System to Retrieve Information facilitated. Many factors contribute to this lack of data, from Drug Evidence (STRIDE) data, Rohypnol including the short period of time that the drug can be seizures were at their highest in 1995, with 164,534 detected in the victim’s system. Also, victims may not dosage units, and have since decreased to 4,967 units seek help until days after the assault, partly because the in 2000. drug impairs their memory and partly because of their inability to recognize signs of sexual assault. As with Regional Observations any sexual assault, survivors need help regaining a According to Pulse Check: Trends in Drug Abuse, sense of control and security. Many victims rely on Rohypnol is now the least available club drug in the a support system to help them deal with the flood of United States. Nevertheless, Los Angeles and El Paso emotions in the aftermath of the assault.
2
Scheduling and Legislation Street Terms As a result of the 1971 United Nations Convention on Psychotropic Substances, the United States placed Street terms for Rohypnol Rohypnol under Schedule IV of the Controlled Sub- stances Act in 1984. Rohypnol is not approved for man- Circles Pingus Roofies ufacture or sale within the United States. Forget me drug R-2 Rope Forget me pill Reynolds Rophies By March 1995, the United Nations Commission on Getting roached Rib Narcotic Drugs had transferred Rohypnol from a Sched- Row-shay La Rocha Roach-2 ule IV to a Schedule III drug. DEA is reviewing the Ruffles Lunch money drug Roapies possibility of reclassifying Rohypnol as a Schedule I Wolfies Mexican valium Robutal drug. At the State level, Rohypnol already has been reclassified as a Schedule I substance in Florida, Idaho, Minnesota, New Hampshire, New Mexico, North Resources Dakota, Oklahoma, and Pennsylvania. Rapists Are Using a New Weapon To Overpower Their In response to Rohypnol abuse and use of the drug to Victims. Santa Monica Hospital Medical Center, Rape facilitate sexual assaults, the U.S. Congress passed the Treatment Center, 1997. Drug Induced Rape Prevention and Punishment Act, www.911rape.org/request/blowouts/brochure.html effective October 13, 1996. The law provides for harsh- In the Spotlight: Club Drugs. National Criminal Justice er penalties regarding the distribution of a controlled Reference Service. substance to an individual without the individual’s con- www.ncjrs.org/club_drugs/club_drugs.html sent and with the intent to commit a crime of violence, including rape. The law imposes a penalty of up to 20 ClubDrugs.org. National Institute on Drug Abuse. years in prison and a fine for the importation and distri- www.clubdrugs.org bution of 1 gram or more of Rohypnol. Simple posses- sion is punishable by 3 years in prison and a fine. Sources In 1997, penalties for possession, trafficking, and dis- Executive Office of the President: tribution of Rohypnol were further increased by the U.S. Sentencing Commission’s Federal Sentencing Office of National Drug Control Policy Guidelines to those of a Schedule I substance because of growing abuse of the drug. Pulse Check: Tends in Drug Abuse, April 2002, NCJ 193398. www.whitehousedrugpolicy.gov/publications/drugfact/ Controlled Substances Act—Formal Scheduling pulsechk/apr02/index.html
Schedule I—The drug has a high potential for abuse, is not cur- Pulse Check: Trends in Drug Abuse, November 2001, rently accepted for medical use in treatment in the United States, NCJ 191248. and lacks accepted safety for use under medical supervision. www.whitehousedrugpolicy.gov/publications/ Schedule II—The drug has a high potential for abuse, is currently drugfact/pulsechk/fall2001/index.html accepted for medical use in treatment in the United States, and may lead to severe psychological or physical dependence. Street Terms: Drugs and the Drug Trade. Schedule III—The drug has less potential for abuse than drugs in www.whitehousedrugpolicy.gov/streetterms/default.asp Schedule I and II categories, is currently accepted for medical use in treatment in the United States, and may lead to moderate or low physical dependence or high psychological dependence. U.S. Department of Justice: Schedule IV—The drug has low potential for abuse relative to Drug Enforcement Administration other drugs, is currently accepted for medical use in treatment in the United States, and may lead to limited physical dependence or psychological dependence relative to drugs in Schedule III. Flunitrazepam (Rohypnol). www.usdoj.gov/dea/concern/flunitrazepam.html Schedule V—The drug has a low potential for abuse relative to drugs in Schedule IV, is currently accepted for medical use in treatment in the United States, and may lead to limited physical Flunitrazepam (Rohypnol) “roofies.” or psychological dependence relative to drugs in Schedule IV. www.usdoj.gov/dea/pubs/rohypnol/rohypnol.htm
3 Drug Intelligence Brief. “Club Drugs: An Update,” National Survey Results on Drug Use From the Monitoring September 2001. the Future Study, 2001. www.dea.gov/pubs/intel/01026/index.html http://monitoringthefuture.org/pubs/monographs/ overview2001.pdf National Drug Intelligence Center Rohypnol and GHB INFOFAX. National Drug Threat Assessment 2002, December 2001. www.drugabuse.gov/Infofax/RohypnolGHB.html www.usdoj.gov/ndic/pubs/716/index.htm American Prosecutors Research Institute: Bureau of Justice Assistance The Prosecution of Rohypnol and GHB Related Sexual Criminal Victimization 2000: Changes 1999–2000 With Assaults, 1999. Trends 1993–2000, June 2001. NCJ 187007. www.ndaa.org/publications/apri/violence_against_ www.ojp.usdoj.gov/bjs/abstract/cv00.htm women.html
National Institute of Justice Other Source:
“Drug-Facilitated Rape: Looking for the Missing Pieces,” Substance Abuse Trends in Texas: 2002, The University of NIJ Journal, April 2000. Texas at Austin. www.ncjrs.org/pdffiles1/jr000243c.pdf http://wnt.cc.utexas.edu/~spence/SubstAbuseTrendsDec 2002.pdf National Institutes of Health:
National Institute on Drug Abuse
Epidemiologic Trends in Drug Abuse, Volume I: Highlights and Executive Summary, June 2001, Community Epidemiology Work Group. www.nida.nih.gov/PDF/CEWG/EXSUMJune01.pdf
This fact sheet was prepared by Jennifer Lloyd of the ONDCP Drug Policy Information Clearinghouse. The data presented are as accurate as the sources from which they were drawn. Responsibility for data selection and presentation rests with the Clearinghouse staff. The Clearinghouse is funded by the White House Office of National Drug Control Policy to support drug control policy research. The Clearinghouse is a component of the National Criminal Justice Reference Service. For further information about the contents or sources used for the production of this fact sheet or about other drug policy issues, call: 1–800–666–3332 Write the Drug Policy Information Clearinghouse, P.O. Box 6000, Rockville, MD 20849–6000, or visit the World Wide Web site at: www.whitehousedrugpolicy.gov
*NCJ~193976* 4 Appendix I:
Drug Associated HIV Transmission Continues in the U.S.
(Centers for Disease Control and Prevention) Drug-Associated HIV Transmission Continues in the United States
Sharing syringes and other equipment for drug injec- AIDS cases among women have been attributed to tion is a well known route of HIV transmission, yet injection drug use or sex with partners who inject injection drug use contributes to the epidemic’ s drugs, compared with 31% of cases among men. spread far beyond the circle of those who inject. People who have sex with an injection drug user Noninjection drugs (such as “crack” cocaine) also (IDU) also are at risk for infection through the sexual contribute to the spread of the epidemic when users transmission of HIV. Children born to mothers who trade sex for drugs or money, or when they engage in contracted HIV through sharing needles or having sex risky sexual behaviors that they might not engage in with an IDU may become infected as well. when sober. One CDC study of more than 2,000 young adults in three inner-city neighborhoods found Since the epidemic began, injection drug use has that crack smokers were three times more likely to be directly and indirectly accounted for more than one- infected with HIV than non-smokers. third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the Strategies for IDUs Must Be 42,156 new cases of AIDS reported in 2000, 11,635 Comprehensive (28%) were IDU-associated. Comprehensive HIV prevention interventions for substance abusers must provide education on how to prevent transmission through sex. Proportion of IDU Associated AIDS Cases, by Exposure Category, Reported in 2000, United States Numerous studies have documented that drug users Sex partners are at risk for HIV through both drug-related and n=11, 635 of IDU sexual behaviors, which places their partners at risk as 13% well. Comprehensive programs must provide the IDU/MSM 13% information, skills, and support necessary to reduce both risks. Researchers have found that many inter- Children IDU of IDUs or ventions aimed at reducing sexual risk behaviors 73% their sex partners among drug users have significantly increased the 1% practice of safer sex (e.g., using condoms, avoiding unprotected sex) among participants. Racial and ethnic minority populations in the United States are most heavily affected by IDU-associated Drug abuse treatment is HIV prevention, AIDS. In 2000, IDU-associated AIDS accounted for but drug treatment slots are scarce. 26% of all AIDS cases among African American and In the United States, drug use and dependence are 31% among Hispanic adults and adolescents, com- widespread in the general population. Experts gener- pared with 19% of all cases among white adults/ ally agree that there are about 1 million active IDUs in adolescents. this country, as well as many others who use noninjection drugs or abuse alcohol. Clearly, the need IDU-associated AIDS accounts for a larger propor- for substance abuse treatment vastly exceeds our tion of cases among adolescent and adult women than capacity to provide it. Effective substance abuse
among men. Since the epidemic began, 57% of all treatment that helps people stop using drugs not only
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ IDU, May 2002 eliminates the risk of HIV transmission from sharing � recognize and overcome stigma associated with contaminated syringes, but, for many, reduces the risk injection drug use, and of engaging in risky behaviors that might result in � tailor services and programs to the diverse sexual transmission. populations and characteristics of IDUs.
For injection drug users who cannot or will Strategies for prevention should include: not stop injecting drugs, using sterile needles and syringes only once remains � preventing initiation of drug injection, the safest, most effective approach for � using community outreach programs to reach drug limiting HIV transmission. users on the streets, To minimize the risk of HIV transmission, IDUs must � improving access to high quality substance abuse have access to interventions that can help them protect treatment programs, their health. They must be advised to always use sterile � injection equipment; warned never to reuse needles, instituting HIV prevention programs in jails and syringes, and other injection equipment; and told that prisons, using syringes that have been cleaned with bleach or � providing health care for HIV-infected IDUs, and other disinfectants is not as safe as using new, sterile � making HIV risk-reduction counseling and testing syringes. available for IDUs and their sex partners.
Having access to sterile injection Better integration of all prevention and equipment is important, but it is not treatment services is critically needed. enough. HIV prevention and treatment, substance abuse Preventing the spread of HIV through injection drug prevention, and sexually transmitted disease treatment use requires a comprehensive approach that incorpo- and prevention services must be better integrated to rates several basic principles: take advantage of the multiple opportunities for intervention—first, to help the uninfected stay that � ensure coordination and collaboration among all way; second, to help infected people stay healthy; and providers of services to IDUs, their sex partners, third, to help infected individuals initiate and sustain and their children, behaviors that will keep themselves safe and prevent � ensure coverage, access to, and quality of transmission to others. interventions,
For more information... CDC National Prevention Internet Resources: CDC National STD & AIDS Hotlines: Information Network: NCHSTP: http://www.cdc.gov/nchstp/od/ 1-800-342-AIDS P.O. Box 6003 nchstp.html Spanish: 1-800-344-SIDA Rockville, Maryland 20849-6003 DHAP: http://www.cdc.gov/hiv Deaf: 1-800-243-7889 1-800-458-5231 IDU:http//www.cdc.gov/idu
NPIN: http://www.cdcnpin.org
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 2 IDU, May 2002 Appendix J:
Viral Hepatitis and Injection Drug Users
(Centers for Disease Control and Prevention) IDU HIV SEPTEMBER 2002 PREVENTION
VIRAL HEPATITIS AND INJECTION DRUG USERS
In the United States, viral hepatitis is an important public health problem because it causes serious illness, it affects millions, and it has a close connection with HIV. This series of fact sheets addresses viral hepatitis, particularly hepatitis B and C – two important blood-borne infections that have a major impact on injection drug users (IDUs).
The fact sheets in this series are: • Viral Hepatitis and Injection Drug Users • Medical Management of Chronic Hepatitis B and Chronic Hepatitis C • Vaccines to Prevent Hepatitis A and Hepatitis B • Hepatitis C Virus and HIV Coinfection • Viral Hepatitis and the Criminal Justice System
See the end of this fact sheet for information on how to get this series and other materials on preventing HIV and other blood-borne infections among IDUs.
http://www.cdc.gov/idu IDU HIV PREVENTION VIRAL HEPATITIS AND INJECTION DRUG USERS
Millions of Americans have viral hepatitis. It is a particularly significant problem among injection drug users (IDUs). Growing awareness of this problem is leading to new initiatives, but efforts to prevent these diseases and reduce their medical, financial, and social costs face challenges.
Viral Hepatitis is an Important uninfected person. High-risk sexual die from complications caused by hepa- Health Issue for the Nation behaviors (unprotected sex with multi- titis B. Chronic liver disease is currently ple partners) and injection drug use are the 10th leading cause of death, and Hepatitis, literally an “inflammation of the major risk factors. About 5% of liver failure due to hepatitis C is the the liver,” has a number of causes. Viral people in the U.S. have evidence of past leading reason for liver transplants. infection is one of them. The most infection with HBV and approximately Annual health care costs and lost wages common types are hepatitis A, hepatitis 1.25 million people have chronic HBV associated with hepatitis-related liver B, and hepatitis C. infection. Like hepatitis C, hepatitis B disease are estimated to be $600 million Viral hepatitis affects millions. disproportionately affects people of for hepatitis C and $700 million for color. An estimated 73,000 new HBV hepatitis B. The costs to individuals and Hepatitis C virus (HCV) infection infections occurred in 2000. Most society of illness related to hepatitis A occurs when blood (or to a lesser infections occurred in young adults, are also substantial. extent, other body fluids such as semen aged 20-39 years. Hepatitis B can be Viral hepatitis can be insidious. or vaginal fluid) from an infected person prevented through immunization. enters the body of an uninfected Frequently, symptoms of newly Hepatitis A virus (HAV) is primarily person. Injection drug use is the major acquired (acute) infection are mild or transmitted through the fecal-oral route, risk factor for HCV infection. About nonexistent, so people may not even be when a person puts something in his or 3.9 million Americans have been infected diagnosed as having viral hepatitis. her mouth (such as food or a beverage) with HCV and 2.7 million have chronic Those who do have symptoms might that has been contaminated with the HCV infection. Hepatitis C dispropor- experience “flu-like” symptoms, fatigue, feces of a person infected with HAV. tionately affects people of color: 3.2% nausea, pain in the upper abdomen, and Outbreaks occur more easily in of African Americans and 2.1% of sometimes jaundice. Mexican Americans are infected with overcrowded areas where poor sanitary HCV, compared to 1.5% of non- conditions exist. Outbreaks of hepatitis People who get HAV infection are able Hispanic whites. These numbers under- A also have been reported among IDUs. to clear the virus from their bodies and estimate the actual impact because they About one-third of Americans have recover fully. They develop a lifelong do not include infections in prisoners or evidence of past infection with immunity to the virus. The situation is the homeless. In 2000, about 30,000 HAV. Hepatitis A can be prevented different with hepatitis B and hepatitis C: new infections occurred. Most of these through immunization. • The majority of people who acquire infections occurred among young adults The medical and health care costs of viral HBV infection after age 5 are able to 20-39 years old. hepatitis are high. clear the virus from their bodies. However, about 2%-6% are not able Hepatitis B virus (HBV) infection Each year, 8,000 to 10,000 people die to clear the virus and go on to occurs when blood or body fluids from from the complications of liver disease become chronically infected. A much an infected person enter the body of an caused by hepatitis C and about 5,000 higher percentage of those who
12 IDU HIV PREVENTION acquire HBV infection as infants Hepatitis C is a particular concern. chronic liver disease, cirrhosis, and (90%) or young children (30%) • So many people have been infected liver cancer to develop, it is conserva- become chronically infected. with HCV. During the 1960s, 1970s, tively estimated that illness and deaths from HCV-related liver disease • About 75%-85% of people with and early 1980s, the number of new among the millions of people infect- HCV infection are unable to clear the cases every year was very high, averaging ed during earlier years will increase 2- virus and become chronically infected. an estimated 240,000 per year during the 1980s. Because many were to 3-fold over the next two decades. Many people with chronic infection – unaware they were infected, the risks Direct medical costs may range from 60% of those with HBV infection and of transmitting the infection to oth- $6.5 to $13.6 billion, with even larg- 70% of those with HCV infection – ers were extremely high. Since then, er indirect and societal costs. develop chronic liver disease, a situation the incidence of HCV infection has • No vaccine to prevent HCV infection in which the virus damages the liver. declined dramatically (only 30,000 is available. The damage may progress to severe new infections estimated in 2000). disease, including cirrhosis, liver cancer, Most of this decline has occurred Viral Hepatitis is a Very Significant and liver failure. This progressive liver among IDUs. The reasons are not Problem Among IDUs disease usually develops slowly over 20 fully understood but may be due to to 30 years. Because symptoms are so safer injection practices resulting from Because HBV and HCV are transmit- frequently mild or nonexistent, the intensive HIV prevention programs ted through exposure to infected blood majority of people with chronic HBV and to the very high proportion of and body fluids, IDUs are at very high and HCV infections do not know they drug users already infected. risk of acquiring and transmitting both are infected and can unknowingly viruses. For example, it is estimated that • Most people with HCV infection transmit the virus to others. For many, 60%, or 17,000, of the 30,000 new develop chronic infection, which fre- signs and symptoms appear only when cases of HCV that occurred in 2000 quently leads to chronic liver disease. liver disease is advanced and treatments occurred among IDUs. Is it estimated are less effective. • The impact of HCV infection may that 17%, or 13,000 of the 73,000 explode over the next 10-20 years. new cases of hepatitis B that occurred Because it takes 20-30 years for in 2000, occurred among IDUs.
Hepatitis A, B, and C at a Glance
Virus Risk of Transmission Course of Does Protective Vaccine Infection Immunity Develop? Available? Injecting Transfusion/ Sex Fecal- Occupational Transplant Oral A low* low high high none acute ➜ resolved yes yes B high low high none high unless acute ➜ chronic yes yes immune due to in 90% of hepatitis B infants, 30% immunization or in children previous infection aged 1-5, 2%-6% of older children and adults C high low low nonelow acute ➜ chronic no no in 75%-85% of adults
* Hepatitis A outbreaks occur among IDUs; mechanisms of transmission are not known with certainty but are related to poor hygiene and sharing drugs, drug solution, syringes, and drug preparation equipment (water, drug solution containers, cotton filters). 3 IDU HIV PREVENTION HBV and HCV infections are also also means that many IDUs are mar- • Capacity. Currently, public health acquired relatively rapidly among IDUs. ginalized and have little or no contact agencies, community-based organiza- Within 5 years of beginning injection with health care providers. tions, and health care professionals drug use, 50%-70% of IDUs become are limited in their ability to respond infected with HBV. Between 50%-80% Agencies and Providers Face a to needs in viral hepatitis. For example, of IDUs become infected with HCV Number of Pressing Issues in their fewer than half of state and local within 5 years of beginning injection Efforts to Address Viral Hepatitis public health laboratories are able to drug use; it is usually the first blood- perform tests to determine HCV In many ways, the current challenges of borne virus they acquire. Several factors infection. Many health care facilities viral hepatitis, especially hepatitis B and favor the rapid spread of HCV infection (such as emergency rooms) that treat hepatitis C, resemble those of HIV in among IDUs: IDUs and others at increased risk do the late 1980s and early 1990s. not routinely provide immunizations • Viral factors – HCV is transmitted Awareness of viral hepatitis as an against hepatitis A and hepatitis B. In efficiently through blood exposure. important public health issue is grow- addition, primary care physicians may ing, but agencies, providers, community- • Host factors – A large number of not have the training or expertise to based organizations, and others who individuals are infected and this pro- diagnose or medically manage chronic work with those at risk must address vides multiple opportunities for hepatitis B or chronic hepatitis C. several key issues: transmission to others. Staff of HIV and sexually transmitted • IDU factors – IDUs often jointly • Prevention. Viral hepatitis is not disease (STD) clinics, substance purchase drugs and prepare the drug inevitable for IDUs and others at risk. abuse treatment programs, and solution together; this solution is All three strains of viral hepatitis can correctional facilities have limited divided among users. Sharing the be prevented. HAV and HBV infec- training and expertise in viral drug solution, syringes, or other drug tions can be prevented through hepatitis issues. preparation equipment (such as water, immunization. All IDUs should be immunized against HAV and HBV • Education. The need to educate, drug mixing containers, and cotton train, and reach the general public, filters) all increase the risk of trans- infections unless they have already had the infection. Reducing or groups at increased risk, and health mission if any of these components care professionals is enormous. This are infected with HCV. eliminating high-risk sexual and drug-use behaviors can help prevent effort needs to: Other circumstances also contribute to the HAV, HBV, and HCV infections. > improve the understanding of viral heavy impact of viral hepatitis on IDUs: Substance abuse treatment is an hepatitis and its risk factors so that • IDUs are at very high risk of important way to help IDUs reduce individuals can reduce their chances coinfection with HIV and HCV. or eliminate drug use. of acquiring or transmitting the • Transmission. Because symptoms of infections and providers can better • Many IDUs drink alcohol, which serve infected and at-risk individuals; damages the liver and accelerates the viral hepatitis are often mild or non- progression of liver disease. existent, many people do not know > encourage high-risk groups to be they’re infected. This means that a tested for HCV infection, receive • HAV infection can be severe and very very large pool of individuals with pre- and post-test counseling, and dangerous in those who already have chronic HBV and HCV infections receive medical treatment if liver disease from chronic hepatitis B may not be using any measures to appropriate; or chronic hepatitis C. reduce the possibility of transmitting these infections to others. > improve hepatitis A and hepatitis B • Treatment of chronic hepatitis B or immunization rates by encouraging chronic hepatitis C can be complicat- • Treatment. Antiviral therapies for high-risk groups to get vaccinated; ed and adherence difficult for infect- chronic hepatitis B and chronic hepa- ed IDUs because many have other titis C are expensive, only moderately > integrate viral hepatitis prevention conditions (HIV, mental illness, alco- effective, and not appropriate for messages and interventions into holism, other illnesses), are poor, and everyone infected with these viruses. existing HIV, STD, substance abuse have unstable living situations. The Determining whether to begin treat- treatment, and criminal justice stigma surrounding injecting drugs ment, and monitoring and adjusting initiatives; and treatment over time for those who do > work to reduce bias and stigma begin antiviral therapy can be difficult. toward groups at increased risk of infection. 34 IDU HIV PREVENTION The National Hepatitis C Prevention • Interventions to Increase IDUs’ Access to of hepatitis C virus infection: implica- Strategy is One Key Response Sterile Syringes, a series of six fact sheets. tions for the future burden of chronic liver disease in the United States. • Drug Use, HIV, and the Criminal Justice In 2001, in collaboration with other Hepatology 2000;31(3):777-782. federal, state, and private sector System, a series of eight fact sheets. Centers for Disease Control and agencies, the Centers for Disease Control • Substance Abuse Treatment and Injection Prevention (CDC). National hepatitis C and Prevention (CDC) launched the Drug Users, a series of six fact sheets. National Hepatitis C Prevention prevention strategy. Summer 2001. Strategy. This effort is aimed at lower- Visit the CDC’s Viral Hepatitis www.cdc.gov/ncidod/diseases/hepatitis/c/ ing the incidence of acute HCV infec- website (www.cdc.gov/hepatitis) for plan/index.htm tions in the U.S. and reducing the dis- information materials and on-line Centers for Disease Control and ease burden from chronic hepatitis C. training for health professionals. Prevention (CDC). Recommendations The principal components of this Visit these websites for additional for prevention and control of hepatitis effort are: C virus (HCV) infection and HCV- information on viral hepatitis: • education of health care and public related chronic disease. Morbidity and health professionals; • The American Liver Foundation: Mortality Weekly Report 1998;47(RR19):1-39. www.liverfoundation.org/ www.cdc.gov/mmwr/preview/mmwrhtml/ • education of the public and individu- 00055154.htm als at increased risk of infection; • The National Institute of Diabetes & Digestive & Kidney Diseases: Centers for Disease Control and • clinical and public health activities to www.niddk.nih.gov/health/digest/pubs/ Prevention (CDC). Epidemiologic identify, counsel, and test persons at hep/index.htm notes and reports: hepatitis A among risk and to improve medical evalua- drug abusers. Morbidity and Mortality Weekly tions and referrals to care; • Hepatitis Foundation International: www.hepfi.org/ Report 1988;37(19):297-300, 305. • outreach and community-based pre- www.cdc.gov/mmwr/preview/mmwrhtml/ vention programs; • Hepatitis C Support Project: 00000024.htm www.hcvadvocate.org/ • surveillance to monitor viral hepatitis Garfein RS, Doherty MC, Monterroso trends; and • National AIDS Treatment Advocacy ER, et al. Prevalence and incidence of Project: www.natap.org/ hepatitis C virus infection among young • research. adult injection drug users. Journal of Check out these sources of For more information about the Acquired Immune Deficiency Syndromes and information: Strategy, visit: http://www.cdc.gov/ Human Retrovirology 1998;18(Suppl 1): ncidod/diseases/hepatitis/spotlights/c_strategy.htm Alter MJ, Kruszon-Moran D, Nainan S11-S19. To Learn More About This Topic OV, et al. The prevalence of hepatitis C Gunn RA, Murray PJ, Ackers ML, et virus infection in the United States, al. Screening for chronic hepatitis B and Visit websites of the CDC 1988 through 1994. New England Journal C virus infections in an urban sexually (www.cdc.gov/idu) and the Academy for of Medicine 1999;341(8):556-562. transmitted disease clinic – rationale for Educational Development Alter MJ, Moyer LA. The importance integrating services. Sexually Transmitted (www.healthstrategies.org/pubs/publications.htm) of preventing hepatitis C virus infection Diseases 2001;28(3):166-170. for these and related materials: among injection drug users in the Hagan H, McGough JP, Thiede H, et • Preventing Blood-borne Infections Among United States. Journal of Acquired Immune al. Syringe exchange and risk of Injection Drug Users: A Comprehensive Deficiency Syndromes and Human Retrovirology infection with hepatitis B and C viruses. Approach, which provides extensive 1998;18(Suppl 1):S6-S10. American Journal of Epidemiology background information on HIV and 1999;149(3):203-213. viral hepatitis infection in IDUs and Armstrong GL, Alter MJ, McQuillan the legal, social, and policy environment, GM, Margolis HS. The past incidence and describes strategies and principles of a comprehensive approach to addressing these issues.
5 IDU HIV PREVENTION Hagan H, Thiede H, Weiss NS, et al. O’Donovan D, Cooke RPD, Joce R, et Sharing of drug preparation equipment al. An outbreak of hepatitis A amongst as a risk factor for hepatitis C. American injecting drug users. Epidemiology and Journal of Public Health 2001;91(1):42-46. Infection 2001;127(3):469-473. Hagan H, Des Jarlais DC. HIV and Ompad DC, Fuller CM, Vlahov D, HCV infection among injecting drug Thomas D. Lack of behavior change users. The Mount Sinai Journal of Medicine after disclosure of hepatitis C virus 2000;67(5-6):423-428. infection among young injection drug www.mssm.edu/msjournal/67/6756.shtml users in Baltimore, Maryland. Presented at 128th Annual Meeting of the Hutin Y, Sabin KM, Hutwagner LC, et American Public Health Association. al. Multiple modes of hepatitis A virus Boston, MA. November 12-16, 2000. transmission among methamphetamine http://apha.confex.com/apha/128am/ users. American Journal of Epidemiology techprogram/paper_4971.htm 2000;152(2):186-192. Thorpe LE, Ouellet LJ, Hershow R, et Margolis HS, Alter MJ, Hadler SC. al. Risk of hepatitis C virus infection Hepatitis B: evolving epidemiology and among young adult injection drug users implications for control. Seminars in Liver who share injection equipment. American Disease 1991;11(2):84-92. Journal of Epidemiology 2000;155(7):645- National AIDS Treatment Advocacy 653. Project (NATAP). Current review and Vento S, Garofano T, Renzini C, et al. update on hepatitis C and HIV/HCV Fulminant hepatitis associated with coinfection. New York: NATAP; hepatitis A virus superinfection in Summer 2001. www.natap.org patients with chronic hepatitis C. National Institutes of Health (NIH). New England Journal of Medicine 1998; Management of hepatitis C: 2002. 338(5):286-290. Consensus Development Statement Wong JB, McQuillan GM, #116. June 10-12, 2002. McHutchison JG, Pynard T. Estimating http://consensus.nih.gov/cons/116/ future hepatitis C morbidity, mortality, 116cdc_intro.htm and costs in the United States. American Novick DM. The impact of hepatitis C Journal of Public Health 2000;90(10); virus infection on methadone mainte- 1562-1569. nance treatment. The Mount Sinai Journal of Medicine 2000;67(5-6): 437-443. www.mssm.edu/msjournal/67/6756.shtml
Department of Health and Human Services http://www.cdc.gov/idu
Through the Academy for Educational Development (AED), IDU-related technical assistance is available to health departments funded by CDC to conduct HIV prevention and to HIV prevention community planning groups (CPGs). For more information, contact your CDC HIV prevention project officer at (404) 639-5230 or AED at (202) 884-8952.
6 CDC. with funding from Educational Development, for the Academy by Produced Appendix K:
Coinfection With HIV and Hepatitis C Virus
(Centers for Disease Control and Prevention) CDC HIV/AIDS Fact Sheet Coinfection with
1-800-CDC-INFO (232-4636) HIV and Hepatitis C In English, en Español 24 Hours/Day [email protected] Virus http://www.cdc.gov/hiv November 2005
Overview combination of two drugs. Treatment will usually take 6-12 months. You should drink little or no • Persons with HIV, especially injection drug alcohol during treatment and may be advised not users, may also be infected with the hepatitis C to have alcohol ever again. Vaccination against virus (HCV). hepatitis A and hepatitis B is also recommended.
• HCV infection is more serious in persons with *It is not known yet whether coinfection with HCV makes HIV disease progress faster. HIV. †”Chronic” means having the disease for a long time.
• Many persons with HCV don’t have any symptoms. Other Ways of Becoming HCV infection can be treated Injecting drugs is Infected with HCV one of the main ways people become infected with There are other ways of becoming infected with HIV. It is also the main way of becoming infected HCV. Persons with hemophilia who received with the hepatitis C virus (HCV). In fact, 50%- clotting factor concentrates before 1987 commonly 90% of HIV-infected injection drug users are also have HCV infection. Becoming infected through infected with hepatitis C. sexual contact is possible, but the risk is much lower than the risk for HIV. Mothers can pass the HCV infection is more serious in HIV-infected infection to their newborn babies, but here too the persons.* It leads to liver damage more quickly. risk is less than that for HIV. Coinfection with HCV may also affect the treatment of HIV infection. Therefore, it’s important for HIV-infected persons to know How to Prevent HCV Infection whether they are also infected with HCV and, if The best way to prevent infection with HCV is to they aren’t, to take steps to prevent infection. stop injecting drugs or never to start. Substance abuse programs may help. If you continue to inject Many people with hepatitis C don’t have any drugs, always use new, sterile syringes and never symptoms of the disease. So your doctor or other reuse or share syringes, needles, water or drug health care provider will have to test your blood to preparation equipment. Do not share toothbrushes, check for the virus. If you test positive, he or she razors and other items that might be contaminated may also do a liver biopsy to determine the amount with blood. Tattooing or body piercing may also of damage to your liver. put you at increased risk for infection with any bloodborne pathogen if dirty needles or other Chronic† hepatitis C can be treated successfully, instruments are used. Practice safer sex. even in HIV-infected persons. Treatment for chronic hepatitis C is with a single drug or Coinfection with HIV and Hepatitis C Virus
Liver Biopsy During a liver biopsy, a tiny piece of your liver is removed through a needle. The tiny piece (or specimen) is then checked for amount of liver damage.
Treating HCV Infection Alpha interferon or pegylated interferon alone, or one of these in combination with ribavirin are the drugs given to patients with chronic hepatitis C who are at greatest risk for progression to serious disease. Treatment is not always successful, but even HIV-infected patients may benefit from treatment. Your doctor or other health care provider will need to make the final decision about if and when you should receive treatment.
For more information . . .
CDC HIV/AIDS http://www.cdc.gov/hiv CDC HIV/AIDS resources
CDC Viral Hepatitis http://www.cdc.gov/ncidod/diseases/hepatitis/index.htm CDC viral hepatitis resources
CDC-INFO 1-800-232-4636 Information about personal risk and where to get an HIV test
CDC National HIV Testing Resources http://www.hivtest.org Location of HIV testing sites
CDC National Prevention Information Network (NPIN) 1-800-458-5231 http://www.cdcnpin.org CDC resources, technical assistance, and publications
AIDSinfo 1-800-448-0440 http://www.aidsinfo.nih.gov Resources on HIV/AIDS treatment and clinical trials
Appendix L:
Syringe Disinfection for Injection Drug Users
(Centers for Disease Control and Prevention) IDU IDUHIV PREVENTION HIV JUNE 2004 PREVENTION SYRINGE DISINFECTION FOR INJECTION DRUG USERS
For 20 years, syringe disinfection has been a part of HIV prevention efforts for injection drug users (IDUs). Questions about it persist, however, because of limited scientific studies, varying recommendations on the right way to disinfect, and evidence suggesting that IDUs do not use this approach very much. This fact sheet presents basic information on disinfection, especially bleach disinfection. The central message is that disinfection is a back-up prevention strategy if the user cannot stop injecting; does not have a new, sterile syringe; and is about to inject with a syringe that has been used before.
How Did Disinfection Become a injecting. Field research in California This led community programs to train Widely-used HIV Prevention showed that IDUs would act to reduce outreach workers to teach IDUs how Strategy? their risks if acceptable measures were they could reduce the risk of infection available to them. One such measure by disinfecting their syringes and needles. The strategy of disinfecting syringes to was syringe disinfection with household Distribution of bleach kits — small prevent HIVemerged in California in bleach. (Disinfection means using (usually 1-oz. size) bottles of full- the 1980s. East Coast epidemics something to kill viruses and bacteria strength household bleach with instruc- among IDUs (especially in New York) that cause infection.) Laboratory tests tions on how to disinfect syringes — made public health officials fear that had shown that bleach killed HIV. quickly became a standard component HIV would be a major threat to Bleach also was cheap, quick, and avail- of IDU prevention in San Francisco. California IDUs. able everywhere. Other U.S. cities then rapidly adopted California IDUs, like those in other this strategy. parts of the country, shared and reused syringes, in part because it was hard for them to get new, sterile ones. This Substance abuse treatment and access to sterile syringes through pharmacies, How Disinfection Can Reduce greatly increased their risk of HIV Transmission Risk: It Reduces transmission (see box, page 2). State physician prescription, and syringe the Number of Viruses and It law made it illegal for drug users to exchange programs are essential com- buy syringes from pharmacies and a ponents of HIV prevention efforts Kills Them among injection drug users. See “To crime to possess them. Restricted Current disinfection recommendations Learn More About This Topic” at the access to sterile syringes, combined are based on the following steps: with limited capacity of substance end of this fact sheet for information • Flush out blood, drugs, and other abuse treatment programs, forced pre- on how to get fact sheets on these organic matter from the syringe. These vention programs to focus on reducing topics as well as other materials on can contain viruses and do interfere injection-related risks among IDUs HIV prevention among IDUs. with the disinfection process. who would not or could not stop
1 IDU HIV PREVENTION • Disinfect the syringe. particles and thoroughly mixes the Does Disinfection Work Against water or disinfectant with material in • Rinse out the disinfectant. Viral Hepatitis? the syringe); then squirt out and The idea behind these steps is to reduce throw away the water; repeat until no Hepatitis B virus (HBV) and hepatitis the risk of HIV transmission in two more blood can be seen. C virus (HCV) cause serious illness ways. First, flushing removes blood and among millions of people. They also are • Leave the water or disinfectant, espe- closely connected with HIV, injection drugs from the syringe, which reduces cially the disinfectant, in the syringe the number of viral particles. Second, drug use, and high-risk sexual behaviors. for a while (in principle, the longer Many people think that disinfection using a disinfectant can kill remaining the better; for example, 30 seconds is viruses so they can’t infect anyone else. doesn’t work against HBV or HCV, but better than 15 seconds); then squirt laboratory studies on HBV show that Instructions for disinfecting syringes out the disinfectant. disinfection works against this blood- usually include ways to make sure that • Rinse out the syringe with clean borne virus in the same ways that it viruses are removed and killed: water (fill syringe, shake or tap, squirt does against HIV. • Fill the syringe with clean water (such out and throw away water); rinsing is Scientists also think that disinfection as water right from a tap or a new done to get rid of disinfectant and kills HCV, although laboratory studies bottle of water). any viruses left in the syringe. of HCV and disinfection are not possi- • Shake or tap the syringe containing ble at this time because HCV cannot be water or disinfectant (this dislodges grown in a test tube and therefore the effect of disinfecting agents can’t be directly tested. An important thing to remember about The Link Between Preparing Injection Drugs and the HBV and HCV is that the numbers of Risk of Transmission viruses in blood are much higher for HBV and HCV than they are for HIV. The drugs used by IDUs (heroin, cocaine, amphetamines) usually are sold as a powder As a result, getting rid of as much that must be dissolved in water before they can be injected. Some injection drugs, such blood as possible by flushing out and as black-tar heroin, which is a gummy solid not a powder, must be heated in a spoon or rinsing is especially important in reduc- bottle cap (a “cooker”) to speed up the dissolving. Once dissolved, the drug is drawn ing the risk of becoming infected with into a syringe through a filter (a “cotton”) that prevents small particles in the solution viral hepatitis. from clogging the needle. The drug is then injected into a vein. Sometimes, two or more IDUs will draw up drugs from the same cooker.
Before injecting, a user must be sure that the needle is in a vein. He or she does this by Disinfection Seems to Make pulling back on the plunger after pushing the needle through the skin in a likely spot. Sense. What’s the Problem? Blood entering the syringe (“registering”) shows that the needle is in a vein. Once the A Disinfected Syringe is NOT a Sterile drug has been injected, the IDU may pull back the plunger, drawing blood back into the Syringe syringe, and then re-inject it into the vein (“booting” or “jacking”). After injecting, the user rinses out the syringe with water to prevent any remaining blood from clogging the If it is done carefully and thoroughly, needle. Users often dissolve drug powder and rinse their syringes with water from the disinfection can reduce the amount of same container. live HIV, BVC, and HCV in a syringe. However, even the best disinfection pro- HIV and hepatitis C virus (HCV) can be transmitted when IDUs share the same syringe. cedure cannot guarantee that all viruses These viruses also can be transmitted when users divide drug solution among several have been killed. The plastic syringes syringes, share rinse water or a cotton or cooker, or mix the drug solution with a used usually used by IDUs are designed for syringe. Transmission can occur when any element — syringe, water, cotton, cooker, one-time use. They are not designed to drug solution — becomes contaminated with blood that is infected with HIV or HCV be cleaned and used again. because that element can contaminate any other element it touches. Even if an IDU is careful to always use a new, sterile syringe to inject drugs, the process of sharing con- Disinfected syringes do NOT meet the taminated equipment, drug solution, or water can increase his or her risk of standards that are applied in all other acquiring or transmitting HIV or HCV. (For more information about drug preparation settings in which people use syringes and viral transmission, see Koester, 1998.) (such as hospitals, other health care set-
2 IDU HIV PREVENTION tings, and insulin injections by people disinfection procedures, or the time nec- if they do use it. Many factors make it with diabetes). In these settings, people essary for adequate disinfection. hard for IDUs to disinfect: must use a new, sterile syringe for every • Current instructions involve a lot of Studies of IDUs Do Not Prove That Bleach injection. steps and IDUs may think it is Disinfection Protects them Against HIV or impossible to do correctly. For these reasons, a disinfected syringe Viral Hepatitis is NOT as safe as a new, sterile syringe. • IDUs may not be able to get clean Studies have looked for differences in Recommendations about disinfecting water. syringes with bleach or others agents the number of new infections between apply ONLY to situations in which injectors who say they always disinfect • They may not want to carry bleach or IDUs do not have sterile syringes. and injectors who say they do not dis- other disinfectants because it marks infect. They have found no significant them as drug users. Scientists Have Limited Laboratory Evidence difference in new infections among that Disinfection Works Against HIV in IDUs in the two groups. One possible Syringes and Other Injection Equipment explanation is that bleach disinfection does not protect against infection. Scientists have published a small num- Other factors also may help explain ber of laboratory studies on the ability these findings. Bleach has Advantages of bleach and other agents to kill HIV. These experiments try to mimic condi- • Studies don’t measure risk behaviors and Disadvantages as a tions faced by IDUs and usually test the completely. Studies don’t always col- Disinfectant impact of disinfection on blood to lect detailed risk information and may Advantages: which HIV grown in a test tube has focus only on an IDU’s risky drug been added. practices. As a result, a study focusing • It can reduce the amount of infec- on disinfection may not show any- tious HIV, HBV, and HCV in a used However, these conditions are not the thing if the infection is due to some- syringe. same as those faced by IDUs, and find- thing else, such as having unprotected ings are not definitive. In laboratory sex with infected partners. • It is readily available. studies, fresh undiluted household bleach • It is inexpensive. (5.25% sodium hypochlorite) appears to • Some studies have technical limita- kill HIV pretty well. Scientists also have tions. For example, sometimes it is Disadvantages: hard for a scientist to know whether a tested whether other liquids can disinfect • IDUs, outreach workers, and person is really a “disinfector” or a syringes. These liquids, which are some- policymakers may mistakenly “non-disinfector.” IDUs in the study times used by IDUs, include dish deter- believe that disinfecting with may not remember correctly whether gent, rubbing alcohol, hydrogen peroxide, bleach is as safe as using a new, or how many times they used bleach and fortified wine. Results of these few sterile syringe. studies are limited. during a certain period in the past. Or, they may think that saying they • It does not sterilize the syringe, so Some research has found that even sev- used bleach is the answer the scien- the syringe may still carry infec- eral vigorous rinses with clean water tists want to hear. As a result, IDUs tious viruses after disinfection. may be as effective as undiluted house- who say they disinfect may seem to • Studies have not shown that hold bleach because they do a good job be at the same risk of infection as bleach disinfection prevents HIV of reducing the number of infectious whose who say they don’t disinfect. viruses. or HCV transmission. Barriers Make it Hard for IDUs to Results of these studies depend on • If a person carries small bottles of Disinfect Correctly and Can Prevent Them many things, including the strength of bleach, police may assume he or from Doing It At All the agent, whether the HIV is in whole she is a drug user. blood or by itself, and the steps used. IDUs may agree that disinfection is a • Sunlight, warm temperatures, and Because few laboratory studies have good idea if they cannot get new, sterile exposure to air gradually weaken been published, we have only limited syringes. However, some investigators bleach so that it doesn’t work data on disinfection. As a result, we have found that few IDUs actually use anymore; IDUs have to be sure to don’t have clear answers to questions bleach to disinfect syringes or they don’t use fresh, full-strength bleach. about which agents work best, the best go through all the recommended steps • It damages the syringe.
3 IDU HIV PREVENTION • Withdrawal symptoms (being “drug What are the Take-Home number of and kill some of the HIV, sick”) and the overpowering need to Messages? HBV, or HCV in a syringe. As a inject as soon as possible also may drive result, disinfection can be a useful • The way that an IDU prepares and an IDU to inject without disinfecting. back-up strategy for IDUs. injects drugs is important in deter- • Some IDUs need help to inject and mining the risk of that person get- • We don’t have clear, consistent labo- other people give them the injection. ting or transmitting HIV, HBV, and ratory evidence about the best disin- The person doing the injecting may HCV: fection procedure and we don’t know not disinfect thoroughly. how effective this strategy is. So, we Any item — syringe, water, drug suggest steps that seem logical. • Drug users may not have time to dis- solution, cooker, cotton — that is infect carefully because they must pre- contaminated with blood contain- • Disinfection should be used only pare the drug solution and inject quick- ing these viruses can contaminate when an IDU has no safe options ly (for example, police are nearby). all the other items. for preventing transmission. • Once the IDU has injected, the Even if an IDU uses a sterile Disinfection is not as good as stop- effects of the drug may prevent him syringe each time, he or she can ping injecting, getting into sub- or her from disinfecting carefully become infected if the drug solu- stance abuse treatment, using a new before the next injection (this may be tion or preparation equipment is sterile syringe, and not sharing drug especially true with cocaine, which is shared with others who are infected. solution and equipment. commonly injected multiple times in • Disinfection will not make injecting Bleach and other disinfectants do a drug use session). drugs “safe.” It may make injecting NOT sterilize the syringe. “less risky” because it can reduce the
What Should We Tell IDUs? Keeping Everything Clean is an Important Part of Education and outreach workers should stress the following messages when they Reducing HIV and Viral Hepatitis Risk talk to IDUs: More and more, health workers are realizing that cleanliness and good hygiene can go a • The best way for you to prevent HIV, long way to reducing an IDU’s risk of getting or transmitting HIV or HCV. Good hygiene HBV, and HCV transmission is to can also help prevent sores and bacterial infections in the skin where IDUs inject. The NOT inject drugs. following tips are an important part of the prevention message to IDUs who cannot or • Entering substance abuse treatment will not stop injecting: can help you reduce or stop injecting. • Wash your hands and arms before preparing to inject. This will lower your chances of infec- • Use a clean surface to prepare drugs for injection, or spread out a piece of clean tion. paper. • Get vaccinated against hepatitis A • Use an alcohol pad to clean the skin where you’re going to inject. and hepatitis B. You can prevent these kinds of viral hepatitis if you get vac- • After injecting, use a gauze pad to stop the bleeding. cinated. • Put a bandage on the place where you injected. • If you cannot or will not stop inject- • Throw away the used alcohol pad and gauze, and all the other drug preparation ing, you should: equipment. Use a new, sterile syringe obtained • Clean anything else blood might have touched (such as the tourniquet, your inject- from a reliable source to prepare ing space, or your clothes). and divide drugs for each injection.
• Safely dispose of the syringe. Never reuse or share syringes, water, cookers, or cottons. • Wash your hands again to clean off dirt, blood, and viruses. Use sterile water to prepare drugs Sources: Marcia Bisgyer of SafetyWorks, Inc., Mamaroneck NY, and Allen Clear of Harm each time, or at least clean water Reduction Coalition, New York, NY (www.harmreduction.org) from a reliable source.
4 IDU HIV PREVENTION Keep everything as clean as possible Approach, which provides extensive Check out these sources of information: when injecting (see box, left). background information on HIV and Abdala N, Crowe M, Tolstov Y, Heimer viral hepatitis infection in IDUs and • If you can’t use a new, sterile syringe R. Survival of human immunodeficien- the legal, social, and policy environ- and clean equipment each time, then cy virus type 1 after rinsing injection ment, and describes strategies and disinfecting with bleach may be better syringes with different cleaning solu- principles of a comprehensive than doing nothing at all: tions. Substance Use and Misuse approach to addressing these issues. 2004;39(4):581-600. Fill the syringe with clean water • Interventions to Increase IDUs’ Access to and shake or tap. Squirt out the Abdala N, Gleghorn AA, Carney JM, Sterile Syringes, a series of six fact water and throw it away. Repeat Heimer R. Can HIV-1-contaminated sheets. until you don’t see any blood in the syringes be disinfected? Implications for syringe. • Drug Use, HIV, and the Criminal Justice transmission among injection drug System, a series of eight fact sheets. users. Journal of Acquired Immune Deficiency Completely fill the syringe with Syndromes 2001;28(5):487-494. fresh, full-strength household • Substance Abuse Treatment and Injection bleach. Keep it in the syringe for 30 Drug Users, a series of six fact sheets. Bourgois P. Anthropology and epidemi- seconds or more. Squirt it out and ology on drugs: the challenges of cross- • Viral Hepatitis and Injection Drug Users, throw the bleach away. methodological and theoretical dia- a series of five fact sheets. logue. The International Journal of Drug Fill the syringe with clean water Policy 2002(4);13:259-269. and shake or tap. Squirt out the Small numbers of these publications water and throw it away. can be ordered at no charge from Centers for Disease Control and www.cdc.gov/idu. Prevention. Recommendations for pre- • If you don’t have any bleach, use clean vention and control of hepatitis C virus water to vigorously flush out the See the July 1994 issue of the Journal (HCV) infection and HCV-related syringe: of Acquired Immune Deficiency Syndromes. chronic disease. Morbidity and Mortality Fill the syringe with water and This issue of the Journal includes seven Weekly Report 1998;47(RR 19):1-39. shake or tap it. Squirt out the water papers from a workshop on the use of www.cdc.gov/mmwr/preview/ and throw it away. bleach to disinfect drug injection equip- mmwrhtml/00055154.htm ment. The papers provide an historical Do this several times. perspective on the use of bleach in Ciccarone D, Bourgois P. Explaining the HIV/AIDS prevention activities, review geographical variation of HIV among results of laboratory studies on the injection drug users in the United effectiveness of various agents in inacti- States. Substance Use and Misuse. Disinfection should be used vating HIV, and describe the results of 2003;38(14):2049-2063. ONLY when an IDU has no safe field studies on the disinfection prac- Clatts MC, Heimer R, Abdala N, et al. options for preventing tices of IDUs. (Journal of Acquired Immune HIV-1 transmission in injection para- Deficiency Syndromes 1994;7(7):741-776.) transmission. phernalia: heating drug solutions may inactivate HIV-1. Journal of Acquired See the April 1993 CDC/CSAT/NIDA Immune Deficiency Syndromes HIV/AIDS Prevention Bulletin. This 1999;22(2):194-199. To Learn More about This Topic publication reviews the topic of disin- Hagan H, Thiede H. Does bleach disin- fection and concludes that stopping fection of syringes help prevent hepati- Visit websites of the Centers for injection or using new, sterile syringes is Disease Control and Prevention tis C virus transmission? [letter] superior to disinfection. (Curran JC, Epidemiology 2003;14(5):628-629. (www.cdc.gov/idu) and the Academy Scheckel LW, Millstein RA. for Educational Development HIV/AIDS prevention bulletin. Hagan H, Thiede H, Weiss NS, et al. (www.healthstrategies.org/pubs/ Centers for Disease Control, Center for Sharing of drug preparation equipment publications.htm) for these and related Substance Abuse Treatment, and as a risk factor for hepatitis C. American materials: National Institute on Drug Abuse, Journal of Public Health 2001;91(1):42-46. • Preventing Blood-borne Infections Among April 19, 1993.) www.cdc.gov/idu/ Hughes RA. Drug injectors and the Injection Drug Users: A Comprehensive pubs/bleach_letter.htm cleaning of needles and syringes. European Addiction Research 2000;6(1):20-30.
5 IDU HIV PREVENTION Kapadia F, Vlahov D, Des Jarlais DC, et of sterile needles and bleach. among young adult injection drug users al. Does bleach disinfection of syringes Washington, DC: National Academy who share injection equipment. American protect against hepatitis C infection Press, 1995. Chapter 6, The effective- Journal of Epidemiology 2002;155(7):645- among young adult injection drug users? ness of bleach as a disinfectant of infec- 653. Epidemiology 2002;13(6):738-741. tion drug equipment. www.nap.edu/ books/0309052963/html/ United States Public Health Service Koester SK. Following the blood: (USPHS). HIV prevention bulletin: syringe reuse leads to blood borne virus Sattar SA, Tetro J, Springthorpe VS, medical advice for persons who inject transmission among injection drug Giulivi A. Preventing the spread of hep- illicit drugs. Atlanta (GA) and users. [letter] Journal of Acquired Immune atitis B and C viruses: Where are germi- Rockville (MD): USPHS, May 9, Deficiency Syndromes and Human Retrovirology cides relevant? American Journal of Infection 1997. www.cdc.gov/idu/pubs/ 1998;18(Suppl 1):S139-S140. Control 2001;29(3):187-197. hiv_prev.htm Normand J, Vlahov D, Moses LE, eds. Thorpe LE, Ouellet LJ, Hershow R, Preventing HIV transmission: the role et al. Risk of hepatitis C virus infection
http://www.cdc.gov/idu
Through the Academy for Educational Development (AED), IDU-related technical assistance is available to health departments funded by CDC to conduct HIV prevention and to HIV prevention community planning groups (CPGs). For more information, contact your CDC HIV prevention project officer at (404) 639-5230 or AED at (202) 884-8952. Produced by the Academy for Educational Development, with funding from CDC. with funding from Educational Development, for the Academy by Produced Appendix M:
Physician Prescription of Sterile Syringes to Injection Drug Users
(Centers for Disease Control and Prevention) IDU HIV FEBRUARY 2002 PREVENTION PHYSICIAN PRESCRIPTION OF STERILE SYRINGES TO INJECTION DRUG USERS
Injection drug users (IDUs) who continue to inject can substantially reduce their risk of acquiring or transmitting HIV, hepatitis B and C, and other blood-borne infections if they use sterile syringes. Physician prescription of syringes is one way to improve IDUs’ access to sterile injection equipment. It also can help IDUs obtain medical services and substance abuse treatment.
Injection Drug Users are at High social services. This reduces their chances to • create links to other health care and social Risk of HIV and Hepatitis. They Also obtain needed medical care and enter substance services; abuse treatment. Need Medical Care and Substance • create links to substance abuse treatment; and Abuse Treatment Physician Prescription of Sterile • open the door for doctors and patients to HIV and hepatitis B and C can be transmitted Syringes Can Help IDUs in Several discuss and take action on a range of high- directly when infected IDUs share syringes Important Ways risk behaviors and activities. with others. These viruses can also be trans mitted when infected IDUs jointly prepare Because physicians are key gatekeepers to The Rhode Island Experience and use drugs and share other drug injection syringe access, efforts to encourage them to Currently, few physicians in the United States equipment. As a result, the U.S. Public prescribe syringes to IDUs will help ensure prescribe syringes to IDUs. However, a research Health Service and other scientific and that those who continue to inject can legally study in Rhode Island is examining the governmental agencies have recommended obtain sterile syringes. Involving physicians that IDUs who continue to inject should also illustrates the medical rationale for feasibility of physician prescription in a com always use sterile syringes and use them increasing IDUs’ access – that improving munity care setting, with promising results. only once. This recommendation is a central access to sterile syringes has a legitimate In the spring of 1999, the state’s Department strategy in the effort to prevent HIV and medical purpose in preventing disease. of Health, with the support of the Rhode other blood-borne diseases. However, IDUs Physician prescription on its own may not Island Medical Society, the Rhode Island often have difficulty obtaining sterile syringes have a large-scale public health impact, but it Pharmacists’ Association, the Rhode Island because of laws, regulations, and pharmacy adds another valuable option to efforts to Board of Medical Licensure and Discipline, and prescription rules that limit the sale and improve IDUs’ access to sterile syringes. the Rhode Island State Board of Pharmacy, possession of syringes. These efforts include initiatives to review and others, invited all the state’s physicians to Many IDUs also suffer from other serious and revise laws and policies, support syringe participate in a clinical program to prescribe problems, including drug overdoses, sexually exchange programs, and collaborate with sterile syringes to IDUs. In her letter of invi transmitted diseases (STDs), liver disease, pharmacists. tation, the director of the Health Department tuberculosis, abscesses, bacterial infections, informed physicians that syringe prescription Encouraging physician involvement in syringe mental illness, and violence. was legal. prescription has another important benefit – Because of the illicit nature of their drug use it provides a way for programs and providers This pilot program now operates at two and the stigma attached to it, IDUs often to reach out to high-risk and stigmatized locations and includes a staff of four physicians, fear and mistrust health care providers and individuals. Placing syringe prescription within one substance abuse referral specialist, one have few or no links to regular health care or a broader physician-patient relationship can: nurse, one interviewer, and one administrator.
1 IDU HIV PREVENTION
To date, the clinic has prescribed more • Prescribing syringes should be one element • had doubts about the legality of physician than 60,000 syringes to 350 participants. of a comprehensive relationship between prescription; many expressed concern that Participants who have received syringe pre the physician and the patient and should they could lose their medical license or be scriptions have also received basic clinical be done within the context of the patient’s sued if they prescribed syringes to IDUs. exams, medical care, tests for HIV and viral overall medical and health needs. Prescribing and dispensing sterile injection hepatitis, hepatitis A and B immunizations, and • Success is more likely if physicians can equipment is governed principally by state links to substance abuse treatment and social work with IDU patients in a non-judg law. A recently published analysis of the laws services. The services are provided free of charge. mental, culturally sensitive way that in all 50 states, the District of Columbia, An in-depth evaluation of the program is includes an openness to discussing injec and Puerto Rico showed that prescribing and underway. Preliminary findings indicate that: tion-related activities and a willingness dispersing injection equipment to patients as • patients are not requesting prescriptions for to provide links to other needed programs a means of preventing disease transmission more syringes than they are using; and services. during drug use is clearly legal in most states: • most patients report appropriate disposal • In these discussions, physicians should • Physician prescription of injection equip of syringes; and first emphasize the dangers of continued ment is legal in 48 of the 52 jurisdictions injection and urge their patients to stop (it is illegal in Delaware and Kansas). • some drug-use behaviors have declined. injecting. Recommending reducing or In two other jurisdictions (Ohio and Fostering Physician Prescription stopping drug use without alienating Oklahoma) physicians have a “reasonable Requires Work on a Community the patient can be challenging, however. claim to legality.” This means that the laws Training or continuing education may help in that jurisdiction neither explicitly allow and Individual Level physicians improve their skills and abilities nor forbid prescribing or dispensing, so that The community level to deal with these sensitive drug use issues. an attorney “acting ethically and in good faith” could argue that the practice was • Physicians should document in the As the Rhode Island experience shows, legal (see Burris et al., 2000). communities that are working to encourage patient’s medical record the recommenda physician prescription can help the process tion to stop injecting and the need and • It is also legal for pharmacists to fill the by obtaining the support of the state and rationale for the decision to prescribe prescriptions in 26 states (it is illegal local health departments, pharmacy boards, syringes (similar to that done for any other only in Delaware, Kansas, Georgia, and medical boards, and other key stakeholders. prescription). Physicians should also Hawaii). In 22 other jurisdictions they Formal endorsement and promotion of this record alternative options that have been have a “reasonable claim to legality.” explored, such as referrals to substance practice by these bodies can do much to reas The authors of this analysis note that abuse treatment. sure physicians that this activity is both legal although states differ, physicians generally and a legitimate medical practice. Physician Prescription of Syringes have broad discretion to prescribe drugs and Communities also should act to educate and to IDUs is Feasible but It Faces devices that they believe are medically benefi cial for their patients. Several major medical persuade physicians, pharmacists, and other Challenges health providers about the public health and and legal societies, including the American individual benefits of prescribing sterile Legal issues Medical Association, the Infectious Diseases syringes to IDUs and how it should be done Society of America, and the American Bar In 1999, at the start of the Rhode Island within the medical care setting. Education Association all support efforts to improve study, the investigators conducted a survey of about how to help patients dispose of syringes IDUs’ access to sterile syringes, including all the state’s infectious disease and addiction appropriately and safely should also be physician prescription. medicine physicians on their attitudes toward included. Establishing regular communication and practices in prescribing syringes to among interested physicians, through periodic Attitudinal issues IDUs. The responses of these physicians may meetings or a newsletter, may stimulate For physician prescription to become more well echo those of others around the country. physicians’ willingness and ability to work common, both physicians and IDU patients Responding physicians: with IDUs. Tracking physician prescription may need to gain a greater understanding of activity, evaluating its outcomes, and publish • believed that syringe prescription was a the issues facing people who inject and how ing these data can be another important way useful tool for preventing transmission of to address health behaviors that might be to cultivate support. blood-borne infections; changed. Physicians may need to: The individual level • were willing to prescribe if it were clearly • become willing to openly acknowledge and legal, though none had ever prescribed a discuss patients’ injection drug use; Individual physicians who wish to prescribe syringe for the express purpose of prevent sterile syringes to IDU patients should first • accept that syringe prescription is helpful ing infection in an IDU; and know the legal status in their community to the patient because it can prevent of prescribing syringes to IDUs. Other disease; and important recommendations include:
2 IDU HIV PREVENTION
• become more knowledgeable about the and viral hepatitis infection in IDUs and Check out these sources of information: issue, how to recognize patients who may the legal, social, and policy environment, American Medical Association (AMA). be IDUs, and how to help IDU patients. and describes strategies and principles of Access to sterile syringes. Chicago (IL): a comprehensive approach to addressing IDUs may need to: AMA; June 2000; www.ama-assn.org/ama/ these issues. pub/category/1808.html • overcome fear and mistrust of physicians • Drug Use, HIV, and the Criminal Justice System, and the medical establishment and be Burris S, Lurie P, Abrahamson D, Rich JD. a series of eight fact sheets. open to developing a trusting relationship Physician prescribing of sterile injection with a physician; and • Substance Abuse Treatment and Injection Drug equipment to prevent HIV infection: time Users, a series of six fact sheets. for action. Annals of Internal Medicine 2000; • be willing to discuss their concerns about 133(3):218-226. any legal ramifications of having a prescrip Visit the website of the Project on Harm tion (for example, will it help them if they Reduction in the Health Care System Infectious Diseases Society of America (IDSA). are stopped by the police?). (www.temple.edu/lawschool/aidspolicy/default.htm), IDSA public statements and positions: located at the Beasley School of Law, Temple supporting document for IDSA’s policy To Learn More About This Topic University. The Project investigates the pre- statement on syringe exchange, prescribing Read the overview fact sheet in this series on scribing and dispensing of sterile injection and paraphernalia laws. Alexandria (VA): interventions to increase IDUs’ access to ster equipment as one strategy for reducing harm IDSA; November 2000. www.idsociety.org/PA/ ile syringes – “Access to Sterile Syringes.” It to injection drug users who cannot or will PS&P/SyringeSupport_11-17-00.htm not enter drug treatment. provides basic information, links to the other Rich JD, Macalino GE, McKenzie M, Taylor fact sheets in this series, and links to other See the Winter 2001 issue of Health Matrix: LE, Burris S. Syringe prescription to prevent useful information (both print and web). Journal of Law-Medicine. A special feature enti HIV infection in Rhode Island: a case study. Visit these websites of the Centers for Disease tled “Symposium: Legal and Ethical Issues American Journal of Public Health 2001;91(5):1-2. of Physician Prescription and Pharmacy Sale Control and Prevention (www.cdc.gov/idu) and Rich JD, Whitlock TL, Towe CW , et al. of Syringes to Patients Who Inject Illegal the Academy for Educational Development Prescribing syringes to prevent HIV: a survey Drugs” includes five papers that present the (www.healthstrategies.org/pubs/publications.htm) to get: of infectious disease and addiction medicine rationale for physician prescription of syringes physicians in Rhode Island. Substance Use • Preventing Blood-borne Infections Among Injection and explore related legal and ethical issues. & Misuse 2001;36(5):535-550. Drug Users: A Comprehensive Approach, which Health Matrix: Journal of Law-Medicine provides extensive information on HIV 2001:11(1):1-147. om CDC. lopment, with funding fr e v
Department of Health and Human Services r Educational De http://www.cdc.gov/idu o y f
Through the Academy for Educational Development (AED), IDU-related technical assistance is available the Academ to health departments funded by CDC to conduct HIV prevention and to HIV prevention community planning groups (CPGs). y For more information, contact your CDC HIV prevention project officer at 404-639-5230 or AED at (202) 884-8952. oduced b Pr 3 Appendix N:
Syringe Exchange Programs
(Centers for Disease Control and Prevention) Syringe Exchange Programs December 2005
In 1997, a Report to Congress concluded that needle exchange programs can be an effective component of a comprehensive strategy to prevent HIV and other blood-borne infectious diseases in communities that choose to include them.(1) Federal funding to carry out any program of distributing sterile needles or syringes to IDUs has been prohibited by Congress since 1988. In addition, several states have restricted the funding or operation of syringe exchange programs (SEPs).
As of 2004, injection drug use accounted for about one-fifth of all HIV infections and most hepatitis C infections in the United States.(2,3) Injection drug users (IDUs) become infected and transmit the viruses to others through sharing contaminated syringes and other drug injection equipment and through high-risk sexual behaviors. Women who become infected with HIV through sharing needles or having sex with an infected IDU can also transmit the virus to their babies before or during birth or through breastfeeding.
To succeed in effectively reducing the transmission of HIV and other blood-borne infections, programs must consider a comprehensive approach to working with IDUs. Such an approach incorporates a range of pragmatic strategies that address both drug use and sexual risk behaviors. One of the most important of these strategies is ensuring that IDUs who cannot or will not stop injecting drugs have access to sterile syringes. (See the related fact sheet Access to Sterile Syringes.) This strategy supports the "one- time-only use of sterile syringes" recommendation of several institutions and governmental bodies, including the U.S. Public Health Service.(4)
What Are Syringe Exchange Programs?
It is estimated that an individual IDU injects about 1,000 times a year.(5) This adds up to millions of injections, creating an enormous need for reliable sources of sterile syringes. Syringe exchange programs (SEPs) provide a way for those IDUs who continue to inject to safely dispose of used syringes and to obtain sterile syringes at no cost. (See the related fact sheets Syringe Disposal and Pharmacy Sales of Sterile Syringes.)
The first organized SEPs in the U.S. were established in the late 1980s in Tacoma, Washington; Portland, Oregon; San Francisco; and New York City. By 2002, there were 184 programs in more than 36 states, Indian Lands and Puerto Rico. These programs exchanged more than 24 million syringes.(6)
In addition to exchanging syringes, many SEPs provide a range of related prevention and care services that are vital to helping IDUs reduce their risks of acquiring and transmitting blood-borne viruses as well as maintain and improve their overall health.
These services may include: • HIV/AIDS education and counseling; • condom distribution to prevent sexual transmission of HIV and other sexually transmitted diseases (STDs); • referrals to substance abuse treatment and other medical and social services; • distribution of alcohol swabs to help prevent abscesses and other bacterial infections; • on-site HIV testing and counseling and crisis intervention; • screening for tuberculosis (TB), hepatitis B, hepatitis C, and other infections; and • primary medical services.
SEPs operate in a variety of settings, including storefronts, vans, sidewalk tables, health clinics, and places where IDUs gather. They vary in their hours of operation, with some open for 2-hour street-based sessions several times a week, and others open continuously. They also vary in the number of syringes allowed for exchange. Many also conduct outreach efforts in the neighborhoods where IDUs live.(7)
What Is the Public Health Impact of SEPs?
SEPs have been shown to be an effective way to link some hard-to-reach IDUs with important public health services, including TB and STD screening and treatment. Through their referrals to substance abuse treatment, SEPs can help IDUs stop using drugs.(8) Studies also show that SEPs do not encourage drug use among SEP participants or the recruitment of first-time drug users. In addition, a number of studies have shown that IDUs will use sterile syringes if they can obtain them.(9) SEPs provide IDUs with an opportunity to use sterile syringes and share less often.(10)
The results of this research, and the clear dangers of syringe sharing, led the National Institutes of Health Consensus Panel on HIV Prevention to stated that:(11)
"An impressive body of evidence suggests powerful effects from needle exchange programs....Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs."
Economic studies have concluded that SEPs are also cost effective. At an average cost of $0.97 per syringe distributed, SEPs can save money in all IDU populations where the annual HIV seroincidence exceeds 2.1 per 100 person years.(12) The cost per HIV infection prevented by SEPs has been calculated at $4,000 to $12,000, considerably less than the estimated $190,000 medical costs of treating a person infected with HIV.(13)
What Issues Do SEPs Face?
SEPs face a variety of issues in their operation. One of the most substantial is coverage. For example, Montreal—a city that has active and well-supported SEPs, allows sales of syringes without prescription, and encourages pharmacy sales—was able to meet less than 5 percent of the need for sterile syringes in 1994.(14) Of the 126 SEPs participating in a 2002 survey, the 11 largest exchanged almost half of the 24.8 million syringes exchanged. Most of the remaining SEPs exchanged much smaller numbers (the 22 smallest volume SEPs exchanged fewer than 5,000 syringes each).(6)
SEPs also face significant legal and regulatory restrictions. For example, 47 states have drug paraphernalia laws that establish criminal penalties for the distribution and possession of syringes. Eight states and one territory have laws that prohibit dispensing or possessing syringes without a valid medical prescription. (See the related fact sheet, State and Local Policies Regarding IDUs’ Access to Sterile Syringes.) Public health authorities in communities have employed a number of strategies to ensure the legal provision of SEP services, including declaring public health emergencies.(15)
Local community opposition also can be an issue. Residents may be concerned that the programs will encourage drug use and drug traffic and increase the number of used discarded syringes in their neighborhoods. Studies have found no evidence of increases in discarded syringes around SEPs.(16) Finally, some IDUs avoid SEPs because they fear that using a program that serves IDUs will identify them as IDUs. For others, the fear of arrest, fines, and possible incarceration if caught carrying syringes to or from the SEP is a potent deterrent.(17)
What Have Communities Done?
Activities have included:
• Supporting community-based discussions of the role that SEPs can play in comprehensive HIV and viral hepatitis prevention and care programs, in particular in getting SEP users into substance abuse treatment programs. • Educating policy makers about the facts of injection-related transmission of blood-borne pathogens and the public health benefits of providing access to sterile syringes as part of a comprehensive public health approach. • Encouraging collaborative review of the public health impact of repealing drug paraphernalia laws that penalize the possession or carrying of syringes.
For More Information
Read A Comprehensive Approach: Preventing Blood-Borne Infections Among Injection Drug Users, which provides extensive background information on HIV and viral hepatitis infection in IDUs and on the legal, social, and policy environment. It also describes strategies and principles for addressing these issues.
Sources
1. Shalala, DE. Needle Exchange Programs in America: Review of Published Studies and Ongoing Research. Report to the Committee on Appropriations for the Departments of Labor, Health and Human Services, Educations and Related Agencies. February 18, 1997 2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. 2005 National HIV Prevention Conference; June 12–15, 2005. Atlanta, GA. Abstract T1-B1101.
3. Centers for Disease Control and Prevention (CDC). Hepatitis C fact sheet. Accessed December 22, 2005 from http://www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm.
4. Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institute on Drug Abuse and Substance Abuse and Mental Health Services Administration. HIV prevention bulletin: Medical advice for persons who inject illicit drugs. May 9, 1997.
5. Lurie P, Jones TS, Foley J. A sterile syringe for every drug user injection: how many injections take place annually, and how might pharmacists contribute to syringe distribution? Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S45-S51.
6. Centers for Disease Control and Prevention (CDC). Update: syringe exchange programs— United States, 2002. Morbidity and Mortality Weekly Report 2005; 54(27);673-676
7. Centers for Disease Control and Prevention (CDC). Update: syringe exchange programs— United States, 1997. Morbidity and Mortality Weekly Report 1998;47(31):652-655.
8. Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Reports 1998;113(Suppl 1):75-80.
9. Des Jarlais DC, Friedman SR, Sotheran JL, Wenston J, Marmor M, Yancovitz SR, Frank B, Beatrice S, Mildvan D. Continuity and change within an HIV epidemic: injecting drug users in New York City, 1984-1992. JAMA 1994;271:121-127.
10. Heimer R, Khoshnood K, Bigg D, Guydish J, Junge B. Syringe use and reuse: effects of needle exchange programs in three cities. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S37-S44.
11. National Institutes of Health. Consensus Development Statement. Interventions to prevent HIV risk behaviors, February 11-13, 1997:7-8.
12. Lurie P, Gorsky R, Jones TS, Shomphe L. An economic analysis of needle exchange and pharmacy-based programs to increase sterile syringe availability for injection drug users. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S126-S132.
13. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1997; 16:54-62.
14. Remis RS, Bruneau J, Hankins CA. Enough sterile syringes to prevent HIV transmission among injection drug users in Montreal? Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S57-S59. 15. Burris S, Finucane D, Gallagher H, Grace J. The legal strategies used in operating syringe exchange programs in the United States. American Journal of Public Health 1996;86(8 Pt 1):1161-1166.
16. Doherty MC, Garfein RS, Vlahov D, Junge B, Rathouz PJ, Galai N, Anthony JC, Beilenson P. Discarded needles do not increase soon after the opening of a needle exchange program. American Journal of Epidemiology 1997;145(8):730-737.
17. Springer KW, Sterk CE, Jones TS, Friedman L. Syringe disposal options for injection drug users: a community-based perspective. Substance Use and Misuse 1999;34(13):1917-1934.
http://www.cdc.gov/idu/facts/aed_idu_syr.htm Accessed February 6, 2006