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Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives Editors: Robert J. Battjes, D.S.W. Roy W. Pickens, Ph.D. Division of Clinical Research National Institute on Drug Abuse NIDA Research Monograph 80 1988 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402 NIDA Research Monographs are prepared by the research divisions of the National Institute on Drug Abuse and published by its Office of Science. The primary objective of the series is to provide critical reviews of research problem areas and techniques, the content of state-of-the-art conferences, and integrative research reviews. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisors MARTIN W. ADLER, Ph.D. MARY L. JACOBSON Temple University School of Medrcrne National Federation of Parents for Philadelphia. Pennsylvania Drug-Free Youth Omaha, Nebraska SYDNEY ARCHER, Ph.D. Rensselaer Polytechnic Institute Troy, New York REESE T. JONES, M.D. Langley Porter Neuropsychiatric lnstitute RICHARD E. BELLEVILLE. Ph.D. San Francisco, California NB Associates, Health Sciences RockviIle, Maryland DENISE KANDEL, Ph.D. KARST J. BESTEMAN College of Physicians and Surgeons of Alcohol and Drug Problems Association Columbia University of North America New York, New York Washington, D. C. GILBERT J. BOTVIN, Ph.D. Cornell Unrversrty Medical College HERBERT KLEBER, M.D. Yale University School of Medicine New York, New York New Haven, Connecticut JOSEPH V. BRADY, Ph.D. The Johns Hopkins Unrversrty School of Medicine RICHARD RUSSO Baltimore, Maryland New Jersey State Department of Health Trenton, New Jersey THEODORE J. CICERO, Ph.D Washington University School of Medicine St Louis, Missouri NIDA Research Monograph Series CHARLES R. SCHUSTER, Ph.D. Director, NIDA THEODORE M. PINKERT, M.D.,J.D. Acting Associate Director for Science, NIDA Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives ACKNOWLEDGMENT This monograph is based upon papers and discussion from a technical review which took place on May 18 and 19, 1987, at Bethesda, Maryland. The review meeting was sponsored by the Division of Clinical Research, National Institute on Drug Abuse. COPYRIGHT STATUS All material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. The views and opinions expressed on the following pages are solely those of the authors and do not necessarily constitute an endorse- ment, real or implied, by the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commer- cial product or company. Trade or proprietary names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. DHHS publication number (ADM) 89-1567 Printed 1988, Reprinted 1989 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, Biosciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. iv Foreword Checking the spread of AIDS is the most urgent task confronting public health officials today. One in four persons with AIDS in the United States has used illicit drugs intravenously. Hence the National Institute on Drug Abuse (NIDA) has committed its re- sources on many fronts to help curb this deadly infection among intravenous drug abusers, their sexual partners, and their children. Transmission of the AIDS virus-human immunodeficiency virus (HIV)-among intravenous drug abusers most often occurs when they share drug injection equipment. Small amounts of contami- nated blood left in needles or syringes can carry the virus from person to person. Almost all intravenous drug users sometimes share their “works,” for reasons that include convenience, friend- ship, and ritual. In some cities in the United States, rates of HIV infection among intravenous drug users are already high. In many others, still in relatively early stages of the AIDS epidemic, a window of opportu- nity exists to prevent catastrophe. How can the risks from sharing injection equipment, commonplace among intravenous drug users, be reduced? How can individuals who are often hard to reach and unresponsive to “authority” be made aware of the danger and moti- vated to change long-established behaviors? To review existing research and program experience in dealing with these questions, NIDA convened more than 40 experts for a 2-day meeting in May 1987. They came from across the United States and from England, The Netherlands, and Italy, from governments, universities, treatment facilities, and professional associations. v Participants described a wide variety of programs and policies which have been implemented in U.S. cities and in Western Europe. They spoke from diverse perspectives and expressed dif- fering views. This monograph, summarizing the presentations at the meeting, is both informative and thought-provoking. lt can provide a valuable basis for further discussion about the challenging problem of stopping the spread of AIDS through “needle sharing.” Charles R. Schuster, Ph.D. Director National Institute on Drug Abuse vi Contents Page Foreword . v Participants . ix Needle Sharing Among Intravenous Drug Abusers: An Overview Robert J. Battjes and Roy W. Pickens . 1 Overview: HIV Infection Among Intravenous Drug Abusers in the United States and Europe Harry W. Haverkos. 7 Needle Sharing and Street Behavior in Response to AIDS in New York City William Hopkins. .18 The Ethnography of Needle Sharing Among Intravenous Drug Users and Implications for Public Policies and Intervention Strategies Harvey W. Feldman and Patrick Biernacki. .28 Mexican-American Intravenous Drug Users’ Needle-Sharing Practices: Implications for AIDS Prevention Alberto G. Mata and Jaime S. Jorquez . .40 Amsterdam’s Drug Policy and Its Implications for Controlling Needle Sharing Ernst C. Buning, Giel H.A. van Brussel, and Gerrit van Santen . , . .59 vii Page The Influence of AIDS Upon Patterns of Intravenous Use- Syringe and Needle Sharing-Among Illicit Drug Users in Britain Robert Michael Power . .75 Injecting Equipment Exchange Schemes in England and Scotland Gerry V. Stimson . .89 Sharing Needles and the Spread of HIV in ltaly’s Addict Population Enrico Tempesta and Massimo Di Giannantonio . 100 Drug Addiction and AIDS in France in 1987 Claude Olievenstein . 114 Intravenous Drug Abuse and AIDS Transmission: Federal and State Laws Regulating Needle Availability Chris B. Pascal . 119 Combining Ethnographic and Epidemiologic Methods in Targeted AIDS Interventions: The Chicago Model W. Wayne Wiebel . 137 Why Bleach? Development of a Strategy To Combat HIV Contagion Among San Francisco Intravenous Drug Users John A. Newmeyer. 151 The Sharing of Drug Injection Equipment and the AIDS Epidemic in New York City: The First Decade Don C. Des Jarlais, Samuel R. Friedman, Jo L. Sotheran, and Rand Stoneburner. 180 Needle Sharing Among Intravenous Drug Abusers: Future Directions Robert J. Battjes and Roy W. Pickens . 176 List of NIDA Research Monographs . 184 viii Participants National Institute on Drug Abuse Technical Review Meeting on Needle Sharing Among Intravenous Drug Abusers: National and lnternational Persectives, Bethesda MD, May 18-19, 1987 MODERATORS Don C. Des Jarlais, Ph.D. Assistant Deputy Director Robert J. Battjes, D.S.W. New York State Division of Associate Director for Planning Substance Abuse Services Division of Clinical Research 55 West 125th Street, 10th Floor National Institute on Drug Abuse New York, NY 10027 Parklawn Building, Room 10A-38 (212) 8708362 5600 Fishers Lane Rockville, MD 20857 Harvey W. Feldman, Ph.D. (301) 4436697 Executive Director Youth Environment Study, Inc. Roy W. Pickens, Ph.D. 1779 Haight Street Director, Division of San Francisco, CA 94117 Clinical Research (415) 751-4221 National Institute on Drug Abuse Parklawn Building, Room 10A-38 Harry W. Haverkos, M.D. 5600 Fishers Lane Chief, Clinical Medicine Branch Rockville, MD 20857 Division of Clinical Research (301) 4436697 National Institute on Drug Abuse Parklawn Building, Room 10A- REVIEWERS 5600 Fishers Lane Rockville, MD 20857 Ernst C. Buning, Psychologist (301) 443-1801 Drug Department GG & GD Valckenierstraat 2 1018 XG Amsterdam The Netherlands 01131 20 5555 349 ix William Hopkins, Ph.D. Robert Michael Power, Ph.D. Supervisor, Street Research Unit Research Fellow New York State Division of Drug Indicators Project Substance Abuse Services Department of Politics Vincent Building and Sociology 55 West 125th Street Birkbeck College New York, NY 10027 University of London (212) 8708501 16 Gower Street London, WC1, England Alberto G. Mata, Ph.D. 441 631 6246 Postdoctoral Fellow Center for Health Promotion Gerry V. Stimson, Ph.D. University of Texas Director, Monitoring
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