Correspondence
Crack Cocaine and HIV in the Inner City
N Engl J Med 1995; 332:1233-1235May 4, 1995
- Article
To the Editor:
Our observations at our substance-abuse program for pregnant women and mothers correspond to those of Edlin and colleagues (Nov. 24 issue).1 Women addicted to “crack” cocaine are at substantially increased risk of contracting human immunodeficiency virus (HIV) infection as a result of their engaging in prostitution to support their addiction. We agree with the call for more substance-abuse treatment.
In their Sounding Board article, Des Jarlais and colleagues (Nov. 24 issue)2 stress the importance of devoting resources to teaching safer sex strategies to drug addicts but do not explicitly mention the need to devote more funds to substance-abuse treatment. Teaching safer sex techniques to addicts who actively abuse drugs without devoting the necessary resources to drug-abuse treatment is not enough to stem the epidemic of HIV. The essential feature of substance abuse is a maladaptive pattern of substance use despite the occurrence of recurrent and serious adverse effects.3 We surveyed the participants in our young-mothers program and found that 78 percent engaged in unprotected sexual acts in order to support their addiction. All who did so were aware that they risked becoming infected with HIV. Their only concern at the time of the act was to continue getting high. The exceedingly high risk of HIV infection is due to the high-risk sexual behavior in a context of intense craving caused by crack addiction.
Treating drug abuse can have a vital role in our response to the AIDS epidemic.4 Such treatment can and does work, though it may not work the first time and it may not work for everyone. We must devote sufficient funds to providing accessible substance-abuse treatment. Since crack addiction and HIV infection affect a disproportionately large number of inner-city women, the approach to treatment must be sensitive to the needs of these women and their families.
4 ReferencesKate Sugarman, M.D.
Merrill Herman, M.D.
Montefiore Medical Center, Bronx, NY 104671
Edlin BR ,Irwin KL ,Faruque S , et al. Intersecting epidemics -- crack cocaine use and HIV infection among inner-city young adults. N Engl J Med 1994;331:1422-1427
Full Text | Web of Science | Medline2
Des Jarlais DC ,Padian NS ,Winkelstein W Jr . Targeted HIV-prevention programs. N Engl J Med 1994;331:1451-1453
Full Text | Web of Science | Medline3
Diagnostic and statistical manual of mental disorders. 4th ed.: DSM-IV. Washington, D.C.: American Psychiatric Association, 1994.
4
Selwyn PA . Injection drug use, mortality, and the AIDS epidemic. Am J Public Health 1991;81:1247-1249
CrossRef | Web of Science | Medline
To the Editor:
. . . Driven by a moral opprobrium for injection-drug users, the war on AIDS has been subordinated to the politics of the war on drugs.1 Thus, despite evidence that HIV is transmitted through needle sharing and that injection-drug users would use their own needles and thus avoid HIV infection if they could carry needles without fear of arrest, and contrary to international experience, the United States continues to criminalize the possession of drug paraphernalia. This has unleashed the AIDS epidemic among injection-drug users, their sexual partners, and their newborn infants. Given the disproportionate impact of drug-related AIDS on African Americans and Hispanics, the failure to liberalize policies is viewed as an effect of racism. And in the United States, as opposed to Europe and Australia, there is great racial and ethnic disparity between those infected and policy makers.2 Given the scarcity of treatment, it is unethical, and even immoral, to condemn injection-drug users to contract HIV and to infect their sexual partners and infants in satisfying their addiction.
The United States must decriminalize the possession of drug paraphernalia as a strategy to control AIDS. We must give injection-drug users an opportunity to avoid infection until quality treatment is available. Dead addicts do not recover. AIDS is deadly and costly.
2 ReferencesDaniel Fernando, Ph.D.
175C Overmount Ave., West Paterson, NJ 07424Author/Editor Response
The authors reply:
To the Editor: We appreciate the comments by Drs. Sugarman and Herman and Dr. Fernando emphasizing the importance of access to sterile syringes and substance-abuse treatment for drug users.
The spread of HIV infection in inner-city communities is driven by the use of contaminated injection equipment by injection-drug users and by high-risk sexual practices among both crack-cocaine smokers and injection-drug users. Several types of interventions will be necessary if the epidemic is to be stopped. First, substance-abuse treatment must be made available to all drug users who wish to stop using drugs. Second, those who continue to use drugs must be allowed the means to protect themselves from HIV infection. Injection-drug users, for example, must have access to sterile needles and syringes if they are to avoid HIV infection.
Crack smokers must also protect themselves. Our data suggest that crack smokers will take steps to reduce their risk of HIV infection. Crack smokers are sometimes considered particularly difficult to reach with prevention messages. We found, however, that when approached in a nonjudgmental way, in their own neighborhoods, by outreach workers who were often from the same neighborhoods, the vast majority agreed to participate in our study, be interviewed about their high-risk sexual and drug-use practices, and be tested for HIV. Moreover, of the women who told us they were engaging in sex in exchange for money or drugs, nearly half said their partners were using condoms every time they engaged in this behavior. And, indeed, the prevalence of hIV infection in this group was less than half that among those whose partners did not use a condom every time. Thus, crack smokers are willing to talk about their risk of HIV infection, many are already trying to reduce that risk, and some are succeeding.
Among those who fail, however, HIV will continue to spread rapidly, as our study demonstrates. Thus, a third type of intervention, and perhaps the most important, is needed — one that will prevent young people from becoming drug users in the first place. As we suggested, this may require addressing the broader social and economic conditions that afford inner-city youths few opportunities for rewarding lives.
We would also like to acknowledge the contribution of Drs. Robert Fullilove and Mindy Fullilove, who, while at the Center for AIDS Prevention Studies in San Francisco, participated in the early conception and design of our study. They used the term “intersecting epidemics” several years ago to describe the potential of crack cocaine use to promote the spread of sexually transmitted diseases.1
1 ReferencesBrian R. Edlin, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333Sairus Faruque, M.D., M.P.H.
P.O. Box 396, Tiger, GA 30576Clyde B. McCoy, Ph.D.
University of Miami, Miami, FL 33136Carl O. Word, Ph.D.
Bayview–Hunter's Point Foundation, San Francisco, CA 941241
Fullilove MT ,Fullilove RE III . Intersecting epidemics: black teen crack use and sexually transmitted disease. J Am Med Wom Assoc 1989;44:146-7, 151
Medline
Author/Editor Response
We discussed the need for both universal prevention activities and prevention activities targeted according to risk behavior and demographic and geographic factors. Although space limitations precluded extended discussion of drug-abuse treatment, we have elsewhere advocated providing “drug abuse treatment on demand” as part of HIV prevention.1 Persons who exchange sex for crack are a good example of a population in need of targeted prevention efforts. We agree with Sugarman and Herman that increased drug-abuse treatment could be an important component of HIV prevention in this group.
The need to provide drug-abuse treatment does not, however, obviate the need to provide the means for practicing safer sex and safer methods of drug injection. Because of the limitations of current forms of drug-abuse treatment, many people would continue to use psychoactive drugs even if treatment were available on demand.
Sugarman and Herman also note that drug dependence is by psychiatric definition a maladaptive pattern of substance use, persisting despite negative consequences. We strongly object to any implication that hIV infection is an inevitable consequence of continued drug use. One of the most consistent findings in research on risk behavior in HIV is the extent to which injection-drug users will adopt safer means of injection in response to the threat of AIDS.2 Recent studies show that changes in behavior confer strong protective effects against infection with blood-borne viruses3 (and Stimson GV: personal communication).
Although providing treatment for cocaine dependence will be very helpful in reducing the rate of HIV transmission in sex-for-crack exchanges, other strategies are also needed, including treatment of sexually transmitted diseases (which facilitate the transmission of HIV) and the development of viricidal agents that women can use. We also need programs to convince the paying customers to use condoms in sex-for-crack exchanges. Ethnographic studies of crack houses in New York indicate that the women are quite willing to have condoms used, but the men have control over condom use (Hamid A: personal communication).
AIDS was recognized in drug users in 1981, yet we still have not expanded drug-treatment programs or provided federal support for syringe-exchange programs. The behavior of many of our political leaders with respect to the prevention of HIV has been at least as maladaptive as the behavior of drug users.
3 ReferencesDon C. Des Jarlais, Ph.D.
Beth Israel Medical Center, New York, NY 10013Nancy Padian, M.P.H., Ph.D.
University of California, San Francisco, San Francisco, CA 941051
National Commission on Acquired Immune Deficiency Syndrome. The twin epidemics of substance use and HIV. Washington, D.C.: Government Printing Office, 1991.
2
Des Jarlais DC ,Friedman SR ,Choopanya K ,Vanichseni S ,Ward TP . International epidemiology of HIV and AIDS among injecting drug users. AIDS 1992;6:1053-1068
CrossRef | Web of Science | Medline3
Hagan H, Des Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk of hepatitis B among tacoma syringe exchange users. Presented at the 122nd Annual Meeting of the American Public health Association, Washington, D.C., October 30–November 3, 1994. abstract.
- Citing Articles (3)
Citing Articles
1
Gerald J. Stahler, Kimberly C. Kirby, MaryLouise E. Kerwin. (2007) A Faith-Based Intervention for Cocaine-Dependent Black Women. Journal of Psychoactive Drugs 39:2, 183-190
CrossRef2
Scott S. Santibanez, Richard S. Garfein, Andrea Swartzendruber, Peter R. Kerndt, Edward Morse, Danielle Ompad, Steffanie Strathdee, Ian T. Williams, Samuel R. Friedman, Lawrence J. Ouellet. (2005) Prevalence and correlates of crack-cocaine injection among young injection drug users in the United States, 1997–1999. Drug and Alcohol Dependence 77:3, 227-233
CrossRef3
Salaam Semaan, Lynne Kotranski, Karyn Collier, Jennifer Lauby, Joan Halbert, Kelly Feighan. (1998) Temporal Trends in HIV Risk Behaviors Among Out-of-Treatment Women Crack Users: The Need for Drug Treatment. Drugs & Society 13:1-2, 13-33
CrossRef
