SEPTEMBER 1998

NUMBER ONE

Getting Help Is Hard

Intravenous drug needle sharing is the second leading cause of HIV infection in men and women in the U.S., with one third of new infections in the U.S. associated with contaminated needles. A new survey by University of California researchers shows that sharing works remains common, even when IV drug users get access to traditional outreach, counseling, and behavior-modification programs.

Health Risks: Recreational drugs are dangerous to your health, often addictive, and linked with an increased risk of HIV, tuberculosis, and sexually transmitted diseases (see "Street Drugs: The Basics"). When needles are shared, tetanus and hepatitis B and C are also commonly acquired. New surveys report a high concordance between tetanus cases and injection use in California; the tetanus vaccine is recommended for prevention of these diseases. Injection drug users may develop bacterial infections and pus-filled abscesses on their skin that heal poorly; these lesions also increase the risk of HIV transmission to their sex partners. Long-term malnutrition is also common, as is lung damage for those who smoke crack cocaine. Studies have also shown that recreational drug use increases the risk of HIV transmission in pregnant women, prompting government researchers to include treatment for drug addiction in prenatal care for HIV-positive women using IV drugs.

Special Obstacles: Less than half the 191 injection drug users in one study were taking HAART a year after becoming eligible for these therapies, researchers at the British Columbia Centre for Excellence in HIV/AIDS at St. Paul's Hospital in Vancouver found. Those not enrolled in drug-treatment programs were also three times less likely to receive HAART therapy. Younger injection-drug users, and especially girls and women, are less likely to seek or receive HAART therapy.

Standard of Care: A recent seven-year study of heroin users found that 51 percent of those who never entered treatment were exposed to HIV, compared with 21 percent of treated addicts. These numbers underscore the need for drug-treatment programs as an intrinsic part of HIV prevention.

Ideally, HIV medications should be offered as part of a comprehensive services program that links substance-abuse treatment to HIV care and focuses on the issues that affect adherence, including access to clean needles, housing, food, jobs, and a refrigerator to house medications.

But what's actually available is quite different. Getting help is not easy, even if you truly want to get off drugs. Only about 15 percent of individuals in the U.S. who want treatment for addiction now get it. Under the successive Reagan and Bush administrations, funds for methadone programs were cut nationwide, which contributed to the current severe shortage of drug-treatment programs. Seven states don't offer methadone clinics, for example, and every U.S. methadone clinic has a waiting list.

Buried inside these statistics are certain groups left out: Only 5 percent to 20 percent of pregnant women using injection drugs reportedly gain access to drug-treatment programs-because there aren't any that target them, or they can't afford them, or inpatient programs won't accept their children.

Harm Reduction: The facts are clear: Many of the estimated 6.7 million U.S. drug addicts relapse after treatment in programs that emphasis kicking and abstinence-not using IV drugs at all.

Given the high failure rate, HIV advocates back a harm-reduction approach to drug addiction that focuses on helping people make commitments toward a specific plan of action. Empowering individuals to set their own behavior-modification goals appears successful. Interestingly, a survey of five recent studies found that when given a choice, 70 percent of individuals actually chose abstinence as their goal.

Politics: For now, advocates argue that the criminalization of injection drug users and the continuing federal ban on needle-exchange programs remain pressing political barriers that are fueling, not reducing, the spread of HIV transmission among drug addicts (see "Clinton Flip-Flops"). Americans prefer to jail drug users than use tax money for treatment. Ironically, the toll on the average taxpayer is high: it costs $25,900 to keep someone in jail for a year, compared with $1,800 a year for a traditional outpatient treatment programs.

Adherence: Side effects, drug interactions, and drug resistance compound the problems injection drug users face using combination HIV therapies. Recent studies show that HIV triple-drug therapy can benefit HIV-positive IV drug users who comply with their regimens. But compliance with rigid drug schedules continues to be an issue that is limiting access of IV drug users to new meds. Since missing doses leads to HIV resistance, many physicians are unwilling to risk giving HIV drugs to their patients who are IV drug addicts, because they feel the risks of noncompliance and adverse drug interactions are too great. Although that risk is real, advocates contend that physicians are also biased and unwilling to consider ways to assist HIV-positive IV drug users. Many IV drug users already have frequent contact with the medical system, including methadone centers.

Drug Interactions: Protease inhibitors are processed by the same P450 3A4 liver enzyme pathways as methadone and heroin, which makes predicting how these drugs will interact with a given HIV regimen difficult (see "HIV-Recreational Drug Interactions"). The purity of street drugs also varies greatly, adding yet more danger to the risk of mixing drugs.

TIPS:

• If you're shooting or are addicted to illegal drugs, you're at high risk for HIV. Consider getting help from trained professionals to reduce your risk. A drug-addiction treatment program and counseling are often the first steps toward managing HIV prevention, care, and treatment.
• If you use IV drugs and want to take HIV drugs, get your liver checked regularly and ask your doctor about potential interactions and dosing issues.
• Try not to use recreational drugs during your first six to eight weeks on HIV combination therapies.
• To reduce the risk of drug interactions, don't take HIV meds and recreational drugs at the same time.
• Drink lots of water to flush out your kidneys, and avoid alcohol.
• Getting high increases your chance of forgetting to take HIV meds. Get a drug buddy/friend to help you remember to take your HIV drugs on schedule.
• Report suspicious interactions to the FDA at 1-800-FDA-1088.