NIDA Responds to the Changing Dynamics of the AIDS Epidemic

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NIDA Director, Alan I. Leshner

Drug abuse and the spread of HIV/AIDS, as well as other infectious diseases such as hepatitis and tuberculosis, are inextricably linked public health problems that require many and multifaceted solutions.

A majority of new HIV infections in this Nation are related to drug abuse-through sharing of contaminated drug injection paraphernalia, through sexual contact with an injection drug user, or through the transmission of HIV perinatally.(See "CDC Report Highlights Link Between Drug Abuse and Spread of HIV,"). NIDA has expanded its research efforts in this area to meet this challenge. The Institute has also set policies to ensure that all participants in NIDA-supported AIDS research are offered HIV testing and counseling.

NIDA-funded research has found that, through drug abuse treatment, prevention,and community-based outreach programs, drug abusers can change their behaviors. They can reduce or eliminate drug use, drug-related HIV risk behaviors such as needle sharing, unsafe sex practices, and, in turn, the risk of HIV/AIDS. NIDA research also is working to reduce HIV and other AIDS-related illnesses and improve overall survival rates for HIV-infected drug abusers by increasing their access and adherence to medical treatment. With a comprehensive research portfolio that is responsive to the changing dynamics of the AIDS epidemic, NIDA is improving the quality of life for many, as well as saving both lives and enormous costs to society.

Drug abuse treatment, prevention, and community-based outreach programs can change behaviors to decrease the risk of HIV/AIDS.

NIDA-funded research has clearly shown that drug abuse treatment is highly effective in preventing the spread of HIV. Numerous studies have shown that individuals who enter drug abuse treatment programs reduce their drug use, which, in turn, leads to fewer instances of HIV high-risk behaviors.

NIDA's research into this field began early in the AIDS epidemic. One of the Institute's first investigations of drug use patterns among injection drug users (IDUs)-conducted in methadone treatment programs in New YorkCity, Philadelphia, and Baltimore-found that not only did participants report reduced sharing of needles, but also, 70 percent reported that they no longer injected drugs daily.

In addition to reducing injection drug use, individuals in drug abuse treatment programs have been found to have significantly lower HIV infection rates than drug abusers not in treatment. Researchers in Philadelphia compared HIV infection rates among drug abusers enrolled in methadone treatment programs to rates among those not in treatment. During the first 18 months of the study, those who remained out of treatment were nearly seven times more likely to have become infected with the AIDS virus than those in treatment. The investigators also found that the longer drug abusers remained in treatment,the less likely they were to become infected.

In aggregate, studies that look at abuse of drugs other than heroin and other injection drugs also are showing that drug abuse treatment lowers rates of HIV risk behaviors and infection. The bottom line is that providing access to effective drug abuse treatment programs is a proven way to prevent the spread of HIV/AIDS.

This is encouraging news. The discouraging news, of course, is that only a small percentage of those who need drug abuse treatment receive it. In fact, about 85 percent of chronic drug abusers are not in drug abuse treatment at any given time.

To reach that 85 percent, NIDA launched research to develop community-based outreach interventions to reduce the spread of HIV. The National AIDS Demonstration Research (NADR) Program was the first multisite research program to deliver and evaluate HIV risk reduction outreach programs to drug abusers not in treatment. As part of the interventions, outreach staff indigenous to the selected communities met with IDUs in their natural settings to distribute HIV risk reduction information and offer additional counseling and HIV testing. The outreach workers acted as credible messengers, provided risk reduction materials and education, and arranged for IDUs to receive free, private HIV testing and counseling. The ongoing Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program uses similar behavioral interventions to reduce HIV risk taking and increase protective behaviors.

These programs and other NIDA-funded research have helped identify intervention models that enable IDUs to reduce their drug use, needle-sharing practices, unsafe sex behaviors, and, importantly, their HIV infection rates.

For example, a 4-year study at one of the first NADR projects in Chicago used ex-addicts to deliver HIV prevention services such as HIV testing and counseling. IDUs who were exposed to the intervention showed a significant decrease in the rate of new HIV infections. This is just one illustration of how outreach can help IDUs not in treatment change their HIV risk behaviors.

While we continue to fund research on interventions that change behaviors and prevent HIV transmission, we are also studying how to link HIV-infected drug abusers to the medical care they need for their HIV and related illnesses. Other NIDA-funded research is examining ways to increase drug abusers' compliance with medical treatment. Long-term studies are examining the influence of drug use on the progression of HIV and on the effectiveness of medical treatment.

We are also funding research that is examining the special needs of HIV-infected women who are drug abusers. Unfortunately, with AIDS now being the fourth leading cause of death among women 15 to 44, the need is greater than ever to address the multitude of issues concerning this population. Among other things, NIDA-funded research is investigating the impact of drug use on maternal-infant HIV transmission, the course of the disease in drug-abusing women and their infants, and treatment with HIV medications to reduce transmission.

Given the public health implications of HIV/AIDS and drug abuse, NIDA must work to disseminate its research findings to the public health community at large. NIDA is teaming with the Centers for Disease Control and Prevention to reach their network of public health professionals in order to inform them what NIDA's research is showing about the inextricable link between these two diseases. Despite substantial progress in HIV/AIDS prevention with drug abusers, unacceptably high numbers of new HIV infections are occurring in drug abusers, their sex partners, and their children. Many drug abusers still are engaging in high risk practices. To curtail or reverse this trend, NIDA will continue to build a comprehensive research portfolio that will respond to the changing dynamics of the AIDS epidemic. Equipped with the knowledge that drug abuse treatment, prevention, and community-based outreach programs can change behaviors to decrease the risk of HIV/AIDS, NIDA is in a position to develop the most innovative and effective programs possible through its research.