Substance Use and Human Immunodeficiency

Substance use and human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) are often interrelated conditions. Although globally, injection drug use is related to between five and ten percent of HIV infections, in certain countries in Asia, Europe, the Middle East, North America, and South America, up to 80% of all HIV infections are related to injection drug users (Von Unger & Collins). Following are reviews of three articles dealing with the implications of HIV / AIDS and the diagnosis, prevention, and treatment of substance use disorders.

Transforming the meaning of HIV / AIDS in recovery from substance use: A qualitative study of HIV-positive women in New York:

Von Unger and Collins note that for women with HIV / AIDS, recovering from substance abuse is often also a primary concern. The authors implemented a qualitative study to explore how the meaning of a woman's HIV / AIDS infection transforms as they from drug use to recovered drug user. Although the researchers found that most women did not feel their main reason for starting the drug use recovery was their HIV / AIDS diagnosis, the dual diagnosis program facilitated a significant transformation of the meaning of this diagnosis. Previously, a diagnosis of HIV / AIDS was often seen as an excuse to continue to use drugs. However, Von Unger and Collins found that the dual diagnosis program transformed the participants' mindset so that they found this diagnosis now a motivator to stay drug-free, even though initially it wasn't a primary motivator for recovery.

Since the beginning of the AIDS epidemic through 2003, 163,396 women had been diagnosed with AIDS. Of these diagnoses, 38% of the women had had a history of injection drug use. However, Von Unger and Collins cite large cohort studies, which found that only ten percent of women diagnosed with HIV / AIDS had used drugs in the recent past. These results suggest that a large proportion of women infected with HIV have made the decision to discontinue injection drug use. This recovery process is multi-phased process that often includes relapses.

The impetus to seek treatment and discontinue drug use is different for each drug user. A moment of crisis, or hitting 'rock bottom' is often expressed as a reason for going into recovery, for some addicts. Von Unger and Collins note that for women this catalyst sometimes comes in the form of the realization that they have narrowing life options, are not able to 'take care of business,' or a pregnancy. Additionally, there are a variety of external and internal factors that play a role in influencing women to seek treatment for their addiction. Externally, social and health service interventions, the threat of lost child custody, court-ordered substance abuse treatment, relatives and friends, and a need to remove oneself from a physically abusive situation often motivate women to seek treatment. Internally, health problems, psychological problems, an inner desire to fulfill the role of a parent, and hitting rock bottom are all common treatment motivators for female drug users. As stressful events in life can be effective in prompting women's drug use recovery, Von Unger and Collins explored what impact an HIV / AIDS diagnosis had on prompting women to enter recovery.

Theoretically, as HIV / AIDS is known to cause both emotional and physiological distress, this may be a motivating factor for women to seek treatment. Citing past research, Von Unger and Collins note that stress-related personal growth leading to other positive changes have been found in women with HIV / AIDS. However, being diagnosed with HIV has also shown negative effects for those affected, which can lead to increased drug use. In one 2002 study, Von Unger and Collins note that 30% of the participants in the study reported using alcohol and drugs as a coping mechanism following an HIV diagnosis. The researchers further caution readers' expectations that an HIV / AIDS diagnosis will encourage women to seek treatment in the United States, given the demographic of most American women diagnosed with HIV / AIDS. Most are women of color, from low-income populations and are subjected to a wide variety of stressful life events. An HIV / AIDS diagnosis may not be the single most important factor in their decision to seek treatment. "In fact, women with HIV / AIDS often perceive violence, separation form their children, poverty, drug use, and housing needs as more urgent and significant matters than their HIV infection" (310).

Von Unger and Collins interviewed 15 female participants of various racial backgrounds, between the ages of 30 and 52 years old. These participants reported that their predominant drug of choice was either crack/cocaine or heroin; however, most participants were multi-substance users. Interestingly, there was very little emphasis placed on the participant's HIV infections, when they were interviewed, although this differed slightly depending on the participants' health status. Instead, most participants spent more time discussing their substance abuse and recovery. The diagnosis of HIV / AIDS was seen as a symptom of a much greater problem -- drug use. This finding confirmed the researchers' theories regarding the stressors present in the lives of low-income, ethnic minority women who are the predominant female HIV / AIDS victims in the United States.

It was found that when a participant received an HIV diagnosis while they were actively addicted, this diagnosis simply added stress to their life and thus resulted in either continued or increased substance abuse. This finding is supportive of past research Von Unger and Collins cite which found that women who are substance abusers have a tendency to turn to increased drug use after receiving a positive test result. However, there has been other research that has found that an HIV diagnosis serves to be a life-altering event that serves as a catalyst for some women to seek treatment. Von Unger and Collins explain this discrepancy with the diversity within the group of HIV-positive women who use drugs. Also, their research found that HIV did become a motivating factor for treatment and recovery at the onset of HIV-related symptoms and when they had seen others suffering from AIDS or had enrolled in the program, not at the receipt of positive test results and not the onset of symptoms alone. Instead, as previous research had indicated, participants in this study indicated that the onset of symptoms alone sometimes led to increased drug use. The hopelessness, depression and feeling of lack of support many women experience during the active stage of drug addiction exacerbated the situation, resulting the many of the participants feeling their HIV infection was another justification to use drugs.

Only those women who "had reached a level of frustration with their drug-using lifestyle, when they were 'ready' to change, and when they were able to find treatment and support, they tended to perceive their HIV infection in a different light" (Von Unger & Collins, 321). Even those women who entered treatment programs recalled that their interpretation and understanding of their HIV infection changed, due to the treatment program. Thanks to their participation in the treatment program, the women were able to better consider their diagnosis, and thus it stopped being a reason to use drugs. Treatment provided hope that the women could live with HIV. For those participants who were in more advanced stages of HIV / AIDS, they related that disease symptoms and death provided motivation to remain drug free. For this reason, the researchers concluded that the process of drug recovery actually transformed the meaning of the disease, for the women participating in their study.

Factors associated with HIV / AIDS high-risk behaviors among female injection drug users:

Fitzgerald, Lundgren and Chassler examined the factors that were associated with the engagement of high-risk HIV / AIDS behaviors for female injection drug users. The researchers included using injection drugs within the past six-month, sharing needles within the past six months, and engaging in unprotected sex in the past thirty days, as high-risk behaviors. It was found that whether or not the participant lived with a spouse, at the one-year point following the first interview, was positively and significantly associated with the defined high-risk behaviors, at both the initial interview and the one-year interview. Interestingly, two factors that were significantly negatively associated with high-risk HIV / AIDS behaviors was when the participant was being prescribed medication for emotional or psychological problems or had tested positive for HIV / AIDS.

Fitzgerald, Lundgren and Chassler interviewed 185 Hispanic, African-American and White-European female injection drug users twice, with the interviews spaced 12 months apart. Specifically, their study focused on whether women who lived with a spouse or partner were more likely to report engagement in high-risk HIV / AIDS behaviors. In the beginning a variety of partnership status types were measured. "However, only living with a spouse was significantly associated with being in the high-risk category, with 70% of those living with a spouse being in the high-risk group" (71). It was found that women who lived with their spouse were nearly 12 times more likely to take part in high-risk HIV / AIDS behaviors at both interview times, when compared with those who didn't live with a spouse, after the researchers controlled for all other model variables. Those participants in the high-risk groups were found to significantly associated with certain psychiatric conditions. These included: anxiety/tension, depression, having serious thoughts of suicide, experiencing hallucinations, and difficulties concentrating. In addition, participants who had reported being bothered by psychological or emotional problems, within the last 30 days, were also significantly more likely to be in the high-risk HIV / AIDS group.

This is in contrast to the results of those who had tested positive for HIV / AIDS, with only 15% of respondents who were HIV / AIDS positive being in the high-risk group, according to Fitzgerald, Lundgren and Chassler. In fact, those participants who were HIV / AIDS positive were approximately 82% less likely to be found to engage in the defined high-risk behaviors, when compared with those who had not tested HIV / AIDS positive. In addition, at the bivariate level, the researchers found no significant difference in employment or homelessness for the two groups. The other factor that was also found to be significantly negatively associated with high-risk HIV / AIDS behaviors was prescription of psychiatric medications. It was found that participants of the study who had been prescribed medications for psychological or emotional problems were 61% less likely to take part in high-risk HIV / AIDS behaviors, when compared to participants who did not report having medications prescribed.

Fitzgerald, Lundgren and Chassler surmise that their findings suggest that the relationship injection drug using women have with spouses can be a significant factor in exposing these women to high-risk HIV / AIDS behaviors. In addition, testing for HIV / AIDS and ensuring female drug users receive the proper psychiatric medications may help protect them from the increased relationship risks associated with living with a spouse. Their "study findings verify the importance of interpersonal relationships in women's HIV / AIDS risk and are consistent with recommendations made by Amaro (1995) who suggests a switch in the focus of HIV / AIDS research from using individualistic behavioral and learning theory models to more holistic models addressing the complex set of issues women face in our society" (72).

Medication assisted treatment in the treatment of drug abuse and dependence in HIV / AIDS infected drug users:

As with the other two sets of researchers, Kresina, Bruce and McCance understand the strong association between HIV / AIDS infection, drug use and associated behaviors and deem this the twin epidemics -- HIV / AIDS and drug/alcohol use. This results in challenges in the management of medical care for health care providers, as well as researchers, working in the international HIV prevention and treatment fields.

Access to care and treatment, medication adherence to multiple therapeutic regimens, and concomitant drug -drug interactions of prescribed treatments are difficult barriers for drug users to overcome without directed interventions. Injection drug users are frequently disenfranchised from medical care and suffer sigma and discrimination creating

additional barriers to care and treatment for their drug abuse and dependence as well as

HIV infection (354). .

The researchers cite past research that has demonstrated how medication-assisted treatment of substance abuse dependence has been a valuable component of HIV / AIDS prevention intervention. Their article presents the total evidence that supports how important this medication-assisted treatment is for the treatment, care and prevention of HIV / AIDS infected people who are also drug and/or alcohol abusers.

As Fitzgerald, Lundgren and Chassler also had noted, Kresina, Bruce and McCance also recognize the relationship between the use and abuse of drugs and high-risk HIV / AIDS behaviors that increase the chance of infections. The authors specifically recognize the consumption of alcohol, which results in enhanced sexual sensation seeking and a greater HIV / AIDS risk. This theory is supported by World Health Organization publications and research studies. Studies in Sub-Saharan Africa has found that heavy alcohol use has resulted in less condom use, a greater number of sexual partners, and a greater acquisition of sexually transmitted diseases, including HIV / AIDS. The same is true for illicit drug use. Specifically in adolescents, drug use significantly increases high-risk HIV / AIDS behaviors, due to the perception of enhanced sexual arousal combined with reduced inhibitions and increased perceived social stature. In Central and Southeast Asia, heroin use and needle sharing are increasingly common high-risk HIV / AIDS behaviors. For these reasons, individuals who are at risk for being infected by HIV or who are already HIV positive, are individuals who use drugs. The prevention intervention programs for these individuals, as well as the treatment and care programs, need to also address the individual's drug abuse and dependence. Kresina, Bruce and McCance cite past studies that show that in programs when substance abuse and dependence is not addresses, the patients are not as likely to take part in anti-retroviral treatment for HIV / AIDS infection. However, for programs that do also provide substance abuse treatment as part of the program, they are more likely to begin treatment for their HIV / AIDS infection.

To determine the appropriate substance abuse treatment component, Kresina, Bruce and McCance surmise that the first step is to identify both the quantity and pattern of substance use. "Substance abuse is a complex physiological, social and behavioral disorder that often coexists with psychiatric illness as well as co-morbid medical conditions" (355). As such, substance users should also be screened for co-morbid psychiatric conditions as a component of any medical intervention, in addition to a comprehensive drug use treatment program. Additionally, the authors note that drug abuse treatment is a powerful strategy in HIV / AIDS prevention. Adding a mental health services components to a substance abuse treatment program further enhances the medical outcomes for treatment.