Drugs 

and 

Aids

NN0012
Drugs 

and 

Aids
ii

Introduction

The National Institute on Drug Abuse (NIDA) supports most of the world’s research on drug abuse and addiction. 

NIDA-funded research enables scientists to apply the most advanced techniques available to the study of every aspect of 

drug abuse, including:

• genetic and social determinants of vulnerability and response to drugs;

• short- and long-term effects of drugs on the brain, including addiction;

• other health and social impacts of drug abuse, including infectious diseases and economic costs;

• development and testing of medication and behavioral treatments for abuse and addiction; and

• development and evaluation of effective messages to deter young people, in particular, from abusing drugs.

Included in this document are selections of topic-specific articles reprinted from NIDA’s research newsletter, 

NIDA NOTES. Six times per year, NIDA NOTES reports on important highlights from NIDA-sponsored research, 

in a format that specialists and lay readers alike can read and put to use. Selections like the current one are intended to 

remind regular NIDA NOTES readers and inform other readers of important research discoveries during the periods 

they cover.

We hope the information contained here answers your needs and interests. To subscribe to NIDA NOTES and for further 

information on NIDA’s drug abuse and addiction research, please visit our Web site at www.drugabuse.gov.
Selenium Shows Promise as an Adjunct Therapy 

for HIV (V22-2; December 2008)................................ 1

Morphine Speeds AIDS Onset in Monkeys 

(V21-6; June 2008)....................................................... 2

Researchers Report on Progress of NIDA’s Southern 

Africa Initiative (V21-5; March 2008) .......................... 3

HIV Patients Show Better Immune Recovery With 

Early Initiative of HAART (V21-5; March 2008)......... 4

Meeting Reviews Roles of Drug Abuse and Risky 

Behavior in HIV (V21-4; October 2007)...................... 5

Journal Highlights Global Nexus of Drug Abuse and 

HIV/AIDS (V21-4; October 2007) .............................. 7

Challenges in HIV/AIDS Research 

(V20-6; July 2006)........................................................ 8

Methamphetamine Increases, and HIV Decreases, 

Brain Volumes (V20-6; July 2006) ............................... 9

Cocaine Abuse and HIV Are Linked With Coronary 

Calcification (V20-5; April 2006)............................... 11

NIDA Launches HIV/AIDS Public Awareness 

Campaign (V20-5; April 2006)................................... 13

NIDA at Work: AIDS Research Program 

(V20-4; March 2006).................................................. 14

Expanded HIV Testing: Benefits May Warrant Costs 

(V20-3; October 2005)............................................... 16

HIV/AIDS Research and Education Are Crucial 

to Drug Abuse Prevention (V20–3; October 2005).... 19

Researchers Adapt HIV Risk Prevention Program 

for African-American Women (V19-1; April 2004).... 20

High-Risk Sex Is Main Factor in HIV Infection 

for Men and Women Who Inject Drugs 

(V17-2; May 2002)..................................................... 23

NIDA Announces Science-Based Principles 

of HIV Prevention in Drug Users 

(V17-1; April 2002).................................................... 25

NIDA Research Advances Global Efforts To 

Prevent and Treat AIDS (V17-1; April 2002)............. 26

Prevention Program for HIV-Positive Youths 

Reduces Risks of Further HIV Transmission 

(V17-1; April 2002).................................................... 28

PSAs Warn Young Adults: Drug Use Can 

Impair Judgment, Result in Health Problems 

(V17-1; April 2002).................................................... 30

Preventing Drug Abuse-Related Infectious 

Diseases Through Community Outreach 

(V16-1; March 2001) ................................................ 31

Gender Differences in Drug Abuse Risks and 

Treatment (V15-4; September 2000) ......................... 32

Heating Solutions Used in Drug Injection 

May Inactivate HIV (V15-3; August 2000) ............... 33

Drug Abuse Treatment Programs Make Gains in 

Methadone Treatment and HIV Prevention 

(V15-3; August 2000) ................................................ 34

Addressing the Medical Consequences of 

Drug Abuse (V15-1; March 2000) ............................. 36

Among Drug Users, Peers Can Help 

Spread the Word About AIDS Prevention 

(V14-5; December 1999) ........................................... 38

Gender Differences in Progression to AIDS 

(V14-3; September 1999) .......................................... 41

Drug Abuse Research Helps Curtail the 

Spread Of Deadly Infectious Diseases 

(V14-2; August 1999) ................................................ 42

Heroin Snorters Risk Transition To 

Injection Drug Use And Infectious Disease 

(V14-2; August 1999) ................................................ 44

Special Journal Supplement Summarizes 

Research On HIV Prevention in Drug-Using 

Populations (V13-5; February 1999) ......................... 46

Researchers Find Gender Differences In How 

Drug Abusers Respond To HIV Prevention 

Strategies (V13-4; November 1998) ........................... 47

Drug Abuse Cost to Society Set at $97.7 Billion, 

Continuing Steady Increase Since 1975 

(V13-4; November 1998) .......................................... 48

Curbing Tuberculosis in Out-of-Treatment 

Injecting Drug Users (V13-3; July 1998) ................... 51

Linking Medical Care With Drug Abuse 

Treatment Stems Tuberculosis Among 

HIV-Infected Drug Users (V13-3; July 1998) ............ 52

iii

Table of Contents
Interagency Pacts and NIH Collaborations Extend 

NIDA’s Research Reach (V13-1; June 1998) ............. 54 

Contributions of Behavioral Research 

To AIDS Studies Recognized 

(V12-6; November/December 1997) ......................... 56

Other Drug-Use Paraphernalia Besides 

Needles May Increase HIV Infection Risk 

(V12-2; March/April 1997) ....................................... 57

CDC Report Highlights Link Between 

Drug Abuse and Spread of HIV 

(V12-2; March/April 1997) ....................................... 58

NIDA Responds to the Changing Dynamics of the 

AIDS Epidemic (V12-2; March/April 1997) ............. 60

Drug Use During Pregnancy Associated With 

Increased Risk of Transmitting HIV to Infants 

(V11-4; September/October 1996) ............................ 62

Opioid Analogue May Slow Spread of HIV in 

Brain (V11-4; September/October 1996) .................. 63

Drug Abuse Links to AIDS Prompt Highly Targeted 

Responses (V10-6; November/December 1995) ........ 65

Treatment and Outreach Research on AIDS: 

Identifying and Treating Those at Risk 

(V10-3; May/June 1995) ........................................... 67

NIDA Urges HIV Counseling, Testing for 

Research Subjects (V10-3; May/June 1995) ............... 70

NIDA Plays Key Role in Studying Links Between 

AIDS and Drug Abuse (V10-3; May/June 1995) ...... 71

Basic and Clinical Research on AIDS: From the 

Molecule to the Patient (V10-3; May/June 1995) ..... 73

AIDS Brings Greater Research Obligation, More 

Potential for Results (V10-3; May/June 1995) ........... 76

iv
Selenium Shows Promise as an Adjunct Therapy for HIV

Research Findings

Volume 22, Number 2 (December 2008)

Daily selenium supplements could serve as a useful adjunct therapy for HIV infection by 

holding HIV-1 viral load in check and elevating levels of infection-fighting CD4 cells. A 

randomized controlled trial, led by Dr. Barry Hurwitz of the University of Miami, included 262 HIV-infected men and women. After 9 months of treatment, greater increases 

of serum selenium predicted lower HIV viral load and greater CD4 cell count. Notably, 

of the 141 selenium-treated participants, the 50 whose selenium levels increased by 

26.1 mg/L or more displayed no increase in HIV viral load, and their concentrations of 

CD4 cells increased by 24.2 percent. In contrast, the 121 placebo-treated participants averaged an increase of 20.2 percent in HIV viral load, which researchers consider large enough 

to affect the course of the disease. The selenium-treatment advantage, which was gained 

only by participants who took the supplement as scheduled, held when the researchers accounted for factors that affect 

immune responses, including antiretroviral therapy. No side effects were observed.

Source

• Archives of Internal Medicine 167(2):148-154, 2007. 

1
Morphine Speeds AIDS Onset in Monkeys

Research Findings

Volume 21, Number 6 (June 2008)

Dr. Anil Kumar and colleagues at the Ponce School of Medicine, Puerto Rico, have discovered key ways in which morphine may accelerate the progression of AIDS: The drug increases both viral replication and alterations in a particular 

part of the virus’s coating. Monkeys exposed to long-term morphine administration—20 weeks prior to infection with 

simian/human immunodeficiency virus (SIV/SHIV) and throughout the 56-week study period—progressed to AIDS 

faster and showed more signs of compromised immune systems than comparison animals. Of the morphine-exposed 

animals that developed AIDS, three demonstrated higher viral replication in their blood and cerebrospinal fluid (CSF). 

When the researchers zeroed in on particular areas of the viral envelope—a lipid-protein covering that helps viruses penetrate cells—they found that morphine-exposed monkeys demonstrated a higher degree of change in the V4 region than 

control animals. This difference, which may expand the range of cells that HIV can infect, occurred in both CSF and 

blood. The extent of V4 evolution corresponded with rapid disease progression. Studies such as this aim to open new 

avenues for intervening against HIV.

Sources

• Virology 354(1):192-206, 2006.

• Virology 358(2):373-383, 2007.

2
Volume #, Number # (Month Year)

3

Researchers Report on Progress of NIDA’s Southern Africa 

Initiative

Research Findings

Volume 21, Number 5 (March 2008)

Research projects conducted under NIDA’s Southern 

Africa Initiative help universities and other organizations in southern Africa build research capacity and 

infrastructure in the area of addiction, particularly drugrelated HIV transmission. The Initiative, administered by 

NIDA’s Special Populations Office (SPO) with assistance 

from the International Program, comprises 12 research 

projects. NIDA-funded investigators based in the United 

States and African collaborators recently reported on the 

progress of their projects, most of which have taken place 

or are ongoing in the Republic of South Africa.

Dr. Torrance Stephens of Morehouse School of Medicine 

and Dr. Sibusiso Sifunda of the South African Medical 

Research Council described the development and testing 

of a peer-led intervention to prevent about-to-be-released 

prison inmates from spreading sexually transmitted diseases, including HIV, to community residents. The intervention—which included cultural perspectives on manhood 

and responsibility, videotaped stories from role models, 

and group discussions—improved participants’ attitudes 

regarding safe sex and their motivation to reduce risky 

behaviors. The research team worked closely with the 

South African minister of corrections and the Department 

of Correctional Services (DCS) in nine provinces and four 

prisons to provide training for DCS staff and peer education for ex-inmates.

Dr. Murelle Harrison of Southern University in Baton 

Rouge, Louisiana and Dr. Dorothy Malaka of the 

University of Limpopo, South Africa, reported on a comparison of African-American and South African families 

living in rural areas. They observed similar sociodemographic and family characteristics and youth behaviors 

in both populations. For example, children who spent 

more time interacting with their mothers also showed 

better self-control and cognitive development. The team 

hopes the baseline data will serve as a foundation for a 

subsequent family intervention. In other project results, 

22 South African students were trained in epidemiological data collection methods, two South African researchers 

observed rural data collection in the United States and 

sharpened skills with computer software for data analysis, and 18 primary school teachers and nine principals 

received assistance with educational computer technology.

Dr. Donnie Watson of the Friends Research Institute 

in Torrance, California and Dr. Solomon Rataemane of 

the University of Limpopo reviewed preliminary findings from a comparison of three different approaches to 

teaching experienced drug abuse counselors cognitivebehavioral therapy: (1) in-person training with subsequent 

supervision, (2) distance learning of the same training 

with subsequent telephone-based supervision, and (3) selfstudy with a therapy manual after an initial orientation. 

The in-person and distance-learning approaches were wellreceived, and the team continues to recruit licensed clinicians who work in 30 South African National Council on 

Alcoholism and Drug Dependence treatment centers. 

“The Southern Africa Initiative represents a relatively 

small investment, $2 to $2.5 million, with a tremendous 

payoff for all participants,” says SPO Chief Dr. Lula 

Beatty. “After hearing reports on the research projects, my 

colleagues and I were struck by the immediate impact that 

some of the collaborations had on communities.” NIDA 

hopes that information obtained from the projects will 

facilitate the use of evidence-based interventions that are 

culturally appropriate for southern Africa and that the 

training activities will strengthen addiction research in the 

region. 

3
HIV Patients Show Better Immune Recovery With Early Initiation 

of HAART

Research Findings

Volume 21, Number 5 (March 2008)

4
Meeting Reviews Roles of Drug Abuse and Risky Behavior in HIV

Research Findings

Volume 21, Number 4 (October 2007)

More than 400 researchers and clinicians gathered in 

Bethesda, Maryland, May 8-9 to discuss the impact of 

drug abuse on the spread of HIV. NIDA sponsored the 

meeting in collaboration with other National Institutes of 

Health agencies and the Centers for Disease Control and 

Prevention.

Drug and alcohol abuse can prompt poor judgment and 

actions that people might not engage in otherwise, for 

example, risky sexual behaviors with infected partners. 

Drug abuse also may increase HIV transmission when 

abusers trade sex for drugs or money. The increased risk of 

HIV related to drug abuse extends beyond the sharing of 

drug injection equipment to include such risky behaviors.

Dr. Igor Grant of the University of California, San Diego, 

addressed methamphetamine abuse and HIV. The drug 

and the infection each cause degenerative brain disease. 

They may damage neural tissue through a common biological pathway—for example, enhanced inflammatory 

responses—but also seem to generate distinct pathologies 

that may combine to exacerbate each other. The resulting 

cognitive impairments may explain why methamphetamine abuse reduces adherence to HIV medications, that, 

in turn, may facilitate HIV transmission.

Dr. Jonathan M. Ellen of the Johns Hopkins University 

School of Medicine linked marijuana abuse with risky 

sexual behavior among African-American youth in San 

Francisco. Another study indicated that HIV-infected 

young women who abuse marijuana are less likely to 

keep medical appointments. Dr. Richard A. Rawson 

of the University of California, Los Angeles, reported 

preliminary results suggesting that addiction treatment 

reduced risky sexual behaviors among methamphetamine 

abusers—adding to similar findings among methamphetamine-abusing men who have sex with men (see 

“Treatment Curbs Methamphetamine Abuse Among 

Gay and Bisexual Men,” NIDA Notes, Vol. 20, No. 4) 

Similarly, Dr. Kenzie L. Preston of NIDA’s Intramural 

Research Program reported that adding behavioral therapy 

to methadone maintenance treatment can reduce risky 

behaviors among outpatients addicted to heroin and 

cocaine.

NIDA-funded research on the link between drug abuse 

and HIV infection extends to the international community. Dr. Steffanie A. Strathdee, an infectious disease epidemiologist at the University of California, San 

Diego, reported that HIV infection among injection 

drug users has risen sharply in many countries—including the Ukraine, the Russian Federation, Vietnam, Iran, 

and China—with emerging epidemics in other nations. 

Interventions that reduce risky behaviors among populations that interact with both high- and low-risk individuals (for example, prisoners, non-injecting drug users, and 

sex workers who inject drugs) are important opportunities 

for HIV prevention.

Participants also discussed the disproportionate burden 

of HIV/AIDS among people in prisons and jails and the 

importance of interventions in such settings. Improved 

technology now allows for faster HIV testing, and expanded testing and counseling are key components of prevention strategies for drug abusers and other groups.

Adolescent Inhalant Use Is Stable Overall, but Rising 

Among Girls

Almost 5 percent of girls between the ages of 12 and 17 

used an inhalant to get high in 2005, an increase from 

4.1 percent in 2002, according to a new report. Overall, 

inhalant use by boys and girls in this age group remained 

stable over the 4-year period, at an average annual rate of 

4.5 percent, or an estimated 1.1 million adolescents.

The report, “Patterns and Trends in Inhalant Use by 

Adolescent Males and Females: 2002-2005,” is based on 

an analysis of the 2002-2005 National Household Survey 

on Drug Use and Health, an annual survey sponsored 

by the Substance Abuse and Mental Health Services 

Administration (SAMHSA). SAMHSA, NIDA, and other 

federal agencies released the report at a March 15 press 

conference to kick off the 15th National Inhalants and 

Poisons Awareness Week, March 18-25. 

5
6

“Young people who turn to inhalants may be completely 

unaware of the serious health risks,” said NIDA Deputy 

Director Dr. Timothy P. Condon. “We know that inhalant abuse can start early, with research suggesting that 

even preadolescent children seek them out because they 

are easy to obtain. NIDA research also indicates that those 

who begin using inhalants at an early age are more likely 

to become dependent on them—and long-term inhalant 

abusers are among the most difficult drug abuse patients 

to treat.”

The report is available at www.drugabusestatistics.samhsa.

gov/2k7/inhalants/inhalants.pdf. 

6
Volume #, Number # (Month Year)

7

Journal Highlights Global Nexus of Drug Abuse and HIV/AIDS

Research Findings

Volume 21, Number 4 (October 2007)

One of the most urgent public health goals of addiction 

researchers is to curb drug abuse behaviors that contribute 

to the spread of HIV/AIDS, says a special supplement 

to Drug and Alcohol Dependence sponsored by the NIDA 

International Program.

Dr. Steven Gust, director of the program and an editor 

of the supplement, observes that about 5 percent of the 

world’s population aged 15 to 64 abuses drugs and that 

this behavior is a major factor in the transmission of 

HIV/AIDS and other illnesses. Two key routes of HIV 

infection are through the sharing of needles and other 

drug injection paraphernalia and high-risk sexual contact, 

with the latter being one of the fastest-growing routes 

among women.

NIDA-supported research has shown that preventive 

interventions and substance abuse treatment can reduce 

the transmission of HIV in drug-abusing populations. 

By promoting collaborative research across the globe, the 

NIDA International Program hopes to improve treatments and outreach programs to reduce high-risk drug use 

and sexual behaviors, Dr. Gust says.

The supplement compiles studies—several of them funded 

by NIDA—on drug-related HIV transmission in 16 different localities across the globe. Most of the studies focus 

on injection drug use, a primary pathway for HIV transmission. Some of the topics covered are:

• The relationships between needle-sharing practices 

and HIV infection among heroin abusers in Dar es 

Salaam, Tanzania; 

• The prevalence of HIV and hepatitis C infections 

among injection drug users receiving substance abuse 

treatment in two large hospitals in Barcelona, Spain; 

• HIV prevalence among heroin-addicted individuals in 

Muar, Malaysia; 

• Sexual risk behaviors among injection drug users in 

Shanghai, China; 

• The impact of drug abuse on adherence to highly 

active antiretroviral therapy (HAART) among HIVpositive outpatients in France; 

• HIV/AIDS risk factors along the U.S.-Mexico border; 

• Regional differences in the characteristics of injection 

drug users in New South Wales, Australia; and 

• The acceptability of audio computer-assisted selfinterview among substance abusers in Rio de 

Janeiro, Brazil. 

Since 1990, the NIDA International Program has fostered 

cooperative research and the exchange of scientific information by drug abuse researchers worldwide. The program’s objectives include promoting international research 

and collaboration, communicating and disseminating 

science-based drug abuse information, and supporting 

research training and exchange opportunities. More information on the link between drug abuse and HIV/AIDS is 

available at www.hiv.drugabuse.gov.

Source

• Gust, S.W., Strathdee, S.A., and Winstanley, E.L., 

eds.. Drug Abuse and HIV/AIDS: International 

Research Lessons and Imperatives. Drug and Alcohol 

Dependence 82(S1), 2006. 

7
Challenges in HIV/AIDS Research 

By NIDA Director Nora D. Volkow, M.D.

Research Findings

Volume 20, Number 6 (July 2006)

The HIV/AIDS epidemic has always been a moving target 

for health and prevention planners, with infection rates 

rising in some population groups as they 

level off or fall in others. Recently, the disease has spread most rapidly among women, 

minorities, lower income groups, and young 

men who have sex with men (MSM). Of 

particular concern to NIDA are the heavy 

burden of HIV among African-Americans 

and the growing importance of heterosexual 

activity associated with drug use as a source 

of viral transmission. To elucidate the current dynamics, NIDA has developed two 

new initiatives: Health Disparities in 

HIV/AIDS: Focus on African Americans 

(PA-06-069) and Non-injection Drug 

Abuse and HIV/AIDS (PAS-06-054).

African-Americans: Higher Prevalence, Worse 

Prognosis

People from all racial and cultural backgrounds contract 

HIV/AIDS, but in the United States, African-Americans 

carry a disproportionate burden of the disease. Although 

they make up only 12 percent of the U.S. population, 

African-Americans accounted for half of the new AIDS 

cases diagnosed in 2003. Of persons diagnosed with AIDS 

since 1995, a smaller percentage of African-Americans (60 

percent) than Whites (70 percent) were alive 9 years after 

diagnosis. NIDA-supported investigators have identified 

some contributing factors:

• A higher likelihood that a particular episode of sexual 

activity or injection drug abuse will result in HIV 

transmission among African-Americans than other 

ethnic groups: The elevated prevalence of HIV in the 

African-American community raises the chances that 

a sexual or needle-sharing partner will have the virus.

• Lack of awareness of HIV status: African-Americans 

account for more than half of those receiving an 

AIDS diagnosis within 1 year of testing positive for 

HIV, an indication that the infection went undiagnosed for a long time. A related finding suggests that 

as many as 90 percent of African-American 

HIV-positive MSM do not know they are 

infected. 

NIDA’s African-American initiative will 

support research to further illuminate the 

causes of the HIV disparities affecting 

African-Americans, as well as research on:

• Access to HIV treatment and 

services available to drug-abusing 

African-Americans;

• Connections between HIV/AIDS and 

criminal justice involvement;

• Mental health issues that influence 

HIV high-risk behaviors; and

• Sociocultural factors that enhance, sustain, or perpetuate health disparities. 

Noninjection Drug Use and HIV/AIDS

Since the early years of the epidemic, NIDA-supported 

research contributed to a decline in the proportion of 

HIV/AIDS cases attributable to injection drug use. Now, 

NIDA is also focusing attention on ways that noninjection 

drug use—more prevalent by far—may contribute to new 

HIV infections. We know that drug abuse affects judgment and may lead to high-risk sexual encounters that 

increase transmission rates. There also is evidence that, 

regardless of the route of exposure, drugs have immunological effects that may increase the risk of HIV transmission and disease sequelae. To further advance 

scientific understanding of the relationships, we support 

studies that help explain how, where, why, and among 

whom HIV/AIDS is spreading through noninjection 

drug use and associated high-risk sexual behavior; and 

studies that develop effective prevention and treatment 

interventions. 

8
Methamphetamine Increases, and HIV Decreases, Brain Volumes 

HIV infection and methamphetamine addiction produce distinct, partly overlapping effects on 

brain structures.

By John S. DeMott, NIDA Notes Contributing Writer

Research Findings

Volume 20, Number 6 (July 2006)

In a study that confirmed the association between HIV 

infection and loss of brain volume, NIDA-funded investigators also found an association between methamphetamine addiction and increased regional brain volume. 

Each type of volume change was associated with neurocognitive impairments, but it was unclear whether the two 

together caused any cognitive effects beyond the sum of 

what each produced individually.

Using structural magnetic resonance imaging (MRI), Drs. 

Terry L. Jernigan, Anthony C. Gamst, and colleagues at 

the University of California, San Diego (UCSD) mapped 

the major gray-matter brain structures of 103 people 

in four age- and educationmatched groups: HIVinfected; methamphetamineaddicted; having both 

conditions; and having 

neither. The methamphetamineaddicted individuals were 

in recovery at UCSD’s HIV 

Neurobehavioral Research 

Center.

After accounting for normal 

age-related reductions in brain 

volume, the participants with 

HIV had smaller volumes of 

cortical, limbic, and striatal 

structures, with the associations being most 

pronounced in the frontal 

and temporal lobes. 

Methamphetamine addiction 

was linked with increased 

volume in the parietal cortex 

and in all three segments of 

the basal ganglia—caudate 

nucleus, lenticular nucleus, 

and nucleus accumbens 

(NAc). In the caudate, 

volume reductions related 

to HIV and increases related 

to methamphetamine overlapped, producing a net volume approximating normal.

A further analysis of the volume data may reinforce existing evidence that drug abuse is especially damaging during 

adolescence and young adulthood, when the brain is still 

developing. The results showed that addicted individuals 

who were younger had greater NAc volume differentials 

compared with their non-drug-abusing age mates than 

did older addicted individuals. One possible explanation 

for this is that the drug interfered with the pruning of 

some NAc connecting fibers that normally occurs in the 

transition to adulthood, producing a small but measurable 

reduction in NAc volume. “While we can’t be certain of 

the explanation, this finding highlights the concern that 

9
exposure during adolescence may alter the course of 

ongoing brain maturation,” says Dr. Jernigan (see chart).

Although the study results provided little information 

about specific drug mechanisms, the investigators note 

that animal studies have shown methamphetamine can 

incite inflammatory responses and abnormal growth of 

nerve fibers, each of which can increase tissue volume. 

“These findings emphasize that the brain’s response to 

stimulant exposure, and indeed to HIV as well, is probably quite dynamic, characterized by overlapping responses 

in different glial, as well as neuronal, cell populations,” 

says Dr. Jernigan. “The findings raise interesting questions 

for multiple-modality imaging studies, and underscore the 

degree of neural plasticity, and thus the potential for targeted intervention.”

Dr. Jernigan says a finding of extensive change in the parietal cortex of methamphetamine abusers “helps to confirm 

the importance of parietal lobe involvement and may help 

correct a tendency in the field to neglect this region.”

Implications for Brain Function

The researchers looked for correlations between the brain 

volume abnormalities and ratings of neuropsychological 

impairment. At the outset of the study, all other groups 

were significantly impaired relative to the HIV-negative 

and methamphetamine-negative group, which had a rating of 2.9 compared with 4.7 for those with both conditions, 4.2 for methamphetamine-addicted participants 

and 4.1 for HIV-positive individuals. Brain impairment 

was most pronounced in the HIV-positive participants 

with the most extensive loss of cortical volume and in the 

methamphetamine-addicted participants with the highest 

increase in cortical volume. The investigators found only 

one significant correlation between brain volumes and 

impairment in addicted individuals with HIV, a finding 

they believe probably reflects confounding by the opposed 

volume impacts of the two pathologies. The correlation 

was between hippocampal volume—a structure that both 

factors may damage—and severity of cognitive impairment in the dually diagnosed group.

“The fact that brain alterations in methamphetamine 

dependence and HIV infection are distinct from each 

other is a clue that may help us to sort out the origins 

of different kinds of mental problems in these individuals,” Dr. Jernigan says. “This is very exciting, because our 

results raise a number of specific questions that may not 

have been posed without these findings.”

Dr. Ro Nemeth-Coslett, a NIDA psychologist, agrees. 

“As often happens in research, these results raise more 

questions than they answer. Dr. Jernigan’s findings of 

structural inconsistencies in pathology are unaccounted 

for. Now we need mechanistic studies to provide a clearer 

understanding of what aspects of microscopic cellular 

organization actually drive the MRI measures.”

Source

• Jernigan, T. L., et al. Effects of methamphetamine 

dependence and HIV infection on cerebral morphology. American Journal of Psychiatry 162(8):1461-

1472, 2005. 

10

“The fact that brain alterations in 

methamphetamine dependence and 

HIV infection are distinct from each 

other is a clue that may help us

to sort out the origins of different 

kinds of mental problems in 

these individuals.”

The healthy comparison curve is shown.
Research Findings

Volume 20, Number 5 (April 2006)

11

Cocaine Abuse and HIV Are Linked With Coronary Calcification

Cardiovascular changes that are potential risk factors for serious heart disease are detected in relatively 

young people with HIV infection or a history of cocaine abuse.

By Lori Whitten, NIDA Notes Staff Writer

Cocaine abuse and HIV infection each raise the likelihood that calcium deposits will form in coronary arteries, 

according to a NIDA-supported study. The findings, by 

Dr. Shenghan Lai and colleagues at The Johns Hopkins 

University, suggest that individuals with either problem 

may develop elevated risks for serious, potentially fatal 

heart disease. The gradual buildup of calcium deposits and 

fat along the inner walls of blood vessels produces atherosclerosis, the narrowing and obstruction of the vessels that 

is a major cause of strokes and heart attacks. Although 

none of the participants in the study had a clinical heart 

problem, all were relatively young to have coronary 

calcification.

Dr. Lai and his colleagues used cardiac computed tomography (CT) scanning to detect the presence of coronary 

calcification and the number, size, and volume of calcium 

deposits in 192 African-American men and women aged 

25 to 45. Thirty-two of the participants did not have HIV 

infection and had never abused cocaine (HIV-/cocaine-), 

28 had the infection and were nonabusers (HIV+/cocaine-), 

47 did not have the infection and had abused cocaine 

(HIV-/cocaine+), and 85 had both conditions (HIV+/

cocaine+). About two-thirds were men.

The results revealed coronary calcification in almost onethird (31 percent) of the participants. The prevalence was 

twice as high in the HIV+/cocaine+ group (38 percent) as 

in the HIV-/cocaine- group (19 percent). In the other two 

groups, the proportion of participants with the condition 

fell in between, with 29 percent of the HIV+/cocaine- and 

30 percent of the HIV-/cocaine+ groups showing coronary 

calcification (see chart). In the U.S. population as a whole, 

the prevalence of coronary calcification among 25- to 

45-year-olds is about 18 percent.

Participants with HIV infection and/or a history of 

cocaine abuse had more calcium deposits and a greater 

volume of calcification than nonabusers without the infection. Compared with the HIV-/cocaine- group, the total 

volume of coronary calcium was 2.9 times as high in the 

HIV+/cocainegroup, 2.6 times 

as high in the 

HIV-/cocaine+ 

group, and 3.5 

times as high in 

the HIV+/

cocaine+ group. 

The associations 

held when the 

researchers took 

into account 

cardiovascular 

disease risk factors, including 

age, body mass 

index, lipid 

“Coronary calcification among people 

at such a young age is a striking 

observation and suggests that clinicians should monitor heart diseases 

in these populations, advise patients 

to make lifestyle changes, and perhaps treat conditions that affect heart 

health, such as high blood pressure.”
12

levels, blood pressure, and whether patients were taking 

HIV medication. The study was too small to determine 

whether HIV and cocaine contribute independently to 

calcification when both are present, or whether they interact physiologically to promote it even more.

Cardiovascular complications have been well documented 

in patients who abuse cocaine and also have HIV infection, but this study is the first to show arterial changes 

prior to the development of cardiovascular symptoms and 

to link them with cocaine abuse alone and HIV infection alone. Larger, longer studies are needed to confirm 

Dr. Lai’s associations and to determine whether or how 

cocaine- and HIV-associated calcification progresses to 

clinical atherosclerosis and heart disease.

Dr. Jag Khalsa of NIDA’s Division of Pharmacotherapies 

and Medical Consequences of Drug Abuse says early 

signs of cardiovascular disease should be taken very seriously because they are strongly connected to two major 

causes of death—stroke and heart attacks. “Coronary calcification among people at such a young age is a striking 

observation and suggests that clinicians should monitor 

heart disease in these populations, advise patients to make 

lifestyle changes, and perhaps treat conditions that affect 

heart health, such as high blood pressure,” says 

Dr. Khalsa.

Source

• Lai, S., et al. Human immunodeficiency virus 1 

infection, cocaine, and coronary calcification. Archives 

of Internal Medicine 165(6):690-695, 2005. 
NIDA Launches HIV/AIDS Public Awareness Campaign

Research Findings

Volume 20, Number 5 (April 2006)

The link between drug abuse and HIV infection is the 

focus of a new public awareness campaign launched by 

NIDA on November 29, 2005. NIDA Director Nora D. 

Volkow, M.D., announced the campaign and screened 

“Text Message,” a new public service announcement 

(PSA) aimed at teenagers, during a press conference at the 

National Press Club in Washington, D.C. “Drug abuse 

prevention is HIV prevention,” says Dr. Volkow. “In 

recent years, the number of young people in the United 

States diagnosed with AIDS rose substantially. Because 

drug use encourages risky behaviors that can promote 

HIV transmission, NIDA views drug abuse prevention 

and treatment as essential HIV prevention.”

The PSA shows young women text messaging on cell 

phones about a friend who contracted HIV after using 

drugs and having sex at a party. The dialogue says, 

“She got high, got stupid, and now she has HIV.” The 

announcement is being aired on television stations across 

the country.

The PSA was produced in collaboration with students from the Duke Ellington School of the Arts, a 

Washington, D.C., public high school. Students were 

involved in developing the concept for the PSA and also 

performed the lead roles. The intent is to dispel the myth 

that only intravenous drug abuse can lead to HIV infection and to promote awareness of the consequences of 

the risky sexual behavior that can follow any type of 

drug abuse.

“Before working on the PSA, I was more concerned about 

pregnancy as a result of unprotected sex than HIV infection, which seemed only to affect older people,” said 

Ellington student Rebecca Hollingsworth. Research has 

shown that this view is widespread: A large proportion of 

youths are not concerned about becoming infected with 

HIV, despite the fact that young people between the ages 

of 13 and 24 represent a growing percentage of new 

infections.

NIDA has formed a coalition with organizations including the American Academy of Child and Adolescent 

Psychiatry; the AIDS Alliance for Children, Youth and 

Families; and the United Negro College Fund Special 

Programs Corporation to get this important message 

about the link between drug abuse and HIV infection 

to teenagers and young adults. In addition to the PSA, 

which will be aired on television stations across the United 

States, posters advertising NIDA’s message—“Drug Abuse 

and HIV: Learn the Link”—will be displayed on public 

transportation and buses in Washington, D.C., Chicago, 

and Dallas.

NIDA’s public awareness campaign also includes a recently launched Web site, www.hiv.drugabuse.gov, where visitors can browse publications such as the new HIV/AIDS 

Research Report, download the PSA, and read about the 

latest scientific findings on the relationship between drug 

abuse and HIV infection.

13

An image from NIDA’s “Text Message” public service announcement
NIDA disburses more than $275 million 

annually to support research on HIV and 

AIDS. The mandate to ensure that this 

investment yields the greatest possible 

return in new knowledge leading to more 

effective treatment and prevention lies 

with NIDA’s AIDS Research Program.

Under the direction of Dr. Jacques 

Normand, the AIDS Research Program 

oversees all the Institute’s HIV-related 

grantmaking. Dr. Normand works with 

three associate directors: Dr. Lynda 

Erinoff is in charge of planning the basic 

science grant portfolio; Ms. Helen Cesari 

manages the social science programs; 

and Ms. Katherine Davenny coordinates 

collaborative projects with other NIH 

Institutes and external organizations 

engaged in HIV/AIDS research. Every 

other month, the AIDS Research Program 

staff convenes an AIDS workgroup consisting of 20 NIDA grantmaking staff 

with expertise in all science areas relevant 

to HIV, including representatives from 

four Program Divisions, three Offices, the 

Center for Clinical Trials Network, and 

the International Program. In the meetings, NIDA scientists exchange up-to-date 

information, identify research needs and 

opportunities, set priorities, and look for 

ways to coordinate ongoing research and 

new initiatives.

In pursuing its mandate, the AIDS 

Research Program builds upon NIDA’s 

more than 20-year history of accomplishment in HIV research. In the early 1980s, 

when it became apparent that injection 

drug use was playing a critical role in the 

spread of the newly recognized deadly 

disease, Congress identified NIDA as a 

key component of the Nation’s response. 

The Institute initiated a research program 

that has had significant impact on the epidemic. 

Along with underwriting studies leading to crucial 

discoveries, such as the finding that providing methadone 

treatment slows the spread of the disease among injection 

opioid abusers, NIDA has supported the development and 

testing of effective science-based education, outreach, and 

preventive interventions for drug-abusing and other at-risk 

NIDA at Work: AIDS Research Program

By Lori Whitten, NIDA NOTES Staff Writer

Research Findings

Volume 20, Number 4 (March 2006)

14

U.S. AIDS Epidemic Shifts

(A) The proportion of newly diagnosed AIDS cases due to injection drug use has dropped 

since the 1980s, and the proportion due to heterosexual contact has increased. (B) Fortyseven percent of newly diagnosed AIDS cases in 2003 were in non-Hispanic Blacks. 
populations. Partly as a result of these efforts, the number 

of newly diagnosed AIDS cases attributable to injection 

drug use in the United States dropped from 19,943 in 

1995 to 6,938 in 2004.

Shifting With the Epidemic

Established in February 2005, the AIDS Research 

Program has come into being at a time when the character of the HIV epidemic is in transition. Since the mid1980s, heterosexual contact—often with an injection drug 

user or while under the influence of drugs—has become 

an increasingly important route of transmission of the 

HIV virus. The proportion of newly diagnosed AIDS 

cases attributable to heterosexual contact has increased 

while that attributable to sexual contact among men who 

have sex with men and that directly attributable to injection drug use have dropped. The rise in heterosexual 

transmission has been especially pronounced among 

African Americans and women (see exhibit on the previous page, “U.S. AIDS Epidemic Shifts”).

A recent case highlights the AIDS Research Program’s role 

in generating efficient responses to developments in the 

epidemic. In February 2005, New York City public health 

officials reported that a new strain of HIV had been isolated from a methamphetamine-abusing man who engaged 

in high-risk sex with male partners. The patient responded 

poorly to initial treatment and progressed rapidly from 

infection to AIDS. The officials, worried that such a 

highly virulent, treatment-resistant strain might become 

widespread, called for heightened monitoring of treatment-resistant HIV. The AIDS Research Program and the 

AIDS workgroup promptly developed a plan to promote 

collaborations between epidemiologists, social scientists, 

virologists, immunologists, and infectious disease experts. 

Their work aims to produce a comprehensive assessment 

of the potential for treatment-resistant viral strains among 

infected men who have sex with men and who also abuse 

methamphetamine.

As they realign research priorities to match the new 

dynamics of the epidemic, NIDA’s AIDS Research 

Program and the AIDS workgroup members will 

draw on the results of NIDA’s Sexual Acquisition and 

Transmission of HIV Cooperative Agreement Program 

(SATH-CAP). This program’s four interdisciplinary 

research teams are studying the patterns of viral spread 

from high-risk, drug-using groups to lower risk groups; 

for example, from drug injectors to noninjecting sexual 

partners, or from bisexual men to female sexual partners. 

Mapping these patterns will enable prevention practitioners to focus their initiatives on the social networks and 

activities with the most potential for containing the spread 

of the epidemic. SATH-CAP investigative teams are working in geographical areas where HIV is in a rapid process 

of bridging from one population to another. For example, 

one team is studying the epidemic in St. Petersburg, 

Russia, where the primary route of transmission is in transition from injection drug use to sexual contact. 

The treatment-resistant HIV and SATH-CAP initiatives 

exemplify how NIDA, through the AIDS Research 

Program, brings the power of interdisciplinary research to 

bear on the intertwined problems of drug abuse and 

HIV/AIDS. “Interdisciplinary research among investigators with different expertise typically does not happen 

without coordination,” says Dr. Normand. “The AIDS 

Research Program is the place where NIDA ensures that 

its research on epidemiological, biological, and behavioral 

aspects of the infection among drug abusers works in concert and that knowledge from the research is translated 

into clinical and community practice.” 

15
Expanded HIV Testing: Benefits May Warrant Costs

By Lori Whitten, NIDA NOTES Staff Writer

Research Findings

Volume 20, Number 3 (October 2005)

Offering voluntary HIV testing on a routine basis 

in outpatient health care settings would slow the 

spread of HIV and improve the survival of many of 

the estimated 280,000 Americans who are unaware 

that they are infected. The value of extending HIV 

screening to relatively low-risk populations in outpatient settings would be on par with the value of 

routine screening for other common conditions, 

such as colon cancer, according to two studies 

funded by NIDA.

In the United States, about one-quarter of the 1.04 

million people estimated to be HIV infected do 

not know they have the virus. Under current testing guidelines, many of these individuals are likely 

to remain ignorant of their status for as long as 

they remain relatively healthy, because they do not 

belong to any of the high-prevalence subgroups 

to whom testing is recommended, and only those 

who live in areas with high infection rates will be 

screened as hospital inpatients. Meanwhile, their 

disease advances undiagnosed, compromising their 

prospects for future health and survival. They 

remain unaware of the need to take precautions 

against spreading the infection, and according to 

estimates from the Centers for Disease Control and 

Prevention (CDC), transmit the virus to 27,000 

others each year. 

Lead investigators in the two studies, Dr. A. David Paltiel 

of Yale University School of Medicine and Dr. Gillian 

Sanders of Duke University’s Clinical Research Institute, 

used computer models to determine whether it would 

be cost-effective to extend routine voluntary screening 

to subpopulations with moderate prevalence of infection 

or to the whole population. The models use data on the 

estimated cost associated with an HIV test, the number of 

additional people who would be tested and the number of 

cases likely to be diagnosed sooner (and how much sooner), the greater benefits of therapy in earlier as opposed 

to later stages of infection, and the number of new infections that will be avoided when people who find out they 

are infected take precautions against transmission. Their 

work updates previous cost analyses by incorporating the 

use of state-of-the-art antiretroviral treatment (HAART) 

for HIV. The analyses yield estimates of the cost of each 

additional year of life expectancy that would be gained by 

expanded testing. Policymakers use such analyses to 

decide how to allocate funds for health.

Benefits of Early Detection

Dr. Sanders, Dr. Douglas Owens of the Veterans Affairs 

Palo Alto Health Care System, and their colleagues analyzed a hypothetical group of patients typical of those in 

general health care settings. The researchers assumed the 

patients’ average age was 43 and their rate of unknown 

HIV infection was 1 percent, the level at which the CDC 

recommends routine testing. A 1 percent prevalence of 

unknown infection is probably high compared with the 

overall U.S. population (0.1 percent), but lower than 

high-risk populations currently screened (3 percent). By 

comparing three different scenarios of HIV detection—

symptom-based diagnosis, with a one-time voluntary test, 

and through testing every 5 years—the researchers were 

able to assess the lifetime benefits to patients and their 

partners, as well as the costs, of expanded testing.

The analysis found that one-time HIV testing would 

increase the life expectancies of individuals in the hypothetical population by an average of 4.7 quality-adjusted 

days and cost about $15,078 for every year of life gained. 

16

Compared with HIV detection based on symptoms, routine voluntary HIV 

testing would enhance the life expectancy of people with the infection by 

getting them into life-prolonging care earlier. Estimates are based on the 

assumption that state-of-the-art therapy would be initiated when patients 

had a relatively favorable CD4 count of 350 cells/m3 as opposed to 175 

cells/m3, the average count associated with detection based on symptoms. 

The CD4 count is a measure of immune system health.

Study Predicts Routine Voluntary HIV Testing 

Would Extend Survival
Patients whose HIV was discovered earlier and treated 

sooner would live on average 1.5 years longer as a result 

of the testing. 

The $15,078 figure assumes that earlier HIV detection 

would reduce the spread of infection by 20 percent. Some 

such reduction would be likely because once people know 

they have HIV, they tend to change their behavior to 

avoid infecting others, and when they start antiretroviral treatment their body fluids become less infectious. If 

transmission were not reduced, one-time HIV testing in 

the hypothetical population would cost $41,736 per year 

of life gained—comparable to the cost-effectiveness of 

routine testing for colon cancer, hypertension, and type 2 

diabetes. The researchers further suggested that one-time 

testing might be justified in terms of value in a hypothetical population with an HIV infection prevalence as low as 

0.05 percent.

In the second study, Dr. Paltiel and his colleagues compared current practice with routine voluntary HIV testing 

among high-risk communities (3 percent prevalence), 

communities with 1 percent prevalence, and the general 

population of the United States (0.1 percent prevalence). 

They estimated that adding a one-time voluntary HIV 

test to current care for people at high risk of infection 

would cost $36,000 per life-year gained. Testing a population that meets the l percent threshold raises the cost to 

$38,000—a figure similar to the $41,736 estimate of Dr. 

Sanders and colleagues. In the high-risk population, testing every 5 years would cost $50,000 per added life-year, 

rising to $63,000 if testing were done every 3 years. The 

findings suggest that voluntary testing every 3 to 5 years 

in all populations except those with the lowest prevalence 

would increase survival at a comparatively attractive cost 

by U.S. standards, says Dr. Paltiel. A one-time voluntary 

screening in the general population may also be costeffective, but merits further investigation, he adds. 

“Expanding voluntary HIV testing will require an investment—but it delivers better value for money than many 

other chronic disease testing programs that are routinely 

used in the United States today,” says Dr. Paltiel. Neither 

research project addressed who should pay for expanded 

HIV screening, but the findings serve as a springboard for 

policy discussions involving all people with a stake in the 

decision. “Cost-effectiveness is just one consideration in 

policy decisions. Implementing expanded HIV testing also 

will require people believing it’s an important use of limited resources,” says Dr. Sanders. 

The findings have made an impact in the state with the 

largest HIV caseload in the nation. Citing the research, 

the New York State Department of Health has revised 

its HIV guidelines, urging State health care providers to 

integrate routine testing into their medical care, use rapid 

HIV testing, and refer patients with positive test results to 

care, among other things. 

“People may think of computer-based analyses as isolated 

and abstract, but this AIDS modeling program encourages 

researchers to use findings from a wide range of relevant 

disciplines and incorporate advice from clinicians,” says 

Dr. Peter Hartsock of NIDA’s Division of Epidemiology, 

Services and Prevention Research. “These two studies 

integrated data from many perspectives, and their results 

provide rigorous but practical information that can guide 

the societal discussion of what to do about the problem.”

Sources

• Paltiel, A.D., et al. Expanded screening for HIV in 

the United States—an analysis of cost-effectiveness. 

New England Journal of Medicine 352(6):586–595, 

2005.

17

HIV Testing and Other Routine Tests: 

Cost-Effectiveness Compared

The cost-effectiveness of various HIV testing approaches 

compared with that of common routine tests.

Test $/QALY* Gained

HIV test: All inpatients† 38,600

HIV test every 5 years: People at high 

risk (3% prevalence)† 50,000

HIV test one time (1% prevalence)‡

 Individual benefit only

 Including benefit to others

41,736

15,078

HIV test one time: U.S. general 

population (0.1% prevalence)† 113,000

Breast cancer test: Annual 

mammogram, age 50-69§ 57,500

Colon cancertest: FOBT + SIG every 

5 years, age 50-85§ 57,700

Type 2 diabetes test: Fasting blood 

glucose, age >25§ 70,000

Hypertension testing§ 48,000

FOBT indicates fecal occult blood test; SIG, sigmoidoscopy.

*In quality-adjusted life years (QALYs), which account for both longevity and 

health-related quality of life. 

†Paltiel et al (2005); ‡Sanders et al (2005); §Adapted from personal communication, 

Sanders and Paltiel, 2005. 
• Sanders, G.D., et al. Cost-effectiveness of screening 

for HIV in the era of highly active antiretroviral 

therapy. New England Journal of Medicine

352(6):570–585, 2005. 

18

Dr. Sanders and colleagues estimated that routine HIV testing would be relatively economical even if the prevalence rates of undiagnosed infection were as low as 0.05 percent (half that 

of the U.S. general population estimate) when reduced transmission to partners is considered 

(dashed line). Even when transmission is not considered (solid line), HIV testing might be a 

financially attractive option at prevalence rates well below 1 percent.

Study Estimates Range of Value Associated

With Routine Voluntary HIV Testing
HIV/AIDS Research and Education Are Crucial to 

Drug Abuse Prevention

Research Findings

Volume 20, Number 3 (October 2005)

19

Behavior associated with 

drug abuse is the single 

largest factor in the spread 

of HIV infection in the 

United States, where about 

one-third of HIV/AIDS 

cases are related to injection drug abuse. 

NIDA’s Web site, http://hiv.drugabuse.gov, provides 

research-based information about HIV/AIDS and its relationship to drug abuse. A compendium of NIDA publications and public service announcements, the Web site is a 

valuable resource for care providers as well as parents and 

teens looking for information. Visitors to the site will find 

a list of drugs that are commonly abused, a phone number 

and Web site for treatment referrals, up-to-date research 

findings, and announcements in English and Spanish 

about special events. 

Using or sharing drug paraphernalia such as unsterile 

needles, cotton swabs, rinse water, and cookers to inject 

heroin, cocaine, or other drugs places drug abusers at risk 

for contracting or transmitting HIV. Drug abuse without 

the use of needles and syringes can also foster the spread 

of HIV. Research sponsored by NIDA and the National 

Institute on Alcohol Abuse and Alcoholism has shown 

that drug and alcohol use can interfere with judgment 

about sexual behavior and thereby affect the likelihood of 

engaging in unplanned and unprotected sex. This increases the risk for contracting HIV from infected sex partners. 

In the past 15 years, 

NIDA has sponsored a 

comprehensive research 

program in response to 

the dynamic nature of 

the co-occurring epidemics 

of drug abuse and 

HIV/AIDS. This research 

has yielded science-based 

principles that should 

prove useful to community 

planners, policymakers, 

service providers, and 

medical practitioners as 

they develop and implement programs to prevent 

the spread of HIV and 

other infections among injecting and noninjecting drug 

users and their sexual partners. To foster widespread use 

of these principles, NIDA has produced a number of 

publications, such as Principles of HIV/AIDS Prevention 

in Drug-Using Populations and The NIDA CommunityBased Outreach Model: A Manual To Reduce the Risk of 

HIV and Other Blood-Borne Infections in Drug Users. 

The Web site also offers the “Jack & Jill” public service 

announcements, which are geared toward teens and provide information about substance abuse and risky sexual 

behavior.“Jack & Jill” was the first installment in NIDA’s 

“Keep Your Body Healthy” campaign, and deals with the 

connection between drug abuse and contracting HIV/

AIDS. It has been estimated that at least half of all new 

HIV infections in the United States are among people 

under age 25, and most of these young people are 

infected sexually.

NIDA’s Web sites, including http://hiv.drugabuse.gov, 

help bring the Institute’s research and policies to a wide 

audience; by disseminating material online, parents, teens, 

and providers have an accessible resource for the latest in 

drug abuse research. 

Exposure 

category

Males Females Overall total

No. % No. % No. %

Male-to-Male 

Sexual Contact 384,784 55 — — 384,784 55

Injection Drug 

Abuse 151,367 22 58,552 39 209,919 30

Heterosexual 

Contact 36,692 5 63,379 42 100,071 14

Source: CDC. HIV/AIDS Surveillance Report: Cases of HIV infection and AIDS in the United States, 

Vol. 14, 2002. Atlanta, Georgia: U.S. Department of Health and Human Services.

AIDS Cases By Exposure Category and Sex Through 2002
20

Researchers Adapt HIV Risk Prevention Program for 

African-American Women

By Jill Schlabig Williams, NIDA NOTES Contributing Writer

Research Findings

Volume 19, Number 1 (April 2004) 

The HIV/AIDS epidemic has taken a disproportionate 

toll on racial and ethnic minority populations, especially 

women. In its surveillance report on the number of 

Americans living with HIV/AIDS in 2002, the Centers 

for Disease Control and Prevention estimates that among 

women with HIV/AIDS, non-Hispanic African-American 

women outnumbered non-Hispanic white women by 

three to one—a racial disparity not found among men. 

African-American drug-using women were addressed 

in two recent studies by NIDA-funded researchers in 

Atlanta. Dr. Claire E. Sterk of Emory University, Dr. 

Kirk W. Elifson of Georgia State University, and colleagues developed and tested gender-tailored, culturally 

specific adaptations of a standard NIDA HIV prevention 

intervention. They found that female African-American 

injecting drug users (IDUs) and crack cocaine users who 

received 

either of 

two targeted 4-week 

prevention 

programs 

reduced their 

risk behaviors 

related to drug-taking and sex more than did women who 

received the standard intervention.

“These studies are examples of research that is responsive 

to community needs,” says Dr. Dionne Jones of NIDA’s 

Center on AIDS and Other Medical Consequences of 

Drug Abuse. “When it comes to designing a prevention 

program, it’s not one-size-fits-all. You have to consider 

social context, be culturally sensitive and appropriate, and 

tailor your message to the group.”

The researchers’ goal was to 

develop culturally appropriate programs grounded in the reality of 

the daily lives of women most at 

risk and the difficulties they face in 

their individual, social, family, and 

sexual relations and activities. “We 

worked hard to develop interventions with input from this target 

population, deliver the interventions in a setting where they feel 

comfortable, and involve them in 

planning, implementing, and 

evaluating the interventions,” 

says Dr. Sterk. 

Over 1 year, using one-on-one 

interviews and small focus groups, 

the researchers sought to define 

the key issues in the women’s lives 

and identify ways to address those 

issues, including such factors as 

gender dynamics, economic stressors, gender-specific norms and 

values, and power and control. 

Two interventions came out of this 

research phase. One, a motivation 

African-American drug-using women in three intervention groups reduced behaviors that 

heightened their risk of HIV infection. However, women receiving the culturally specific, 

gender-tailored motivation and negotiation interventions generally reported greater reductions 

in risky behaviors after their participation than women in the NIDA standard intervention. 

Behavior in 

Past 30 days

NIDA Standard 

Intervention Group

Motivation 

Intervention Group

Negotiation 

Intervention Group

 Baseline Six-Month

 Followup

 Baseline Six-Month

 Followup

 Baseline Six-Month

 Followup

Number of days 

injected powder 

cocaine

8.2 3.1 6.4 0.1 4.7 0.2

Number of days 

injected heroin 16.4 8.9 12.7 1.5 9.8 3.2

Percentage who 

traded sex for drugs 70.4 40.7 50.0 20.0 42.9 10.0

Mean number of 

days crack used 17.7 12.9 18.2 15.6 18.7 13.8

Percentage who had 

vaginal sex with 

one or more paying 

partners

43.9 24.6 34.3 19.2 30.8 20.5

Injecting Drug Users Crack Cocaine Users

Tailored Interventions Build on NIDA Intervention To 

Help Drug-Using Women Reduce HIV Risk
21

intervention, was designed to motivate the participants to 

change their behavior. The other, a negotiation intervention, recognized that women may fear verbal or physical 

abuse if they propose safer sex or safer needle use and 

thus sought to strengthen their negotiation and conflictresolution skills. 

“Our goal in the motivation intervention was to reduce risk 

based on what’s realistic in the context of the participant’s 

life,” explains Dr. Sterk. “We worked with the women to 

set short- and long-term goals, celebrate successes, analyze 

failures, and identify and overcome barriers.” The negotiation intervention recognizes that many of the women’s 

challenges dealt with the need to resolve conflict and that 

negotiation skills are key to reducing risk.

Once the interventions were ready, more than 300 

African-American women ages 18 to 59 years—68 IDUs 

and 265 crack cocaine users—were enrolled in the studies. All were HIV-negative and heterosexually active. The 

women were randomly assigned to one of the three interventions. The NIDA standard intervention was delivered 

in two one-on-one sessions; the motivation and negotiation interventions each involved four one-on-one sessions. 

(See textbox, below, for descriptions of each intervention.) 

At the 6-month followup, both IDUs and crack cocaine 

users in all three groups reported lower levels of drugusing behavior and risky sexual behaviors than they had 

reported before receiving the interventions. Reductions 

were greater among women who received the tailored 

interventions. 

Injecting Drug Users. The motivation and negotiation 

interventions were equally effective in reducing the incidence of needle and injection-works sharing. At 6 months, 

there was no sharing of drug injection paraphernalia in 

these groups; in the standard intervention group, 13 percent reported sharing needles and 18 percent reported 

sharing injection works. Although women in all intervention groups reduced their number of injections over time, 

only those in the tailored interventions reported statistically significant decreases. Participants in the motivation 

intervention were most likely to attend drug treatment, 

whereas women in the negotiation intervention reported 

more changes in their sexual behavior than did women in 

other interventions.

Crack Cocaine Users. All three interventions were associated with a drop in crack use in the 30 days preceeding 

followup. About 40 percent of the women in each group 

reported no use during that period. Among those still abusing crack at followup, women in the motivation intervention were more likely to have reduced their use of crack 

in risky settings, such as outside or in a crack house, hotel 

room, or car. Women in the standard and motivation intervention groups significantly decreased the number of paying partners for vaginal sex and the frequency of sex with 

paying partners.

Protocols for Standard, Motivation, and Negotiation Interventions

All interventions include discussion of the local HIV epidemic, sex and drug-related risk behaviors, safer sex and 

drug use, and HIV risk-reduction strategies. The two tailored interventions also include a discussion of the impact 

of race and gender on HIV risk and protective behaviors. 

The NIDA standard intervention is an HIV/AIDS education program that was developed in the early 1990s. It 

builds on standard HIV testing and counseling developed by CDC and adds discussion of the principles of HIV 

prevention for drug users and their sex partners. The intervention involves testing, counseling, and educating participants through use of cue cards on such topics as the definition of HIV/AIDS, who is at risk, and ways to reduce 

risk. Also offered are demonstrations on condom use and equipment-bleaching techniques for IDUs. Referrals to 

counseling and other services are provided.

The motivation intervention follows the format of the standard intervention for the first session but ends with asking participants to consider what they are motivated to change in their lives. During the second session, this list is 

reviewed and short- and long-term goals are set. The third and fourth sessions involve discussion of experiences with 

behavior change, including the woman’s sense of control and feelings of ambivalence about behavior change. Riskreduction messages tailored to the participant’s level of readiness to change are also delivered in the fourth session.

The negotiation/conflict-resolution intervention also follows the NIDA standard intervention for the first session, 

but it ends with a discussion of intended behavior changes. The second session reviews the list of possible behavior 

changes and the level of control the participant believes she has and introduces general communication skills and 

strategies to develop assertiveness. Short-term goals are set for strengthening communication, gaining control, and 

developing assertiveness. Negotiation and conflict-resolution strategies are introduced during the third session and 

tailored to the individual during the final session.
22

Dr. Sterk suggests that the study’s 

results show it may be optimal to 

create an intervention that combines 

skills taught in both the negotiation 

and motivation interventions. While 

participants in the negotiation intervention were generally more successful at reducing sexual risk behaviors, 

including decreasing the number 

of paying partners and increasing 

condom use with steady partners, 

participants in the motivation intervention had more success at changing 

drug-use behaviors.

Efforts were also made to assist 

program participants in their lives 

outside of the program, with success 

extending well beyond the study’s 

parameters, notes Dr. Sterk. “A lot 

of the women who received the 

one-on-one support available through 

the tailored interventions said the 

program served as a re-entry into 

society. For example, they were 

encouraged to obtain a photo ID. 

Many reported that this simple act 

made them feel more connected 

to society again, part of the larger 

world.” Program graduates returned 

to school, earned their GED, found 

jobs, joined the project to become 

counselors/interviewers, and stopped 

using drugs.

“Over and over, researchers are finding that we need to 

take a more holistic approach to intervention programs,” 

says NIDA’s Dr. Jones. “We can’t just focus on drugs and 

sex. We must look at the big picture. It involves childcare, education, employment, housing, and job training. 

Community stakeholders need to develop programs that 

address multiple needs.”

The project maintained a high retention rate—96 percent of the women enrolled in the studies completed the 

6-month followup interview. Dr. Sterk attributes this 

success to the fact that the project was grounded in the 

community and to the value of involving community 

consultants—residents, both former drug users and others, who played key roles in recruiting, interviewing, and 

counseling participants.

In future research, Dr. Sterk intends to examine the 

cost-effectiveness of various intervention formats. “It 

appears that individual sessions may be more desirable 

and cost-effective,” she predicts. Dr. Sterk would like to 

continue the research, assessing the long-term effects of 

specific interventions. She wants to develop an intervention that focuses on women’s households, targeting both 

the woman and her main partner, and she is interested in 

capacity-building—translating her research into other 

settings and training people to develop similar programs 

in more communities.

Sources

• Sterk, C.E.; Theall, K.P.; and Elifson, K.W. 

Effectiveness of a risk reduction intervention among 

African-American women who use crack cocaine. 

AIDS Education and Prevention 15(1):15–32, 2003.

• Sterk, C.E.; Theall, K.P.; Elifson, K.W.; and Kidder, 

D. HIV risk reduction among African-American 

women who inject drugs: A randomized controlled 

trial. AIDS and Behavior 7(1):73–86, 2003. 

Principles That Guide Format, Content of Interventions

The interventions used by Dr. Sterk and her colleagues in this study are 

firmly based in theoretical research. The researchers conducted a series of 

one-on-one interviews and focus groups with the target population. These 

interviews yielded the following key principles that guided both the format 

and the content of the interventions.

• Offer counseling sessions on an individual basis. “It was very clear 

that women wanted to start with one-on-one sessions,” says Dr. Sterk. 

“HIV risk behaviors involve so many private, personal issues—previous 

abuse experiences, actions to support their drug habits, things they’d 

never before discussed. They found it easier to discuss these experiences 

with one person, not a group.”

• Adopt a holistic approach. Along with this research project, a clothing 

fair was conducted and clothes made available to program participants. 

Food for breakfast was provided; daycare was close by; and ongoing 

services, such as help preparing for job interviews, were provided. 

• Make programs community-based. The project was headquartered 

in a house in the community, which was key to participants’ convenience and comfort. Researchers also found it important for the women 

to link participation in this project to local social and health services, 

including local drug treatment, daycare centers, health services, and 

other community-based organizations. Community consultants played 

a key role in the project. 

• Address women’s multiple social roles in the intervention.

Participants insisted that they didn’t want to be labeled simply as drug 

users. Instead, they wanted the social context of their daily lives to be 

addressed, including their roles as mothers and steady partners.
Research Findings

23

High-Risk Sex Is Main Factor in HIV Infection for Men and Women 

Who Inject Drugs

By Robert Mathias, NIDA NOTES Staff Writer

Volume 17, Number 2 (May 2002)

A 10-year study has found that the biggest predictor of 

HIV infection for both male and female injecting drug 

users (IDUs) is high-risk sexual behavior, not sharing 

needles used to inject drugs. High-risk homosexual activity was the most important factor in HIV transmission for 

men; high-risk heterosexual activity was most significant 

for women. Risky drug-use behaviors also were strong predictors of HIV transmission for men but were less significant for women, the study found.

“In the past, we assumed that IDUs who were HIVpositive had been infected with the virus through 

needle-sharing,” says Dr. Steffanie Strathdee of the Johns 

Hopkins University Bloomberg School of Public Health 

in Baltimore, who conducted the NIDA-funded study. 

“Our analysis indicates that sexual behaviors, which we 

thought were less important among IDUs, really carry a 

heavy weight in terms of risks for HIV seroconversion for 

both men and women.” 

In the study, Dr. Strathdee led a team of researchers who 

analyzed data collected every 6 months from 1,800 IDUs 

in Baltimore from 1988 to 1998. Participants had to be 

at least 18 years of age when they entered the study, have 

a history of injection drug use within the previous 10 

years, and not have HIV infection or AIDS. More than 

90 percent of the participants said they had injected drugs 

in the 6 months prior to enrolling in the study. In their 

semiannual interviews, study participants reported their 

recent drug use and sexual behavior and submitted blood 

samples to determine if they had become HIV-positive 

since their last visit.

Researchers analyzed the role of homosexual activity in 

HIV seroconversions among male IDUs in the study, after 

taking into account other factors that increased their risk of 

acquiring HIV, such as their drug injection practices. This 

analysis revealed that the incidence of HIV infection among 

male IDUs who had engaged in homosexual activity within 

the previous 6 months was 10.44 percent a year, compared 

to 3.01 percent among men who did not report having 

homosexual sex.

Visiting “shooting galleries,” where drug abusers gather 

to obtain and inject drugs, sharing needles used to inject 

drugs with multiple partners, and injecting drugs daily 

also were independently linked to significantly higher rates 

of HIV infection among men in the study. Men who said 

they had used shooting galleries had an HIV incidence 

rate of 6.28 percent per year, and men who shared needles 

with more than one partner had a rate of 5.52 percent per 

year. These infection rates were more than double those 

found among men who had not engaged in these behaviors. Men who injected drugs at least once a day had HIV 

infection rates of 4.68 percent, more than one and onehalf times the rate among men who had injected less than 

once a day.

Sharing needles also increased risk of HIV infection 

among women IDUs. However, high-risk heterosexual 

activity was a much more important risk factor for these 

women, the study found. In fact, other than being younger than 30 years—which independently predicted HIV 

infection for both sexes—high-risk heterosexual activity 

was the main predictor of HIV seroconversion among 

women. Women who reported having a recent sexually 

High-risk sexual behavior played the biggest role in HIV infection 

for both male and female injection drug users (IDUs) in this study 

of 1,800 IDUs. Significant risk factors for men were high-risk 

homosexual activity, using shooting galleries, and sharing needles 

used to inject drugs with multiple partners. For women, high-risk 

heterosexual activity, as indicated by reporting a recent sexually 

transmitted disease (STD), was the most significant cause of 

HIV infection.

High-Risk Sexual Behavior Leading

Cause of HIV Infection Among Injection

Drug Users in 10-Year Study
24

transmitted disease (STD), an indicator of unprotected 

sex, had more than 2.5 times the rate of HIV infection of 

women who did not have an STD.

“Both homosexual men and heterosexual women IDUs 

appear to be at dual risk for becoming infected with 

HIV,” Dr. Strathdee says. “In previous studies by our 

group, being a gay male IDU was closely linked to visiting shooting galleries and sharing needles. Heterosexual 

women IDUs tend to have more of an overlap in their 

sexual partners and their drug use than men do. This 

puts them at increased HIV risk because they are sharing 

needles and having unprotected sex with a partner who is 

more likely to be infected with the virus.

“HIV prevention programs have done a good job in 

reducing needle-sharing and other drug-use behaviors 

that spread the virus among IDUs,” Dr. Strathdee says. 

“However, our study indicates that HIV prevention programs can achieve better results by also addressing sexual 

risk behaviors among IDUs. A multifaceted approach is 

needed that screens both men and women IDUs for STDs 

at places where they go, such as needle-exchange programs 

and methadone treatment programs, and provides comprehensive treatment at those sites. 

“HIV prevention efforts also should be gender-specific, 

targeting the important differences we have found in 

sexual and drug-use behaviors among men and women 

that increase their risk of acquiring and transmitting 

HIV,” Dr. Strathdee says. “For example, women IDUs 

in stable relationships could be shown how to negotiate condom use with their partners and offered couple 

counseling to educate both partners about HIV risks 

associated with their drug use and sexual behaviors. We 

need more research to identify and evaluate HIV prevention approaches for male IDUs who have sex with men to 

determine what kinds of interventions might work.”

Source

• Strathdee, S.A., et al. Sex differences in risk factors 

for HIV seroconversion among injection drug users. 

Archives of Internal Medicine 161:1281–1288, 2001. 
Research Findings

25

NIDA Announces Science-Based Principles of HIV Prevention 

in Drug Users

Volume 17, Number 1 (April 2002)

During the past 15 years, NIDA research on the co-occurring epidemics of drug abuse and HIV/AIDS has yielded a 

set of prevention principles to guide community planners, 

policymakers, service providers, and medical practitioners. 

To foster widespread application of these science-based 

principles in programs to prevent the spread of HIV and 

other infections among drug users and their sexual partners, NIDA has prepared a new handbook: Principles of 

HIV Prevention in Drug-Using Populations. 

Scheduled for release in summer 2002, the handbook 

summarizes the overarching principles that characterize 

effective HIV/AIDS prevention in drug-using populations, elaborates on these principles in a “frequently 

asked questions” section, describes the epidemiology of 

HIV/AIDS risk behaviors, and provides an overview 

of related, NIDA-supported research programs. The 17 

science-based prevention principles are: 

• Reducing the risk of HIV/AIDS in drug users is an 

achievable goal. 

• A community must start HIV/AIDS prevention 

programs as soon as possible. 

• Effective prevention programs require a comprehensive 

range of coordinated services. 

• Prevention programs should work with the community 

to plan and implement interventions and services. 

• Prevention programs must be based on a thorough, 

continuing assessment of local community needs, and 

the effectiveness and impact of these programs must 

be continually assessed. 

• Prevention services can most effectively reach drugusing populations when they are available in a variety 

of locations and at a range of operating times. 

• Prevention and 

treatment efforts 

should target 

drug users who 

already have 

HIV infection, 

as well as their 

sex partners. 

• Prevention 

efforts must 

target not only 

individuals, but 

also couples, social networks, and the broader 

community of drug users and their sex partners. 

• Community-based outreach is an essential component 

of HIV/AIDS prevention and must be directed to 

drug users in their own neighborhoods. 

• Prevention interventions must be personalized for 

each person at risk. 

• Drug users and their sex partners must be treated with 

dignity and respect and with sensitivity to cultural, 

racial/ethnic, age, and gender-based characteristics. 

• As part of a comprehensive HIV prevention program, 

injection drug users should have ready access to sterile 

injection equipment to reduce their use of previously 

used injection equipment. 

• In a comprehensive program, interventions that target 

injection risk must address sharing other injection 

equipment in addition to syringes. 

• While necessary, risk-reduction information alone 

cannot help drug users and their sex partners make 

lasting behavioral changes. 

• Prevention efforts must address the risks of transmitting HIV and other infections sexually as well as 

through drug injection. 

• HIV/AIDS risk-reduction interventions must be 

sustained over time. 

• Community-based prevention is cost-effective. 

HIV prevention interventions must be 

personalized for each individual at risk.

NIDA research on the co-occurring 

epidemics of drug abuse and 

HIV/AIDS has yielded a set of prevention principles to guide community 

planners, policymakers, service 

providers, and medical practitioners.
Research Findings

26

NIDA Research Advances Global Efforts To Prevent and Treat AIDS

By NIDA Acting Director Glen R. Hanson, Ph.D., D.D.S. 

Volume 17, Number 1 (April 2002)

In the 20 years since AIDS was first identified, the disease has killed 25 million people. 

From the beginning of the epidemic, drug 

abuse has played an important role in transmitting HIV, the virus that causes AIDS. 

Injection drug use has accounted for approximately 35 percent of the 774,467 AIDS cases 

reported in the United States through 2000 

and is now the predominant mode of HIV 

transmission in many areas of the world.

Injecting drug users (IDUs) can acquire and 

transmit HIV when they share syringes and 

other paraphernalia for preparing and 

injecting drugs. Injecting and 

non-injecting drug users also are at 

increased risk for engaging in 

unprotected sexual activity, which, 

in turn, can result in acquisition or 

transmission of HIV. Finally, women 

who abuse drugs or have sexual contact with drug abusers have elevated 

rates of HIV and so are more likely 

than women who don’t engage in 

these behaviors to give birth to 

HIV-infected infants.

NIDA-supported research on drug abuse has greatly 

increased our understanding of the complex role drug 

abuse plays in the HIV/AIDS epidemic, fueled the 

development of a broad range of HIV prevention and 

treatment approaches for drug abusers and their sexual 

partners, and helped reduce the spread of HIV/AIDS 

in the United States. In the past few years NIDA also 

increased its response to the global spread of HIV by 

expanding its efforts to foster international research 

and exchange scientific findings on drug abuse-related 

HIV/AIDS with other nations. 

Research has shown that drug abuse treatment is one of 

the most effective ways to curtail the spread of HIV and 

its health consequences. For example, one recent study 

found that IDUs in methadone treatment contracted HIV 

at one-sixth the rate of IDUs who were not in treatment. 

Unfortunately, approximately 85 percent of chronic drug 

abusers are not in treatment, so strategies to reach this 

population are also extremely important. Two major 

NIDA-supported HIV prevention research studies have 

shown that comprehensive community-based outreach 

programs for out-of-treatment drug abusers 

can be doubly beneficial in reducing HIV 

transmission—they recruit drug abusers into 

treatment programs and they help to reduce 

AIDS-related risk behaviors even among 

those who do not have access to or are not 

ready to begin treatment. Over 15 years, 

60,000 IDUs and their sex partners in communities across the Nation participated in 

the research that produced these results. 

To facilitate the widespread application of 

research-based HIV-prevention information, 

NIDA recently issued The NIDA 

Community-Based Outreach Model: 

A Manual To Reduce the Risk of HIV 

and Other Blood-Borne Infections 

Among Drug Users. Initially developed for IDUs, the model has 

been adapted successfully for crack 

cocaine users, tailored to specific atrisk groups, and found to be effective with drug-using populations 

regardless of race, ethnicity, gender, 

and HIV status. In 2002, NIDA 

plans to publish another manual detailing the essential 

research-based principles of HIV prevention for out-oftreatment drug abusers.

NIDA-supported research also has improved our understanding of the clinical course of HIV/AIDS in drug users. 

For example, a study that followed more than 200 IDUs 

for 10 years after they became HIV-positive found that 

women develop AIDS as swiftly as men despite having 

much lower levels of the virus in their blood during the 

early years of HIV infection. Such findings help shape 

HIV treatment for drug users and inform guidelines used 

by clinicians to provide women with potent antiretroviral 

medications and other medical care to retard AIDS’ 

deadly advance.

While progress in the fight against AIDS has been 

significant, the constantly evolving dynamics of the 

epidemic continue to pose challenges for drug abuse 

research. NIDA’s Center on AIDS and Other Medical 

Consequences of Drug Abuse, which coordinates NIDA’s 

AIDS research, has identified several areas for increased 

emphasis. These include developing approaches to 

preventing and treating drug abuse and its medical 

Research has shown that 

drug abuse treatment is one 

of the most effective ways to 

curtail the spread of HIV and 

its health consequences. 
27

consequences among women, including those who are 

pregnant, and the prevention and treatment of other 

blood-borne and sexually transmitted diseases, such as 

hepatitis B and C, which are prevalent in drug users and 

their sexual partners. The same behaviors spread hepatitis 

and HIV among drug abusers and it is more difficult to 

treat patients who suffer from both diseases. 

Also receiving increased emphasis will be HIV prevention in adolescents and other populations at risk for 

drug abuse and for acquiring or transmitting the virus. 

Findings from HIV-related research will be disseminated 

widely for use by practitioners and the general public. 

For example, NIDA recently launched a series of public service announcements to increase awareness among 

young people that drug use can lead to risky sex that can 

transmit HIV/AIDS. The announcements reinforced the 

theme of World AIDS Day 2001: “Youth and AIDS in 

the 21st Century.” (See “PSAs Warn Young Adults: Drug 

Use Can Impair Judgment, Result in Health Problems,” 

NIDA NOTES, Vol. 17, No. 1.)

In contrast to the progress we have made against AIDS 

in the United States, the global epidemic continues to 

escalate. More than 40 million people worldwide now are 

estimated to be living with HIV/AIDS with 5 million 

new infections occurring in 2001. NIDA has responded 

by collaborating with other NIH institutes, the World 

Health Organization, and other agencies to support 

efforts to develop effective HIV prevention and treatment approaches with scientists and public health officials 

around the world. 

In July 2000, NIDA cosponsored a conference in Durban, 

South Africa, on the relationship between drug abuse, 

HIV/AIDS, and poverty, where researchers from both 

countries shared strategies for HIV prevention, treatment, 

and future research. In October 2001, NIDA cosponsored the fourth annual meeting of the Global Research 

Network (GRN) on HIV Prevention in Drug-Using 

Populations in Melbourne, Australia. As one of the founding organizations of the GRN, NIDA helps support its 

critically important efforts to exchange scientific information and develop collaborative research on international 

HIV trends and prevention strategies. 

In the years ahead, developing and implementing effective 

HIV prevention and treatment for drug abusers and their 

sexual partners is likely to offer the greatest opportunity 

for making further progress against AIDS and other 

blood-borne infectious diseases around the world. As it 

has to date, NIDA’s multidisciplinary AIDS research program—in partnership with other medical, governmental, 

and private initiatives—will continue to be a formidable 

force in reducing the ravages of drug abuse and 

HIV/AIDS. 

NIDA supports efforts to develop 

effective HIV prevention and treatment 

approaches with scientists and public 

health officials around the world. 
28

Prevention Program for HIV-Positive Youths Reduces Risks of 

Further HIV Transmission

By Patrick Zickler, NIDA NOTES Staff Writer 

Research Findings

Volume 17, Number 1 (April 2002)

Youths between the ages of 13 

and 24 account for 18 percent of 

reported HIV cases in the United 

States. If these youths engage in 

unsafe sexual behaviors or injection 

drug use, they risk infecting others or becoming infected with new 

strains of HIV. To help reduce 

these risks, NIDA-supported 

researchers at the University of 

California, Los Angeles (UCLA), 

have developed intervention programs designed specifically to 

reduce unsafe behaviors by HIVpositive youths.

Dr. Mary Jane Rotheram-Borus 

and colleagues at UCLA’s Center 

for HIV Identification, Prevention, 

and Treatment Services designed the 

intervention programs—“Act Safe” 

and “Stay Healthy”—and evaluated 

their impact on risk-related behaviors 

of 208 youths aged 13 to 24. They found that the Act 

Safe program reduced both substance abuse and high-risk 

sexual behaviors that contribute to the spread of HIV and 

that participants in the Stay Healthy program were more 

likely than nonparticipants to make lifestyle changes that 

improved their own health. “It is important to change risk 

behaviors in infected youth both for their self-protection 

and to prevent transmission to others,” Dr. RotheramBorus says.

The participants were recruited from HIV/AIDS care programs for adolescents in Los Angeles, Miami, New York 

City, and San Francisco and had tested positive for HIV 2 

years, on average, before being enrolled. Most (78 percent) 

were male, 88 percent of whom were homosexual. Roughly 

15 percent of participants reported injection drug use. 

Sexual behaviors were the most likely route of infection for 

most participants, according to Dr. Rotheram-Borus.

The Stay Healthy program consisted of 12 group counseling sessions conducted over 3 months. In the sessions, 

12 to 15 participants and 2 counselors focused on coping 

with HIV status, developing healthier daily routines, and 

participating in health care decisions. Six months after the 

sessions ended, participants 

had adopted more positive 

lifestyle changes than those 

who had not attended the 

intervention programs. These 

changes included improved 

diet, exercise, and sleep patterns as well as improved living arrangements and more 

frequent visits to health care 

facilities. Participants also 

showed improvement in a 

summary assessment of 23 

physical health measures. 

Overall, females improved 

more than males.

The Act Safe program 

consisted of 11 small-group 

sessions conducted over 

3 months.

Participants were counseled 

in ways to identify and change substance abuse and sexual 

behaviors that increased their risk of transmitting HIV or 

of contracting additional infections. The researchers conducted followup assessments 6 months after the sessions 

ended. Compared with their behavior before participation, 

those who attended the Act Safe sessions reported having 

45 percent fewer sex partners; 50 percent fewer of the sex 

partners were HIV-negative or had unknown HIV status. 

Compared with youths who did not participate in the 

interventions, attendees were more likely to use protection 

during sex. Protected sex was less common—for attendees 

and nonattendees—with partners known to be HIVpositive than with partners of negative or unknown HIV 

status, Dr. Rotheram-Borus says. Use of drugs and alcohol 

dropped by nearly a third (31 percent) among those who 

attended the Act Safe sessions.

“These results are generally very encouraging,” Dr. 

Rotheram-Borus says. “Risk behaviors went down, healthy 

behaviors went up, and the effect seems to be persistent; 

the gains from the interventions were maintained at least 

through 6 months after the sessions ended.”

HIV-positive youths who attended intervention sessions 

designed to reduce unsafe behaviors were more likely than 

nonparticipants to make lifestyle changes that improved 

their own health and less likely than nonparticipants to 

engage in sexual behaviors that might infect others.
29

The youths enjoyed the small-group format, but scheduling problems and fear of stigmatization reduced attendance, Dr. Rotheram-Borus says. Only about half (51 

percent) of the participants attended 6 or more of the 12 

Stay Healthy sessions, and 53 percent attended 5 or more 

of the 11 Act Safe sessions.

“These interventions work. The next step is to develop 

alternative ways to deliver the same product that better 

accommodate the youth we are trying to reach,” Dr. 

Rotheram-Borus says. “We are now developing group sessions that can be conducted by telephone and evaluating 

efficient ways to provide individual sessions.” 

Source

• Rotheram-Borus, M.J., et al. Efficacy of a preventive 

intervention for youths living with HIV. American 

Journal of Public Health 91(3):400–405, 2001. 
Research Findings

30

PSAs Warn Young Adults: Drug Use Can Impair Judgment, 

Result in Health Problems

Volume 17, Number 1 (April 2002)

“Jack and Jill went up the hill . . .,” but what happens 

next is not your typical nursery rhyme.

Using up-to-the-minute slang and animation, NIDA’s 

new series of TV public service announcements (PSAs) is 

designed to engage young viewers with a cautionary tale 

about the dangerous link between drug use and sexual 

transmission of HIV/AIDS. Among 13- to 24-year-olds 

with diagnosed HIV infection in 1999, nearly half of the 

cases (49 percent) were attributed to sexual transmission.

The messages show that when people take drugs, their 

judgment suffers, and they may fail to consider the possible health consequences of sexual activity. The conclusion 

is, “When you use drugs, there’s no happy ending. Keep 

your body healthy. Don’t use drugs.”

Broadcast outlets received eight versions of the 30-

second PSA. Six are in English, three narrated by a male 

and three by a female, each narrator addressing general 

drug use, ecstasy use, and World AIDS Day. In the two 

Spanish versions of the PSA, titled “Juan y María,” a male 

announcer presents the general drug use and World AIDS 

Day messages.

Radio versions of the PSAs were released in January, and 

NIDA is also distributing print ads from the Jack and 

Jill campaign for national publication in such markets as 

TV magazines included in Sunday newspapers. Marvel 

Comics included a full-page Jack and Jill ad in one of its 

December 2001 editions. 

Announcer: The National Institute 

on Drug Abuse presents a tale about 

the dangers of drugs entitled “Jack and 

Jill.”

Jill got dizzy and so did he. They both 

got busy and felt so free.

Announcer: When you use drugs, 

there’s no happy ending. Keep your 

body healthy. Don’t use drugs.

Never did it occur that the other may 

be, the one infected with HIV.
Research Findings

31

Volume 16, Number 1 (March 2001)

Preventing Drug Abuse-Related Infectious Diseases Through 

Community Outreach

Drug abuse service providers in the field now have a new 

tool to help them reduce the spread of drug-related disease among drug abusers. The NIDA Community-Based 

Outreach Model: A Manual To Reduce the Risk of HIV 

and Other Blood-Borne Infections Among Drug Users is 

designed to help community planners, policymakers, program developers, and service providers develop outreach 

programs to prevent the spread of infectious diseases associated with drug use—primarily HIV/AIDS, hepatitis B 

(HBV), and hepatitis C (HCV).

The manual is based on more 

than 15 years of NIDA-supported 

research in nationwide HIV prevention projects. The Outreach Model, 

tested in 52 U.S. communities with 

more than 60,000 injection drug 

users, 14,000 crack users, and many 

of their sexual partners, has been 

found effective with drug-using populations regardless of race, ethnicity, 

gender, and HIV status.

In more than 30 studies using community-based outreach, a significant 

proportion of participating 

drug users:

• entered drug treatment; 

• stopped or reduced their 

frequency of injection; reuse of 

needles, syringes, other injection 

equipment; and use of crack 

cocaine; 

• increased condom use and reduced the frequency of 

unprotected sex; 

• obtained HIV testing with counseling before and 

after the tests; and 

• averted HIV infection. 

Published last fall, the manual guides outreach workers 

step by step on how to select outreach sites where drugs 

are purchased and used, engage drug users, and educate 

and counsel drug users about reducing their drug- and 

sex-related risks for infection. The community-based 

approach typically relies on outreach workers who are 

indigenous to the community and thus uniquely able 

to serve as role models, educators, and advocates for 

drug users.

The outreach manual helps community workers choose 

an appropriate “base” site, such as a converted recreational 

vehicle or mobile home; contact drug users where they 

congregate; open conversations with individuals at risk for 

infection; and enlist those individuals 

to attend counseling and education 

sessions in connection with HIV testing. Additional program services are 

recommended, such as couples or 

group counseling and sexually transmitted disease screening, diagnosis, 

and treatment and HIV treatment. 

Alternatively, it is recommended that 

outreach workers provide referrals for 

those services.

The manual recommends that drug 

users recruited to attend the 20- to 

30-minute education and counseling sessions be provided accurate 

and up-to-date information on risky 

behaviors, concrete strategies and 

behavioral skills for reducing drugusing and sexual risks, and reinforcement for behavior change. A set of 24 

cue cards guides counselors and drug 

users through the sessions, leading logically from “What 

is HIV/AIDS? HBV? HCV?” to how the infections are 

transmitted and how drug users can reduce their risk.

The education sessions give clear, detailed instructions for 

reducing the risks related to drug use and sexual activity, 

and they promote addiction treatment as the best method 

of disease prevention. The NIDA Community Outreach 

Model recommends HIV, HBV, and HCV testing, 

followed by appropriate counseling on positive or 

negative results. 
32

Gender Differences in Drug Abuse Risks and Treatment

Research Findings

Volume 15, Number 4 (September 2000)

Over the past few years NIDA has made a major research 

commitment to identifying and understanding differences in the ways that women and men—or girls and 

boys—are first exposed to drugs, in their risks of abuse 

and addiction, and in the effectiveness of drug treatment. 

Understanding these differences, and incorporating that 

understanding into drug abuse prevention and treatment, 

can reduce the dangers and improve outcomes. NIDAsupported research has shown that gender differences play 

a role from the very earliest opportunity to use drugs, that 

women and men tend to abuse different drugs, that the 

effects of drugs are different for women and men, and 

that some approaches to treatment are more successful for 

women than for men.

Are Women Less Likely Than Men to Abuse Drugs?

Men are more likely than women to have opportunities to 

use drugs, but men and women given an opportunity to 

use drugs for the first time are equally likely to do so and 

to progress from initial use to addiction. However, women 

and men appear to differ in their vulnerability to some 

drugs. Both are equally likely to become addicted to or 

dependent on cocaine, heroin, hallucinogens, tobacco, and 

inhalants. Women are more likely than men to become 

addicted to or dependent on sedatives and drugs designed 

to treat anxiety or sleeplessness, and less likely than men 

to abuse alcohol and marijuana. There are also differences between men and women who seek treatment for 

drug abuse. Women in treatment programs are less likely 

than men to have graduated from high school and to be 

employed and are more likely than men to have other 

health problems, to have sought previous drug treatment, 

to have attempted suicide, and to have suffered sexual 

abuse or other physical abuse.

Are There Gender Differences In the Biological 

Effects of Drugs?

Animal research and human studies have revealed that 

males and females may differ in their biological responses 

to drugs. In studies of animals given the opportunity to 

self-administer intravenous doses of cocaine or heroin, 

females began self-administration sooner than males and 

administered larger amounts of the drugs. Women may 

be more sensitive than men to the cardiovascular effects 

of cocaine. In human studies, women and men given 

equal doses of cocaine experienced the same cardiovascular response despite the fact that blood concentrations of 

cocaine did not rise as high in women as in men. In 

studies involving long-term cocaine users, women and 

men showed similar impairment in tests of concentration, 

memory, and academic achievement following sustained 

abstinence, even though women in the study had substantially greater exposure to cocaine. Women cocaine users 

also were less likely than men to exhibit abnormalities 

of blood flow in the brain’s frontal lobes. These findings 

suggest a sex-related mechanism that may protect women 

from some of the damage cocaine inflicts on the brain.

Does Gender Play a Role in Nicotine Addiction?

Women and men are equally likely to become addicted 

to nicotine, yet women typically smoke cigarettes with 

lower nicotine content than those smoked by men, smoke 

fewer cigarettes per day, and inhale less deeply than men. 

Overall, however, women are less successful than men 

in quitting smoking and have higher relapse rates after 

they do quit. Treatment involving nicotine replacement 

therapy—nicotine gum or patch—works better for men 

than for women.

What Are Women’s Risks for HIV/AIDS?

Research suggests that there are sex-related differences 

in some fundamental aspects of the HIV/AIDS disease 

process. For example, an HIV-infected woman with half 

the amount of virus circulating in the bloodstream as an 

infected man will progress to a diagnosis of AIDS in about 

the same time. And, according to the Centers for Disease 

Control and Prevention, among cases that progress to a 

diagnosis of AIDS, drug abuse accounts for a greater percentage of cases among women than among men. Nearly 

half (47 percent) of all women diagnosed with AIDS are 

injecting drug users (IDUs), whereas among men, IDUs 

account for 32 percent of AIDS cases. An additional 19 

percent of women, compared with 2 percent of men, with 

AIDS report having sex with users who inject drugs. In 

all, drug abuse is nearly twice as likely to be directly or 

indirectly associated with AIDS in women (66 percent) as 

in men (34 percent).

For More Information

NIDA’s gender-related research is discussed in Drug 

Addiction Research and the Health of Women, available 

on NIDA’s home page on the World Wide Web: 

www.drugabuse.gov. 
33

Heating Solutions Used in Drug Injection May Inactivate HIV

Research Findings

Volume 15, Number 3 (August 2000)

A NIDA-funded study has found that heating drug 

solutions containing HIV to 65 degrees centigrade (149 

degrees Fahrenheit) may inactivate the virus. Heating drug 

solutions for at least 15 seconds can achieve this temperature and may reduce the potential for HIV transmission 

among injecting drug users (IDUs) who share the solution, the study indicates.

The study, led by Dr. Michael Clatts of National 

Development and Research Institutes in New York City, 

first observed injection equipment and practices used by 

out-of-treatment IDUs in New York City and Denver 

when they prepared drug solutions for shared injection. 

Laboratory studies conducted by Dr. Robert Heimer 

of Yale University School of Medicine in New Haven, 

Connecticut, then found that HIV in cookers—typically 

spoons or bottle caps in which drugs are mixed with water 

and heated before injection—was inactivated once the 

temperature reached 65 degrees centigrade. Thin bottlecap cookers reached this temperature fastest, the researchers say.

These findings indicate that HIV prevention strategies 

should convey the message to IDUs that heating drug 

solutions for at least 15 seconds can reduce the spread of 

HIV, the researchers conclude. The study appeared in the 

Journal of Acquired Immune Deficiency Syndrome. 
Research Findings

34

Drug Abuse Treatment Programs Make Gains in Methadone 

Treatment and HIV Prevention

By Steven Stocker, NIDA NOTES Contributing Writer 

Volume 15, Number 3 (August 2000)

Drug abuse treatment programs have substantially 

improved their methadone treatment practices and 

increased their HIV prevention efforts since the late 

1980s, according to recent NIDA-funded research. These 

improvements appear to be partly the result of NIDA’s 

efforts to improve drug abuse treatment and HIV/AIDS 

outreach.

Clinical studies conducted in the late 1980s and early 

1990s indicated that methadone treatment is more likely 

to reduce heroin use if the dose level is at least 60 milligrams per day (mg/day), if patients are given a voice 

in determining their dose levels, and if no restriction is 

placed on treatment duration. Subsequent research, however, indicated that the majority of the Nation’s methadone treatment facilities were dispensing methadone doses 

less than 60 mg/day, were not giving patients a voice in 

dosage decisions, and were encouraging patients to stop 

taking methadone in 6 months or less.

In response to this situation, NIDA and other Federal 

agencies took steps to improve methadone treatment. 

NIDA funded an Institute of Medicine report that recommended changes in heroin addiction treatment practices 

and their regulation. NIDA also funded the development 

of a quality assurance program that evaluates methadone 

treatment facilities in terms of patient outcomes. In addition, the Center for Substance Abuse Treatment (CSAT) 

developed a set of methadone treatment guidelines and 

distributed them to State substance abuse agencies and 

treatment providers around the country.

To determine whether these efforts were in fact improving methadone treatment practices, in 1995 Dr. Thomas 

D’Aunno of the University of Chicago and his colleagues 

at the University of Michigan in Ann Arbor collected data 

from 116 methadone treatment facilities located throughout the country and compared them with data collected 

on these same facilities in 1988 and 1990. Results 

showed improvement during the 7-year period, particularly regarding methadone dosage. The average dose was 

45 mg/day in 1988 and 46 mg/day in 1990. By 1995, 

however, the average dose had increased to 59 mg/day. 

Also, more programs were allowing patients to participate 

in dosage decisions, and more programs were waiting at 

least a year before encouraging patients to stop taking 

methadone.

“Although these results show that methadone treatment 

facilities have made substantial improvements, we still 

need to make more progress,” says Dr. D’Aunno. “We 

found an average dose of 59 mg/day in our sample of 

treatment facilities, but recent research indicates that doses 

between 80 and 100 mg/day may be the most effective in 

reducing heroin use.”

The study found differences in treatment practices in 

different areas of the country and for different population groups. Dr. D’Aunno suggests that efforts targeted 

at particular groups of programs may be a further step to 

improve treatment.

Dr. Bennett Fletcher of NIDA’s Division of 

Epidemiology, Services, and Prevention Research agrees 

that efforts to improve methadone treatment practices 

should continue, but adds that misunderstandings some 

patients have about methadone may also contribute to 

the problem. For example, he says, some patients attribute adverse effects to methadone that it actually does 

not cause. “These patients may develop medical or dental problems while taking heroin, but they don’t notice 

them either because of heroin’s analgesic effect or because 

they are distracted by withdrawal symptoms during 

abstinence,” he says. “Once they’re in methadone treatment and physiologically stabilized, the medical or dental 

problems are unmasked. It is easy to blame methadone 

for these problems, when in fact they were pre-existing.” 

These misunderstandings may cause some patients to 

request lower methadone doses or to stop methadone 

prematurely, says Dr. Fletcher.

The treatment facilities most likely to 

conduct HIV prevention activities were 

those that had more patients at high 

risk of HIV infection, more resources, 

and lower patient-to-staff ratios.
35

The Bandwagon Effect

Dr. D’Aunno, along with colleagues at the University of 

Iowa in Iowa City and the Centers for Disease Control 

and Prevention in Atlanta, also evaluated treatment facilities’ HIV prevention efforts, including HIV testing, 

counseling, and outreach. For this project, they used data 

collected from the sample of methadone treatment facilities plus other substance abuse treatment facilities for a 

total of 618 facilities.

As with the methadone treatment practices, the investigators found that the facilities had made substantial 

improvements in their HIV prevention efforts over the 

period from 1988 to 1995. In both 1988 and 1990, only 

39 percent of the facilities provided HIV testing and 

counseling, but by 1995, 61 percent were providing these 

services. Also, 51 percent of the facilities in 1988 and 65 

percent in 1990 were engaging in HIV outreach, but by 

1995 this had increased to 75 percent.

The investigators found that the treatment facilities most 

likely to conduct HIV prevention activities were those 

that had more patients at high risk of HIV infection, 

more resources, and lower patient-to-staff ratios. Also, 

these facilities generally were publicly rather than privately 

funded and had clinical supervisors who supported HIV 

prevention practices.

Perhaps the most important factor in promoting HIV 

prevention practices, however, seemed to be pressure 

from people in the drug abuse treatment field. “When the 

HIV epidemic first started, many treatment facilities were 

uncertain how to react,” says Dr. D’Aunno. “As some 

facilities began conducting HIV testing, counseling, and 

outreach, pressure began to mount for other facilities to 

do the same. This eventually created a bandwagon effect.”

NIDA helped get the bandwagon going by supporting 

research programs in which scientists worked together 

with practitioners to develop effective HIV/AIDS outreach techniques, according to Dr. D’Aunno. “These 

programs set a good example for treatment providers,” 

he says. “The providers saw local researchers and other 

providers working together on HIV prevention, and they 

decided to follow their lead.”

Sources

• D’Aunno, T.; Folz-Murphy, N.; and Lin, X. Changes 

in methadone treatment practices: Results from a 

panel study, 1988–1995. American Journal of Drug 

and Alcohol Abuse 25(4):681–699, 1999. 

• D’Aunno, T.; Vaughn, T.E.; and McElroy, P. An 

institutional analysis of HIV prevention efforts by the 

Nation’s outpatient drug abuse treatment units. 

Journal of Health and Social Behavior 40(2):175–192, 

1999. 
Research Findings

36

Addressing the Medical Consequences of Drug Abuse

By NIDA Director Alan I. Leshner, Ph.D.

Volume 15, Number 1 (March 2000)

When people hear the words “consequences of drug 

abuse,” they usually think of addiction, crime, and 

other social disruptions. However, the most immediate, extensive, and long-lasting problems caused by drug 

abuse, both for individuals and for society, 

are often medical in nature. For example, 

known drug abuse-related health problems 

and resulting lost productivity alone cost 

our society more than $33 billion each year.

Illicit drugs directly cause many medical 

problems. Stimulants such as cocaine and 

methamphetamine increase the heart rate 

while constricting the blood vessels; in 

susceptible individuals, these two actions 

together set the stage for cardiac arrhythmias and strokes. The club drug methylenedioxymethamphetamine (MDMA, also 

called “ecstasy”), which many users 

mistakenly believe to be safe, has 

caused malignant hyperthermia, 

permanent kidney damage, and 

death. MDMA also damages serotonin nerve fibers in the brain. 

Heroin can cause a life-threatening 

kidney condition called focal glomerulosclerosis. The list continues: 

NIDA research has shown that almost every drug 

of abuse harms some tissue or organ.

The circumstances and behaviors associated with drug 

abuse add to the adverse impacts on health. Inadequate 

housing and poor nutrition, common accompaniments of 

drug abuse, can increase exposure to diseases and reduce 

ability to fight off infections. Injecting drug use promotes 

blood clots, severe skin infections, and blood-borne infections including life-threatening endocarditis, viral hepatitis, and HIV/AIDS. Abuse of some drugs is associated 

with impulsive sexual activity that elevates individuals’ 

risks for acquiring and transmitting HIV/AIDS and other 

sexually transmitted diseases.

The hepatitis C virus (HCV) is another blood-borne 

pathogen that is easily transmitted through contaminated 

drug injection paraphernalia. In some NIDA-funded studies nearly two-thirds of individuals have acquired HCV 

within 1 year of beginning injection drug use. Screening 

studies have found that 70 to 90 percent of individuals in 

some drug-injecting populations are infected and at risk 

for developing chronic liver inflammation and hepatic 

cancer or liver failure requiring transplantation.

Many of the health consequences of drug abuse also 

have implications for the health of the non-drug-abusing 

public. Tuberculosis (TB) is an important 

example. Chronic drug abusers have higher 

rates of TB infection and disease than the 

general public, largely because inadequate 

nutrition, HIV/AIDS, and other factors lower 

their resistance. Reducing this high prevalence by screening and treating infected 

drug abusers is an important strategy in 

efforts to control TB in the Nation.

NIDA-sponsored research, much of it carried out under the auspices of the Institute’s 

Center on AIDS and Other Medical 

Consequences of Drug Abuse, has made 

crucial contributions to understanding drug-related behavioral risks in 

the spread of infectious diseases and 

to reducing the incidence and impact 

of HIV, HCV, and TB among 

drug abusers and other at-risk 

populations. For example, research 

has shown that, contrary to what 

was once assumed, individuals who 

enter treatment for their drug abuse and receive appropriate management and followup can adhere to the complicated, lengthy medication regimens necessary to control 

these diseases. This is an extremely important finding, 

since finishing the entire regimen is crucial to successful 

treatment and also to prevent the growth of resistant viral 

or bacterial strains that can withstand currently available 

medications and potentially give rise to devastating 

epidemics.

NIDA-supported research has also demonstrated that drug 

abusers are willing and able to change their behaviors to 

prevent HIV transmission. For example, researchers have 

documented reductions in HIV risk behaviors among 

drug abusers who were contacted by a 21-site communitybased prevention outreach program. Significant numbers 

of drug abusers stopped injecting or lowered their frequency of injecting, stopped reusing syringes or started 

disinfecting syringes, and entered treatment as a result of 

the outreach activities.

NIDA research has shown that 

almost every drug of abuse 

harms some tissue or organ. 
37

While we now know that chronic drug abusers can comply with medication regimens, we also know that a large 

percentage of them do not. Thus we still need to learn 

much more about both adapting medication regimens for 

drug abusers and techniques for increasing their adherence. Moreover, some illicit drugs and drug abuse medications can interact with medications used for treating 

diseases, resulting in possible loss of efficacy and adverse 

effects. An extremely important interaction can take place, 

for example, between methadone and the protease inhibiting drugs that are currently the most effective treatments 

for HIV infection. The result can be ineffectiveness and 

increased toxic side effects from one or both drugs. In 

some cases, the presence of a protease inhibitor has inhibited the processing of methadone sufficiently to cause 

patients to develop symptoms of withdrawal. The identification of such interactions and development of alternative 

regimens is a high NIDA priority.

As the issue of drug-and-medication interactions illustrates, 

the approaches to drug abuse and its medical consequences 

must be integrated if optimal results are to be achieved. A 

NIDA-supported project at Montefiore Hospital in The 

Bronx, New York, has demonstrated that offering drug 

abuse treatment and primary care services at the same site 

can reduce the occurrence and severity of medical consequences of drug abuse. In what appears to be another very 

promising intervention, NIDA is evaluating the use of 

mobile health vans that reach out to drug abusers with both 

treatment and primary care. In 9 cities, vans are regularly 

visiting poor and medically underserved neighborhoods 

with concentrated populations of drug abusers. Each is 

staffed and equipped to provide drug abuse counseling and 

referral, vaccinations and screening for common and dangerous diseases, prevention education, and limited primary 

care. For patients with complicated medical conditions, the 

vans also provide referrals to local hospitals and clinics. 

During the 4 years that the mobile vans have been in service, their staff has seen drug abusers gradually develop the 

confidence to come forward for care, then start to bring 

friends and family members with them. Novel approaches 

such as these are only first steps toward fully integrating 

drug abuse and overall medical treatment for chronic drug 

abusers—but as always, the first steps are critical to get the 

momentum started. 
Research Findings

38

Among Drug Users, Peers Can Help Spread the Word 

About AIDS Prevention 

By Steven Stocker, NIDA NOTES Contributing Writer 

Volume 14, Number 5 (December 1999)

In traditional AIDS prevention programs, professional 

outreach workers inform injecting drug users (IDUs) 

about drug-related and sexual behaviors that can lead to 

HIV infection. NIDA-supported research is demonstrating that recruiting IDUs to help disseminate this information may be a way to reach more drug users and reduce 

their risky behaviors.

Dr. Robert Broadhead, Dr. Douglas Heckathorn, and 

their colleagues at the University of Connecticut in Storrs 

recruited IDUs in Middletown, Connecticut, to educate 

their peers about reducing the spread of HIV and give 

them HIV prevention materials, such as condoms and 

bleach for cleaning their syringes. The IDU recruiters also 

encouraged their peers to visit a storefront office where 

they would be tested for HIV and learn more about how 

to reduce their risk of contracting AIDS.

At the storefront, program staff gave IDUs a brief AIDS 

prevention quiz to determine how well the IDU recruiter 

had educated them in the community. The staff also 

interviewed IDUs about their HIV risk behaviors, counseled them about how to reduce these behaviors, and tested them for HIV. Each IDU was given the opportunity to 

recruit and educate three peers for compensation. These 

IDUs, in turn, were given the opportunity to recruit and 

educate still more peers. Thus the number of recruits 

grew rapidly.

The researchers compared the effectiveness of this 

approach, called peer-driven intervention, with the more 

common approach involving outreach workers, called 

traditional outreach intervention. In the traditional 

approach, three salaried outreach workers in Windham, 

Connecticut, were instructed to recruit new IDUs, educate them about AIDS prevention, and encourage them 

to visit a storefront in Windham. Frequently, traditional 

outreach workers are former drug users from the neighborhood. When the IDUs came to the storefront, 

they received the same intervention as the IDUs in 

Middletown, except that they were not given the opportunity to recruit their peers.

Over a 2-year period, the researchers found that the peerdriven intervention recruited 317 IDUs, 36 percent more 

than the 233 recruited in the traditional approach. The 

IDUs recruited by peers were more representative of the 

racial and ethnic composition of the community. The 

peer-driven intervention was also more effective in 

reducing HIV risk behaviors. In initial interviews with 

recruits and in followup interviews 6 months later, the 

Dr. Carl Latkin (left) and ethnographer James Peterson in the 

Baltimore neighborhood where they enlisted the help of injecting drug 

users to reduce the spread of HIV in the drug-using community. 

Dr. Douglas Heckathorn (left), Dr. Robert Broadhead, and their 

colleagues found that injecting drug users (IDUs) educated about 

HIV risk reduction by peers shared injection paraphernalia and 

injected drugs less often than did IDUs educated traditionally. 
39

researchers found that IDUs recruited by peers shared 

syringes and other injection paraphernalia less often and 

injected drugs substantially less often than did the IDUs 

recruited traditionally. The peer-recruited IDUs also 

scored higher on the AIDS prevention quiz administered 

when they first visited the storefront. In addition, the 

researchers determined that educating IDUs in the community was much less expensive in the peer-driven intervention than in the traditional outreach.

One reason the peer-driven approach was more effective was that participant IDUs were exposed more often 

to HIV prevention information than in the traditional 

approach, says Dr. Broadhead. In the peer-driven intervention, IDUs were first educated by peer recruiters on 

the street, then again by program staff at the storefront. 

This information was reinforced three more times when 

the recruits educated and recruited three of their peers. 

Finally, the IDU recruiters were exposed to the information again when they came to collect their compensation 

for educating and recruiting their peers. In contrast, IDUs 

recruited in the traditional intervention received only two 

exposures—once when they were recruited on the street 

and then again when they visited the storefront.

About 40 percent of the IDUs in the peer-driven 

approach became active recruiters, says Dr. Broadhead. 

“We stopped paying them after three recruits, but some of 

them continued to bring in their peers even though they 

knew they weren’t going to get paid for it,” he says. He 

also reports that some recruiter IDUs called the storefront 

to speak to health educators to make sure that they were 

passing on correct information.

Active IDUs are more effective in recruiting and educating 

other drug users because the latter are more likely to listen 

to people whom they consider to be like themselves, Dr. 

Broadhead says. Active drug users may view professional 

outreach workers with suspicion, even if the outreach 

workers are former drug users, he says.

Dr. Broadhead suggests that using both IDUs and traditional outreach workers works well because the IDUs 

are more effective at education and recruitment in the 

community, while traditional outreach workers are better 

prepared for tasks such as interviewing, case management, 

and referrals to community agencies.

Outreach Boosts Peer Leaders’ Self-Image

In a related study, Dr. Carl Latkin at The Johns Hopkins 

University in Baltimore also used current IDUs to provide 

AIDS prevention information to drug users in the community. In Dr. Latkin’s study, the IDUs who conducted 

AIDS outreach were recommended by their peers. Drug 

users who volunteered for the study were asked to recommend other drugs users in the community who might be 

effective communicators of AIDS prevention information. 

These peer leaders were then invited to attend 10 training sessions, for which they were compensated. After the 

fourth session, the leaders began their outreach activities, 

for which they were not compensated.

At the end of 3 months, the researchers interviewed peer 

leaders and IDUs who used drugs and engaged in sexual 

relations with one another. The HIV-related behaviors of 

the peer leaders and their IDU contacts were compared to 

the self-reported behaviors of IDUs who received standard 

HIV testing and counseling from outreach workers, and 

the behaviors of the peer leaders were compared to their 

own behaviors at the beginning of the study. The scientists found that both the peer leaders and their IDU contacts were more likely to clean their syringe needles with 

bleach before either injecting themselves or sharing the 

syringe with others. Also, the leaders reported significantly 

more use of condoms.

In the training sessions, the leaders discussed how their 

attitudes toward the program changed as it progressed. 

Initially, they viewed AIDS outreach as theoretically 

important but they were not enthusiastic about engaging 

in the program. However, once they started their outreach 

activities and began to receive positive feedback from the 

community, they developed a higher regard for the 

program.

“Most of these people have had very few prosocial roles in 

their lives,” says Dr. Latkin. “Consequently, giving them 

a prosocial role that people in the community respect and 

consider beneficial is a powerful motivator.”

Because drug users began to view the peer leaders as 

experts, they started asking them about matters other than 

HIV prevention, such as how to get treatment for AIDS 

or drug addiction and how to get food, shelter, and other 

necessities. To help the peer leaders meet these requests, 

Dr. Latkin and his colleagues prepared information about 

health and social service agencies that peer leaders could 

hand out.

A surprising result of the study was the increase in condom 

use reported by the peer leaders. Studies have consistently 

found that reducing risky sexual behaviors is much more 

difficult than reducing risky drug-taking behaviors. Peer 

leaders may have increased their condom use because they 

wanted to live up to their new status as role models, Dr. 

Latkin speculates. “Also, I think that talking about condoms 

and carrying them around may have made them more 

comfortable with condoms,” he says.

Complementary Approaches

Enlisting current drug users to perform AIDS outreach 

may be an effective way to reach some subgroups of the 

drug-using population not reached by traditional outreach 
40

workers, says Dr. Richard Needle of NIDA’s Center on 

AIDS and Other Medical Consequences of Drug Abuse. 

“I think that if you are conducting an AIDS outreach 

project, you might want a combination of outreach workers—some of whom are current users and some of whom 

are not,” he says. He also thinks that Dr. Broadhead’s and 

Dr. Latkin’s studies should be tested in other communities to see whether their results can be replicated.

“NIDA is interested in exploring a range of outreach strategies and trying to determine the advantages and disadvantages of each of them,” says Dr. Needle. “I suspect that the 

different approaches will prove to be complementary.”

Sources

• Broadhead, R.S., et al. Harnessing peer networks as 

an instrument for AIDS prevention: Results from 

a peer-driven intervention. Public Health Reports

113(Suppl. 1):42–57, 1998.

• Latkin, C. A. Outreach in natural settings: The use 

of peer leaders for HIV prevention among injecting drug users’ networks. Public Health Reports

113(Suppl. 1):151–159, 1998.

• Needle, R.H., et al. HIV prevention with drug-using 

populations—current status and future prospects: 

Introduction and overview. Public Health Reports

113(Suppl. 1):4–18, 1998.

• Coyle, S.L.; Needle, R.H.; and Normand, J. 

Outreach-based HIV prevention for injecting drug 

users: A review of published outcome data. Public 

Health Reports 113(Suppl. 1):19–31, 1998. 
41

Research Findings

Volume 14, Number 3 (September 1999)

Gender Differences in Progression to AIDS

NIDA-funded research on injecting drug users (IDUs) 

conducted by Dr. Homayoon Farzadegan and his colleagues at The Johns Hopkins University School of 

Hygiene and Public Health in Baltimore has shown that 

the course of HIV infection differs in women and men, so 

that gender-specific treatment may be needed. This study 

of 2,960 adult IDUs, begun in 1988 with followup in 

1992 and 1997, revealed that although women progressed 

to AIDS as rapidly as men, they had approximately half 

the viral load in their bloodstreams when they developed 

AIDS. Initiation of AIDS treatment is based on HIV viral 

load, and current treatment guidelines are derived mainly 

from studies with men. 

The researchers speculate that physiological factors such 

as hormones may account, in part, for their findings. 

Dr. Farzadegan and the research team believe that these 

gender differences must be explored further, and the 

possibility that women are being under-treated based on 

current guidelines warrants considering a change in when 

women start therapy. The study was published in 

Lancet in 1998. 
Research Findings

42

Drug Abuse Research Helps Curtail the Spread Of Deadly 

Infectious Diseases

By NIDA Director Alan I. Leshner, Ph.D.

Volume 14, Number 2 (August 1999)

Drug abuse plays a central role in the spread 

of infectious diseases that threaten our 

Nation’s health. Injection drug use now 

accounts for about one-third of all new cases 

of AIDS reported in the U.S. each year, 

according to figures from the Centers for 

Disease Control and Prevention. Other 

statistics show that drug abuse is strongly 

linked to the spread of hepatitis, tuberculosis 

(TB), and syphilis and other sexually transmitted diseases. To address this major 

public health challenge, NIDA has long 

supported a broad program of research on 

drug abuse and infectious 

diseases. (For more information on drug abuse and infectious diseases, see “Infectious 

Diseases and Drug Abuse,” 

NIDA NOTES, Vol. 14, 

No. 2.)

Over the last decade, NIDAfunded researchers have developed and evaluated a range 

of interventions to reduce the 

spread of HIV among drug 

abusers, their sexual partners, and their children. Drug 

abuse treatment and community-based outreach and education programs have consistently demonstrated that drug 

abusers will reduce the drug-use and sexual behaviors that 

put them at risk for HIV and other blood-borne infectious diseases and that these changes in behavior lead to 

declines in new HIV infections. For example, one study of 

heroin addicts conducted by NIDA-supported researchers 

at the University of Pennsylvania in Philadelphia found 

that injecting drug users (IDUs) in a methadone treatment program contracted HIV at one-sixth the rate of 

addicts who were not in treatment. 

NIDA-supported researchers also have contributed to 

meeting the serious public health challenge posed by 

the re-emergence of TB in the last decade. HIV became 

prevalent among IDUs in the mid-1980s and transformed 

the latent TB infection that has always been widespread 

in this population into the contagious form of the disease. 

NIDA-supported epidemiologic, community, and treatment research among drug users at high risk for HIV and 

TB played an important role in a coordinated Federal and State initiative that led to the 

implementation of effective strategies to prevent and treat TB. As a result, from a peak 

of 26,673 cases in 1992, new TB cases fell 

to an all-time low of 19,851 in 1997. (For 

more information, see “Linking Medical 

Care With Drug Abuse Treatment Stems 

Tuberculosis Among HIV-Infected Drug 

Users,” NIDA NOTES, Vol. 13, No. 3.)

NIDA’s TB and HIV research has demonstrated that providing medical care to 

IDUs in conjunction with drug abuse treatment can curb the spread of 

infectious diseases. NIDA 

now is promoting further 

research to identify factors 

that support or hinder linkages between drug abuse 

treatment and primary medical care among a variety of 

populations, particularly 

women and racial and ethnic 

minorities. 

NIDA-supported research 

also has developed approaches that can check the spread 

of infectious diseases among the approximately 85 percent of IDUs who are not in treatment. For example, one 

long-term study in Baltimore providing directly observed 

preventive therapy and a variety of health care services in 

one convenient setting virtually eliminated new TB cases 

among out-of-treatment IDUs. We now are developing 

additional research initiatives to add drug abuse treatment 

to vans that provide comprehensive medical services in 

neighborhoods with large populations of out-of-treatment 

heroin addicts. We believe these coordinated mobile clinics may lead to further reductions in drug abuse and infectious diseases in this population. 

Noninjection drug use also fosters the spread of infectious diseases. For example, smokers of crack cocaine, 

particularly women who exchange sex for drugs, are at 

high risk for infection with HIV, hepatitis, TB, and sexually transmitted diseases. In addition, it appears that many 

heroin users who begin by snorting that drug sooner or 

Research has consistently demonstrated that drug abusers will reduce 

the drug-use and sexual behaviors 

that put them at risk for HIV and other 

blood-borne infectious diseases. 
43

later progress to injection drug use with its attendant risks. 

Early data from a NIDA-supported study by scientists at 

National Development and Research Institutes, Inc., in 

New York City indicate that a substantial portion of 

heroin snorters become injectors, engage in a high level 

of risky drug-use and sexual behaviors, and begin to contract hepatitis C soon after they start injecting drugs. By 

also shedding light on the complex individual and social 

factors that contribute to transition from noninjection 

to injection drug use, 

this study will help us 

develop new approaches 

to forestall the progression to injection drug 

use and infectious 

disease. (See “Heroin 

Snorters Risk Transition 

to Injection Drug Use 

and Infectious Disease,” 

NIDA NOTES, Vol. 14, 

No. 2.)

While we have made 

much progress in 

preventing and treating infectious diseases 

among drug abusers, the continued high prevalence of 

diseases such as HIV/AIDS and hepatitis in this population indicates that much remains to be done. Therefore, 

NIDA recently established the Center on AIDS and Other 

Medical Consequences of Drug Abuse. Headed by Dr. 

Henry Francis, the Center is coordinating a multidisciplinary program of research on the full spectrum of critical 

health issues associated with drug abuse. Components of 

the program include tracking the extent and progression 

of infectious diseases among drug users, assessing the 

effect of illicit drugs on the immune system, linking drug 

abuse treatment and medical care, and developing new 

educational and behavioral strategies for drug abusers who 

are not in treatment. Ultimately, the program will generate 

new strategies for reducing the spread of infectious diseases. (For additional information, see “New NIDA Center 

Will Address Health Issues Associated With Drug Abuse,” 

NIDA NOTES, Vol. 13, No. 5.) 

Because drug abuse and infectious disease have implications for many areas of biomedical research, the Center 

also is fostering collaborative research efforts with other 

institutes of the National Institutes of Health (NIH), 

government agencies, and private sector groups. 

Currently, NIDA supports more than 10 interagency and 

interinstitute studies 

involving drug abuse and 

infectious disease. For 

example, the Women 

and Infants Transmission 

Study being conducted 

by NIDA, the National 

Institute of Allergy and 

Infectious Diseases, and 

the National Institute 

of Child Health and 

Human Development 

is investigating motherto-infant transmission 

of HIV. NIDA also is 

participating in a new, 

congressionally mandated 

NIH research initiative that is responding to the health 

problems associated with hepatitis C. Approximately 4 

million Americans are infected with this virus, which can 

cause chronic liver disease that results, in many cases, in 

death due to cirrhosis and liver cancer. NIDA-supported 

research will be critical to the success of the NIH initiative 

because of the major role injection drug use plays in the 

transmission of this insidious infection. 

In the years ahead, drug abuse and infectious disease 

will continue to pose challenges to the Nation’s health. 

NIDA’s broad program of research on the medical consequences of drug abuse will continue to provide the scientific knowledge needed to overcome those challenges with 

multifaceted public health responses. 

Early data from a NIDA-supported study 

by scientists at National Development and 

Research Institutes, Inc., in New York City 

indicate that a substantial portion of heroin 

snorters become injectors, engage in a high 

level of risky drug-use and sexual behaviors, 

and begin to contract hepatitis C soon 

after they start injecting drugs. 
Research Findings

44

Heroin Snorters Risk Transition To Injection Drug Use And 

Infectious Disease

By Robert Mathias, NIDA NOTES Staff Writer

Volume 14, Number 2 (August 1999)

Heroin users who think they can avoid the harmful consequences of drug injection by snorting or smoking the drug 

may be dangerously mistaken. A NIDA-funded study indicates that noninjecting heroin users (NIUs) are at considerable risk of becoming drug injectors, thereby incurring risks 

for HIV, hepatitis, and other serious diseases. Moreover, 

regardless of whether they go on to inject drugs, a significant 

number contract hepatitis, the study shows. 

“Becoming a drug injector is not inevitable for heroin 

snorters who have never injected drugs, but the risk of 

making the transition to injection drug use is fairly substantial,” says Dr. Alan Neaigus of National Development 

and Research Institutes (NDRI), 

Inc., in New York City. Dr. 

Neaigus and his colleagues at 

NDRI have been examining rates 

of transition to injection drug use 

and disease incidence among 560 

NIUs recruited from March 1996 

through April 1998. The study 

group consists of heroin users who 

have never injected drugs and former heroin injectors who had not 

injected drugs for at least 6 months prior to the study. 

Data from followup interviews conducted with 331 study 

participants show that more than 15 percent transitioned 

to drug injection during an average period of a little more 

than a year. The researchers found no significant difference in the transition rate between NIUs who had never 

injected heroin and the 31 percent of the study group 

who were former injectors.

Previous studies have found higher rates of transition from 

noninjection to injection drug use, particularly among 

former injectors. However, Dr. Neaigus says a number 

of factors may now be slowing the rate at which heroin 

snorters are initiating or resuming injection of the drug. 

First, a dramatic increase in the purity of heroin during 

the 1990s has made it possible for snorters to achieve a 

high that is similar to what they can obtain from injection. Second, greater awareness of the risk of contracting 

AIDS from injecting drugs may be dissuading more users 

from the practice.

The NIU study supported earlier research findings that 

NIUs who socialize, use drugs, or have sex with IDUs 

significantly increase their risk of crossing the line from 

snorting to injecting drugs. Preliminary analysis further 

suggests that being in the presence of an IDU who is 

injecting drugs may play an important role both in the 

initiation and resumption of injection drug use, Dr. 

Neaigus says. This finding suggests that the direct transfer 

of information and techniques used to inject drugs may be 

an important factor in the transition to injection drug use.

The level of heroin addiction is another major factor in 

the transition to injection. The NIU study participants’ 

levels of addiction ranged from snorting heroin occasionally on weekends through using several bags a day, Dr. 

Neaigus says. Previous research 

has suggested that even with the 

availability of high-purity heroin, 

more heavily addicted heroin 

snorters may turn to drug injection because it remains a more 

effective way to take the drug. For 

example, in a study conducted 

between 1991 and 1993 by Dr. 

Samuel R. Friedman, also of 

NDRI, 30 percent of 755 IDUs 

in Brooklyn, New York, reported they started to inject to 

get a better high.

NIUs and Infectious Disease

The health risks associated with noninjecting heroin use 

are substantial, both for NIUs who become IDUs and for 

those who don’t, the study found. All study participants 

received counseling about the risks of drug injection, 

hepatitis, and HIV. Nevertheless, almost 23 percent of 

the NIUs who began to inject drugs contracted hepatitis 

C (HCV) over the average followup period of a little over 

a year. HCV leads to chronic liver infection in about 80 

percent of patients, most of whom eventually develop fatal 

liver diseases such as cirrhosis and liver cancer, says Dr. 

Henry Francis, who directs NIDA’s Center on AIDS and 

Other Medical Consequences of Drug Abuse.

Because injection drug use is the primary mode of HCV 

transmission, “the rapid rate of transmission of hepatitis C 

among NIUs who initiate or resume injecting was expected,” 

Dr. Neaigus says. “However, it is still alarming,” he adds. 

What was unexpected was that some NIUs who did not 

NIUs who socialize, use drugs, 

or have sex with IDUs significantly increase their risk of 

crossing the line from snorting 

to injecting drugs.
45

begin to inject drugs—about 4 percent—also contracted 

HCV during the followup period. NDRI researchers now 

are attempting to determine how these NIUs contracted 

the infection, Dr. Neaigus says.

NIUs who did not transition to injection drug use were 

also at substantial risk of becoming infected with hepatitis 

B (HBV), the study shows. About 9.5 percent contracted 

HBV during the followup period. Though it receives less 

attention than HCV, HBV 

can develop into chronic 

infection and serious 

liver disease in up to 20 

percent of cases, says NIDA’s 

Dr. Francis.

The considerable amount of 

HBV found among NIUs, 

particularly among those who 

have never injected, reflects 

substantial sexual transmission of this disease, Dr. Neaigus says. Though the study 

only measured sexual activity over a 30-day period, “we 

found a lot of sexual risk in this group,” he says. For 

example, about 70 percent of NIUs were sexually active 

during this period with two-thirds of them engaging in 

unprotected sex, many with partners who had HIV or 

were IDUs, says Dr. Neaigus.

To date, the study has not found any new cases of HIV 

either among NIUs who began injecting drugs or among 

those who did not. However, Dr. Neaigus says that the 

high rates of new HBV and HCV infections found among 

NIUs may serve as markers for sexual behaviors and drug 

injection practices that continue to put NIUs at risk for 

infection with HIV. In addition to finding extensive highrisk sexual activity among NIUs, the study found NIUs 

who had recently transitioned 

to injection drug use commonly shared injection 

equipment, such as cookers, cotton, and rinse water. 

However, they infrequently 

shared syringes and over half 

obtained all their syringes 

from syringe exchange 

programs.

Noninjection drug use is 

two-edged in its effect on 

heroin users’ risk of contracting infectious diseases, Dr. 

Neaigus concludes. On the one hand, the considerable 

numbers of former IDUs who are now snorting heroin 

instead of injecting it have reduced their risk of AIDS 

and HCV considerably. On the other hand, NIUs who 

have never used heroin before have increased their risk 

of heroin addiction, transition to injection drug use, and 

contracting HIV, HCV, and HBV.

Sources

• Neaigus, A., et al. Trends in the noninjected use of 

heroin and factors associated with the transition to 

injecting. In J.A. Inciardi and L.D. Harrison (eds.), 

Heroin in the Age of Crack Cocaine, Sage Publications, 

Inc., Thousand Oaks, CA, pp. 131–159, 1998.

• Neaigus, A.; Friedman, S.R.; Hagen, D.L.; Miller, 

M.; and Des Jarlais, D.C. Transitions to injecting and 

seroconversions for HIV, hepatitis B, and hepatitis C 

among non-injecting heroin users. Paper presented at 

the 12th World AIDS Conference, Geneva, 1998.

• Neaigus, A.; Hagen, D.L.; Friedman, S.R.; Miller, 

M.; and Des Jarlais, D.C. Transitions to injecting 

drug use among non-injecting heroin users. Paper 

presented at the American Public Health Association 

annual meeting, Washington, D.C., 1998. 

Drug injection is the primary mode of hepatitis C transmission. In a New York City study, a large percentage of noninjecting heroin users who transitioned to injection drug use 

contracted the disease.

“This is the era of AIDS, and everyone 

knows about the risks from needles. 

When you sniff, you don’t have to 

worry about AIDS.”

— Noninjecting heroin user interviewed

in New York City

Hepatitis C Among Noninjecting Heroin Users
46

Research Findings

Special Journal Supplement Summarizes Research On HIV 

Prevention in Drug-Using Populations

Volume 13, Number 5 (February 1999)

To underscore the importance of research on prevention 

of HIV/AIDS in drug-using populations, the publishers of Public Health Reports issued a special supplement 

in June 1998 focusing on the current status of national 

and international research on the subject. In the supplement, co-edited by Dr. Richard Needle, chief of NIDA’s 

Community Research Branch (CRB), Dr. Susan Coyle, 

chief of NIDA’s Clinical, Epidemiological, and Applied 

Sciences Review Branch, and Helen Cesari of CRB, 

researchers report on interventions that have proven 

effective in helping drug users change their behaviors and 

reduce their risk of HIV infection. 

The supplement reviews more than a decade of HIV prevention research supported by NIDA. Research reported 

in the issue indicates that community-based intervention 

strategies have proved to be effective in averting HIV 

infection by providing drug-using populations with the 

means for changing their drug use patterns, needle practices, and sexual behaviors. 

Articles highlight seven HIV prevention principles, 

including the need to: 

• initiate HIV prevention interventions early in the 

epidemic; 

• implement interventions at legal, institutional, 

community, network, and individual levels; 

• implement interventions in multiple settings such 

as streets, shooting galleries, clinics, needle exchange 

programs, and drug treatment centers; 

• target multiple risk behaviors such as drug use, needle 

risk, and sexual practices; 

• provide access to risk reduction information and 

supplies, including injection hygiene materials, condoms, and HIV antibody testing with counseling; 

• recognize that populations at risk for HIV are in 

varying stages of readiness to engage in interventions 

and create opportunities for repeated exposures; and 

• be assured that risk reduction is an appropriate, 

realistic outcome of HIV interventions. 

NIDA made this supplement available to scientists at the 

12th World AIDS Conference in Geneva last summer. 
47

Research Findings

Researchers Find Gender Differences In How Drug Abusers 

Respond To HIV Prevention Strategies

By Steven Stocker, NIDA NOTES Contributing Writer 

Volume 13, Number 4 (November 1998)

Men who abuse drugs are more likely to reduce their sexual risks of HIV infection if they are given risk-reduction 

information on the street, while women drug abusers 

respond better if they are given this information in an 

office with counseling. This is 

one of the findings of a NIDAfunded study on the effectiveness of HIV risk-reduction 

programs tested in two towns in 

Arizona. 

Dr. Robert Trotter and his colleagues at Northern Arizona 

University in Flagstaff developed 

two enhanced programs for 

reducing drug-related and sexual 

risks for HIV transmission and 

added the programs to a standard program developed by the 

Centers for Disease Control and 

Prevention and modified by 

NIDA. The standard program 

recruits drug abusers on the 

street and then provides HIV 

risk-reduction information at the 

project office. In the office, counselors provide information on proper condom use and bleach disinfection of 

drug injection equipment. Drug abusers also are offered 

testing for HIV infection. 

One of the enhanced programs developed by the researchers, called the active outreach intervention, provides the 

HIV risk-reduction information on the street rather than 

in the office. Later, the entire network of people who use 

drugs together and share drug use equipment is invited 

into the office for a group discussion of HIV transmission 

risks. 

The other enhanced intervention, called the office-based 

intervention, involves the same recruitment procedure 

as the standard intervention, but additional counseling 

techniques are used when the drug abuser visits the office. 

In the office, the person is first asked to identify at least 

one HIV risk in his or her life. The person is then asked 

how this risk might be reduced and is encouraged to do 

so. Like the active outreach intervention, the office-based 

intervention also involves a subsequent group session with 

the network of drug abusers. 

All three interventions, both the 

standard and the two enhanced, 

reduced HIV risk behaviors; however, for reducing sexual risks, the 

researchers found that the active 

outreach intervention worked better 

for men, and the office-based intervention worked better for women. 

The men seemed to respond well 

to being taught about HIV riskreduction on the street because that 

was the environment in which HIV 

risks often occurred, Dr. Trotter 

speculates. “Some pretty solid social 

science theory states that, for certain 

kinds of behavior, providing the 

behavior reduction intervention in 

the context in which the behavior 

occurs is more effective,” he says. 

However, this theory did not apply to the women in the 

study. The women told the researchers that they felt safe 

discussing sensitive matters in the office, where they were 

not under pressure from family and other drug abusers. “If 

we had conducted the interventions with these women on 

the street or in their homes, people would be around who 

might hear what they were saying, and the women were 

afraid of the repercussions. In the office, the women felt 

emotionally and physically protected,” Dr. Trotter says. 

Source 

• Trotter, R.T.; Bowen, A.M.; Baldwin, J.A.; and Price, 

L.J. The efficacy of network-based HIV/AIDS riskreduction programs in midsized towns in the United 

States. Journal of Drug Issues 26(3):591–605, 1996. 

Dr. Robert Trotter of Northern Arizona University 

discusses with his staff possible strategies for reducing 

HIV transmission risks among drug abusers who use 

drugs together and share drug injection equipment.
Research Findings

48

Drug Abuse Cost to Society Set at $97.7 Billion, Continuing 

Steady Increase Since 1975

By Neil Swan, NIDA NOTES Staff Writer 

Volume 13, Number 4 (November 1998)

The economic cost to U.S. society of drug abuse was an 

estimated $97.7 billion in 1992, according to recent calculations. The new cost estimate continues a pattern of 

strong and steady increase since 1975, when the first of 

five previous cost estimates was made. The current estimate is 50 percent higher than the most recent previous 

estimate—which was made for 1985—even after adjustment for population growth and inflation. 

The parallel cost to society for alcohol abuse was estimated at $148 billion, bringing the total cost for substance 

abuse in 1992 to $246 billion. This total represents a cost 

of $965 for every person in the United States in 1992. 

The per-person cost for drug abuse alone was $383. 

These estimates were calculated for NIDA and the 

National Institute on Alcohol Abuse and Alcoholism 

by The Lewin Group, a private health care research and 

consulting company in Fairfax, Virginia. The results were 

prepared by analysts using data from a variety of public 

and private sources and were released in May 1998 in a 

220-page report, The Economic Costs of Alcohol and Drug 

Abuse in the United States, 1992. 

Inflation and population growth have driven the cost 

of drug abuse even higher since 1992, the analysts said. 

Updating the estimates developed in their study, they 

calculated that the cost of drug abuse increased 12.5% 

from 1992 to 1995, bringing the cost to $109.8 billion 

in 1995. 

“Substance abuse and addiction have serious medical and 

social consequences,” says NIDA Director Dr. Alan I. 

Leshner. “These rising costs warrant a strong, consistent, 

and continuous investment in research on prevention and 

treatment. We must publicize these cost-to-society estimates 

to educate people that drug abuse is enormously expensive 

to the entire Nation, that the cost has been rising steadily, 

that extensive research shows that drug abuse can be treated, 

and that drug abuse treatment reduces that cost.” 

The report’s authors said substance abuse brings specific 

well-recognized consequences and costs in three categories: 

first, health consequences and their impacts on the health 

care system; second, criminal behavior, either as a livelihood, participation in the drug trade, or violence related 

to drug abuse; and finally, job losses, family impoverishment, and subsequent reliance on welfare or other elements of society’s safety net. 

New Cost Estimates Reflect Recent Developments 

The new cost estimates reflect major developments since 

the last analysis, including: 

• increased availability of cocaine and crack cocaine; 

• the spread of HIV and AIDS among injecting drug 

users; 

• increasing numbers of people treated for alcohol 

abuse who also have drug abuse problems; 

• increased availability of, and support for, substance 

abuse treatment, largely during the late 1980s; 

• significant restructuring of the delivery of health 

services for drug abuse; and 

• expansion of scientific knowledge about drug abuse 

problems and their impact on society.

The analysis notes that the epidemics of cocaine abuse and 

HIV/AIDS were in their early stages when the last economic 

cost estimate was compiled in 1985. In addition, heavy drug 

use was higher in 1992 than in 1985, the analysts reported. 

Who Bears the Cost of Drug Abuse?
49

Changes in the methodology used to calculate estimates 

resulted in higher cost estimates for various health problems 

attributable to drug abuse, the researchers say. However, 

while 80 percent of the increase in estimated costs of 

alcohol abuse can be attributed to changes in methodology 

in the new study, more than 80 percent of the increase 

in estimated costs of drug abuse is due to real changes 

in drug-related emergency room episodes, health service 

delivery trends, and criminal justice expenditures. 

Law enforcement and incarceration costs played a significant role in the increases. Although crime rates remained 

relatively stable between 1985 and 1992, criminal justice 

expenditures more than doubled overall, even after adjusting 

for inflation. Increases in the numbers of people incarcerated were a major factor in rising drug-related costs, 

reflecting increases in drug-related arrests and changes in 

sentencing practices for drug crimes. 

Health Costs 

Health care expenditures for drug abuse problems were 

estimated to total $9.9 billion. Of this total, $4.4 billion 

was for drug abuse treatment, detoxification, and rehabilitation services, as well as prevention, training, and research. 

Treatment for drug abuse-related health problems—

including HIV infection and AIDS, other diseases, and 

injuries—totaled $5.5 billion. Compared to past analyses, 

the new estimate shows greater recognition for healthrelated costs of coexisting substance abuse and other 

medical or mental disorders. 

Some 25,000 premature deaths were attributed to drug 

abuse in 1992, for a total cost of $14.6 billion, a figure 

that represents the value of expected lifetime earnings 

that were lost. The analysts calculated the average loss per 

death at about $350,000. Many of the deaths were among 

drug abusers 20 to 40 years of age, many of whom died of 

accidents, trauma, or HIV/AIDS. 

An additional $14.2 billion in lost potential productivity 

was estimated for drug-related illness and disability for 

1992. This loss was in the form of work not performed, 

including household tasks. The authors point out that the 

study does not attempt to estimate the burden of drug 

abuse on work sites or employers because no reliable data 

are available on which to base an estimate. 

Crime and Welfare Administration Costs 

The costs of crime that were attributed to drug abuse 

were estimated at $58.7 billion in 1992. Drug abuse was 

implicated in the cost analysis as the cause of 25 to 30 

percent of all income-generating crime, such as burglary 

and robbery; 5 percent or less was attributed to alcohol 

problems. In contrast, alcohol abuse was implicated in 25 

to 30 percent of violent crimes, with only 5 percent or 

less of violent crimes attributed to drug abuse. Criminal 

justice system costs due to drug abuse, including drug 

traffic control expenditures, totaled $17.4 billion. 

The indirect costs of drug-related crime include lost lifetime earnings of homicide victims, totaling $1.4 billion, 

and $2.06 billion in lost earnings for victims of nonfatal 

crimes. 

Enormous costs to society were attributed to lost income 

for incarcerated drug criminals and lost legitimate income 

when individuals instead pursue illegitimate, drug-related 

livelihoods. Some 460,000 drug offenders were incarcerated 

throughout 1992, for a calculated loss of potential 

productivity of $17.9 billion. What the analysts call the 

costs of “crime careers” were set at $19.2 billion in 1992. 

This figure assumes the equivalent of 600,000 drug abusers and drug traffickers dropping out of full-time, legitimate jobs to earn their living from predatory or consensual crime, such as drug trafficking and prostitution. 

Social welfare spending attributable to drug abuse-related 

impairments was $3.8 billion in 1992. Of that figure, 

administrative costs account for an estimated $337 million. Only these administrative costs are included in the 

Health Costs

Direct

Drug Abuse Services $4,400

Medical Consequences $5,531

Indirect (Lost Earnings)

Premature Death $14,575

Illness $14,205

Institutionalization $1,477

Total Health Costs $40,188

Crime and Other Costs

Direct

Crime $17,970

Social Welfare Administration $337

Indirect (Lost Earnings)

Victims of Crime $2,059

Incarceration $17,907

Crime Careers $19,198

Total Crime and Other Costs $57,471

Total Cost $97,659

Estimated Economic Cost of Drug Abuse In the 

United States, 1992 (Millions of Dollars)
50

report’s cost estimates because cash transfer programs, 

such as social welfare, simply represent a redistribution 

of resources. 

Who Pays These Costs? 

The Nation as a whole pays the costs of drug and alcohol 

abuse, the authors concluded. Many of the costs fall on 

the alcohol or drug abuser. Drug abusers and their families bear $42.9 billion of the total, including costs related 

to health problems, early death, or lost earnings. The government bears the largest share, paid for services such as 

criminal justice. Other costs are transferred through insurance mechanisms, including welfare, health coverage, and 

unemployment and disability insurance. 

For More Information 

The Economic Costs of Alcohol and Drug Abuse in the 

United States, 1992 (#BKD265) is available on NIDA’s 

Web site at www.nida.nih.gov/EconomicCosts/Intro.html.
51

Research Findings

Curbing Tuberculosis in Out-of-Treatment Injecting Drug Users 

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 13, Number 3 (July 1998)

In addition to developing strategies to deal successfully 

with tuberculosis (TB) among injecting drug users with 

HIV in drug abuse treatment programs, NIDA-supported 

researchers also have developed effective approaches to 

preventing and treating tuberculosis among out-of-treatment injecting drug users with HIV. 

Out-of-treatment injecting drug users represent an even 

bigger threat than those in treatment for spreading infectious diseases such as HIV and TB, says Dr. David Vlahov 

of The Johns Hopkins University in Baltimore. “At any 

one time only 15 percent of drug users are in drug abuse 

treatment,” Dr. Vlahov says. “The question is, what do 

you do about the other 85 percent?” he asks. Historically, 

most of these individuals have had little or no access to 

health services where treatment for infectious diseases 

could be provided, he points out. 

Some solutions to this problem have come from a NIDAsupported study led by Dr. Vlahov that has been following 

3,000 out-of-treatment drug users in Baltimore since 1988. 

Dubbed the AIDS Linked to the Intravenous Experiences 

(ALIVE) cohort, the study was originally funded by NIDA 

to track how HIV/AIDS progresses in this population. 

Slightly more than 700 of the nearly 3,000 study participants 

tested positive for HIV when they were first assessed. In 

the succeeding 10 years, another 290 participants became 

HIV positive. 

NIDA-supported research has shown that HIV infection can activate latent TB infection, which is widespread 

among injecting drug users. Thus, in 1990, the ALIVE 

study began to conduct TB testing on 600 HIV-positive 

and 600 HIV-negative study participants when they visited a community-based clinic for assessment and health 

care every 6 months. In 1991, the study began to offer 

directly observed tuberculosis prevention treatment to participants with and without HIV infection who tested positive on a skin test for tuberculosis infection. With directly 

observed prophylaxis, study staff observed patients take 

twice weekly doses of isoniazid, a tuberculosis prevention 

medication, for at least 6 months. 

Out-of-treatment drug users do not have the incentive of 

getting a daily methadone dose that can bring in-treatment 

patients back to a clinic for regular medical treatment, Dr. 

Vlahov points out. Initially, the ALIVE study used street 

outreach, word of mouth, and a small cash payment to 

recruit participants for initial assessment and testing, he 

says. To get these participants to come back for followup 

assessments and treatment, the ALIVE staff provided a 

supportive clinic environment that offered strict confidentiality, a refuge from the street, and easily accessible health 

care services, he says. 

“The key to providing health care services for out-of-treatment drug users is one-stop shopping combining as many 

services as possible in one location,” Dr. Vlahov says. The 

clinic for ALIVE participants was located in the Baltimore 

City Department of Health building. A health department 

nurse assigned to the clinic provided TB prevention medications onsite; and patients could easily be referred to 

other clinics in the building for specialized health services, 

he notes. 

As a result of offering directly observed TB therapy within 

this comprehensive, supportive health-care environment, 

“the incidence of new cases of tuberculosis among the 

patients in the study, which had peaked at 12 cases of 

active disease in 1991 when we started offering TB 

prophylaxis, went down to nearly zero,” Dr. Vlahov says. 

“Basically, we’ve eradicated TB from our cohort,” he says. 

Source 

• Graham, N.M.H.; Galai, N.; Nelson, K.E.; 

Astemborski, J.; Bonds, M.; Rizzo, R.T.; Sheeley, L.; 

and Vlahov, D. Effect of isoniazid chemoprophylaxis 

on HIV-related mycobacterial disease. Archives of 

Internal Medicine 156:889–894, 1996. 
Research Findings

52

Linking Medical Care With Drug Abuse Treatment Stems 

Tuberculosis Among HIV-Infected Drug Users

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 13, Number 3 (July 1998)

Injecting drug users with HIV/AIDS can be treated successfully for tuberculosis (TB) in methadone treatment programs that provide comprehensive medical care, according 

to NIDA-supported research. Integrating medical care and 

drug abuse treatment also has been effective in preventing new cases of TB from developing among HIV-positive 

patients, the research indicates. 

“A key to dealing successfully with infectious diseases, such 

as TB and HIV, among drug abuse patients is the linkage of 

primary care and drug abuse treatment in a drug abuse treatment setting,” says Dr. Paul A. Coulis of NIDA’s Center on 

AIDS and Other Medical Consequences of Drug Abuse. “In 

places where this has been done, such as New York City, it 

has been effective, so we know it works,” he says. 

TB is a chronic and infectious lung disease. People with 

latent tuberculosis infection do not have symptoms, may 

not develop active disease, and cannot spread TB. However, 

if such individuals do not receive preventive therapy, they 

may develop active TB, which is contagious. 

Research has shown that injecting drug users have high 

rates of latent tuberculosis infection. NIDA-supported 

studies among injecting drug users have shown that HIV 

can activate this latent TB infection and increase the risk 

that active TB will develop. In New York City, which 

was hard hit by the linked epidemics of HIV and TB 

during the mid-1980s and early 1990s, 30 percent of persons with active TB were injecting drug users, according to 

the Centers for Disease Control and Prevention (CDC). 

Rates of TB have declined both nationally and in New 

York City since 1992. However, injecting drug users 

continue to be at high risk for HIV and tuberculosis. For 

example, about one-third of the 900 methadone treatment 

patients in the Montefiore Medical Center’s Substance 

Abuse Treatment Program in The Bronx, New York, 

have HIV, and TB rates are much higher than they are in 

the general population, says Dr. Marc Gourevitch, who 

directs a NIDA-funded study of TB infection in drug users 

enrolled in the program. “Almost all the active TB cases we 

see among drug users in our program are among those who 

are HIV-positive,” Dr. Gourevitch notes. 

To respond to the complex health needs of its patients, the 

Montefiore treatment program used funding from NIDA 

and the Health Resources and Services Administration to 

begin providing medical care on site along with methadone 

treatment in 1989. In addition to general and HIV-related 

primary care, on-site services now include mental health 

and social support services; HIV testing and counseling; 

and TB testing, prevention, and treatment. “Our model 

has been to build comprehensive primary care services into 

the same site at which people are receiving their drug treatment to make it easier for them to get their medical care,” 

Dr. Gourevitch says. This treatment model has enabled the 

program to achieve excellent success in getting drug abuse 

treatment patients to complete the full course of TB therapy needed to curtail the spread of the disease, he says. 

Patients must follow demanding medication regimens to 

prevent and treat TB. To complete the full course of TB 

prevention, injecting drug users with latent TB infection 

must take one medication, isoniazid, daily for up to a year. 

Patients with active tuberculosis require an initial hospitalization with a 4-medication regimen and then must take 2 

to 4 medications daily or several times a week for up to a 

year. Failure to complete the full course of TB treatment 

can spawn an even more deadly form of the disease, one 

that is resistant to tuberculosis medications. 

In 1989, the Montefiore treatment program implemented 

a strategy called directly observed therapy (DOT) that was 

designed to increase patients’ adherence to TB therapy. 

With DOT, treatment personnel observe patients taking 

each dose of their TB prevention and treatment medications. Now a widely accepted TB treatment practice, DOT, 

along with improved management of TB cases to ensure 

completion of a full course of therapy, has been credited by 

the CDC as playing a major role in the overall reduction in 

TB rates in the United States since 1992 (see “The Rise and 

Fall of TB in the United States.”). Methadone treatment 

programs offer an ideal setting to implement DOT and 

ensure that injecting drug users complete the full course 

of treatment because patients are coming in daily for their 

methadone anyway, Dr. Gourevitch says. “It’s a natural 

process to administer the anti-TB medications and methadone at the same time under direct supervision,” he says. 

Directly observed tuberculosis prevention and treatment 

are voluntary at Montefiore. No incentives are offered for 

participating in supervised preventive therapy, and methadone is not withheld if drug abuse treatment patients do 

not accept TB therapy. “Yet, almost everyone opts for 

observed therapy because it eliminates the hassle of having 

to remember to take TB medications at other times of the 

day,” Dr. Gourevitch says. 
53

Research conducted by Dr. Gourevitch shows that a high 

percentage of patients receiving directly observed prophylaxis and treatment in the context of their methadone 

treatment adhere to and complete TB therapy. In one 

study, more than 80 percent of 114 eligible patients had 

completed or were still receiving prophylaxis or treatment 

at the end of a 2-year period. Additional research by Dr. 

Gourevitch indicates that completion of TB prophylaxis 

was associated with a 75 percent reduction in the TB rate 

in this high-risk population and that providing on-site 

directly observed prophylaxis is cost-effective in terms 

of preventing the costs of treating active TB. 

“What we’ve learned is that having primary care integrated with drug abuse treatment is a very effective way 

to treat and prevent various diseases among drug users,” 

concludes NIDA’s Dr. Coulis. 

Sources 

• Gourevitch, M.N.; Alcabes, P.; Wasserman, W.C.; 

and Arno, P. Cost-effectiveness of directly observed 

chemoprophylaxis of tuberculosis among drug users 

at high risk for tuberculosis. International Journal of 

Tuberculosis and Lung Disease, 2(7):531–540, 1998.

• Gourevitch, M.N.; Hartel, H.; Schoenbaum, E.E.; 

Selwyn, P.A.; and Klein, R.S. Effectiveness of isoniazid (INH) chemoprophylaxis in tuberculin-positive 

drug users with HIV infection. Abstract presented at 

the Conference on Global Lung Health and the 1997 

Annual Meeting of the IUATLD, Paris, France, 1997. 

• Gourevitch, M.N.; Wasserman, W.; Panero, M.S.; 

and Selwyn, P.A. Successful adherence to observed 

prophylaxis and treatment of tuberculosis among drug 

users in a methadone program. Journal of Addictive 

Diseases 15(1):93–104, 1996. 

• Herman, M.; and Gourevitch, M.N. Integrating 

primary care and methadone maintenance treatment: 

Implementation issues. Journal of Addictive Diseases

16(1):91–102, 1997. 

After decades of decline, tuberculosis (TB) re-emerged 

during the 1980s to mount a new threat to the Nation’s 

public health. From a low of 22,201 cases in 1985, TB 

rates started to increase in the remaining years of the 

decade, according to the Centers for Disease Control 

and Prevention (CDC). The rise in new TB cases accelerated into the early 1990s, peaking at 26,673 in 1992. 

Injecting drug use and the onset of the HIV/AIDS epidemic during the 1980s both have played important 

roles in the resurgence of TB. Rates of latent, or inactive, TB have always been high among injecting drug 

users. NIDA-supported studies show that HIV infection, 

which is also prevalent among injecting drug users, can 

activate this latent TB and accelerate the course of the 

disease. Lack of access to TB therapy or failure to complete a full course of therapy also contributes to development of active TB and transmission of the infection. 

To counter the threat of TB, a number of Federal agencies, including the National Institutes of Health (NIH) 

and CDC, worked with State health departments in 

the early 1990s to develop a national TB elimination 

strategy. As a result, State and local health departments 

received increased Federal resources to improve their TB 

prevention and control programs, and NIH institutes 

increased their funding for TB research. The resulting 

NIDA-supported TB research focused on charting the 

course of TB among drug users and improving strategies 

to halt its spread by increasing drug users’ adherence to 

TB medication regimens.

This coordinated effort led to the development of effective strategies to identify and treat persons with TB. As a 

result, the tide of TB now appears to have turned in the 

United States. Nationally, new TB cases have been on the 

decline since 1992. 

In 1996, new TB 

cases fell to an alltime low of 21,337 

cases, according 

to the most recent 

statistics from the 

CDC.

“The national TB 

control strategy has 

been very effective,” 

says Dr. Henry 

Francis, director 

of NIDA’s new 

Center on AIDS 

and Other Medical 

Consequences 

of Drug Abuse. 

However, rates of 

latent TB infection 

remain high among 

injecting drug users 

and in geographical pockets and have the potential for active disease and 

transmission, he notes. “It is important to maintain our 

vigilance, or we will see TB rates start to climb again,” 

he says.

Source

• Centers for Disease Control and Prevention. 

Tuberculosis morbidity United States, 1996. 

Morbidity and Mortality Weekly Report 46(30):

695–700, 1997. 

The Rise and Fall of TB In the United States

After many years of declining, TB rates 

in the United States started to increase 

again in 1986, and accelerated into the 

early 1990s, peaking at 26,673 in 1992. 

Since then, new TB cases have declined, 

falling to an all-time low in 1996.

Tuberculosis Cases Reported 

in the U.S. 

1975–1996

Source: Centers for Disease Control and Prevention 
Research Findings

54

Interagency Pacts and NIH Collaborations Extend NIDA’s 

Research Reach 

By Neil Swan, NIDA NOTES Staff Writer 

Volume 13, Number 1 (June 1998)

Teamwork with sister Institutes of the National Institutes 

of Health (NIH) and other Federal agencies is increasing 

the cost-effectiveness and extending the reach of NIDA’s 

research. 

In one current research collaboration, NIDA is a key 

participant in a broad new effort extending across several 

Federal agencies to examine the links among violence, 

crime, and drug abuse. Research focuses on a host of 

criminal, medical, and social problems that are often 

related to drug abuse. These problems include sexual and 

physical abuse of children, violence against women, teenage crime and violence, trends in public attitudes toward 

violence, and violence-related demands on the Nation’s 

courts, prisons, and delivery of health services. 

Called the Violence Initiative, the cooperative research 

enterprise involves more than 20 Federal agencies collaborating under an Interagency Agreement. Two departments 

spearhead the Initiative: the Department of Health and 

Human Services (HHS), with NIDA taking a lead role; 

and the Department of Justice, represented by its research 

agency, the National Institute of Justice (NIJ). NIJ conducts research to fight crime, improve criminal justice, and 

evaluate criminal justice programs. 

The 3-year Interagency Agreement for violence-related 

research also involves the Department of Housing and 

Urban Development, which has an interest in crime and 

social issues in public-supported housing. Also participating are the Department of Education, the Centers for 

Disease Control and Prevention (CDC), and other NIH 

Institutes in addition to NIDA—agencies with diverse 

objectives but a common interest in violence, its causes, 

and its consequences. 

The Initiative is formally named the Interagency 

Consortium for Research on Violence Against Women and 

Violence Within the Family. It allows NIDA and the other 

agencies to bridge the gap between two bodies of research—

studies relating to drug abuse, drug addiction, and mental 

health and studies relating to social and criminal justice 

questions. The Initiative spans academic disciplines to make 

the benefits of NIDA’s biological and behavioral drug abuse 

research—ranging from basic neuroscience studies to investigations of the cost-effectiveness of drug abuse treatment 

innovations—applicable to those agencies interested in the 

many drug-related aspects of violence. 

The research interests of NIDA and NIJ frequently overlap. For example, NIJ is vitally interested in causes of 

recidivism—the return to jail of inmates who have committed new crimes since their release—says Dr. Donald 

Vereen, NIDA’s representative to the founding interdepartmental group. Recidivism and other disruptive or 

criminal behaviors may relate to what research has shown 

are drug-induced changes in the brains of drug abusers, 

which may be associated with drug craving, explains Dr. 

Vereen, who is NIDA’s special assistant to the Director 

for medical affairs. Thus, drug abuse research can help 

in designing inmate drug abuse education and treatment 

programs, he says. NIDA-funded research already has 

provided much of the impetus toward innovative “drug 

courts” that seek to address both criminal justice and 

addiction problems by striving to keep offenders enrolled 

in drug abuse treatment programs, he says. 

The initial research findings under the Initiative have 

not yet been reported, but previous cooperation between 

NIJ and NIDA has already proved productive, says Sally 

Hillsman, NIJ deputy director. “For example, we have 

benefited greatly from the work of NIDA’s Community 

Epidemiology Work Group [which monitors trends in drug 

use patterns in selected U.S. cities].” 

After the agreement was signed in late 1995, the participating agencies called for research proposals relating to 

various aspects of violence. Ten projects have now been 

funded, all of them studying drug or alcohol abuse-related 

violence issues, according to Dr. Coryl Jones of NIDA’s 

Epidemiology Research Branch, who is monitoring the 

projects. Sometimes the substance abuse factor in the violence studies becomes much more apparent as the project 

continues, she says. For example, one Initiative project is 

studying violence toward female care providers—wives and 

daughters—over age 55. As the project continues, researchers are finding strong evidence that drug and alcohol abuse 

by the women’s mates or parents is an important factor in 

their victimization by violence, she says. 

Planning for the $1.8 million Violence Initiative evolved 

from policymakers’ interest in the Violence Against 

Women Amendment to the Violent Crime Control and 

Law Enforcement Act of 1994. “Early on, NIDA Director 

Dr. Alan Leshner got involved. He pushed us to get people from agencies outside of NIDA to participate,” says 

Dr. Vereen. 
55

The agencies are able to collaborate thanks to the 

Interagency Agreement, a formal contract that spells out 

terms and financial commitments for participant agencies. “The Interagency Agreement is tailor-made for broad 

cooperative efforts like the Violence Initiative,” says Dr. 

Vereen. “It’s good for research as an 

enterprise, and it’s good for science. 

It takes advantage of an existing 

infrastructure. All the participating 

agencies get something out of it.” 

“The Interagency Agreement is 

a good tool for funding in situations when there is no handy grant 

mechanism,” says Carol Cornwell, a 

budget analyst in NIDA’s Program 

and Financial Management Branch, 

who manages the Initiative’s funds 

since NIDA was designated 

“banker” for the collaborative operation. “Several of the 

Violence Initiative’s participating agencies do not have a 

grant-issuing mechanism. But they can participate in the 

Interagency Agreement, making funding contributions, 

and have a say in the type of research that is funded.”

NIDA is also involved in other Interagency Agreements, 

including collaborating with the State Department to 

improve drug abuse research in South America (see 

“NIDA Advances Drug Abuse Research in Andean 

Countries,” NIDA NOTES, September/October 1997). 

The Institute is also working with other NIH Institutes, 

the Department of Energy, and the Department of 

Veterans Affairs to develop improved “informed consent” 

policies to ensure that people participating in research are 

adequately informed of related ethical issues and risks to 

their health. 

Interagency Agreements are only one way that NIDA teams 

up with fellow Federal agencies. There are also collaborations 

in which NIDA joins with other NIH Institutes to conduct 

mutually beneficial research. These collaborations have proven 

to be productive and beneficial, says Dr. Vincent Smeriglio of 

NIDA’s Clinical Medicine Branch. 

NIDA currently is involved in four major collaborations 

with other NIH Institutes and public health agencies. 

In the Maternal Lifestyles Study, NIDA collaborates 

with the National Institute of Child Health and Human 

Development (NICHD), the HHS Administration 

on Children, Youth, and Families, and the Center for 

Substance Abuse Treatment. The agencies are studying 

the health and development of infants and children who 

are exposed to illicit drugs during their mothers’ pregnancies. More than 11,000 mothers were interviewed about 

their pregnancies and drug use, and some 1,400 infants 

are enrolled in followup studies. The continuing project 

is building valuable information for developing enhanced 

interventions to better address prenatal drug exposure and 

its possible consequences. 

The Women and Infants Transmission Study (WITS) 

is a six-site collaborative project studying mother-toinfant transmission of HIV. NIDA is collaborating with 

the National Institute of Allergy and Infectious Diseases 

(NIAID), the lead NIH Institute involved in HIV and 

AIDS research, and NICHD. 

More than 1,200 HIV-infected 

women and 800 of their children 

have been enrolled. Approximately 

half of the WITS participants are 

current or former drug abusers. 

NIDA joined the collaboration 

to support and promote focused 

research regarding the impact of 

drug use on the transmission and 

course of HIV disease. 

Reaching for Excellence in 

Adolescent Care and Health

(REACH) is an NICHD-initiated project with NIDA 

as a key collaborator. REACH seeks to learn more about 

HIV disease progression and its relationship to other 

health factors, such as drug use among adolescents aged 

12 to 19. NIDA support emphasizes research on both the 

impact of drug use on the course of HIV disease as well 

as the impact of HIV on drug use. Also participating in 

the REACH collaboration are NIAID and the Health 

Resources and Services Administration. 

The Women’s Interagency HIV Study (WIHS) and the 

companion HIV Epidemiology Research Study (HERS) 

investigate the medical and psychosocial impact of HIV 

on women. Most of the women being studied have a history of current or past drug use. The studies have enrolled 

2,500 HIV-positive women and 775 HIV-free women. 

NIDA collaborates in these studies with NIAID, NICHD, 

the National Cancer Institute, the National Institute of 

Dental Research, and the CDC. NIDA funding supports 

research on how drug use and addiction may influence 

women’s vulnerability or resistance to HIV infection, the 

consequences of coinfection with HIV and other diseases 

associated with drug abuse, the effectiveness of HIV medical treatment, and biomedical factors related to the development of HIV disease. 

“Each of these collaborations ensures that NIDA’s knowledge 

and expertise in drug abuse and related conditions are 

pooled with the knowledge of our colleagues in other 

Institutes and agencies conducting vital HIV research,” says 

Dr. Smeriglio. “It’s a highly cost-effective way to bolster 

NIDA’s clinical research and to expand interest in drug 

abuse issues among a larger pool of investigators.” Together 

with the Interagency Agreements, these collaborations 

broaden the consequences of NIDA research and extend 

NIDA’s science-based findings into new realms. 

“The Interagency Agreement 

is tailor-made for broad 

cooperative efforts like the 

Violence Initiative. It’s good for 

research as an enterprise, and 

it’s good for science.” 
56

Research Findings

Contributions of Behavioral Research To AIDS Studies Recognized

By Neil Swan, NIDA NOTES Staff Writer 

Volume 12, Number 6 (November/December 1997)

Behavioral and social sciences research is playing an increasingly critical role in the Nation’s public health response 

to the spread of AIDS, according to experts at a National 

Institutes of Health (NIH) symposium last summer. 

Dr. James Curran, an AIDS epidemiologist and professor at 

Emory University in Atlanta, said that science has made significant advances in recognizing the “previously marginal” 

role for behavioral studies related to AIDS. He spoke at the 

half-day symposium, Substance Abuse and AIDS: Research 

from the Behavioral and Social 

Sciences. The meeting at the NIH 

campus in Bethesda, Maryland, was 

cosponsored by NIDA. 

AIDS is still a young epidemic, said 

Dr. Curran, formerly head of the 

Division of HIV/AIDS Prevention 

at the Centers for Disease Control 

and Prevention (CDC) in Atlanta. 

Early public responses tended to “ghettoize” those with 

AIDS, downplaying its spread into the general population 

through heterosexual contacts, he said. As a result, the public mistakenly has failed to recognize the importance of heterosexual contacts in the spread of HIV. Among women, 

particularly among poor and minority women, heterosexual 

sex is key to the currently increasing rate of HIV infections, he said. Statistics from the CDC support this view. 

In September, the CDC reported that the number of AIDS 

cases is increasing faster among women than among men 

and that sex with infected men has overtaken drug abuse as 

the leading cause of HIV infection among women. From 

1991 through 1995, the number of men diagnosed with 

AIDS increased by 12.8 percent, versus an increase of 63 

percent for women. However, many of the sex partners of 

these HIV-infected women are men whose own infections 

are drug abuse related. 

Behavioral factors play an important part in these gender 

differences, say experts. Studies show that homosexual men, 

who now account for approximately 48 percent of all AIDS 

patients, are often well educated, aggressive about their 

treatment options, and responsive to prevention efforts. But 

many women with HIV are poor, are not well educated, 

and may have limited access to health care. As a result, 

these women may not respond as well as some men do to 

prevention or treatment efforts. 

Behavioral studies are vital to learning more about the 

spread of the HIV infection, agreed Dr. William Paul, 

former director of NIH’s Office on AIDS Research. After 

reviewing NIH-supported AIDS research, outside experts 

recommended strengthening the social sciences and behavioral components of the research portfolio, advice now 

being heeded in NIH’s AIDS research agenda, said Dr. 

Paul. NIDA ranks third among NIH Institutes in the level 

of funding it receives for AIDS studies, and much of the 

NIDA-supported research is already devoted to behavioral 

and social sciences investigations into the link between drug 

abuse and AIDS. 

“AIDS and drug abuse are two epidemics that are totally 

intertwined,” NIDA Director Dr. 

Alan I. Leshner reminded those 

attending the session. “It’s impossible to speak about one and not 

the other. Behavioral and social 

science research is critical to gaining 

insights into the epidemiology of 

AIDS, and it helps the broader 

scientific community get a handle 

on this intersection of drug abuse and AIDS.” 

Studies of social and personal networks are vital to understanding HIV transmission and prevention, said Dr. Carl 

Latkin, a NIDA-supported researcher at Johns Hopkins 

University in Baltimore. “We need to look not so much at 

individual behavior but more at social-network aspects of 

behavior,” he said. “We need to learn more about support 

networks that provide protection against HIV transmission 

and risk networks that actually promote high-risk 

behaviors.”

Numerous studies have documented that significantly lower 

rates of HIV risk behaviors are practiced by drug abusers 

who are enrolled in treatment programs, said Dr. David 

Metzger, another NIDA-funded researcher at the University 

of Pennsylvania. “The consistency of these findings suggests 

that increasing the access to drug abuse treatment is a legitimate and absolutely necessary HIV prevention activity,” 

he said. “Although the data [supporting the effectiveness of 

drug abuse treatment in preventing HIV transmission] are 

strongest for methadone treatment of opiate dependence, 

there also is growing awareness of the important role that 

noninjection drug use has played in the sexual transmission 

of HIV.”

He noted that the protective effects of drug abuse treatment 

are not immediate and not universal. This underscores the 

need to investigate all modalities of treatment to document 

the effectiveness of each in changing behaviors to prevent 

HIV transmission. 

“Increasing access to drug 

abuse treatment is a legitimate 

and absolutely necessary HIV 

prevention activity.” 
57

Other Drug-Use Paraphernalia Besides Needles May Increase

HIV Infection Risk

Research Findings

Volume 12, Number 2 (March/April 1997)

Educating injecting drug users (IDUs) to reduce 

their risks of HIV transmission by using clean needles 

and by switching to other drug use practices may be 

communicating only part of the message necessary to 

effectively change high-risk behaviors, according to a 

NIDA-funded study.

The study is among the first to show that drug paraphernalia other than needles and syringes also may place IDUs 

at increased risk of HIV infection, according to Drs. 

Paul Shapshak, Syed Shah, and Clyde B. McCoy of the 

University of Miami and their colleagues, who conducted 

the study. The researchers detected evidence of the AIDScausing virus in injection paraphernalia found in Miami 

“shooting galleries,” where drugs regularly are injected and 

traded, often in exchange for sex. Their evidence indicates 

that using contaminated water for rinsing needles, cotton 

swabs for filtering drug solutions, and “cookers” such as 

spoons or bottle caps for dissolving drugs possibly may be 

responsible for transmitting the AIDS virus. 

The researchers used HIV’s distinctive genetic structure, 

its DNA, as a marker to detect its presence in the injection paraphernalia. They found evidence of HIV DNA in 

up to 85 percent of contaminated needles collected 

from shooting galleries and in up to 36 percent of cotton swabs, 54 percent of cookers, and 67 percent of rinse 

water samples.

AIDS prevention efforts targeting IDUs have focused on 

encouraging them to clean their needles or to not swap 

needles, points out Dr. McCoy. This strategy implies that 

using clean needles eliminates the risk of HIV transmission when that may not be true, he warns.

“These drug users need to understand that all of the 

paraphernalia—the rinse water, cottons, cookers—are 

potential vehicles for transmission of HIV.” 

Source

• Shah, S.M.; Shapshak, P.; Rivers, J.E.; Stewart, R.V.; 

Weatherby, N.L.; Xin, K.-Q.; Page, J.B.; Chitwood, 

D.D.; Mash, D.C.; Vlahov, D.; and McCoy, C.B. 

Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in 

Miami: A preliminary report. Journal of Acquired 

Immune Deficiency Syndromes 11(3):301–306, 1996.
Research Findings

58

Volume 12, Number 2 (March/April 1997)

CDC Report Highlights Link Between Drug Abuse and 

Spread of HIV

By Neil Swan, NIDA NOTES Staff Writer

An extensive review of existing research data confirms that 

behavior associated with drug abuse is the single largest 

factor in the spread of HIV/AIDS in this country. Half of 

all new infections with HIV, the virus that causes AIDS, 

now occur among injecting drug users (IDUs), according 

to the data review, which was conducted at the Centers 

for Disease Control and Prevention (CDC) in Atlanta.

The study focused on three groups recognized as being 

at highest risk for transmission of HIV: IDUs, men who 

have sex with men, and heterosexual men and women 

who are at risk because they have sex with IDUs and/or 

bisexual or gay men. The review used data gathered from 

America’s 96 largest cities, where HIV infection rates are 

the highest in the Nation. The trends in HIV infection 

rates found in these cities also apply to the Nation’s 

population in general, says the CDC reviewer Dr. Scott 

D. Holmberg.

Most newly HIV-infected IDUs live in northeastern cities 

from Boston to Washington, D.C., as well as in Miami 

and San Juan, Puerto Rico, reports the CDC reviewer. 

In these cities, where injection drug use rates are also the 

highest among the 96 cities surveyed, an average of 27 

percent of all IDUs are HIV-infected.

“These data confirm and underscore the connection 

between injection drug use and the continuing spread 

of HIV and AIDS,” says NIDA Director Dr. Alan I. 

Leshner. “Drug abuse and HIV are truly interlinked 

epidemics.”

“The information further demonstrates that NIDA has a 

critical role indeed in addressing the drug abuse-HIV connection and in focusing scientific research to understand 

and deal with the further spread of this devastating 

disease,” he says.

The data confirm earlier figures from periodic CDC 

reports on the number of newly diagnosed cases of AIDS 

and HIV infection, which suggested that the proportion of new HIV cases linked to drug abuse was close to 

one-half. (See “NIDA Plays Key Role in Studying Links 

Between AIDS and Drug Abuse,” NIDA NOTES, 

May/June 1995, p. 88.)

Dr. Holmberg set out to estimate the size and direction 

of the HIV epidemic in major U.S. cities with populations greater than 500,000. He compiled a large computer 

model for tracking disease trends by reviewing more than 

350 documents, several large research data sets, and information from 220 public health authorities. Some of the 

reports date back 10 or more years.

The 96 metropolitan areas Dr. Holmberg looked at have 

an estimated 1.5 million IDUs, 1.7 million gay and bisexual men, and 2.1 million at-risk heterosexuals. Among 

these three risk groups there are currently an estimated 

565,000 HIV infections, with 38,000 new infections 

occurring each year. Using these data to make nationwide 

projections, the review concludes that there are about 

700,000 current HIV infections, with 41,000 new HIV 

infections occurring each year in the U.S. population.

Estimated New HIV

Estimated Number Estimated Percent Infections Each Year Per 

Risk Group in Risk Group HIV Positive 100 Group Members

Injecting Drug Users 1.5 million 14.0% 1.5

Men Who Have Sex 

With Men 1.7 million 18.3% 0.7

At-Risk Heterosexuals* 2.1 million 2.3% 0.5

* Men and women who are at risk because they have sex with injecting drug users and/or bisexual or gay men. 

Chart shows percentages of at-risk groups in major cities who tested positive for HIV. Estimates were compiled in 1996.

HIV Infections Among At-Risk Populations In America’s 96 Largest Cities
59

An estimated 19,000 IDUs are infected each year in 

these 96 metropolitan areas, indicating an HIV incidence 

rate of about 1.5 infections per 100 IDUs per year, Dr. 

Holmberg reports. Infection rates are lower for the other 

two high-risk groups. Although gay and bisexual men still 

represent the group with the greatest number of current 

HIV infections, the rate of infection—except in young 

and ethnic/minority gay men—is much lower now than 

it was a decade ago, Dr. Holmberg reports. For gay and 

bisexual men, the HIV infection rate per 100 persons 

per year is 0.7; for at-risk heterosexuals—those who have 

sex with IDUs or gay and bisexual men—the rate is 0.5 

infections per 100 persons per year. At-risk heterosexual 

women outnumber at-risk heterosexual men about 4 to 1.

In the research review, HIV incidence rates for metropolitan areas were broken down by estimated numbers 

of HIV-infected people in each of the three at-risk groups. 

An estimated HIV infection rate for each group in each 

city was also provided. “This is highly valuable epidemiological information for better targeting prevention 

strategies,” says Dr. Leshner.

“The HIV epidemic is now clearly driven by infections 

occurring among injecting drug users, their sex partners, 

and their offspring,” concludes Dr. Holmberg in his 

review. However, NIDA-funded efforts to educate IDUs 

to modify their risky drug use behaviors have proven 

effective, he says. Evidence shows that HIV infection rates 

in injecting drug users have declined over the past several 

years in the largest drug-using communities, he reports.

In cities in New York and northern New Jersey, the 

epicenter of the AIDS epidemic among injecting drug 

users, many IDUs are switching to practices that may 

lessen their risk of contracting HIV, such as using sterile, 

never-used needles and syringes; cleaning needles and 

paraphernalia; sniffing rather than injecting heroin and 

cocaine; or abstaining from drug use altogether. This 

shows that drug abuse and AIDS prevention programs 

targeting IDUs are working, Dr. Holmberg says.

His review further illuminates the link between the AIDS 

epidemic and drug abuse as primarily a public health 

issue. Within this public health perspective, the CDC 

scientist’s review also provides important insights for policymakers, clinicians, and administrators who are planning 

and implementing drug abuse and HIV prevention and 

treatment programs. Targeting HIV treatment and prevention programs to IDUs also holds potential for reducing the spread of other blood-borne infections, including 

hepatitis B and C viruses.

Source

• Holmberg, S.D. The estimated prevalence and incidence of HIV in 96 large U.S. metropolitan areas. 

American Journal of Public Health 86(5):642–654, 

1996. 
Research Findings

60

NIDA Responds to the Changing Dynamics of the AIDS Epidemic

By NIDA Director Alan I. Leshner, Ph.D.

Volume 12, Number 2 (March/April 1997)

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 NOTES,

Vol. 12, No. 2.) 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 NIDAsupported 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.

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 York City, 

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 

Drug abuse treatment, 

prevention, and 

community-based outreach 

programs can change 

behaviors to decrease 

the risk of HIV/AIDS.
61

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. 
62

Research Findings

Drug Use During Pregnancy Associated With Increased Risk of 

Transmitting HIV to Infants

By Robert Mathias, NIDA NOTES Staff Writer 

Volume 11, Number 4 (September/October 1996)

A national, multicenter study has found that HIV-infected 

women who used illicit drugs during pregnancy had a 

higher risk of transmitting HIV to their infants than 

did HIV-infected women who did not use drugs while 

pregnant. 

The study, known as the Women and Infants 

Transmission Study (WITS), was launched in 1989 by 

the National Institute of Allergy and Infectious Diseases 

(NIAID) to track the natural history of HIV in infected 

women and their infants. The study currently is funded 

by NIAID, NIDA, and the National Institute of Child 

Health and Human Development. 

In the study, researchers analyzed data on 530 HIVinfected pregnant women and their infants who were 

treated in obstetric and pediatric clinics in five cities across 

the United States. The analysis showed that the HIV perinatal transmission rate for women who used drugs during 

pregnancy was 27 percent compared with a 16 percent 

transmission rate among HIV-infected women who did 

not use drugs. Forty-two percent of the women in the 

study used illicit drugs during pregnancy; 44 percent of 

those women used multiple drugs. The most commonly 

used drug was cocaine, used either alone or in combination with other drugs. 

The study’s findings emphasize the critical role of drug 

abuse treatment in prenatal health care for HIV-infected 

pregnant women who use drugs, according to Dr. 

Evelyn M. Rodriguez of the Health Resources Services 

Administration and her colleagues in the WITS. The 

WITS findings also underscore the importance of ensuring that all HIV-infected women receive information on 

how AZT (zidovudine) treatment during pregnancy can 

significantly reduce perinatal transmission of HIV, the 

researchers conclude. 

Large multisite studies such as the WITS enable researchers to investigate both the behavioral and basic biological 

factors that may contribute to maternal-infant transmission of HIV, according to Dr. Vincent Smeriglio and 

Katherine Davenny of NIDA’s Division of Clinical and 

Services Research, who are members of the WITS research 

staff. Further research is planned to verify the association 

between maternal drug use and infant HIV infection and 

to clarify the possible mechanisms of this association, 

they indicate. 

Source 

• Rodriguez, E.M.; Mofenson, L.M.; Chang, B.H.; 

Rich, K.C.; Fowler, M.G.; Smeriglio, V.; Landesman, 

S.; Fox, H.E.; Diaz, C.; Green, K.; and Hanson, I.C. 

Association of maternal drug use during pregnancy 

with maternal HIV culture positivity and perinatal 

HIV transmission. AIDS 10(3):273–282, 1996. 
Research Findings

63

Opioid Analogue May Slow Spread of HIV in Brain

By Neil Swan, NIDA NOTES Staff Writer 

Volume 11, Number 4 (September/October 1996)

Synthetic compounds, or analogues, related to the opiates 

morphine and heroin can limit the growth of HIV—

the virus that causes AIDS—in the brain, according to 

NIDA-funded research findings. The study with human 

cell culture suggests that a synthetic compound that binds 

to the brain’s kappa opioid receptors (KOR) may curtail 

a virus subtype called HIV-1 from spreading in the brains 

of people infected with the AIDS virus. A drug analogue 

is a chemical compound that differs slightly from 

another drug. 

Although the study was performed in cell culture, the 

results suggest the possibility that a medication could 

be developed to prevent a particularly destructive aspect of 

AIDS—the loss of intellectual 

capacity. This research is part of a 

broad range of NIDA-supported 

studies of the complex relationship between drugs of abuse and 

AIDS, including studies of the 

effects of drug use on the body’s 

immune system and, subsequently, on infection and disease progression. The study also provides 

an example of how research on 

drugs of abuse can have benefits 

in other areas of medicine. 

In some HIV-infected patients, HIV-1 infection in the 

brain leads to a disease syndrome called “AIDS dementia 

complex,” which results in apathy, difficulties in muscle 

control and movement, and problems in performing complex tasks. The mental capacity of patients with dementia 

complex may deteriorate until they are incapable of voluntary acts. 

When HIV-1 involves the brain, the infection occurs in 

microglial cells, found throughout the nervous system, 

which are the principal sites for HIV growth in the brain. 

The study was conducted by Drs. Chun C. Chao 

and Phillip K. Peterson and their colleagues at the 

Minneapolis Medical Research Foundation and the 

University of Minnesota Medical School. It builds 

on research by Dr. Jean Bidlack of the University of 

Rochester Medical School in New York and the late Dr. 

Sydney Archer of Rensselaer Polytechnic Institute in Troy, 

New York. 

Dr. Chao says the collaboration developed at a NIDAsupported symposium on interactions between drugs of 

abuse and the immune function. 

To learn more about these interactions, the Minnesota scientists first treated microglial cell cultures with two KOR 

agonists—compounds that mimic actions of the body’s 

natural kappa opioids—for 24 hours and then infected the 

treated cells with HIV-1 for another 24 hours. When the 

researchers examined the cell culture after 14 days, they 

found that pretreatment with the KOR agonists U50,488 

and U69,593 prevented the growth of HIV-1. Currently, 

they are testing other synthetic KOR compounds for their 

potential for treating AIDS 

dementia complex. 

The next step will be to conduct 

similar studies on the effect of 

KOR compounds on the spread 

of HIV in living animals, says 

Dr. Chao. Some of these studies 

likely will examine the growth of 

simian immunodeficiency virus 

(SIV) infections. SIV is an 

HIV-like virus found in monkeys. “One possibility is to treat 

SIV-infected monkeys with 

kappa opioid compounds, such 

as those we used in the human 

cell culture study, to test whether these KOR compounds 

have therapeutic value in monkeys with SIV,” Dr. Chao 

says. 

Dr. Chao presented his findings at the Fourth Annual 

Symposium on AIDS, Drugs of Abuse, and the NeuroImmune Axis held in conjunction with the annual meeting of the College on Problems of Drug Dependence in 

San Juan, Puerto Rico, in June. Scientists at the symposium concentrated on both human and animal data to 

study the relationships among drug abuse, immune 

function, and infectious diseases. 

Both human and animal studies show that different drugs 

and different classes of opiates regulate the immune system function in different ways. For example, earlier 

findings by Dr. Chao and his colleagues show that in 

human cell culture morphine, unlike the KOR agonists, 

may stimulate growth of HIV in microglia. 

This research is part of a broad 

range of NIDA-supported studies of the complex relationship 

between drugs of abuse and 

AIDS, including studies of the 

effects of drug use on the body’s 

immune system. 
64

Likewise, a particular drug may regulate the human 

immune system differently than it does an animal’s 

immune system. Sometimes drug-induced influences on 

immune function increase the death rate of animals with 

infectious disease. 

A study by Dr. M.P. Yeager at Dartmouth-Hitchcock 

Medical Center in Lebanon, New Hampshire, on the 

acute effects of morphine on 

humans did show that morphine 

caused marked immune suppression. But epidemiologic research 

has provided only limited evidence 

of similar findings. 

While some epidemiologic studies 

indicate that injecting drug users 

(IDUs) are at increased risk for 

infection with tuberculosis and 

HIV, natural history studies can 

find no evidence that HIV infection progresses more rapidly among 

IDUs than among other risk 

groups, including people who do 

not abuse drugs: both homosexuals 

and heterosexuals. Other research 

also suggests that some drug abusers may be more susceptible than are people who do not 

abuse drugs to “opportunistic” infectious diseases, such as 

pneumonia, that may arise after physiological damage or 

weakening of the immune system by AIDS. The basis of 

this apparent susceptibility is not clear. 

“You can find drug-induced effects in test-tube experiments and in animals that you can’t duplicate in 

humans,” says Dr. John Madden of Emory University in 

Atlanta, cochair of the symposium. “In the test tube and 

in animals, researchers are usually testing the short-term, 

acute effects of drugs on the immune system and disease 

progression. But in humans addicted to heroin, they are 

more often dealing with long-term, chronic drug effects. 

It appears that addicts build up a state of homeostasis in 

which the immune system over time adapts to the effects 

of the drugs and returns to an apparent state of normalcy.” He notes that this state of apparent normalcy can be 

disturbed, however, by stresses such as drug withdrawal, 

infectious diseases, or poor nutrition. 

Researchers are seeking to develop a research model in 

monkeys that more closely resembles the chronic effects 

found in human addicts, says Dr. Madden. They are also 

focusing more on other variables, such as the effects on 

the immune system of stress induced by drug withdrawal, 

and the relationship between drug use and disease susceptibility in the early stages of addiction. 

Inconsistencies between laboratory animal findings and epidemiologic data on the effect of 

drugs of abuse on the progression 

of AIDS in humans may result 

from a number of other factors, 

researchers say. These include 

the overall health status of drugabusing individuals, which can 

vary significantly among different 

drug-using groups; difficulty in 

tracking injecting drug users over 

time; and the possibility that the 

death or serious illnesses of some 

study subjects may go unreported 

when they are instead counted 

as study “dropouts.” In addition, 

polydrug abuse may have compounding or even conflicting effects since there is evidence 

some drugs of abuse may actually counteract the immune 

system effects of other drugs. Researchers have noted that 

many HIV-infected people studied use both heroin and 

cocaine, which may have opposing or conflicting effects 

on immune system regulation and, perhaps, on AIDS 

disease progression. 

Sources 

• Chao, C.C.; Gekker, G.; Hu, S.; Sheng, W.S.; 

Shark, K.B.; Bu, D-F.; Archer, S.; Bidlack, J.M.; and 

Peterson, P.K. Kappa opioid receptors in microglia downregulate human immunodeficiency virus-1 

expression. Proceedings of the National Academy of 

Sciences 93:8051–8056, 1996. 

• Yeager, M.P.; Colacchio, T.A.; Yu, C.T.; 

Hildebrandt, L.; Howell, A.L.; Weiss, J.; and Guyre, 

P.M. Morphine inhibits spontaneous cytokineenhanced natural killer cell cytotoxicity in volunteers. 

Anesthesiology 83(3):500–508, 1995. 

In some HIV-infected patients, 

HIV-1 infection in the 

brain leads to a disease 

syndrome called “AIDS

dementia complex,” which 

results in apathy, difficulties in 

muscle control and movement, 

and problems performing 

complex tasks. 
Research Findings

65

Drug Abuse Links to AIDS Prompt Highly Targeted Responses

By Neil Swan, NIDA NOTES Contributing Writer 

Volume 10, Number 6 (November/December 1995)

NIDA-supported research to prevent the spread of 

AIDS related to drug abuse is building on what has been 

learned from an array of prevention approaches that target specific populations and selected high risk drug-use 

and sexual practices. At the same time, basic research 

sponsored by the Institute is probing factors associated 

with the dual epidemics of AIDS and drug abuse, including the role of drug use in the rate of disease progression 

to AIDS following exposure to HIV, the human immunodeficiency virus, which causes AIDS. 

Presentations at two recent NIDA conferences on AIDS 

and drug abuse reflect the profound role drug abuse plays 

in the spread of HIV. (See “NIDA Plays Key Role in 

Studying Links Between AIDS and Drug Abuse,” NIDA 

Notes, May/June 1995.) The conferences were held last 

summer in Scottsdale and Flagstaff, Arizona. 

“We’re learning what works for whom” in interventions 

to reduce the risk of infection with HIV, explains Dr. 

Richard H. Needle, chief of the Community Research 

Branch in NIDA’s Division of Epidemiology and 

Prevention Research. 

“The cumulative research literature can be examined for 

indications of progress,” says Dr. Needle, whose branch 

helped sponsor the Flagstaff meeting. “Each individual 

study has strengths and limitations, but, collectively, 

generalizations can be drawn. We see where we have been 

effective and we learn how to be even more effective” in 

curtailing behaviors that put people at risk of contracting 

or transmitting HIV. 

“These conferences were extremely useful in bringing 

researchers together, involving other agencies, and sharing 

important data that have not yet been published,” says 

Dr. Harry W. Haverkos, director of NIDA’s Office on 

AIDS, which sponsored the Scottsdale meeting. 

Drug Injection and AIDS Prevention

One conference presentation examined “sociometric and 

personal networks” of street injecting drug users (IDUs). 

These risk networks consist of a limited number of core 

users whose network standing and prominence may influence drug use practices of others at the network fringes. 

The NIDA-funded study queried 687 street-recruited 

injecting drug users in New York City about their drug 

use and sexual behaviors. Researchers identified two network variables as significant predictors of HIV infection: 

being a core network member and having an older IDU 

in one’s personal network. 

Drs. S.R. Friedman and A. Neaigus of National 

Development and Research Institutes, Dr. D.C. Des Jarlais 

of Beth Israel Medical Center, and their colleagues in New 

York City concluded that future prevention efforts for street 

IDUs should target core network members and address 

factors leading to core group membership as well as 

injection practices among groups of users of different ages 

and experiences. 

Among emerging intervention approaches are those that 

target groups with dual risks for acquiring HIV. Men who 

have sex with other men and also inject drugs engage in 

two high-risk behaviors. They can serve as a “bridge” linking others who belong to one of these two high-risk populations. In many western states, this dual-risk category was 

identified in as many as 50 percent of HIV cases. 

Programs are under way in Seattle, San Francisco, and Los 

Angeles to target this bridge population composed of both 

HIV-infected and uninfected persons. Innovative interventions to counsel, educate, and reduce behavioral risks 

are proving effective, according to several measures. They 

result in less needle sharing; reduced frequency of drug 

use; increased knowledge about unsafe sex practices, sexually 

transmitted diseases, and HIV; and improved compliance 

with tuberculosis and HIV medication regimens, according to a NIDA-funded grantee, Dr. Michael Gorman of 

the University of Washington. Injecting drug using men 

who have sex with other men “represent a critical, hidden, 

heretofore underserved, poorly understood population” 

that can benefit from innovative public health prevention 

interventions, he reported. 

A similar NIDA-facilitated study describes HIV prevention interventions that target men who have sex with men 

and who use methamphetamine. HIV prevention efforts 

in Seattle, San Francisco, and Los Angeles—cities with a 

high prevalence of AIDS among men who have sex with 

men and methamphetamine use—are being studied. 

Another analysis of Seattle’s needle-exchange program 

examined IDUs who regularly pool their pocket money to 

buy drugs. The study found a link between pooling money 

for drugs and high-risk practices like the sharing of needles 

and drug paraphernalia. “It may be worthwhile to target 

prevention efforts at this clustering of risk around the joint 

purchase of drugs,” reported Dr. James McGough of the 

King County, Washington, Health Department. 
66

Drug Abuse Treatment

Several studies and analyses presented at the two conferences further document the effectiveness of drug abuse 

treatment in reducing drug use, crime, and HIV infection. 

Data on AIDS risk behaviors of some 10,000 drug abuse 

treatment clients from 1991 to 1993, collected by NIDA’s 

Drug Abuse Treatment Outcome Study, were analyzed 

by Dr. Wendee M. Wechsberg and others of the Research 

Triangle Institute and NIDA. The patients, from 99 treatment programs, reported that behaviors putting them at 

risk of HIV infection needle sharing, sex with multiple 

partners, and unprotected sex were reduced somewhat during treatment. Researchers suggest this large-scale survey 

validates findings of smaller studies, demonstrating the benefits of drug abuse treatment and emphasizing the importance of AIDS prevention interventions during treatment. 

While drug abuse treatment is generally recognized as 

effective in reducing HIV risks among those in treatment, the impact of effective treatment extends beyond 

treated individuals and into their social networks, research 

indicates. Recent studies in the Philadelphia area suggest 

that treatment not only reduces the frequency of injection drug use but also changes patterns of use. Individuals 

in treatment report less injection drug use with strangers 

and acquaintances. There is a corresponding increase in 

the number of individuals who report always using drugs 

alone. Treatment thus has the effect of removing links 

in drug-using networks and reducing the risk of spreading HIV through those networks. In reducing drug use 

with others, treatment’s “role in tertiary prevention is 

significant and perhaps under-appreciated,” concluded Dr. 

Martin Y. Iguchi of the Medical College of Pennsylvania 

and Hahnemann University. 

Basic Research on Drug Abuse and AIDS

A number of NIDA-funded basic science investigations 

examining the relationship between drugs of abuse and 

the functions of the immune system were presented at the 

conferences. 

Previous research had found evidence that drugs of abuse 

can suppress the immune system in laboratory animals. 

But scientists have not demonstrated the clinical impact 

in humans. It is, therefore, important to select and use 

appropriate laboratory animal models of HIV infection 

and progression patterns in humans. 

Research by Dr. Lisa H. Gold and colleagues at the 

Scripps Research Institute demonstrates that neurobehavioral abnormalities in rhesus monkeys and cats infected 

with viruses similar to HIV (simian and feline immunodeficiency viruses) and in certain genetically engineered 

mice make these animals suitable experimental models 

for future studies of the interactions between drugs and 

HIV. Cognitive testing partially supported by NIDA, 

along with other neurological assessments, indicates that 

monkeys infected with the simian immunodeficiency virus 

undergo nervous system changes similar to those seen in 

HIV-infected human patients. 

Another study examined the effects of morphine on the 

immune status and disease resistance of monkeys infected 

with the simian immunodeficiency virus. The study found 

that the effect of opiates on the immune system may be 

variably and conditionally dependent on whether the drug 

doses are long-term and steady or sporadic, with sporadic 

dosing having less apparent effect. The NIDA-supported 

study was conducted by Robert M. Donahoe and colleagues 

at Emory University and Dr. Mario Aceto of the Medical 

College of Virginia. 

Evidence shows that opiates play a role in modulating HIV 

infection in the brain, according to another study by Dr. 

Chun C. Chao of the University of Minnesota and others. 

They found that an artificial compound called U50,488 

that binds selectively to the kappa opioid receptor markedly 

suppresses HIV cell reproduction in the brain, where the 

deadly virus usually replicates. 

Other AIDS and HIV Prevention Research

More than 100 oral presentations were given and scores of 

scientific abstracts were displayed at the NIDA conferences, 

including those with these findings: 

• Although drug use itself was not found to be associated with mother-to-child HIV transmission in the 

women studied, drug users had poorer prenatal care, 

more adverse birth outcomes, and many clinical characteristics like increased rates of anemia, pneumonia, 

and smoking that may increase the possibility of HIV 

transmission to their newborns. 

• Interventions with out-of-treatment heroin addicts are 

more successful when they include actual scheduling 

of treatment admission instead of simply distributing 

lists of treatment centers. This active referral results 

in higher treatment rates, and those persons entering 

treatment are more strongly associated with reduced 

drug use and less criminal activity. 

• Research on community outreach for HIV prevention 

in mid-sized towns determined that adding two sessions to a “standard” office-based counseling program 

led to additional reductions in HIV risks in Flagstaff, 

Arizona, as reported by Dr. Robert Trotter of 

Northern Arizona University. 
Research Findings

67

Treatment and Outreach Research on AIDS: Identifying and 

Treating Those at Risk

By Neil Swan, NIDA NOTES Contributing Writer 

Volume 10, Number 3 (May/June 1995)

NIDA’s drug abuse treatment and outreach research is 

taking the Institute’s AIDS prevention mission onto the 

front lines of the battle against HIV infection. NIDAsupported researchers in these programs work face to face 

with drug abuse populations to learn and implement more 

effective ways to reduce the risk of contracting HIV and 

AIDS. An important component in both treatment and 

outreach programs has been the search for ways to reduce 

HIV risks related to drug-injection practices. 

Treatment Research

NIDA’s years of experience in developing and implementing drug abuse treatment programs have enabled the 

Institute to identify, study, and modify drug-use behaviors 

that increase HIV transmission risks among people who 

are in treatment. 

The Institute’s AIDS-related treatment research has three 

major goals: improving therapies and getting more addicts 

into treatment, integrating effective HIV risk-reduction 

tactics into existing treatment programs, and designing 

treatment and services for targeted at-risk subgroups. 

These subgroups include gay men who are also drug users, 

women who don’t abuse drugs but who have sex with 

men who do, HIV-positive addicts, and drug abusers who 

are in prison or are otherwise involved with the criminal 

justice system. 

NIDA-funded studies have shown repeatedly that injecting drug users who are in treatment programs are less 

likely to engage in high-risk sexual and drug-using behaviors than are comparable addicts who are not enrolled in 

treatment. For example, a 1988 study of methadone treatment programs for heroin addicts found that comprehensive drug abuse treatment is effective in reducing injection 

drug use and needle sharing among most heroin addicts. 

Subsequent NIDA-funded studies have reinforced these 

initial findings. University of Pennsylvania researchers 

studying heroin addicts in Philadelphia found that out-oftreatment subjects were injecting drugs, sharing needles, 

visiting shooting galleries, and practicing unsafe sex at 

significantly higher rates than in-treatment subjects. The 

1993 study found that the addicts who did not receive 

treatment had a conversion rate to HIV-positive status 

that was six times higher than the rate among in-treatment 

injecting drug users who had been regularly exposed to 

risk-reduction education, counseling, and other 

strategies. 

Unfortunately, HIV risk-reduction education and counseling, HIV testing, and AIDS risk behavior assessments have 

not yet been assimilated into many existing treatment programs for heroin and cocaine addicts. In response, NIDA 

is encouraging researchers who are developing and testing 

behavioral therapies for drug abuse and dependence to 

also develop HIV risk-reduction interventions that can be 

readily incorporated into existing drug-abuse treatment 

programs. 

The Institute’s behavioral therapies development program 

announcement has recently been expanded to specifically encourage behavioral research to develop HIV riskreduction interventions. The program will identify, test, 

and introduce new behavioral therapies for drug abuse 

that ultimately can be used in community treatment clinics. Researchers will develop behavioral counseling, cognitive therapies, and other types of treatment designed to 

reduce the risk of HIV infection and will explore ways to 

improve treatment compliance, keep potential dropouts 

enrolled, and appeal to those who resist treatment. 

Another new effort will seek to expand basic behavioral 

research to develop models of behavior and behavior 

Case Manager Andrea Coward (left) listens to a client describe his 

life in a culture of drug abuse. “Hearing themselves say things to 

another person, a light bulb will go on, and it helps them realize 

what they can do to help themselves,” Ms. Coward says. 
68

change relevant to HIV risk. These will include psychological, social, and biological approaches to explain and 

predict HIV-related behaviors among persons and groups 

in various settings. A significant aspect of this initiative 

will bring together researchers from different disciplines 

in a collaborative way to integrate scientific approaches 

in order to develop novel ways to address the HIV/AIDS 

problem. 

Outreach Programs

Two landmark outreach programs, initiated by NIDA’s 

Community Research Branch in collaboration with 

researchers around the country, have set the standard 

for investigations that shoulder the dual responsibility of 

AIDS prevention and drug abuse outreach and treatment. 

The National AIDS Demonstration Research (NADR) 

Project, conducted from 1987 to 1992, funded 29 community-based HIV-prevention programs for out-of-treatment injecting drug users and their sexual partners. The 

followup Cooperative Agreement for AIDS CommunityBased Outreach/Intervention Research Program, launched 

in 1990, is currently evaluating the effectiveness of NADR 

intervention programs among different populations in 

different communities across the Nation, as well as looking at ways to expand the programs. As the examples 

cited below clearly illustrate, the interventions for out-oftreatment drug users undertaken in both programs accomplished statistically significant and clinically meaningful 

decreases in HIV-related risk behaviors. 

NADR lived up to its description as an outreach program, reaching thousands of out-of-treatment drug users 

and their sexual partners during its 5-year life span. 

Reductions in risk behavior, from initial assessment to 

followup assessment at 6 months, were striking and 

encouraging. Followup data revealed that 46 percent of 

NADR participants reduced or stopped injecting drugs, 

37 percent reduced or stopped sharing needles, 50 percent 

reduced or stopped borrowing needles, and 60 percent 

reduced or stopped sharing other injection equipment. 

In addition, a substantial minority of injecting drug users 

underwent treatment after intervention, many for the first 

time in their lives. 

Although changes in high-risk sexual behaviors were less 

marked than changes in drug-use behavior, they did show 

substantial improvement. For example, the proportion of 

injecting drug users who always used condoms increased 

from 10 percent before intervention to 19 percent afterward. The decrease in the percentage of subjects who 

reported having two or more sexual partners dropped 

from 44 to 36 percent. 

The Cooperative Agreement for AIDS Community-Based 

Outreach/Intervention Research Program continues 

NADR’s goals of preventing the further spread of HIV 

infection among drug users and their sexual partners. Like 

NADR before it, the program uses street-based, face-toface outreach and risk-reduction interventions and pretest 

and posttest HIV antibody counseling. The Cooperative 

Agreement takes NADR’s research one step further, with 

controlled experimental research. Specific, well-defined 

populations have been recruited for intervention at multiple sites, and a standardized intervention is being used. 

The Cooperative Agreement is currently the only system 

of its kind that captures epidemiologic information on 

hard-to-reach, out-of-treatment drug-using populations.

As with research results from NADR, results from the 

Cooperative Agreement reveal a remarkable success story 

in reducing HIV risk behaviors. Examples of changes in 

risk behavior, from initial assessment to followup assessment at 6 months, include: 

• a 41 percent reduction in frequency of injection, from 

64 times in the past 30 days prior to intervention to 

38 times in the past 30 days after intervention; 

• a 54 percent reduction in reusing other persons’

syringes, with 17 percent reusing another person’s 

syringes before intervention and 8 percent at followup; and 

• a reduction from 22 percent to 14 percent in the 

proportion of sexual partners who injected. 

Outreach approaches are still being developed and evaluated. As the epidemiologic characteristics of the epidemic 

continue to change, becoming increasingly concentrated 

in hard-to-reach populations and subgroups, new techniques for monitoring the extent of HIV disease prevalence and for delivering effective interventions are critical 

in developing effective prevention strategies. NIDA is now 

Counselor James Gaines (left), Community Outreach Program 

in Long Beach, California, discusses risk reduction with patient. 

NIDA-funded studies show that injecting drug users in treatment 

programs are much less likely to engage in high-risk sexual and 

drug-using behaviors than are comparable users not in treatment.
69

funding new epidemiology studies to better define the 

communities and demographic subgroups in which HIV 

is spreading, to further identify the specific behavioral risk 

factors related to the spread of HIV in each subgroup, 

and to evaluate what has been learned about using effective risk-reduction messages tailored to the needs of these 

subgroups. Research will concern the unique health care 

needs of high-risk populations of drug users, seeking ways 

to better meet their medical and social service needs. 

Needle Exchange and Hygiene

NIDA has taken the lead in fighting the spread of AIDS 

among injecting drug users by studying various strategies 

to reduce HIV risks related to needle use. 

One such study, the first federally funded needle-exchange 

evaluation, tracked the use of syringes among injecting 

drug users in New Haven, Connecticut, over 3 years. 

Data from the locally operated project, which includes 

HIV testing and medical monitoring, show that after the 

needle-exchange service was provided, the proportion of 

needles that tested positive for HIV dropped significantly. 

Using these data, the New Haven researchers estimated 

that there would be a 33 percent reduction in new cases 

of HIV infection among injecting drug users as a result of 

the needle-exchange program. Significantly, they also have 

reported that 17 percent of the study subjects have been 

referred to drug abuse treatment. NIDA is now funding 

similar evaluations in six other cities. 

NIDA’s multisite observation of needle hygiene practices 

among injecting drug users in 1993 provided information about another HIV risk involved in injection drug 

use—indirect sharing, which can occur when water or 

cookers used to mix drugs, cotton swabs, or a drug solution that contacts the bleach of one injecting drug user is 

used by another in the process of preparing or injecting 

drugs. Indirect sharing also can occur with the transfer 

of drugs from one syringe to another before injection. 

NIDA researchers’ data show that, despite reductions in 

the frequency of syringe sharing among users, indirect 

sharing remains a common practice, and some high-risk 

subgroups have not yet been targeted for risk-reduction 

interventions. 

NIDA research in the 1980s suggested that common 

household bleach is more effective than most other readily 

available solutions such as alcohol and hydrogen peroxide in disinfecting needles and syringes used by injecting drug users. Bleach soon became the standard for use 

in needle hygiene programs, and small bottles of bleach 

and other HIV risk-reduction educational materials were 

widely distributed by outreach workers throughout the 

country. Because of wide disparities in bleach disinfection techniques by drug users, in 1993 NIDA issued a 

Director’s Alert and later joined with the Centers for 

Disease Control and Prevention and the Substance Abuse 

and Mental Health Services Administration’s Center for 

Substance Abuse Treatment in issuing a bulletin on the 

most effective bleach disinfection procedures and urging 

the use of new or sterile equipment. 

Now NIDA is recruiting researchers for a second generation of studies to examine strategies used in different 

injection risk-reduction projects—counseling, education, 

the crafting of messages targeting specific subgroups, linkages to drug treatment, and other variable components. 

Sources 

• National Institute on Drug Abuse. Cooperative 

Agreement for AIDS Community-Based Outreach/ 

Intervention Research Program, 1990–Present. 

Rockville, MD: NIDA, 1995. 

• National Institute on Drug Abuse. Outreach/Risk 

Reduction Strategies for Changing HIV-Related Risk 

Among Injection Drug Users. NIH Publication No. 

94-3726. Rockville, MD: NIDA, 1994. 
70

Research Findings

Volume 10, Number 3 (May/June 1995)

NIDA Urges HIV Counseling, Testing for Research Subjects

Because of the strong link between drug abuse and the 

transmission of HIV, NIDA-funded researchers are 

strongly urged to provide HIV risk-reduction counseling and access to HIV antibody testing to individuals 

who are participating in NIDA-supported study projects. 

In announcing the policy, NIDA Director Dr. Alan I. 

Leshner pointed out that HIV risk-reduction interventions 

have been shown to be effective in reducing drug abuserelated behaviors that heighten the risk of spreading HIV. 

The policy applies both to NIDA-funded programs for 

community outreach and intervention and to research 

conducted in clinics, hospitals, or clinical laboratories that 

involves ongoing contact with persons at risk for HIV 

infection. Those considered at risk include injecting drug 

users, crack cocaine users, and sexually active drug users 

and their sexual partners. 

“Given the tremendous impact of the AIDS epidemic and 

the significant role of drug abuse in the transmission of 

HIV, NIDA has developed a policy to help reduce HIV 

risk behaviors and infection in drug-using populations, 

their sexual partners, and their children,” said 

Dr. Leshner. 

HIV risk-reduction counseling includes education about 

HIV and AIDS, the behaviors that transmit HIV, and 

how to reduce the risk of transmission. Counselors also 

encourage individuals to have their blood tested for HIV. 

Current grantees are encouraged to implement the policy 

as soon as possible. NIDA will use this policy when considering requests for supplemental funding of ongoing 

projects. 
Research Findings

71

NIDA Plays Key Role in Studying Links Between 

AIDS and Drug Abuse

By Neil Swan, NIDA NOTES Contributing Writer 

Volume 10, Number 3 (May/June 1995)

Since AIDS was first identified in 1981, the disease has 

brought death and widespread physical and social devastation to people and nations worldwide. An estimated 

1 million Americans today are infected with HIV, the 

human immunodeficiency virus, which causes AIDS; 

as many as 17 million people are infected worldwide. 

According to the Centers for Disease Control and 

Prevention (CDC), 441,528 cases of full-blown AIDS 

were reported in this country through the end of 1994. 

Of these, approximately 60 percent have died.

HIV infection is now the leading cause of death among 

Americans ages 25 to 44, according to the CDC. The 

transmission of HIV from women to their newborn 

infants is also a growing problem. 

The critical connection between drugs and AIDS has 

become increasingly evident. Injection drug use was the 

second leading cause of new AIDS cases through mid1994, accounting for 31.8 percent of all cases, according 

to the CDC (see chart). 

One analysis based on current CDC data concluded that 

more than half of the 40,388 new HIV infections in 1994 

were drug related. Groups at extremely high risk of infection include injecting drug users who share needles and 

other drug-use paraphernalia as well as crack addicts who 

engage in unprotected sex with multiple partners. Also 

at high risk are sexual partners and offspring of these 

drug abusers. 

Because of this crucial link between AIDS and drug abuse, 

NIDA has played a critical role in the Government’s 

strategy to control the spread of AIDS since early in the 

epidemic. Today, with a budget of $147 million for 

AIDS-related research, NIDA is the third largest supporter 

of AIDS research among the 17 Institutes of the National 

Institutes of Health. One-third of NIDA’s research funding is committed to studying AIDS. 

For its AIDS research agenda into the 1990s, NIDA has 

taken its lead from the 1988 Charlottesville, Virginia, 

conference of the Public Health Service’s leading AIDS 

experts, who coordinated a major public health response 

to the epidemic. The Charlottesville meeting set a number 

of public health goals relating to the drug abuse population: increasing the number of drug abuse treatment slots 

for injecting drug users; improving the quality and effectiveness of drug abuse treatment; recruiting and training 

drug abuse treatment specialists; increasing outreach and 

education efforts for injecting drug users and their sexual 

partners; and conducting research to clarify the extent, 

nature, and natural history of injection drug use and needle sharing, with special attention to cultural and ethnic 

differences in drug-related practices and behavior. 

To advance those goals, NIDA has supported a broad 

agenda of research into AIDS-related drug-use behaviors 

and HIV risk-reduction interventions. Central to these 

efforts have been studies to improve drug abuse treatment 

and outreach strategies to reduce injecting drug use and 

related risk behaviors. Other NIDA studies have monitored the natural history and epidemiology of HIV and 

AIDS; explored basic research areas such as immunology 

and neuropharmacology; examined the needs of special 

populations such as women, children, and racial and ethnic minorities; and enhanced medical care and services to 

improve the lives of those who are HIV infected. 

NIDA’s research findings have resulted in major advances 

toward curtailing the spread of AIDS. Research has shown 

that comprehensive drug abuse treatment programs can be 

effective in reducing high-risk HIV behaviors. For addicts 

not in treatment, community-based street outreach 

(prevention and intervention) programs have been 

Injection drug use was the second leading cause of new AIDS 

cases through mid-1994.
72

effective in recruiting hard-to-reach crack smokers and 

injecting drug users and in educating and motivating 

them to change high-risk drug-use practices and sexual 

behaviors. Basic and clinical research has provided vital 

information on the origin and development of drugrelated HIV and AIDS. 

The challenge for NIDA now is to build on the advances 

already gained, fostering further research to unravel the 

intricate secrets of AIDS and designing improved interventions to bring this epidemic under control. To meet 

this challenge, NIDA in 1993 

adopted a 5-year strategic plan 

for AIDS research to learn 

more about reducing the transmission of HIV among drug 

users, their sexual partners, and 

their children. The plan has six 

elements: 

• to conduct research to 

improve existing treatment 

approaches and develop pharmacologic and nonpharmacologic therapies; 

• to carry out research to 

improve educational and 

behavioral strategies, including studies on outreach 

approaches, prevention and 

early diagnosis, and treatment 

of drug abuse; 

• to undertake natural history 

studies of drug abusers, studies of drugs as potential cofactors in HIV disease, and 

basic and clinical immunological studies; 

• to conduct seroepidemiological studies of drug abusers, 

studies of the nature and extent of at-risk drug-use and 

sexual behaviors (such as the “sex-for-crack” phenomenon), and ethnographic studies; 

• to swiftly disseminate research findings and technologies using conferences, publications, and mass media 

campaigns; and 

• to make recommendations to policymakers on strategies to counter the spread of AIDS and to establish 

close liaison with other AIDS research programs. 

Building on its past research and the potential for 

improved AIDS prevention strategies, NIDA is now 

inviting scientists to join its efforts in devising innovative 

AIDS research initiatives that build on and extend prior 

NIDA-funded research. A broad range of basic and clinical research pathways, behavior-changing strategies, and 

drug-related variables are candidates for study. Investigators who can demonstrate the relevance of their proposed AIDS-related research to drug abuse are eligible to 

seek NIDA funding. 

Source: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Vol. 44, No. 4, Feb. 3, 1995 

NIDA’s AIDS and NonAIDS Expenditures

Source: NIDA Budget Office

Reported U.S. AIDS Cases by HIV-Exposure Category—1994
Research Findings

73

Basic and Clinical Research on AIDS: From the 

Molecule to the Patient

By Neil Swan, NIDA NOTES Contributing Writer 

Volume 10, Number 3 (May/June 1995)

Both NIDA’s basic research and clinical research programs 

explore ways drugs of abuse affect the spread of HIV and 

AIDS. Studies funded under these programs range from 

complex molecular-level investigations to human studies. 

Basic Research

Immunopharmacological research on drugs of abuse 

already has advanced understanding of the origin and 

development of drug-related HIV infection and AIDS. 

This research is accumulating evidence to indicate that 

opiates, marijuana compounds, and other drugs of abuse 

can suppress or enhance the immune system in laboratory 

animals. 

Based on these findings, researchers supported by NIDA’s 

Division of Basic Research are studying the complex interactions between the nervous system, where drugs of abuse 

have long been known to act, and the immune system, 

where recent studies show they act as well. 

Several studies are exploring how opiates and other drugs 

modify or weaken immune defenses, alter neural capacity, 

and increase the potential for dementia. Neuroscientists 

have found that glial cells—the nonneuronal supporting 

cells in the brain and nervous system—help to modulate 

the immune defense against infection and are a primary 

focus of neuronal injury after infection. 

Studies by NIDA-funded researchers have shown that 

opioids (morphine and naturally occurring morphine-like 

compounds) act on these glial cells to regulate this damage 

to the neurons in the brain. 

One avenue of research is examining the ability of a specific protein on the surface of the HIV to activate certain 

neuron-damaging cytokines, the immune system’s regulating neurotransmitters. NIDA-supported researchers have 

found that morphine and dynorphin, a compound similar 

to morphine that occurs naturally in the human body, 

enhance the ability of these HIV-activated cytokines to 

destroy human brain cells. This research holds promise for 

the development of new therapies for HIV-related brain 

diseases and HIV infection, as well as for brain injuries 

that are aggravated by inflammation. 

Basic research suggests that opioids may suppress immune 

function by modulating the levels of these cytokines. The 

effectiveness of macrophages—large cells that circulate in 

the blood destroying disease microorganisms—is reduced 

by both infection and opioids, causing either an increase 

in the production of destructive cytokines or a decrease in 

the levels of beneficial cytokines. 

Morphine, for example, appears to enhance the progression of infectious pneumonia by reducing the number 

of macrophages in pigs, whose immune systems closely 

resemble those of humans. In contrast, it appears that the 

progression of encephalitis may be slowed by opioids. 

Another NIDA-funded study showed that the centrally 

mediated effects of morphine on the immune response 

of laboratory rats is markedly enhanced by psychological 

stress. Other studies are examining the morphine-induced 

conditioning of the immune system. Enkephalins, which 

are endogenous opioids considered to be possible neurotransmitters, appear to be important regulators of immune 

responses. For example, studies show that by regulating 

white blood cells in a developing fetus, enkephalins may 

have a role in the development of immune function in the 

maturation of fetal tissues and organs. This information 

could have significance for further research into the progression of HIV disease in infants and children. 

These opioid agonists (opiates and other compounds that 

stimulate opioid responses) characteristically suppress 

immune responses. On the other hand, opioid antagonists, compounds that block the opioid response, also 

block most immune-suppressing actions of opioid agonists. NIDA-funded basic researchers have observed this 

blocking of the suppressing action by naloxone, one of the 

family of opioid antagonists used to treat heroin overdoses. 

These findings support the view that opioid agonists 

suppress immune responses by employing typical opiate 

mechanisms and present important ramifications for 

further studies of immune function and disease. 

In a study of rhesus monkeys infected with simian immunodeficiency virus (SIV), an animal model for studies of 

HIV and AIDS, NIDA-supported researchers have shown 

that opioids increase the mutation of the virus in the 

early stages of SIV infection. These results suggest that, in 

humans, this type of mutation could lead to the development of a form of the virus that is resistant to zidovudine, 

or AZT, the drug most commonly used to treat AIDS 

patients. 
74

Evidence from other studies indicates that cannabinoids, 

the psychoactive components of marijuana, also suppress the immune response. NIDA-funded researchers are 

investigating how this process differs from immune system 

actions mediated by the central nervous system (CNS), 

how the immune cells differ from those in the CNS, 

and how certain cannabinoid-like compounds that occur 

naturally in the body act on these different systems. Other 

scientists have determined that one cannabinoid (THC) 

interferes with the ability of immune cells to target and 

destroy cancer cells as well as invading bacteria, fungi, and 

viruses. 

Still other NIDA-funded basic research is examining 

how the abuse of nitrite inhalants depresses the immune 

response, thus apparently increasing abusers’ risk of 

acquiring AIDS. The effects of abuse of anabolic steroids 

on the immune system are also being studied. 

Clinical Research

NIDA’s Division of Clinical 

and Services Research supports 

clinical studies of HIV and 

AIDS among drug users, including people in and out of drug 

abuse treatment. NIDA’s multidisciplinary research program 

involves studies of behavioral and 

biological factors associated with 

drug abuse and HIV infection. 

Current studies of HIV focus on 

HIV disease progression, treatment of HIV-infected drug users, 

linkage of drug abuse treatment 

and primary medical care, the 

relationship between HIV and other infectious diseases 

common among drug users, and studies of HIV disease in 

pregnant women and their infants. The goal of the clinical 

research program is to understand the unique aspects of 

HIV and AIDS among drug users to develop better prevention and treatment strategies. 

For nearly 10 years, NIDA has supported a program of 

longitudinal research on the natural history and progression of HIV disease in drug users. Long-term studies 

provide data on both the incidence and prevalence of 

HIV disease in various groups of drug users and permit 

researchers to define the clinical course of the disease from 

early infection through its long-term consequences. These 

studies require medical assessment and followup of 

complex conditions while also evaluating the impact of 

behavioral and medical interventions on the course 

of the disease. 

Because drug users have poor access to medical care in 

general as well as to HIV-specific treatment, and because 

adherence to treatment regimens is often a problem, 

AIDS-related health services research—including delivery 

of treatment, linkage of drug abuse treatment and primary 

care, and access and adherence to medication protocols—is 

a component of NIDA’s clinical research program. Other 

areas of focus include barriers to medical treatment; psychosocial and behavioral factors associated with success 

or failure of treatment regimens; the impact of episodic 

or erratic patterns of drug use on treatment effectiveness; 

fetal and infant outcomes; and how HIV disease medications, HIV-related opportunistic infections, and other diseases prevalent among drug users affect HIV progression 

and the long-term survival of the victim. 

Development of better treatment strategies for HIVinfected pregnant women is a high priority, given 

the recent findings that use of AZT can significantly 

reduce the rate of mother-to-infant HIV transmission. 

Opportunities exist for enhanced studies of effective treatment for drug-using women in 

collaboration with large national 

clinical studies supported by the 

National Institutes of Health. For 

example, through a collaborative agreement with the National 

Institute of Allergy and Infectious 

Diseases at NIH, NIDA supports 

followup studies of a group of 

pregnant HIV-infected women in 

New York City, most of whom 

are drug users. Research on the 

role of active drug use in maternal-infant HIV transmission and 

the effectiveness of AZT treatment in preventing such transmission is a focus of this effort. 

Suppression of the immune system, characteristic of HIV, 

puts infected individuals at higher risk for other infectious diseases, including tuberculosis. NIDA is supporting 

a program of research on TB, one of several infections 

common among drug users. The focus of this research 

includes studies of the consequences of coinfection with 

HIV and TB, as well as the development of better strategies to screen for TB among drug users and to improve 

access and adherence to treatment. Treatment regimen 

adherence is critical in controlling further transmission of 

TB and in preventing the development of treatmentresistant strains of TB. 

Other current areas of HIV clinical research include studies of markers and predictors related to the virus and the 

immune system that are associated with rates of disease 

progression and survival, hepatitis C virus infection 

among HIV-infected and uninfected active drug users 

and the impact on HIV disease course, the interaction of 

components of the immune system with the virus and the 

impact on disease status and progression among 

AIDS-related health services research is a component of 

NIDA’s Clinical Research Program.
75

HIV-infected children, determination of viral strain differences that may influence the rate of disease progression, 

and the impact of ongoing drug injection on the activation of the immune system and the proliferation of viral 

strains. 

NIDA-funded clinical research has contributed substantially to current knowledge about HIV infection and 

disease progression in populations of drug users. For 

example: 

• Although basic research indicates that opioids can 

modulate (suppress or enhance) the immune response, 

clinical studies of HIV disease progression, as measured by decline in immune cell (CD4) counts, have 

not demonstrated that immune suppression is more 

rapid among actively injecting polydrug (cocaine and 

heroin) users than among other risk groups. 

• Studies of clinical manifestations and predictors of 

HIV disease progression among drug users found 

that progression to AIDS was best predicted by low 

numbers of immune (CD4) cells; the presence of an 

oral infection called candidiasis; bacterial infections 

including sepsis, pneumonia, and TB; and by nonuse 

of AZT. 

• Smoking of illicit drugs increases the risk of contracting bacterial pneumonia among HIV-infected injecting drug users who have a history of AIDS-related 

pneumonia. 

• HIV infection appears to be associated with increased 

rates of endocarditis infection, a serious heart disorder 

common among injecting drug users, but the frequency of injection apparently is not a factor. 

• Although results of a skin test indicating immune 

suppression when testing for TB infection in HIVinfected patients have been used as a reason to initiate 

TB therapy, recent clinical studies of injecting drug 

users show that the skin-test responsiveness can fluctuate over time, bringing into question its reliability 

for use in determining treatment initiation. 

• New HIV infection rates among HIV-negative drug 

users who remained continuously in methadone treatment for 18 months were found to be six times lower 

than the incidence rates in comparable drug users 

who remained out of methadone treatment for the 

same time period. 

• Studies of several laboratory markers indicative of 

immune status and duration of HIV infection and the 

relationship of these markers to the risk of developing 

HIV disease indicated that only low immune cell 

(CD4) counts were independently related to increased 

risk of AIDS, that CD4 counts of less than 150 were 

strongly related to immediate risk of adverse outcome, 

and that disease outcomes tended to occur as a progressive series of events (constitutional symptoms, oral 

candidiasis, bacterial infections, and AIDS). 

For nearly 10 years, NIDA has 

supported longitudinal research on 

the natural history and progression of 

HIV disease in drug users.
Research Findings

76

AIDS Brings Greater Research Obligation, More Potential 

for Results

By NIDA Director Alan I. Leshner, Ph.D.

Volume 10, Number 3 (May/June 1995)

In 1994, the Centers for Disease Control and Prevention 

(CDC) received 80,691 new reports of Americans with 

AIDS. This 1-year toll is almost one-fifth of all U.S. AIDS 

cases ever reported. 

While the epidemic continues its spread, 

it is also evolving, targeting different 

population groups. We have clear evidence that drug-related transmission 

of HIV, the AIDS virus, is increasing 

significantly. Analysis of new CDC data 

suggests a majority of new HIV cases last 

year involved drug abusers—heroin and 

crack addicts—and their sexual partners. 

While new cases among homosexual and 

bisexual men are decreasing, heterosexual 

transmission of HIV is increasing. In 

fact, the fastest-growing subgroup of 

patients with AIDS over the last several 

years has been heterosexual men and 

women, most of whom are linked sexually to drug users. 

The changing nature of the AIDS epidemic, especially its growing association with drug abuse, 

increases the Institute’s responsibilities in fulfilling its 

public health mission. When you consider how closely 

drug abuse is linked to the spread of AIDS, it should be 

no surprise that NIDA allocates one-third of its budget to 

AIDS-related aspects of drug abuse. 

NIDA has supported and will continue to support 

research aimed at developing strategies to reduce drug 

abuse as an important contribution to AIDS prevention 

efforts. NIDA-supported researchers have shown that drug 

abuse treatment and street outreach to drug abusers not 

in treatment can be effective in changing high-risk sexual 

and drug-use behaviors associated with contracting and 

transmitting HIV. Scientists have shown that it is possible 

to get addicts to change these high-risk behaviors even 

while they are still using drugs. 

Over the years, NIDA-funded researchers have also 

probed drug-related aspects of AIDS in the areas of epidemiology, disease origin and progression, immunology, and 

neurobiology. They have shed new light on treatment, 

interactions between disease medications and those for 

drug abuse, health care services delivery, and transmission 

of HIV from mothers to their infants. 

While some NIDA-funded researchers have been learning how to teach street addicts to modify high-risk drugrelated behaviors, other investigators have 

been conducting cellular and molecular 

studies of the connections between drugs 

of abuse and the body’s disease-fighting 

immune system. 

Beyond research in the streets and 

the laboratories, NIDA has supported 

research training programs to increase 

the ranks of researchers qualified to deal 

with the scientific and medical aspects 

of AIDS. In past years, NIDA provided 

training in AIDS and related drug abuse 

issues to thousands of treatment counselors and administrators and helped 

35 States develop training programs on 

AIDS and drug abuse. In addition, the 

Institute has mounted a number of informational and public education initiatives to warn people about the links between drug abuse 

and AIDS. These initiatives have included, for example, 

nationwide TV campaigns aimed at young people. 

NIDA is committed to building on its previous research. 

That means the Institute is calling on researchers, in turn, 

to expand their horizons in designing future investigations, to consider AIDS- and HIV-related issues in the 

design of new experiments. We encourage scientists to 

develop and submit their own investigator-originated 

funding requests for drug-abuse-related AIDS research. 

Some 14 years into the AIDS epidemic, NIDA is still 

broadening the scope of its AIDS research, building on 

progress. We must learn more about how to improve 

drug abuse treatment and outreach programs to reduce 

high-risk behaviors associated with drug use and sexual 

practices, how to prevent relapses to high-risk behaviors, 

and how to improve clinical management of HIV-positive 

drug abusers. We must develop more research-based 

responses to the special AIDS risks and needs of minorities, women, infants, and children. We must probe the 

enigmatic connection between drugs of abuse and the 
77

immune system. And we must ensure that HIV riskreduction strategies are incorporated into all appropriate 

NIDA-funded research strategies. 

In short, we must further demonstrate to the public that 

preventing the spread of AIDS means, in large part, preventing drug abuse. 

In broadening the scope of our research, we are not lessening our commitment to drug abuse research. By mounting an enhanced, research-based response to the AIDS 

epidemic, NIDA is also tapping new opportunities for 

scientific advancement that extend beyond AIDS. The 

Institute’s AIDS research helps us learn more about how 

drugs of abuse work in the central nervous system, how 

disease spreads among at-risk subgroups of drug abusers, how drug-related cellular and molecular mechanisms 

modulate the progress of disease, and how the immune 

system functions to protect the human body from invading microorganisms. 

NIDA’s broadened research agenda will help us learn how 

to devise innovative therapies and responses effective not 

only against AIDS but also against drug abuse. 

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