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New Picture of Who Will Get AIDS Is Dominated by Addicts.(Science Desk)(Medical Science Page). by Gina Kolata.
The New York Times Feb 28, 1995

THE AIDS epidemic, continuing its demographic evolution, is becoming ever more closely tied to the drug epidemic, a new study shows. Not only are intravenous drug users becoming infected, but so are crack addicts and other drug abusers, many of whom are women.

An extensive, unpublished analysis by researchers at the Federal Centers for Disease Control and Prevention in Atlanta has found that nearly three-quarters of the 40,000 new infections with H.I.V., the virus that causes AIDS, last year were among addicts.

Many of the addicts are IV drug users who share infected needles, but an increasing number are crack addicts who are contracting the AIDS virus through unprotected sex, often with multiple partners. Men and women alike often go on binges, having sex with many partners in exchange for crack or the money to buy it. "Maybe as much as half of the new infections among heterosexuals are occurring in relation to crack cocaine," said Dr. Scott Holmberg, a C.D.C. epidemiologist who conducted the study.

Data and analyses from the C.D.C. show that the people diagnosed with AIDS in 1993, the most recent year for which statistics on the disease are available, are a very different group from those the 1994 statistics show are now being infected with the virus. Development of AIDS generally occurs about a decade after infection.

Of those newly diagnosed with AIDS in 1993, who were probably mostly infected in the early to mid-1980's, about half were gay men and a little more than a quarter were intravenous drug users. Fewer than 10 percent were heterosexuals. The remaining cases were hemophiliacs and gay men who injected drugs.

Now, in his analysis of national data for new H.I.V. infections in 1994, Dr. Holmberg finds a very different pattern, which is continuing this year. Only a quarter of the most recent infections are in gay men. About half of the new infections are among drug users who shared needles. And about a quarter are heterosexually transmitted. Dr. Holmberg said that 70 to 80 percent of people who are getting H.I.V. infections through heterosexual transmission are women and the majority of those are women had sex with men who got infected when they injected drugs. Many had sex with these men during crack binges, or while they were abusing other drugs or alcohol, when they were not inclined to think about safe sex, Dr. Holmberg said.

The crack addicts who are becoming infected, Dr. Holmberg said, are mostly young men and women who live in inner cities and are members of minority groups. They often have other sexually transmitted diseases, which is thought to make it easier for the AIDS virus to infect them.

Recently published statistics -- that AIDS is now the leading killer of young adults and that the largest-percentage increases in new infections are among women -- take on a different tone when read in the context of Dr. Holmberg's study. There are not many competing causes of death among those under 45. And although new infections are spreading fastest among women who acquire the infection through heterosexual intercourse, as many as half of these women are crack addicts.

Experts caution that the data do not mean that the virus is no longer a threat to Americans who do not use illicit drugs, and say that men and women should practice safe sex. Some researchers and advocates for people with AIDS are also concerned that the information carries another risk: that the nation will turn its back on these infected groups.

"That's a real worry," said Dr. Don C. Des Jarlais, an AIDS expert who directs the chemical dependency unit at Beth Israel Medical Center in New York. But, he said, fear of telling the truth about the epidemic is "one reason we have our priorities so out of order."

He added: "You're never going to have good public policy and stop an epidemic if you base your policy on misinformation or wrong information. You have to know where the disease is occurring and how to go after it."

Two years ago, Dr. Des Jarlais, a member of a committee of the National Research Council, argued that efforts to stamp out the epidemic should have a tighter focus. A report by the committee said that the epidemic was "settling into spatially and socially isolated groups and possibly becoming epidemic in them." The latest data provide a clearer picture of the characteristics of these isolated groups.

"It's a real dilemma," said Stephen Soba, communications director for the Gay Men's Health Crisis, an advocacy group for people with AIDS. "But we have to acknowledge that the face of the epidemic has changed and continues to be changing."

Mark Barnes, executive director of the AIDS Action Council, said: "These are tough issues. What this has meant for AIDS advocacy is that we have to not simply advocate around safer sex but for substance abuse treatment and for substance abuse treatment research, particularly for crack cocaine."

Others, however, fear that if the AIDS prevention message becomes a drug abuse prevention message, people outside the inner cities will falsely feel that they are not at risk.

"There is no magic ring around the inner city," said Dr. Mindy Fullilove, an associate professor of clinical psychiatry and public health at Columbia University in New York. "I think you can do targeting that makes people in the suburbs feel safe, and I don't agree with that."

But Dr. Des Jarlais said he feared more for the addicts, adding that the problem of redirecting AIDS prevention efforts hinges to a greater extent on the tendency of society to turn its back on addicts than on the dollars involved. He points out that it costs $3,000 to $4,000 a year to treat a heroin addict with methadone and that it costs $6,000 to $20,000 for residential treatment for a cocaine addict. But, he said, "The cost of just medical care for an H.I.V. infection is $120,000."

Perhaps the biggest surprise in the new image of H.I.V. infections is the rapid spread of the virus among crack users. Yet it makes sense, said Dr. James Yorke, a mathematician who has modeled the spread of AIDS and other diseases and who is director of the Institute for Physical Sciences and Technology at the University of Maryland. Dr. Yorke noted that transmission of H.I.V. differs from that of other sexually transmitted disease in that it is riskier to have sex with many partners, only some of whom are infected, than to have sex the same number of times with one infected person.

The reason, Dr. Des Jarlais said, is that H.I.V. is transmitted more easily during two periods of the infection: when a person first contracts the virus and a decade or so later when the immune system is collapsing. If a woman, for example, has sex 100 times with a man who is infected with H.I.V. but is in the long latent stage when the virus is more difficult to transmit, she is much less likely to get infected than if she has sex just once with one man who may be in the infectious stage. So a woman is at much greater risk having sex once with 100 partners, most of whom are infected, than having sex 100 times with a man who is infected but in the latent stage.

Knowing who is becoming infected, and how, investigators say that they can envision strategies that could push down the rate of new infections. But, they say, it will take a shift of emphasis and resources. It means aggressively offering drug treatment and social programs, including jobs and support for addicts who often are homeless and have lost hope of being part of society. It means finding much better treatments for crack addiction. It means stopping transmission from infected heroin addicts, by supplying them with clean needles and by providing them with methadone. It means viewing AIDS as a consequence of the drug epidemic, and not as a separate entity.

The problem, said Dr. Sten Vermund, chairman of the department of epidemiology at the University of Alabama in Birmingham, is that to fight AIDS, "we have to have the political will to make investments in drug treatment and drug control." And to do that means giving inner city residents resources. "If we are hostile to drug treatment and job creation, then the epidemic will rage," he added.

Dr. Vermund said that he would like to see some money and effort diverted from the search for treatments and vaccines and put into prevention. "I, for one, think that the balance is distorted," he said. But, he said, at the very least, the way money is spent on AIDS prevention should be reconsidered.

AIDS prevention funds, "which are miserably inadequate to begin with, are largely spent on counseling and testing centers and in somewhat ineffectual mass media approaches," he said. To have an impact the money should be redirected to provide drug treatment. "I'm talking about removing the waiting lists for drug treatment," Dr. Vermund said. "Now a motivated addict who wants treatment in a city like New York is put on a waiting list for six months. That is a national disgrace."

Dr. Des Jarlais said that it is also crucial that "legal access to sterile needles should be implemented on a nationwide basis."

Mr. Barnes of the AIDS Action Council said that not only must advocates for people with AIDS start demanding research on substance abuse and substance abuse treatment, but they must also start insisting that education about AIDS prevention be incorporated into existing substance abuse treatment programs.

And those efforts, Mr. Barnes said, should include "everything from talking about issues of responsibility toward others and responsibility toward yourself to offering, even aggressively offering, partner notification strategies." Such efforts, he added, "are not something we have traditionally done as a nation," but that is in part because "we have separated prevention from treatment" of AIDS.

Dr. Vermund said, "It's a tough nut to crack." But he added: "We pay the price, and not merely in diseases like H.I.V. and sexually transmitted diseases and hepatitis, but also in our crime losses and correctional institutions."

As a society, he said, "we reap what we sow."