N A T I O N A L I N S T I T U T E O N D R U G A B U S E Research Report S E R I E S It is hard to believe that the HIV/AIDS human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic has been with us for a quarter of a century now. Today, an entire generation of young adults has never known a world without HIV/AIDS. Early in the epidemic, drug abuse How Does Drug Drug abuse and addiction can also worsen the progression and HIV were typically connected in people’s minds with injection drug Abuse Impact the of HIV and its consequences, use and needle sharing. However, this view greatly underestimates the HIV/AIDS Epidemic? especially in the brain. In animal studies, methamphetamine D impact that drug abuse can have on rug abuse and addiction the spread of HIV and AIDS through increased HIV viral replication;2 the dangerous risk behaviors it have been inextricably in human methamphetamine engenders. Drug and alcohol intox- linked with HIV/AIDS abusers, HIV caused greater ication affect judgment and can since the beginning of the lead to risky sexual behaviors that neuronal injury and cognitive put people in danger of contracting epidemic. While intravenous impairment compared with or transmitting HIV. In addition, drug use is well known in this nondrug users.3,4 from the director substance abuse may facilitate regard, less recognized is the the progression of HIV infections by further compromising the immune system. role that drug abuse plays more generally in the spread of HIV— Who Is At Risk Initially characterized by relatively the virus that causes AIDS—by for HIV Infection localized outbreaks, HIV/AIDS has now become a pandemic that increasing the likelihood of high- and How Does risk sex with infected partners.1 has literally put the world at risk, affecting diverse populations in This is because of the addictive HIV Become AIDS? A different ways. And while all nyone is vulnerable to nations are affected by HIV/AIDS, and intoxicating effects of many each faces differing underlying drugs, which can alter judgment contracting HIV. And causes requiring customized and inhibition and lead people while injecting drug users prevention and treatment strategies. to engage in impulsive and (IDUs) are still at great risk of NIDA’s response to the ongoing epidemic of HIV/AIDS is multifaceted. unsafe behaviors. contracting HIV/AIDS, anyone We support research to learn more about the pivotal role of drug abuse in the spread of HIV/AIDS and to develop effective strategies to prevent and treat this disease. NIDA has established that drug abuse treatment is HIV prevention. This Research Report is designed to highlight the state of the science and raise awareness of the linkages between drug abuse and HIV/AIDS. Nora D.Volkow, M.D. Director National Institute on Drug Abuse Approximately 4 out of 10 U.S. AIDS deaths are related to drug abuse. U.S. Department of Health and Human Services • National Institutes of Health 2 NIDA RESEARCH REPORT SERIES under the influence of drugs or AIDS. Recent developments have The number of HIV infections alcohol is at heightened risk. led to better treatments for HIV is harder to confirm given that, This includes IDUs who share infection, the most effective being unlike AIDS reporting, HIV contaminated syringes or injection a strategy known as highly active reporting is not mandatory. paraphernalia, as well as anyone antiretroviral therapy (HAART). Currently, only about two-thirds who engages in unsafe sex (e.g., of States report HIV infections; multiple partners, unprotected sex) or “transactional” sex What Is the Scope from these data, it is estimated that 40,000 new HIV infections (e.g., trading sex for drugs or of HIV/AIDS in the have been occurring annually money) that could expose them to infection. United States? since the early 1990s, down from the peak of 160,000 new infec- C A person infected with urrently, an estimated tions per year in the mid-1980s. HIV has a virus that lives and 1 million people in the Nonetheless, the persistence of multiplies primarily in the white United States are living with this rate for more than a decade blood cells, which are part of HIV/AIDS. In this country, annual indicates that much remains to the immune system. An infected reported AIDS cases peaked in be done to improve the effective- person may look and feel fine 1993 at approximately 80,000. ness of HIV prevention. for many years and may not even be aware of the infection. Between 1993 and 1998, the However, as the immune system incidence of new cases declined steadily before leveling off What Is HAART? weakens, the individual becomes T between 1999 and 2001. However, he availability of HAART more vulnerable to illnesses and since 2001, the number of new since 1996 has had a common infections. Over time, cases has increased slightly each dramatic effect on the face the untreated HIV patient is likely to succumb to multiple, year with approximately 42,500 of HIV/AIDS. HAART is a custo- concurrent illnesses and develop new AIDS cases reported in 2004. mized combination of different classes of medications that a physician prescribes based on Estimated Number of AIDS Cases and Deaths such factors as the patient’s viral Among Adults and Adolescents with AIDS, load, CD4+ lymphocyte count, 1985–2003—United States and clinical symptoms. CD4+ lymphocytes are white blood I AIDS 90 cells that HIV infects and kills, I Deaths 1993 Case Definition* leading to a weakened immune No. of Cases and Deaths (in thousands) 80 system and AIDS. Though not a 70 cure, HAART controls viral load, helping to delay the onset of 60 symptoms and achieve prolonged 50 survival in people diagnosed with HIV/AIDS.5 40 With HAART, the medical 30 consequences associated with HIV/AIDS have changed. New 20 diagnoses of HIV-associated infections and some neurological 10 complications, such as HIV 0 dementia, have decreased since ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 its introduction.5,6 However, other Year of Diagnosis or Death neurological problems, such as *CDC expands AIDS case definition. Source: CDC, U.S. Department of Health and Human Services. peripheral nerve damage, have increased with the use of this NIDA RESEARCH REPORT SERIES 3 resulting from living longer with Hepatitis C the disease. Which Populations HCV infection, the leading cause of liver disease, is highly prevalent among IDUs and often co-occurs with HIV. In fact, between 85 and 90 percent of HIV-infected IDUs may also Are Most Affected? W hile all groups are be infected with HCV.7 NIDA-funded studies have found that with- in 3 years of beginning injection drug use, a majority of IDUs affected by HIV/AIDS, contract HCV. not all are affected equally. The first populations Approximately 4 million people in the United States are currently to be affected by AIDS were infected with HCV; of these, approximately 400,000 are co-infected primarily men who have sex with HIV, enhancing the risk of severe liver disease, especially with men (MSM) and IDUs. In among drug addicts.8 Chronic HCV and HIV co-infection results in fact, injection drug use has been an accelerated progression to end-stage liver disease and death associated directly or indirectly when compared with individuals infected with HCV alone. (e.g., through sex with IDUs, mother-child transmission) with While the treatment of co-occurring HIV and HCV presents certain more than one-third of AIDS challenges, treatment during the acute phase of HCV infection cases in the United States. IDUs (i.e., within 6 to 12 months of detection) has shown promise. continue to be at increased risk Treatment thereafter significantly improves infected patients’ quality of HIV and other infections of life and should also be pursued. associated with drug abuse, including the hepatitis C virus (HCV), hepatitis B virus (HBV), therapy. HAART is also reported One of the challenges for endocarditis, skin infections, and to be associated with increased patients treated with HAART is abscesses. Over the past several lipid levels (including cholesterol) adhering to the medication years, however, the proportion in the blood, abnormal glucose routine needed for maximum of AIDS cases attributable to metabolism, and other clinical benefit from this therapy. injection drug use has declined, complications such as heart Adherence can be particularly while AIDS cases attributable to disease. problematic for drug abusers heterosexual transmission have Potential interactions between with chaotic lifestyles, which increased. From 2000 through HAART and medications used to can interfere with their ability to 2004, the annual number of treat drug addiction may decrease follow prescribed regimens. In AIDS diagnoses attributable to the effectiveness of either or addition, because HAART reduces heterosexual contact increased both treatments. For instance, viral load, some patients mistak- 18 percent among women and when methadone, a treatment enly believe that they do not 24 percent among men. In 2003, for heroin and other opioid need to adhere to the treatment addictions, is administered with regimen or that reduced viral MSM and those exposed through certain antiretroviral medications load means elimination of the heterosexual contact together that are components of HAART risk of transmitting HIV.10,11,12 This accounted for approximately therapy, the concentration of belief can, in turn, lead to com- 77 percent of cases, with MSM methadone in the blood is signif- placency about risk behaviors accounting for roughly 46 percent icantly decreased,9 potentially and resumption of unsafe sex of the total cases.14 compromising its effectiveness. and injection practices.13 NIDA- African-Americans experience Research is under way to deter- supported research has helped to striking disparities in HIV-infection mine if buprenorphine, a newer improve HIV outcomes among rates compared with other medication for the treatment of IDUs and has advanced new populations, and they are at opioid addictions, has similar discoveries and approaches for particularly high risk for develop- liabilities. treating medical consequences ing AIDS. To illustrate, while 4 NIDA RESEARCH REPORT SERIES African-Americans make up just for 68 percent of the female ages 13–19 represent only 15 13 percent of the U.S. population, HIV/AIDS diagnoses from 2001 percent of U.S. teenagers, they they accounted for more than half through 2004 while White females accounted for 66 percent of new of the total AIDS cases diagnosed accounted for 16 percent and AIDS cases reported among in 2004. Moreover, African- Hispanic females 15 percent.15 teens in 2003.16 American females accounted And although African-Americans Young people (ages 13 to 24) are also at risk for HIV/AIDS, with minority youth at particularly high risk. According to the HIV/AIDS: The Differential Experience Centers for Disease Control and of African-Americans Prevention (CDC), an estimated 40,000 young people in the United States had been diagnosed Disproportionate rates of HIVAfrican-Americans African-end with 2004, an estimated 178,000 infection among Americans have increased steadily over time. By the were living of with AIDS. This number repre- sents approximately 4 percent of the cumulative AIDS cases AIDS, the highest proportion of any racial/ethnic group. African- through 2004. Moreover, between Americans also represent 43 percent of AIDS cases diagnosed 2000 and 2004, the proportion since the start of the epidemic, which has disproportionately of young people diagnosed with affected subgroups of African-Americans as well, including women, AIDS increased from 4.3 percent youth, and MSM. to 5.1 percent. Particular HIV risk behaviors of this group, including HIV/AIDS is now the leading cause of death among all African- sexual experimentation and drug Americans ages 25–44, ahead of heart disease, accidents, abuse, are often influenced by cancer, and homicide.17 The disproportionate rates of HIV infection strong peer group relationships among African-Americans is not due to higher rates of injection and diminished parental involve- drug use or addiction in this population. Recent research suggests, ment that can occur during in fact, that African-Americans have lower rates of addiction than adolescence. Whites (8.3 percent vs. 9.6 percent of drug or alcohol abuse or Compounding this adolescent dependence),18 but the two groups do not differ significantly in vulnerability today is the notion their rates of injection drug use. The noted disparities may in part of “generational forgetting,” reflect data showing that African-Americans are predominant which is a diminished view of among those who become aware of their infection at later the dangers of HIV/AIDS among stages in the disease process, and who therefore represent lost certain members of today’s opportunities for treatment. generations. Studies show that today’s youth may be more To address these disparities, NIDA is encouraging research that likely to hold this view than examines the relationship between drug abuse and prevalence older Americans who witnessed of HIV- and AIDS-related morbidity and mortality among African- a higher AIDS mortality rate Americans, as well as studies that measure the effectiveness of associated with the rapid pro- HIV prevention and treatment programs within these populations. gression from HIV to AIDS early NIDA also is encouraging studies that focus on the nexus of in the epidemic. In addition, drug abuse, HIV/AIDS, and criminal justice involvement among one study comparing youth African-Americans to determine when the risk for contracting living with HIV before and after and transmitting HIV is greatest (e.g., during community-based the era of HAART found that supervision, in prison/jail, or during re-entry into society). post-HAART youth were more Additional studies are needed that characterize risk and pro- likely to engage in unprotected tective factors in order to develop culturally sensitive prevention sex and substance abuse; how- interventions to reduce HIV infection and minimize associated ever, whether this outcome is a health consequences and co-occurring conditions such as HCV. direct result of the availability of HAART is not known.19 NIDA RESEARCH REPORT SERIES 5 How Does to 1 day per month at 6-month followup among noninjection Treating Drug cocaine abusers. Reduction in cocaine use was associated with Abuse Affect an average 40 percent decrease the HIV/AIDS in HIV risk across gender and ethnic groups, mainly as a result Epidemic? of fewer sexual partners and less unprotected sex.5 Among gay S ince the late 1980s, research has shown that drug abuse and bisexual men who abused methamphetamine, compre- treatment is effective HIV hensive behavioral treatment prevention. Drug abusers in reduced sexual risk behaviors treatment stop or reduce their and sustained those reductions drug use and related risk behav- for at least 1 year following iors, including risky injection shows that comprehensive HIV substance abuse treatment.22 practices and unsafe sex.20 Drug prevention strategies can be cost- Behavioral treatments have treatment programs also serve effective and reliable in prevent- also shown promise for enhanc- an important role in providing ing new HIV infections among ing adherence to antiretroviral current information on HIV/AIDS diverse populations of drug therapy. Interventions aimed and related diseases, counseling abusers and their communities.23 at increasing HIV treatment and testing services, and referrals adherence are crucial to treat- Recent research confirms these for medical and social services. ment success, but usually require findings, demonstrating that Combined pharmacological dramatic lifestyle changes. school- and community-based and behavioral treatments for Effective treatment often includes prevention programs designed drug abuse have a demonstrated providing a consistent medical for inner-city African-American impact on HIV risk behaviors regimen to counter the often boys can be effective in reducing and incidence of HIV infection.20 irregular lifestyle created by high-risk behaviors, including For example, recent research drug abuse and addiction. drug abuse and risky sexual showed that when behavioral practices that can lead to HIV therapies were combined with infection.24 This research also methadone treatment, approxi- Which HIV/AIDS underscores the importance of mately half of study participants who reported injection drug use Prevention ensuring cultural relevancy for specific populations. at intake reported no such use at Programs Work Early detection of HIV is study exit, and over 90 percent of all participants reported no Best? another approach for preventing HIV transmission. Research indi- C needle sharing at study exit.21 umulative research has cates that routine HIV screening While these findings show great shown that comprehensive in healthcare settings among promise for achieving reductions HIV prevention—drug populations with a prevalence in sexual and drug-related risk addiction treatment, community- rate as low as 1 percent is as behaviors, studies are now based outreach, testing, and cost effective as screening for needed to determine the long- counseling for HIV and other other conditions such as breast term effectiveness of such infections—is the most effective cancer and high blood pressure. interventions. way to reduce risk of blood- These findings suggest that HIV Moreover, drug treatment has borne infections among drug- screening can lower healthcare also been shown to decrease abusing individuals. NIDA’s costs by preventing high-risk cocaine use from an average extensive prevention research practices and decreasing virus of 10 days per month at baseline portfolio, begun in the 1980s, transmission.25,26 6 NIDA RESEARCH REPORT SERIES How Has the Heterosexual sex has now become a major transmission How Can We HIV/AIDS Epidemic route for HIV and is a leading Counter These Changed Over the cause of infection among women, especially within minority com- Trends? Past 25 Years? S munities. In fact, the proportion cientific knowledge is the of total AIDS cases attributed to best tool we have to address C DC surveillance data heterosexual transmission has the disease of addiction and reveal a notable shift in increased sixfold since 1989 from its consequences, including HIV. the HIV/AIDS epidemic in 5 percent to 31 percent. Research has taught us that drug the United States, with a higher abuse is preventable and that Emerging trends in HIV infec- proportion of new AIDS diag- addiction is treatable. Promising tion include an increase in new noses today occurring among prevention and treatment strate- infections among MSM, after gies continue to emerge to women, racial/ethnic minorities, years of decline. This increase low-income groups, and young address this devastating disease, has been associated with a yet much remains to be done. MSM. Early in the HIV/AIDS resurgence of risky sexual The greater proportion of HIV epidemic, infections were mainly behavior linked to the use of infections associated with hetero- seen among White, urban, MSM methamphetamine and other sexual contact requires additional or male IDUs. However, over club drugs. While the link research to better unravel the the past 25 years, the boundaries between HIV infection and dynamics behind how drug between groups at greater and methamphetamine abuse is not abuse may be contributing to lesser risk for contracting the established for heterosexuals, cases of new HIV infections. We virus have been dissolving, with data show an association know that substance abuse may the diversity of those potentially between methamphetamine affect judgment and decision- at risk rapidly increasing. use and risky sexual behavior. making and lead to high-risk sexual encounters and that sexu- ally active drug abusers increase Proportion of AIDS Cases Among Adults and Adolescents, the likelihood of HIV transmis- by Transmission Category and Year of Diagnosis, sion. However, we have not yet identified all of the behavioral, 1985–2003—United States biological, and environmental processes involved in the sexual 70% I Male-to-male sexual contact transmission of HIV among drug I Injection drug use (IDU) abusers. We now need to estab- 60 I Heterosexual contact I Male-to-male sexual contact and IDU lish how an individual’s peers, 50 relationships, social networks, and environment influence both 40 drug abuse and sexual risk taking. Cases Linkages to drug diffusion, drug 30 abuse practices, and HIV risk 20 behaviors are of particular interest. 10 Next Steps R 0 esearch is also needed to 1985 1988 1991 1994 1997 2000 2003 understand the factors Year of Diagnosis leading to disparities in HIV infection and survival rates Note: Data adjusted for reporting delays and for estimated proportional redistribution of cases in persons initially reported without an identified risk factor. among racial and ethnic minori- Source: CDC, U.S. Department of Health and Human Services. ties, particularly among African- Americans. We can begin with NIDA RESEARCH REPORT SERIES 7 research that characterizes the extent and nature of disparities Glossary in the rates of HIV infection and Acquired immune deficiency syndrome (AIDS): The most severe manifestation of infection with the occurrence of co-infections HIV. An AIDS diagnosis is based on the presence of clinical symptoms, a patient’s HIV viral load, and a and other conditions among CD4+ lymphocyte count at or below 200 cells per microliter in the presence of HIV infection. Persons drug-abusing minorities, taking living with AIDS often have infections of the lungs, brain, eyes, and other organs, and frequently into account age, gender, educa- suffer debilitating weight loss, diarrhea, and a type of cancer called Kaposi’s sarcoma. tion, sexual identity, geographic region, and socioeconomic status. Addiction: A chronic, relapsing disease characterized by compulsive drug seeking and abuse and by Studies are also needed to char- long-lasting changes in the brain. acterize risk and protective fac- Antiretroviral drugs: Medications used to kill or inhibit the multiplication of retroviruses such as HIV. tors so as to develop culturally sensitive prevention interventions. Behavioral treatments: A set of treatments that focus on modifying thinking, motivation, coping Research on HIV disease mechanisms, and choices made by individuals. progression and its relationship to the use and availability of CD4+ lymphocyte: A type of cell involved in protecting against viral, fungal, and protozoal treatment services will help us infections. These cells normally stimulate the immune response, signaling other cells in the immune develop better interventions. system to perform their special functions. Finally, research is needed to Cultural relevancy: The ability of an intended audience to view an intervention as applicable to investigate the transmission of their life circumstances. treatment-resistant HIV strains among drug abusers and to Generational forgetting: Term to describe when knowledge of adverse consequences experienced explore the extent to which by a particular generation or population is lost by a younger cohort. In this report, it refers to the drug abuse may contribute to diminished view of the dangers of HIV/AIDS among those 25 and younger. the development of resistant viral infections. Highly active antiretroviral therapy (HAART): A combination of three or more antiretroviral drugs used in the treatment of HIV infection and AIDS. Summary Hepatitis C virus (HCV): A virus that causes liver inflammation and disease. Hepatitis is a general W hile calls for more term for liver damage and hepatitis C is the most common type of hepatitis found among those with HIV. research continue, impor- Human immunodeficiency virus (HIV): HIV is the virus that causes AIDS. tant discoveries made possible by NIDA and others Injection drug use: Act of administering drugs using a hypodermic needle and syringe. have positioned the field to move forward in developing effective Opioid: A compound or drug that binds to receptors in the brain involved in the control of pain and prevention and treatment other functions (e.g., morphine, heroin, oxycodone). approaches. Three key findings Pharmacological treatment: Treatment using medications. inform our approach, linking the interactions of drug abuse and Viral load: The quantity of HIV RNA (ribonucleic acid) in the blood. Research indicates that viral load HIV/AIDS in ways that extend is a better predictor of the risk of HIV disease progression than the CD4+ lymphocyte count. The lower far beyond injection drug use. the viral load, the longer the time to AIDS diagnosis and the longer the survival time. Viral load testing First, drug abuse impairs judg- for HIV infection is used to determine when to initiate or change therapy. ment and good decisionmaking, leaving people more prone to engage in HIV risk behaviors, Resources: including risky sexual behavior and nonadherence to HIV treat- a. Department of Health and Human Services AIDSinfo Web site (www.aidsinfo.nih.gov) ment. Second, drug abuse b. Institute of Medicine Report “No Time to Lose” (www.nap.edu) adversely affects health and may c. National Institute of Allergy and Infectious Diseases (www.niaid.nih.gov) exacerbate disease progression. d. NIDA’s HIV Prevention Principles (www.drugabuse.gov/POHP/principles.html) Third, and most important, because of these linkages, we e. The Centers for Disease Control and Prevention (www.cdc.gov) must recognize that drug abuse f. U.S. Preventive Services Task Force (www.preventiveservices.ahrq.gov) treatment is HIV prevention. 8 NIDA RESEARCH REPORT SERIES References 1 Royce RA, Sena A, Cates W Jr, Cohen MS. 12 Boily MC, Bastos FI, Desai K, Masse B. Changes in the 24 Flay BR, Gramlich S, Segawa E, Burns JL, Holliday MY. Sexual transmission of HIV. N Engl J Med transmission dynamics of the HIV epidemic after the Effects of two prevention programs on high risk 336(15):1072–1078, 1997. wide-scale use of antiretroviral therapy could explain behaviors among African-American youth. Arch Pediatr increases in sexually transmitted infections: Results Adolesc Med 158(4):337–384, 2004. 2 Gavrilin MA, Mathes LE, Podell M. Methamphetamine from mathematical models. 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Available at http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm 5445a1.htm. on the Internet 5 Woody GE, Gallop R, Luborsky L, Blaine J, Frank A, Salloum IM, Gastfriend D, Crits-Christoph P; Cocaine 16 Centers for Disease Control and Prevention. • What’s new on the NIDA Web site Psychotherapy Study Group. HIV risk reduction in the “HIV/AIDS Surveillance in Adolescents, • Information on drugs of abuse National Institute on Drug Abuse Cocaine Collaborative L265 Slide Series,” CDC, 2003. Available at • Publications and communications Treatment Study. J Acquir Immune Defic Syndr. http://www.cdc.gov/hiv/graphics/adolesnt.htm. (including NIDA NOTES) 33(1):82–87, 2003. 17 Anderson RN, Smith BL. Deaths: Leading causes for • Calendar of events 6 McArthur JC. HIV dementia: An evolving disease. 2001. Natl Vit Stat Rep 52(9):27–33, 2002. • Links to NIDA organizational units J Neuroimmunol 157(1–2):3–10, 2004. • Funding information 18 Office of Applied Studies. 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