NIDA Research Report on HIV AIDS

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					                         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

                    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

                    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?

                    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.
                    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-

   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

                                                                                    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
                                                                                                                              consequences associated with
                                                                                                                              HIV/AIDS have changed. New
                                           20                                                                                 diagnoses of HIV-associated
                                                                                                                              infections and some neurological
                                                                                                                              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?

                                                                                          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

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
                                                                         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

     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-

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

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-
Past 25 Years?
                                                           munities. In fact, the proportion                    cientific knowledge is the
                                                           of total AIDS cases attributed to                    best tool we have to address

      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.

                                                                                                           Linkages to drug diffusion, drug
          30                                                                                               abuse practices, and HIV risk
          20                                                                                               behaviors are of particular interest.

          10                                                                                               Next Steps

           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

         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 (
ment. Second, drug abuse              b.   Institute of Medicine Report “No Time to Lose” (
adversely affects health and may      c.   National Institute of Allergy and Infectious Diseases (
exacerbate disease progression.       d.   NIDA’s HIV Prevention Principles (
Third, and most important,
because of these linkages, we         e.   The Centers for Disease Control and Prevention (
must recognize that drug abuse        f.   U.S. Preventive Services Task Force (
treatment is HIV prevention.

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