HIV & Substance UseHIV & Substance Use

What is the connection…

• Between HIV and substance use?

Drug, Set & SettingDrug, Set & Setting

• Dr. Norman Zinberg– RAND study of

“alcoholics”

• Challenges the underlying assumption of the Disease Model.

DRUG, SET AND SETTING

DRUG

SET SETTING

Drug, Set and SettingDrug, Set and Setting

• DRUG

– Is defined not only by the pharmacological makeup of the particular substance, but also any substance that the drug is cut with, the potency of the drug, and the method with which the drug is taken.

– Example of harm related to drug:• Injecting heroin puts one at greater risk for overdose than snorting

heroin.

Drug, Set and SettingDrug, Set and SettingSET (SELF)

◦What the individual brings to the drug experience. This includes the individual’s psychological approach to drug taking -- What is the expectation of the person taking the drug?

◦What motivates me to take this drug? For recreation? For medication? For escape?

◦ The same drug may act differently in different people.

◦ Example of harm related to set: A person who is anxious may be more likely to have a "bad trip" or

paranoid reaction if using LSD (Acid), a hallucinogenic drug.

Drug, Set and SettingDrug, Set and Setting

• SETTING:

– The environment in which the drug is taken (e.g., person’s home, bathroom in a club, an abandoned building). Setting also refers to the culture within which the drug use takes place and the messages, values, and expectations that shape the meaning of drug use within society, different communities, and subcultures.

– Example of harm related to setting:• A person who uses MDMA (Ecstasy) at a Rave with little

ventilation or available water may suffer heat exhaustion.

SEX, Set and SettingSEX, Set and Setting

• How can “drug, set & setting” be modified to discuss sexual behavior?

Drivers of HIVDrivers of HIV• The HIV Prevention Planning Council has developed a definition

and criteria for identifying Drivers of HIV in San Francisco.• A “Driver” is defined as “underlying condition that is directly

linked to a large number of new HIV infections in San Francisco.”

• Criteria for determining a Driver of HIV in SF:» Prevalence of 10% or greater. A driver has at least 10%

prevalence among one of the high-risk BRPs where the bulk of new infections occur (MSM, IDU, TFSM).

» Two-fold increase in risk. A driver is an independent factor for HIV, making a person in a high-risk BRP at least twice as likely to contract HIV compared to someone who is not affected by the driver.

Drivers of HIVDrivers of HIV After a thorough review of the literature the

following factors were identified to be driving new HIV infections in SF:

Cocaine/crackHeavy alcohol useMethamphetaminePoppersGonorrheaMultiple partners

Cocaine/Crack UseCocaine/Crack Use•Stimulant•Enhances sexual interest and pleasure•Decreases inhibitions•Heightens sense of invulnerability•Inhibition of ejaculation•Numbing effects

Cocaine/Crack UseCocaine/Crack Use

•Prevalence of cocaine/crack use among MSM and IDU ranges from 15-25%

•Independently associated with HIV seroconversion, increasing odds of seroconversion from 2.5-2.8%

Heavy Alcohol UseHeavy Alcohol Use•“Four or more drinks every day or six or more drinks on a typical day when drinking.”

•Depressant•Pleasurable feelings•Reduce inhibitions•Confusion

Heavy Alcohol UseHeavy Alcohol Use

•Prevalence of heavy alcohol use among MSM ranges from 30-52%

•Independently associated with HIV seroconversion, increasing odds of seroconversion 2.0%

Methamphetamine UseMethamphetamine Use•Stimulant•Prolonged energy•Feeling of euphoria•Increased self-confidence•Increased sexual interest•Can prolong erections and length of sexual activity

Methamphetamine UseMethamphetamine Use

•Prevalence of meth use among MSM and IDU ranges from 13-20%

•Independently associated with HIV seroconversion, increasing odds of seroconversion by at least 2.0%

Poppers UsePoppers Use•Alkyl nitrates•Feeling of euphoria•Reduced inhibitions•Muscle relaxation (facilitates anal play)•Increased sexual interest•Increased ability to ejaculate and intensification of orgasm

Poppers UsePoppers Use

•Prevalence of poppers use among MSM ranges from 19-37%

•Independently associated with HIV seroconversion, increasing odds of seroconversion by 2.2%

Sterile Syringe Access in the U.S.Sterile Syringe Access in the U.S.

• Nearly 200 syringe exchange programs currently operate in 38 states, Puerto Rico, Washington DC.– 1st program endorsed by a local government in the U.S.

was where?

• Endorsed by AMA, APHA, US Conference of Mayors, among many other legal, medical & policy institutions.

• Federal ban on funding for syringe access programs – only lifted this year after 20 years

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Pharmacy ProvidersPharmacy Providers• In 2005, California Senate Bill

1159, “Pharmacy Access to Syringes” was enacted.– Allows any city or county to

authorize pharmacies within its jurisdiction to sell or provide up to 10 syringes to someone over 18 years of age without a prescription (sunsets in 2015).

Approved Pharmacy SalesApproved Pharmacy Sales

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Syringe Access in CaliforniaSyringe Access in California

• Syringe Programs approved in:– 19 counties

• (33% of counties)– 4 cities

• Pharmacy sales of syringes approved in:– 15 counties

• (26% of counties)– 4 cities

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Only 22% of counties have both options

Only 36% of counties have some legal syringe access option

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IDUs in San FranciscoIDUs in San Francisco

• 16,790 injection drug users (IDUs)– Plausible total range is 13,536-24,438

• 7,076 men who have sex with women • 5,234 men who have sex with men• 4,030 women• 449 transgender individuals

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Persons Living with AIDS and Persons Living with Persons Living with AIDS and Persons Living with HIV Non-AIDSHIV Non-AIDS

  PLWAPLWA(N=9018)(N=9018)

PLWHPLWH(N=4627)(N=4627)

GenderMaleFemaleTransgender

92%6%2%

92%6%2%

RiskMSMMSM+IDUIDUNo Reported RiskOther

73%14%9%1%3%

76%10%7%4%3%

Source: SFDPH. HIV/AIDS Epidemiology Annual Report, 2008Source: SFDPH. HIV/AIDS Epidemiology Annual Report, 2008

San Francisco, December 31, 2007San Francisco, December 31, 2007

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Syringe Access & Disposal ProgramsSyringe Access & Disposal Programs• Goal: To eliminate the transmission of bloodborne

viruses among people who inject drugs or other substances and their sexual partners.

– Objective: To reduce risk behaviors that may lead to the transmission of bloodborne viruses among people who inject drugs and their sexual partners.

– Strategies: • Provide access to sterile syringes, injection supplies, and safer

sex supplies.• Promote safe disposal of syringes and injection supplies,

including collection and disposal of used syringes.• Develop & deliver education programs relevant to the goal.• Provide information on & referrals to other health services.

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Syringe Access & Disposal ProgramsSyringe Access & Disposal Programs

• Community providers– 5 publicly funded providers operate

18 sites each week.

• July 1, 2007 - June 30, 2008– Provided nearly 2.5 million syringes.

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Community Syringe ProgramsCommunity Syringe Programs– Some sites focus on access for special populations.

For example:

• Ladies’ Night– Biological and transgender women

• St. James Infirmary– Sex workers & their partners

• Asian & Pacific Islander Wellness Center– Transgender individuals

• TRANS Thrive– Transgender individuals

• Homeless Youth Alliance– IDUs under the age of 30

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For more information…For more information…

www.sfhiv.org

Emalie Huriaux+1 415 437 4694emalie.huriaux@sfdph.org