HIV infection among drug abusers in the Belgrade area

Sections

ABSTRACT
Introduction
Intravenous drug abuse
HIV Infection among drug addicts
Trend in HIV seropositivity
AIDS among drug addicts
Degree of risk
Other sexually transmitted Infections among opiate-addicted persons
Concluding remarks

Details

Author: M. KILIBARDA
Pages: 135 to 146
Creation Date: 1993/01/01

HIV infection among drug abusers in the Belgrade area

M. KILIBARDA
Institute on Addictions, Belgrade

ABSTRACT

The abuse of heroin and other opiates by intravenous injection is identified as the major risk for the spread of infection, by the human immunodeficiency virus (HIV) and of acquired immunodeficiency syndrome (AIDS) to the population at large. From 1980 to 1992, 2,712 opiate-addicted intravenous drug users with severe complications and behavioural problems were treated at the Institute on Addictions, Belgrade; 2,090 of them were from the Belgrade area and 622 from other urban areas. All of them had used heroin by intravenous injection during a certain period of their addiction careers. A majority of the patients had started using heroin by the age of 20, and begun treatment after six or more years of addiction. An informal, survey of heroin-addicted intravenous drug users newly admitted for treatment showed that every respondent knew from 10 to 20 other heroin users who had not sought treatment. It was estimated that a majority of intravenous drug users may not have been known to the authorities.

Of 551 intravenous - opiate - addicted patients from the Belgrade area tested between 1987 and 1992, 43.7 per cent were HIV- seropositive, or 47.9 per cent of HIV-seropositive males and 32.9 per cent of females, while for the same period, of 366 tested patients from other urban areas, 4.6 per cent were HIV-seropositive, 5.2 per cent of them males and 1.8 per cent females.

The distribution by sex of the intravenous-opiate-addicted patients indicated that the percentage of females who started using heroin earlier in their lives and the percentage of those who sought treatment late - after six or more years of addiction - were higher than the corresponding percentages of males. Also, female patients tended to become infected with HIV earlier in their lives than male patients.

Introduction

In some parts of the world, intravenous drug abuse is one of the major factors responsible for the spread of HIV infection and the AIDS epidemic [ 1] , [ 2] . In the Belgrade area, intravenous drug users have been seriously afflicted by AIDS-related problems, with great individual suffering and huge social costs. Such a development places drug abuse by intravenous injection in the focus of the AIDS epidemic.

The first cases of HIV-seropositivity among persons undergoing treatment at the Institute on Addictions, Belgrade, were identified in the mid-1980s, soon followed by the rapid spread of HIV infection among heroin-addicted intravenous drug users [ 3] . The present paper, on the basis of drug treatment data, reviews both the extent of intravenous drug abuse in the Belgrade area and the spread of HIV infection and the AIDS epidemic specifically associated with such abuse.

Intravenous drug abuse

Occasional cases of intravenous abuse of heroin and other opiates by young persons appeared in major cities, mainly Belgrade, during the 1970s. At the beginning of the 1980s, in the Belgrade area, heroin began to be increasingly abused by intravenous injection, and such abuse among young people soon reached epidemic proportions [ 4] . Intravenous heroin abuse has extended to other urban areas of the country, but to a much lesser extent than at Belgrade. Concurrent with the heroin abuse epidemic, an increasing number of heroin-related deaths has occurred among young people. In addition to heroin injection, cannabis-smoking and oral abuse of sedative - hypnotics are widespread. Sniffing of volatile solvents by children and young adolescents is a problem, mainly in the newly urbanized sections of the city. Injection of cocaine hydrochloride and smoking of cocaine base are sporadically observed, mainly in association with heroin abuse. However, intravenous heroin abuse is the most serious drug abuse problem, and shows an increasing trend. When heroin is not easy to obtain, users resort to an opium poppy decoction, synthetic narcotics and multiple drug abuse [ 5-7] .

Table 1 shows cumulative data on 2,712 opiate-addicted intravenous drug users who were treated at the Institute on Addictions, Belgrade, at some time between 1980 and 1992. Although some of the opiate - addicted abusers covered in table I might have used two or more psychoactive substances or been enrolled in the methadone - maintenance programme of the Institute, intravenous heroin injection played a primary role in a certain period of their addiction careers. Most of them were "hard-core addicts" who suffered from psychological and somatic complications and disturbed social relations, pursued a "chaotic" life-style with drug-seeking behaviour, and were well established- in the drug-using subculture [ 6] , [ 7] .

Table 1. Geographical distribution and sex of opiate-addicted patients treated at the Institute on Addictions, 1980-1992

 

Belgrade area

Other urban areas

Total

Sex

Number

Percentage

Number

Percentage

Number

Percentage

Male
1545 73.9 528 84.9 2073 76.4
Female
545 26.1 94 15.1 639 23.6
Total
2090 100.0 622 100.0 2712 100.0

Of the total number of patients covered intable 1, 2,090 (77.1 per cent) were from the Belgrade area and 622 (22.9 per cent) from other urban areas. Among them, 23.6 per cent were females and 76.4 per cent males. With regard to sex distribution, the patients from the Belgrade area, 26.1 per cent of whom were females and 73.9 per cent males, differed from the patients from other urban areas, 15.1 per cent of whom were females and 84.9 per cent males. It is noteworthy (see table 1) that the percentage of female patients from the Belgrade area (26.1 per cent) was much higher than that of female patients from other urban areas (15.1 per cent).

Table 2 shows that 62.7 per cent of the intravenous-opiate-addicted patients were unmarried, 13.9 per cent married and 23.4 per cent divorced.

Table 2. Marital status of opiate-addicted patients treated at the Institute on Addictions, 198O -1992

 

Percentage by marital status

Sex

Number

Unmarried

Married

Divorced

Male
2073 66.8 10.6 22.6
Female
639 49.6 21.9 28.5
Total
2712 62.7 13.9 23.4

Males differed from females with regard to marital status (see table 2).

The percentage of married females (21.9 per cent) was much higher than that of married males (10.6 per cent), and the percentage of divorced females (28.5 per cent) was slightly higher than the corresponding percentage of males (22.6 per cent). The percentage of unmarried males (66.8 per cent) was substantially higher than that of females (49.6 per cent).

Table 3 shows that only 17.7 per cent of the intravenous-opiate- addicted patients were employed, with a slightly higher rate of employment among females (18.9 per cent) than among males (17.4 per cent).

Table 3. Employment status of opiate-addicted patients treated at the Institute on Addictions, 1980-1992

 

Percentage by employment status

Sex

Number

Employed

Unemployed

Male
2073 17.4 82.6
Female
639 19.9 81.1
Total
2712 17.7 82.3

Table 4 shows that 44.6 per cent of the opiate-addicted patients had completed primary school, 45.3 per cent secondary school and 5.9 per cent a higher institution, while 4.2 per cent had graduated from a university. The data showed that females were somewhat better educated than males.

Table 4. Education of opiate - addicted patients treated at the Institute on Addictions, 1980 - 1992

 

Percentage by educational level

Sex

Number

Primary school (8 years)

Secondary school (12 years)

Higher institution (14years)

University graduate

Male
2073 46.8 43.5 5.8 3.9
Female
639 36.0 52.5 6.3 5.2
Total
2712 44.6 45.3 5.9 4.2

Table 5 shows that 32.0 per cent of the intravenous - opiate - addicted patients commenced using heroin or other opiates before reaching the age of 17, and 34.7 per cent started using those drugs in the 17-20 age group. The percentages of females who started using heroin or other opiates early in their lives were slightly higher than the corresponding percentages of males.

Table 5. Age at which opiate-addicted patients treated at the Institute on Addictions started using heroin or other opiates, 1980-1992

 

Percentage by age group

Sex

Number

16 or below

17-20

21-24

25 or above

Male
2073 31.3 32.8 17.1 19.1
Female
639 32.3 36.8 16.5 14.1
Total
2712 32.0 34.7 16.6 16.7

Table 6 shows that prior to treatment, 42.1 per cent of the intravenous-opiate-addicted patients had addiction careers of up to 5 years, 33.9 per cent of 6 to 9 years, and 24.0 per cent of 10 or more years.

Table 6. Period of opiate addiction of the patients before they started treatment at the Institute on Addictions, 1980-1992

 

Percentage by years of addiction

Sex

Number

5 or less

6-9

10 or more

Male
2073 43.9 31.6 24.5
Female
639 41.4 36.7 21.9
Total
2712 42.1 33.9 24.0

The data in tables 5 and 6 show that 66.7 per cent of the intravenous - opiate - addicted patients began using heroin or other opiates by the age of 20, and that 57.9 per cent sought treatment after six or more years of addiction. This indicates that more effective preventive measures need to be taken by society and the community.

Although treatment at the Institute was voluntary, most of the first-time patients accepted treatment as a result of a certain degree of pressure from the family or a court of law, or because of deteriorating health. The majority of heroin users are not motivated to seek treatment. A recent informal survey of intravenous heroin users newly admitted for treatment at the Institute on Addictions showed that each of them knew 10 to 20 other heroin users who had not sought treatment. The above data on patients treated for heroin or other opiate addiction therefore represent only the "tip of the iceberg", as the majority of users may have remained in the community [ 6] , [ 7] .

HIV Infection among drug addicts

In the Belgrade area, the intravenous abuse of heroin or other opiates poses the greatest risk of a spread of HIV infection not only to the population of drug abusers themselves, but also to their sexual partners and offspring. Approximately three quarters of all known HIV seropositives in the Belgrade area are addicted to drugs [ 8] . As of 30 June 1992, 214 cases of AIDS in the entire country had been reported to the Federal Institute of Public Health, 124 of them being drug addicts. Of the latter number, 120 were drug addicts from the Belgrade area [ 9] .

Cumulative data of the Institute on Addictions showed that 43.7 per cent of all tested opiate-addicted patients from Belgrade who have been treated at the Institute were HIV-seropositive (see table 7). Sharing injection equipment and unsafe sexual practices are common behaviours among intravenous drug users. A substantial number of intravenous drug users have sexual partners who may not be using drugs. It is also common for drug users to resort to prostitution to support their drug habits. Such behaviour increases the likelihood of the spread of HIV infection and other sexually transmitted diseases from intravenous drug users to the population at large.

Table 7. Number and percentage of HIV seropositives among the tested opiate-addicted patients at the Institute on Addiction, 1987-1992

 

Belgrade area

Other urban areas

Sex

Number tested

Number of seropositives

Percentage

Number tested

Number of seropositives

Percentage

Male
399 191 47.9 310 16 5.2
Female
152 50 32.9 56 1 1.8
Total
551 241 43.7 366 17 4.6

Table 7 shows that out of 551 tested intravenous-opiate-addicted patients from the Belgrade area, 241 (43.7 per cent) were HIV- seropositive. The patients covered in table 7 were treated at the Institute on Addictions at some time between 1987 and 1992. Of the males tested, 47.9 per cent were HIV-seropositive, and of the females tested, 32.9 per cent (see table 7). Such rates are rather high, compared with relevant data from other parts of the world, where intravenous drug abuse represents one of the major risks among the possible causes of HIV infection [ 1] .

Table 7 also shows that the HIV seropositivity rate of the tested patients from urban areas other than Belgrade was much lower (4.6 per cent) than the rate of those coming from the Belgrade area (43.7 per cent).

Of the total of 241 HIV-seropositives among the intravenous- opiate-addicted patients (see table 8), the highest percentage (34.0 per cent) was in the 25- to 29-year age group, followed by the 30- to 34-year age group (30.7 per cent). The highest percentage of males was in the 30- to 34-year age group (34.1 per cent), followed by the 25- to 29-year age group (31.9 per cent), while for females, the highest percentage was in the 25- to 29-year age group (42.0 per cent), followed by the 20- to 24-year age group (22.0 per cent). Thus, females showed some tendency to become infected with HIV earlier than males (see table 8). A greater portion of females started using heroin or other opiates earlier than males (see table 5). This might help to explain why the rates of HIV seropositivity of females were higher in younger age groups than those of males.

Table 8. Percentage distribution by age groups and sex of HIV-seropositive opiate-addicted patients from the Belgrade area treated at the Institute on Addictions, 1987-1992

 

Percentage distribution by age group

Sex

Number

19 or below

20-24

25-29

30-34

35 or above

Male
191 1 16.8 31.9 34.1 16.2
Female
50 4 22.0 42.0 18.0 14.0
Total
241 1.7 17.8 34.0 30.7 15.8

Trend in HIV seropositivity

Table 9 shows the trend in HIV seropositivity among intravenous- opiate-addicted patients from the Belgrade area and urban areas other than Belgrade. The patients covered table 9 were treated at the Institute on Addictions at some time between 1987 and 1992. The identification of the first HIV-seropositive patients in the mid-1980s was followed by an outbreak among patients from Belgrade [ 3] . Data of the Institute on Addictions show that in 1987, in the Belgrade area, 91 HIV- seropositive patients were identified, or 64.5 per cent of 141 tested patients. The outbreak continued at a similar level among the Belgrade patients in 1988, when 79 HIV-seropositive patients were identified, or 63.7 per cent of 124 tested patients. From then to 1992, the trend in HIV seropositivity gradually declined. The decline has been attributed mainly to preventive and therapeutic measures, such as the methadone- maintenance programme introduced by the Institute.

Table 9. Percentages of HIV seropositivity by year of identification among opiate- addicted patients at the Institute on Addictions, 1987 - 1992

 

Belgrade area

Other urban areas

Year

Number tested

Number of seropositives

Percentage

Number tested

Number of seropositives

Percentage

1987 141 91 64.5 50 1 2.0
1988 124 79 63.7 46 2 4.3
1989 62 20 32.2 49 5 10.2
1990 61 16 26.2 91 3 3.3
1991 91 21 25.9 83 4 4.8
1992 82 14 17.1 47 2 4.2
Total
551 241 43.7 366 17 4.6

The data in table 9 show that the rates of HIV-infected patients from the Belgrade area were relatively high, ranging from 64.5 per cent in 1987 to 17.1 per cent in 1992, the average rate for the period being 43.7 per cent.

The trend in HIV seropositivity among the patients from urban areas other than Belgrade remained at a relatively low level throughout the period from 1987 to 1992 (see table 9).

AIDS among drug addicts

As of 30 September 1992, 239 cases of AIDS in Yugoslavia had been reported to the Federal Institute of Public Health, 59 of them within the previous nine months [ 10] . In 1991, 37 cases, and in 1990, 28 cases, of AIDS were reported; 57.3 per cent of the reported AIDS cases in Yugoslavia were known to have died [ 10] . Of the total number of 239 cases, 135-(56.5 per cent) were drug addicts, the great majority of them being from the Belgrade area [ 10] . As of June 1992, 120 AIDS cases were known to have been drug addicts from the Belgrade area [ 9] .

Degree of risk

Sharing contaminated injection equipment played a predominant role in the Belgrade AIDS epidemic, and still presents the greatest risk factor in the transmission of HIV and a range of other infections, such as hepatitis B viruses and bacterial endocarditis. In addition to the needle and syringe, some other items of the injection equipment could be contaminated,- such as the spoon used. to dissolve a drug, cotton used to eliminate undissolved particles from the spoon, and water used to rinse out the needle. Almost all intravenous drug addicts report that at least at some time in their addiction career they have shared injection equipment.

The symptoms and signs of drug withdrawal greatly increase the likelihood of an intravenous drug addict sharing injection equipment. Frequent drug injection and a high prevalence of the AIDS virus among intravenous drug addicts also increase the risk of spread of the HIV infection.

Under the influence of drugs, a person may act in a way that he or she would not normally act. Drug use, both injecting and non-injecting, impairs judgement and decreases sexual inhibitions, which may lead to unsafe sexual behaviour, thus heightening the risk of acquiring and spreading HIV infection.

Other sexually transmitted Infections among opiate-addicted persons

Research carried out in 1991 jointly by the Institute of Public Health, Belgrade, and the Institute on Addictions showed that 64.9 per cent of the patients at the Institute on Addictions were contaminated by hepatitis B viruses. The same research showed that 17.3 per cent of the patients had positive Wasserman test results for syphilis [ 7] .

Concluding remarks

Drug treatment data in the Belgrade area reveal very high rates of HIV infection among intravenous drug users, identified as the major vector for the spread of HIV infection and AIDS to the population at large. Assessment of intravenous drug abuse is therefore essential to check the spread of infection in the community. However, data are available only about those intravenous drug users who have undergone treatment. In this connection, it should be recalled that drug abuse develops along a continuum that starts with experimental or occasional drug use and ends with heavy drug abuse, often followed by severe psychosomatic and social problems. The data set out in the present article relate only to intravenous drug abuse with complications at the end of the continuum, and not to some earlier point in its progression.

Drug- addicted persons are not generally motivated to seek treatment. The data show that a majority of the opiate-addicted intravenous drug users had sought treatment after six or more years of addiction. In an informal- survey, conducted in 1992, of intravenous heroin abusers newly admitted for treatment, every respondent said that he or she knew 10 to 20 other heroin abusers who had not sought treatment [ 6] , [ 7] . The foregoing data led the author of the present article to suppose that a majority of intravenous drug abusers may not have been known to the health or other city authorities. It is hoped that the current epidemiological and outreach efforts of the Institute on Addictions will help to better assess the situation of intravenous drug abuse in the city.

The data presented on intravenous-opiate-addicted patients showed considerable variation in terms of sex (see table 1). In the population of patients from the Belgrade area females were much more represented (26.1 per cent) than in that of patients from other urban areas (15.1 per cent). The difference is probably culturally determined. -Women in smaller urban areas are more likely to become stigmatized for being treated for drug abuse than women in the capital city. Data on the entire population of patients showed that the percentage of married women was almost double that of men (see table 2), the percentages of educated women were higher than those of men (see table 4), and the percentage of employed women was also higher than the -corresponding percentage of men (see table 3). However, the percentages of women who started using heroin or other opiates earlier in their lives were higher than those of men (see table 5), and the percentage of women who sought treatment late - after six or more years of addiction - was also higher than the corresponding percentage of men (see table 6).

The rates of HIV infection among intravenous-opiate-addicted patients showed great geographical variations, with an average rate of 43.7 per cent for the tested patients from the Belgrade area and 4.6 per cent for those coming from other urban areas. The spread of HIV seropositivity among intravenous drug addicts from the Belgrade area was discovered in 1985 and 1986 [ 3] . In 1987 and 1988, the spread took the form of an outbreak, and thereafter it showed a declining trend (see table 9). Finally, female patients (see table 8) have shown a tendency to become HIV-seropositive earlier in their lives than male patients.

References

01

R. J. Battjes and others, "The acquired immunodeficiency syndrome and intravenous drug abuse", Bulletin on Narcotics (United Nations publication), vol. 40, No. 1 (1988), pp. 21-34.

02

J. F. Jackson, L. G. Rotkiewicz and R. C. Baxter, "The role of drug abuse treatment programs in AIDS prevention and education programs for intravenous drug users: the New Jersey experience", in AIDS and Intravenous Drug Use: Community Intervention and Prevention, C. G. Leukefeld, R. J. Battjes and Z. Amsel, eds. (New York, Hemisphere Publishing, 1990), pp. 167-186.

03

S. erjav and others, "Contribution to the epidemiological study of AIDS in Belgrade", Srpski arhiv celokupnog lekarstva, vol. 115, 1987, pp. 715-723.

04

M. Vukov and others, "Karakteristike narkomanije u naaoj sredini", Socijalna politika i socijalni rad, vol. 28, No. 1 (1992), pp. 84-89.

05

M. Vukov and G. Eljdupovi, "The Yugoslavian drug addict family structure", The International Journal of Addictions, vol. 26, No. 4 (1991), pp. 415-422.

06

M. Kilibarda, "Heroin addiction and associated HIV infection: extent, patterns and trends in Serbia", in Proceedings: The Third Annual Conference on Drug Use and Drug Policy, J. B. Nebille and F. Tellier, eds. (Loughborough, Midlands Centre for Criminology and Criminal Justice, Loughborough University, November 1992), pp. 273-277.

07

M. Kilibarda, "Drogenmissbrauch in Serbien", paper presented at the Neunte Wissenschaftliche Tagung der DG-Sucht, held at Passau, Germany, from 28 to 30 April 1992, organized by Deutsche fr Suchtforschung und Suchttherapie in cooperation with the World Health Organization Regional Office for Europe (forthcoming).

08

V. Ili and others, "Epidemiology of AIDS in Belgrade (Yugoslavia)", paper presented in the poster abstracts of the VIIIth International Conference on AIDS, held at Amsterdam from 19 to 24 July 1992, No. PoC 4636.

09

Federal Institute of Public Health, "AIDS in Yugoslavia - situation as of June 1992", Information No. 33 (Belgrade, Federal Institute of Public Health, 1992), pp. 1-5.

10

Federal Institute of Public Health, "AIDS in Yugoslavia - situation as of 30 September 1992", Information No. 34 (Belgrade, Federal Institute of Public Health, 1992), pp. 1-4.