Don C. Des Jarlais, Samuel R. Friedman, Jo L. Sotheran, and

Rand Stoneburner


Through April 29, 1987, there were 3,464 cases of AIDS among

intravenous (IV) drug users in New York City. There were an

additional 201 cases of AIDS among persons who did not inject drugs

themselves but were heterosexual partners of IV drug users, and 154

cases in children of IV drug users (New York City Department of

Health, 1987). These 3,825 cases in which IV drug use was involved

as a potential source of HIV infection account for 38 percent of the

10,116 cases in the City through that date. The number of cases of

AIDS among IV drug users in New York City is roughly comparable to

the total number of cases in San Francisco and is approximately three

quarters of the total number of cases in Europe.

In addition to the current cases, approximately 50 percent (Marmor et

al., 1987) of the estimated 200,000 IV drug users in New York City

(New York State Division of Substance Abuse Services, unpublished

data) have been exposed to human immunodefeciency virus (HIV). Given

the estimates that from 20 to 50 percent of HIV-exposed persons will

develop AIDS (National Academy of Sciences, 1986), the number of new

cases will be increasing for the next several years.

Table 1 shows the (self-reported) sexual orientation and ethnic

composition of the adult IV-drug-use AIDS cases in New York City.

Male homosexual IV drug users are undoubtedly overrepresented among

the AIDS cases. Based on our studies in New York, we would estimate

that only 5 percent of IV drug users regularly engage in homosexual

activity (Marmor et al., 1987)

Table 1. Sexual orientation and ethnicity among IV drug users

with AIDS in New York City


Sexual Orientation/ethnicity Number Percent


Sexual Orientation

Heterosexual Male 2,365 68

Female 628 18

Homo/bisexual Male 469 14


Total 3,462 100


Black 1,540 44

White 626 18

Hispanic 1,289 39

Other/Unknown 7 -


Total 3,462 99

Ethnicity (Homo/bisexual

Males Excluded)

Black 1,383 46

White 437 15

Hispanic 1,167 39

Other/Unknown 6 -


Total 2,993 100

Females are under represented among IV-drug-use AIDS cases, even if

the male homosexual cases are removed. Based on data from heroin

users entering treatment in the City, 27 percent of the IV drug users

are female (Des Jarlais et al., 1984). After removing male

homosexual IV drug users, females account for only 21 percent of the

AIDS cases among IV drug users in New York. No studies of HIV

exposure among IV drug users in New York show a significantly lower

seropositivity rate among females, so it is unlikely that the

underrepresentation of females is the result of differences in

exposure. The underrepresentation of females among the AIDS cases

may be the result of a possible gender-related cofactor in the

progression of HIV infection (Des Jarlais and Friedman, in press).

There is also underrepresentation of non-Hispanic whites among the

IV-drug-use AIDS cases in the City. Based on the entry-into-

treatment data, non-Hispanic whites comprise 25 percent of the IV

drug users in the City (NYSDSAS, unpublished data). Two studies

(Schoenbaum et al., 1986; Mamor et al., 1987) have shown higher HIV

seropositivity among blacks and Hispanics in the City, so that the

underrepresentation of whites among the cases probably reflects HIV

exposure rates and underlying patterns of association within the

ethnic groups.


The social organization of the IV-drug-use subculture in New York is

a good starting point for understanding the economic forces and

interpersonal relationships involved in the sharing of drug injection

equipment. This social organization contributed to the rapid spread

of HIV among IV drug users in New York and provides the framework in

which AIDS risk reduction among IV drug users will operate.

Because there are very few formal organizations of IV drug users,

there is a common misconception of IV drug users as not organized. A

multibillion-dollar industry does not persist over time without

social organization. Sociologists and anthropologists have

conceptualized the organization of IV drug users as a "deviant

subculture" (Des Jarlais et al., 1986; Agar, 1973; Johnson and

DeHovitz, 1986) with shared values, a common argot, and rules for

allocating status. The primary value is "getting high," and the

primary basis for having high status within the group is the ability

to obtain and use large quantities of high-quality drugs while

minimizing adverse social, legal, and health consequences of such

drug use.

There is strong, often brutal, competition within the IV-drug-use

subculture. There is competition for customers among persons

distributing the illicit drugs for injection, and conflict of

interest between dealers and customers over the price and quality of

the drugs being sold. Among IV drug users, there is competition for

the money needed to purchase drugs, for the very limited supply of

drugs, and sometimes even for the equipment needed to inject the

drugs. The illegal status of the drugs keep prices high, reinforcing

economic competition and often leading to a reliance on illegal

methods of obtaining money to purchase drugs. The illegal nature of

IV drug use also leads to a reliance on threatened or actual violence

as a means for resolving disputes.

The IV-drug-use subculture would not be able to persist over time

without some positive social relationships to balance the

mistrusting, often violent, interactions associated with the illegal

nature of IV drug use. There is some degree of common identity as

persons allied against "straight" (conventional) society. This

encourages the sharing of information about drug availability,

actions of the police, and new developments that affect the group.

This sharing of information is almost totally oral, with very little

communication through written or broadcast material. The oral

information network often spreads inaccurate news but is efficient

enough to maintain the substantial economic scale of IV drug use in

the United States, Europe, and several developing countries.

The primary positive social relationship with the IV-drug-use

subculture is the small friendship group. The high price/limited

supply of drugs make it effective for many users to work together in

pairs or small groups to obtain money and drugs. Teamwork provides

more opportunities for obtaining money and protection against others

who might use force against one. Sharing resources within a

friendship group provides a greater likelihood that an individual

drug user will be able to obtain drugs on any given day.

The social structure of the IV-drug-use subculture promotes the

sharing of equipment for injecting drugs in two ways: (1) the ethic

of cooperation within small friendship groups is applied to the

sharing of equipment for injecting drugs; and (2) a refusal to share

drug injection equipment within the small friendship group (without a

socially legitimate reason) would call into question the reliability

of the person with respect to other cooperative actions within the


Limited supplies of drug injection equipment can also lead to sharing

between casual acquaintances or complete strangers. Legal

restrictions on the sale of needles and syringes, refusal of

pharmacists to sell them even when they are permitted to do so, and

laws against the possession of narcotics paraphernalia all serve to

reduce the availability of sterile equipment for injecting illicit

drugs. Even when there is no legal restrictions on drug injection

equipment, sterile equipment is often not available at the times and

places where IV users want to inject.

Persons who have drugs to inject but do not have injection equipment

readily available may borrow equipment from acquaintances, sometimes

in trade for small quantities of the drug. Such sharing contains

elements of both social solidarity and economic cooperation.

The widest sharing occurs through the use of "shooting galleries" or

"house works." Shooting galleries are places where one can rent drug

injection equipment for a small fee (typically $1 or $2 in New York

City). After use, the equipment is returned to the proprietor of the

shooting gallery for rental to the next customer. The needle and

syringe are used until they become clogged or the needle becomes too

dull for further use. Shooting galleries are typically located in or

near "copping areas" (places where illicit drugs can be easily

purchased). "House works" are an extra set of drug injection

equipment that a small-scale "dealer" (drug distributor) will

maintain for lending to customers. These works are then returned to

the dealer for lending to the next customer who may want to borrow


Both shooting galleries and house works provide the opportunity to

inject very soon after the drugs have been obtained. This temporal

proximity may be a critical obstacle to reducing the sharing of drug

injection equipment. Addicted heroin users often have entered

withdrawal by the time they obtain their next dose of the drug (the

duration of action of injecting heroin in an addicted person is

typically 4 to 6 hours). Through classical conditioning, the

possession of heroin can itself trigger withdrawal symptoms in a very

experienced heroin user (Wikler, 1973). Withdrawal from heroin is

not life threatening but is extremely unpleasant both physically and

psychologically. Relief from distress is almost instantaneous with

the injection of heroin. IV drug users report that almost all of

them will use whatever injection equipment is readily available when

possessing heroin and experiencing withdrawal (Des Jarlais et al.,


Although shooting galleries and house works provide injection

equipment near in time to obtaining drugs, they unfortunately lead to

the sharing of equipment with large numbers of anonymous other IV

drug users. This breaks the limited protection that would occur if

sharing drug injection equipment were confined to friendship groups.

Prior to concern about AIDS, the sharing of drug injection equipment

was normal behavior among IV drug users. There were multiple reasons

for sharing, from the social norms within small friendship groups to

greater availability of used equipment when a person had drugs to

inject. While there were was some concern about hepatitis, there

were no overriding reasons not to share drug injection equipment.

In addition to the social and economic considerations surrounding the

sharing of drug injection equipment, the number of persons who want

to inject drugs and the availability of drugs to be injected

obviously affect the frequency of drug injection, and, prior to

awareness of AIDS, the frequency of sharing drug injection equipment.

New York City, along with the Unites States as a whole, experienced

an epidemic level increase in heroin injection during the late 1960s

and early 1970s. During the middle 1970s, there was a general

community reaction against heroin injection that reduced recruitment

into drug injection. Production was essentially halted in the

Turkish opium fields during this time, leading to very poor quality

heroin available in New York and lower frequencies of drug injection

among persons with histories of drug injection (Des Jarlais and

Uppal, 1980). Persons who had become confirmed heroin users often

injected heroin on an irregular basis during the middle 1970s,

interspersing a wide variety of non-injected-drug use with their

injections of heroin (Johnson et al., 1985). During this time, there

was an estimated 200,000 IV drug users in New York City.

During the late 1970s, the production of opium is Southwest Asia

(primarily Iran, Pakistan, and Afghanistan) greatly increased,

leading to much greater availability of heroin in New York City

(Frank, 1980). There was some recruitment of new heroin users,

maintaining an estimated number of 200,000 heroin injectors in the

city during the early 1980s. The primary use of this increased

heroin, however, was by previous heroin injectors, who increased

their frequency of injection.

Shortly following this increased availability of heroin, there was a

substantial increase in the popularity and availability of cocaine.

This was, of course, not confined to New York City, but was a

nationwide phenomenon. Unfortunately for the coming AIDS situation,

persons in New York with a history of injecting heroin preferred to

use cocaine by injection, often combining with heroin in a

"speedball." This cocaine epidemic may have severe consequences for

the spread of HIV since, at present, we have no wide-scale treatment

program to reduce cocaine injection among those addicted to cocaine.

Additionally, many heroin IV users inject cocaine on an infrequent

basis and see no reason to eliminate this use of the drug.


HIV was probably introduced into the IV-drug-use group in New York

City during the middle 1970s. The first physical evidence of HIV

infection comes from three maternal-transmission pediatric AIDS

cases. In 1977, three children who developed AIDS were born to

mothers who were IV drug users (New York City Department of Health,

1987). Historically collected sera from IV drug users in New York

show the first seropositive sample from 1978 (Novick et al., 1986).

Men who engaged in homosexual activity as well as injecting drugs

appear to have been the bridge group to spread the virus from

homosexuals who did not inject drugs to heterosexual IV drug users.

The first cases of AIDS in New York have been retrospectively

diagnosed as occurring in 1978, with the first cases in IV drug users

appearing in 1980 (Novick et al., 1986). There were 10 cases of drug

of AIDS among IV drug users in 1980, of whom 4 also reported male

homosexual activity as a risk factor (New York City Department of

Health, 1987). Approximately 5 percent of male IV drug users in New

York report regular homosexual activity (Des Jarlais, in

preparation), so that 4 of 10 cases is a great overrepresentation.

Male homosexual activity has also been shown to be associated with

HIV exposure among male IV drug users in Manhattan, independent of

drug use behavior (Marmor et al., 1987)

Once HIV was introduced into the IV-drug-use group in New York, there

was a rapid spread of the virus among active users. The historically

collected serum samples from Manhattan show over 40 percent

seropositivity in 1980. In the three studies of risk factors for HIV

seropositivity that have been reported from the New York area (marmor

et al., 1987; Schoenbaum et al., 1986/Selwyn et al., 1986; Weiss et

al. 1985), two factors were often associated with exposure to the

virus. Frequency of drug injection was associated with

seropositivity in all three studies (the more frequently a drug user

was injecting, the more likely he or she was to share equipment with

someone who could transmit the virus). The use of shooting galleries

(places where one can rent drug using equipment) was associated with

seropositivity in the Manhattan (Marmor et al., 1987) and Bronx

(Schoenbaum et al., 1987) studies.

The rapid spread of HIV among IV drug users in New York is thus

likely to be a result of three factors. A relatively large number of

homosexual men who injected drugs and shared equipment with

heterosexual IV drug users provided multiple entry points for the

virus into the IV-drug-use group. The increasing availability of

heroin and cocaine in the late 1970s led to a general increase in

drug injection--and associated sharing of equipment--just after the

virus had been introduced into the area. Finally, the use of

shooting galleries permitted rapid dissemination of the virus across

friendship groups.


Despite the popular conception that IV drug users have no concern for

health, there is consistent evidence that the majority of IV drug

users in NEW York have changed their behavior in order to reduce the

risk of developing AIDS. Data we collected from IV drug users in

1983 (Des Jarlais et al., 1986) and 1984 (Friedman et. al., 1987)

indicated that essentially all IV drug users in New York City were

aware of AIDS by the middle of 1984, and that over half of them were

reporting some form of risk reduction. Data collected in 1985 by

Selwyn and colleagues again showed essentially universal knowledge of

AIDS and its transmission through the sharing of injection equipment.

Over 60 percent of the subjects in the Selwyn study reported changes

in drug injection behavior undertaken to reduce the risk of

developing AIDS (Selwyn et al., 1986).

In both our and the Selwyn et al. studies, the two most commonly

reported forms of risk reduction were increased use of (illicitly

obtained) sterile injection equipment and a reduction in the number

of persons with whom the subject would share injection equipment.

Approximately one-third of the subjects in the studies reported each

of these methods of AIDS risk reduction. Reduction of drug injection

was a much less common form of behavior change, reported by less than

20 percent of the subjects in the studies. The Selwyn study

specifically asked about sterilizing used drug injection equipment.

Very few subjects--less than 4 percent--reported this type of AIDS

risk reduction.

Evidence for the validity of these self-reported behavior changes

comes from findings of better immune system status in those

seropositives reporting AIDS risk reduction (Friedman et al., in

press(b)) and from studies of the marketing of illicit sterile

injection equipment in New York. There was a great increase in the

demand for illicitly obtained sterile injection equipment in 1984-85

in New York City (Des Jarlais et al., 1985). The demand became

strong enough to support a market for "counterfeit" sterile injection

equipment, something that had never occurred prior to AIDS in New

York. (The counterfeit equipment consisted of used needles and

syringes that were rinsed out and placed in the original packaging,

which was then resealed. Careful inspection of these needles and

syringes could usually detect the resealing).

These risk reduction efforts by IV drug users occurred prior to any

formal AIDS prevention programs established by health authorities,

and indicated spontaneous change occurring within the IV-drug-use

subculture in New York around the dangers of sharing drug injection

equipment. The risk reduction reported in these studies should not,

however, be seen as risk elimination. Increased use of illicitly

obtained sterile equipment does not imply exclusive use of that

equipment--the situation in which an IV drug user is undergoing

withdrawal appears to lead to a willingness to use whatever injection

equipment is handy. Reduction in the number of persons with whom one

is willing to share equipment will often not be extended to persons

with whom one has a close personal relationship (Des Jarlais et al.,

1986). The reduction typically involves refusing to share drug

injection equipment with strangers, casual acquaintances, and,

especially, persons who "look sick" (Sotheran et al., 1987).

There is also the possibility that some of the efforts to use "clean

needles" will not be effective. The methods of cleaning drug

injection equipment prior to AIDS were primarily used to prevent

blood from clogging the needle and syringe. Thus, they were

associated with extended and likely multiple-person use of the

equipment. In none of the studies of HIV-exposure risk factors was

cleaning injection equipment associated with avoiding exposure to the



At present, there are a number of AIDS prevention efforts aimed at IV

drug users in New York City. These include telephone hotlines.

pamphlets and posters, education conducted within treatment programs,

additional drug treatment capacity, and face-to-face education

conducted by trained ex-addicts for IV drug users who are currently

not in treatment. [These, as well as prevention programs in other

areas, are reviewed in Friedman et al. (in press (a))].

It is clearly much too early to assess the effectiveness of these

AIDS prevention programs, but some preliminary observations can be

made. With respect to informing IV drug users about the basics of

AIDS, the data cited above indicated that this basic information has

been widely disseminated. The current posters, pamphlets, and basic

education programs should therefore be assessed in terms of their

repetitive effects. The parallel would be advertising, where

repetition is used to create a persuasive effect rather than

informative effect.

As a response to the AIDS epidemic, 3,000 new drug abuse treatment

positions are being opened. These are in addition to the 500

additional treatment positions opened over the last few years. The

500 positions have been filled, and there are still waiting lists of

approximately 1,000 persons seeking drug abuse treatment in the City.

Nevertheless, it does not appear likely that enough new treatment

programs can be opened in time to have a large-scale effect on the

spread of HIV through the sharing of drug injection equipment in the

City. (There is currently no treatment for injected cocaine abuse

that could be applied nationally on a large scale.) This means that

the immediate reduction in IV-drug-use transmission will have to be

made by reducing the sharing of nonsterile drug injection equipment.

The face-to-face education programs and many of the pamphlets being

distributed include information about how to sterilize previously

used drug injection equipment. This information appears to be well

received and greatly needed by current IV drug users. Data from a

1986 study of IV drug users in treatment indicate that there is still

considerable ignorance among IV drug users about how to clean drug

injection equipment in a manner that kills HIV (Sotheran et al.,

1987). When the subjects were asked, "What is the best way to clean

your works?" only 69 percent mentioned ways that might inactivate HIV

if done correctly (boiling, soaking in bleach, or soaking in a high

concentration of alcohol). Only 8 percent mentioned the use of

bleach, which may be the most effective and convenient method of

sterilizing drug injection equipment.

In addition to the lack of knowledge among these IV drug users, the

subjects who were injecting the most frequently were also those who

were least likely to know proper sterilization techniques.

Apparently, knowledge of these sterilization techniques were

disseminated primarily from drug abuse treatment personnel to IV drug

users in treatment (Sotheran et al., 1987). The persons with the

highest level of recent drug injection were those who had been in

treatment for the shortest length of time *Abdul-Quader et al., 1987)

and, perhaps, were those who were less likely to have formed positive

relationships with treatment staff. Thus, the IV drug users most in

need of the knowledge of how to sterilize drug injection equipment

properly were the least likely to have this information.

The two face-to-face ex-addict AIDS education programs in New York

are currently providing information on how to properly sterilize drug

injection equipment. One of the programs (ADAPT) has started to

distribute bleach and alcohol in order to provide current IV drug

users with a relatively easy means of sterilizing injection

equipment, and the other program is considering this also.

(Implementation of this has been delayed by considerations of

liability if Government funds were used to provide for the

distribution of bleach for sterilizing drug injection equipment.)

The degree to which dissemination of information and/or means for

properly sterilizing drug injection equipment will lead IV drug users

to sterilize used equipment remains to be seen. The current best

estimate from the ex-addict education programs is that no more than

10 percent of active IV drug users are sterilizing equipment that has

previously been used by another person (Mauge, 1987). This would

represent a significant improvement over the 4 percent found in the

Selwyn et al. (1986) study, but clearly is not sufficient to halt the

spread of HIV among IV drug users in the City.

Barring a dramatic breakthrough with respect to increased use of

proper sterilization techniques, IV drug users must have easy access

to noncontaminated injection equipment if the spread of HIV among

continuing IV drug users in NEW York is to be contained. The

difficulties in relying upon an illicit distribution system for a

significant reduction in the spread of HIV have led to calls by a

number of public health officials for increasing the legal

availability of sterile injection equipment. The New York City

Department of Health has proposed an experimental study of a needle

exchange for IV drug users. This modeled after the system in

Holland, in which drug users return used injection equipment and then

are given new, sterile equipment at no charge. This proposal has the

support of the mayor but has not received approval at the State

government level.


A final comment on the current AIDS prevention programs in New York

City concerns apparent "contradictions" between the different

efforts. Teaching IV drug users how to sterilize equipment--and

actually providing sterile equipment to them--have been opposed by

some (often police agencies) as "encouraging" IV drug use. Based on

current data from the face-to-face education programs, there appears

to be no contradiction between teaching IV drug users how to

sterilize drug injection equipment and reducing IV drug use. As part

of the AIDS education process, many of the drugs users realize that

they continue to be at risk for AIDS when they are in a state of

strong physical dependence on drugs. These drug users ask for and

receive referrals for expedited entry into treatment programs (Mauge,

1987). Thus, nonjudgmental programs for AIDS risk reduction--

programs that do not tell an IV drug user that he or she must stop

injecting drugs--appear to be "discouraging" rather than

"encouraging" IV drug use.

The situation with respect to AIDS prevention among IV drug users is

changing rather rapidly, as the public concern over IV drug users as

a "bridge" to generalized heterosexual transmission grows. New

prevention efforts are likely to be established. Attempts will also

be made to evaluate the effectiveness of many of these prevention

efforts, although historical change during the time in which a

prevention program is studied will make interpretation of findings



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Preparation of this paper was supported by grant R01-DA03574 from the

National Institute on Drug Abuse.


Don C. Des Jarlais, Ph.D. Samuel R. Friedman, Ph.D.

NYSDSAS Jo L. Sotheran, M.A.

55 West 125th Street, 10th Floor Narcotic and Drug Research, Inc.

New York, NY 10027 55 West 125th Street, 10th fl.

New York, NY 10027

Rand Stoneburner, M.D., M.P.H.

New York City Department of Health

123 Worth Street

New York, NY 10013



This information is in the public domain and may be copied without

permission. Citation of the source is appreciated.

Needle Sharing Among Intravenous Drug Abusers: National and

International Perspectives

NIDA Research Monograph 80

DHHS Publication No. (ADM)88-1567

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