Drug use contexts and HIV-consequences: the effect of drug policy on patterns of everyday drug use in Rotterdam and the Bronx.

Epidemiological data on HIV seroprevalence has been essential in assessing the (future) extent of the AIDS epidemic. By coupling these data with quantifiable variables related to injection drug use (frequency of injecting, number of needle sharing partners) specific 'risk behaviors' could be determined, accounting for the rapid spread of the virus in the injecting drug user (IDU) population. Yet, such data give little information on the social mechanisms and setting generating such risk behaviors. In order to understand the transmission of HIV among the IDU population one needs to study the micro settings and social context of drug use. This paper describes and explores certain patterns of drug use, sharing, and natural support systems found amongst IDUs in two very different cities, Rotterdam (The Netherlands) and the Bronx, New York City (USA). By specifying details of the micro-settings of everyday drug use in both locales, it is possible to identify certain common elements and consequences of personal and social behavior driven by drug use per se (e.g. drug preference), and to differentiate these from behaviors and consequences determined by drug policy and the social context in which drug use actually occurs. These policies and the social context they create can in turn be shown to relate to risks for HIV transmission, e.g. the increased likelihood of sharing injection equipment. A more careful ethnographic approach, taking advantage of natural experimental opportunities, comparisons and controls, may be utilized to examine drug-related behaviors in their social context and to better assess their relevance to public health--especially to AIDS.

Reaching the unreached: targeting hidden IDU populations with clean needles via known user groups.

Needle exchange is a practical and important part of the Dutch prevention strategy to check the spread of HIV among injecting drug users (IDUs). However, needle-exchange programs are often tied to drug treatment programs that only reach a limited number of IDUs. To overcome this limitation, alternative designs are considered and initiated. This article describes a community-based approach to needle exchange that is built on empowerment of, and intense participation by, known IDUs to target unknown IDUs for delivery of clean needles. The needle-exchange patterns of the IDUs participating in this collective scheme are compared to those of other users who exchanged needles on an individual basis. It was found that this approach extended the reach of the program to a great degree and that it was well received in the IDU community. However, the results were negatively influenced by police activities aimed at closing down places where drugs were used and sold. It is concluded that engaging IDUs in peer-group-directed prevention efforts is both feasible and promising.

Needle sharing in The Netherlands: an ethnographic analysis.

BACKGROUND: Needle sharing has been reported to be the main cause of the rapid spread of the human immunodeficiency virus (HIV) among injecting drug users. Risk behaviors such as needle sharing are, however, the end result of complicated interaction patterns in drug user networks, which have their specific rules and rituals, and larger social structures and official drug policy. METHODS: To study these interaction patterns we examined the drug administration rituals of heroin addicts in Rotterdam, The Netherlands. Intensive ethnographic descriptions were collected by participant observation. RESULTS: In less than 10% of the observed self-injections unsafe syringes were used. In 68% of the self-injections new, sterile syringes were used. Needle sharing as a planned sequence was not observed. Sharing was determined primarily by the availability of syringes, experience with the injecting ritual, and drug craving. In all observed needle-sharing events, subjects were aware of the risks involved and undertook efforts to clean the injection equipment. CONCLUSIONS: In contrast to psychological approaches aimed at reducing individual "risk behavior," these findings suggest that HIV prevention can be made more effective if active drug injectors are organized to help themselves and their peers prevent high-risk exchange situations.

Changing cocaine smoking rituals in the Dutch heroin addict population.

Recently the use patterns, circumstances and consequences of cocaine have become of interest to both researchers and policy makers in Europe. Currently only a few studies have been conducted of the social epidemiology of cocaine. In this article, focus is placed upon the use of cocaine in one subpopulation, heroin addicts. Based mainly upon ethnographic research conducted in the city of Rotterdam it can be estimated that the prevalence of cocaine use in this population has reached a very high level. The mode of ingesting cocaine parallels that of heroin; Injecting Drug Users inject cocaine-hydrochloride, heroin smokers smoke cocaine base. This cocaine base is mainly processed by users themselves. An exception to this rule of self-processing can be found in the most marginalized addicts who do not have access to the house addresses where both heroin and cocaine-hydrochloride are sold. In this group the selling of 'cooked cocaine', a crack-like product, has occurred. The circumstances and potential consequences of the emergence of 'cooked cocaine' are discussed.

Drug sharing and HIV transmission risks: the practice of frontloading in the Dutch injecting drug user population.

Injecting drug users may now be the largest group at risk for contracting HIV, mainly through the sharing of drug injection equipment (including lending, borrowing, and renting). This article presents the results of an ongoing ethnographic study into the drug-taking rituals of heroin addicts. A possible additional route of HIV contamination is presented, namely the ritual sharing of drugs through a practice termed "frontloading," which is embedded in a broader pattern of the sharing of resources among addicts. It is hypothesized that in the Netherlands this practice may be responsible for a substantial proportion of HIV spread among injecting drug users.