AIDS and Intravenous Drug Use - Sharing Equipment

Drug use can lead to HIV infection, then to AIDS, then to death because drug users share equipment contaminated with infected blood. The equipment involved is the syringe, the needle, the "cooker," cotton, and rinse water used to prevent blood from clotting in the needle and syringe.

The syringe and the needle can become contaminated when infected blood is left behind between uses. This can occur when users draw back their own blood into a syringe and then inject the blood again several times in an attempt to capture and inject all of the drug held in the syringe. This practice, known as "booting," does not occur when users practice intramuscular or subcutaneous injection, known as "skin popping."

Tests have shown that bleach, hydrogen peroxide, and alcohol can kill HIV in a test tube (in vitro). These substances can be effective for cleaning a syringe and needle if the solution fills the syringe completely, but using disinfected syringes and needles is still not as safe as using new, sterile equipment.

The "cooker" is any small container, usually a spoon or a bottle cap, used to dissolve the injectable drug, most often a powder. Contamination may occur when infected blood is pushed out of the needle or syringe into the cooker while a new shot of the drug is being drawn up. If the needle and syringe are effectively sterilized, the cooker will not be contaminated. In the event of cooker contamination, heating the cooker between shots can kill the virus.

Drug users sometimes employ a piece of cotton as a strainer to trap any impurities from the cooker solution. They strain the solution through the cotton as they draw solution into the syringe. Instead of disposing of each piece of cotton immediately after use, a user will sometimes "beat the cotton" with a little

TABLE 9.1
Reported AIDS cases, by sex, age, and transmission category, through 2003
SOURCE: "Table 17. Reported AIDS Cases, by Age Category, Transmission Category, and Sex, Cumulative through 2003—United States," in HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, December 2004, http://www.cdc.gov/hiv/stats/2003SurveillanceReport.pdf (accessed March 31, 2005)

	Males				Females				Total
	2003		Cumulative through 2003a		2003		Cumulative through 2003a		2003		Cumulative through 2003a
Transmission category	No.	%	No.	%	No.	%	No.	%	No.	%	No.	%
Adult or adolescent
Male-to-male sexual contact	15,859	48	401,392	55	—	—	—	—	15,859	35	401,392	45
Injection drug use	4,866	15	156,575	21	2,262	20	61,621	38	7,128	16	218,196	24
Male-to-male sexual contact and injection drug use	1,695	5	57,998	8	—	—	—	—	1,695	4	57,998	6
Hemophilia/coagulation disorder	74	0	5,130	1	11	0	318	0	85	0	5,448	1
Heterosexual contact	3,371	10	40,947	6	5,234	45	70,200	43	8,605	19	111,147	12
Sex with injection drug user	477	1	10,930	1	985	9	24,148	15	1,462	3	35,078	4
Sex with bisexual male	0	0	0	0	223	2	4,402	3	223	0	4,402	0
Sex with person with hemophilia	7	0	80	0	16	0	465	0	23	0	545	0
Sex with HIV-infected transfusion recipient	24	0	505	0	37	0	705	0	61	0	1,210	0
Sex with HIV-infected person,
risk factor not specified	2,863	9	29,432	4	3,973	34	40,480	25	6,836	15	69,912	8
Receipt of blood transfusion, blood
components, or tissueb	111	0	5,219	1	108	1	4,076	2	219	0	9,295	1
Other/risk factor not reported or identifiedc	7,274	22	62,217	9	3,946	34	27,181	17	11,220	25	89,399	10
Subtotal	33,250	100	729,478	100	11,561	100	163,396	100	44,811	100	892,875	100
Child ( < 13 yrs at diagnosis)
Hemophilia/coagulation disorder	0	0	227	5	0	0	7	0	0	0	234	3
Mother with the following risk factor for,
or documented, HIV infection:	61	87	4,232	88	70	85	4,317	95	131	86	8,549	91
Injection drug use	6	9	1,643	34	11	13	1,645	36	17	11	3,288	35
Sex with injection drug user	8	11	784	16	6	7	741	16	14	9	1,525	16
Sex with bisexual male	0	0	95	2	2	2	102	2	2	1	197	2
Sex with person with hemophilia	1	1	21	0	0	0	15	0	1	1	36	0
Sex with HIV-infected transfusion recipient	0	0	11	0	0	0	16	0	0	0	27	0
Sex with HIV-infected person,
risk factor not specified	18	26	705	15	18	22	737	16	36	24	1,442	15
Receipt of blood transfusion, blood
components, or tissue	0	0	73	2	0	0	83	2	0	0	156	2
Has HIV infection, risk factor not specified	28	40	900	19	33	40	978	21	61	40	1,878	20
Receipt of blood transfusion, blood
components, or tissueb	1	1	244	5	1	1	143	3	2	1	387	4
Other/risk factor not reported or identifiedd	8	11	80	2	11	13	98	2	19	13	178	2
Subtotal	70	100	4,783	100	82	100	4,565	100	152	100	9,348	100
Total	33,320	100	734,261	100	11,643	100	167,961	100	44,963	100	902,223	100
a Includes persons with a diagnosis of AIDS, reported from the beginning of the epidemic through 2003. Cumulative total includes							1 person of unknown sex.
b AIDS developed in 46 adults/adolescents and 3 children after they received blood that had tested negative for HIV antibodies. AIDS developed in 14 additional adults after they received
tissue, organs, or artificial insemination from HIV-infected donors. Four of the 14 received tissue or organs from a donor who							was negative for HIV antibody at the time of donation.
c Includes 36 adults/adolescents who were exposed to HIV-infected blood, body fluids, or concentrated virus in health care, laboratory,							or household settings, as supported by
seroconversion, epidemiologic, and/or laboratory evidence. One person was infected after intentional inoculation with HIV-infected blood. For an additional 361 persons who acquired
HIV infection perinatally, AIDS was diagnosed after age 13. These 361 persons are tabulated under the adult/adolescent, not the							pediatric, transmission category.
d Includes 5 children who were exposed to HIV-infected blood as supported by seroconversion, epidemiologic, and/or laboratory evidence: 1 child was infected after intentional
inoculation with HIV-infected blood and 4 children were exposed to HIV-infected blood in a household setting. Of the 178 children, 23 had sexual contact with an adult with or at high
risk for HIV infection.

water in an attempt to extract the tiniest bit of the drug that may be left in it. The cotton can become infected if the syringe and needle have not been properly sterilized.

Syringes and needles are usually rinsed out before reuse, not necessarily to decontaminate them but to prevent clotting blood from blocking the equipment. If the rinse water does not contain bleach to disinfect the instruments, use and reuse of the same rinse water can also be a source of contamination.

When two drug users share equipment, one positive for HIV, one not, and the equipment is not properly sterilized between uses, the infection can pass from the carrier of HIV to the healthy person. Other blood-borne diseases can follow the same pathway, including Hepatitis B and Hepatitis C viruses, which cause liver disease.

HIV infection caused by sharing drug paraphernalia can pass to others through sexual contact, and it can also pass to newborn children through childbirth and breastfeeding.

TABLE 9.2
Estimated number of deaths from AIDS, by selected characteristics, 1999-2003
SOURCE: "Table 7. Estimated Numbers of Deaths of Persons with AIDS, by Year of Death and Selected Characteristics, 1999-2003—United States," in HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2003, Department of Health and Human Services, Centers for Disease Control and Prevention, December 2004, http://www.cdc.gov/hiv/stats/2003SurveillanceReport.pdf (accessed March 31, 2005)

	Year of death
	1999	2000	2001	2002	2003	Cumulative through 2003a
Age at death (years)
< 13	97	51	48	35	29	5,103
13-14	18	8	4	11	8	252
15-24	232	216	270	199	229	9,789
25-34	3,258	2,823	2,512	2,143	1,928	142,761
35-44	7,706	7,138	7,525	6,896	6,970	216,093
45-54	4,994	5,203	5,548	5,737	5,964	104,064
55-64	1,556	1,631	1,873	1,840	2,146	33,717
≥ 65	630	670	743	696	741	12,282
Race/ethnicity
White, not Hispanic	5,834	5,559	5,524	5,128	4,767	230,289
Black, not Hispanic	9,106	8,832	9,345	8,923	9,048	195,891
Hispanic	3,341	3,162	3,435	3,274	3,915	92,370
Asian/Pacific Islander	113	103	108	94	85	3,340
American Indian/Alaska Native	79	67	83	79	78	1,529
Transmission category
Male adult or adolescent
Male-to-male sexual contact	6,703	6,316	6,479	6,012	6,015	257,898
Injection drug use	4,425	4,182	4,298	4,126	4,166	107,797
Male-to-male sexual contact and injection drug use	1,335	1,334	1,396	1,285	1,233	38,083
Heterosexual contact	1,403	1,417	1,585	1,526	1,644	23,080
Otherb	194	204	174	166	140	9,846
Subtotal	14,061	13,454	13,932	13,116	13,198	436,704
Female adult or adolescent
Injection drug use	2,051	1,925	1,985	1,956	2,056	39,848
Heterosexual contact	2,157	2,192	2,444	2,335	2,584	37,901
Otherb	97	92	92	89	95	4,115
Subtotal	4,305	4,209	4,521	4,379	4,736	81,864
Child ( < 13 yrs at diagnosis)
Perinatal	117	72	67	58	78	4,961
Otherc	8	5	4	4	5	531
Subtotal	124	78	71	62	83	5,492
Region of residence
Northeast	5,698	5,294	5,344	5,015	6,140	168,213
Midwest	1,712	1,685	1,839	1,550	1,343	50,258
South	7,406	7,352	7,624	7,526	7,068	178,447
West	2,952	2,681	2,817	2,520	2,588	107,767
U.S. dependencies, possessions, and associated nations	723	729	900	947	877	19,375
Totald	18,491	17,741	18,524	17,557	18,017	524,060
Note: These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. The estimates do not include adjustment for incomplete reporting.
aIncludes persons who died with AIDS, from the beginning of the epidemic through 2003.
bIncludes hemophilia, blood transfusion, perinatal, and risk factor not reported or not identified.
cIncludes hemophilia, blood transfusion, and risk factor not reported or not identified.
dIncludes persons of unknown race or multiple races and persons of unknown sex. Cumulative total includes 640 persons of unknown race or multiple races. Because column totals were calculated independently of the values for the subpopulations, the values in each column may not sum to the column total.