Changes of consciousness and the risk of sexual contamination
by Dr Kemal Cherabi
Public health specialist
Institut de médecine et d'épidémiologie africaine
mspimea@

The abuse of psychotropic substances may increase the risk of HIV infection via the sexual pathway. Unfortunately, very few studies have been carried out so far on the link between drug abuse and sexual contamination. Nor have any preventive campaigns apparently been carried out so far on this specific point.

The connection between illicit drug abuse and HIV transmission via the sexual pathway is more difficult to assess and to prevent than the risks associated with needle-sharing.

It is common knowledge that drugs and HIV infection are closely interconnected, since the HIV virus can be transmitted by injecting psychoactive products with infected syringes. This situation arises in those countries where injection is the main mode of drug consumption. Does this mean that there exist no other links between the abuse of drugs of all kinds and the risk of contamination? Certainly not. But the link between the abuse of alcohol, for instance, and the risks involved (those run by the drivers of motor vehicles, in particular) is perfectly obvious and leads to the adoption of preventive policies, whereas little has been done so far to explore what can be done to promote awareness of the link between the abuse of psychotropic substances of all kinds and the tendency to have unprotected sexual intercourse. The connection between illicit drug abuse and HIV contamination via the sexual pathway is certainly much more difficult to assess and to prevent than the risks involved in the sharing of syringes.

People who take drugs can suffer from psychological disturbances such as changes of mood, difficulty in concentrating, anxiety, which affect their behaviour, especially in the context of the social exclusion to which drug abuse can lead. Some drug consumers become generally rather negligent, which increases the risk of transmission of sexually transmissible diseases (STDs), including AIDS. People's perception of the risk itself seems to change when they are under the influence of these substances. In an exploratory study carried out in Senegal, Kenya and South Africa, Bjorn Franzen, a consultant with the UNIDCP West African Office (1), reported that condoms were not being properly used, if used at all by drug abusers. The male inhabitants of these countries were already rather reluctant to use condoms, and this tendency was exacerbated by the use of drugs.

A study carried out by IREP (Institute for Epidemiological Research on Pharmacodependency) (2), has shown that the current tendency for drug addicts to go in for multidrug abuse, including amphetamines* and cocaine derivatives, is associated with an alarming increase in the incidence of sexually transmissible diseases, especially among women. In some parts of the United States, the combined use of heroin and cocaine (speed ball*), like the use of cocaine alone, increases the risk of HIV transmission (3). Drug consumers who take mixed substances, which have stronger behavioural effects, are thought to be more highly exposed to the risk of HIV infection because they tend to have more frequent unprotected sexual contacts.

It has been reported that in the United States, the incidence of STDs, including HIV infection, has increased due to the occurrence of genital ulcers among the crack consumers. This is probably due to the high rate of prostitution and the lack of individual protective measures. Since crack* is taken in frequent doses at short intervals, it weakens the ability of female prostitutes to negotiate the use of condoms with their clients. In addition, the results of a recent study published by IREP have shown that these processes involving both prostitution and the use of crack are now developing in many of the world's large cities (4).

The tendency to take sexual risks does in fact seem to be due to the effects of these products, although they all have different properties and psychoactive effects. Some studies have been carried out at the international level (5) with a view to explaining risk behaviour in terms of the side effects, as follows: "some drugs depress the central nervous system, whereas drugs such as cocaine, crack and amphetamines not only stimulate the central nervous system but also have anesthetic side effects".

Kall et al (6) have pointed out that the use of various drugs affects HIV transmission in different ways. It emerged from this study that local cultural differences as far as drugs and drug-related sexual behaviour are concerned probably lead to variations in the way in which HIV infection spreads, depending on the population of drug injecters under consideration. As established in a study by Hudgins et al (7), cocaine injecters run a higher risk of being contaminated with the HIV virus than heroin injecters, not only because they inject the drug more frequently, but also because they have more regular sexual contacts.

In their study on the use of amphetamines, Darke et al (8) concluded that this is a more sociable and public practice than the consumption of heroin; whereas heroin abuse is a more solitary practice, which takes place in a more personal, private context. In addition, amphetamine abusers are more active sexually than heroin addicts, and the latter group also tend to be older. The abuse of amphetamines, combined with the social aspects of this practice, may therefore lead to a higher level of exposure to the HIV virus (9).

Based on neurobiological studies, all emotions, pleasure and enjoyment are known to involve a complex mechanism. The interactions occurring between some neurotransmitters such as dopamine, endorphines, sexual hormones, etc. trigger a set of pleasure reactions in the brain.

The active ingredients of some drugs affect these chemical fluxes, especially those involving dopamine, and can exacerbate sensations of pleasure and enjoyment and even prolong the sexual act. In a study published by UNIDCP (10), health professionals working in subSaharan Africa reported that drug users often declared that they consumed cocaine and its derivatives mainly in order to improve their sexual performances.

Virtually no efforts have been made so far to prevent the risks of STD and HIV contamination via the sexual pathway linked to the use and abuse of licit and illicit drugs. And yet the few existing studies on this topic have shown that complex correlations of this kind definitely exist in many cases. Research has been carried out on these lines in a few North American and Western European countries only. It is now vital to extend the geographical scope of these studies in order to determine the effects of contextual factors on the risk behaviour of drug abusers, whatever the legal status of the drugs involved may be. The consumption of alcohol, for example, can have surprisingly strong effects (see the accompanying diagram) on the rate of sexual contamination.

The changes of consciousness induced by drugs may not of course entirely explain this rate of contamination, since age, the social and economic context, the social and cultural background, the level of education and social exclusion also have to be taken into account. However, the fact that the contribution of drug abuse to contamination with the HIV virus and AIDS has not yet been properly assessed should not discourage those responsible for prevention from informing people about the changes which affect drug abusers' state of consciousness and the resulting behavioural effects. The injecters of heavy drugs have already proved that taking psychotropic substances is not incompatible with adopting behaviour which is conducive to good health, since they have stopped sharing their syringes in many countries.

In setting up preventive campaigns to inform the consumers of legal and illicit drugs about these matters, it is essential that social science research workers and public health specialists should combine their efforts to devise preventive programmes based on what is known about the effects of the various products, the cultural factors associated with their modes of consumption and the level of sociability associated with the practices in question, both before and afterwards.

1 Bjorn Franzen, "Substance abuse ..... in Sub-Saharan Africa (et non African)...

2 IREP

3 Neil McKEGANEY, AIDS in Europe 1998, p.81-91 4 Toufik A., Du crack au VIH, Journal du SIDA 1995, p.75 76:22

50 Siegal et al., Sexually transmitted diseases, 23(4): 277282 and Hudgins et al., Cocaine use and risky injection and sexual behaviors. Drug and Alcohol Dependence, 37:7-14

6 Kall et al., Aids Care 1995, p.171 7 Hudgins et al. 1995, p.171

8 Darke et al., Injecting and sexual risk behaviour among regular amphetamine users, AIDS Care , 7 (1) :19-26

9 Neil McKeganey, University of Glasgow. 10 Bjorn Franzen, op. cit.