The Risk of HIV Transmission from sharing water, drug mixing containers and cotton filters among intravenous drug users

STEPHEN KOESTER, Ph.D., ROBERT BOOTH, Ph.D., University of Colorado School of Medicine

WAYNE WIEBEL, Ph.D., University of Illinois School of Public Health.

The sharing of hypodermic syringes is the most likely route of HIV transmission among intravenous drug users. Data gathered from focused interviews with intravenous drug users in Denver suggests that drug users may inadvertently transmit the virus by sharing water and other items in their drug injecting kit as well. The succession of steps in which water is shared may place users at risk even when they have their own syringes and clean their syringes with bleach.

The second wave of the HIV infection is well established and growing in the United States. Intravenous drug users account for 21% of all AIDS cases (Centers for Disease Control, 1990) . Among American women with AIDS, 53% have injected drugs and another 20% have male sexual partners who are IVDU's (National Institute on Drug Abuse, 1989), and intravenous drug use is the single most significant risk factor for AlDs among African Americans (Centers for Disease Control, 1989). In several northeastern cities the doubling time for AIDS cases among drug injectors has been estimated to be between 5 and 6 months (Kaplan 1989).

As communities mobilize to halt the spread of HIV among intravenous drug users, many are relying in part on an intervention model that stresses a "Don't Share Your Needle" message and its corollary, "If you do share, use bleach" (Friedman et al. 1989, Newmeyer 1988, Newmeyer et al. 1989, Wiebel 1988). More recently, some American communities have initiated needle exchange programs similar to those in Europe and Australia. All of these efforts focus on the syringe since it is the most likely mechanism of HIV transmission among intravenous drug users; small amounts of blood remain in the syringe and its needle after injection (Marmor et al. 1989).

Ethnographic fieldwork among intravenous drug users in Denver and discussions with AIDS prevention outreach workers indicate that the "Don't Share" message needs to be extended to include other items in the drug user's injecting kit. Information provided by users shows that additional aspects of drug preparation and use may compromise the effectiveness of a prevention effort that only stresses the "do not share your syringe" and "use bleach" messages. It is our hypothesis that the succession of steps common in drug reparation and injection leaves users at risk of contracting HIV.

Accordingly, we argue that more emphasis needs to be placed on educating drug injectors about the danger of using water, cookers or spoons and cottons that have been used by someone else. The most likely point of contamination besides the sharing of an unclean "fit" (syringe) may be the sharing of water. It is very common for a group of users to share a container of water even if they have their own syringes. If an HIV positive user injects and then places his or her syringe in this water before cleaning it with bleach the water may become contaminated. A small quantity of blood enters the water each time a user dips a just-used needle in it.

Methods

Focused, open ended interviews were conducted with 40 actively using drug injectors in three racially distinct Denver neighbourhoods. White, Hispanic and black users were interviewed. All three primary drugs used intravenously were represented (heroin, cocaine and methamphetamine). Participant observation on the part of the project anthropologist and outreach workers enabled us to describe the steps in drug preparation and syringe rinsing, and led to the conclusion that current cleaning efforts were often inadequate. Data collected from NIDA's GAIA questionnaire added quantitative support for our conclusions.

Results

Ethnographic research in Denver indicates that high risk drug preparation activities are common and that the sharing of water, cookers and cottons is widespread. The results of structured interviews with intravenous users in Denver (total N=280) indicate that over 75% of those questioned shared rinse water (N=213). Of these, 47% indicated that they shared their rinse water more than half the time (N=132). Data compiled from interviews with 418 active drug injectors found that sharing a cooker was the most common of all sharing activities: 84% indicated they shared cookers (N=350), including 46% who did so more than half the time (N=192).

Perhaps even more telling were the findings noted among those who appeared to have practised safe needle activities, either through the exclusive use of new needles (N=35) or because they cleaned their needles with boiling water, bleach or alcohol every time they injected (N=52). Of these, 40% of the former group and 85% of the latter reported sharing a cooker. Thus, use of sterile needles, either through effective cleaning or injecting only with new needles, does not indicate risk-free injecting behaviour.

Ethnographic Findings & Discussion

Virological studies indicate that HIV can survive in tap water for an extended period (Resnick et al. 1986); the virus has survived in water at room temperature for over one week (Barre-Sinoussi et al. 1985). As a result, the sharing of water may be an effective mechanism for viral transfer. The likelihood of transmission would probably depend on the quantity of virus exchanged and this would depend in part on the amount of HIV positive blood in the water. In abandoned buildings where users frequently inject, we have observed water in shared containers that has actually become pink from the number of needles placed in it. The chance for infection through shared water is probably less than the risk from sharing an unclean syringe, but since the minimum dose for infection is unknown, we must suggest that users do not share any items in their drug injection kit.

Intravenous drug users require water for two purposes: to rinse the syringe and to mix with the drug (heroin, cocaine, methamphetamine or a pharmaceutical drug) in order to liquefy it for injection. The danger from sharing water is that users frequently rinse their syringes in it immediately after injecting and before they use bleach. They draw water up and then squirt it out; this procedure is repeated two or three times. The purpose of this rinse is not hygienic; it is simply to make sure the syringe does not become clogged with blood and drug residue so that it can be used again. Anyone who uses the water after someone else has rinsed is using water contaminated with the previous user's blood. As one user explained:

"People don't clean their works before they shoot dope, they clean them afterward, and they clean them out of the same cup of water that everybody is using. So, while somebody is rinsing their syringe out in a cup of water, another person is pulling water out to put into their spoon to cook their dope in".

In this case, the user pulling water out to mix his or her drug is withdrawing water that has been contaminated by previous users who have already injected and placed their "dirty" needles in it. This water will then be used to liquefy the drug and it will be injected. As a result, it could contaminate every item that makes up the user's injecting kit, including the spoon or cooker, the "cotton" and the syringe.

What is particularly alarming about this scenario is that it could lead to possible infection even if separate syringes are used or even if users clean a shared syringe with bleach. As another user commented:

"There was times when everybody had to use the same water, or everybody had to use the same spoon. Not the fits so much, but see, it's not only the fits, because you are touching the fit with everything that you use".

The possibility for infection from contaminated water also exists in situations where bleach is used to clean a shared syringe. tinder this circumstance, bleach will only be effective if, immediately after injecting, the user cleans the syringe with bleach. This must be performed before the user places the just-used syringe in the water. Yet some users who are currently using bleach indicated that this was not their normal practice. They explained that a post-injection rinse with water is almost "automatic" and that the responsibility for cleaning with bleach really belongs to the person who follows them. As a result, this second user ends up using contaminated water to rinse the syringe after he or she has cleaned it with bleach. This notion that the responsibility for cleaning a syringe belongs to the borrower and not the lender conforms to the belief among street-based users that they can really only trust and rely on themselves.

Discussions conducted during the course of field work with active IV drug users in Denver indicate that many of them were unaware that this practice placed them at high risk for transmitting and contracting HIV. They seemed to feel that it was sufficient to simply use bleach. Two women who are intravenous drug users explained that they had changed their needle sharing practices more than a year ago after first learning about the danger. They began reducing the number of times they shared needles and they began using bleach whenever they did share. What they did not do is equally significant however; they did not discontinue sharing rinse water and they admitted to putting their needles in this water after others had placed unclean syringes in it. They only stopped this high risk behaviour in the last few months after conversations with an AIDS prevention outreach worker.

Sharing other items in the drug injecting kit may also increase the risk of HIV infection. The containers used for mixing the drug and the filters the drug is drawn through are both likely points of contamination. When users purchase a drug together or when they share a drug they often share a common "spoon" and "cotton". This is frequently the case even when they each have their own syringe.

A bottle cap, a spoon, or some other similarly sized container is used for mixing heroin, cocaine, methamphetamine or a pharmaceutical drug with water. Because spoons are frequently used, these containers are often collectively referred to as "spoons". Since heroin is often heated before injection, this container is also referred to as a "cooker". A "cotton" is a filter users place in the "spoon" to draw the drug through. It screens out any undissolved particles that might remain in the drug solution. If unfiltered, these particles could clog the needle. (Some methamphetamine injectors indicated that the filter is unnecessary in preparing methamphetamine because the drug dissolves so completely). This filter is simply a small piece of cotton from a cotton swab, a cigarette filter or even lint from one's clothing. A brief description of how these items are used demonstrates the part they may play in HIV transmission.

When sharing a drug, users frequently mix it up all at once in a common "spoon" or cooker. The cotton filter is then placed into the solution. The drug solution is then drawn through this "cotton into a single syringe. Each individual's share is then measured using the cubic centimeter graduations on the syringe. After it is measured, the drug is then squirted back into the "spoon". Each user then places his or her needle into the "cotton" and draws up his or her share. A single "cotton" is used in order to minimize the amount of drug lost in the filtering process. Often times, after everyone has injected, a user will place the "cotton" or "cottons" in the "cooker" or "spoon", add water and then gently stir with a plunger from a syringe to squeeze out any remaining drug for one additional injection. This procedure is known locally as "beating a cotton".

Sharing "cottons" and spoons or "cookers" increases the likelihood of HIV transmission because it increases the opportunities for the virus to be passed. This danger remains even when separate syringes are used for injection; if a contaminated needle touches these items, the drug solution they contain may become infected. Once infected these items may remain contaminated for an extended length of time, even if the liquid evaporates and the virus dries (Martin et al. 1985). Heating heroin in a cooker may kill the virus; this would depend on both the temperature at which the drug mixture is heated and the length of time it is heated (McDougal et al. 1985).

Some users distribute the drug solution among a drug injecting group through techniques called frontloading and backloading. When frontloading, the drug is transferred from the syringe used for measuring to another syringe by removing the needle from the receiving syringe and squirting the solution into the opening (Grund et al. 1989). This method is not common in Denver because syringes with detachable needles are not readily available to street users. Instead, insulin syringes with non-detachable needles are the easiest to obtain. Users exchange the drug solution between these types of syringes by removing the plunger from the receiving syringe and then injecting the solution into it; this is called backloading. Both backloading and frontloading are potentially high risk drug preparation activities if the donor syringe is contaminated

We make it a point to emphasise to users that they should not share any part of their drug injecting kit. We recommend that users should have their own individual supply of water, as well as their own spoons and "cottons . We explain that, in situations where water is shared, no one should place a syringe in the water unless that syringe is fresh out of the wrapper, or unless it has just been rinsed out with bleach. In addition, we are distributing an AIDS prevention packet to intravenous drug users that includes a clear plastic bottle of bleach, a blue plastic bottle of water and a cotton swab. ADAPT, the street-based AIDS project in New York City is currently distributing similar materials.

Such behavioural changes may appear simple enough, but to someone who is drug dependent they may not be possible. For many, social and economic factors exacerbate the difficulty of changing their drug injecting behaviour (Friedman et al. 1987, Mason 1989, Schoenbaum et al. 1989, Watters 1989). We have found the degree of sharing described here to be particularly prevalent among poor, street-based IV users. These users frequently pool their limited resources by forming temporary partnerships to buy drugs. After buying together they use together. In the process they often share water, spoons and cottons as well as syringes. Sharing these items may also be reinforced by a more general, opportunistically-motivated sharing ethic common to many users (Des Jarlais et al. 1988). In addition, the places people use drugs may also discourage drug using hygiene. Water is unavailable or limited in abandoned buildings, cars and other common injecting sites dimenez 1989).

Conclusion

Only continued and extensive virological testing can determine if the sharing of water and other injecting items provides HS' with probable routes for transmission. In the future, researchers may find that our concern with the minute amounts of virus present in shared water containers, spoon and cottons was an overreaction and that the virus is simply not that virulent. Until then, we urge AIDS prevention projects to educate users about these possible danger and to design intervention strategies to lessen them.

Attempting to encourage less risky drug using behaviour among intravenous drug users requires a thorough understanding « the risks they take. As this paper illustrate the sharing of unclean syringes may only t one of those risks. Drug preparation and injection involve a complex series of steps that may be in9uenced by any number of variables. These variables may include; the type of drug being injected, the kinds of syringes available, and the beliefs and customs of the users, as well as the economic and social factors described above.

To identify and understand potentially high risk behaviour and the variables in9uencing it, we need to conduct detailed field studies of drug users and their world. The "insider" perspective that comes from ethnography provides this needed dimension. As this brief description of how drug injectors share water, cookers or spoons, and cottons, demonstrates, in depth, observational techniques of the ethnographer are particularly well suited for this task.

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ACKNOWLEDGEMENTS

This research was conducted as part of a Naional Institute on Drug Abuse funded project (Contract number 271-87-8208) aimed at reducing high risk behaviour among intravenous drug users. This project is administered through the University of Illinois, Chicago, and.its subcontracted Addiction Research and Treatment Services of the University of Colorado School of Medicine, Department of Psychiatry. Tom Brewster, LCSW, is the Site Director and George Burke is the Outreach Co-ordinator. Project Safe outreach workers; Betty Simmons, Marty Boger, John Peacock and Bill Bass first alerted me to the possible risk of sharing rinse water and they made important contributions to this paper. Dr. Barry Brown of NIDA, Dr. Charh^(. Schable of CDC and Dr. Paul Shankman, University of Colorado, reviewed this article and offered valuable suggestions.