Through the Commission's hearings and site visits over the last year and a half, the wide range and diverse nature of substance use and the population of substance users has become very much apparent. Substance use problems cross all lines of age, geography, ethnicity and economics. Infants, adolescents and adults, rural and urban, poor and rich – all are affected. Of special concern to the Commission is the importance of recognizing the behaviors that put an individual at risk for exposure to HIV whether or not that individual believes he or she fits into the category of "drug addict." Some high school and college athletes share needles to inject steroids. Individuals from cultures and countries with differing medical practices often share needles to inject vitamins. Practicing these behaviors poses the danger of transmitting and acquiring HIV just as sharing a needle to inject heroin or cocaine does.

The Commission is also deeply concerned by the force with which these twin epidemics have struck communities of color, women, and adolescents. There are significantly elevated rates of HIV infection among blacks and Hispanics compared with whites. The rates of HIV infection related to IV drug use are also growing among women, many of whom do not perceive that they are at risk.

Adolescents are especially at risk. Adolescents, and others, who avoid intravenous drugs still expose themselves to the risk of HIV infection through unsafe sexual behavior during the use of alcohol and other substances. It is important, when considering this issue, to be realistic about when young adults in the U.S. begin having sex. "In 1990, the researchers at the Alan Guttmacher Institute in New York and the Urban Institute in Washington analyzed federally funded surveys of boys and girls conducted in 1988. They reported [that] both boys and girls were more likely to be sexually experienced than those surveyed in the late '70s and early '80s. Half of girls had sex by age 17; half of boys by age 16." The survey also shows that, "...3 out of 4 unmarried 19-year old women and 5 out of 6 unmarried 19-year old men were sexually experienced."

The linkage between sexual behavior and substance use is vividly reflected in the following example from Dr. Robert Johnson of Adolescent Medicine at the University of Medicine and Dentistry of New Jersey:

[O]ur last four adolescents who had heterosexual transmission of the disease all had sexual behavior that was associated with alcohol use, particularly a drug form of 'wine cooler' named Cisco, and these young people who had used condoms in other situations did not use condoms [here]...

Adolescents, and others, are also at risk through the growing practice of trading drugs, especially crack (the smokeable form of cocaine), for sex. Dr. Johnson gave the following example which dramatically illustrates this connection:

One particular crack dealer...in our adolescent clinic in Newark revealed that in the month of August he had sex with 30 different women in trade for crack. In addition, he carried on a sexual relationship with his girlfriend who did not use drugs. All of this activity occurred without the benefit of the protection of condoms. In that month, he and his girlfriend, and his girlfriend's new boyfriend, and his girl friend's new boyfriend's alternative sexual partner, all became infected with gonorrhea and chlamydia.

While much of this, and other substance using activity, is concentrated in urban areas, there has been an increasing trend towards substance use, especially crack, in suburban and rural areas as well. The Commission previously highlighted this trend in its August 1990 report on HIV in rural America. Another disturbing trend, with serious implications for the HIV epidemic, is the resurgence of heroin use in the Northeast.

It can be seen from even this small sample of issues that substance use plays a major role in the transmission of HIV disease – indeed, a much larger role than has been generally recognized. Clearly, our nation's drug control policies must recognize this inextricable linkage between drugs and HIV disease and be designed to address the two aggressively and simultaneously.