Explaining the Geographical Variation of HIV Among Injection Drug Users in the United States

Abstract

Distinct physical and chemical types of street heroin exist worldwide, but their impact on behavior and disease acquisition is not well understood or documented. This article presents a hypothesis to explain the unequal diffusion of HIV among injection drug users in the United States by examining the distribution and use of one type of heroin—“Mexican black tar.” Drawing on ethnographic, clinical, epidemiological, and laboratory data, we suggest that the chemical properties of black tar heroin promote the following safer injection practices: (1) the rinsing of syringes with water to prevent clogging; (2) the heating of cookers to promote dissolution; and (3) a rapid transition from venous injection to subcutaneous or intramuscular injections.

• Black tar heroin
• Geography variation
• HIV
• Risk factors
• Heroin type

Resumen

Aún no se ha estudiado ni documentado adecuadamente la relación entre las distintas composiciones físicas y químicas con que la heroína llega al consumidor mundial y sus métodos de inyección y el contagio de enfermedades. En este trabajo ofrecemos una hipótesis que explicaría la irregular difusión del VIH entre consumidores de drogas inyectables en los Estados Unidos basada en el análisis de la distribución de la heroína tipo “chapopote mexicano.” proponemos, utilizando datos etnográficos, epidemiológicos y de laboratorio, que sus propiedades químicas fomentan métodos de inyección más seguros. Entre ellos se destacan: (1) enjuague de la jeringa para evitar que se obstruya, (2) calentamiento del disolvente para facilitar la disolución, (3) rápida transición de inyección intravenosa a subcutánea o intramuscular.

Résumé

Ll existe différents types physiques et chimiques d’héoïnes a travers le monde mais la façon don’t ces différences influencent les comportements de risques et la contamination n’est ni bien comprise ni bien documentée. Cet article présente une hypothése qui explique la distribution inégale du VIH chez les injecteurs d’heroine aux-Etats-Unis en examinent la distribution et l’utillisation d’un type d'héroïne: la “Mexican black tar” (‘goudron mexicain’). D’après les données ethnographiques, cliniques, épidémiologiques et de laboratoire, nous suggérons que les propriétés chimiques de cette héroïne millitent pour un usage plus sanitaire de l’injection par: (1) rinçage des seringues pour éviter qu’ils se bouchent; (2)chauffage de l’ustensile pour une meilleure dissolution, et (3) transition rapide de l’injection intraveineuse à l’intramusculaire ou la transcutanée.

Notes

^aIn addition to the HIV seroprevalence estimates presented by Holmberg ([1996]) we also examined CDC seroprevalence estimates for IDUs (Centers for Disease Control and Prevention, [1994]). These estimates provide an even stronger ecological association between heroin type and HIV (see also Hahn et al., [1989]). We present the Holmberg estimates, however, because they are not limited to in-treatment IDUs. For the DEA data on drug type we selected the years 1990 through 1993 to coincide with the years of information reviewed by Holmberg and because DEA data prior to 1990 is limited.

^bThe DEA Special Testing Research Laboratory analyses heroin obtained through undercover, retail-level purchases and broad-scale enforcement seizures. It identifies a unique chemical “signature” determining country of origin (Hast, [2001]). Eighty percent of the heroin identified as of Mexican origin is black tar heroin (Drug Enforcement Agency, [2000]). Powder heroin in the eastern U.S. is predominately from South America with diminishing amounts imported from South Asia.

^cThis HIV differential may also have been promoted by higher rates of cocaine injection in Vancouver than in Seattle (Bourgois and Bruneau, [2000])

Additional information

Notes on contributors

D. Ciccarone

Daniel H. Ciccarone, M.D., M.P.H., is a clinician, anthropologist and epidemiologist who has been doing research among—as well as providing primary clinical care to—injection drug users and high-risk youth in San Francisco for years. He is Assistant Professor in the Department of Family and Community Medicine and the Department of Anthropology, History, and Social Medicine at UCSF. Dr. Ciccarone is also a staff research physician at the Urban Health Study where he directs a number of research projects utilizing both quantitative and qualitative methodologies, which aim to deepen our understanding of risk taking among socially marginalized groups.

P. Bourgois

Philippe Bourgois, Ph.D., is a cultural anthropologist who is Professor and Chair of the Department of Anthropology, History, and Social Medicine at the University of California, San Francisco. He is best known for his fieldwork among drug dealers and addicts in the U.S. inner city. His most recent book, In Search of Respect: Selling Crack in El Barrio (1995, with an updated second edition in 2003) won the C. Wright Mills and the Margaret Mead prizes, among others. He is currently conducting fieldwork among homeless heroin injectors and crack smokers in San Francisco with the photographer Jeff Schonberg to prepare a book for the University of California Press, Righteous Dopefiend: Homeless Heroin Addicts in Black and White.