The spread of HIV disease in the United States is fueled in part by the use of illicit drugs. In addition to direct transmission through sharing injection-drug equipment, indirect transmission occurs through sexual contact with HIV-positive injection drug users. Moreover, the use of both injected and noninjected illicit drugs increases risk for HIV because of their effects on decision making and sexual risk taking.


In 2003, the exposure category for 21.9 percent of new AIDS cases among adolescents and adults was injection drug use (IDU).1

Among men, IDU was the exposure category in an estimated 20 percent of new AIDS cases reported in 2003; another 5.9 percent of cases resulted from sexual contact with men who have sex with men and inject drugs.1 Among all men living with AIDS at the end of 2003, 22 percent were estimated to have contracted HIV through IDU, but the rate was higher (30 percent) among Black and Hispanic males.2

Among women, 26.9 percent of new AIDS cases were attributed to IDU in 2003,1 a proportion that has continued to decline over the past decade.1 At the end of 2003, IDU was the HIV exposure category in 35 percent of women living with AIDS, ranging from a high of 41 percent of cases among American Indian/Alaska Native women and 40 percent among Whites to 33 percent among Blacks and Hispanics and just 16 percent among Asian/Pacific Islanders.2

AIDS mortality among people for whom the HIV exposure category was IDU declined just 7 percent from 1998 (when HAART use became widespread) to 2003, compared with a fall of 15.5 percent for MSM. Among women infected through IDU, the rate actually increased by 4.4 percent.3

Critical Issues

Illicit drug use in the United States is an important issue. In 2002, 19.5 million Americans (8.3 percent of the population age 12 and older) were current illicit drug users (i.e., used an illicit drug at least once during the month prior to the survey). In addition, an estimated 22 million Americans age 12 or older are substance dependent or abuse substances.4

The risk for HIV associated with substance abuse involves more than simply the sharing of IDU paraphernalia. The National Institute on Drug Abuse, along with the National Institute on Alcohol Abuse and Alcoholism, have found that use of drugs and alcohol interferes with judgment about sexual and other behavior. As a result, substance users may be more likely to have unplanned and unprotected sex.4

Substance abuse treatment is in short supply, even though it is crucial for staying in HIV care and adhering to treatment regimens. The introduction of buprenorphine, a treatment for opiate addiction that may be given in the primary care setting, offers hope for improved access to treatment for addiction, but barriers still exist. Administering the treatment requires special training and may not be available in many environments with a low incidence of HIV.

Recent studies have found that trauma, substance use, and sexual risk behaviors are interconnected. For example, women who have experienced sexual abuse, whether as a child or as an adult, may have difficulty refusing unwanted sex, may use drugs as a coping mechanism, or may find themselves engaging in sexual activities with strangers more frequently than other women. Past trauma also may cause women to be less assertive with birth control and to have a greater number of lifetime partners, which increase one's risk for HIV.5

Substance Abuse and the Ryan White CARE Act

The Health Resources and Services Administration (HRSA) has been very involved in increasing access to buprenorphine, the Nation's first treatment for opiate addiction that may be administered in a primary care setting. Among HRSA's activities is a special issue of the HIV/AIDS Bureau's (HAB's) technical assistance newsletter (available at and a Special Projects of National Significance initiative that is funding organizations to develop and evaluate innovative models for administering buprenorphine in outpatient HIV care settings.

Users of illicit substances may receive HIV services through all Ryan White Comprehensive AIDS Resources Emergency (CARE) Act programs. The lack of drug treatment services in the United States has placed increased pressure on CARE Act providers because they must address substance abuse issues to sustain individuals in care over time.

Substance Abuse and Infectious Disease: Cross-Training for Collaborative Systems of Prevention, Treatment, and Care is a joint initiative of HRSA, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention (CDC).The project provides training and technical assistance to State and local public health agencies and mental health and substance abuse health care delivery systems so that they can more effectively serve people with substance abuse problems and infectious diseases such as HIV/AIDS, other sexually transmitted diseases, viral hepatitis, and tuberculosis.

A HAB report, Investigation of the Adequacy of the Community Planning Process to Meet the HIV Care Needs of Active Substance Users, provides recommendations on how more effectively to use Title I funds to meet the needs of the substance-using population.

INSPIRE, a 5-year cooperative agreement jointly funded by HRSA and the CDC, is a randomized controlled trial to test a 10-session intervention developed by a multisite research team. The primary objectives of the study are to reduce high-risk behaviors, increase access to medical care, and increase adherence to HIV antiretroviral medication among HIV-positive injection drug users.

Estimated New AIDS Cases Among Women, by Exposure Category, 20031 (N=11,498)
Heterosexual Contact, 70.7%; Injection Drug Use, 26.9%; Other, 2.4%

Estimated New AIDS Cases Among Men, by Exposure Category, 20031(N=31,614)
Male-to-Male Sexual Contact (MSM), 56.8%; Injection Drug Use (IDU) 20.1%; MSM/IDU, 5.9%; Heterosexual Contact, 16.2%; Other, less than 1%


  1. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report. 2003;15:12. Table 3.
  1. CDC. HIV/AIDS Surveillance Report. 2003;15:21. Table 11.

  2. CDC. HIV/AIDS Surveillance Report. 2003;15:16. Table 7.

  3. Substance Abuse and Mental Health Services Administration. Results From the 2002 National Survey on Drug Use and Health. Overview report. Available at:

  4. National Institute on Drug Abuse. Drug Abuse and AIDS. NIDA InfoFacts. Rockville, MD: Author; 2003. Available at:

  5. Simoni J, et al. Triangle of risk: urban American Indian women's sexual trauma, injection drug use, and HIV sexual risk behaviors. AIDS Behav. 2004;8(1):33-45.