The behavior of and interactions between people who inject drugs are often reduced to the rate of needle sharing or some other measure of risk behavior. But just as in any community, the subculture that has evolved around the injected use of illicit drugs cannot simply be reduced to the behavioral sequences that actually transmit HIV.
Indeed, early in the epidemic it was found that injection with infected blood through sequential, multi-person use of drug injection equipment was responsible for the rapid spread of HIV among injecting drug users (IDUs). Although it was certainly an important stimulus for the first prevention programs, to some degree this finding resulted in an excessive focus on the physical instruments of transmission such as needles and syringes. Almost exclusive attention has been directed at the objects instrumental in transmitting the virus, often obscuring the fabric of social relationships and the sociopolitical circumstances in which these objects are used.
The context of drug use includes its natural settings, characteristic local consumer networks, language, norms and values, and rituals and rules. This subculture and its interaction with larger societal structures, including official drug policy and law enforcement practices, may have more significance for determining and, ultimately, changing the concrete behaviors responsible for the spread of HIV within the population of IDUs.
Long before the advent of the HIV/AIDS epidemic, anthropologists and sociologists described the world of drug injecting as a vivid and turbulent subculture. Not infrequently, these descriptions emphasized negative manifestations -- for example, the mistrust and cheating that may occur during the actual acquisition of drugs, the so-called ripping and running. Nevertheless, more recent studies suggest a more balanced picture of a world of multiple sharing and caretaking practices that constitute the bonds of relationships of drug users and their social networks.
In order to fully appreciate the value of this subculture for its participants and its relevance to the HIV/AIDS epidemic, there must be a focus on the daily context of habitual drug use. Participants in this subculture share a strong commitment (based on desire or need) to the use of drugs. However, this commitment places them at odds with the larger society, especially in the United States, which has outlawed the use and trafficking of their drug of preference through a system of prohibition often referred to as the "war on drugs." This makes users of drugs vulnerable to criminal prosecution and social stigmatization.
Known or suspected drug users may, for instance, be stopped and questioned by police without a valid reason. Quite understandably, drug users prefer to avoid such unpleasant encounters. Although always using his or her own equipment would perhaps be the simplest and most significant HIV-prevention measure an IDU could take, personal injection equipment is not carried at all times, as possession of a syringe is reason for arrest or harassment. In January 1996, despite overwhelming scientific evidence pointing to the detrimental effect of these laws, all but four U.S. states still had drug paraphernalia laws (criminalizing possession of needles, syringes, and other drug injecting utensils), and nine states still had prescription laws on the books forbidding over-the-counter sales of needles and syringes.
The prohibition of drugs has also decreased the level of control that drug users can exert over their drug acquisitions. Indeed, prohibition has created a situation in which drugs of unknown quality are sold at inflated prices on unregulated black markets. In the United States, the majority of street drug sales occur under great pressure in anonymous, unstable, and dangerous settings. Unless they have a stable and trusted source, drug users never know whether their next purchase will be a "killer" or a "beat bag" that will cause them harm or even death. The constant threat of arrest leads to a high level of uncertainty as to the whereabouts of the next dose. As a result, behavior patterns related to drug use may become less directed at self-regulation, safety, and health and more directed at safeguarding, covering, and facilitating drug use and related activities, such as the acquisition of the drug itself.
Anthropologist Bronislaw Malinowski called drugs the "instrumental imperative" for the drug scene -- its driving force. As an adaptive response to a hostile environment represented by mainstream society's drug laws and their enforcement, drug users have developed their own specific channels to secure the relatively undisturbed acquisition and use of drugs. Moreover, the stigmatized label of "deviant" attached to the user of these drugs thwarts participation in conventional social structures, leading to increased involvement in the social structure -- a distinct subculture -- formed around this stigmatized and deviant activity. The universal need for interaction, solidarity, and harmony (Malinowski's "integrative imperatives") leads to the integration of drug use into a subcultural set of rules and rituals, a common stock of knowledge and folklore, and its own argot, all aimed at the maintenance of this social structure that is essential for the satisfaction of drug users' needs.
The development of a drug user subculture is far from unique, as revealing similarities may be found within many other stigmatized and criminalized subcultures. For example, in the 1970s, gay men made use of elaborate systems of sign language and codes in both speech and clothing in order to safely communicate information only meant for other gay men. Just as gay men relied on their developed ability (dubbed "gaydar") to distinguish fellow homosexuals from heterosexuals, drug users trust what Beat generation writer William S. Burroughs called "junk radar" to distinguish fellow users from straight folks, who might potentially be undercover police officers. Likewise, many of the activities related to street corner drug sales are reminiscent of the interactions and transactions surrounding male-to-male sex in public places such as parks and public bathrooms. However, whereas the emancipation of gays and lesbians has, at least in many Western countries, come some way, the social status of a known IDU can be compared with that of an "outed" homosexual in the Victorian times of Oscar Wilde.
A considerable number of people who inject drugs are only peripherally involved, but more habituated drug injectors spend their daily lives in the injecting drug use subculture. Although social relations among habitual IDUs are often characterized by informality and opportunism, to survive they must develop trusting relationships through which they cooperate in struggling against the scarcity of drugs and other resources. Of course, drug use is not the only factor that brings and keeps drug users together. Drug users spend considerable time in each other's company even when not collaborating on managing their drug habits. They also seek each other's company when socializing and partaking in common activities such as watching television, talking, and eating. Information is exchanged on issues, ranging from baseball and child care to police activity, sources of needles and syringes, and the quality of certain "brands" of heroin. Valuable items, such as money, housing, food, and clothing are shared on a regular basis. Users frequently help each other with daily problems associated with the lifestyle of a criminalized drug user. They help each other with minor medical problems or when having problems with injecting into overused veins. Remedies for drug-related injuries such as abscesses are a frequent topic of conversation. They may baby-sit each other's children and also watch over one another when someone has used too much and slipped into unconsciousness. Among peers, users do not have to hide their drug use and find recognition and moral support. Not surprisingly, the relationships between drug users are often intense: they are often made up of sexual partners, family, or people sharing living arrangements. Many IDUs enter into relationships, often long term, with a "running mate." Labeled as structural outsiders and ostracized by mainstream society, willingly or not, drug users become mutually dependent on each other for fulfilling basic human needs.
Within this context of social support, the sharing of drugs becomes an important and frequent phenomenon. Drugs may be shared for multiple reasons, and sharing drugs fulfills several important functions. These reasons and functions can be described as instrumental, economic, social, or symbolic. In some drug-sharing interactions, reasons and functions can be rather clearly distinguished, but generally they are highly intertwined. Often, economic incentives prevail. Drugs are frequently shared when users pool money to make cheaper bulk purchases. Although this is found to be a regular practice among dyadic relationships and friendship groups, sometimes relative strangers pool resources when meeting on their way to buy drugs. In such cases, economic incentives prevail, but these drug-sharing interactions may be the start of more lasting relationships.
An important function of drug sharing is the prevention or amelioration of withdrawal. Across cultures, this is found to be a very common practice, and users refer to it as "helping" one another. In The Netherlands, for instance, one helps a fellow user in withdrawal with a beterschapje (a little get well), a small dose to ameliorate withdrawal. In New York, this practice has been termed "sharing a taste" or "doing an angle." Again, these interactions are most prevalent among, but are not limited to, friends and acquaintances.
In addition to clear instrumental reasons, the reciprocal character of these behaviors leads to mutual obligations resulting in more structured relationships. Often, new relationships are initiated and existing relationships reinforced through sharing drugs. Drugs are also shared to mediate conflicts, redeem financial debts, or compensate for damage done. For example, an IDU may sell some of a friend's property to buy drugs when he is "dope sick." The victimized friend may initially express considerable anger, but a week later, they may reconcile while sharing drugs provided by the thief. Drug sharing is also an important part of socializing and may have the intimate cozy and communal feel of socializing in a neighborhood pub.
Thus, drug sharing is a significant and frequent activity, touching the daily lives of habitual IDUs in several different ways. Not surprisingly, drug sharing is regulated by several normative expectations or rules. It is assumed that one shares drugs in exchange for other services related to drug injecting; one shares with one's friends; and one helps a fellow user in withdrawal, which may be the strongest rule. It is also expected that gifts are reciprocated. Failing to comply with these implicit rules may lead to rejection or, at a minimum, expressions of disapproval.
Drug sharing fits more general subcultural exchange and interaction patterns and can therefore be considered a symbolic expression of an elemental interaction pattern of reciprocal exchanges among group members, which provides a practical and emotional balance to daily hardship. At the same time, drug users may also prey upon and victimize each other. Desperate with "dope sickness," many users have found themselves violating even subcultural norms. Drug users live under constant pressure, managing their drug habits while trying to deflect the police and constantly assessing whether other users constitute a threat or a source of friendship or help. Sharing drugs fits this broader context of drug users' lives and finds its function in coping with drug withdrawal and craving, human contact and needs, and life on the margins of society.
Primarily a response to drug prohibition laws and policies, the drug subculture is a socially constructed "culture of survival" in which the orientation and intensity of survival behaviors depend largely on external social pressures. The sharing and the hustling are normal behaviors under the extreme circumstances of the war on drugs. Part of individual and communal survival strategies, they can be compared with behaviors in similar stressful situations of oppression and scarcity, as witnessed during periods of famine or times of war and in prisons and concentration camps. Adaptive responses, such as sharing drugs and sequential, multi-person use of needles, are part of a collective strategy in development since the passing of the Harrison Narcotics Act in the United States in 1914. Once, such drug-sharing behaviors were highly functional; with the onset of the HIV/AIDS epidemic, they turned deadly.
Because the subculture of injecting drug use is so well established, HIV-prevention educational campaigns and outreach projects targeting IDUs have faced many challenges. Early on in the epidemic, it was recognized that, because of the hidden nature of injecting drug use, such traditional outreach methods as media campaigns, health education folders, general medical and social services, and drug treatment facilities would not reach a substantial portion of the population of IDUs. Needle exchange, outreach work and bleach distribution, decriminalization of injecting paraphernalia, peer education projects, and drug user advocacy groups are some of the strategies to reach significant numbers of active drug injectors.
Prevention efforts seek to educate IDUs about injection-related risk behaviors, try to convince them to stop or modify the practices that put them at risk, and suggest safer alternatives. However, such interventions must consider several complications and impediments that hamper the interventions themselves as well as behavioral change at large. For instance, in the IDU's "hierarchy of risk," the risk of arrest or withdrawal are clearly greater concerns than the chance of infection with treatable hepatitis B and perhaps even with HIV. IDUs also have much greater experience with death than other communities affected by AIDS: they have always been at risk for premature death owing to overdose or violence. Likewise, as a result of the illegal, stigmatized, and therefore hidden nature of drug injecting, people are not very eager to identify themselves as IDUs.
Furthermore, for many, access to mass media, general HIV education materials, health care, and social services is limited. Before the onset of the HIV epidemic, health education messages designed for this population were generally nonexistent. Because expansion of addiction treatment was put forward as the only or best HIV-prevention strategy, the availability of treatment did significantly grow in the first 15 years of the epidemic. However, the "high threshold" approach of most U.S. drug treatment programs, in which abstinence is required for receiving other services, leaves a large number of people who are unable or unwilling to comply with such all-or-nothing requirements without needed services.
Thus, in order to reach a large number of active IDUs, interventions have been developed that engage people on their own turf and terms. Early in the epidemic, San Francisco researchers designed an outreach method -- "Reach and Teach Bleach" -- which targeted IDUs in areas with high levels of drug activity, provided them with AIDS education, and taught them how to clean needles with household bleach. Outreach workers were often people with a history of drug use, which facilitated making contacts with active IDUs. Grassroots activists also implemented needle exchanges, which many cities have quietly allowed to operate.
Although these interventions have certainly taken a lead in the fight against the HIV epidemic among IDUs, they are not without limitations or problems. Research suggests that professional outreach programs may suffer a multitude of organizational problems that can seriously decrease their efficacy. In addition, both outreach projects and needle exchanges tend to reach only part of the population at risk. Furthermore, many drug users have more immediate legal, medical, and social concerns with which by now familiar "Don't Share Needles" and "Prevent AIDS" messages cannot compete. Finally, both researchers and activists contend that one cannot expect the IDU culture to change without engaging drug users themselves in the planning and implementation of interventions.
In response to these problems, the first half of the 1990s saw some innovative developments. Needle exchanges have been expanding into alternative health care centers, or harm-reduction centers, providing a wide range of services. Active users have been instrumental in developing interventions in which instruction in street safety; self-injection; and abscess, overdose, and arrest prevention and the dissemination of other practical, relevant, and immediately applicable information serve as vehicles for presenting HIV/AIDS messages, rather than HIV prevention being the focus of the training itself.
Drug users have also organized themselves into drug user advocacy groups in several North American cities, modeled after European and Australian examples. These groups may be the key to cultural change. In The Netherlands, "junkie unions" were the first to implement needle exchanges and to produce information specifically aimed at IDUs, just as in San Francisco and New York gay men organized the first prevention efforts aimed at gay culture. In The Netherlands, Germany, France, the United Kingdom, and Australia, such initiatives are highly valued and funded by the authorities. In Australia, which has managed to keep HIV prevalence comparatively low, organizations of active drug users are included at all levels in the national strategy to combat AIDS among IDUs. U.S. drug users have also initiated needle exchanges, and harm-reduction services for drug users are increasingly staffed by them. In the United States of the 1990s, these developments still represent the alternative, grassroots movement, as, given the war on drugs, government funding seems unlikely.
Abstinence; Drug Outreach Projects; Drug Use; Harm Reduction; Injecting Drug Use; Injecting Drug Users; Interventions; Needle-Exchange Programs; Poverty; Prostitution; Sex Work; Stigma; Surveillance
drug addicts, drug user subculture, injecting drug users (IDUs), intravenous (IV) drug users, junkies
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The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright © 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.
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