SUBSTANCE ABUSE HAS BEEN ASSOCIATED with risky sexual behavior and subsequent sexually transmitted infection (STI), including HIV. 1,2 Intravenous drug addiction is a well-established risk factor for bloodborne STI, hepatitis B virus (HBV), hepatitis C virus (HCV), human T-cell lymphotrophic virus type 1 (HTLV-1), HIV, and syphilis. 3,4 The resurgence of syphilis in several parts of the United States during the past decade has been attributed to crack-cocaine use, particularly in concert with commercial sex work. 5,6 Reports from other industrialized countries reiterate the importance of non-IV drug use in the transmission of the bloodborne STI pathogens. 3,4,6 Intravenous drug addiction is not a problem in Jamaica. Crack-cocaine was only recently introduced, but cannabis is integrated into the Jamaican culture and is used for medicinal, ritualistic, and recreational purposes. 7,8 National surveys showed that alcoholism was a significant problem. Few reports document the effects of substance abuse on the physical health and well being of Jamaicans, but one study identified marijuana smoking before sex as an independent risk factor for STI in Jamaican men. 7–9 Drug users who are in drug treatment programs may receive STI screening, treatment, and risk-reduction interventions. Such patients reduce their substance intake, sexual-risk behaviors, and HIV-risk behaviors. 10,11 We report a retrospective study of sexually transmitted viral infection and syphilis in patients attending a residential detoxification facility in Jamaica.
The Detoxification Assessment and Rehabilitation Unit of the University Hospital of the West Indies is part of the National Council on Drug Abuse. The program was designed for drug and alcohol addicts who had recognized their inability to cope without depending on chemical substances and who were motivated to stop abusing those substances. The period of residential care in this eight-bed facility was 28 days. Admission was voluntary, and after a doctor’s assessment, persons with overriding medical, surgical, or psychiatric conditions were not admitted. Treatment was based on a social model and did not include pharmacologic intervention for addiction, but STI screening was performed routinely as a part of the treatment policy.
Clients admitted consecutively (n = 301) to the detoxification unit between 1994 and 1999 were studied retrospectively. After ethical approval was obtained, a structured form was used to abstract data from each client’s hospital chart. The information collected was self-reported and pertained to demographics, drug history, and the results of serologic tests for bloodborne STI pathogens. As part of the study, the same tests were prospectively performed on sera collected from age-matched and sex-matched blood donors (n = 131) included as controls. Under the same ethical approval, the structured form was applied to the blood donors after informed consent was obtained. The STI investigations performed included HIV-1 and HTLV-1 using an enzyme immunoassay (EIA, Abbott Diagnostic Laboratories, Abbott Park, IL) and western immunoblot confirmatory tests (DuPont, Wilmington, DL). Commercially available kits were also used to detect hepatitis B surface antigen by enzyme immunoassay (Abbott Diagnostika, Weisbaden, Germany), and syphilis was diagnosed using the VDRL and the fluorescent treponemal antibody absorption tests. 12
The data were compared with chi-square and Fisher exact tests, and crude odds ratios (OR) determined.
The sociodemographic characteristics of the 301 patients and the prevalence distribution of STI are shown in Table 1. The mean age was 33 years (range, 14–68 years), and 274 patients (91%) were male. Most patients were single and had received a postprimary education. Fifteen percent were unemployed, and the majority of those who were employed were low-income earners. The number of lifetime sexual partners was ascertained in 36 patients, 34 (94%) of whom had had more than three lifetime sexual partners. Alcohol was the only substance of abuse in 18%, whereas 72% were addicted to illicit drugs. Forty-eight percent of the patients were addicted to both cannabis and cocaine, and 9% were addicted to alcohol, cannabis, and cocaine. None of the patients admitted IV drug use. Seventy-five percent had been non-IV drug abusers for more than 10 years. Thirty-five patients (12%) had a positive test result for at least one bloodborne STI pathogen. A higher prevalence of STI was found in female patients (P < 0.0001) and in those who were unemployed (P < 0.0001). No significant associations were found with STI and age or marital status, level of education achieved, number of lifetime sexual partners, duration of drug addiction, or the type of substance abused.
The overall prevalence of STI in substance abusers did not differ significantly from that in the blood donors (35/301, 12% versus 13/131, 10%). As shown in Table 2, a significantly higher prevalence of syphilis was found in substance abusers compared with blood donors (P < 0.05). The prevalences of HTLV-1 (6/27, 22% versus 10/274, 4%;P < 0.0001) and syphilis (8/27, 30% versus 11/274, 4%;P < 0.0001) were significantly higher in female compared with male substance abusers. In blood donors, a significantly higher prevalence of syphilis was also found in females (4/31, 13% versus 0/100, 0%;P < 0.05). Coinfection with HIV and syphilis or HTLV-1 was found in 2% of the substance abusers, whereas 1% of the blood donors were coinfected with HTLV-1 and syphilis. Fifty-two of the male blood donors (52%) admitted using marijuana, but none used cocaine.
Surprisingly, even with long-standing abuse of illicit drugs and alcohol, the overall prevalence of STI in this cohort of substance abusers did not differ significantly from that in blood donors. This finding may be explained, in part, by the absence of IV drug abuse in Jamaica, and that cannabis use is prevalent in Jamaican blood donors. The prevalences of HIV, HTLV-1, hepatitis B surface antigen, and syphilitic infection were comparable with those found in non-IV drug abusers in studies conducted elsewhere, but notably lower than those reported in IV drug abusers. 3,4,13
Being female and being unemployed were identified as risk factors for STI in substance abusers. It has been suggested that gender-specific differences are the means by which drugs are acquired and might contribute to an increased risk of STI in women because of the rates of transmission. Asymptomatology that obscures the need for treatment might also contribute. 6,14 Dreher 7 reported on women residing at cocaine bases in Jamaica and engaging in commercial sex. Reflecting the economic structure of the Jamaican society, a higher percentage of women treated at the detoxification unit were unemployed compared with male patients. The increased STI risk observed in the unemployed substance abusers raised the question of sex for drugs, but the patients were not routinely asked about sex work, trading sex for drugs, or sexual behavioral practices during admission to the detoxification unit. In support of previous reports, the risk of STI did not vary significantly with the type of non-IV drug addictions when the drugs are not taken by injection. 10,15
The increased prevalence of syphilis observed in the detoxification clients had serious implications because of the possibility of congenital transmission, the late sequelae of untreated syphilis, and particularly the role of syphilis as a cofactor in the transmission and acquisition of HIV and HTLV-1. 3,7,16,17 The 3% seroprevalence of HIV in the substance abusers though differing did not differ significantly from that in blood donors, but was a critical finding. This finding was severalfold higher than the 0.17% to 0.48% prevalence documented in the general Jamaican population during 1998.
The differences observed in the gender distribution of STI in the substance abusers also involved HIV. In women, the seroprevalence of HIV had increased to 7%, which matches the prevalence documented in STD clinic attendees in Jamaica in a 1998 national report. The seroprevalence of syphilis in both categories of females was unexpectedly high. The 30% positivity rate observed in female substance abusers challenged the current opinion of syphilis being on the decline in Jamaica. 12,18,19 These figures implicate women who abuse illicit drugs and alcohol as likely foci of infection and potential contributors to a resurgence of syphilis in the Jamaican population. Dramatic increases in syphilis in other countries have been linked with cocaine use, sex work, and homosexuality. 5,6
The excess of HTLV-1 infection in women compared with men is a well-documented finding. 16,20 Reportedly, this difference increases with age and sexual activity, number of sexual partners, and commercial sex, and is due to the higher probability of male-to-female transmission of HTLV-1 compared with female-to-male transmission. 16,20 The seroprevalence of HTLV-1 seen in the substance abusers per se was similar to that observed in blood donors in this study and in previously documented Jamaican studies. 16,20 This observation should not obscure the problem of HTLV-1 infection in the case of women and the need to target women through prevention strategies. Compared with previous reports and in line with the absence of IV drug use in blood donors, the prevalence of hepatitis B surface antigen was not increased among substance abusers. 21 The 2% coinfection rate of incurable STI substance abusers, such as that observed for HIV, HTLV-1, and syphilis (a curable facilitator of the former and latter), emphasized the importance for drug-abuse prevention and intervention.
Limitations of the study included the retrospective design, the small number of women presenting at the detoxification unit during the 5-year period, and the low frequency of some of the STI in terms of risk analysis. In conclusion, the results endorse the substance abuse treatment policy whereby clients in detoxification units are screened for STI. The results also confirm that non-IV drug use plays an important role in the acquisition and transmission of bloodborne STI. The increased prevalence of bloodborne STI in female substance abusers and blood donors requires urgent and more detailed investigations involving larger numbers of women. These preliminary data also indicate a need for gender-specific approaches to the control of substance abuse and STI.
1. Deas-Nesmith D, Brady KT, White R, Campbell S. HIV risk behaviours in adolescent substance abusers. J Subst Abuse Treat 1998; 16: 169–172.
2. Aarons GA, Brown SA, Coe MT, et al. Adolescent alcohol and drug abuse and health. J Adolesc Health 1999; 24: 412–421.
3. Rodriquez OES, Gil MLM, Santana JFH, Canal JML, Sanchez AMM. Prevalence of serologic markers of HBV, HDV, HCV and HIV in non-injection drug users compared to injection drug users in Gran Canaria, Spain. Eur J Epidemiol 1998; 14: 551–561.
4. Lambden KH, Kennedy N, Beeching NJ, et al. Hepatitis B and hepatitis C virus infections: risk factors among drug users in Northwest England. J Infect 1998; 37: 260–269.
5. Williams LA, Klausner JD, Whittington LH, Handsfield HH, Celum C, Holmes KK. Elimination and reintroduction of primary and secondary syphilis. Am J Public Health 1999; 89: 1093–1094.
6. Rolfs RT, Goldberg M, Sharrar RG. Risk factors for syphilis: cocaine use and prostitution. Am J Public Health 1990; 80: 853–857.
7. Dreher MC, Nugent K, Hudgins R. Prenatal marijuana exposure and neonatal outcomes in Jamaica: an ethnographic study. Paediatrics 1994; 93: 254–260.
8. McDonald A, Duncan ND, Mitchell DIG. Alcohol, cannabis and cocaine usage in patients with trauma injuries. West Indian Med J 1999; 48: 200–202.
9. Simeon DT, Bain BC, Wyatt GE, et al. Characteristics of Jamaicans who smoke marijuana before sex and their risk status for sexually transmitted diseases. West Indian Med J 1996; 45: 9–13.
10. Longshore D, Shih-Chao H. Drug abuse treatment and risky sex: evidence for a cumulative treatment effect? Am J Drug Alcohol Abuse 1998; 24: 439–449.
11. Hoffman JA, Klein H, Clark DC, Boyd FT. The effect of entering drug treatment on involvement in HIV-related risk behaviours. Am J Drug Alcohol Abuse 1998; 24: 259–282.
12. Dowe G, King SD, Smikle MF, Wynter HH, Chout R, Klaskala W. Prevalence of bacterial and viral sexually transmitted pathogens in Jamaican pregnant women. West Indian Med J 1998; 47: 23–25.
13. Gutierrez del Río C, Casanueva Gutiérrez M, de la Fuente García B, Gallo Alvaro C, García-Alcade Fernandez ML, Moris de la Tessa J. Hospital detoxification unit: 4-year experience. Treatment and infections. Ann Med Intern 1998; 15: 528–530.
14. Paschane DM, Fisher DG, Cagle HH, Fenaughty AM. Gonorrhea among drug users: an Alaskan versus a national sample. Am J Drug Alcohol Abuse 1998; 24: 285–297.
15. Samet JH, Mulvey KP, Zaremba N, Plough A. HIV testing in substance abusers. Am J Drug Alcohol Abuse 1999; 2: 269–280.
16. Figueroa JP. Heterosexual transmission of HTLV-1: epidemiological aspects. West Indian Med J 1996; 45: 4–8.
17. Ministry of Health, Jamaica, National HIV/STD Control Program. HIV/AIDS Surveillance 1998 Report. Kingston: Ministry of Health, Jamaica, 1998.
18. Dowe G, King SD, Brathwaite AR, Wynter Z, Chout R. Genital Chlamydia trachomatis
(serotypes D-K) infection in Jamaican commercial street sex workers. Genitourin Med 1997; 73: 362–364.
19. Smikle MF, James O, Prabhakar P. Prevalence of reactive serological tests for syphilis in the Jamaican population. West Indian Med J 1990; 39: 170–172.
20. Murphy EL, Figueroa JP, Gibbs WN, et al. Human T-lymphotropic virus type-1 (HTLV-1) seroprevalence in Jamaica. Epidemiology 1991; 133: 1114–1124.
21. Barton EN, King SD, Douglas LL. The seroprevalence of hepatitis and retroviral infection in Jamaican haemodialysis patients. West Indian Med J 1998; 47: 105–107.