Drug Sharing and HIV Transmission Risks: The Practice of Frontloading in the Dutch Injecting Drug User Population

Abstract

Injecting drug users may now be the largest group at risk for contracting HIV, mainly through the sharing of drug injection equipment (including lending, borrowing, and renting). This article presents the results of an ongoing ethnographic study into the drug-taking rituals of heroin addicts. A possible additional route of HIV contamination is presented, namely the ritual sharing of drugs through a practice termed "frontloading," which is embedded in a broader pattern of the sharing of resources among addicts. It is hypothesized that in the Netherlands this practice may be responsible for a substantial proportion of HIV spread among injecting drug users.

Keywords - drug sharing, frontloading, HIV transmission, injecting drug user, needle sharing

Drug addicts are an identified risk group for human immunodeficiency virus (HIV) infection. Although noninjecting drug-use-related IUV has been reported recently (Chaisson et al. 1990; Golden et al. 1990; Schoenbaum, Hartel & Friedland 1990; Sterk 1988), injecting drug users (IDUs) are particularly at risk because of the use of contaminated injection equipment, which is generally termed "needle sharing" (Chaisson et al. 1987; Brettle 1986). On the basis of extensive research, needle sharing seems to be the most significant AIDS -related risk behavior practiced by IDUs (Hoek et al. 1988a; Chaisson et al. 1987; Marmor et al. 1987; Brettle 1986). Moreover, in the chain of transmission the IDU seems to be the main vector for secondary spread of AIDS to the heterosexual population in the United States (Newmeyer 1987).

In contrast with the United States and many neighboring countries, only a minority of drug addicts inject in the Netherlands. Most Dutch heroin addicts are smoking the drug ftorn tinfoil (called chinesing or chasing the dragon) (Buning et al. 1986). The availability and quality of drugs on the illegal Dutch market has been stable throughout the 1980 at a relatively high level for a moderate price, compared with neighboring countries and the United States (Kaplan, Janse &Thuyns 1986). Mainly because of economic considerations, it seems that many Dutch users do not feel the necessity to start injecting, as do many of their foreign counterparts (Burt & Stimson 1988; Casriel, Rockwell & Stepherson 1988; Power 1988; Kaplan, Janse & Thuyns 1986). However, the minority of addicts that does inject cannot be and is not neglected in the Netherlands. By the mid-1970s, risk-reduction and harm-minimization strategies were adopted by Dutch policymakers and helping organizations. Around 1985, AIDS became a major item of concern in the Netherlands. In 1984, Amsterdam started its needle-exchange system; the number of needles that were distributed grew rapidly from 25,000 in 1984 to 820,000 in 1989 (Buning 1990). Rotterdam started its municipal needle-exchange system in the first half of 1987. Although few seroprevalence studies have been conducted in the Netherlands, it seems that seroprevalence among drug users still is rather low. In a nonrepresentative sample of high-risk drug users in Amsterdam, 26.6% of all drug addicts and 31.2% of the IDUs were found to be seropositive (Hoek et al. 1988a). In a study conducted in Rotterdam on a nonrepresentative sample, seropositivity was found to be 9.7% in 1986 and 6.5% in 1987 (Barends 1988). A study outside the large urban centers indicated a seropositivity of 4.8% in a nonrepresentative sample (Limbeek et al. 1987). Unpublished results from a 1988 study of an intake cohort of a drug treatment introduction program in the Hague showed a seroprevalence of 0% (Cramer 1989).

HIV is undoubtedly transmitted through needle-sharing practices. Nonetheless, especially in situations where clean syringes are not structurally scarce, it is not merely the act of sharing needles that constitutes the risks of spreading the virus. The behaviors associated with needle sharing can be decomposed into different elements that each have their own distinctive probability of risk. The hypothesis of the present article is that a deeper look into drug use contexts reveals other forms of sharing behavior that may be important factors in the transmission of HIV. A look beyond needle sharing involves a look into a world of multiple-sharing and caretaking practices that constitute the bonds of relationships of IDUs' social networks. These relationships are multidimensional and may lead to relationships with non-IDUs.

For analytic purposes, three patterns of sharing behavior directly related to HIV-transmission risks can be observed: sharing syringes or needles (including lending and passing on), sharing other drug-injection paraphernalia, and drug sharing. Specifically, certain forms of drug sharing may provide additional routes by which contaminated needles can present risks of infection to IDUs. The present article examines one such drug-sharing practice, frontloading.

Questionnaires alone may not report socially undesirable behavior reliably, especially in the case of morally sanctioned and criminalized demeanors. Field observations provide the best opportunity to do so because they have an advantage over questionnaires or interviews; namely, they directly record performed behaviors instead of collecting the respondents representation of his or her own behaviors, which can be biased by memory, perceived self-image, fear, and mistrust. However, the methodology can be subject to certain limitations. Validity and generalizability have been questioned (Agar 1986): the presence of researchers might alter the context and behaviors of the study group. Surely this is partly true, but its effect should not be overestimated because after some time, the researcher can become part of the furniture (Agar 1986). Moreover, group members five within well-established tradition that constrains their actions. The presence of the researcher is a new constraint, but in competition with many others that carry the weight of tradition (Becker 1970). For these reasons, selection of and access to research sites and respondents, the development of trust in the researchers, the observational strategy, and the procedures of (on-site) data recording all need ample attention.

The data presented in this article were collected between February 1988 and April 1989 as part of an ongoing research project into the drug-taking rituals of heroin addicts in Rotterdam. The principal method to gather data in this study was ethnographic; intense and unobtrusive participant observation of addicts self-administering heroin and/or cocaine at dealing places, at their homes, or in (semi-)public places. No structured interviews were conducted, but when possible, additional information was collected during informal conversations. Detailed field notes were recorded of 95 observations of the rituals under study. In 44 observations, subjects were smoking (38 chinesing and 6 free basing); in two observations, subjects were snorting; and in 49 observations, subjects were injecting.

Trust, acceptance, and credibility are prerequisites for ethnographic research. These qualities were developed by a field research team consisting of a community fieldworker who was a respected " post-addict" and the principal investigator. During informal conversations with drug users on their problems and life in the drug scene in general, the project's goals were addressed. Also, both the community field-worker and the principal investigator were known to many of the study participants before the onset of the research. Except for an occasional sandwich or cup of coffee in the context of a talk, no participation fees were paid. With some of the study participants, more stable relationships were developed and these drug users, the so-called key informants, supplied the researchers with important information.

Of the 95 observations, most were recorded in the afternoon (94%) and some in the early evening (6%) in two distinct, high drug-activity neighborhoods of Rotterdam (N=95). Ninety-three percent of the observations were recorded at 14 different houses, where addicts lived, dealt drugs or both (n=93). In 53% of the observations, the status of the house was legally rented, in 9% subletted, and in 38% squatted (n=77). Additional observations were recorded in public places, a greenhouse, deserted sheds behind abandoned buildings awaiting renovation, and on the streets. These locations were initially selected by visiting and mapping out both neighborhoods and on the basis of conversations with the key informants. Throughout the fieldwork, researchers at times accompanied participants on their daily rounds. In this way they were introduced to new dealing places, using places, and private homes. During the fieldwork, some of the dealing places were closed down by the police. Although these busts caused some turmoil, they did not seem to have a significant impact on the availability of drugs. Soon new places opened up, sometimes the same day at the same address. Often the researchers were introduced to the owner of a (new) place by a key informant. The researchers basically followed the dynamics of the drug scene; by doing so, most of the dealing addresses in the neighborhood were visited.

The observations were guided by an observational protocol that summarized the focus of the study (Grund et al. 1988). Because the study was primarily concerned with the actual behaviors in the drug self-administration sequence (i.e., the preparation and ingestion of the drug, the use of paraphernalia, order/sequence, places, setting, time) and secondarily with demographics and other characteristics of the people performing the observed behaviors, the former are highlighted in the field notes. Field notes were produced independently by both researchers directly after each fieldwork session or the following morning, based on short notes taken during or immediately after the observations.

The field notes were processed using the Ethnograph, a computer program for the analysis of qualitative data (Seidel 1988). The data were coded in line with the observational protocol and the codes evolved constantly during the data collection and concurrent coding process. The coding and analysis have been regular topics of research staff discussions. In order to corroborate the qualitative analysis, the data were quantified by counting the events that were significant for the analysis, and listing the available demographic and background data on the research subjects. These data were stored in two separate SPSS* data files, and they are intended to support the qualitative analysis; they are not necessarily representative for other (sub)populations.

Characteristics of the Research Subjects

The total number of subjects contacted was 192 (168 males and 24 females). Because no formal interviews were held, not all the subjects' characteristics could be recorded. Hence, only more than half of the subjects are distributed by age. Of the ages that were recorded, some were known exactly but most were estimated by comparing independent field-worker ratings: 30% was under 25 years, 50% between 25 and 35, and 20% over 35 (n=106). This distribution resembles that from RODIS, the Rotterdam registration system of heroin addicts in methadone treatment (1,797 in 1988): 27%, 60%, and 13 %, respectively (Toet & Ven 1989). For a minority (23%), injecting was the main mode of administration. Seventy-seven percent were smoking their drugs (n=162). Approximately 96% used both heroin and cocaine (n= 105). This pattern of combined heroin and cocaine use started in the beginning of the 1980s when an increasing number of heroin addicts added cocaine to their menu. In comparing the validity of this finding, RODIS data reported a prevalence of 72% cocaine use, which is not as high as the community addict sample in the present study, but still almost three-quarters of this treatment sample (Toet & Ven 1989). Moreover, at all dealing places that were visited, both heroin and cocaine were available. Cocaine has become increasingly important to Dutch heroin addicts (Grund et al. In press).

The data provide a broad pattern of sharing behaviors among addicts. The stereotype of addicts is that of ripping off each other as predatory individuals. While this behavior does indeed occur, a more prevalent pattern seems to be sharing. Addicts share many valued items, such as housing, food, and clothing. Often they help one another with daily problems associated with addict life. For instance, homelessness is not uncommon among addicts. In some of the places visited for the present research, several homeless addicts were given shelter. One other such problem is that many addicts suffer from collapsed veins and abscesses due to insufficient hygiene. Some insist on injecting themselves, others are happy to get help from another, often experienced injector as the following field note shows:

A woman and her partner have just bought drugs and are shooting up. Neither has an easy time. The man is trying several spots to shoot up. The woman also tries more than one spot and finally she asks Ria to do it. Ria takes the syringe, looks carefully at the woman's arm and sticks the needle in. 'Men she redraws the piston a little and blood runs into the syringe. She has hit a vein. After seeing the blood she presses the piston, pulls out the syringe and hands it to the woman. Shooting up the woman took her very little time and she looked like a professional nurse doing her daily work.

In contrast with similar American examples involving so-called house doctors or professional hitters in shooting galleries, there is no commercial trade-off in this service (Stem In press; Sterk 1989). Sometimes addicts ingest more of a drug than their usual dose and slip into a deep nod that can end in overdose. They then depend on the safeguarding of a fellow user, as in the following situation:

Ria, Vis, and Jerry are in Gus' house. Gus has just left to do some shopping. Ria is asleep in an armchair. -She has swallowed pills." Jerry says, "she is out now." A little later Ria wakes up a little. "It's alright Ria, just go nicely to sleep," Jerry says to her. Jerry is staying with her in case anything should happen.

In this context of social support in addict networks, the sharing of drugs is an important and frequent phenomenon. Quantitative analysis of the observations of drug self-administration rituals (see Figure 1) clearly shows that drug use rarely is an individual act. In the present research, the most common places where drugs were ingested (n=93) were the dealing place (56%), home (18%), and a friend's home (14%).

Similarly, 43 of 62 observed drug sales were followed by direct ingestion of (at least a part of) the purchased drugs at the dealing place. The mean number of people present at these places during the observed drug-taking event was 4.3. As the vast majority of drugs are consumed at places other than home and with other people around (n=93), it should not be surprising that drugs were shared in 50% of observed events (see Figure 2).

In 81% of observed sharing events (see Figure 3) among IDUs (n=26), drugs were shared by frontloading or streepjes delen (sharing stripes - referring to the scale gradients on the barrel of the syringe), a special technique using two syringes. When sharing by frontloading, the drug is prepared on a spoon and then drawn in one syringe (A). The needle is removed from the second syringe (B), the plunger is drawn back, and a part of the solution from syringe A is injected through the hub of syringe B (see Figure 4). In this way, it is possible to divide the drugs into two or more equal parts.

The following field note documents a representative situation in which drugs are shared by frontloading. Richard and Chris have bought drugs at a dealing place and have gone home to inject:

Back home R and C start preparations to shoot up a cocktail [a mixture of cocaine and heroin, also called a speedball]. R and C both get tools and put them on the table. They Sit down at the same time. R puts the spoon in front of him and takes out the packages. He opens the heroin package, holds it above the spoon and empties it. He adds some lemon and water. Meanwhile C opens two injection swabs (which are dispensed by the Syringe Exchange Program for cleaning the skin before injecting) and puts them on the broad rim (edge) of the ashtray. When R is ready - putting things into the spoon - he nods, which C understands as a sign to light the swabs on fire with his lighter. This produces a flame from +4 cm high, above which R now holds the spoon to boil the contents. C looks curiously at the spoon and says, "I hope it's enough that we feel it." It takes a little more then two minutes to dissolve the heroin. After this, R puts the cocaine in almost right away, without waiting for the solution to cool off. Cotton is used to make a filter, and R draws the cocktail in the syringe without the needle. R also divides the cocktail Ile put$ the needle back on his syringe. C gives him his syringe after removing the needle. R inserts his needle in C's syringe and pushes the piston. Before doing so he looked to see how much cocktail is in his syringe, so he knows how much to put into the other syringe. He then holds the two syringes side by side to compare the contents. In one of them is a little more. That one he gives to C.

Except when the spoon is well cleaned and both of the syringes are new or effectively cleaned (e.g., with bleach or alcohol), there seems to be an increased risk of passing microbacteriological or viral infections when utilizing this technique. The most obvious direction of transmission is from syringe A to syringe B, because blood rests (remnants) present in syringe A are diluted in the drug solution. However, when inserting A into B, the needle of A may come. into contact with virus particles (e.g., in old blood) in the hub of syringe B.

In 83% of the sharing events observed, economic motives were involved. In 68%, social incentives led to sharing of drugs. However, the motives for sharing drugs were often mixed. As in the last field note, heroin users frequently share drugs when these are bought together. Due to the market mechanism, it is worthwhile to buy drugs jointly. Buying together results in more drugs for the same amount of money. A frequent sharing situation very much resembles that of being among friends in a local pub: users sit around a table, talk in a sociable atmosphere, and share the available drugs. More often this concerns those who ingest drugs by smoking. Another common motivation for drug sharing is helping. The term "helping" is common vocabulary and it is a strong rule that one helps a fellow user who is in need of a dose with a betermakertje (a taste - a small dose to ameliorate withdrawal symptoms). This occurs even when one is not very eager, as the following excerpt depicts:

Jack starts to prepare a shot. When he is almost ready, Cor asks him for a little bit of the dope. At first, Jack does not respond, but Cor persists: "Ah, come on Jack, just give me a few drops." Jack does not seem pleased with the situation, but when he draws his shot through the cotton he does not take all the solution from the spoon and pushes the spoon to Cor.

This excerpt also illustrates the sharing of the spoon and the cotton. Both could be agents of HIV transmission (Koester, Booth & Wiebel 1990).

Drug users that shared drugs knew each other in most cases, but the ties often varied in strength and content. In 68% of the observed drug-sharing events, users were mainly related through participation in the regular drugtaking activities, such as buying and using at the same dealing addresses (n=93). At dealing places, users meet friends and make new contacts; however, knowing each other is not a condition per se for drug sharing, as the following field note indicates:

I met Karel last week at the Salvation Army. I didn't know him. But I was sick (withdrawal symptoms) and he helped me out with some bruin (brown heroin]. That never happened to me before, a perfect stranger that's willing to help me.

On the other hand, the relationships were often much more intense and multiplex; that is, drug users did not only frequent the same places to use and buy drugs, but were connected in other aspects as well: sexual partners (9 %), family (9%), or they lived in the same, sometimes squatted, house (5%). Thirty percent of the sharing IDUs were involved in a dyadic relationship. The acquisition and use of drugs is often an essential binding element in these dyadic relationships (Preble & Casey 1969). The following field note provides an illustration:

Meanwhile they are telling how they came together, live together, etc. They're together for +5 weeks now. Chris: "We share everything; social benefit, food, dope, etc." Richard: "For instance, tomorrow Chris gets his benefit and I get dope for it. Friday I'll get my money and we use that to buy dope." He goes on, "We go together into town every day, first to get methadone and then to make money."

IV. a. Social Implications
IV. b. Virological and Epidemiological Implications

IV. a. Social Implications

In the present article, a concept of drug sharing is described based on a study of a Dutch population in a situation of relatively low criminalization of drug use and relatively high availability of both drugs and syringes. However, drug sharing is embedded in a much broader pattern of social behaviors of heroin addicts that includes the sharing of many necessities of life. Although the level of these sharing behaviors could be representative of the "social responsibility" characterizing Dutch society (Hartsock 1987), in essence they are almost universal in drug subcultures and have been documented in many studies and in different places (Des Jarlais et al. 1988; Feldman & Biernacki 1988; Mata & Jorquez 1988; Preble & Casey 1969). Sharing fits the broader context of addict life and finds its function in coping with craving, human contact and needs, and life on the margins of society.

Drug use is not the only factor that brings and keeps drug users together. Drug users engage in many common activities and they devote considerable time to social activities (Kaplan et al. 1990). Nevertheless, drug sharing can be interpreted as an integrating ritual sanctioning a common life-style and strengthening mutual ties (Durkheim 1971). Thus, drugs are shared for an intertwined complex of social and economic reasons. Many events fit both economic and social categories. For instance, users who deal drugs might give a betermakertje (a taste) to someone without money. But this kind of credit is not evenly distributed to all customers; nor is it over time. Dealers take several factors into account. They must control their financial balance and anticipate the financial position of their clients, but they also must remain on good terms with their friends. They do not want to acquire the image of being in it just for the money and become alienated from their personal network. As Mata and Jorquez stated (1988):

Efforts to curb injecting drug use and needle sharing must begin with the understanding that these practices are embedded and maintained by a set of ongoing personal relations and exchanges in injecting drug users' personal social networks. Needle sharing must be seen as pan of the larger picture of drug sharing practices. Drug sharing is at once a means to socialize, to belong. and to provide some measure of protection from the exigencies of I& vida loca. More immediately, it is a means to cope with one's craving for drugs.

Sharing balances the constraints, the "ripping and running" (Agar 1973), the competition, violence, and mistrust of daily addict life. Without a little help from friends it is impossible to survive in the tough parallel world of addicts, dealers, and police. Both the helping and sharing as well as the ripping and violence are normal behaviors under abnormal or extreme circumstances, sometimes associated with similar behaviors in war and concentration camplike situations (Epen 1983; Despres 1976).

IV. b. Virological and Epidemiological Implications

The drug-sharing technique of frontloading seems to constitute an alternative route for HIV infection. An important issue regarding IUV transmission is the survival of HIV in blood rests in a syringe. It has been demonstrated that the virus can be detected for up to 30 days (Wolk et al. 1988) and even in syringes without visible remnants of blood (Chitwood et al. 1990). 'Me presumed infectivity of Western Blot-positive blood (Esteban et al. 1985) supports the notion that syringes that test positive are potentially infectious. Moreover, the interval of 30 days must be regarded as an extremely long period between use and reuse of syringes of IDUs. It is much more plausible that a syringe is used several times a day, especially when cocaine is involved or when employed at shooting galleries. In the present research it was found that when IDUs shared drugs by frontloading, the interval between two shared doses was sometimes even less than half an hour. The upsurge of injecting cocaine may also have additional consequences, as recent findings indicate that cocaine can exacerbate HIV- I transmission and infection in drug users (Lai et al. 1990).

It is hypothesized that the technique of frontloading or similar techniques are known far beyond the research sites of the present study. This hypothesis is supported by the present data and other research. Sharing drugs is a common phenomenon. An evaluation of a needle exchange in a small Dutch town showed that 67% of the exchangers were preparing collective doses (Huson & Neeteson 1989). The observations of frontloading on which the present article is based are recorded in different friendship groups and networks. In addition, a considerable number of the IDUs in the present study have at times been residents in other Dutch or foreign cities. Some have their roots in other cities, others come from neighboring countries. Another obvious ground for sharing drugs is that frontloading is the most efficient. and honest way to split a certain amount of drugs in two or more portions. When dividing the powdered drugs, it is very difficult to cut them into equal doses. By frontloading, the solution can rather simply be proportionated because most syringes have scale gradients on them. This is a strong argument when dealing with goods that on a street level outweigh the price of gold by four to 20 times. Finally and most importantly, this technique has been observed in Warsaw, Poland (Valk & de Jong 1988), in the Bronx (New York City) and Los Angeles (Stem 1990), Barcelona (Bolderhey 1990) and in Basel, Bern, Zurich, and other cities in Switzerland (Weisswange 1990). A similar technique called backloading has been observed in San Francisco (Froner 1989), London (Efthimiou 1990), and in Barcelona (Bolderhey 1990).

The AIDS epidemic among IDUs highlights the importance of basic knowledge of life-styles, behaviors, and interactions of drug users in their social networks. The thesis of the present article has been that a deeper look into this natural territorium may reveal unknown and important matters for IUV prevention. One such matter, the practice of frontloading, has been presented. Besides actual needle sharing, this practice could be an important factor in the spread of HIV among IDUs. In the Netherlands, where there actually is a high availability of sterile syringes and where the actual sharing of needles and syringes has decreased significantly (Hartgers et al. 1988; Hoek et al 1988b; Kaplan, Morival & Sterk 1986), frontloading could even become a main route of the spread of HIV. Thus, needle sharing is a definitionally incomplete notion because the term is a rough simplification of a very complex reality. Interactions of drug-using patterns, situations, and sociocultural factors involved in illegal drug use contribute considerably to the spread of HIV. Further research efforts into drug-sharing practices and related issues should enhance academic appreciation of these sociocultural factors. On the other hand, prevention efforts aimed at clearing such gaps in drug users' knowledge of HIV risks need to be given urgent attention. Because only a minority of drug users are in daily contact with treatment and helping agencies, the methods used to disseminate this knowledge should involve a permanent street education program for active IDUs as well as equipping them with the necessary skills to facilitate healthier behaviors. Outreach work plays a crucial role in this process because the only possible way to reach this target group is to enter its own territory. Good examples of this can be found in the San Francisco bleach campaign (Newmeyer 1988), the Chicago model (Wiebel 1988), the Mersey region outreach strategy in Great Britain (Newcombe 1989), and the cooperation model practiced in the Rotterdam outreach project HADON (Grund et al. In press).

The authors wish to thank the drug users who participated in this study for their cooperation; Professor Jan Huisman (Department of Public Health and Social Medicine, Erasmus University) and Dr. Koen Gerritse (Medical Biological Laboratory, TNO, Rijswijk, The Netherlands) for their constructive reviews of earlier draft versions; Geoffrey Froner (community health outreach worker, San Francisco) for his valuable suggestions; and Dr. Jaap Toet (Rotterdam Municipal Health Service, Epidemiology Department, The Netherlands) for RODIS data and additional analysis.

Agar, M.H. 1986. Speaking of ethnography. Sage University Paper Series on Qualitative Research Methods. Vol. 2. Beverly Hills, California: Sage.

Agar, M.H. 1973. Ripping and Running. New York: Academic Press. Barends, W. 1988. Routinermatig HIV-onderzoek in een Rotterdams methadonprogramma. Medisch Contact Vol. 43(2): 58-60.

Becker, H. 1970. Sociological Work: Method and Substance. London: Penguin.

Bolderhcy, A. 1990. Personal communication. Drugs worker, HIV Vereniging Nederland.

Brettle, R.P. 1986. Epidemic of AIDS related virus infection among intravenous drug abusers. British Medical Journal Vol. 292: 1671.

Buning, E.C. 1990. De GG&GD en het Drugprobleem in Cijfers, Deel IV. Amsterdam: GG&GD.

Buning, E.C.; Coutinho, R.A.; Brussel, G.H.A. van; Santen, G.W. van & Zadelhoff, A.W. van. 1986. Preventing AIDS in drug addicts in Amsterdam. Lancet Vol. 2:1435.

Burt. J. & Stimson, G.V. 1988. Report of ln-depth Survey of Intravenous Drug Use in Brighton. London: Monitoring Research Group.

Casriel. C.; Rockwell, R. & Stepherson, B. 1988. Heroin sniffers: Between two worlds. Journal of Psychaaciive Drugs Vol. 20(4): 437440.

Chaisson, M.A.; Stoneburger, R.L.; Hildebrandt, D.S.; Telzak, E.E. & Jaffe, H.W. 1990. Heterosexual transmission of HIV associated with the use of smokable freebase cocaine (crack). Poster presented at the VI International Conference on AIDS. San Francisco. (abstract no. Th.C.588).

Chaisson, R.E.; Moss. A.R.; Onishi, R.; Osmond, D. & Carlson, J.R. 1987. Human immunodeficiency virus infection in heterosexual intravenous drug users in San Francisco. American Journal of Public Health Vol. 77(2): 169-172.

Chitwood, D.D.; McCoy, C.B. & Inciardi, J.A.; McBride, D.C.; Comerford, M.; Trapido, E.; McCoy, H.V.; Page, J.B.; Griffin, J.; Fletcher, M.A. & Ashman, M.A. 1990. HIV seropositivity of needles from shooting galleries in South Florida. American Journal of Public Health Vol. 80: 150-152.

Cramer, T. 1989. Personal communication. Netherlands Ministry of Health.

Des Jarlais, D.C., Friedman, S.R.; Sotheran, J.L. & Stoneburger, R. 1988. The sharing of drug injection equipment and the AIDS epidemic in New York City: The first decade. In: Battjes, R.J. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. Rockville, Maryland: National Institute on Drug Abuse.

Despres, T. 1976. The Survivor: An Anatomy of Life in the Death Camps. New York: Pocket Books.

Durkheim, E. 1971. The Elementary Forms of the Religious Life. London: George, Allen & Unwin.

Efthimiou, A. 1990. Personal communication. Drugs worker, Terrence Higgins Trust.

Epen, J.H. van. 1983. Drugverslaving en Alcoholisme: Diagnostiek en Behandeling. Amsterdam: Elsevier.

Esteban, J.L.; Shih, J.W.K. & Tai, C-C.; Bodner, A.J.; Kay, J.W. & Alter, H.J. 1985. Importance of Western blot analysis in predicting infectivity of anti-HTLV-III/LAV positive blood. Lancet Vol. 2: 1083-1086.

Feldman, H.W. & Biemacki, R 1988. Ile ethnography of needle sharing among intravenous drug users and implications for public policies and intervention strategies. In: Battjes, R.J. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. Rockville, Maryland: National Institute on Drug Abuse.

Froner, G. 1989. Digging for Diamonds: A Lexicon of Street slang for Drugs and Sex. San Francisco: Health Outreach Team Productions.

Golden, E.; Fullilove, M.; Fullilove, R.. Lennon, R.; Porterfield, D,; Schwartz, S. & Bolan, G. 1990. 'Me effects of gender and crack use on high risk behaviors. Poster presented at the VI International Conference on AIDS, San Francisco. (abstract no. F.C.742).

Grund, I-P.C.; Adriaans N.F.P. & Kaplan C. D. In press. Changes in cocaine smoking rituals in the Dutch heroin addict population. British Journal of Addiction.

Grund, J-P.C.; Blanken, R; Adriaans, N. F.P.; Kaplan, C.D.; Barendregt, C. & Meeuwsen M. In press. Reaching the unreached: An outreach model for "on the spot" AIDS prevention among active, out of treatment drug addicts. In: O'Hare, P.A.; Newcombe, R.; Buning, E.C.; Drucker, E. & Mathews, A. (Eds.) Reduction of Drug-Related Harm. London: Routledge.

Grund, J-P.C.; Kaplan, C.D.; Adriaans, N.F.P. & Harms. J. 1988. Heroin Rituals: Observational Protocol of Endogenous and Exogenous Cuts. Rotterdam: Addiction Research Institute (IVO), Erasmus University.

Hartgers, C.; Butting. E.C.; Santen, G.W. van; Verster, A.D. & Coutinho, R.A. 1988. Intraveneus druggebruik en het spuitenomruilprogramma in Amsterdam. Tijdschrift Sociale Gezondheidszorg Vol. 66: 207-210.

Hartsock, P. 1987. Trip Report -Europe. Rockville. Maryland: National Institute on Drug Abuse.

Hoek, J.A.R. van den; Coutinho, R.A.; Haastrecht, H.J.A. van; Zadelhoff, A.W. van & Goudsmit, J. 1988a. Prevalence and risk factors of HIV infections among drug users and drug using prostitutes in Amsterdam. AIDS Vol. 2: 55-60.

Hock, J.A.R. van den, Haastrecht, H.J.A. van; Zadelhoff. A.W. van-, Goudsmit, J. & Coutinho, R.A. 1988b. HIV-infectie onder druggebruikers in Amsterdam: Preventie en risicofactoren. Nederlands Tijdschrift voor Geneeskunde Vol. 132(16): 723-728.

Huson, D. & Neeteson, K. 1989. Enquete AIDS-Preventie HKPD Vlissingen. Vlissingen, Ile Netherlands: HKPD.

Kaplan, C.D.; Janse, H.J. &Thuyns, H. 1986. Heroin smoking in the Netherlands. In: Community Epidemiology Work Group Proceedings. Rockville, Maryland: National Institute on Drug Abuse.

Kaplan, C.D.; Morival, M. & Sterk, C.E. 1986. Needle exchange IV drug users and street IV drug users: A comparison of background characteristics needle and sex practices, and AIDS attitudes. In: (Eds.) Community Epidemiology Work Group Proceedings. Rockville, Maryland: National Institute on Drug Abuse.

Kaplan, C.D.; Vries, M. de; Grund, J-P.C. & Adriaans, N.F.P. 1990. Protective factors: Dutch intervention, health determinants and the reorganization of addict life. In: Ghodse, H.; Kaplan C. D. & Mann, R.D. (Eds.) Drug Misuse and Dependence. London: Parthenon.

Koester, S., Booth, R. & Wiebel, W. 1990. 'Me risk of HIV transmission from sharing water, drug-mixing containers and cotton filters among intravenous drug users. International Journal on Drug Policy Vol. 1(6): 28-30.

Lai, P.K.; Takayama, H.; Tamura, Y. & Nonoyama, M. 1990. Activation of human immunodeficiency virus in human myeloid cells by cocaine. Poster presented at the VI International Conference on AIDS, San Francisco. (abstract no. S.A.226).

Limbeek, 1. van; Wouters, L.; Hekker, A.C. & Cramer, A. 1987. Een Pilot-Studie naar het Voorkomen van Personen met HIV-Antistoffen in Hulpverleningsprogramma's voor Drugsverslaafden Buiten de Randstad. Bilthoven, Ile Netherlands: FZA.

Marmor, M.; Des Jarlais, D.C. & Cohen, H.; Friedman, S.R.; Beatrice, S.T.; Dubin, N.-. El-Sadr, W.; Mildvan, D.; Yancovitz, S.; MaLhur, U. & Holzman, R. 1987. Risk factors for infection with human immunodeficiency virus among intravenous drug abusers in New York City. AIDS Vol. 1: 3 9-44.

Mata, A.G. & Jorquez, J.S. 1988. Mexican-American intravenous drug users' needle-sharing practices: Implications for AIDS prevention. In: Battjes, R.J. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. Rockville. Maryland: National Institute on Newcombe, R. 1989. Preventing the spread of IUV infection among and from injecting drug users in the U.K. International Journal on Drug Policy Vol. 1(2):20-27.

Newmeyer, J.A. 1988. Why bleach? Development of a strategy to combat HIV contagion among San Francisco intravenous drug users. In: Battjes, R.J. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Mongraph 80. Rockville, Maryland: National Institute on Drug Abuse.

Newmeyer, I.A. 1987. 'Me role of the IV drug user and the secondary spread of AIDS. Street Pharmacologist Vol. 11 (1): 1-2.

Power, R.M. 1988. The influence of AIDS upon patterns of intravenous use syringe and needle sharing - among illicit drug users in Britain. In: Battjes, R.I. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abuse": National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. Rockville, Maryland: National Institute on Drug Abuse.

Preble, E. & Casey, J.J. 1969. Taking care of business -the heroin user's life on the street. International Journal of the Addictions Vol. 1: 1 -24.

Schoenbaum, E.E.; Hartel, D.& Friedland, G.H. 1990. Crack use predicts incident HIV seroconversion. Paper presented at the VI International Conference on AIDS, San Francisco. (abstract no. Th.C. 103).

Seidel, J.V. 1988. 'Me Ethnograph (version 3.0). Littleton, Colorado: Qualis Research Associates.

Sterk, C.E. 1989. Living the Life: Prostitutes and Their Health. Ph.D. dissertation. Rotterdam: Erasmus Universiteits drukkerij.

Sterk, C.E. 1988. Cocaine and IUV seropositivity. Lancet Vol. 1: 1052.

Stern, L.S. In press. Self-injection education for street-level sexworkers In: O'Hare, P.A.; Newcombe:, R.; Buning. E.C.; Drucker, E & Mathews, A. (Eds.) Reduction of Drug-Related Harm. London: Routledge.

Stem, L.S. 1990. Personal communication. Health Educator/Research Assistant, Montefiore Medic-al Center.

Toet, J. & Ven, A.P.M. van de. 1989. Het RODIS uit de Steiger$. Resultaten 1988 Rotterdam. Rotterdam: GGD afdeling Epidemiologie.

Valk. P. van der& long, W. de. 1988. Verslaafd in PoIen. Intermediair

Drug Sharing and HIV Risks

Vol. 24(17): 59 -63.

Weisswange, A. 1990. Personal communication. Outreach worker, Contact Bern.

Wiebel, W.W. 1988. Combining ethnographic and epiderniologic meth. ods in targeted AIDS interventions. In: Battjes, R.J. & Pickens, R.W. (Eds.) Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. Rockville. Maryland: National Institute on Drug Abuse.

Wolk, J.; Wodak, A.; Morlet, A.; Guinan, J.J.; Wilson, E.; Gold, J. & Cooper, D.A. 1988. Syringe HIV seroprevalence and behavioral and demographic characteristics of intravenous drug users in Sidney, Australia, 1987. AIDS Vol. 2: 373-377.

Research supported by Grant No. 900-556-046 from the Nederlandse Organisatie voor Wetenschappelijk Onderzoek, Gebied Medische Wetenschappen, Deelwerkgemeenschap Social Psychiatric (Dutch Organization for Scientific Research, Medical Science Section, Social Psychiatry Working Group). Opinions expressed in this article do not necessarily reflect the policies of the supporting organization.

* EUR Addiction Research Institute (IVO), Medical and Health Sciences Faculty, Erasmus University Rotterdam, Postbus 173 8, 3000 DR Rotterdam, Ile Netherlands.