RESEARCH NEEDED TO FIND WHY HIV HITS CRACK SMOKERS
HARDER

It's no secret that injecting drugs carries with it many dangers, not
the least of which is the risk of infection with the HIV and
hepatitis C viruses.

Consequently, public health authorities have implemented many
innovative and successful interventions, such as needle exchanges and
Vancouver's supervised injection site, to reduce the risks of infection.

What has been a secret, though, is the risks of infection associated
with smoking crack cocaine. Although evidence from the U.S. as far
back as the mid-1990s suggested that smoking crack is associated
with HIV infection, the fact that the drug is smoked rather than
injected led many people to believe that the risks were not
significant.

As a result, health authorities were not as quick to implement harm
reduction measures for crack smokers as they were for injection drug
users. But a study by researchers at the B.C. Centre for Excellence
in HIV/AIDS, published this week in the Canadian Medical Association
Journal, suggests that crack smokers face significant risks, and that
we must therefore evaluate interventions that might reduce those risks.

The researchers assessed the patterns of crack smoking among 1,048
injection drug users in Vancouver between May 1996 and December 2005,
and discovered two things.

First, the rate of crack smoking increased dramatically during the
course of the study: Just 11.6 per cent of study participants were
daily smokers during the first three years of the nine-year study,
while 39.7 per cent were smoking crack daily during the last three
years.

It's not clear what drove this increase in crack use, though it's
generally accepted that both economic and cultural factors play a
role in the rates of use of crack and other drugs.

The second finding was even more striking: Participants who smoked
crack daily were more than four times more likely to become infected
with HIV than injection drug users who smoked less often or not at
all.

It's also not clear why frequent crack smokers are at greater risk of
infection, though the researchers offer several possibilities: Crack
pipes are known to produce wounds in and around the mouth --
particularly when smoking is rushed to avoid detection -- which may
make users more vulnerable to infection when sharing pipes or during
oral sex.

Alternatively, crack smokers may have more HIV-positive individuals
in their social networks, which could lead to increased likelihood of
infection, or users may have been unable to recall risky behaviours
in which they engaged during crack binges.

While the study can't therefore answer all questions, it does provide
evidence that crack smoking is an independent risk factor for HIV
infection. And that, combined with the fact that we don't have all
the answers, makes it clear that we need further research to
determine the best methods of reducing risks associated with crack
smoking.

The authors specifically suggest crack specific measures such as the
distribution of safer crack kits -- which include pipes or
mouthpieces and disinfectants -- and the provision of supervised
inhalation rooms. While controversial, early research suggests that
crack kits are associated with reduced sharing of smoking equipment.

And while inhalation rooms are even more controversial, they have
been successfully implemented in a number of European countries,
including Germany, the Netherlands and Switzerland.

Of course, like much else concerning crack cocaine, we don't really
know what the impact of an inhalation room would be. But that, along
with the very real risk of HIV infection, suggests that we must find
out -- and we can do so by initiating a research project aimed at
evaluating the impact of a supervised inhalation room.

Several medical groups have expressed support for such a research
project and for good reason, because the only thing we have to lose
is our ignorance.