Journal of Substance Abuse Treatment, Vol. 3, pp. 271-274, 1986 Printed in the USA. All rights reserved.

0740-5472/86 $3.00 + .00 Copyright 1987Pergamon Journals Ltd

ORIGINAL CONTRIBUTION

AIDS: Relationship to Alcohol and Other Drugs

LARRY SIEGEL, MD Chairman,Committeeon A.I.D.S. and ChemicalDependency,AmericanMedicalSocietyon Alcoholismand OtherDrugDependencies,Inc.

Abstract-Most people who are exposed to AIDS do not get the syndrome. It seems clear that there must be cofactors. Most people with AIDS have a history o f alcohol or other drug use, and many o f the drugs used have been shown to suppress the immune system. The correlation between drug use and development o f AIDS in several populations is striking, and it is suggested that definitive research into this possible cofactor be urgently initiated. The elimination o f cofactors may present an immediate way to control this epidemic. Suggestions are made as to how and why alcohol and drug treatment professionals should become a part o f this effort. Keywords-AIDS, alcohol, drugs, relationship, cofactors INTRODUCTION Two OF Tim MOSTinteresting questions being asked about Acquired Immunodeficiency Syndrome (AIDS) will be discussed in this paper. The first is why do so many people not become immunodeficient or contract the complicating diseases when exposed to the widely believed causal agent, a retrovirus most commonly called HTLV-III and recently renamed Human Immunodeficiency Virus (HIV). The second is what is there about the "risk" groups that make them susceptible. Why some exposed people do contract it and others do n o t - t h a t is the question. The fact that direct exposure alone does not usually cause AIDS is now known, based on the hundreds of direct exposure to body fluids of all kinds by health workers, with perhaps only two having developed evidence of exposure (HIV +) and none having developed AIDS (Centers for Disease Control, 1986). In addition, seven studies have been performed involving over 350 family members of people with AIDS with close nonsexual contact, and only a single family member (a mother who used no precautions caring for a very sick infant) has developed serologic or virologic evidence of HIV transmission, again demonstrating how difficult it is to get this infection (Centers for Disease Control, 1986). Whereas very long-term effects are not predictable at this time, it is known that at least over a six-year period between 6070 and 90070 of homosexual men infected with HIV did not get AIDS (Jaffee et al., 1985). Recent documentation of the presence of the HIV antibody in 25070 to 4170 of nonrisk group patients with acute malaria but without AIDS further suggests that the exposure to HIV alone is not sufficient for the development of AIDS (Volsky et al., 1986). However, there are still questions as to why the male homosexual population in the U.S. is especially susceptible and what there is about other populations (such as heterosexual blacks in Belle Glade, Florida) that relates to their high incidence. BACKGROUND The presence of something in addition to the HIV virus exposure seems to be required to acquire the virus and become ill from it. One or more cofactors must exist. A variety of such cofactors have been proposed (Seligmann et al., 1984), including repeated exposure to the HIV virus, nutrition, and other coincident infections. In spite of this, very little investigation has been done of some of the more obvious cofactors, such as the use of ethyl alcohol and other drugs by people who get AIDS. M.E. Whiteside and C.L. MacLeod (letter to James Howell, M.D., State of Florida Health Officer, 1986),
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The author wishes to gratefully acknowledge the review and critical comment on this manuscript by Drs. LeClalr Bissell, John Jonikas, Max Schneider, Tom Smith, and Max Weisman and to acknowledge with gratitude the many hours spent by Ms. Ann Weekley typing and editing. Requests for reprints should be sent to Larry Siegel, MD, 520 Southard Street, Key West, FL 33040.

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among others, have repeatedly pointed out that there must be environmental factors that either predispose to the acquisition of AIDS or are cofactors at the time of exposure to the causative virus. What needs more investigation is whether the "internal cellular environment" might not require alteration in order to allow infection and whether that alteration may not be exactly what happens in any of the so-called "high risk" populations that develop AIDS. Of even greater possible impact is the suggestion that removal of such potential precursors or determinants (e.g., alcohol and other drugs) may allow for recovery from and/or avoidance of AIDS in individuals who have not yet progressed to the full-blown syndrome. Drugs, including alcohol, have been used by at least 80% of homosexual men with AIDS (C.A. Caceres, personal letter, 1986; Cohen, 1985). In a review of data compiled by the Centers for Disease Control (CDC), Guinan et al. (1984) found that the adult heterosexual AIDS patients who had been tabulated as having "no identified risk" were reported as users of marijuana. Of 50 homosexual men, 96% had used nitrites, 807o had used marijuana, 66% had used nasal cocaine, and 50o/o had used ethyl chloride (Guinan et al., 1984). No questions were asked of either group regarding alcohol use. The proportion of the homosexual population that problematically uses alcohol and drugs may well be substantially higher than in the nongay population (Fifield, DeChescenzo, & Latham, 1980). While the data are limited and of questionable reliability, Smith has commented that: "On the basis of information obtained from severalresearche r s . . , it would seem that three out of every ten homosexuals are likely to experience significant difficulties as a result of alcohol abuse. In fact, the above percentages may actually be somewhat conservative, as most of them were based on self reports." (Smith, 1980, p. 92) Extensive use of alcohol by people with AIDS in Belle Glade, Florida, is apparently well known (M.E. Whiteside, telephone communication, 1986) but is not part of the surveillance history used by CDC or other health care workers there. The question of drugs and alcohol exposure of hemophiliac people with AIDS and children with AIDS has not been investigated. However, the effects of alcohol on fetal immunity with decreased T-cells and T-cell function (Fetal Alcohol Syndrome) have been shown (Johnson, Knight, Mamer, & Steele, 1981). It has also been demonstrated that T-lymphocyte function in pregnant women who drink is suppressed (Madden, Donahoe, & Smith, 1984).
STATEMENT OF THE PROBLEM

Larry Siegel
tices exists. In one study, 65 % of gay people stated they used alcohol or recreational drugs before or while having sex, and 1870 reported they were so drunk they would not drive a car (Research and Design Corp., 1985). Gay and bisexual men are very aware that they are more prone to have unsafe sex if they have been using alcohol or drugs (Room, 1985). However, it is not at all clear that IV drug users, hemophiliacs, and other HIV-positive individuals and their partners (who may be viremic and infectious) have the same degree of awareness as gay and bisexual men. It seems self-evident that efforts to educate the population of concern regarding the "disinhibiting" effect of drugs and alcohol, and the subsequent risky behavior that ensues, need to be made and evaluated. The disinhibiting effects on behavior caused by alcohol and other drugs are well known and may possibly allow for more frequent and "dangerous" exposure to the probable causative virus of AIDS; however, the question of the effect of drugs and alcohol on the integrity of the immune system, either alone or in combination, has been investigated only sporadically and incompletely (Geokas, 1984). In a recent symposium on alcohol and the immune system, a section on AIDS contained only four abstracts, none having to do with the clinical coexistence of alcoholism, chemical dependency, and AIDS or with basic investigations of susceptibility to AIDS relative to drug and alcohol use, acquisition of HIV infection during drug exposure (e.g., are drunk chimps more susceptible to HIV and AIDS than sober ones?), or progression from Aids-Related Complex (ARC) to AIDS as a potential consequence of chemical use (National Institute on Alcoholism and Alcohol Abuse, 1985). The direct effects of drugs on the immune system have been intermittently studied. While no definite long-term effect on generalized immunity has been documented, suppression of normal lymphocyte function in acute phases of alcohol detoxification has been shown in some studies (Lundy et al., 1975; Watson et al., 1985). Atrophy of the thymus, which is so markedly impaired in AIDS, is the major source of T-cell lymphocyte populations and has been shown to occur in alcohol-fed rats (Tennebaum, Ruppert, St. Pierrer, & Greenbeyer, 1969). In addition, it has been demonstrated that lymphocyte function is suppressed by the presence of clinically observable alcohol concentrations (Glassman, Bennott, & Randall, 1985). T-cell subset analysis in one sample reveals significantly fewer OKT4 (helper) cells in both IV and nonIV drug abusers than controls (Maayon et al., 1984). The correlation between use of nitrites and development of Kaposi's Sarcoma now seems to be much clearer (Mathur-Waugh, Mildaun, & Sehie, 1985). It

Data are now available to show that a relationship between alcohol and drug usage and unsafe sex prac-

AIDS, Alcohol, Drugs

has been known for many years that heavy alcohol use predisposes a person to certain infectious diseases, especially tuberculosis and klebsiella pneumonia, and also to less severe infections. The reasons for this are not clear but have been variously ascribed to poor white blood cell function (including suppression of lymphocytes), to polymorphonuclear cells, and to alteration of protein synthesis including immunoglobulins. Whereas the HIV virus may not cause clinically apparent AIDS in most people who are infected with it, there is a strong coincidence of the appearance of AIDS and the use of chemical substances which not only cause disease in and of themselves but may be cofactors in the development of the full Acquired Immunodeficiency Syndrome. In addition, the frequent pattern among both people with AIDS and among many others as well is concomitant and conconcurrent use of multiple mood-altering substances. The combined effect of multiple drug use at the time of exposure to the HIV virus and the continued suppression of the immune system in the presence of the HIV virus may be enough to lead to the full-blown syndrome. Other aspects of a possible association between AIDS and drugs which are of great interest and concern are (a) the altered effect that alcohol and drugs seem to have on people with AIDS and (b) the need for mood-altering medication in currently abstinent recovered alcoholics and addicts who develop AIDS. Health care workers in the field of substance abuse who also have experience with treating AIDS say that addicted AIDS patients seem to develop exceptional sensitivity to alcohol and drugs. People with AIDS commonly report, "I can't drink like I used to," and when withdrawal symptoms are present they seem more severe than in patients without AIDS. Nonaddictive alternatives for pain and anxiety need to be carefully developed, and professionals familiar with the problems of medication use of all kinds for recovered alcoholics and drug addicts should be part of the treatment team for such patients who also have AIDS. This is essential in order to evaluate medication and to avoid inappropriate withholding of medications as well. RECOMMENDATIONS FOR TREATMENT PROFESSIONALS At this point it should be clear why alcoholism and drug treatment professionals need to be involved with research treatment and policy formation regarding the AIDS epidemic, as inevitably they must be. The reasons include the following: 1. Alcohol and drugs may be cofactors in the acquisition, development, worsening, or transmission of AIDS.

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2. Attention to individuals who are high risk for AIDS and are also ill with chemical dependency should become a very high priority of the A&D community. 3. People with AIDS, or HIV-positive individuals, may recognize their own need for chemical dependency treatment and seek it. 4. Intervention and treatment strategies for people with AIDS, ARC, HIV-positivity (or who are at risk for these conditions) and also have a concomitant substance use disorder are best devised and executed by, or in association with, alcoholism and drug treatment professionals. Some specific recommendations are: 1. Inservice education on AIDS should be provided for all members of the treatment team. This should include all workers on the unit (including maintenance workers) and should occur regularly, with quarterly updates. Lack of transmission of the HIV virus by casual contact needs emphasis. 2. Counselors should become particularly proficient in discussing AIDS-related issues (e.g., fear of touching an IV drug user, or unwillingness to use a washing machine recently used by a gay man on the unit, or aversion to hugging an HIV-positive patient). 3. Entire treatment staff should examine internalized homophobia in themselves and in their patients, including their gay patients. 4. A regular lecture on medical aspects of AIDS should be included in every treatment program as part of the standard orientation to chemical dependency. 5. Treatment programs should form a liaison with medical personnel who are familiar with treatment of problems in AIDS and ARC and who have some knowledge of substance use disorder. 6. Intervention strategies for getting into treatment high-risk AIDS individuals who are also ill with substance use disorder should be devised and implemented, in cooperation with community groups which serve these at-risk populations. Special attention to the problem of intervening with IV drug users will be required. CONCLUSION Fear can easily drown out the voice of reason, which has little chance to develop in an environment of ignorance(Freud, 1952, p. 696). This is certainly true with f6gard to dealing with AIDS as described above. A growing knowledge of AIDS is necessary to change attitudes and to form reasonable policies and can best be acquired by cooperation among the various disciplines involved. The endeavors suggested here should not be left to medical, social service, or other professionals, any more than we now leave to any

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Larry Siegel

one professional g r o u p the t r e a t m e n t of other patients with chemical d e p e n d e n c y . It is h o p e d that the response o f the alcoholism a n d drug t r e a t m e n t comm u n i t y to this new challenge will be similar to those challenges in the p a s t - t h a t we will say, " W e are responsible to see that a p p r o p r i a t e care is p r o v i d e d . "

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Lundy, J., Raaf, J.H., Drakins, S., Wanebo, H.J., Jacobs, D.A., Lee, T.D., Jacobowitz, D., Spear, C., & Oettgen, H.F. (1975). The acute and chronic effects of alcohol on the human immune system. Surgery, Gynecology and Obstetrics, 141, 212-218. Maayon, S., Tainchil, N., Backonroth, R,, Reber, E.E., Pollack, C., Taller, N., & Chiao, J.W. (1984). Cell mediated immunity in drug abusers: Evaluation and comparison of two assessmentmethods. Symposium proceedings, Focus on AIDS: A clinical approach (pp. 22-27). Miami, FL: Meriux Institute. Madden, J.C., Donahoe, R.M., & Smith, I.E. (1984). Increased rate of E. Rosette formation by T-lymphocytes of pregnant women who drink alcohol. Clinical Immunology and lmmunopathology, 33, 67-79. Mathur-Wagh, U., Mildaun, D., & Sehie, R. (1985). Follow up of 4Y2 years of homosexual men with generalized lymphadenopathy. New England Journal of Medicine, 313, 1542. National Institute on Alcoholism and Alcohol Abuse. (1985). Literature search on alcohol and the immune system. Workshop on the effects of alcohol on the immune system. Bethesda, MD: Author. Research and Design Corporation. (1985). A report on designing an effective AIDS prevention campaign for San Francisco: Resuits from the second probability samples of art urban gay male community. San Francisco: San Francisco AIDS Foundation. Room, R. (1985). AIDS and alcohol: Epidemiological and behavioral aspects. NIAAA Consultation on AIDS and alcohol. Bethesda, MD: National Institute on Alcoholism and Alcohol Abuse. Seligmann, M., Ches, L., Fahey, J., Fauci, A.J., Lachmann, P.J., L'Age-Stehr, J., Nev, J., Pinching, A.J., Rosen, F.S., Spira, T.J., & Wybran, J. (1984). New England Journal of Medicine, 311, 1286-1292. Smith, T. (1980). Memo for Tom Smith, M.D., to Larry Meridith and Wayne Clark, San Francisco Substance Abuse Services. Alcohol abuse and alcohol-related problems in San Francisco: A needs assessment: Alcoholism treatment andprevention services. San Francisco: Department of Public Health. Tennebaum, J.l., Ruppert, R.D., St. Pierrer, R.L., & Greenbeyer, N. (1969). The effect of chronic alcohol administration on the immune responses of rats. Journal of Allergy, 44, 272. Volsky, D.J., Wu, Y.T., Stevenson,M., Dewhurst, S., Sinangil, F., Merino, F., Rodriguez, L., & Godoy, C. (1986). Venezuelan patients with acute malarial infections. New England Journal of Medicine, 313, 647. Watson, R.R., Jackson, J.C., Hartman, B., Sampliner, R., MobIcy, D., & Eskelson, C. (1985). Endorphins and alcohol consumption in males. Alcoholism Clinical and Experimental Research, 9, 248-254.