D. A.: Comparison of an active and passive surveillancesystem of primary care providers for hepatitis, measles,rubella, and salmonellosis in Vermont. Am J PublicHealth 73: 795-797 (1983).

8. Kimball, A. M., Thacker, S. B., and Levy, M. E.: Shigellasurveillance in a large metropolitan area: assessment of a

passive reporting system. Am J Public Health 70: 164-166(1980).

9. Rauch, K. J., et al.: Surveillance of AIDS in SanFrancisco: evaluation of the completeness of reporting.Presented as a scientific exhibition at the InternationalConference on AIDS, Paris, June 25, 1986.

The Voluntary Acceptanceof HIV-Antibody Screeningby Intravenous Drug Users

GREGORY A. CARLSONTHOMAS A. McCLELLAN

Mr. Carlson is Consultant to the Outpatient Metha-done Maintenance Program, Veterans AdministrationMedical Center, Minneapolis, MN, and Clinical ServicesCoordinator, Chemical Dependency Program, Universityof Minnesota Hospitals. Mr. McClellan is a ClinicalSocial Worker, Social Work Service, Veterans Adminis-tration Medical Center, Minneapolis.

Tearsheet requests to Mr. Carlson, University ofMinnesota Hospitals, Department of Psychiatry, Box393, Mayo Memorial Bldg., 420 Delaware St., SE,Minneapolis, MN 55455.

Synopsis ....................................

Intravenous drug abusers in a methadone pro-gram in Minnesota were offered HIV-antibody

screening to determine the degree of interest inscreening and extent of infection. Thirty-nine (85percent) were willing to be tested. Only sevenrefused. All patients were aware of acquiredimmunodeficiency syndrome (AIDS) and their highrisk of exposure to the AIDS virus through sharingof injection paraphernalia. None reported exposureto additional risk factors, such as homosexual orbisexual activity or having received a blood trans-fusion.

Of the patients tested, none was positive forHIV antibodies. The high degree of patient interestin screening was unanticipated as was the lack ofpositive laboratory findings for HIV antibodies.Factors associated with acceptance of testing in-cluded patient awareness of high seroprevalencerates, indifference to potential negative socialconsquences of positive HIV-antibody status, andthe voluntary nature of the testing. These findingsraise a cautious sense of optimism about HIV-antibody screening for similar risk groups.

CvONSIDERABLE PUBLIC ALARM HAS BEEN createdby the fear of widespread exposure to acquiredimmunodeficiency syndrome (AIDS). The numberof cases meeting surveillance criteria of the Centersfor Disease Control is predicted to double withinthe year (1). Data indicate extensive exposure tothe AIDS virus human immunodeficiency virus(HIV) or HTLV-III/LAV in high-risk populations(2). In reaction, some local and national politicalfigures have urged the passage of laws for themandatory screening of individuals in the twoprimary high-risk groups-homosexual and bisex-ual males and intravenous (IV) drug users. Incontrast to this stand, the Public Health Servicehas recommended voluntary testing for persons inhigh-risk groups (3).

Intravenous drug users are identified as the

second highest risk group for the development ofAIDS, constituting as many as 32 percent ofreported cases in some areas (4). An estimated270,000 IV drug users are infected in the UnitedStates alone (5). Spira and coworkers (6) foundthat among 86 New York City IV drug users in adrug detoxification program, 87 percent wereseropositive for HIV antibodies in laboratoryscreening (ELISA) (7). In contrast, it has beenreported that less than 10 percent of 35 methadonepatients in New York City were seropositive (8).

Based on these reports, it was estimated that anumber of patients currently active in an outpa-tient methadone maintenance program would testpositive for HIV antibodies. In addition, clinicstaff anticipated difficulty in securing voluntarypatient cooperation with laboratory screening.

July-August 1987, Vol. 102, No. 4 391

Methods

Several patients requested HIV antibody testingwho were active in the Outpatient MethadoneMaintenance Program at the Veterans Administra-tion Medical Center, Minneapolis, MN. In re-sponse, all patients in the program were offeredHIV antibody screening (ELISA) as of October 15,1985. In addition to being offered the test, allpatients were asked about their

* knowledge of AIDS and specific risk factorsassociated with transmission of the virus,* willingness to be tested for presence of HIVantibodies,* exposure to additional risk factors, such ashomosexual and bisexual activity or having re-ceived a blood transfusion,* history of sharing needles and syringes,* geographic mobility, and* history of plasma-blood donation.

Patient records were also reviewed for age, race,length of addiction, urine drug screening record,employment and school status, months in metha-done treatment, and hepatitis-B antigen status.

Information about the availability of screeningwas provided to all patients in clinical interviewsadministered by program staff. Risk-associatedbehavior was discussed, as was the fact that beingHIV-seropositive does not absolutely result indevelopment of AIDS. Patients were told thatscreening results (positive or negative) would bedocumented in their medical record and protectedunder Veterans Administration confidentiality pro-visions requiring signed consent prior to release. Inaddition, patients were instructed that nonparti-cipation would have no effect on their treatment;

that is, screening was not a procedure required bythe program.

Results

There were 46 patients enrolled in the OutpatientMethadone Maintenance Program when laboratoryscreening was made available. All patients weremen with a mean age of 32.2 years (range, 27-53years). Thirty-nine men (84.8 percent) were white,and 7 were black. The length of opiate addictionranged from 2 to 34 years (mean, 16.4 years).Sixty-eight percent reported either full-time em-ployment or being in school. None was positivefor hepatitis-B antigen. The mean length of metha-done maintenance was 2.3 years (range, 1 monthto 7 years). Clinical urine analysis for drugscreening indicated varying degrees of ongoingillicit drug abuse, including those drugs usuallyadministered intravenously. Opiates were the majordrug of abuse. Visual inspection of the antecubitalarea during the blood drawing procedure revealedboth old and recent needle puncture marks, indi-cating continued "at risk" behavior.

In clinical interviews, all patients reportedawareness of AIDS. They were also aware of beingin a high-risk group. Thirty-nine of the 46 patients(85 percent) were willing to be tested for presenceof the HIV antibody. The remaining seven patients(15 percent) refused testing, all stating they hadnot administered drugs intravenously over the pastseveral years and did not consider themselves to beat risk. A review of urine-drug screen records forthese patients confirmed the self-reported absti-nence of five patients, with the remaining twoshowing a pattern of illicit drug use comparable tothose accepting screening. None of the 46 patientsadmitted exposure to additional risk factors, suchas homosexual or bisexual activity or havingreceived a blood transfusion.

Thirty-two patients (69 percent) reported sharingof drug paraphernalia during the past 5 years, witha mean of 140 episodes. Only one clinic patienthad resided out of state prior to entrance into ourmethadone program. Ten patients (22 percent) hadtaken at least one trip for 5 days or longer out ofstate when on methadone maintenance. Trips in-cluded travel to areas of high HIV seroprevalence(New York, Miami, San Francisco, New Orleans).However, only 3 of the 10 patients reportedsharing of injection paraphernalia. Urine-drugscreen analysis for this group did confirm someillicit drug use while out of state. Five of 46patients (11 percent) had donated blood plasma for

392 Public Health Reports

cash an estimated 50 times or more over theprevious 5 years.Of the 39 patients requesting the ELISA test for

HIV antibodies, results from 32 are available.None was serum positive. For the seven remainingpatients, it was not possible to secure a bloodsample beause of the deteriorated condition oftheir veins.

Discussion

It is noteworthy that all clinic patients wereaware of AIDS and their high risk for exposure tothe AIDS virus through IV drug use and thesharing of injection paraphernalia. This is contraryto the widely held belief that opiate addicts are, asa group, poorly informed about health risksassociated with their drug abuse. It has beenreported that drug abusers, unlike the homosexualand bisexual risk group, lack a social network thatwould facilitate dissemination of informationabout AIDS and its transmission (9). We did notfind this to be true for our patients, although therewas no indication that awareness of transmissionfactors directly influenced either entrance intotreatment or avoidance of sharing syringes andneedles.

Second, the clinic staff believed this group ofpatients would resist HIV-antibody laboratory test-ing, for many of them had actively resistedprogram requirements for routine laboratory test-ing and physical and psychological examinations.Surprisingly, the majority of the patients cooper-ated with the HIV-antibody testing and openlydiscussed their risk-associated behaviors. Factorsassociated with voluntary acceptance of HIV-antibody testing included patient awareness of highseroprevalence rates among IV drug users else-where in the United States, an indifference topossible discrimination or negative social conse-quences related to being identified as HIV-antibody positive, and the opportunity in anopen-ended interview to correct erroneous assump-tions and beliefs about AIDS and its transmission.When testing was offered, seroprevelence ratesamong local IV drug users were unknown; how-ever, it was feared by the patients to be high. Thefact that screening was made available on acompletely voluntary basis seemed in and of itselfto influence acceptance strongly. These findingsraised a cautious sense of optimism with regard tothe feasibility of offering voluntary screening tosimilar high-risk groups.The high number of patients (69 percent) report-

ing the sharing of injection paraphernalia over thepast 5 years is of concern. This is consistent withreports elsewhere (4,10). Ongoing urine drug-screenanalysis and visual inspection confirmed the con-tinued at-risk behavior of some patients evenduring participation in a methadone maintenanceprogram. Unlike Friedland and coworkers (10),who found the vast majority of New York Citystreet addicts not to be geographically mobile, 22percent of our midwestern patients had traveledout of state during methadone maintenance. Highmobility may be of concern to programs withserum-positive patients. Although only five pa-tients reported blood plasma donations as a sourceof income, the actual number of such donationswas extremely high. This behavior supports therationale for a recommendation by the PublicHealth Service that high-risk groups not donate(11).Although reassuring, it was unanticipated to

find no serum-positives in this midwestern groupof IV drug abusers. This finding is surprising,considering the 16.4 mean years of addiction andthe urine drug screening indicating ongoing use ofillicit drugs commonly administered intravenously.Although we found no evidence of the spread ofthe AIDS virus among the group surveyed, recentestimates (2) of serum positivity for IV drug usersas a whole provide little basis for a complacentattitude. An unexpected finding may be of concernto persons attempting widespread HIV screeningfor this particular risk group: seven more patientswanted to be tested, but blood samples could notbe drawn because of the condition of their veins.

It is likely that upper midwest addicts enrolledin a Veterans Administration methadone mainte-nance program differ substantially from their peerselsewhere in such ways as preaddiction adjustment,level of educational achievement, employment, andcriminality. Information about the availability of

July-August 1987, Vol. 102, No. 4 393

AAC'

'7....: . ...:: rd h opp.t:ortuntyi a opnene

screening was given to each patient individually byan experienced drug counselor assigned to theprogram for many years. All testing was doneon-site and at times convenient to the patients. Itis not known unequivocally to what extent thesefactors positively influenced interest in screening.The other methadone program in the area did notoffer on-site testing or take particular interest inHIV-antibody screening, and a substantially lowerrate of testing acceptance was reported for itsclients.The results of this survey support the feasibility

of voluntary testing among IV drug users. Such anapproach would be a preferred alternative toproliferation of local and national laws requiringmandatory screening, with the resulting complianceissues complicating an already difficult publichealth problem. Furthermore, it may be thatmethadone maintenance treatment offers someprotection against exposure to the AIDS viruswhile providing a practical setting for AIDS-related education and testing.

References.................................

1. Hardy, A. M., et al.: AIDS trends in the United States;analysis of the first 10,000 cases. Conference paper 222.Presented at the 25th Interscience Conference on Antimi-crobial Agents and Chemotherapy, American Society forMicrobiology, Minneapolis, MN, Sept. 29-Oct. 2, 1985.

2. Fauci, A. S. (moderator): The acquired immunodeficiencysyndrome: an update. Ann Intern Med 102: 800-802(1985).

3. Additional recommendations to reduce sexual and drugabuse-related transmission of HTLV-III/LAV. MMWR35: 152-155, Mar. 14, 1986.

4. Ginzburg, H. M., Weiss, S. H., MacDonald, M. G., andHubbard, R. L.: HTLV-III exposure among drug users.

Cancer Res (Suppl.) 45: 4605s-4608s (1985).5. Swak, S. L., and Wormser, G. P.: How common is

HTLV-III infection in the United States? N Engl J Med313: 1352, Nov. 21, 1985.

6. Spira, T. J., et al.: Prevalence of antibody tolymphadenopathy-associated virus among drug detoxifica-tion patients in New York. N Engl J Med 311: 467-468,Aug. 16, 1984.

7. Saxinger, C., and Gallo, R. C.: Application of the indirectenzyme-linked immunosorbent assay microtest to the de-tection and surveillance of human T cell leukemia-lymphoma virus. Lab Invest 49: 371-377 (1983).

8. Centers for Disease Control: Antibodies to a retrovirusetiologically associated with acquired immunodeficiencysyndrome (AIDS) in populations with increased incidencesof the syndrome. MMWR 33: 377-379, July 13, 1984.

9. Marmor, M., et al.: AIDS among IV drug users. JSubstance Abuse Treatment 1: 237-247 (1984).

10. Friedland, G. H., et al.: Intravenous drug abusers and theacquired immunodeficiency syndrome (AIDS). Arch InternMed 145: 1413-1417 (1985).

11. Prevention of acquired immunodeficiency syndrome(AIDS): report of inter-agency recommendations. MMWR32: 101-104, Mar. 4, 1983.

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