Epidemic crack cocaine use linked with epidemics of genital ulcer disease and heterosexual HIV infection in the Bahamas: evidence of impact of prevention and control measures

BACKGROUND: Epidemic freebase/crack cocaine use began in the Bahamas in 1982, closely followed by epidemics of genital ulcer disease (GUD) and HIV infection. Numbers of new clients receiving ambulatory treatment for cocaine use in Nassau peaked in 1984. GOAL: To assess interrelations among epidemics of crack use, GUD, and HIV infection. STUDY DESIGN: The study was designed for review and comparison of temporal trends in ambulatory and inpatient treatment of cocaine users and in numbers of cases of sexually transmitted disease (STD) and HIV infection in the Bahamas. A retrospective case-control study of cocaine use and STDs was performed at the Comprehensive Dermatovenereology Clinic in Nassau. RESULTS: Ambulatory visits and inpatient admissions for cocaine use peaked in 1984 and 1987, respectively. GUD cases increased 12-fold in the Bahamas from 1983 to the period of 1985-1987 and then declined. At the Comprehensive Dermatovenereology Clinic, gonorrhea cases outnumbered bacterial GUD cases approximately 10:1 in 1982 and 1983, but the latter increased to outnumber gonorrhea cases in 1985 and 1987-1988. Annual HIV seroprevalences at new-problem visits rose from less than 0.3% in 1986 to 12.9% by 1994 and then leveled off. Cocaine use among patients seen with STD from 1985 through 1990 was significantly associated with GUD (odds ratio [OR], 3.3; 95% CI, 2.1-5.1), secondary syphilis (OR 5.5; 95% CI, 2.4-12.6), and HIV infection (OR, 8.1; 95% CI, 4.3-15.2). CONCLUSIONS: In temporally linked successive epidemics of cocaine use, GUD, and HIV infection, case-control analyses confirmed the association of cocaine use with GUD and with HIV infection. Declining GUD and HIV seroprevalence stabilization followed declines in cocaine use and implementation of syndromic management of GUD, as well as intensified partner-notification efforts.