Factors Contributing to Retention of Not-in-Treatment Drug Users in an HIV/AIDS Outreach Prevention Project

SUMMARY

Studies have attempted to identify the characteristics of substance-abusing clients that are related to premature termination from alcohol and drug treatment. Few studies, however, have looked at predictors of loss to follow-up among drug users participating in HIV/AIDS prevention projects. This paper develops and tests models of program retention employing data from approximately 250 not-in-treatment drug users enrolled in an outreach based HIV risk reduction program. Logistic regression was used to fit a model which included measures of: (1) demographic characteristics including: age and ethnicity; (2) social environmental factors including: living situation and type of network connection; (3) risk behaviors including: composite scores for drug use in the past 30 days and history of Sexually Transmitted Diseases (STDs); and (4) program factors including: outreach workers' knowledge of clients and number of intervention sessions received. Findings suggest that social environmental and program factors are most predictive of client retention in the program. Implications for ways in which to monitor retention of out-of-treatment drug users participating in AIDS prevention programs are addressed.     

HIV/AIDS and injecting drug use: Information,education and communication

Information, education and communication (IEC) has an important role to play in HIV/AIDS prevention and harm reduction among injecting drug users and their sexual partners. This paper reviews what is known about the effects of IEC within this context. It distinguishes between six types of individual level intervention in which IEC has a role to play (mass reach interventions, outreach work, harm minimisation, drug cessation/treatment programmes, voluntary and confidential counselling and testing, and risk reduction counselling) and two different styles of structural intervention (structural and environmental outreach work to tackle the structured vulnerabilities associated with HIV/AIDS). Though the evidence base is weak, evidence relating to IEC's contribution and effects in each of these fields is reviewed. Overall, and by itself, IEC can do little more than raise levels of knowledge, awareness and understanding; however, when combined with other measures, including service provision and a supportive social environment, more positive and sustainable effects can be achieved.     

Strategies for Accessing and Retaining Asian Drug Users in Research Studies

SUMMARY

Based on a research project that investigates drug use and HIV risk behaviors among Asian drug users in San Francisco, this paper describes barriers and strategies for accessing, recruiting, and retaining Asian drug users. It also presents culturally appropriate and group specific strategies and underlying cultural norms that outreach workers use to build rapport with targeted drug users and community members. The paper describes culturally appropriate strategies for outreach workers and project staff to recruit and retain Asian drug users. These strategies acknowledge diversities within the targeted ethnic groups and offer flexibility to create other strategies specific to targeted Asian drug users.     

An alternative program for methadone maintenance dropouts: description and preliminary data

Time in drug treatment has been shown to be one of the best predictors of post-treatment success. Since as many as half of the enrollees leave methadone treatment during the first year, the project described in this article was designed to test the effectiveness of an alternative program for individuals who have recently dropped out of methadone maintenance treatment. The goals of this "Alternative Program" are to help participants re-connect with formal drug treatment and other community or medical programs, reduce their HIV risk behavior, decrease or eliminate drug use, join self-help groups, and obtain entitlements. Program components include: contacts by local outreach workers, cognitive-behavioral relapse-prevention group counseling, and individual counseling for needs assessment and referral. This paper describes the basis for development of the intervention, summarizes the methodology being used, and provides preliminary data on participation in the Alternative Program.     

戒毒所内对吸毒人群进行艾滋病干预的效果研究

目的：评价在戒毒所进行艾滋病咨询及心理干预对吸毒人群戒毒的效果。方法采用自行设计的问卷,以面对面询问方式,对戒毒所内的吸毒人员进行干预前后调查。结果261名吸毒者接受了干预前问卷调查,其中132例自愿参与咨询、接受心理干预,并做了干预后调查。干预后吸毒人群对艾滋病防治、性传播疾病、自愿咨询检测知识知晓率均明显提高;自愿咨询检测利用率、性病就诊行为好转率均有明显提高。结论在戒毒所开展咨询与心理干预,可以提高吸毒人群艾滋病的防治知识,改变相关危险行为,在戒毒所对吸毒人群开展艾滋病咨询与心理干预是预防艾滋病在吸毒人群中传播的有效途径。     

Impact of HIV risk and infection and the role of prevention services

Blood-borne infection associated with injection drug use is a significant cause of morbidity and mortality. Over the last decade, HIV infection and its clinical sequelae have had a significant impact on research and interventions involving injecting drug users (IDUs) in the United States and elsewhere. Discussed are some of the major intervention options for reducing blood-borne infections in general and HIV in particular. The use of multiple interventions is considered within the community context in which both IDUs and service providers operate. Intervention options discussed include treatment for drug dependence; voluntary and confidential HIV testing and counseling; community health outreach; bleach distribution; and easy, legal access to needles and syringes through pharmacy sales and needle exchange programs. Many surveillance and evaluative studies have examined multiple intervention efforts that include all or some of these program components and suggest positive outcomes. However, these studies tend to be limited by experimental designs that restrict attribution of causal inference. Examples of such programs in the United States and abroad are examined in terms of their potential for reducing HIV risk behaviors and averting new infections. The article concludes that diversity among AIDS prevention programs, rapid deployment (at earlier stages of epidemics), and effective coordination (minimization of interagency conflicts) are important factors in successful AIDS prevention programming and attaining disease prevention objectives.     

Using Stages of Change to Assess Intervention Readiness and Outcome in Modifying Drug-Related and Sexual HIV Risk Behaviors of IDUs and Crack Users

SUMMARY

This paper examines the utility of the stages-of-change model in assessing intervention readiness and measuring the outcome of targeted interventions in modifying eight drug-related and sexual risk behaviors of active drug users. Injection drug and crack cocaine users (N = 560) recruited through street outreach were administered questionnaires measuring intentions, behaviors, and beliefs pertaining to eight drug-related and sexual strategies for reducing personal HIV risk at the time of their enrollment in an HIV risk intervention program. Six-month follow-up data were available for 205 of the 325 individuals who were eligible for follow-up. At baseline, a large percentage of injectors were in the action or maintenance stage with regard to safe injection practices. Men were significantly higher than women in stage of change for not sharing needles. Very few individuals were using condoms with their main partner, but the percentage was much higher with casual partners, especially among sex workers. Follow-up data indicated a general shift toward higher stages for all behaviors, with changes in both intentional and behavioral stages. Differences between initial and final stage of change were statistically significant for all target behaviors except condom use with main partner.     

Reaching and enrolling drug users for HIV prevention: a multi-site analysis

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.     

The Transformation of Drug Markets and Its Impact on HIV Outreach to Injection Drug Users in New York City, 1987–2008

This oral history describes three periods of street outreach to injection drug users at risk for HIV in New York City: outreach in an era of public drug markets (1987–1993), outreach in an era of private markets (1993–2006), and network-driven outreach (2006–present). Individual interviews with administrators and supervisors of outreach workers are combined with field notes from the ethnographic research experiences of the first two authors to contextualize, compare, and contrast these distinct periods. The combination and triangulation of these sources of data allow for an analysis of both the specific and the wider social and cultural contexts in which outreach intervention efforts were situated. Through these lenses, the article examines some of the reasons why they were or were not successful and discusses prospects for the future.     

Revitalizing the HIV response in Pakistan: A systematic review and policy implications

BackgroundWe sought to describe the epidemiology of HIV in Pakistan and prioritize interventions to improve the effectiveness and efficiency of the response to HIV.MethodsWe conducted a systematic review of the epidemiology of HIV in Pakistan. Data sources included PUBMED and EMBASE and unpublished reports from public, non-governmental organizations and provincial and national stakeholders. We focused on findings from the last 5 years and only evaluated data before 2005 on at risk groups where there were insufficient data published after 2005. A population attributable risk analysis was conducted to estimate the burden of HIV among most at risk populations (people who inject drugs, female sex workers, male sex workers, Hijra or transgender sex workers and men who have sex with men).ResultsPakistan has a concentrated epidemic of HIV-1 among most at risk populations with very low prevalence rates in the general population (0.04%). The majority of current HIV infections are estimated to occur among four at risk populations, despite their accounting for under 2% of all adults. Injecting drug users accounted for 36.4% of HIV cases – the largest share of infections in any one group. Female, male and transgender sex workers accounted for 24%, 12% and 17.5% respectively, a cumulative population attributable risk of 53.5% of all infections occurring among sex workers.ConclusionPakistan must continue to invest in targeted, evidence-based interventions to prevent the spread of HIV and curb the epidemic trajectory in Pakistan. A comprehensive range of services should include needle and syringe exchange, opiate substitution therapy for people who inject drugs, outreach and engagement with injecting drug users, Hijra’ community as well as male and female sex workers and their clients and improved linkage between services and voluntary counseling, testing and anti-retroviral therapy.     

Drug Use Patterns of Substance Abusing Women: Gender and Ethnic Differences in an AIDS Prevention Program

SUMMARY

The social context of drug use defines women's experiences of addiction and their patterns of use. Gender relations and roles, ethnic identity, poverty, and local circumstances, including drug-related epidemics such as the human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs), constitute powerful social forces that create a unique set of risky conditions for women drug users. This paper presents findings from a community-based AIDS prevention research project for 1,022 out-of-treatment drug users recruited through street outreach and targeted sampling. Data from a baseline risk behavior assessment and in-depth interviews on contexts of women's drug use show different patterns of use when comparing women to men, and among women comparing African Americans, Puerto Ricans, and Whites. Related differences in prevalence of HIV, STDs, and other consequences of drug use and addiction also are presented. Implications of these findings are discussed in terms of the development of drug treatment and harm reduction programs that are appropriate for women of different ethnic backgrounds.     

Values and Identity: The Meaning of Work for Injection Drug Users Involved in Volunteer HIV Prevention Outreach

Most HIV behavioral interventions provide participants with preventive information emphasizing how not to behave, and have neglected to provide attractive and feasible alternatives to risky behavior. Interventions that emphasize cultural strengths may have more powerful effects and may help remove the stigma of HIV, which has hampered prevention efforts among African American communities. Starting in 1997, the SHIELD (Self-Help in Eliminating Life-Threatening Diseases) intervention trained injection drug users (N = 250) to conduct risk reduction outreach education among their peers. Many participants saw their outreach as “work,” which gave them a sense of meaning and purpose and motivated them to make other positive changes in their lives.     

Challenges in Recruiting and Training Drug Treatment Patients as Peer Outreach Workers: A Perspective From the Field

Hispanic patients were recruited from methadone maintenance treatment programs in 2005–2008 to be trained as peer outreach workers, targeting migrant drug users from Puerto Rico. Goals of the outreach focused on reducing HIV-related risk behaviors. A total of 80 peers were recruited from 4 clinics in New York and New Jersey. Following training, they conducted outreach in their communities for 12 weeks. This paper describes the challenges encountered during the recruitment, training, and outreach phases of the project, from the field perspective. Recommendations for future efforts in training drug treatment patients as outreach workers are provided.     

Values and identity: the meaning of work for injection drug users involved in volunteer HIV prevention outreach

Most HIV behavioral interventions provide participants with preventive information emphasizing how not to behave, and have neglected to provide attractive and feasible alternatives to risky behavior. Interventions that emphasize cultural strengths may have more powerful effects and may help remove the stigma of HIV, which has hampered prevention efforts among African American communities. Starting in 1997, the SHIELD (Self-Help in Eliminating Life-Threatening Diseases) intervention trained injection drug users (N=250) to conduct risk reduction outreach education among their peers. Many participants saw their outreach as "work," which gave them a sense of meaning and purpose and motivated them to make other positive changes in their lives.     

The relationship between social network factors, HIV, and Hepatitis C among injection drug users in Chennai, India

Objective

The purpose of this study was to examine whether social network factors predict HIV and Hepatitis C (HCV) serostatus after controlling for individual-level factors at baseline among a cohort of male injection drug users in Chennai, India.

Methods

The sample, which was recruited through street outreach, consists of 1078 males who reported having injected drugs in the last 6 months.

Results

The participants reported 3936 social support and risk network members. HIV and HCV positive serostatus were negatively associated with network member providing emotional support, and positively associated with network member providing material support. In addition, HCV positivity was associated with network member being an active drug user known for more than 10 years and network member being male kin networks, even after adjusting for individual demographic factors and risk behaviors.

Conclusions

These findings suggest that social network factors are significantly linked to HIV and HCV status among IDUs in Southern India and highlight the mixed effects of social capital on health. Future HIV/HCV prevention efforts should incorporate IDU peers to alter drug network injection risk norms. For drug users who have minimal network support, support groups and other informal and formal support mechanisms may be need to help them with health care and psychological support needs for dealing with HIV/HCV.     

针具交换结合同伴宣传对吸毒者艾滋病知识及高危性行为的干预效果分析

目的:通过同伴宣传和针具交换项目提高干预对象关于艾滋病知识的知晓率,减少吸毒者传播和感染艾滋病病毒的高危行为,降低吸毒人群中艾滋病病毒的传播流行。方法:通过卫生工作人员和同伴宣传员向吸毒者提供并回收清洁针具、发放宣传折页、张贴宣传画以及对吸毒者进行面对面的宣传等措施在广西壮族自治区百色地区的注射吸毒者中开展了为期1 a的针具交换和同伴宣传项目。在干预前后分别进行基线和终期横断面调查,通过对比两次调查中吸毒者的艾滋病知识和自我报告的高危性行为等变化情况对干预效果进行评估。结果:终期调查时,吸毒者所有艾滋病知识的知晓率均显著高于基线调查时;在终期调查时吸毒者的单一性伴比例为50.5%,显著高于基线调查(27.6%)时,但是他们在婚外性行为中的安全套使用率却显著低于基线调查。结论:同伴宣传结合针具交换干预措施能显著提高吸毒者关于艾滋病方面的知识,显著降低吸毒者多性伴的比例,但是对于提高他们的安全套使用率方面却没有效果。     

Cost of Outreach for HIV Prevention Among Drug Users and Youth at Risk

SUMMARY

Economic evaluation has become an increasingly important component in determining the effectiveness of HIV prevention programs. One type of intervention that governmental and nongovernmental organizations have supported to prevent the spread of HIV is outreach. We conducted a cost analysis at eight sites that provide outreach services to two populations at high risk for HIV infection: injection drug users and street youth. We assessed the potential benefit of HIV prevention through outreach services by comparing outreach costs with the medical costs of treating an HIV infected individual.

The average cost of outreach services was $13.30 per contact. The cost per contact for services to street youth was 78% higher than for drug users. Comparing the cost per contact with HIV treatment costs, if only two in 10,000 contacts reduce their high-risk behavior so as to avoid transmission of HIV, outreach would yield a net benefit. These results provide evidence that outreach programs compare favorably to other HIV prevention strategies in terms of cost.     

Indigence, marginalization and HIV infection among Brazilian cocaine users

In recent years the HIV/AIDS epidemic in Brazil has increasingly affected younger and more impoverished segments of the population. The rate of infection among drug users has also risen dramatically over the past decade. Despite these alarming trends, epidemiologic studies of indigent drug users in Brazil are virtually nonexistent. In order to fill this void, a research demonstration program was initiated in Rio de Janeiro which targeted drug users from the poorest strata of society, assessed their HIV risk behaviors and serostatus, and provided HIV prevention counseling, hygiene materials, and follow-up. Because participation in the intervention program appeared to impact on drug use and sexual risk behaviors, the implementation of successful prevention programs with this population appears feasible. In that HIV prevalence among this sample of poor injectors was markedly lower than that reported in previous studies of higher socioeconomic status injectors, the timely and widespread implementation of risk reduction strategies assumes great importance for the prevention of HIV infection in the most marginalized segments of Brazilian society.     

Physicians' Assessment of Drug Use and Other HIV Risk Behavior: Reports by Female Drug Users

SUMMARY

With epidemiological trends indicating that Acquired Immune Deficiency Syndrome (AIDS) is the third leading cause of death among women ages 25 to 44 in the United States, it is becoming increasingly important to deal with the issue of Human Immunodeficiency Virus (HIV) prevention for women. Recommendations for primary and secondary prevention strategies tailored to the needs of women have been formulated. Such calls have included the recommendation that prevention efforts be intensified in medical settings regularly frequented by women. One setting identified is that of gynecological and obstetric services where HIV risk assessment, testing, and counseling would be an excellent means of reaching a maximum number of women of child-bearing age. Despite calls by the American College of Obstetricians and Gynecologists for OB/ GYN service providers to engage in HIV prevention, research has shown that physicians remain reluctant to address the issue with patients. This study explored the likelihood of physicians and other health service providers to engage in HIV prevention through risk behavior assessment, HIV testing, and HIV counseling by requesting information from female drug abusers not currently in substance abuse treatment. Sixty percent of the drug abusing women in this study did not receive HIV information from their health care provider, 70% did not receive HIV counseling, 68% were not offered HIV testing, and 66% were not asked to provide a drug history. Of those participants who had not been asked to provide a drug history, almost half indicated that they would have been willing to provide truthful answers had they been asked. These findings indicate that a prime opportunity for HIV prevention is being missed by women's health care providers. Neglecting to ask female patients about their drug use history and to explore their risk for HIV infection can have dire consequences for these women. Early intervention is less likely if the topic is not broached by service providers, increasing the likelihood of infection and the spread of the disease.