AFRICAN-AMERICAN INJECTION DRUG USERS: TENSIONS AND BARRIERS IN HIV/AIDS PREVENTION

This exploratory study utilized a focus group methodology to explore tensions and barriers in HIV/AIDS prevention among African-American injection drug users. Participants discussed HIV infection risks, national/community HIV prevention effectiveness, prevention barriers, ideas on barrier removal, and the tensions which exist between users and the larger African-American community. Recognizing the inevitability of continued drug use for many injectors, participants requested basic harm-reduction supplies including condoms, needle exchange programs, additional drug user treatment services, and the use of culturally- and gender-matched peer-led prevention and treatment outreach. Preliminary recommendations are made for consideration in HIV/AIDS prevention among African-American IDUs. [Translations are provided in the International Abstracts Section of this issue.]     

Opportunities for AIDS prevention in a rural state in criminal justice and drug treatment settings

This study examined the likelihood that drug users would receive HIV/ AIDS prevention information and supplies (e.g., condoms and bleach) in the rural state of Kentucky. Despite evidence of high HIV risk among criminal justice and substance-using populations, incarceration and substance-user treatment were only minimally associated with prior HIV prevention exposure or HIV testing. These data strongly support the use of criminal justice and treatment settings to provide AIDS prevention interventions for the high-risk drug-using populations they serve, and to target HIV prevention services in rural as well as urban areas.     

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.     

HIV risk reduction and service delivery strategies in criminal justice settings

Because of the HIV risk behaviors of substance abusers, particularly injection drug users and those who exchange sex for drugs, and the large numbers who are already infected with HIV or showing symptoms of AIDS, significant service delivery issues are associated with their criminal justice processing. Many strategies have been implemented in correctional settings in an effort to prevent and control the transmission of HIV. A number of these are for the purpose of lowering transmission risk in institutions, whereas others have been structured for the sake of offering prevention/intervention to inmates before they return to the free community. As such, prisons and jails represent opportune settings for HIV prevention and education. The most common HIV control/prevention/education strategies include mandatory testing of inmates for HIV, segregating infected inmates from the general prison population, establishing special health care units for HIV positive and AIDS symptomatic inmates, offering HIV prevention and risk reduction programs, and granting medical parole for the terminally ill. Because drug abuse treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV and AIDS among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision: primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and, tertiary treatment in ongoing aftercare.     

“Someone who is in this thing that I am suffering from”: The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a “siloed treatment experience”), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.     

Opportunities for AIDS Prevention in a Rural State in Criminal Justice and Drug Treatment Settings

This study examined the likelihood that drug users would receive HTV/ AIDS prevention information and supplies (e.g., condoms and bleach) in the rural state of Kentucky. Despite evidence of high HIV risk among criminal justice and substance-using populations, incarceration and substance-user treatment were only minimally associated with prior HIV prevention exposure or HIV testing. These data strongly support the use of criminal justice and treatment settings to provide AIDS prevention interventions for the high-risk drug-using populations they serve, and to target HIV prevention services in rural as well as urban areas. [Translations are provided in the International Abstracts Section of this issue.]     

Practice Guidelines

State agencies have been profoundly impacted by the AIDS epidemic. In the absence of a vaccine that would prevent AIDS or of medacines that would cure it, the primary strategies of such agencies have focused on reducing the spread of AIDS by promoting cessation of high risk behaviors and thus preventing or slowing its transmission. Recent research indicates that the primary route of AIDS transmission into the general heterosexual population is by intravenous (IV) drug abusers, who directly account for about 17% of AIDS cases nationwide. Reducing the spread of AIDS within this group would not only reduce the overall toll of the disease but should limit its spread to the population at large. Infection by the human immunodeficiency virus (HIV) can be minimized by reducing or eliminating certain high-risk activities. In the IV drug using community, the primary intervention strategies include: educating IV drug users about the hazards of AIDS and sharing of needles; enrolling them in treatment programs to reduce drug use; promoting the use of new or sterilized syringes and needles among those who will not abstain from drug use; and discouraging high-risk sexual activity among thsoe who are already infected by HIV. The State of California has already increased the number of treatment slots for IV drug users and, through the Department of Alcohol and Drug Programs, is scaling up its educational, prevention, and intervention activities, particularly those related to safe sex, promoting the cessation of IV drug use, and improving equipment hygience by those who continue use.     

Opportunities for enhancing and integrating HIV and drug services for drug using vulnerable populations in South Africa

BackgroundLittle has been done to improve the integration of drug use and HIV services in sub-Saharan Africa where substance use and HIV epidemics often co-exist.MethodsData were collected using rapid assessment methods in two phases in Cape Town, Durban and Pretoria, South Africa. Phase I (2005) comprised 140 key informant and focus group drug using interviewees and 19 service providers (SPs), and Phase 2 (2007) comprised 69 drug using focus group interviewees and 11 SPs.ResultsDrug users put themselves at risk for HIV transmission through various drug-related sexual practices as well as through needle sharing. Drug users in both phases had limited knowledge of the availability of drug treatment services, and those that had accessed treatment identified a number of barriers, including affordability, stigma and a lack of aftercare and reintegration services. SPs identified similar barriers. Drug users displayed a general awareness of both HIV transmission routes and prevention strategies, but the findings also indicated a number of misperceptions, and problematic access to materials such as condoms and safe injection equipment. Knowledge around HIV treatment was low, and VCT experiences were mixed. SPs recognized the importance of integrating HIV and substance use services, but barriers such as funding issues, networking/referral gaps and additional burden on staff were reported in Phase 2.ConclusionA comprehensive, accessible, multi-component intervention strategy to prevent HIV risk in drug users needs to be developed including community outreach, risk reduction counselling, VCT and substance use treatment.     

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.     

凤凰计划及星火行动-在吸毒群体中推行防治艾滋病教育

香港现时因静脉注射毒品而感染艾滋病病毒人数仍维持在低水平,但邻近地区吸毒者的感染率显著上升。香港戒毒会自2000年起推行“凤凰计划”,招募成功戒毒人士为义工,向街头吸毒者宣传预防艾滋病讯息。2006年再推行“星火行动”计划,为感染了艾滋病病毒的美沙酮服药人士提供服务,减少他们进一步传播病毒的机会。本文回顾滥用药物和艾滋病的关系和香港艾滋病病毒感染情况,介绍上述两项计划的成立背景、目标、内容和运作情况。     

南宁市吸毒人群婚外性行为现状及影响因素分析

目的:了解南宁市吸毒人群婚外性行为现状,分析其影响因素。方法:采用匿名填写问卷的方式,对来自社区和戒毒所的781名吸毒人员进行艾滋病预防知识和行为调查。结果:当地吸毒人群最近一年与临时性伴、商业性伴发生性关系的比例分别达到了40.1%和15.0%。男性、低年龄组、非在婚状态的吸毒者发生婚外性行为的水平较高;有共用针具行为的吸毒者与临时性伴、商业性伴发生性关系的水平均明显高于不共用针具者。分别有47.6%、37.6%的吸毒人员在与临时性伴、商业性伴发生性关系时从不使用安全套。对与临时性伴发生性关系的多因素Lgistic回归分析显示,性别、年龄、婚姻状况、是否与他人共用过注射器、艾滋病预防知识得分是具有统计学显著意义的影响因素。对与商业性伴发生性关系的多因素Lgistic回归分析显示,性别、首次注射吸毒年龄、是否与他人共用过注射器是具有统计学显著意义的影响因素。结论:稳定的婚姻关系有助于减少吸毒人员与临时性伴发生性关系,但是无助于减少与商业性伴的性行为;共用注射器是增加吸毒人群与临时性伴、商业性伴发生性关系的影响因素;掌握艾滋病预防知识并不能减少吸毒人群的婚外性行为,在加强艾滋病防治知识宣教的同时,更加要侧重于行为的干预。     

Prevention of HIV among drug users

The relationship between injection drug use and HIV was established early in the HIV epidemic, and injection drug use has continued to be an important risk factor for HIV throughout the world. This panel included 4 papers related to HIV prevention among drug users, focusing on effective prevention strategies, the importance of organizing the AIDS-affected community, the impact of knowledge of serostatus on risk behaviors, and developing interventions for drug-using homosexual and bisexual men. These papers, addressing various aspects of the epidemic and methods to enhance prevention efforts, all indicate that although extensive knowledge regarding how to reduce HIV risks among drug users has accumulated, many areas for further research and intervention development remain.     

PREVENTION OF HIV AMONG DRUG USERS

The relationship between injection drug use and HIV was established early in the HIV epidemic, and injection drug use has continued to be an important risk factor for HIV throughout the world. This panel included 4 papers related to HIV prevention among drug users, focusing on effective prevention strategies, the importance of organizing the AIDS-affected community, the impact of knowledge of serostatus on risk behaviors, and developing interventions for drug-using homosexual and bisexual men. These papers, addressing various aspects of the epidemic and methods to enhance prevention efforts, all indicate that although extensive knowledge regarding how to reduce HIV risks among drug users has accumulated, many areas for further research and intervention development remain.     

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.     

Barriers associated with the treatment of hepatitis C virus infection among illicit drug users

BACKGROUND: Illicit drug users account for the majority of cases of HCV infection in the developed world, but few have received treatment. METHODS: We evaluated barriers to initiating HCV treatment -- including general treatment willingness -- and factors associated with these among HCV infected illicit drug users. Participants were recruited via convenience sampling from two community clinics in Canada. Individuals age >18 years with a history of illicit drug use completed interviewer-administered surveys. Those reporting positive HCV testing underwent additional questioning on willingness, uptake and barriers to treatment for HCV. RESULTS: Of 188 HCV positive illicit drug users, 16% (n=30) had received treatment for HCV. Factors associated with a decreased treatment uptake included current heroin use and HIV/HCV co-infection. Among those not having received therapy, 77% (117/153) indicated a willingness to receive HCV treatment. Factors associated with treatment willingness included not being infected with HIV, having not recently used drugs by injection and having reported physical health problems. Among those not having sought HCV treatment (n=107), the major reasons for not doing so were: lack of information about HCV or knowledge that treatment was available (23%), the absence of symptoms (20%) and the perceived side effects of treatment (14%). CONCLUSIONS: Among illicit drug users attending inner city clinics, we have observed a low uptake of HCV treatment, but a high willingness to receive therapy. An increased focus on improving education about the long-term consequences of HCV and the availability of effective treatment are important components for expanding HCV treatment among illicit drug users.     

Book Reviews

Summary

In the United States, the AIDS epidemic is a dynamic process with increasing rates of AIDS reported among women, minority populations, heterosexual men, and users of drugs by routes other than injection. The 1993 CDC AIDS definition change has created some difficulties in interpreting trends in the United States. Drug use continues to represent a significant problem among HIV-infected persons. Several strategies have been advanced to decrease transmission of HIV among drug users, their sexual partners and children. However, more effective and comprehensive prevention and treatment strategies are needed.     

A Comparison of HIV Related Risk Behaviors of Street Recruited and Treatment Program Recruited Injection Drug Users

SUMMARY

This paper compares the demographic traits and the risk behaviors of injection drug users (IDUs) not in treatment who were recruited into an AIDS risk reduction program in Miami, FL with attributes of IDUs who were clients of drug treatment programs. The majority of both IDU samples were male and in their 30's. Most street IDUs were African-American; a majority of treatment clients were White, non-Hispanic. Prevalence of HIV was high for African-Americans and Hispanics from both IDU samples. Prevalence of HIV was relatively low among both samples of White, non-Hispanic IDUs but somewhat higher among White street IDUs than among White treatment clients. Similar proportions of street and treatment IDUs injected daily, but street IDUs were more likely to share works, inject in shooting galleries, use crack and alcohol daily, have multiple sex partners and have IDU sex partners.     

The Evolution of Spanish HIV Prevention Policy Targeted at Opiate Users: a review

Spain is the European country with the highest cumulative AIDS caseload and presently has an estimated population of at least 120,000 persons living with HIV. Most Spanish HIV and AIDS cases are due to needle sharing in the context of intravenous drug use. This article traces the development of targeted HIV prevention policy in the field of drug use, exploring the reasons for the time-lag in making harm reduction among drug users a policy priority. Reports about dramatically high HIV prevalence rates among Spanish drug users had already emerged by 1986-1987. However, the Spanish government began to devise large-scale harm reduction programmes for drug users only in the years 1992-1994. This new development has led to the establishment of Europe's largest methadone maintenance programme. In the meantime, though, the central government (as opposed to health authorities in some of Spain's regions) continued to treat public health concerns as secondary to a drug policy focused on the goal of abstinence. The article argues that both (a) the rapid diffusion of HIV among drug users in the late 1970s and early 1980s and (b) the time-lag in elaborating an adequate policy reaction to the emerging AIDS crisis were related to the country's transition from an authoritarian regime to democratic government. Rather than in terms of direct continuity, it is argued, authoritarianism left its mark on HIV epidemiology and policy in terms of the fast social change triggered by its demise.     

The Evolution of Spanish HIV Prevention Policy Targeted at Opiate Users: a review

Spain is the European country with the highest cumulative AIDS caseload and presently has an estimated population of at least 120,000 persons living with HIV. Most Spanish HIV and AIDS cases are due to needle sharing in the context of intravenous drug use. This article traces the development of targeted HIV prevention policy in the field of drug use, exploring the reasons for the time-lag in making harm reduction among drug users a policy priority. Reports about dramatically high HIV prevalence rates among Spanish drug users had already emerged by 1986-1987. However, the Spanish government began to devise large-scale harm reduction programmes for drug users only in the years 1992-1994. This new development has led to the establishment of Europe's largest methadone maintenance programme. In the meantime, though, the central government (as opposed to health authorities in some of Spain's regions) continued to treat public health concerns as secondary to a drug policy focused on the goal of abstinence. The article argues that both (a) the rapid diffusion of HIV among drug users in the late 1970s and early 1980s and (b) the time-lag in elaborating an adequate policy reaction to the emerging AIDS crisis were related to the country's transition from an authoritarian regime to democratic government. Rather than in terms of direct continuity, it is argued, authoritarianism left its mark on HIV epidemiology and policy in terms of the fast social change triggered by its demise.