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.     

Struggling to achieve a ‘normal life’: A qualitative study of Vietnamese methadone patients

Background:Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country’s drug policy – from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment.Methods:A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017.Results:The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness.Conclusion:The current practices of methadone programmes pose challenges to patients’ recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.     

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.     

Linking female sex workers with substance abuse treatment

We evaluated mobile street-based outreach as a modality for linking street-walking female sex workers with substance abuse treatment in New York City. Sex workers (N = 179) approaching an existing outreach facility were randomly assigned to receive usually provided services, or to receive an enhanced version of these services. Among the 144 women successfully followed for 6 months, 35.0% were detoxified; 43.1% of the 78 current heroin users received methadone maintenance; and 35.4% of the followed-up clients received some other type of treatment. Intervention group differences in these outcomes were not significant. Detoxification during followup was associated with heroin dependence and lifetime detoxification. Methadone maintenance (among heroin users) was associated with Hispanic ethnicity and legally mandated treatment. Other types of treatments were negatively associated with the degree of involvement in the sex trade. We conclude that a variety of factors affect motivation for substance abuse treatment among female sex workers, and that street-based outreach is a highly effective modality for linking this population with much needed treatment.     

同伴人员实施纳洛酮现场急救可行性调查

目的:针对云南省接受过纳洛酮急救服务注射吸毒人员进行调查,以了解由同伴人员实施纳洛酮现场急救可行性及满意度,为下一步政策倡导提供科学依据。方法:选取云南省13个县2010年1月至2011年7月接受过外展人员纳洛酮急救服务的所有吸毒人员作为调查对象,知情同意后采用项目设计并经预实验修正后问卷,由经培训过的外展人员进行现场调查,内容包括人口学特征、毒品使用及过量、现场急救服务情况等。结果:108名经过救治的吸毒人员参与调查,50.0%有11-24 a吸毒史;26.6%人员存在多药滥用情况;13.0%吸毒人员过去一年过量次数大于5次;31.4%吸毒人员过去6个月过量次数大于1次;同伴人员所提供的纳洛酮急救服务全部成功,服务提供时间平均19 min,不收取费用。结论:由同伴实施纳洛酮急救可行且更愿意被接受。救治效果满意,但如何让服务合法化并尽快推广值得讨论。     

Training Drug Treatment Patients to Conduct Peer-Based HIV Outreach: An Ethnographic Perspective on Peers' Experiences

From 2005 to 2008, the Bienvenidos Project trained Puerto Rican patients of New York City and New Jersey Methadone Maintenance Treatment Programs to conduct peer-based community outreach to migrant Puerto Rican drug users to reduce migrants’ HIV risk behaviors. Ethnographic research, including focus groups, individual interviews, and observations, was conducted with a subset of the patients trained as peers (n == 49; 67%% male; mean age 40.3 years) to evaluate the self-perceived effects of the intervention. Results of the ethnographic component of this study are summarized. The role of ethnographic methods in implementing and evaluating this kind of intervention is also discussed.     

Cultural Factors Influencing HIV Risk Behavior Among Dominicans in New York City

Abstract

Hispanics in the United States have disproportionately high rates of HIV. The existence of ethnically and culturally diverse Hispanic communities indicate that qualitative research on HIV-related attitudes and behaviors within subgroups is needed to develop successful interventions. Findings from interviews with 20 Dominicans involved with drug-related or sex work-related activities in New York City are presented in terms of predominant cultural influences and specific issues regarding sex work, drug use, and HIV/AIDS. Several directions for interventions in the Dominican community are indicated, e.g., outreach efforts sensitive to the stigmatization of behaviors such as needle use and homosexuality, and the encouragement of sex workers to use condoms with their partners as well as clients. Additional information regarding such areas as contraception, family planning, and drug treatment services is needed within this community. A knowledge of cultural norms can serve as a foundation for these intervention and education efforts.     

Using Goal-Oriented Counseling; and Peer Support to Reduce HIV/AIDS Risk Among Drug Users Not in Treatment

SUMMARY

A six-month HIV/AIDS risk intervention program for injection drug and crack users not in treatment is described, incorporating behavioral contracting, social support, and social modeling as core elements. The program utilizes goal-oriented behavioral counseling and HIV testing in conjunction with social support by peers and project outreach workers to facilitate personal change by drug-using participants. The intervention incorporates both group workshops and individual counseling sessions plus monthly social events for participants, supportive peers, and project staff. Local drug users who have successfully reduced their own risk of HIV/AIDS are utilized as positive role models for risk reduction. In addition, outreach workers maintain structured supportive contacts with program participants on a scheduled basis. The efficacy of this enhanced intervention program in comparison with standard HIV testing and AIDS education is currently being evaluated in a follow-up study.     

Circumstances of initiation into new-type drug use among adults in Shanghai: Are there differences by types of first new-type drug used?

Background

This study investigated circumstances of initiating new-type drug use among adult new-type drug users and differences among those who first used methamphetamine, ecstasy and ketamine.

Methods

A total of 276 participants were recruited, using respondent-driven sampling (RDS) from nine seeds recruited through NGOs, social workers and outreach workers in Shanghai, China.

Results

Methamphetamine was the most frequently reported first new-type drug used (37.1%), followed by ecstasy (35.6%) and ketamine (20.0%). 38.7% of participants initiated new-type drug use before the age of 21 years. 47.8% knew at initiation that club drugs can be harmful. Most were introduced to new-type drug use by friends, spouses or boy/girlfriends. The three most common reasons for initiation were curiosity, peer influence, and wishing to dull one's emotions. Those first using methamphetamine were more likely to be female, have a monthly individual income less than 3000 Yuan (approx. $476), initiate use at 21 years or older and at private setting than those first using ecstasy and ketamine.

Conclusions

There is an urgent need for drug education efforts in China to raise awareness of the harms of new-type drugs, as well as to increase knowledge about the paradox of new-type drug effects. Drug prevention and intervention programs should be tailore to target populations and their social context.     

Substance abuse treatment entry,retention and effectiveness: out-of-treatment opiate injection drug users

This study was designed to assess the effect of client characteristics and community interventions on treatment entry and retention, and to evaluate the relative effectiveness of treatment, compared to other interventions, in reducing drug use and crime among out-of-treatment opiate injectors. Subjects (N = 2973) from 15 cities were randomly assigned to: standard intervention (SI)-HIV testing and counseling; or enhanced intervention (EI)-SI plus additional educational sessions stressing responsible drug use. EI in some cities included staff assistance with treatment admission (i.e. ‘active’ referral). All locations provided intervention by community outreach workers. Factors positively associated with treatment entry included: prior treatment, intervention by community workers, assignment to the EI, not injecting cocaine, injecting opiates, and fewer program interventions received. Sites where the EI included active referral achieved significantly higher treatment entry rates than sites where the EI did not. Findings supported the efficacy of treatment over other interventions in reducing drug use and arrests, the addition of staff assistance to facilitate clients' entry into treatment, and the involvement of community outreach workers in achieving treatment entry.     

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.     

HEPATITIS C AMONG NONINJECTING DRUG USERS: A REPORT

Objectives: This report documents the prevalence of hepatitis C virus (HCV) infection among self-reported noninjecting drug users recruited from two New York City neighborhoods. Methods: Participants were recruited in separate studies from East Harlem and the Lower East Side of Manhattan and were administered structured questionnaires and tested for HCV. Results: HCV prevalence rates among those reporting no history of injecting drugs ranged from 5% to 29%, according to age, gender, and study location. Conclusions: Our results suggest that more research is needed to elucidate potential noninjecting routes of HCV transmission among drug users. Moreover, policies that rely predominantly on injector status as the only drug-related risk factor for HCV screening need to be reassessed in light of these findings.     

Development of an enhanced needle and syringe programme: the First Step programme pilot

The First Step programme is a new approach to needle and syringe exchange services established to help intravenous drug users reduce harmful drug use behaviours, provide psychoeducation and act as a point of transition enhancing access to other health and community services. The First Step assertive treatment approach was implemented in a medium-sized community area health service and evaluated over an 18-month period. A pilot evaluation of staff training was also conducted, demonstrating a significant improvement in staff skills in assertive outreach, needs assessment, engagement, psychoeducation and referral. Measures of drug-related harm showed the benefits of new early engagement-enhancing psychoeducational interventions, with increases in needles distributed and returned and greater referrals to drug and alcohol and other health services. Training needle and syringe workers towards a more assertive community outreach role gives them the ability to provide psychoeducation and harm minimization strategies and act as a conduit for intravenous drug users to enter treatment. [Hudoba M, Grenyer BFS, O'Toole M. Development of an enhanced needle and syringe programme: the First Step programme pilot. Drug Alcohol Rev 2004;23:295-297]     

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.     

Drug Dependence and Associated Risks Among Female Street-Based Sex Workers in the Greater Sydney Area,Australia

Background: This study examines drug use and dependence and associated risks among female street-based sex workers. Methods: Cross-sectional data collected from 72 women between April and August 2005 in Sydney, Australia, via face-to-face interviews. Sample: The average age was 34 years. Results: Risk factors associated with developing problematic drug use were prevalent. Child sexual abuse, leaving home before the age of 16, and exposure to multiple traumas was common. Depression and posttraumatic stress disorder were also prevalent. A substantial minority reported cocaine dependence which was associated with engaging in sex and injecting risk behaviors. Conclusions: More targeted interventions for this group are needed. Research on the value of extending existing outreach services to further reduce the harms associated with sex work and drug use is indicated. The study's limitations are noted.     

Review of European-Drug Emergencies Network (Euro-DEN) training package for non-specialist workers to assess acute recreational drug and new psychoactive substance toxicity in night-time economy environments

Aims: The initial management of acute recreational drug and new psychoactive substance (NPS) toxicity is often by non-specialists working in the night-time economy. The aim was as part of the European Drug Emergencies Network (Euro-DEN) project to pilot training of these workers in multiple European countries. Methods: Following evaluation of training needs, guidelines and training package were developed. Night-time economy workers in London, UK; Pärnu/Tallinn, Estonia; and Oslo, Norway participated in a 1- to 2-h interactive case-based training session. Participants completed a questionnaire pre-/post-training to assess confidence in managing acute recreational drug/NPS toxicity and evaluate the training package/guidelines. Findings: 98 (London: 42; Oslo: 39; Pärnu/Tallinn: 17) completed both pre-/post-training questionnaires. Participants felt significantly more confident in managing someone unwell following classical recreational drug use compared to NPS (5.6?±?2.9 vs. 4.3?±?2.7, p?<?0.001); this difference persisted after the training (7.6?±?1.9 vs. 6.9?±?2.0, p?<?0.001). 147 (London: 42; Oslo: 88; Pärnu/Tallinn: 17) completed the post-training evaluation; the training session and the guidelines were rated 8.2?±?1.4 and 8.7?±?1.7, respectively (out of 10). Conclusions: The guidelines and training were well received by night-time economy workers in three European countries and improved confidence in managing acute recreational drug/NPS toxicity. Appropriate national and European bodies need to look at wider dissemination of this work.     

Street-outreach Improves Detection but not Referral for Drug Users with Latent Tuberculosis,New York City

Street outreach in two New York City communities, Harlem and the South Bronx, between May 2001 and March 2003, provided tuberculin skin test (TST) screening to illicit drug users outside the traditional health care system. Persons who used heroin, cocaine, and/or crack were offered a TST, incentives to return for TST reading, and further evaluation if TST was positive. Of 809 participants, 530 (66%) accepted a TST and 81% (429/530) returned for TST reading. Of 429 participants, 40 (9%) were TST positive. Participants found TST positive did not differ from those found TST negative in previous drug user treatment or drug use practices including snorting heroin, sniffing cocaine, smoking crack, and injecting drugs of any kind. Of the 40 participants found TST positive, the 21 who tested TST positive for the first time were more likely to be male (p = .03) and noninjectors (p = .02), than the 19 who had tested TST positive in the past. Only two newly identified persons pursued follow-up care. Street recruitment expanded testing. Better follow-up strategies are needed. The study's limitations are noted.     

A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting

Background

The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services.

Methods

A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

Results

Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment.

Discussion

Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.     

Young offender drug use: knowledge and perceptions of Juvenile Justice Centre youth workers

Juvenile Justice Centre youth workers in New South Wales (n = 106) were surveyed by questionnaire as to their knowledge and perceptions of alcohol and other drug issues of those in their care. Some background variables were also collected. About 30% of the sample reported having (had) a problem with alcohol and/or other drugs and approximately the same percentage came from families with such a problem. Over 50% had received some form of drug education. There was an overestimation of the level of use of narcotics, sedative/hypnotics, anti-anxiety agents and hallucinogens of the youth workers and an underestimation of the level of use of analgesics, alcohol, cannabis and inhalants. Peer pressure was perceived as central in the initiation of use and “denial” in not gaining assistance; the style and belief systems of agencies were not seen as crucial in retaining young people in treatment. Youth workers, who are not required to have any specific education or training prior to employment, did not see themselves as well equipped to assist drug-affected or detoxifying detainees and requested more training/education. It is recommended that this could be provided through tertiary courses and/or in-service staff development.