Relationship between time spent in treatment and client outcomes from therapeutic communities

Research found that therapeutic communities and other types of residential programs are effective in reducing drug use, unemployment, and criminal behavior and that length of time spent in treatment is an important predictor of client outcomes from programs. Studies vary considerably, however, in terms of the amount of time they found clients need to stay in treatment to produce those outcomes. Data collected for the Treatment Outcome Prospective Study (TOPS) were analyzed to explore the relationship between time spent in treatment and client outcomes from therapeutic communities and other types of residential drug treatment programs. The analysis took into account client characteristics and whether clients received drug treatment during the follow-up year. The results indicate there is a stronger relationship between time spent in treatment and client outcomes from therapeutic communities than was suggested in earlier analysis of TOPS data.     

Chapter 3: Method

The AIDS pandemic has called attention to the existence of intravenous drug abuse among American Indians/Alaskan Natives. Epidemiological data on AIDS and attitudinal surveys provide evidence that IV drug abuse is occuring in American Indian/Alaskan Native communities. There is a need for ongoing research into the prevalence of IV drug abuse in the American Indian/Alaskan Native population. Existing alcoholism treatment programs for Native Americans must be expanded to treat non-alcohol and polysusbtance abuse. HIV education and outreach must be initiated with American Indian/Alaskan Native IV drug abusers.     

Tracking coverage on the silk road: time to turn theory into practice

Scaling up coverage of programs that effectively reduce the spread of HIV among vulnerable populations, including injecting drug users (IDUs), sex workers (SWs), and men who have sex with men (MSM), is a critically important issue for many countries today. However, in addition to the lack of a commonly accepted definition of coverage, there are currently no universally accepted standards, methodologies, or tools to track coverage among these groups. Globally, most programs working to prevent HIV among vulnerable populations are not using monitoring & evaluation (M&E) systems that accurately track numbers of clients and frequency of contact with those clients. Nor do most programs have targets on the frequency of contact needed to effectively promote healthy behaviours. This article presents a narrative of how one program in Central Asia developed a simple M&E system to track the extent and frequency of contacts among clients. The system uses a simple and anonymous "Unique Identifier Code" (UIC) that is assigned to each client and recorded into a simple database to track the client's interaction with the program. The system allows program managers to track numbers of clients served and at what frequency and to better monitor progress towards goals. The data produced by the UIC system, when compared against HIV and sexually transmitted infection (STI) sentinel surveillance data by site, allows programs to test theorized definitions of the quantity of coverage needed to reduce the risk behaviours that spread HIV among vulnerable populations. Such systems can then provide urgently needed data to help national HIV/AIDS programs understand current coverage levels and gaps in coverage that need to be filled in order to reduce the spread of HIV. Such a system provides valuable data to enable decision makers to make evidence-based decisions on how to allocate resources to reach sufficient coverage to reduce the spread of HIV among populations most at risk of HIV.     

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.     

The changing face of HIV/AIDS among Native populations

AIDS has steadily increased in recent years, becoming the ninth leading killer of Native people between the ages of 15 and 44. In 2003, the Centers for Disease Control and Prevention (CDC) reported that ethnic minorities account for more than 71% of all reported AIDS cases and that there are still increases in AIDS cases in the American Indian population. Despite the work that has been done related to HIV/AIDS, there remain some major challenges in the prevention of HIV/AIDS in Native communities. Yet, there are changes on the horizon and these changes bring hope to Native communities in the ongoing battle to decrease HIV and AIDS. This article details information about the biological, social, economic and behavioral cofactors related to the rise in HIV/AIDS in Native communities and follows with issues related to special populations and consideration of the unique needs of prevention in these subpopulations. The need for norming of HIV testing is discussed as is the need for Native-specific programs and interventions. Finally, changes in the recognition of the culturally specific needs of Native people are noted and new resources are presented.     

Drug treatment staff attitudes toward AIDS and workplace transmission of HIV: A survey and follow-up—Spectrum House, Inc.

A growing number of cases of HIV infection and AIDS in the U.S. have been reported among intravenous drug users and their sexual partners. This increase in cases has begun to have a significant impact on substance abuse treatment programs; in addition to the complexities of HIV education and counseling, the staff of such programs must deal with their own fears regarding HIV infection, since many experientially trained staff are, themselves, former IV drug users. Other staff members may experience irrational anxiety about working HIV-infected clients, due to the fear of workplace exposure to the virus. In order to assess the extent and nature of such anxieties among its staff, Spectrum House, Inc., a comprehensive substance abuse treatment program, administered a Staff AIDS Survey in 1986 and again in 1987. Responses reflected a marked decrease in staff anxieties relating to workplace transmission of HIV during the 14-month period between surveys, seemingly related to both the implementation of AIDS education and an increase in contact with HIV positive clients. Those staff members whose contact with HIV positive clients remained infrequent between surveys, however, continued to show higher levels of fear about casual contact and workplace exposure to HIV. These results indicate that increased staff-client interaction may be an effective addition to other forms of staff AIDS education in substance abuse treatment programs.     

HIV/AIDS and Native Americans: the health departments' response

For some time, state health department HIV/AIDS programs have worked with communities of color to address their unmet needs. Because of the need for a holistic approach to the multiple issues impacting these communities, efforts to address HIV/AIDS in Native American communities are often integrated into programs addressing related issues, such as substance abuse, mental health and other STDs. Building upon a recent report from the National Alliance of State and Territorial AIDS Directors (NASTAD), this article will review the numerous challenges state and local health departments face in supporting HIV/AIDS-focused health and human services in Native American communities and how some health departments have worked with Native American communities to respond to these challenges. A series of recommendations and next steps for health departments seeking to improve services in Native American communities will be offered.     

Assessment of an AIDS intervention program during drug abuse treatment

Since 1985, many drug abuse treatment centers and health care providers have implemented special education programs for individuals who inject drugs. They focus primarily on increasing awareness of the threat of the human immunodeficiency virus (HIV) being spread through drug injection equipment and by sexual activities. As part of the Drug Abuse Treatment for AIDS- Risk Reduction (DATAR) project, the AIDS/HIV Risk Reduction Module was designed to meet these special intervention needs. This study examined program impact on 110 methadone treatment clients. Results indicated that for those in treatment less than 4 months, the AIDS intervention program enhanced specialized knowledge about AIDS, aided in the reduction of AIDS-risky behaviors, and enhanced attitudes toward achieving and maintaining abstinence from drug use. Thus, AIDS education and intervention programs appear to be effective and should be emphasized in the early phase of drug abuse treatment.     

Residential Detoxification for Substance Abusers with HIV/AIDS: Walden House Detoxification Program

Substance abusers with HIV/AIDS have a complex array of problems that are not easily addressed in outpatient or long-term residential programs. A new but promising treatment modality is residential detoxification for substance abusers with HIV/AIDS, such as described by this paper. The purpose of the program is profiled, as well as its general components and the aspects that address the special needs of HIV clients. Data indicating the successes and limitations of the program are presented, along with recommendations for further addressing the needs of substance abuses with HIV/AIDS.     

The argument against HIV-antibody testing in chemical dependence treatment programs

As HIV continues to spread among chemically dependent populations, chemical dependence treatment programs are beginning to address the issue of routine HIV-antibody testing. While there are many rationales given for testing, only two are deemed acceptable in chemical dependence treatment programs: to permit medical personnel to institute therapy promptly; and to assist in behavior modification (risk reduction). Early intervention is deemed premature because federal regulations disallow the use of drugs, such as AZT, until T-4 cell counts are lower than 200. In addition, many clients may not stay in treatment long enough to institute therapy and ongoing treatment. Many experimental drug trials exclude drug addicts and women. Chemically dependent individuals have neither the knowledge nor the funds to obtain experimental drugs from other countries. Moreover, current protocols of HIV test-related counseling are insufficient to assist clients in changing their high-risk behaviors. Many chemically dependent clients who receive a positive test result relapse to drug abuse or act out sexually; many who receive a negative test result deny the need to change behaviors to avoid infection. Additionally, test result validity and discrimination are presented as deterrents to testing. In long-term treatment situations, where HIV/AIDS education and counseling are done over time as part of treatment and where support systems are in place, HIV testing can be an aid in behavior change.     

Cabenuva®: Differentiated service delivery and the community Pharmacists’ roles in achieving UNAIDS 2030 target in Nigeria

The approval of the novel long-acting HIV injection; Cabenuva®- Cabotegravir and Rilpivirine injectable formulation) and the recent call by the World Health Organization for promoting community-based ART management, underscore the remarkable progress towards meeting the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95–95–95 targets by 2030.As the availability of antiretroviral therapy (ART) for the treatment of HIV/AIDS has increased in resource-limited settings, there has been a move to develop and implement alternative treatment delivery models such as Differentiated Service Delivery (DSD) in high prevalence countries to meet the global targets for HIV treatment while maintaining the quality of care. However, there is limited data on the involvement of community pharmacies in the delivery of ART within the community. Although, in western countries, several studies have documented the different roles community pharmacists can play in the management of HIV/AIDS. Community pharmacists are the most accessible and first points of health care for most clients. They are trusted, highly trained health care professionals. They should be incorporated and allowed to administer the Cabenuva® injection if the battle against the HIV pandemic is to be totally won. In this paper, we, therefore, aim to explore how the community pharmacist can be positioned in HIV service delivery regarding the administration of the Novel long-acting Cabenuva® injection formulation. It is therefore recommended that the Nigerian government embrace community pharmacy-led drug administration initiatives and embark on accredited training programmes for the profession in line with drug administration services. The government should also put in place necessary funding mechanisms for community pharmacists for the extra workload placed on them in administering injection drug formulation in their respective pharmacies.     

Cabenuva®: Differentiated service delivery and the community Pharmacists’ roles in achieving UNAIDS 2030 target in Nigeria

The approval of the novel long-acting HIV injection; Cabenuva®- Cabotegravir and Rilpivirine injectable formulation) and the recent call by the World Health Organization for promoting community-based ART management, underscore the remarkable progress towards meeting the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95–95–95 targets by 2030.As the availability of antiretroviral therapy (ART) for the treatment of HIV/AIDS has increased in resource-limited settings, there has been a move to develop and implement alternative treatment delivery models such as Differentiated Service Delivery (DSD) in high prevalence countries to meet the global targets for HIV treatment while maintaining the quality of care. However, there is limited data on the involvement of community pharmacies in the delivery of ART within the community. Although, in western countries, several studies have documented the different roles community pharmacists can play in the management of HIV/AIDS. Community pharmacists are the most accessible and first points of health care for most clients. They are trusted, highly trained health care professionals. They should be incorporated and allowed to administer the Cabenuva® injection if the battle against the HIV pandemic is to be totally won. In this paper, we, therefore, aim to explore how the community pharmacist can be positioned in HIV service delivery regarding the administration of the Novel long-acting Cabenuva® injection formulation. It is therefore recommended that the Nigerian government embrace community pharmacy-led drug administration initiatives and embark on accredited training programmes for the profession in line with drug administration services. The government should also put in place necessary funding mechanisms for community pharmacists for the extra workload placed on them in administering injection drug formulation in their respective pharmacies.     

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.     

Substance abuse treatment and HIV services: Massachusetts' policies and programs

States and communities use many strategies and policies to facilitate the integration of HIV and AIDS services with alcoholism and drug abuse treatment and prevention programs. Massachusetts' policy initiatives that promoted collaboration between substance abuse programs and AIDS services are outlined. The review begins with an overview of the HIV epidemic in Massachusetts and reflects on the initial challenges of building system capacity so that HIV and substance abuse services could become more closely integrated. The discussion summarizes specific policy strategies implemented to encourage system development and to develop program and staff skills for working with men and women with HIV/AIDS and at risk of infection. The initiatives included integration of alcoholism and drug abuse treatment programs, expansion of Medicaid reimbursement for substance abuse treatment, training and skills development for counselors, and coordinated service development and advocacy for substance abuse and AIDS/HIV services.     

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.     

HIV antibody testing and client retention in the therapeutic community: A preliminary report of Phoenix House

This report describes the current approach to testing for the human immunodeficiency virus (HIV) antibody at Phoenix House, a large therapeutic community (TC) in the northeastern United States, and presents findings on retention of clients who have been tested for HIV antibodies and notified of their HIV serostatus. A total of 240 clients were tested while in treatment at Phoenix House between April 1988 and July 1992. Of these, 51 tested HIV positive. An additional 76 clients had tested positive for HIV antibodies prior to entering treatment. The differences in length of treatment stay between those who tested negative while in treatment and those who tested positive while at Phoenix House was not significant (t = 0.41, df = 238, p > .683). Although clients who tested seronegative during treatment were found to remain in treatment a significantly longer amount of time than the total population of seropositive clients (t = 4.54, df = 314, p < .001), those who learned of their seropositive status while in treatment remained in the program longer than clients who entered treatment aware of their seropositivity (t = 4.08, df = 125, p < .001). These findings suggest that acute reactions to the knowledge of seropositivity did not determine most premature terminations. The use of a small group, a core technical element of the TC, may have provided a favorable context for the task of HIV counseling and testing.     

Peer and sexual relationships in the experience of drug-dependent adolescents in a therapeutic community

Introduction and Aims. Evidence for success of adolescent treatment programs, including therapeutic communities, has been found among those who complete treatment. However, there is a lack of research examining peer relationships as part of treatment experience. Given the central role of ‘community’, including peers, as agents of change in therapeutic communities, there is a need to better understand peer relationships in treatment. This ethnographic study provides a window into the dynamics of adolescent relationships in a residential treatment program. Design and Methods. Four months of participant observation, including 21 residents (15 male and 6 female) aged between 14 and 18 years—comprising all residents admitted during the study. All the data in this paper are from those who were 16 years or over. Results. The data reveal the complex peer relationships that form for some residents. Peer groups were found to provide a space for residents to feel included but more often were a mechanism to ostracise or bully others. In contrast to past studies, our study found sexual activity was widespread, in particular among girls. A lack of sex caused frustrations for some and sexual encounters were found to coincide with overt conflict between residents. Conclusions. Treatment programs for adolescents need to more explicitly grapple with the complexity of resident's peer relationships, which may impact on treatment experience. Our study suggests sexual relationships may be common in treatment programs for adolescents and a cause of conflict. Further research about the mediating impact of peer relationships, including sexual relationships, is needed.[Nathan S, Foster M, Ferry M. Peer and sexual relationships in the experience of drug‐dependent adolescents in a therapeutic community. Drug Alcohol Rev 2011;30:419–427]     

云南省1139例美沙酮门诊受治者6个月HIV新发感染率调查

目的獉獉:了解云南省美沙酮门诊受治者HIV新发感染率及其影响因素。方法獉獉:于2008年10月招募HIV血清抗体阴性的美沙酮门诊受治者1139名进入队列,6个月后随访并进行血清学检测确定HIV新发感染率。将结果进行χ2检验及帕松回归分析。结果獉獉:6个月后随访894名调查对象,观察总人年为505.25人年,HIV阳转12人,HIV新发感染率为2.38/100人年。影响因素有:临沧地区门诊,"输入带有HIV的血液或血液制品会感染HIV"知识点答错,未了解或接受过免费安全套发放服务,了解或接受过机会性感染治疗、抗病毒治疗的调查对象HIV新发感染率较高。结论獉獉:美沙酮门诊受治者HIV新发感染率低于一般静脉吸毒人员。在美沙酮门诊加强艾滋病知识的培训,各种服务获得途径的宣传,以及扩大安全套免费发放的范围和数量,对于降低HIV新发感染率有意义。     

Problems and emerging approaches in HIV/AIDS vaccine development

According to recent estimates, 39.5 million people have been infected with HIV and 2.9 million have already died. The effect of HIV infection on individuals and communities is socially and economically devastating. Although antiretroviral drugs have had a dramatically beneficial impact on HIV-infected individuals who have access to treatment, it has had a negligible impact on the global epidemic. Therefore, the need for an efficacious HIV/AIDS vaccine remains the highest priority of the world HIV/AIDS agenda. The generation of a vaccine against HIV/AIDS has turned out to be extremely challenging, as indicated by > 20 years of unsuccessful attempts. This review discusses the major challenges in the field and key experimental evidence providing a rationale for the use of non-structural HIV proteins, such as Rev, Tat and Nef, either in the native form or expressed by viral vectors such as a replicating adeno-vector. These non-structural proteins alone or in combination with modified structural HIV-1 Env proteins represent a novel strategy for both preventative and therapeutic HIV/AIDS vaccine development.