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.     

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.     

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.]     

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.     

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.     

Holistic Native network: integrated HIV/AIDS, substance abuse, and mental health services for Native Americans in San Francisco

The Holistic Native Network provides a model for integrated HIV/AIDS, substance abuse and mental health services in a cultural context. Funded in 2002 by a grant from the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) initiative, the Holistic Native Network is a collaboration of the Native American Health Center and Friendship House Association of American Indians, two community-based organizations with facilities in San Francisco and Oakland. Substance abuse and mental health services are integrated into primary HIV/AIDS medical care. San Francisco has the largest population of Native Americans with HIV/AIDS in the country. Since its inception, 45 Native Americans with HIV/AIDS have been enrolled in the Holistic Native Network. These clients were surveyed upon admission and at three months in treatment. The results indicated positive changes in quality of life. The success of this program lies in the way that culture and community is included at every stage of service provision. From outreach to case management to substance abuse and mental health services, the Holistic Native Network meets the spiritual, medical and psychosocial needs of HIV+ Native Americans.     

中国部分地区疾病预防控制工作人员HIV/AIDS知识、态度及行为的调查分析

目的了解中国部分地区疾控人员HIV/AIDS知识、态度及行为状况,指导当地开展健康教育。方法采用自填式问卷,分别调查省级、市级和区/县级单位疾控人员,进行流行病学现况研究。结果95%以上的疾控人员对HIV/AIDS相关知识掌握较好;50%左右的疾控人员认为患艾滋病是件不光彩的事情,害怕别人知道;40%左右的疾控人员对由不良行为感染HIV的患者心存厌恶态度;工作中接触到艾滋病患者时,61.8%的疾病控制人员愿意做全部的工作;在自己感染HIV后,68.3%的疾控人员认为能够正常工作生活。不同单位级别间认知程度无明显差别;但态度和行为存在差别,且差别不一致。结论应加强HIV/AIDS态度和行为相关的健康教育,端正疾控人员对艾滋病病人或感染者的态度和行为。     

Therapeutic communities: AIDS/HIV risk and harm reduction

The limited survey data available suggest that therapeutic communities have increasingly organized themselves to develop HIV prevention programs and to integrate HIV-infected and AIDS clients into the treatment community while providing specialized program as necessary. Nonetheless, there remains a need for a comprehensive survey of the response of therapeutic communities to AIDS and the risk of HIV infection. There is need as well for studies that can build on findings linking retention in the therapeutic community to strategies that focus on clients' motivation or readiness for treatment. In addition, therapeutic community programs can ally with outreach programs both to provide priority admission to seropositive clients, women with children, adolescents, and criminal justice clients, and to provide harm reduction services to those unwilling to enter treatment while also taking incremental steps to engage those clients in ever increasing behavior change initiatives.     

Acceptability and utilisation of services for voluntary counselling [corrected] and testing and sexually transmitted infections in Kahsey Abera Hospital, Humera, Tigray, Ethiopia

OBJECTIVES: A study was conducted to assess the acceptability and utilization of voluntary counselling and testing (VCT) and sexually transmitted infection (STI) services in Kahsey Abera Hospital, Humera. METHODS: Retrospective data was taken from hospital consultation logbooks from January 2002 to February 2003, and focus group discussions were conducted in March 2003 in the community. RESULTS: While the services were known and utilization is increasing, important misconceptions about the medical services, disease transmission, and STI treatment persist. Although hospital care was generally considered of high quality, persons often go to pharmacies to self-treat for STIs due to concerns about confidentiality, and the stigma of HIV deters many from wanting to know their serostatus. CONCLUSIONS: Additional education is needed on HIV/AIDS, STIs, and the medical services provided. Education may make use of community health workers or outreach workers in a small group where participants can feel comfortable to ask sensitive questions. HIV/AIDS treatment is planned for the near future and may be significant in reducing HIV/AIDS stigma.     

贵阳市HIV/AIDS社区支持与关怀模式研究

目的 探索在城市开展艾滋病病毒感染者(HIV)／艾滋病人(AIDS)社区支持与关怀模式。方法 对HIV感染者／家属进行健康教育,给予医疗和心理关怀,使他们有一个宽松的环境。通过宣传倡导,对艾滋病的有关知识问题进行讨论,深入宣传发动工作,引起全社会的重视。结果 通过对部分HIV感染者及家属的支持与关怀活动,了解到吸毒人群中HIV感染者迫切需要解决的是戒除毒瘾问题,他们与家属共同呼吁,能得到有关部门帮助他们戒除毒瘾,希望能制定有关政策,解决其就业、医疗及最低生活保障,渴望能生活在一个不受歧视、平等和宽松的生活环境。本次HIV／AIDS社区支持与关怀项目时间较短,由于经费与技术支持不能继续,其可持续性发展难以进行。结论 开展HIV／AIDS社区支持与关怀,首先需由政府领导、多部门合作、全社会参与,及时制定相关配套政策;加强健康教育,让全社会了解掌握有关艾滋病传播途径及预防艾滋病的知识,反对歧视,将HIV／AIDS纳入传染病的常规管理;美沙酮替代治疗应尽快在吸毒人群中广泛开展;艾滋病防治可持续发展经费,除政府建立艾滋病防治专项基金并纳入每年计划外,应考虑募集可持续发展经费的支援。     

The AIDS research agenda at the National Institutes of Health.

The foundation, goals, and components of the research strategy developed by the National Institutes of Health to combat AIDS and HIV infection are discussed. The AIDS research agenda, based on systems originally designed to coordinate cancer research, involves a national effort to study various aspects of the disease, disseminate information, and rapidly develop and test drugs and vaccines to treat and prevent AIDS and HIV disease. AIDS research makes up approximately 10% of the total NIH budget of $7.6 billion, and the largest portion of that allocation goes to improving current treatments and developing new agents. Drug discovery efforts are supported by the National Institute of Allergy and Infectious Diseases (NIAID) through the Division of Intramural Research, in which biomedical and clinical research is conducted, and the Division of AIDS, which coordinates extramural research in university-based centers and community programs. By providing educational materials and sponsoring conferences, NIAID also helps to disseminate the results of the research it coordinates. Pharmacists support AIDS research through their involvement with study drug products and their role in protocol development, regulatory affairs, product development, and accumulation and distribution of drug information. Research initiatives sponsored by the federal government combine resources of investigators from government, academia, and the pharmaceutical and biotechnological industries to meet the challenges posed by the AIDS epidemic.     

Drug use, AIDS knowledge, and HIV risk behaviors of Cuban-, Mexican-, and Puerto-Rican-born drug injectors who are recent entrants into the United States.

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

Drug use,AIDS Knowledge,and HIV Risk Behaviors of Cuban-, Mexican-, and Puerto-Rican-Born Drug Injectors who are Recent Entrants into the United States

To date, relatively little research attention has been devoted to the HIV-risky behaviors of persons who are newly arrived in the United States and who use drugs. Data gathered from street-recruited injection drug users (IDUs) recruited in 10 United States cities who were born in Mexico, Cuba, and Puerto Rico and who are recent entrants into the United States suggest that, in comparison to US-born IDUs, Mexican-born subjects are at elevated risk for acquiring and transmitting HIV as a result of sharing needles with friends and running partners; sharing drug injection implements such as cookers, cotton, and rinse water; frequent injection in HIV-risky settings; use of unsterilized needles; and relatively frequent trading of sex for drugs or money. Puerto-Rican-born IDUs were found to inject drugs relatively frequently, and to do so relatively often in high-risk settings in which sterile injecting equipment and cleaning materials often are scarce. These data also show generally lower levels of AIDS knowledge among the in-migrant IDUs than among US-born IDUs. Respondents from each nationality group most often cited television as the source of their most useful and reliable AIDS information, but also tended to regard community outreach workers as a significant source of reliable AIDS and needle cleaning information. The high levels of involvement in HIV-risky behaviors, deficits in knowledge concerning the means of HIV transmission, and relative ease of mobility of the at-risk (for HIV) individuals examined here indicate a need for a comprehensive public health prevention initiative to limit the future spread of HIV. At a minimum, such an undertaking would do well to incorporate group-specific, culturally appropriate behavioral interventions as well as an information campaign.     

The changing epidemiology of prevalent diagnosed HIV infections in Taiwan, 1984-2005

By the end of 2005, there were 10,158 reported cases of HIV infections in Taiwan, of them, 2,403 had developed full blown AIDS, and 1,333 had died. It represented an average annual increase of 15% in HIV diagnoses before 2003. The most common route of transmission is through men having sex with men followed by heterosexual contact, while infections through injecting drug use (IDUs) remained low. However, the number of newly reported HIV infections has been rising sharply since 2003, mainly among IDUs. The consequences of this HIV/IDU epidemic include a rapid increase in female HIV/AIDS patients and a decreased mean age of HIV/AIDS cases. Only 2% of patients in the IDU group have been diagnosed with AIDS, suggesting that most IDU cases are in the early stage of HIV infections.HIV/AIDS patients are provided with free medical care by the government in Taiwan, including anti-retroviral treatment. The case fatality rate of AIDS cases declined gradually from 64% in 1996 to 8.9% in 2005. Patients in the IDU group seek medical care less frequently than patients in the sexual contact group. Statistics show that 61.4% of patients in the IDU group did not seek HIV-related medical care, significantly higher compared to the sexual contact group.The Taiwanese government implemented a trial “Harm Reduction Programme,” which involved a needle-syringe programme (NSP) and substitution treatment, in August 2005. After 1 year's pilot study, the HIV incidence in cities with NSP decreased from 13.9 to 13.3 per 100,000 persons compared to an incidence increase from 11.5 to 15.3 per 100,000 persons in cities without NSP. We scaled up the programme to cover the whole of Taiwan in July 2006 and are expecting to see the efficacy in the near future.     

Outpatient substance abuse treatment and HIV prevention: an update

Testing and counseling, along with community outreach, have been identified as valuable in the prevention of human immunodeficiency virus (HIV) and other blood-borne diseases. This article assesses the extent to which outpatient substance abuse treatment (OSAT) programs provide such services. Longitudinal data for 1988-2000 were analyzed from the National Drug Abuse Treatment System Survey (NDATSS). Random-effects regression was used to examine factors associated with the provision of prevention services. HIV testing, which had became more common between 1990 and 1995, continued to proliferate between 1995 and 2000. The proportion of units that provide HIV testing and counseling increased from 66% to 86%. The proportion of units that provide HIV community outreach increased significantly before 1995 but then slightly decreased from 77% to 73% between 1995 and 2000. In conclusion, HIV testing and counseling widely proliferated in OSAT care. However, OSAT units remain less likely to offer HIV community outreach services.     

滁州市2012-2015年艾滋病病毒感染者/艾滋病患者病例流行特征分析

目的 分析滁州市2012-2015年历年新报告艾滋病病毒感染者/艾滋病患者(HIV/AIDS)的流行病学特征,为滁州市有针对性开展艾滋病防控工作提供科学依据.方法 首先滁州市疾病预防控制中心通过“艾滋病网络直报系统”进行艾滋病疫情的汇总和核实,本次研究的资料直接来源于滁州市疾病预防控制中心,然后利用Excel和SPSS软件对疾病进行“三间分布”的描述性分析.结果 2012-2015年,滁州市新报告HIV/AIDS病例数总共为383例,并且呈逐年增长趋势;男女性别比为4.2∶1,20～＜40岁年龄组病例占58.2％;30.8％的新报告HIV/AIDS病例为农民,其次家政服务行业占19.6％;病例主要集中在凤阳县、明光市,定远县、琅琊区及天长市,占76.0％;异性性传播为主要传播途径;同性传播所致的感染呈逐年上升趋势.结论 滁州市艾滋病疫情具有明显的时间、地区和人群分布特征.异性传播为滁州市艾滋病流行的主要传播途径,因此需要加强广大人民群众的安全性行为意识教育以及对特定人群的重点监测,开展有针对性的防控工作,探索适合的防控模式,有效遏制艾滋病在滁州市的传播和流行.     

Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users

This paper focuses on the evidence for the effectiveness of community-based outreach intervention as one component of a comprehensive HIV prevention model for preventing HIV infection in injecting drug user (IDU) populations. Three empirical questions guided the review of the evidence. This article includes primarily published literature on community-based outreach derived mostly from developing countries but also unpublished literature. Wherever possible, evidence from multi-country, multi-site studies or meta-analytical studies is included. More than 40 published studies reveal that injecting drug users (IDUs), who are reached by community-based outreach and provided with access to risk reduction services, report reducing HIV risk behaviours. The strength of the evidence was assessed using Hill's criteria, which permit a review of multiple studies with different designs. Using the criteria, it is possible to infer causation about the evidence of effectiveness of the intervention. The evidence for the effectiveness of a community-based outreach strategy is strong. Despite evidence from 20 years of evaluation studies of the effectiveness of community-based outreach, a huge gap exists in most countries between the number of IDUs who want or could benefit from outreach services and the number of IDUs who actually receive them. Findings from evaluation studies on the effectiveness of community-based outreach must be made accessible, disseminated globally and provided to policy- and decision-makers to persuade them to take action and implement scaled-up prevention programmes. This requires ongoing advocacy and constant strengthening of the evidence base. Plans are needed to link evidence-based findings with technical assistance as well as training to enhance the capacity of regions and countries to introduce, scale up and sustain HIV prevention outreach to IDUs as part of a comprehensive HIV prevention strategy.     

The Feasibility of a Syringe-Needle-Exchange Program in Vietnam

Since the beginning of the HIV/AIDS epidemic, syringe-exchange programs have been established in a number of developed countries and have proven effective in reducing the transmission of HIV. Very few similar programs have been established in developing countries. This study reports on the feasibility of establishing a syringe-exchange program in Vietnam. Process data collected since the beginning of the program indicate the feasibility of establishing such a program as well as highlight a number of important issues. These issues are: 1) Acceptability of the program in the community which has been achieved through workshops with key community people including the local police; 2) training and recruitment of ex-user outreach workers; 3) the distribution of clean syringes and needles through outreach services rather than at established exchange sites; 4) the establishment of appropriate methods for the collection of used injection equipment. Further research is needed to examine the efficacy of the program in reducing risks and acceptability of the program in the larger society.     

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.