A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users
Chapter 3, Section 2: Key Strategies
HIV COUNSELING AND TESTING,
PARTNER COUNSELING AND REFERRAL SERVICES, AND PREVENTION CASE MANAGEMENT
A comprehensive approach to preventing HIV and
other blood-borne infections must include the opportunity for individuals
to discover whether they are infected, and if they are, to help them
inform their partners. If they are not infected but engage in high-risk
practices, the approach can also help IDUs begin or sustain behavior
changes that will reduce their risk of acquiring or transmitting the
infection. Three interrelated services are designed to meet these objectives:
HIV prevention counseling and testing;
partner counseling and referral services; and
prevention case management.
Because these services are one-on-one and focused
around the needs of the client, they have the potential to address the
complex lives and circumstances of IDUs and more effectively influence
their risk behaviors than can more limited and diffuse interventions.
In addition, partner counseling and referral services and prevention
case management have the potential to provide the continuity of care
that is so important to successful outcomes with IDUs.
HIVcounseling and testing (C&T) is a prevention
intervention that provides HIV antibody testing and individual client-centered
counseling. The counseling is focused on working with the client to
identify his or her risk behaviors and then to develop an individualized
risk reduction plan. It provides a private and confidential way for
individuals to learn their HIV serostatus and get further help, whatever
the results of the testing. A number of C&T approaches have been developed
that are well suited to IDUs, including new, rapid HIV antibody tests
that allow a person to be tested and receive their results in one visit
(CDC, 1998b), other new tests that allow testing to be conducted with
oral fluids rather than blood, and C&T settings designed to attract
IDUs (CDC, 1989).
Partner counseling and referral services (PCRS),
formerly known as "partner notification," begin when a person seeks
HIV counseling and testing. If the test is positive for HIV, he or she
is given the opportunity to receive PCRS at the earliest appropriate
time. During the initial PCRS interview, the counselor will discuss
with the client his or her responsibilities to sex and drug-use partners
and available options for notifying them of the client's infection.
The HIV- infected client is encouraged to voluntarily and confidentially
disclose identifying, locating, and exposure information for each partner.
The PCRS provider and client together formulate a plan and set priorities
for notifying partners.
PCRS can have important benefits for individuals
and communities in that they provide an opportunity for agencies to
notify the partners of infected individuals of their exposure to HIV
and, potentially to viral hepatitis also. If already infected, the partners'prognosis
can be improved through earlier diagnosis and treatment. If not infected,
the partners can be assisted in changing their risk behavior, thus reducing
the likelihood of acquiring the virus. From an epidemiological standpoint,
following the chains of transmission from one infected individual to
another within and across social networks permits public health investigators
to chart the course of the epidemic and reach individuals at very high
risk.
Prevention case management (PCM) is an intensive,
ongoing, client-centered HIV prevention activity designed to help individuals
with complex lives and circumstances adopt and maintain HIV risk-reduction
behaviors. It provides counseling, support, and help with services to
address the relationship between HIV risk and other issues such as substance
abuse, STDs, mental health problems, and social and cultural factors.
Because it has the potential to address a wide range of social problems
and risk behaviors, PCM is particularly suited for individuals like
IDUs, who have or are likely to have difficulty initiating or sustaining
practices that reduce or prevent HIV transmission and acquisition. PCM
strives to develop an ongoing relationship with each client to provide
an environment of trust and understanding within which prevention counseling
can take place.
OUTREACH - ASSISTED MODEL OF PARTNER NOTIFICATION
Helping
HIV+ IDUs Tell Their Partners
Despite the benefits of HIV testing,
many people find it difficult to complete the process because of worries
related to being possibly infected. Fear of partner retaliation; stigma;
and future health, employment, and insurance problems all may prevent
a person from discovering his or her HIV infection status and disclosing
it to others. IDUs face all these concerns and more. For example, the
formality and perceived hostility of the health care system discourage
IDUs from seeking testing. If they do get tested and find they are infected,
finding and notifying partners may be difficult. Users may not know the
names of their partners, know only street names, or lack adequate locating
information. IDUs may be involved in illegal activities with partners
and that makes them reluctant to reveal names. Given these realities,
alternative models of providing counseling, testing, and partner notification
services clearly are needed.
One such model is the Outreach-Assisted Model of
Partner Notification, an intervention of the Partners in Community Health
Project, located on Chicago's west side. This model expands traditional
community outreach activities to include counseling and testing and partner
notification. As part of their regular HIV/AIDS prevention and education
responsibilities, trained indigenous outreach workers, who are already
familiar figures in the community, talk to high-risk IDUs and their drug-using
and sex partners about the benefits of voluntary HIV testing and partner
notification. Confidential testing is offered at the intervention's neighborhood
storefront office. An HIV counselor provides pre- and post-test counseling
to IDUs who come in for testing and works with infected individuals to
determine how partners will be notified. If an infected IDU prefers to
notify partners, the counselor will help prepare the person for these
conversations. The IDU can also request that the outreach workers notify
the partners. In this case, the counselor provides the locating and identifying
information to the outreach workers; the outreach workers do not know
the identity of the infected IDU. In the course of their regular duties,
the outreach workers will locate partners and inform them of their possible
exposure.
This model has a number of benefits. For one thing,
it offers community-based testing and counseling in a non-threatening
and familiar environment by counselors and outreach workers who are trusted
by and can communicate with those who live in the neighborhood. The outreach
workers' thorough knowledge of the neighborhood and its social networks
makes it possible for more partners to be located and informed than if
outsiders were to do it. In addition, because the outreach workers are
in the neighborhood all the time and often talking with individuals, their
presence does not automatically indicate that they are there for partner
notification. Thus, it provides a measure of privacy and protection for
partners who are notified.
This model was tested on Chicago's west side over
the course of a year. During this time, the project recruited 386 IDUs.
Almost all -376- returned to get their results and of these, 60 IDUs tested
positive. All but one were willing to identify their partners to the HIV
counselor. Rather than seeing notification by others as intrusive or unwanted,
the majority - 82 percent - welcomed the help and asked that the outreach
staff notify one or more partners. One concern that is often expressed
about HIV testing and partner notification is that notification can lead
to violence, but fortunately this did not occur. Moreover, recruitment
for testing continues successfully in neighborhoods where notification
has occurred. These results suggest that expanding traditional community
outreach to include counseling, testing, and partner notification is a
viable HIV prevention strategy among IDUs.
For more information: Levy and Fox, 1998.
THE
C.A.R.E. PROGRAM
Using C&T,
PCRS, and Case Management as an Entry Point to Reach IDUs with Multiple
Services
In 1988, Austin's Community AIDS Resources
and Education (C.A.R.E.) Program first began offering services to IDUs
and their drug-using and sex partners. The program offers four major types
of services-counseling, testing, and partner notification; early intervention
services; street and community outreach; and case management. In addition,
C.A.R.E. offers TB screening, client advocacy, acu-detox (a 15-point acupuncture
procedure for stress reduction and relapse prevention), and a Journey
program (outpatient substance abuse treatment designed specifically for
individuals living with HIV).
C.A.R.E. provides free, no-appointment-needed confidential
and anonymous counseling and testing at its clinic, at two Travis County
correctional facilities, and at each of the publicly funded drug treatment
programs. These services are the "entry point" for 85 percent of C.A.R.E.'s
clients and they lead directly into the program's other highly integrated
services.
C.A.R.E.'s work with jail inmates shows how this
operates. Individuals who test positive for HIV while in jail are linked
immediately with a C.A.R.E. community outreach worker. This worker stays
in touch with the inmate, works with the correctional facility medical
staff to ensure that the inmate receives medical care, and develops a
case management plan for that person that includes provisions for continuity
of care and HIV medications once the inmate is released. This worker also
makes sure that the street outreach team is aware of any inmates who may
be released from jail earlier than expected, which helps to ensure that
the person stays linked to the help he or she needs. C.A.R.E. also provides
education and early intervention services to all inmates at correctional
facilities. In 1999, the program educated 3,443 men and women in jails
about HIV and STD prevention, safer sex practices, hepatitis C prevention,
and harm reduction.
C.A.R.E. receives its funding from a variety of sources,
including the Texas Department of Health, the Texas Commission on Alcohol
and Drug Abuse, Ryan White Title III, and the City of Austin.
For more information: C.A.R.E., Austin,
TX, 512/473-2273 x 108.
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