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A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users

Chapter 3, Section 1: Guiding Principles

ENSURE COVERAGE, ACCESS, AND QUALITY

Programs and interventions will not be effective if they do not reach a critical mass of people who need them, if IDUs cannot or will not use them, or if they are of poor quality. The first of these elements, coverage concerns whether services or interventions are reaching a sufficient number of IDUs to make a real difference. For example, it is estimated that only a small percentage of those needing substance abuse treatment actually receive those services (Epstein and Gfroerer, 1998). Similarly, pharmacies and syringe exchange programs help a growing number of IDUs who continue to inject to obtain sterile syringes. However, these programs often fall short of reaching all those who desire to reduce their transmission risks by obtaining and using sterile syringes (Lurie et al., 1998; Remis et al., 1998).

The second concern, access, relates to issues such as the number and location of prevention and care services and programs, whether they are free or not, whether IDUs need a referral to use them, and whether IDUs know about their availability. Problems with access stem from the very nature of IDUs' lives as well as from the way in which the services and programs are organized and delivered. IDUs may not know what services are available to them, how to get to them, or how to use them. Frequently, their lives are so dominated by the demands of their addiction that participation in organized interventions is beyond their capability. Further, when IDUs do attempt to use care systems or programs, they report that some procedures and staff are insensitive and demeaning, confidentiality is not protected, and agency policies effectively pose barriers to care (NYHRE, 1998; Rogers et al., 1998; Thaca, 1997). This creates powerful feelings of mistrust and alienation and a strong reluctance to seek out or participate in programs and services.

The third issue, quality of care provided to IDUs, covers a host of issues such as the training and competency of service providers, the adequacy of medications prescribed (for example, are IDUs receiving a more effective dose of 80-100 mg of methadone per day [Strain et al., 1999] or only 30 mg per day?), and the provision of all necessary services (for example, are substance abuse treatment services accompanied by needed primary medical care or psychosocial services?). The ability of IDU to comply with treatment regimens, maintain or improve their health, and reduce their risks of acquiring or transmitting HIV and other blood-borne pathogens is directly related to the quality of the prevention and care services they receive.

If agencies and providers hope to truly help IDUs, they must consider ways to effectively deal with these key issues of coverage, access, and quality as they plan, deliver, and monitor programs and services.

NEW YORK HARM REDUCTION EDUCATORS
(NYHRE)

Focusing on Coverage, Access, and Quality

NYHRE is the largest harm reduction program in New York State. Now in its ninth year, its services also include outreach, HIV/AIDS prevention education, psychotherapy, treatment advocacy, referrals to health care, syringe exchange, and training for service providers. The ways in which it plans and provides its services and programs provide a useful perspective on the issues of coverage, access, and quality. About 35,000 people are enrolled in NYHRE programs and the staff sees about 8,000 individuals each year. In the last three years, NYHRE has doubled in size and budget and the number of staff has tripled. Reaching a critical mass of those who need help is a long-term and often difficult process, particularly in a city like New York, which has an extremely large IDU population. However, NYHRE's philosophy of reaching as many users as possible "where they are," providing as many different types of services as possible, and creating linkages among a myriad of services and service providers are good ways to address existing gaps in coverage.

"We understand that there are reasons why people use drugs and good reasons why they are not connected to services. We take that as our point of departure," says Terry Ruefli, NYHRE's executive director, in describing the ways in which NYHRE helps IDUs break down barriers to obtaining services. For example, says Ruefli, NYHRE provides traditional services in a nontraditional way. "We have a psychotherapist, but he doesn't sit in his office and wait for patients to come to him. He sets up two chairs on the sidewalk, and hangs his diploma on one of them. We do all our services on the street. Everything. Whatever need you have, you can get it met in this program in one way or another."

As part of its efforts to improve service quality and increase coordination among providers, NYHRE conducts harm reduction training programs. These workshops increase participants' awareness of the difficulties that IDUs face in obtaining high-quality services and provide training in the principles and practices of harm reduction. These trainings help providers learn to respect the ethnic and street cultures from which their clients come, which, in turn, helps them understand drug users, what makes sense to them, how they interpret the world, how they expect to be treated, and what kinds of interventions will be most effective.

Located in one of the poorest urban communities in the nation-the Hunts Point section of the Bronx-NYHRE has worked hard to collaborate with others on a variety of projects whose needs are defined by the community itself. Ruefli explains that NYHRE is "part of the process by which IDUs see that there's light at the end of the tunnel. They're not condemned to die of AIDS, to be homeless, to be mentally ill. We are one of the ways in which people can climb out of that."

For more information: New York Harm Reduction Educators, Inc., Bronx, NY, 718/842-6050.


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