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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