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U.S. Department of Health and Human Services

Archival Content: 1999-2005

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

Chapter 3, Section 1: Guiding Principles


Current medical care, social service, and HIV and drug use prevention and treatment systems are complex and governed by a patchwork of federal, state, and local funding arrangements and regulatory environments (AED, 1999). Service providers report frustrations with the barriers these multiple systems create and the ways in which they limit providers' ability to provide a continuum of services to meet the complex needs of injection drug users (AED, 1999). If interventions with IDUs are to succeed, agencies and providers must find ways to work within these systems to coordinate their efforts.

This principle also embodies another idea-collaboration. The profound and often conflicting differences in approach and orientation espoused by various organizations, philosophies, and providers, and the resulting reluctance of agencies and providers to work together for IDUs contributes to the fragmented service delivery system and leads to policies, laws, and regulations that can be inconsistent, contradictory, and sometimes at cross-purposes. Providers, agencies, and policy makers must collaborate, sharing their various skills, perspectives, and experiences, building on prior relationships, and reaching out to groups with whom they may not have worked before. Partners in this effort need not agree on every thing, but they do need to find ways to cooperate so as to achieve the larger goals of reducing HIV and viral hepatitis infection in injection drug users and reducing substance abuse.


Cross-Training for HIV/AIDS, Infectious Diseases, and Substance Abuse Providers: A Novel Idea Becomes a Nationwide Trend

In 1996, the Georgia Department of Health received funding from the Center for Substance Abuse Treatment (CSAT) of the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to develop and deliver a series of workshops to bring together staff from the state's public health and substance abuse treatment agencies. CDC also participated by providing technical assistance and oversight. The genesis of this project was the fact that the shift of the epidemic toward IDUs and disadvantaged and minority populations meant, increasingly, that providers were working with clients who had multiple problems. Having providers focus only on a client's substance abuse problem, or STD, or high-risk sexual behaviors was clearly not adequate. But significant barriers prevented these professionals from providing more comprehensive services. Staff from public health or substance abuse treatment didn't know what questions to ask to assess a client's problems in the other arena, or felt it wasn't appropriate to ask those questions. Federal confidentiality protections precluded substance abuse treatment and public health staff from discussing a client who was being seen at both types of facilities. Longstanding patterns of limited communication between the different agencies created an additional barrier.

Clearly, something was needed to help break down these barriers and foster collaboration. Staff needed an opportunity to learn about each other's subject areas, client assessment procedures, and treatment options. More than that, they also needed an opportunity to make personal connections across agency disciplines, cultures, and bureaucracies - connections that would allow them to develop mutual respect and a common vocabulary, foster a willingness to hear each other's point of view, and understand the realities of each agency's funding and policy requirements. The desired outcome? Collaborative working relationships, strong channels of regular communication, and ultimately, system-wide positive change.

Over a 7-month period in 1997, 24 2-day workshops were held across the state. About 1,100 nurses, counselors, social workers, clinicians, and epidemiologists participated. The first part of each workshop focused on one of the biggest difficulties - lack of knowledge. The trainers provided the public health participants with a "Substance Abuse 101"; the substance abuse treatment participants received the same for STDs. The entire group received an update on the HIV/AIDS and TB epidemics. The remainder of the workshop emphasized skills-building so that participants could conduct more comprehensive prescreening, risk assessment, and counseling with clients. Throughout the workshop, participants were encouraged to talk with each other, share experiences, and learn about the day-to-day realities and challenges faced by others.

An essential element in the success of the workshops was including all the involved parties in planning and implementation. Before the workshops, high-level administrators and front-line staff from the public health and substance abuse treatment agencies met to discuss existing barriers to collaboration, needed tools and skills, and goals and objectives for the workshops. They also discussed Qualified Service Organization Agreements (QSOA), which would allow substance abuse treatment and public health provider agencies to share limited information about clients within the legal constraints of federal confidentiality protections.

The response to the workshops was immediate, powerful, and positive. They changed attitudes, altered the way that many participants worked with clients, created collaborations, and led to requests for further trainings. Since then, several other series of cross-training workshops in Georgia have helped participants develop new approaches to dealing with issues such as substance abuse treatment planning, harm reduction, and confidentiality.

In 1998, CSAT, CDC, and the Health Resources and Services Administration (HRSA) developed an interagency agreement to expand the cross-training concept. This initiative, called "HIV/AIDS, TB and Infectious Diseases: The Alcohol and Other Drug Abuse Connection," provides training and technical assistance to state infectious disease and substance abuse health care delivery systems so that they can more effectively serve individuals who have or are at high risk of having concurrent conditions. During FY99 alone, 13 cross-training workshops were held in 6 states. In addition, trainers have responded to 40 requests for cross-training information and technical assistance from states and federal agencies.

Many components and principles of the early cross-training experiences have been applied in the current initiative:

  • Reflect the diversity of the epidemic. Because success in one area is dependent on addressing others, the workshop now covers prevention, treatment, and care issues for the various substance abuse and infectious disease topics (HIV, STDs, TB, hepatitis). Workshop planners and participants include representatives from mental health and criminal justice as well as from infectious diseases and substance abuse. Planners report that this greater diversity in the cross-training helps participants more easily appreciate and understand other points of view and approaches than does a workshop with more restricted representation or content.

  • Tailor to the local community. Before a workshop is held, planners research the disease issues in the community to ensure that topics and skills-building exercises reflect and are tailored to the needs, cultures, and languages of the community. Participant lists reflect the particular needs and existing service delivery systems of the community. Planners also select workshop trainers with this principle in mind.

  • Build local commitment and capacity. Although a request for a cross-training workshop may come from one agency or organization, all the potential partners must agree to support and participate in the training. They are also part of the planning group, select the participants, and identify local co-trainers. All of these activities help to build local capacity for further training and encourage widespread institutional commitment to improving prevention, treatment, and care systems.

  • Follow up. An essential element of the initiative is long-term follow up to track changes that result from workshops (Are trainings being replicated? How many QSOAs have been signed? Have other types of collaborative activities developed?) and to provide necessary technical assistance to states.

For more information: HIV/AIDS, TB and Infectious Diseases Cross-Training: The Alcohol and Other Drug Abuse Connection. to a Non-CDC Link


One-stop Shopping to Help Programs Work Better

The Statewide Partnership for HIV Education in Recovery Environments (SPHERE) develops and delivers training to substance abuse treatment providers, AIDS service organizations, and community-based health centers in HIV/AIDS prevention and substance abuse issues and related topics such as capacity building, policy development, organizational development, and coordination and collaboration. Increasingly, programs are calling SPHERE for help in developing long-term training and development plans and this contributes to system-wide positive change.

Funded by the Massachusetts Department of Health's AIDS bureau and its substance abuse treatment bureau, SPHERE's primary goal is to foster and support interdisciplinary collaboration across the many groups that work with substance abusing populations and those at risk of or infected with HIV and other blood-borne pathogens. By holding cross-trainings and educational workshops and conducting outreach to HIV/AIDS, substance abuse, syringe exchange, mental health, primary care, and other providers, SPHERE hopes to create a synergy among providers so that they can learn with and from each other, share best practices, and overcome philosophical barriers.

In addition to its trainings and efforts to foster collaboration, SPHERE has developed a number of tools and forms that have been adopted by many organizations and service providers in the state. Among these are new standardized intake and record release forms and a comprehensive HIV risk assessment tool and a program satisfaction and evaluation tool.

For more information: SPHERE, Brockton, MA, 800/530-2770.

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