A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users
Chapter 3, Section 1: Guiding Principles
ENSURE COORDINATION AND COLLABORATION
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.
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
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,
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
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
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.
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
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
For more information: SPHERE, Brockton, MA, 800/530-2770.