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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 2: Key Strategies


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.


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.


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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