A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users
Chapter 3, Section 2: Key Strategies
COORDINATED SERVICES FOR IDUS LIVING
WITH HIV/AIDS
Because HIV disease is a chronic and complex condition
with frequently changing recommendations for treatment regimens, infected
IDUs and their families require close monitoring and a constantly changing
array of services in their homes, in the hospital or health care facility,
and in the community (Keenan, 1990). With appropriate and high-quality
services and medications, IDUs living with HIV can lead fulfilling,
productive lives.
Many IDUs continue to engage in high-risk behaviors
after they learn they are infected with HIV and, thus, place others
at risk of HIV infection and themselves at risk for collateral health
problems (CDC, 1996; HRSA, 1994; Kwiatkowski et al., 1998; Metsch et
al., 1998). When HIV-infected IDUs are actively engaged in health care,
however, they can be followed to identify renewed high-risk sex or drug
use and counseled about the effects of these behaviors on themselves
and others. HIV- infected drug users who are in substance abuse treatment
and are receiving other health services are more likely to comply with
HIV/AIDS drug treatment regimens and to reduce their sex and drug risk-related
behaviors (Booth et al., 1999).
As a marginalized population, IDUs can be less
connected to the AIDS service delivery system than are other infected
individuals. Like non-IDU consumers, many IDUs do not know where to
go to obtain services or what services are appropriate for different
people at different stages of the disease. The service delivery system
can be too complex and fragmented for them to navigate and often too
remote geographically, socially, and culturally. Some programs prohibit
services to active drug users, which presents formidable barriers for
IDUs. Negative attitudes by staff toward IDUs' behaviors and life circumstances
further exacerbate the situation. IDUs living with HIV/AIDS therefore
need a full complement of services, delivered in a setting geared to
attract IDUs from the community and retain them. Case managers and prevention
case managers should offer risk reduction counseling and prevention
services to these individuals and assist them with managing their chronic
and acute health care needs, including taking anti-HIV medication and
opportunistic infection prophylaxis as recommended. In addition, a full
range of complementary, affordable, and accessible services should be
made available, including substance abuse treatment services, mental
health services, and help with other basic needs such as food, housing,
child care, and job training.
HEALTH BRIDGE
Coordinated
Services Improve the Health and Quality of Life of IDUs Living with HIV
Working in upper Manhattan and the
South Bronx, Health Bridge's goal is to engage, link, and provide continuous
care to HIV-infected men and women who have fallen through the cracks
and are lost to follow-up within the traditional medical care delivery
system. According to Debbie Indyk, director of Health Bridge, the key
is to "identify strategic sites for reaching people who are not reached
elsewhere, and engage them for whatever they need to be engaged for. We
have lots of people with HIV who know their status but aren't in care
and lots of people who don't even know their status. But we can reach
these people if we think strategically about where to find them and establish
linkages and infrastructure. Through outreach you find crises, but subsequently,
you can also deal with stabilization and growth and development."
Working closely with the Mount Sinai Jack Martin
Fund Clinic and other New York City programs for IDUs, Health Bridge staff
provide holistic care to HIV-infected individuals who live in single room
occupancy (SRO) hotels. Through their "home visiting" approach and consistent
presence in the hotels, Health Bridge staff are able to successfully engage
clients and provide various services, including wound care, urgent care,
entry into substance abuse treatment, and stage-based links to primary
care. For those clients who are not ready to come into the clinic for
care, a Health Bridge team consisting of a physician assistant, a part-time
attending physician, a medical assistant, and two case managers provide
care, support, and referrals to housing, case management, and other services
at the SRO hotels.
A fundamental element of the Health Bridge model
is recognizing that disenfranchised individuals, such as HIV-infected
IDUs, need support through various phases of engagement and retention
in care. For example, clients may be willing to meet with Health Bridge
staff but not come to the clinic for care; they may be ready to take AZT
to reduce the risk of perinatal transmission, but not want to begin treatment
for their own HIV disease. Through a model derived from the stages of
change theory and using sustained outreach to reach individuals "where
they are," Health Bridge staff have built a safety net that can quickly
identify people in crisis as well as those ready to be engaged in medical
care, substance abuse treatment, and other care and support services.
Since its inception in 1998, Health Bridge has reached
well over 100 people living in three SRO hotels. Over one-half are African
American and about two-thirds are men. Recognizing the very great need
in this part of New York, Health Bridge is actively trying to expand its
capacity and linkages so that it can serve increased numbers of infected
and at-risk individuals.
For more information: Health Bridge, New York,
NY 212/241-7863.
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