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

Chapter 3, Section 3: Next Steps for Communities

This chapter has described the elements of a comprehensive approach to preventing the continued transmission of blood-borne pathogens among IDUs-eight strategies supported by four essential principles. Health departments, community planning groups, community-based organizations, health care and social service providers, correctional facilities, policy makers, and others who work with IDUs are already carrying out many of these elements and working in creative ways to enhance the impact and reach of their efforts.

At the same time, communities and community planning groups must deal with various realities that hamper their ability to bring individual efforts together into a truly comprehensive approach. These realities can include limited funding; restrictive laws and regulations; community opposition; a lack of trained staff; insufficient knowledge about the extent and nature of the community's HIV, hepatitis, and injection drug use problems; a limited understanding of the community's IDU populations; or polarized political and philosophical viewpoints among different organizations and providers. What can communities do to adjust their programs to overcome these realities?

One important step that communities can take is to assess existing IDU-related prevention needs, services, interventions, and barriers in light of the comprehensive approach. The process of gathering this information does not have to involve a formal or lengthy needs assessment. Health department staff, service providers, and other interested local groups may already know much of this information or have ongoing working relationships with those who do. An important group to include in this process is IDUs themselves, for they have a unique perspective on the programs and services that are designed for them. Various reports have been written that also provide valuable back ground information and expert consensus on effective interventions (NIH, 1997b).

The following questions, organized around the four principles that guide the comprehensive approach, provide a framework for communities to generate the information necessary for this assessment.

ENSURE COORDINATION AND COLLABORATION

Successfully reaching IDUs must involve arange of services and interventions. By definition, this means that different agencies, health and social services providers, health professionals, and others active in the community must work together to plan, carry out, manage, and monitor these efforts. Understanding ongoing efforts as well as the attitudes of key players toward coordination is an essential first step to building and maintaining effective collaborations.

• What kinds of collaborations and coordination currently exist among health department staff, community planning groups, community organizations, health and social services providers, correctional institutions, policy makers, and others who work with IDUs?
• How might these collaborations be strengthened or new ones created?
• What barriers to coordination and collaboration exist (e.g., philosophical differences, organizational characteristics of service delivery systems, funding limitations, legal or regulatory barriers, lack of communication)?
• How might these barriers be overcome?
• Do the various providers who work with IDUs (such as those in substance abuse treatment, public health, primary care, criminal justice, mental health, and social services) have opportunities to learn about each others' issues and treatment approaches and philosophies (e.g., through cross-training, site visits, formal or informal networking)?
• Are IDUs involved in planning, designing, and carrying out services and interventions?

ENSURE COVERAGE, ACCESS, AND QUALITY

Assessing services and programs from these three perspectives will provide valuable insight into the strengths of existing programs and services and the ways in which communities can build on these strengths. This exercise can also shed light on the barriers that individuals face as they attempt to obtain or participate in them and reveal gaps or weaknesses in programs that must be addressed.

Coverage

• Which of the eight key strategies are being carried out at present? At whom are they directed and how are they being implemented?
• How many IDUs receive which services and interventions (e.g., are there multiple outreach teams to cover the multiple neighborhoods that have injection drug use problems)?

Access

• Do IDUs know which prevention and care services and interventions are available to them?
• Where are services and interventions located (e.g., in a central location only, in multiple storefront locations across the community)?
• What must IDUs do to obtain the services or interventions (e.g., get a referral, fill out forms, be on a waiting list, pay a fee, attend weekly sessions)?
• What sort of barriers to these requirements exist and how can they be ameliorated?

Quality

• Do IDUs obtain services and medications inappropriate and recommended quantities (e.g., sufficient daily doses of methadone, psychosocial support services in tandem with substance abuse treatment)?
• Are IDUs able to obtain services or participate in interventions for a sufficient length of time (e.g., substance abuse treatment that extends beyond initial detoxification)?
• Do the services obtained by IDUs complement and reinforce each other (e.g. , assistance with basic living needs provided along with substance abuse treatment, risk reduction counseling that covers sexual risk behaviors as well as drug use behaviors)?

RECOGNIZE AND OVER COME STIGMA

In addition to collecting facts about services, programs, and interventions, it will be important for those participating in the assessment to examine the community's attitudes toward IDUs, including the attitudes of the general public, providers, and policy makers. An important element of this task will be to explore the community's legal, policy, and social environment and how it affects the services and programs available to IDUs. For example, one community may have laws that penalize IDUs for carrying syringes and an outspoken citizen group that opposes syringe exchange programs. These clearly are barriers to IDUs in their attempts to obtain sterile syringes and reduce transmission risks. Another community may have laws allowing possession of a certain number of sterile syringes and a strong outreach initiative with active peer-led education groups that are successful in helping IDUs change their behaviors. Learning about attitudes and environments and how they inhibit or encourage successful implementation of programs and services is critical.

• How has the community responded to efforts to establish and expand services and programs for IDUs (e.g., substance abuse treatment programs or drop-in clinics for IDUs)?
• Is the current concept of addiction as a brain disease known and understood by providers and the public?
• How have current attitudes about IDUs and resulting laws and policies helped or hindered prevention and treatment initiatives?
• What are the current laws and regulations regarding sale, distribution, and possession of sterile syringes?
• Do syringe exchange programs operate in the community? Under what legal and organizational auspices do they operate?

TAILOR SERVICES AND PROGRAMS

To effectively plan and deliver prevention and care services, providers and organizations need to understand the particular characteristics and risk pro files of the various IDU populations in the community. Generating this information will help providers to more effectively reach those at highest risk.

• What are the demographic, language, and cultural characteristics of the IDUs in the community?
• Are there specific groups at particularly high risk of acquiring or transmitting blood-borne pathogens?
• If so, what are their particular patterns of drug use and sexual behavior and how do these behaviors increase transmission risk?
• What percentage of the IDUs in the community are homeless? Mentally ill? Have other serious medical conditions? In what demographic, racial, or ethnic groups do they belong?
• Do providers and service agencies have sufficient staff who are culturally and linguistically capable of working with the community's IDU populations?
• Are IDUs involved in planning, designing, and carrying out services or interventions?

Because it may not be financially possible or organizationally feasible for a community to implement all eight of the strategies described in this chapter, agencies, organizations, and providers will need to make choices and trade-offs. The information that emerges from answering the questions listed above can help communities, community planning groups, and health departments set priorities and plan programs because it will reveal gaps in services, needs for expanded or new services, and existing duplication of services and interventions. The assessment also can be useful in helping organizations match high priority needs with potential areas of collaboration as they plan activities and determine how funding, staff, and other resources are to be allocated.

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