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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


Because injection drugs are illegal and drug users often resort to crime to support their drug addiction, IDUs are frequently arrested and imprisoned. A recent study on substance abuse and prisoners found that 81 percent of state inmates, 80 percent of federal inmates, and 77 percent of local jail inmates had some type of drug abuse problem (Belenko, 1998). In 1996, an estimated 250,000 state prison inmates had injected drugs, including 120,000 who had shared needles. Some 14,000 federal prison inmates had injected drugs, including 6,000 who shared needles (Belenko, 1998).

At the same time, inmates in prisons and jails have disproportionately high rates of HIV infection and other STDs, hepatitis, and other health problems. At the end of 1996, 2.3 percent of male and 3.5 percent of female state and federal prison inmates were known to be infected with the HIV virus (Hammett et al., 1999). AIDS was diagnosed in 0.5 percent of all inmates, a rate six times higher than that of the U.S. population. The high-risk behaviors responsible for the transmission of HIV and other blood-borne illnesses among inmates include high-risk sexual activity, sharing of needles and other drug injection equipment, and tattooing with improvised tools and materials (Calzavara et al., 1997; Dolan et al., 1996; Mahon, 1996; Struckman-Johnson et al., 1996).

In light of the many IDUs who are in the criminal justice system and the large numbers of at-risk and infected individuals, this setting is a crucial venue for HIV- and hepatitis-related interventions and services. Providing a range of health and prevention education interventions to inmates not only benefits them and their overall health but can also improve the health of the communities to which the vast majority of inmates return (Hammett et al., 1999).

One of the most important types of interventions in prisons and jails is education and prevention efforts led by inmates themselves. These programs can be cost-effective and they have a credibility that programs led by outsiders cannot match. Peer-led programs also provide significant benefits to the peer educators themselves. Through participating in the programs, peer leaders can develop a positive focus in their lives, regain a sense of purpose and empowerment, and realize that they are able to influence others in ways they never believed possible (Hammett et al., 1999).

Prevention services currently offered to inmates vary widely across state, county, and city jails and prisons. They include instructor-led and/or peer-led HIV education, pre- and post-test counseling, multi-session prevention counseling, the use of audiovisual materials, and the distribution of written materials. Most correctional systems provide HIV antibody testing, although testing policies differ widely. Few systems routinely screen inmates for STDs and only limited viral hepatitis prevention and treatment services are available. A very few systems make condoms available to inmates.

New antiviral and combination therapies are widely available in correctional facilities (Hammett et al., 1999). However, a number of factors, including the high cost of the regimens, inmate reluctance to seek testing and treatment, uneven clinical quality of services, and a lack of uniform treatment standards means that the availability of comprehensive care for infected inmates that involves case management, psychosocial treatment in conjunction with medical services, hospice care, substance abuse treatment, and continuity of services between prison and the community, may be limited (Hammett et al., 1999)


An Innovative Approach to Working with IDUs Within the Court System

Since the early 1990s, 400 jurisdictions have established drug courts with the idea that a different approach was needed. In the drug court model, the emphasis shifts from incarceration with occasional treatment, to treatment with (hopefully) only occasional incarceration. In most drug courts, substance abusing defendants who have been charged with nonviolent offenses are screened for eligibility. If eligible, the defendant will be offered a deferred prosecution or the opportunity to plead guilty to the charges with the promise that if he or she complies with court-mandated substance abuse treatment, the court will vacate the plea and dismiss the charges. If the defendant refuses treatment or fails to fully comply, the case will be prosecuted in the usual fashion. Defendants who choose treatment regularly report back to the court on their progress. A central component of the model is monitoring of drug use through frequent drug tests. The court uses escalating sanctions for drug use and rewards for progress to create incentives for the defendant's recovery.

The Brooklyn Treatment Court (BTC) has taken this model a few steps further. What it has tried to do is recognize the myriad needs and situations of substance abusing individuals who come into the criminal justice system. These men and women are not just addicted to drugs. They have serious health problems as well as employment, housing, and social service needs. Women drug users have particularly complex situations; many have experienced physical or sexual abuse and many have child custody issues.

To accommodate these needs, the BTC has developed a broad network of on-site and off-site collaborative services. For example, the New York City Department of Health provides screening, testing, and education for HIV, TB, STDs, and pregnancy. The NYU Division of Nursing, in collaboration with the Brooklyn Hospital, provides primary health care services. The Human Resources Administration provides assistance with welfare, food stamps, and Medicaid. The BTC also provides acupuncture and short-term drug education and intervention through its Treatment Readiness Program. The BTC's Project Connection has relationships with many local organizations, which helps clients return to their communities after treatment and promotes enhanced court-community relations. BTC also works with attorneys to advocate for women involved in child custody cases and collaborates with the Family Court and the Administration for Children's Services to coordinate case management of women who are involved in the criminal justice and Family Court systems.

In describing BTC's approach and philosophy, Valerie Raine, BTC's project director, says, "What we have tried to do here is bring as many services on site to the courthouse, so this population is not tossed around and referred out. You lose them the minute you refer them even across the street. A lot of what we're trying to do is to integrate services. Because, especially in New York, services are so frequently fragmented in a way that doesn't effectively meet the needs of the population. If you only meet one need and not the others, they are probably going to fail-to recidivate, to start using again."

The Brooklyn Treatment Court has been in operation since 1996. It has placed more than 1,525 people in treatment; more than 500 are still in treatment and about 374 have "graduated." It enjoys a high retention rate about-60 percent.

For more information: Brooklyn Treatment Court, Brooklyn, NY, 718/243-2639. www.drugcourttech.orgLink to a Non-CDC Link

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