Archival Content: 1999-2005

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

Introduction and Overview

Since 1981, 733,374 cases of AIDS have been reported to the Centers for Disease Control and Prevention (CDC). In 1999, 46,400 new cases were reported. It is estimated that 650,000 to 900,000 Americans are now living with HIV, and that approximately 40,000 new infections occur each year. Approximately 1 to 1.25 million Americans are chronically infected with hepatitis B virus (HBV), and since 1995, approximately 185,000 new infections have occurred each year. An estimated 2.7 million Americans are chronically infected with hepatitis C (HCV).

These blood-borne infections are transmitted primarily through two routes-sharing contaminated syringes, needles, and other drug injection equipment, and having unprotected sex with infected individuals. Through both types of risk behaviors, injection drug users (IDUs) are an important factor in the continuing evolution of these epidemics. Women who become infected with HIV through sharing needles or having sex with an infected IDU can also transmit the virus to their babies before or during birth or through breastfeeding.

To address this critical public health issue, program managers and staff, policy makers, HIV prevention community planners, and others in the public health community must focus attention on ways in which they can more effectively reach and influence IDUs and must intensify efforts to develop and carry out prevention and treatment strategies directed to IDUs and their sex partners and children. This technical assistance document is designed to help staff, planners, and policy makers accomplish this goal. It first describes the complex problems facing programs and professionals who work with the issue of preventing blood-borne infections in IDUs and then proposes a comprehensive approach to ameliorating these problems. We recognize that other drugs besides injection drugs are also important in the transmission of blood-borne infections. However, we focus on injection drugs in this document because of the key role they play in the intersection of addiction and infection and because of the myriad ways in which communities and providers can work with injection drug users to reduce their risk and burden of infection.

The core of the comprehensive approach is a group of pragmatic strategies. These strategies recognize that services and interventions for IDUs must be organized so that prevention and behavior change messages can be delivered and reinforced across various settings, populations, life circumstances, patterns of drug use, and stages of behavior change. Though many kinds of services and interventions can be directed toward IDUs and the issues of drug use and disease, eight strategies are included here. They are:

• substance abuse treatment;
• community outreach;
• interventions to increase access to sterile syringes;
• interventions in the criminal justice system;
• strategies to prevent sexual transmission;
• counseling and testing, partner counseling and referral services, and prevention case management;
• coordinated services for IDUs living with HIV/AIDS; and
• primary drug prevention.

These eight strategies are supported by four cross-cutting principles:

• Ensure coordination and collaboration. A coordinated and collaborative approach to serving IDUs, their sex partners, and their children is essential because no one provider or institution can or does deliver all required services. The comprehensive approach outlined in this document requires action by many sectors. Providers must work together, sharing their various expertises and outlooks, recognizing and overcoming their philosophical differences, building on existing relationships, and reaching out to groups with whom they may not have worked before.
• Ensure coverage, access, and quality. Programs and interventions will not be effective if they do not reach a critical mass of people who can be helped, if IDUs cannot or will not use them, or if they are of poor quality. If they hope to truly reach and help IDUs, agencies and providers must consider ways to effectively deal with these issues as they plan, deliver, and monitor programs and services.

• Recognize and overcome stigma. Many people fear and disapprove of injection drug use and consider IDUs to be bad or weak people whose addiction results from moral failure. IDUs live in an environment of high risk and are frequently ostracized. Many, though not all, are poor and live on the margins of society. If IDUs are to be successfully engaged in prevention efforts and if public policy is to move for ward, these negative attitudes and misconceptions must be recognized and addressed. Addiction is now known to be a treatable, chronic brain disease. Making this understanding of addiction more generally known and accepted is key to overcoming stigma.

• Tailor services and programs. IDUs are tremendously diverse. They have different languages, cultures, sexual orientations, life circumstances, behaviors, and requirements for services. In planning and delivering interventions, programs and providers must take into account the factors that characterize IDUs-who they are, where they are, what they do, what motivates them, and with whom they socialize. Tailoring services and programs and involving IDUs in their planning, implementation, and monitoring will make them more effective.

This document describes in more detail the need for and characteristics of the comprehensive approach. It is divided into three chapters:

Chapter 1: Injection Drug Users Play a Key Role in the Transmission of HIV and Other Blood-borne Infections. This chapter provides epidemiologic detail on the importance of injection drug use in the epidemics of HIV and other blood-borne infections and describes the drug use and sexual behaviors that place IDUs at risk of infection.

Chapter 2: The Legal, Social, and Policy Climate Limits Prevention Options for IDUs. This chapter describes the context within which prevention programs with IDUs must work-the existing stigmas and biases that characterize many public and provider attitudes toward IDUs, even in the face of current knowledge about the nature of addiction, and the policy, legal, and service provision climate that has emerged from these attitudes.

Chapter 3: A Comprehensive Approach is a More Effective Approach. This chapter briefly describes the component strategies and principles of the comprehensive approach. Vignettes about selected programs are included throughout this chapter to illustrate the ways in which the strategies and principles are being applied in diverse communities and settings.

This document also includes two

Appendixes. Appendix A provides greater detail on each of the eight key strategies, including findings from programs and research and discussions of issues and barriers faced by agencies and providers in each of these areas. Appendix B is a matrix of the many research studies and reports cited in Appendix A, organized by strategy so that readers have easy access to this rich literature.

More effective and comprehensive prevention approaches for IDUs will clearly benefit injection drug-using men and women and their partners and children. The benefits have important implications for society as a whole as well, for reducing the transmission of HIV and other blood-borne infections in this population means reducing transmission in the broader population. The results will be a smaller impact on and costs for health and social services, reduced crime, and a more productive society. Many individuals, organizations, and agencies have recognized the importance of the issue of HIV and other blood-borne infections among IDUs and are acting in innovative ways to address them. We hope this document provides the vision and impetus for other program staff and policy makers to take the steps necessary to effectively address the prevention and care needs of injection drug users.

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