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U.S. Department of Health and Human Services

Archival Content: 1999-2005

HIV Prevention Among Drug Users:
A Resource Book for Community Planners & Program Managers


Introduction

The Need for a Resource Book on HIV Prevention Among Drug Users

Drug use is a complex health and social problem that affects all segments of American society. How to respond to this problem continues to be at the center of national and local debates. Further complicating the issue is the rapid rise in HIV infection reported among drug users and their sex partners and children. The proportion of AIDS cases in the United States attributed to injection drug use, for example, has steadily increased from 12 percent of cases reported in 1981 to 32 percent of cases reported between July 1995 through June 1996 (CDC, 1996).

Through June 1996, AIDS cases related to injection drug use accounted for fully one-third of all AIDS cases reported in the US to date, with women, children, and minorities disproportionately affected (CDC, 1996):

  • 46 percent of women with AIDS had injected illicit drugs;
  • 18 percent of women reported with AIDS are sex partners of IDUs;
  • 54 percent of infants reported with AIDS are born to mothers who injected drugs or who are sex partners of male IDUs; and
  • 36 percent of all male African Americans reported with AIDS and 37 percent of all male Hispanics reported with AIDS are IDUs.

Clearly, HIV prevention efforts must focus on drug injection practices. At the same time, however, a focus solely on drug injection practices is not adequate to prevent the further spread of HIV. Sexual risks associated with drug use, both injection and non-injection, are critical components of the rise in HIV infection. Recent estimates suggest that the HIV/AIDS epidemic in the US is currently being driven by subepidemics in three groups (Holmberg, 1996):

  • injection drug users and their sex partners and children
  • heterosexual women who use crack
  • young and minority men who have sex with men (MSM)

Of these three subepidemics, two are directly associated with drug use and underscore the importance of drug use and sexual behaviors to the spread of HIV. In addition, there is some evidence that the third subepidemic is associated with drug use. Among MSM, non-injection drug use (e.g., current or past heavy alcohol use, and current use of stimulants, hallucinogens, and inhalents) has shown to be associated with higher-risk sexual behavior (Woody et al., 1996).

In the past, HIV prevention efforts often focused on either the injection drug-related or the sexually-related risk behaviors of individuals, neglecting both the interrelationships among these behaviors and the social context in which they occur. The association between non-injection drug use and sexually-related risk behaviors has also been ignored. Now, however, those involved in efforts to contain the spread of HIV infection in drug users acknowledge a pressing need to focus on both drug-related (injection and non-injection) and sexually-related risk behaviors.

Developing and conducting programs to modify HIV risk behaviors related to drug use and to sustain changes in behavior present significant challenges. Addiction, poverty, homelessness, crime, and violence are only a few of the social conditions that may affect a drug user's ability to initiate and maintain risk reduction behaviors related to drug use, sexual practices, and HIV transmission.

Another significant challenge to the design, development, and implementation of effective HIV prevention programs among drug users is the complex social and political issues that surround such programs. Societal attitudes vary on the ways to address sensitive issues such as drug use and sexual risk behaviors. Supporters of HIV prevention programs based on drug use abstinence, for example, fear that anything less might send the message that drug use is acceptable and could result in an increase in use. Other prevention advocates believe that lowering the risks related to drug use is a realistic component to contain the continued spread of HIV, considering the difficulties encountered in stopping drug use, the high rates of relapse after treatment, and the lack of available, publicly-funded drug treatment.

HIV Prevention Community Planning Groups and other HIV prevention planners and program managers can make a significant contribution to reducing the spread of HIV by supporting comprehensive, community-based programs that address drug use as well as sexual behaviors, and that pay attention to the social conditions under which these behaviors occur. Recent research has shown that behavior change is occurring. With properly designed interventions, drug users can make the changes necessary to reduce their risk of HIV infection.

Community planning for HIV prevention is a decision-making process involving broad-based, active involvement of persons with a wide range of viewpoints. Differences in background, perspective, and experience are essential and valued (AED, 1994). Prevention planners and program managers must include both HIV and substance abuse experts as well as community representatives in their efforts, and must have access to the knowledge gained through behavioral and social science research on the theoretical foundations and elements of effective interventions. HIV Prevention Among Drug Users: A Resource Book for Community Planners and Program Managers (referred to in this document as "the HPDU Resource Book") is intended to support the need of prevention planners and program managers to learn about and understand the critical issues involved in drug use, sexual behavior, HIV transmission, and their interrelationships. It is only through such understanding that wise decisions can be made about program priorities and design.


Audience and Purpose

The HPDU Resource Book is designed to be used by HIV prevention planners and program managers involved in the community planning process and other community-based prevention initiatives for drug users and their sex partners. Other potential readers include staff of:

  • state and local drug and alcohol agencies
  • state and local correctional systems
  • local, regional, or national non-governmental organizations

It was developed in response to needs identified by those directly involved in HIV prevention planning. A group of consultants from national and local organizations, research institutions, health departments, and community-based programs provided early guidance in determining the design of the book and also provided feedback at key points in its development. Specifically, the HPDU Resource Book is intended to increase the reader's understanding of:

  • drug use and its effects
  • drug use, sexual behavior, and HIV risk
  • social and behavioral theory and its use in selecting and designing effective HIV prevention interventions in drug-using populations
  • public policy and HIV prevention programs for drug users
  • resources for HIV prevention planners and program managers related to HIV prevention in drug-using populations

Organization of the HPDU Resource Book

The HPDU Resource Book is organized into five major PARTS. Each PART focuses on a key area related to HIV prevention among drug users:

PART 1: Drug Use and Its Effects examines the complex nature, consequences, and treatment of drug use, abuse, and dependence. Specific topics include:

  • major categories of drugs linked to HIV risk and their effects
  • patterns of drug use in the United States
  • definition and characteristics of drug use, abuse, and dependence
  • key components of the drug treatment system
  • sources of national, state, and local data on drug use

PART 2: Drug Use, Sexual Behavior, and HIV Risk explores the link between drug use, sexual behavior, and HIV transmission. Specific topics include:

  • drug-using practices, sexual behaviors, and the social context of drug use, and how these factors influence risk for HIV infection
  • characteristics of special groups of drug users who are heavily affected by the HIV epidemic
  • sources of national, state, and local data on trends in transmission of HIV among drug users

PART 3: Social and Behavioral Interventions addresses theoretical and practical aspects of planning HIV prevention programs among drug users. Specific topics include:

  • the use of social and behavioral theory in the design and implementation of effective HIV prevention interventions
  • an approach to systematically deciding HIV prevention interventions
  • components of effective HIV prevention programs
  • results of social and behavioral research on intervention effectiveness

PART 4: Public Policy Issues looks at several key public policy issues associated with HIV and drug use from a national, state, local, and agency perspective. Specific topics include:

  • community attitudes and beliefs
  • laws, regulations, and practices
  • agency policies and practices

PART 5: Resources offers information on an array of federal, national, state, and other programs that provide information, materials, and technical assistance services related to HIV prevention among drug users. Specific topics include:

  • national clearinghouses on HIV and drug use
  • HIV and drug use information resources from federal agencies and national and state level non-governmental organizations
  • publication ordering information

In addition to the five PARTS, the HPDU Resource Book contains five APPENDICES:

APPENDIX A contains summaries of individual evaluation studies conducted on successful interventions with various drug-using populations.

APPENDIX B contains summaries of resources that address behavioral theories and research on HIV prevention interventions with drug users.

APPENDIX C is a glossary containing terms and acronyms used in the HPDU Resource Book.

APPENDIX D is a bibliography containing all of the references cited in the document as well as other source materials used in its preparation.

APPENDIX E is a list of the HPDU Resource Book Consultant Panel.

Although comprehensive in scope, the HPDU Resource Book is meant to be only one component of an ongoing effort to assist state and local HIV prevention planners and program managers. These individuals must address the specific issues and challenges in their own communities. Often, specific, local information will be needed. PART 5 provides various sources for further information and materials. PARTS 1 and 2 also include information on sources of local data on drug use and HIV infection.


References

Academy for Educational Development (AED). Handbook for HIV prevention community planning. Washington (DC): Academy for Educational Development; 1994 April. Contract No.: 200-91-0906. Funding provided by the Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention (CDC). HIV/AIDS surveillance report 1996;8(1).

Holmberg SD. The estimated prevalence and incidence of HIV in 96 large U.S. metropolitan areas. American Journal of Public Health 1996;86(5):642-654.

Woody GE, Donnell D, Metzger D, Marmor M, Gross M, McKirnan D, Koblin BA, Seage G, Buchbinder S, Stone B. Substance use and risky behavior among men who have sex with men. Poster presented at the XI International Conference on AIDS; 1996 July 7-12; Vancouver, Cananda.

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