Archival Content: 1999-2005
HIV Prevention Among Drug Users:
Designing HIV Prevention Interventions
Once prevention planners and program managers decide that an intervention is necessary to meet identified community prevention needs, the specific features of the interventions must be determined. It is not sufficient to simply refer to "distribution of condoms and bleach" in describing a planned intervention. More specific information is needed on where, to whom, by whom, over what period of time, and under what circumstances an intervention will be delivered. Specifying the key features of the intervention is useful for a number of reasons. First, it allows prevention planners to more clearly communicate the types of priority interventions that they are recommending to prevention service providers, and it helps providers more clearly design interventions and implement them as planned. Thinking through the details also helps providers apply elements of behavioral and social science research and theory where useful in designing specific interventions.
Making decisions about the key features and describing the program in this way can also be strategically useful if a program intends to get support, or continue to get support, from outside funders and the community. Finally, a systematic description encourages a thorough implementation of the intervention, allows for replication of the intervention for other groups or communities, and provides a structure to design and carry out process and outcome evaluations.
Interventions for drug-using populations generally fall into one of three major categories: counseling, testing, referral, and partner notification (CTRPN); health education/risk reduction (HE/RR); and health communication/public information (HC/PI). Earlier materials developed by CDC for community planning groups described a taxonomy or classification system based on these categories.3 This taxonomy can help planners and managers develop a common terminology and differentiate types of interventions. Exhibit G builds on this taxonomy and presents information on the key features of interventions that prevention planners and program managers need to consider. It is organized around four basic questions:
Who will receive the intervention?
Prevention planners and program managers need to understand and describe who will receive the intervention. This includes addressing certain key features of the target group, such as their racial/ethnic background; their other defining characteristics (e.g., gender, age, overlap with other at-risk populations such as drug users who are MSM, homeless, mentally ill, sex industry workers, immigrants, or prison inmates or parolees); their geographical location (e.g., section or neighborhood in the community); and their general risk for HIV infection (e.g., unprotected sex with many partners, injection drug use, crack use). A target group can also be described in terms of its general readiness for behavior change, or its stage of behavior change. The stage of change could refer to the stage of drug use behavior (e.g., initiation, maintenance, risk reduction, relapse) or stage of behavior change as described in Table 3.2 (i.e., precontemplation, contemplation, preparation, action, maintenance).
What is the proposed intervention?
Planners and program managers need to address key features of the intervention itself. This includes the level at which the intervention will be targeted, which may be at the individual, couple, group/social network, community, or general public level. For example, counseling, testing, and referral interventions for the drug-using population most often target individual drug users. Health education and risk reduction efforts generally target drug users' social networks or the community.
It is important to clearly specify the behavioral objectives of the intervention. Which drug-using and sexual risk behaviors are targeted for change? For injection drug-using populations, these behaviors might include the frequency of injection, sharing of injection equipment, needle sharing, type of drug injected, mode of drug use, type of sexual activities and partners, and number of sex partners. Behavioral objectives for non-injectors might include high-risk sexual activities associated with the exchange of sex for crack or money to buy crack.
What factors are expected to affect the risk behaviors of the target population? Some interventions attempt to improve skills at cleaning equipment or using condoms. Others address barriers to obtaining clean needles and condoms. Because risk taking occurs in the context of social relationships, factors such as perceived peer and community norms are important. Behavioral and social science theories will inform and enrich the decisions about how to influence risk behaviors.
Interventions also provide different services, materials, or information. A program manager will need to determine the types of activities, written documents, and other materials to deliver to achieve intervention outcomes. These can include HIV counseling and testing, partner notification, client case management, STD and TB treatment, referrals for drug treatment or other health and social services, HIV/AIDS education workshops or video presentations, support groups, and distribution of written educational materials or injection equipment. Here again, consideration may be given to where the individual, group, network, or community is on the continuum of change for a particular behavior.
Where is the intervention being delivered?
The settings and locations where behavioral interventions are delivered for drug users vary considerably. Some interventions are delivered in institutional settings, such as STD clinics, community-based organizations, store fronts, health vans, or other more formal settings. Other interventions are street-based, where drug users hang out or use drugs (e.g., street corners, shooting galleries, crack houses). Still others are community-wide, for example, a media campaign that delivers the prevention messages in multiple locations in the community. Some interventions may even use multiple settings, such as a program that does both street outreach and conducts other services in an institutional setting. The delivery setting is a key feature of intervention design.
How is the intervention being delivered?
This question covers a range of important implementation decisions. One key feature related to this issue is the person(s) delivering the intervention or the individuals responsible for the delivery of specific services, information, or materials. These could include peers, indigenous workers from the community, community volunteers, and health professionals or paraprofessionals. Research has shown that respected peers in the drug users' social network or community are often effective deliverers of services (Wiebel et al., 1996; Des Jarlais et al., 1993). This is partly due to the illicit behaviors engaged in by drug users and their distrust toward "outsiders" and institutional authority figures.
Another key feature related to how the intervention will be delivered is the visibility of the intervention to the target group. In order for an intervention to affect the target group, the group must be aware of its existence and have an appreciation of how the intervention services can address its needs. This can be accomplished through multiple methods, such as the use of local media (radio, newspapers), outreach to other services agencies that serve the target group, and outreach directly to the population.
The frequency and duration of the intervention are key to program delivery. Programs can be either one-time only, periodic (e.g., once a week for five weeks), or ongoing. They can be as short as a few minutes or as long as hours or days. Programs for drug users have used different time periods and levels of intensity in order to respond to the varied lifestyles and circumstances of drug users. One-time, short outreach interventions are often conducted with drug users on the street. Periodic, moderately intensive HE/RR interventions often are conducted in community-based organization environments. Ongoing, more intensive interventions with drug users have been implemented in long-term treatment programs.
To demonstrate the potential impact of a proposed intervention, prevention planners and program managers need to describe its scale and significance. This includes the number of target group members the intervention intends to reach, and, if possible, whether or not the projected target group size will be sufficient to make a measurable impact on the epidemic.
Contextual factors may need to be considered in the delivery of an intervention to a particular population. Work with drug-using populations in particular requires awareness of important contextual issues, such as type of drug used; health problems and health status of the target population; the competing needs for food, shelter, health care, employment, and protection from violence; HIV serostatus/prevalence of those in their network, including sexual and needle-sharing partners; and legal/institutional issues that affect availability and access to services, information, and materials (e.g., local laws and policy issues related to needle exchange, over-the-counter sale of syringes, possession of sterile needles and equipment, and police and correctional officer confiscation of condoms from inmates and sex workers).
Finally, an important feature in intervention planning and delivery is the extent of coordination between the intervention and the services of other agencies in the area. Drug users have multiple needs, depending on their physiological and mental states and personal resources. To strengthen the delivery of needed services and to avoid duplication of effort, HIV prevention programs should be well coordinated with other agencies that can respond to these multiple needs and be aware of how other HIV prevention services in the area can effect program implementation.
Exhibit H illustrates how prevention planners in the National Institute on Drug Abuse addressed these key features when planning the HIV Counseling and Education Intervention Model, an intervention designed and developed to influence the risk behaviors of drug users and their partners (Coyle, 1993).
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