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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

Community Attitudes and Beliefs

Beliefs About Drug Use

Drug use is generally viewed as bad for individuals and for society. Over the last 20 years, criminal penalties for the sale and possession of drugs have increased as part of what political leaders refer to as the "war on drugs." The growing intolerance of drug use and fear of drug users have been accompanied by an increasingly heated debate about programs that provide treatment and other health care services for drug users. The approaches taken with HIV prevention activities are often a central element of that debate.

People may agree that there is a need for HIV prevention activities, but disagree about their goals and methods. They also may disagree about who should have the final authority in choosing which prevention methods to use. The core of most debate about prevention methods is whether an "abstinence-based approach" or a "risk-reduction approach" is most effective.

Abstinence-based approaches to HIV prevention stress methods such as admission to a drug treatment program to help individuals. Abstinence-based approaches oppose interventions such as bleach distribution, syringe exchange, and increasing access to over-the-counter sale of syringes, since these methods are not directly linked to stopping drug use and may appear to encourage drug use.

Risk reduction (also referred to as "harm reduction") approaches emphasize that most drug users are unable or unwilling to stop drug use immediately and completely; that there are limited drug treatment program "slots" available; that many drug users cannot stop drug use even when they are enrolled in drug treatment programs; and that many of the drug users who are able to stop using drugs may relapse. Risk reduction approaches emphasize a variety of interventions with drug users, particularly those who continue to use. These interventions include providing access to sterile syringes through over-the-counter sale from pharmacies and syringe exchange programs; stressing never sharing syringes, water, or drug preparation equipment; emphasizing bleach disinfection for drug users who do not have sterile syringes; providing alcohol swabs to clean injection sites to reduce the occurrence of abscesses; and offering hepatitis B and other vaccinations to active drug users.

Views on the best approaches to deal with HIV prevention among IDUs vary dramatically at both the community and national level. Case Example 4.1 highlights some viewpoints on the appropriateness of HIV prevention activities.

Case Example 4.1

Opposing Views on HIV Prevention Approaches

"Our gains against drug use have been hard-won, and this is no time to jeopardize them by instituting needle exchange programs. Despite all the arguments made by proponents of needle exchange, there is no getting around the fact that distributing needles facilitates drug use and undercuts the credibility of society's message that using drugs is illegal and morally wrong."

Source: Martinez,1992.

"The predominant policy approach has characterized drug use as a criminal rather than a public health problem....Those who find it impossible to stop using drugs, or relapse following a period of abstinence from drugs, must be encouraged to practice safer sex and safer drug use and must be taught how to do so....Legal barriers to the purchase and possession of injection equipment should be removed. Legal barriers...limit the availability of new, clean injection equipment, thereby encouraging the sharing of injection equipment, and the increase in HIV transmission."

Source: National Commission on AIDS, 1991.

The Importance of Community Attitudes Regarding HIV Prevention Interventions

The HIV epidemic has had a disproportionate impact on certain communities, particularly minority communities. In some communities, such as youth, the rapidly growing impact of HIV infection portends an important future public health concern. A broad range of HIV prevention efforts have been launched to respond to this situation, and communities have differed in their reactions. Even within communities, opinions and support can vary widely. For example, some African American leaders believe that HIV has been deliberately introduced into the African American community as a form of racial genocide and are suspicious of government prevention efforts (Thomas et al., 1993). At the same time, others support a full range of HIV prevention measures. This section of PART 4 provides two examples of differing attitudes toward HIV prevention efforts. They illustrate for prevention planners and program managers the fundamental importance of understanding the community's attitudes toward HIV prevention if successful interventions are to be implemented.

A study on syringe exchange in the U.S. and Canada conducted by the Institute for Health Policy Studies at the University of California, San Francisco, identified four major reasons for opposition expressed by African Americans to HIV risk reduction programs: (1) failure to provide adequate drug treatment; (2) failure by advocates of syringe exchange programs to meet with community leaders; (3) lack of recognition by those who advocate syringe exchange of the negative effects of the existing drug market and of drug use on communities of color; and (4) failure to explain how syringe exchange can help, in the long term, to curb the impact of drug use (Lurie et al., 1993).

In spite of skepticism expressed by some African American leaders, many others support a full range of HIV prevention measures. For instance, African American mayors in New York, Baltimore, New Haven, and Washington, DC, have publicly expressed their support for HIV risk reduction programs that incorporate access to sterile injection equipment (Lurie et al., 1993). Joining in this support for HIV risk reduction efforts are a number of African American-operated HIV prevention agencies, including, for example, the Black Coalition on AIDS in San Francisco. Some religious leaders who initially supported only abstinence-oriented interventions have changed their position in the face of the ever-increasing number of people of color affected by HIV.

An African American Leader Speaks Out in Defense of HIV Risk Reduction

"I'm one who spoke out very harshly against the distribution of condoms and the distribution of needles, saying that it's cooperation with evil....If it's going to save lives and it's going to allow for an arresting of this disease in our community so that people who have heart attacks and other ailments can get into the emergency rooms and be treated, then I think that these measures are not bad measures and lots of us are going to have to think real hard about how we oppose things that could stop this disease. In drastic times, you have to take drastic actions. My prayer is that our drastic actions will do enough quickly enough because too many people, homosexual, heterosexual, rich, poor, educated, non-educated, male and female are dying...."

Reverend Calvin Butts, Harlem, New York
Source: Lurie et al.,1993.

The second illustration shows the importance of community attitudes regarding HIV prevention programs for adolescents. Investigators now report that the average age of those diagnosed with AIDS has declined each year, and that an increasing number of adolescents are becoming infected with HIV (Rosenberg, 1994). Comprehensive studies have also made it clear that drug use plays an important role in HIV infection among adolescents. In fact, 23 percent of all cases of adolescents diagnosed with AIDS are directly attributable to injection drug use or to sex with individuals who inject drugs (CDC, 1995). NIDA's Monitoring the Future survey, an annual study of the prevalence of drug use among U.S. adolescents, indicates that drug use among 8th, 10th, and 12th graders increased in 1994, continuing the growth seen in 1993. Although the sharpest rises in drug use were for marijuana, other substances, such as cocaine, showed significant increases as well (Johnson et al., 1995).

The debate over what is an appropriate approach to HIV prevention among adolescents is heated. Community support for or opposition to educational programs about human sexuality and about drugs can be a critical element in the success or failure of an HIV prevention intervention. Case Example 4.2 illustrates the power of community opposition.

Case Example 4.2

Community Opposition to Condom Distribution in Schools

The superintendent of public schools in a large northeastern city supported a program making condoms available in the city's high schools because of the high prevalence of sexually transmitted diseases, including HIV, among the city's adolescents. Strong parental opposition contributed to his dismissal and to the abrupt discontinuation of the program.

Source: Blair et al., 1994.

In other communities, however, parents and school officials have expressed strong support for a comprehensive approach to sex education for youth that includes equipping young people with knowledge and decision-making skills. In some communities, this includes support for efforts to make condoms available through school-based, school-wide, or district-wide health programs. Table 4.1 lists a number of cities where condoms are now available through school-based programs.

Table 4.1: Cities with School-Based Health Centers Offering Condom Availability Programs

The Advocates for Youth (formerly the Center for Population Options, Washington, DC) estimate that condoms are now available to sexually active students in more than 100 school-based health clinics in the following communities:

Little Rock, AR

Chicago, IL

Jackson, MS

Portland, OR

Culver City, CA

Boston, MA

Portsmouth, NH

Philadelphia, PA

Los Angeles, CA

Cambridge, MA

Espanola, NM

Dallas, TX

Miami, FL

Baltimore, MD

Taos, NM

Houston, TX

Quincy, FL

Readfield, ME

New York, NY

In addition to understanding community attitudes toward HIV prevention programs for adolescents, prevention planners and program managers need to have a thorough knowledge of the laws and regulations regarding HIV prevention activities for adolescents. These include the need for parental consent to administer medical care to minors except for those deemed "emancipated" by the courts. These youth have been legally released from the supervision of their parents. However, in every state there are now laws that permit minors to give their own consent for certain health services, which may include those related to STDs and other infectious diseases. Those states that consider HIV or AIDS either an infectious or sexually transmitted disease often permit adolescents to provide their own consent for receiving HIV prevention counseling and testing.

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