Archival Content: 1999-2005

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

The policies and practices of agencies serving drug users vary in relation to HIV prevention. For instance, drug treatment programs may be concerned that HIV education will undermine their messages about abstaining from drug use. Similarly, correctional officers may be apprehensive about discussing safer sex or syringe disinfection because sexual behavior and drug use are prohibited within correctional institutions. These conflicting views often result in discontinuity of prevention services needed for drug users. HIV prevention planners and program managers must recognize that programs linking various service agencies need to be coordinated to ensure a comprehensive and consistent approach to HIV prevention among drug users. This section takes a closer look at some of the dynamics associated with differences among agency policies and practices.

Abstinence-Based Drug Treatment Programs and HIV Risk Reduction

The purpose of most drug treatment programs is to help clients stop all drug use. Given that goal, many drug treatment programs have difficulty providing their clients with drug-related risk-reduction education and advice. Telling drug users that, if they relapse, they should use sterile syringes to mix and prepare drugs and never use a cooker or cotton after another drug user may appear to be tempting the recovering user to restart drug use. This conflict may exist even though the staff of the drug treatment program acknowledge that relapse is a real risk for clients.

For some treatment programs, educating clients on how to prevent the sexual transmission of HIV may seem unrelated to, or even in conflict with, their mission to help the person recover from drug dependence. This is particularly true if a program subscribes to the philosophy that individuals in the early stages of recovery should refrain from forming sexually intimate relationships.

Abstinence-based treatment programs encourage clients to disclose what may be very personal information about their drug use and its consequences as a means to maintain their recovery. However, conflicts regarding confidentiality and the right to privacy may arise for clients who are HIV-infected. At the very outset of treatment, clients in such programs need to be fully apprised of the program's philosophy and expectations as well as be made aware of the measures that are in place to safeguard their rights regarding such personal matters as HIV status.

AIDS Service Organizations

Although early in the epidemic many AIDS Service Organizations (ASOs) focused their efforts on gay and bisexual men, a large number now conduct comprehensive prevention programs for injection and non-injection drug users. These include a range of activities, from one-on-one counseling to street outreach, syringe exchange, and community-wide initiatives.¹

ASOs with HIV prevention programs may be an excellent source of information about high-risk drug users. These organizations may be able to supplement existing epidemiologic data with qualitative information based on research conducted during the design of programs. ASO personnel also may be able to provide insights about drug related behavior gained from many hours of direct observation.

Many ASOs have adopted risk reduction or "recovery readiness" programs that focus on reducing the individual drug user's risk of contracting HIV rather than on requiring immediate participation in drug treatment programs. This approach recognizes the difficulty inherent in abstaining from drug use and the lack, in many communities, of adequate treatment facilities. Case Example 4.6 describes one such approach, the Gay Men's Health Crisis (GMHC) "Steps Toward Change" program.

Case Example 4.6

As a community-based AIDS service organization, the Gay Men's Health Crisis (GMHC) in New York City advocates the use of multiple approaches and interventions to address the many needs of their clients. Drawing on aspects of risk reduction, recovery readiness, and treatment approaches, GMHC created the "Steps Toward Change" model with the following goals:

• to work with the individual wherever he or she happens to be along the spectrum of drug use
• to avoid demanding that each individual be committed to a goal of abstinence
• to work with the individual to set his or her own priorities and timelines for action, rather than to assume that a particular hierarchy of issues has to be addressed
• to develop effective alcohol and other drug-related interventions and to integrate them into the ancillary mission of providing such support as health and social services

Source: Gay Men's Health Crisis,1994.

The Criminal Justice System

The HIV/AIDS epidemic has had important implications for the criminal justice system, particularly in the Northeast and other areas with high HIV seroprevalence among drug users. Yet, within the confines of the criminal justice system, traditional policies prohibiting sexual activity and drug use make it difficult for corrections staff to establish HIV prevention programs.

Despite these constraints, however, many have succeeded in developing constructive and dynamic HIV prevention programs. These programs serve not only those who are incarcerated, but also those who soon will be released into society. Many of these programs actively discuss safer sex practices, as well as procedures for disinfecting drug injection equipment. According to the National Institute of Justice, 86 percent of all U.S. federal and state prison systems and 58 percent of all city/county correctional systems provided instructor-led AIDS education for inmates over the course of the previous year (DOJ, 1994). Currently, condoms are made available to inmates in the following six correctional systems: District of Columbia, Mississippi, Vermont, New York City, San Francisco, and Philadelphia. Several examples of collaborative efforts to develop and implement HIV prevention programs within correctional systems are described in Exhibit J.

Exhibit J: Collaborative HIV Prevention Efforts in Correctional Systems

Improving Cooperation Among Programs Serving Drug Users

Drug injectors and persons using crack cocaine account for a major proportion of the HIV and AIDS cases in many parts of the United States, particularly the Northeast, South, and Puerto Rico (Johnson, Bassin, and Shaw, vol. I, 1995). If the spread of HIV among drug users, their sex partners and children is to be slowed, the organizations providing HIV prevention, drug treatment, medical and social services to drug users must cooperate.

Substantial barriers prevent agencies from working together, however. For example, significant differences in philosophy and organizational culture among drug treatment, health department, and community-based programs often exist. In addition, the laws and regulations established to protect HIV-infected people in drug treatment from stigma and discrimination may make it more difficult for the organizations attempting to help these individuals to obtain or share basic information about the clients.

Despite these barriers, prevention planners and program managers should promote interagency collaboration to foster more effective HIV prevention efforts. Examples include better collaboration between:

• correctional institutions and the essential services that discharged inmates will need in the community (e.g., drug treatment, HIV prevention programs designed for parolees, housing, job preparedness)
• agencies addressing homelessness, mental illness, drug dependence, and HIV prevention for hard-to-reach populations
• school-based health clinics and health education programs that are working with youth at risk for drug use or HIV, and community-based organizations and religious organizations that are addressing prevention issues for youth

For those involved in planning or implementing HIV prevention programs, the message is clear. To make community programs serving drug users and their sex partners more effective, substantial efforts must be made to:

• identify all the programs working with drug users in any capacity; bring them together so that philosophical and cultural differences can be identified and understood
• provide cross-training for the staff of the organizations that need to cooperate
• develop "structural" relationships (e.g., memoranda of understanding, qualified service organization agreements) that will facilitate cooperation
• identify ways to continually maintain and enhance established linkages.

Some examples of inter-agency efforts appear in Exhibit K.

Exhibit K: Inter-Agency HIV Prevention Efforts

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1. For information about ASOs that provide these services in specific communities, contact the CDC's National AIDS Clearinghouse. PART 5: RESOURCES contains contact information for the Clearinghouse.

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