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Current Trends Coordinated Community Programs for HIV Prevention among Intravenous-Drug Users -- California, Massachusetts
This report describes two coordinated communitywide programs that provide education for intravenous-drug users (IVDUs) and their sex partners to reduce the transmission of human immunodeficiency virus (HIV).Sacramento, California
In 1985, the University of California, Davis (UCD), detected HIV antibody in less than 1 (0.6%) of 178 IVDUs in two drug-treatment programs in Sacramento (S. Jain, UCD, personal communication, October 1988). Subsequently, UCD collaborated with the Sacramento AIDS Foundation, Sacramento's drug-treatment programs, the Sacramento County health and sheriff's departments, and the Sacramento Police Department to form a task force to slow the spread of HIV among IVDUs in the community. An acquired immunodeficiency syndrome (AIDS) education, prevention, and testing (EPT) program was developed in the spring of 1987 for the estimated 8000 or more IVDUs in the area (1) and funded by the State of California and Sacramento County.
The EPT program consists of individual counseling of IVDUs about their risk for HIV infection and AIDS and about practical methods to avoid becoming infected, including stopping drug injections, "safer shooting" for those who would not desist, and "safer sex." After informed consent is obtained, each IVDU is given a standardized, questionnaire-guided interview and a confidential HIV-antibody test. In a second counseling session, HIV test results are given in private to each IVDU, and knowledge of HIV-infection risk-reduction techniques is reassessed. IVDUs are recruited from drug-treatment programs, major public hospitals, correctional facilities, and the county counseling and testing site. Seronegative IVDUs are encouraged to return for follow-up HIV testing and interview 4 months after initial testing. IVDUs are paid for follow-up HIV-antibody tests.
Although most participating IVDUs have been clients of drug-treatment programs, the EPT program recently has been offered to IVDUs receiving medical care at the UCD Medical Center (UCDMC), the primary source of medical care for IVDUs in the county. Serologic testing has been conducted in city and county correctional facilities, but the entire EPT program has not yet been implemented in these sites.
Overall, 42% of IVDUs offered the EPT program in drug-treatment centers have participated: 235 (24%) of 970 in the outpatient methadone program and 365 (80%) of 459 in drug-free programs (Table 1). Of the 701 IVDUs recruited at drug-treatment programs and the medical-care facilities, 14 (2%) have HIV antibody (Table 1). Of those eligible for retesting after an initial negative test, 116 (24%) of 490 returned to be retested, and none have seroconverted.
Self-reported high-risk drug use has decreased since the beginning of the program. Of 720 IVDUs recruited in 1988, 295 (41%) report that either they did not share or they "usually" or "always" disinfected their paraphernalia with an effective disinfectant ("safer shooting"), compared with 19 (23%) of 83 IVDUs recruited in 1986. Among IVDUs returning for retesting, 44 (57%) of 77 of those still injecting drugs reported using "safer shooting" techniques.Worcester, Massachusetts
The Worcester AIDS Consortium was established in spring 1987 to provide comprehensive, coordinated communitywide AIDS education and risk-reduction efforts for IVDUs and their sex partners. The Consortium includes the local health and school departments, drug-treatment program, neighborhood health centers, community agencies, AIDS Project Worcester, jail, and the University of Massachusetts. This program, which is funded by the Commonwealth of Massachusetts, the National Institute on Drug Abuse, and CDC and administered through the Massachusetts Department of Public Health, is coordinated with the Worcester Department of Public Health hepatitis B prevention program (2).
The Consortium activities include 1) educational programs in schools and the community and 2) educational/voluntary HIV-antibody testing programs for IVDUs and their sex partners offered at health-care facilities, drug-treatment programs, and the local correctional facility (3-6).
An estimated 3000-4000 IVDUs reside in metropolitan Worcester (total population, 175,000). The drug rehabilitation program educates IVDUs in drug-treatment programs and provides interventions to reduce transmission of HIV among IVDUs not in treatment, including distribution of bleach to clean drug paraphernalia and expedited admission of seropositive addicts to drug treatment.
The approximately 600 inmates of the Worcester County House of Corrections are offered weekly educational sessions, voluntary individual HIV/AIDS counseling, and confidential HIV testing, with follow-up support available through the advocacy services of AIDS Project Worcester.
Free voluntary pre- and post-test counseling and HIV-antibody testing have been incorporated into the routine activities of all drug-treatment programs of the rehabilitation program; the two major community health centers serving indigent, disadvantaged minority populations; the Worcester Department of Public Health Hepatitis B/ HIV Clinic; and the Worcester City Hospital.
A standardized interview is used at all sites to obtain demographic data and information on the drug use and sexual behaviors of participants.
As of July 31, 1988, 1081 persons had participated in individual interviews and counseling sessions, including approximately 90% of clients in drug-treatment programs, 85% of persons referred for HIV counseling and testing to clinics, and 50% of inmates who attended group educational sessions (Table 2). Participants were predominantly male (76%) and white (69%); 19% were Hispanic and 9%, black; 29% were 17-24 years of age, 49%, 25-34 years, and 22%, greater than or equal to 35 years. Recent needle use was reported by 263 (76%) of 348 clients in drug treatment and 175 (38%) of 459 jail inmates*, compared with 38 (14%) of 274 clinic patients interviewed (4). One hundred fifty-eight (58%) of 274 clinic patients and 173 (38%) of 459 jail inmates interviewed reported no needle use and no sexual contact with needle users at any time.
Among the reported recent needle users, 122 (70%) of 175 of jail inmates, 28 (74%) of 38 of clinic patients, and 157 (60%) of 263 current drug-treatment clients reported they had never been in a drug-treatment program. Among recent needle users, 144 (48%) of 301 in drug-treatment programs and medical clinics had previously been in jail, in contrast to 144 (82%) of 175 prisoners. In addition, 365 (77%) of the 476 recent needle users reported recent sharing of needles; 37% had shared drug injection equipment in a "shooting gallery" and 8% had shared drug injection equipment in New York City.
Of the 792 (73%) persons for whom HIV-antibody test results were available, 71 (9%) were seropositive. Seropositivity prevalences were proportionate to reported risk activities: three (10%) of 31 persons with no needle use or sexual contact with IVDUs; two (5%) of 42 former sex partners of IVDUs; two (4%) of 52 recent sex partners of IVDUs; nine (11%) of 81 former needle users; and 55 (18%) of 304 recent needle users.
HIV seropositivity in recent needle users was higher among Hispanics (23 (36%) of 64) and blacks (nine (35%) of 26) than among whites (22 (12%) of 183) (p less than 0.001). HIV seropositivity among recent needle users also varied by site of recruitment: eight (10%) positive of 80 in the drug-treatment programs, 36 (21%) of 169 in jail, and 11 (30%) of 37 in clinics (p=0.02). However, because the proportion of all those interviewed who agreed to HIV testing varied from 119 (34%) of 348 in the drug-treatment programs to 434 (95%) of 459 at the jail, the overall HIV seropositivity prevalences among persons in these institutions are unknown.
Among recent needle users, there was no statistically significant association between HIV seropositivity and age, sex, marital status, previous drug treatment, and previous incarceration (5,6). Of the reported drug-use behaviors among recent needle users, only sharing drug injection equipment in a "shooting gallery" was associated with HIV seropositivity (27% vs. 15%) (p=0.009). Reported by: N Flynn, MD, S Jain, MBBS, A Sweha, MBBCh, V Bailey, MSC, N Nassar, MBBCh, B Siegel, MD, N Levy, MD, S Enders, Univ of California at Davis Medical Center; G Acuna, PhD, Sacramento AIDS Foundation; P Hom, MD, B Hinton, MD, D Webb, MA, Sacramento County Health Dept; D Ding, Bi-Valley Medical Clinic, Sacramento and the Sacramento AIDS-IV Drug Abuse Task Force. B Koblin, PhD, J McCusker, MD, Div of Public Health, Univ of Massachusetts, Amherst; J Sullivan, MD, S Noone, Dept of Pediatrics, Univ of Massachusetts Medical School, Worcester; B Lewis, EdD, Spectrum House, Inc; S Sereti, F Birch, Worcester Dept of Public Health. Office of the Director, Center for Prevention Svcs, CDC.
Editorial Note: In 1988, 30% of U.S. adults with AIDS reported only IV-drug use (24%) or both IV-drug use and male homosexual/bisexual behavior (6%) as risk factors. This represents an increase from 25% in previous years (in part due to revision of the AIDS case definition in 1987 (7)). In addition, 55% of AIDS cases in the heterosexual-contact exposure category in 1988 were attributed to HIV infections acquired from IVDUs.
The programs in Sacramento and Worcester represent coordinated efforts to educate IVDUs about HIV/AIDS and to change their sexual and drug-use behaviors. These programs have coordinated the HIV prevention activities of universities, health departments, correctional facilities, police departments, health-care institutions, and drug-treatment programs. Because only 10%-15% of IVDUs are in drug-treatment programs at any time, HIV counseling and testing of IVDUs in health-care facilities and in correctional/criminal justice facilities are also important. Data from Sacramento and Worcester suggest that different populations of IVDUs were reached at each of the different institutions.
The Worcester program illustrates the potential impact of HIV prevention programs on IVDUs in correctional institutions. More than half of the recent needle users recruited at medical clinics and drug-treatment programs had previously been in jail. In addition, among the recent needle users recruited in jail, 83% had been in jail at least once before the current incarceration.
Although street/community outreach teams are important elements of comprehensive HIV prevention programs for IVDUs, such teams were not part of the initial Worcester and Sacramento programs. A street outreach program will be added in Sacramento.
The changes in the behaviors reported by IVDUs participating in the educational programs were modest. In Sacramento, the proportion of IVDUs reporting "safer shooting" drug-use practices increased from 23% in 1986 to 41% in 1988 (8). Among IVDUs returning for follow-up interviews and HIV testing, 57% of those using drugs reported using "safer shooting" techniques. While these results suggest that some IVDUs will adopt lower risk behaviors, many of the IVDUs interviewed did not report adoption of safer behaviors.
Programs to prevent HIV transmission among IVDUs and their sex partners should be carefully evaluated with follow-up surveys of self-reports of drug use and sexual behaviors; admission to and success of drug-treatment; follow-up serologic testing of IVDUs who are seronegative; and monitoring of other infections (e.g., hepatitis B virus, bacterial endocarditis).
Among IVDUs, seroprevalence of HIV antibody is highest in New York City and Puerto Rico (45%-60%), high in the Northeast, and low in the Central and Southwestern United States (9,10). The high seropositivity levels in the New York City area and Puerto Rico indicate the potential for rapid transmission of HIV to uninfected IVDUs, unless effective HIV education and prevention programs are developed for IVDUs in areas of the United States where seroprevalence is presently low.
Worcester and Sacramento are medium-sized cities (populations of 175,000 and 330,000, respectively) with an estimated 3000-4000 and at least 8000 IVDUs, respectively. Similar efforts in larger cities with larger numbers of IVDUs may be more difficult to achieve. Nevertheless, attempts to coordinate efforts through integration of educational activities in health-care institutions, correctional/criminal justice facilities, health department clinics, and drug-treatment programs (combined with street outreach) are important in reducing the risk of transmission of HIV among IVDUs and their sex partners.
drug users (IVDU) in an area of low prevalence: a comprehensive approach (Abstract). IV International Conference on AIDS. Book 2. Stockholm, June 12-16, 1988:391.
2. CDC. Delta hepatitis--Massachusetts. MMWR 1984;33:493-4. 3. Noone S, Birch F, Sereti S, et al. A comprehensive prison program for AIDS risk reduction (Abstract). IV International Conference on AIDS. Book 1. Stockholm, June 12-16, 1988:313.
4. McCusker J, Koblin B, Lewis B, Sullivan J, Birch F, Hagan H. Differential characteristics of IVDU populations by enrollment site in a single community (Abstract). IV International Conference on AIDS. Book 2. Stockholm, June 12-16, 1988:197.
5. Koblin B, McCusker J, Lewis B, Sullivan J, Birch F, Hagan H. Racial differences in HIV infection in IVDUs (Abstract). IV International Conference on AIDS. Book 2. Stockholm, June 12-16, 1988:196.
6. Lewis B, Sullivan J, McCusker J, Birch F, Koblin B, Hagan H. Comprehensive surveillance of HIV among IVDUs in Worcester, Massachusetts (Abstract). IV International Conference on AIDS. Book 2. Stockholm, June 12-16, 1988:197.
7. CDC. Update: acquired immunodeficiency syndrome--United States, 1981-1988. MMWR 1989;38:229-36.
8. Jain S, Flynn N, Bailey V, et al. IV drug users and AIDS: changing attitudes and behavior (Abstract). IV International Conference on AIDS. Book 1. Stockholm, June 12-16, 1988:449.
9. CDC. Human immunodeficiency virus infection in the United States: a review of current knowledge. MMWR 1987;36(suppl S-6):40. 10. Hahn RA, Onorato IM, Jones TS, Dougherty J. Prevalence of HIV infection among intravenous drug users in the United States. JAMA 1989;261:2677-84. *Since drug-treatment clients are interviewed on entry into treatment, recent needle use for them would be before admission to drug treatment. For jail inmates, recent needle use refers to the period before incarceration.
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