Counseling and Testing Intravenous-Drug Users for HIV Infection -- Boston

Despite the increased risk for human immunodeficiency virus (HIV) infection among intravenous-drug users (IVDUs), many IVDUs have not been counseled and tested for HIV infection. In the Boston metropolitan area, which has an estimated 14,000 IVDUs, only 473 persons who identified themselves as IVDUs were tested for HIV antibody at anonymous counseling and testing sites and sexually transmitted disease (STD) clinics in 1988. To increase counseling and HIV testing of IVDUs in the Boston area, Project TRUST (Teaching, Referral, Understanding, Support, and Testing) was established at Boston City Hospital in November 1987 in collaboration with the City of Boston's Department of Health and Hospitals, the Division of Drug Rehabilitation of the Massachusetts Department of Public Health (MDPH), and the Massachusetts Center for Disease Control, MDPH.

Project TRUST staff includes nurses, counselors, and outreach workers (some of whom are recovering IVDUs). Services are provided without charge in a setting intended to attract IVDUs. Project TRUST is located in a neighborhood with a visible drug-user presence and is promoted among IVDUs by pamphlets and word of mouth.

Project TRUST offers anonymous testing for HIV antibody after counseling about HIV prevention and the advantages divided by isadvantages of the test. The use of bleach to disinfect needles and use of condoms to reduce sexual transmission of HIV are described, and supplies of each are provided free of charge. Pregnancy testing, the Mantoux skin test for tuberculosis, and selected additional services are also available on-site. Referrals are made for drug and alcohol treatment, social services, and medical evaluation. Social support groups for HIV-seropositive English- and Spanish-speaking clients meet on-site.

During its first year of operation, Project TRUST offered counseling and HIV testing to 688 clients. Of the 635 (92%) who were voluntarily tested for HIV antibody, 107 (17%) tested positive (Table 1, page 495). Seropositivity was greater in black and Hispanic clients and in current IVDUs than in white clients and former IVDUs, respectively; sex partners of IVDUs had a lower seroprevalence than did IVDUs themselves (Table 1, Figure 1, page 495).

Of the 635 clients tested, 503 (79%) returned to Project TRUST to receive HIV-antibody test results and counseling (Table 1). The proportion returning did not vary substantially by sex, race/ethnicity, or risk behavior group.

Excluding laboratory testing (which was funded separately), expenditures for personnel, overhead, and supplies for the first year of operation of Project TRUST were $174,120, or $253 per client served.

Project TRUST also includes outreach to high-risk neighborhoods, hospital inpatients, and patients in chronic-care facilities. These outreach programs include education sessions about drug addiction, HIV infection, and healthy lifestyles conducted in schools, drug and alcohol detoxification programs, and STD clinics. Specific efforts are made to provide referrals to and information about other community resources, and psychologic support for hospitalized persons with HIV infection is provided. Reported by: BA Comella, F Felch, KA Steger, MPH, J Harris, MD, GA Lamb, MD, DE Craven, MD, Boston City Hospital, Boston; LM Kunches, MPH, V Berardi, Massachusetts Center for Disease Control, Jamaica Plain; D Mulligan, Massachusetts Dept of Drug Rehabilitation, Boston, Massachusetts. Office of the Director, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The effectiveness of AIDS prevention efforts in many states and urban areas depends greatly on interrupting the chain of HIV transmission among IVDUs, their sex partners, and their children. In 1988, 33.3% of U.S. AIDS cases and 27.8% in Massachusetts were associated with IV-drug use (1).

Features that may contribute to the acceptance of Project TRUST in Boston are the range of free services available without appointment, the presence of former IVDUs on the staff, and anonymity (i.e., clients are given a code rather than registered by name). The high percentage (79%) of IVDUs who returned for their test results indicates that HIV prevention measures can be effectively provided to IVDUs if services are tailored to the specific needs and circumstances of this high-risk group.

A constraint of anonymous testing is the inability to reach seropositive persons who fail to return. Project TRUST and other programs providing HIV testing must develop follow-up approaches to reach such clients.

To induce long-term changes in the behavior of IVDUs, ongoing counseling and education and access to drug treatment are necessary (2). IVDUs also need medical services such as detoxification programs and screening and therapy for tuberculosis (3) and STDs (4). Clinical evaluation of HIV-infected IVDUs should include T-cell phenotyping and, when indicated, prophylaxis against Pneumocystis carinii pneumonia (5). Local efforts such as Project TRUST and others (6) to provide IVDUs with HIV-antibody testing, counseling, and other services are important in directing efforts to a group accounting for an increasing percentage of HIV infections and AIDS cases.

References

1. CDC. Update: acquired immunodeficiency syndrome associated with intravenous-drug use--United States, 1988. MMWR 1989;38:165-70.

2. Brickner PW, Torres RA, Barnes M, et al. Recommendations for control and prevention of human immunodeficiency virus (HIV) infection in intravenous drug users. Ann Intern Med 1989;110:833-7.

3. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(no. S-3):5.

4. CDC. Relationship of syphilis to drug use and prostitution--Connecticut and Philadelphia, Pennsylvania. MMWR 1988;37:755-8,764.

5. CDC. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus. MMWR 1989;38(no. S-5).

6. CDC. Coordinated community programs for HIV prevention among intravenous-drug users --California, Massachusetts. MMWR 1989;38:369-74.

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