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HIV Prevention Among Injection Drug Users

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Archival Content: 1999-2005

Training Doing the Work

Additional Scientific Articles on Outreach

Anderson JE, Cheney R, Clatts M, Faruque S, Kipke M, Long A, Mills S, Toomey K, Wiebel W. HIV risk behavior, street outreach and condom use in eight high-risk populations. AIDS Education and Prevention 1996;8(3):191-204.

The populations surveyed engaged in high levels of sexual risk behavior: 20% to 46% reported two or more sex partners in the past month. Most of the injection drug users and high-risk youth were at risk through unprotected sex with main partners; 56% to 75% reported protected vaginal sex with casual partners. Of this group, 58% to 84% had been tested for HIV infection, compared with 25% of the national adult population. Having a condom at time of interview was the most consistent predictor of condom use during most recent intercourse. A variable percentage of injection drug users had shared needles in the past month (10% to 53%). Many respondents had been in contact with street outreach programs and had received condoms, bleach, and other materials from workers.

Anderson JE, Cheney R, Faruque S, Long A, Toomey K, Wiebel W. Stages of change for HIV risk behavior: Injecting drug users in five cities. Drugs and Society 1996;9(1/2):1-17.

Respondents from the street-based samples interviewed at the five AESOP sites that were focused on injection drug users had a very high level of risk for HIV, in terms of sex and drug-using risk behavior. The level of stage of change for condom use was higher for casual partners than for main partners. Having a condom at interview was the most consistent predictor of respondent's level of stage of change for condom use. Homelessness and crack use were associated with lower level of stage of change for not sharing needles. Program staff need to be aware of the predominant level of readiness to change in order to design and implement effective programs.

Anderson J, Greenberg J, MacGowan R. Enhanced street outreach and condom use by high-risk populations in five cities. In: Greenberg J, Neumann M, eds. What have we learned from the AIDS evaluation for street outreach projects (AESOP): A summary document. Atlanta (GA): Centers for Disease Control and Prevention, 1998: 83-109.

Booth R, Koester S, Brewster JT, Weibel WW, Fritz RB. Intravenous drug users and AIDS: risk behaviors. American Journal of Drug and Alcohol Abuse 1991;17(3):337-353.

Risk-taking behaviors were studied in this assessment of 345 intravenous drug users from Baltimore, El Paso, and Denver. In an analysis of risk according to location, Baltimore subjects were significantly less at risk according to number of needle-sharing partners, borrowing needles, sharing a “cooker,” injection in a “shooting gallery,” cleaning needles, use of disinfectants, number of sexual partners, and use of condoms than either their cohorts in El Paso or Denver. Street outreach to modity risk behaviors among IVDUs began in Baltimore approximately 2 years prior to funding in El Paso and Denver. These results suggest that there may be a potential to moderate risk through intervention.

Centers for Disease Control and Prevention. Assessment of street outreach for HIV prevention—selected sites, 1991-1993. Morbidity and Mortality Weekly Report 1993;42(45): 873, 879-880.

This report is a description of the first 2 years of the AESOP project and includes results from the initial round of closed- end interviews. Results indicated that 17% to 65% of injection drug users and 23% to 46% of youth in high-risk situations (YHRS) reported talking with an outreach worker; 14% to 58% of IDUs and 11% to 26% of YHRS had received HIV prevention literature; 16% to 58% of IDUs and 22% to 39% of YHRS had received free condoms; and 13% to 55% of IDUs and 7% to 10% of YHRS had received bleach kits from outreach wor05/08/2007entified and reached through outreach programs; will talk with outreach workers about HIV prevention; and will accept HIV prevention literature, materials, and referral services from outreach workers.

Centers for Disease Control and Prevention. Street outreach for STD/HIV prevention—Colorado Springs, Colorado, 1987-1991 Mortality and Morbidity Weekly Report 1992;41(6):94

The increased risk for gonorrhea and other STDs among prostitutes reflects their increased exposure to infected sex partners. In Colorado Springs, street outreach, the active distribution of condoms, and repeated testing and counseling to reinforce risk-reduction messages were key components of the program initiated in 1987 to promote the proper and consistent use of condoms to prevent sexual transmission of HIV. Although direct measures of condom use are unavailable, the recent decline in gonorrhea may indicate, in part, increased condom use by sex partners of prostitutes.

Cheney R, Merwin A. Integrating a theoretical framework with street outreach services: Issues for successful training. Public Health Reports 1995;110(Suppl 1):1-5.

The authors discuss three key components necessary to integrate a behavioral research perspective (in this instance, the stages-of-change model) into the design of outreach programs: (a) training for successful service delivery, (b) training for a theory-guided intervention, and (c) feedback and evaluation. The third component measures the benefits of staff training to the outreach workers and to their ability to apply in the field what they have learned.

Clatts MC, Bresnahan M, Davis WR, Springer E, Backes G. The harm reduction model: An alternative approach to AIDS outreach and prevention for street youth in New York City. In: Ericson P et al., eds. Harm reduction: A new direction for drug policies and programs. Toronto: University of Toronto Press, 1997.

The authors provide a demographic and behavioral profile of street youth in New York City and discuss the history of AIDS prevention services for these young people. A network of outreach programs developed for AESOP, the Youth At Risk Cooperative, and the foundation for the network’s training program for outreach workers in the harm reduction model are described. Case study material from staff who integrated the model into case management activities provides a constructive demonstration of the potential of the harm reduction model as a service-delivery strategy for street youth.

Clatts MC, Davis WR, Atillasoy A. Hitting a moving target: The use of ethnographic methods in the development of sampling strategies for the evaluation of AIDS outreach programs for homeless youth in New York City. In: Lambert EY, Ashery AS, Needle RH, eds. Qualitative methods in drug abuse and HIV research NIDA Research Monograph 157, NIH Publication No. 95-4025. Rockville, MD: National Institute on Drug Abuse, 1995.

This chapter shows how ethnographic methods that include participant observation and life history interviews were used as a sampling strategy and a means of obtaining less accessible information. Interviews included how youth met everyday needs and consequently how they participated in the street economy. In addition to identifying important geographic and temporal gaps in services, the data provided useful information about a population of youth about whom little is known.

Clements K, Gleghorn A, Garcia D, Katz M, Marx R. A risk profile of street youth in northern California: Implications for gender-specific human immunodeficiency virus prevention. Journal of Adolescent Health 1997;20(5):343-353.

Most of the youth were heterosexual, white, male, and without stable housing. Of the total, 60% had had vaginal sex in the past 30 days; only 44% had used a condom during their most recent sexual encounter. One third of the sample reported having injected drugs. Compared with males, females were equally likely to use injection and noninjection drugs but were more likely to be sexually active, to have been given a diagnosis of a sexually transmitted disease, and were less likely to report consistent condom use. Females without stable housing were less likely to have used condoms during their most recent vaginal intercourse. These findings suggest an urgent need for gender-specific prevention efforts and increased housing options for youth.

Dickson-Gómez JB, Knowlton A, Latkin C. Values and identity: The meaning of work for injection drug users involved in volunteer HIV prevention outreach. Substance Use and Misuse, 2004;39(8):1259-1286.

Most HIV behavioral interventions provide participants with preventive information emphasizing how not to behave, and have neglected to provide attractive and feasible alternatives to risky behavior. Interventions that emphasize cultural strengths may have more powerful effects and may help remove the stigma of HIV, which has hampered prevention efforts among African American communities. Starting in 1997, the SHIELD (Self-Help in Eliminating Life-Threatening Diseases) intervention trained injection drug users (N=250) to conduct risk reduction outreach education among their peers. Many participants saw their outreach as “work,” which gave them a sense of meaning and purpose and motivated them to make other positieve changes in their lives.

Dickson- Gómez J, Knowlton A, Latkin C. Hoppers and oldheads: Qualitative evaluation of a volunteer AIDS outreach intervention. AIDS & Behavior 2003;7(3):303-315.

Qualitative research can play an important role in explaining outcomes of behavioral interventions and constitutes a largely unrealized potential of ethnographic methods in AIDS research. The Self Help in Eliminating Life Threating Diseases (SHIELD) intervention trained African American injection drug users to conduct outreach among their drug-using peers and sexual partners. Though the intervention was not targeting adolescents, some participants chose to conduct outreach with youth found on the street. Still others spoke to groups of youth in their homes. Contextual features that were important in determining the quality of outreach encounters with youth included the setting (on the street or in the home), characteristics of the outreach worker such as gender, content of the outreach message, and style of interpersonal communication.

Gleghorn AA, Clements KD, Marx R, Vittinghoff E, Lee-Chu P, Katz M. The impact of intensive outreach on HIV prevention activities of homeless, runaway, and street youth in San Francisco: The AIDS Evaluation of Street Outreach Project (AESOP). AIDS and Behavior 1997;1(4):261-271.

The authors evaluate the impact of an HIV prevention intervention combining street outreach, storefront prevention services, and subculture-specific activities for street youth in intervention and comparison sites before and during implementation of the intervention. Youth at both types of sites reported high rates of risky sex and drug-using behaviors. The intervention did not affect HIV risk behaviors but was independently associated with increased contact with outreach workers and increased referrals for services. Higher levels of contact with outreach workers were associated with following through with HIV-related referrals and using new syringes. Youth-oriented needle exchange increased the use of new syringes.

Greenberg J, MacGowan R, Neumann M, Long A, Cheney R, Fernando D Sterk C, Wiebel W. Linking injection drug users to medical services: Role of street outreach referrals. Health and Social Work 1998;23(4):298-309.

This analysis, from 3,237 structured interviews conducted with injection drug users (IDUs) at five sites between January1994 and October 1995, examines contact with outreach workers, the most common medical referrals received and acted on as a result of this contact, and whether more frequent contact was associated with increased acting on medical referrals. Of the IDUs interviewed, 42% to 67% had talked with an outreach worker in the past 6 months and reported referrals to a number of medical services, especially HIV counseling and testing and drug treatment. IDUs with more than three contacts with outreach workers during the past 6 months were more likely to seek services. To maximize the effect of outreach on acting on referrals, training for outreach workers should address techniques for follow-up with referred IDUs; identifying and overcoming barriers to seeking medical services, especially those for minority clients; after-care referrals for clients exiting drug treatment programs; and the importance of treatment for sexually transmitted diseases in reducing risk for HIV infection.

Kipke MD, O’Connor S, Palmer R, MacKenzie RG. Street youth in Los Angeles: Profile of a group at high risk for human immunodeficiency virus infection. Archives of Pediatric and Adolescent Medicine 1995;149(5):513-519.

Of the youths, 70% were sexually active (average of 11.7 sex partners during past 30 days). High-risk sex and drug-using behaviors were prevalent and interrelated in this sample of urban street youth. Substance-using youth were 3.6 times more likely to use drugs during sex, 2.2 times more likely to engage in survival sex, and 2.5 times more likely to report a sexually transmitted disease. Youth with multiple partners were more likely to report a previous sexually transmitted disease and survival sex. New and innovative educational promotions and prevention interventions for this population are needed.

Latkin C, Sherman S, Knowlton A. HIV Prevention among Drug Users: Outcome of a Network-Oriented Peer Outreach Intervention. Health Psychology. 2003;22(4):332-339.

A network-oriented HIV prevention intervention based on social identity theory and peer outreach was implemented for HIV positive and negative drug users. A community sample of 250 were randomly assigned to an equal-attention control condition or a multisession, small-group experimental condition, which encouraged peer outreach; 94% of participants were African American, and 66% used cocaine or opiates. At follow-up, 92% of participants returned, and experimental compared with control group participants were 3 times more likely to report reduction of injection risk behaviors and 4 times more likely to report increased condom use with casual sex partners. Results suggest that psychosocial intervention emphasizing prosocial roles and social identity, and incorporating peer outreach strategies, can reduce HIV risk in low-income, drug-using communities.

MacGowan RJ, Sterk CE, Long A, Cheney R, Seeman M, Anderson J. E. New needle and syringe use and use of needle exchange programmes by street recruited injection drug users in 1993. International Journal of Epidemiology 1998;27(2):302-308.

Street-recruited injection drug users were interviewed in five U.S. locations in 1993. Most (75% to 95%) reported that it was easy to get a new syringe. For their most recent injection, 45% to 77% had used a new syringe, and 2% to 18% had used a syringe previously used by another injector. The use of needle exchange programs (NEPs) ranged from 8% to 16% in Chicago, Philadelphia, and Los Angeles County. Factors associated with NEP use differed across sites, which suggests that the dispersion of NEPs and the removal of legal barriers that restrict access to sterile syringes may be more important to increasing the use of sterile syringes and NEPs.

National Institute on Drug Abuse (NIDA) Outreach Articles from NIDA NOTES:Link to a Non-CDC site

Preventing Drug Abuse-Related Infectious Diseases Through Community OutreachLink to a Non-CDC site (March 2001;16(1))

Among Drug Users, Peers Can Help Spread The Word About AIDS Prevention Research FindingsLink to a Non-CDC site (December, 1999;14(5))

Drug Abuse Among Runaway and Homeless Youths Calls for Focused Outreach SolutionsLink to a Non-CDC site (May/June 1997;12(3))

Treatment and Outreach Research on AIDS: Identifying and Treating Those at RiskLink to a Non-CDC site (May/June 1995;10(3))

Robles RR, Shepard EW. Accessing hard-to-reach populations: The illicit drug market as a workplace of the outreach worker in Puerto Rico. Puerto Rico Health Sciences Journal 2004;23(3):217-222.

This descriptive paper reports findings from a formative research study on the drug market as a workplace of the outreach worker in Puerto Rico, and outlines strategies used by outreach workers to enable them to work effectively in these sites. Data were collected via outreach worker focus groups and participant observations at drug market sites. A social system theoretical model was used for analyzing data on drug market sites, and results are reported in terms of three basic social system components: structure, culture, and process. The authors recommend using outreach workers as part of prevention and treatment teams in organizations providing services to drug users, as well as other hard-to-reach populations such as street sex workers and the homeless.

Schilling RF, Fernando D, Fontdevila J. El-Bassel N. HIV risk reduction among injection drug users: explaining the lack of anticipated outcomes in a community-level controlled comparison study. Evaluation & Program Planning. 23(3):301-313, 2000 Aug.

A quasi-experimental evaluation design was used to determine whether community outreach efforts would result in reductions in drug- and sexual-related HIV risk behavior among injection drug users in two control and two experimental neighborhoods in the South Bronx. The study also aimed to gain insight into the potential effect of enhanced outreach on increased client participation in drug abuse treatment and STD/HIV services. In sum, HIV risks declined over time in both conditions, but there were no apparent differences in behavior change or treatment/services entry between the control and enhanced outreach neighborhoods. The study underscores the difficulty of interpreting cross-community comparisons of intervention outcomes in an environment of changing risks and neighborhood dynamics.

Wiebel WW, Jimenez A, Johnson W, Ouellet L, Jovanovic B, Lampinen T, Murray J, O'Brien MU. Risk behavior and HIV seroincidence among out-of-treatment injection drug users: A four-year prospective study. Journal of Acquired Immune Deficiency Syndromes. 1996;12(3):282-289.

Trends in HIV risk behaviors and seroconversion among out-of-treatment injection drug users (IDUs) receiving street-based outreach intervention were monitored from 1988 to 1992. The intervention was guided by the Indigenous Leader Outreach Model: Ex-addicts deliver HIV-prevention services targeting IDU social networks in community settings. Primary outcome measures were HIV seroconversion and HIV risk behaviors. Observed incidence of HIV infection decreased, from 8.4 to 2.4 per 100 person-years. Prevalence of drug risk behaviors also decreased, from 100 to 14%. Seroconversion was associated with injection risk behavior. Sex risk behavior also decreased, but less dramatically, from 71 to 45%. Out-of-treatment IDUs in Chicago reduced their rates of new HIV infection by reducing their injection risk behavior. New infections were strongly associated with injection risk behavior but not with sex risk behavior.

Valentine J, Wright-DeAgüero L. (1996). Defining the component of street outreach for HIV prevention–the contact and the encounter. Public Health Reports 1996;111 (Suppl. 1):69-74.

The discussion suggests techniques for enhancing the encounter between outreach workers and clients by using the conceptual framework of the social-work helping relationship. Five elements of the encounter are defined and developed: screening, engagement, assessment, service delivery, and follow-up. The encounter represents an enhancement of the traditional street outreach interaction and a more systematic approach to promoting the behavioral change goals of AESOP.

Wright-DeAgüero LK, Gorsky RD, Seeman GM. (1996). Cost of outreach for HIV prevention among drug users and youth at risk. Copublished in Drugs and Society 1996;9(1/2):185-197; and In: Trotter T. II, ed. Multicultural AIDS prevention programs. Binghamton, NY: Harrington Park Press.

The authors present the results of a cost analysis at eight sites that provide outreach services to injection drug users and street youth. They assessed the potential benefit of HIV prevention through outreach services by comparing outreach costs with the costs of treating an HIV-infected person. The average cost of outreach services was $13.30 per contact. Costs per contact were 78% higher for street youth than for drug users. Comparing cost per contact with HIV treatment, if only 2 in 10,000 outreach contacts reduce their risky behavior to avoid the transmission of HIV, these programs compare favorably with other HIV prevention strategies in terms of cost.

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