Update: Reducing HIV Transmission in Intravenous-Drug Users Not in Drug Treatment -- United States

In 1987, the National Institute on Drug Abuse (NIDA) initiated ongoing demonstration projects to study and change the high-risk behaviors of both intravenous-drug users (IVDUs) who were not enrolled in drug treatment and their sex partners (1). The goal of the projects is to eliminate or reduce the likelihood of human immunodeficiency virus (HIV) transmission from these two high-risk groups. As of July 1, 1990, the projects included greater than 30,000 IVDUs and their sex partners in 41 community-based programs. This report describes preliminary data (as of January 1990) based on follow-up interviews of 1584 primarily less than 40-year-old, black, male IVDUs recruited from 1987 through 1989 in Chicago, Houston, Miami, Philadelphia, and San Francisco (Table 1, page 535).

In these projects, IVDUs were recruited through community-based outreach workers who were familiar with the neighborhoods in which the programs operate, were often former drug users, and had access to neighborhoods in which drugs were used. Eligibility criteria for participants included intravenous (IV)-drug use during the 6 months before recruitment and no enrollment in a drug-treatment program during the 30 days before recruitment. Clients were paid for their participation. The return rates for participants from initial to follow-up interviews were greater than 65% in four cities--ranging from 45% (Houston) to 78% (Philadelphia).

The specific interventions to reduce risk behaviors varied by city but included one or more of the following: 1) individual and group counseling, 2) efforts to build peer support for behavior change, and/or 3) demonstration and practice of behaviors that reduce risk. All interventions emphasized termination of IV-drug use. IVDUs were urged to start drug treatment as soon as it became available to them. In all cities, the programs strongly encouraged those who did not stop IV-drug use to 1) stop sharing drug-injection equipment (e.g., needles and syringes, drug-cooking implements, and rinse water); 2) use only sterile needles and syringes from unopened packages; and/or 3) disinfect drug-injection equipment with bleach or other appropriate agents. The interventions related to sexual activity advocated celibacy and, for persons who were sexually active, safer sexual practices, including use of condoms and reduction of the number of sex partners.

Fourteen percent to 35% of IVDUs participating in the first follow-up interview had entered a drug-treatment program during the approximately 6 months after enrollment (Table 1). Forty-nine percent to 75% of IVDUs reported stopping or decreasing their frequency of drug injection during the approximately 6 months between the initial intervention and follow-up interview (Table 1)--including 16%-47% who reported stopping all use of IV drugs.(Continued on page 535)

In all five cities, the percentage of IVDUs who reported not sharing drug-injection equipment with friends increased in the approximately 6 months between initial and follow-up interviews, as did the percentage of IVDUs who reported not borrowing previously used drug-injection equipment (Table 1). Thirty-four percent (Houston) to 59% (Chicago) of IVDUs reported decreased sharing of drug-injection equipment; 22% (San Francisco) to 37% (Chicago) of IVDUs reported decreased borrowing of drug-injection equipment.

Of those who continued to inject drugs at follow-up, except for those who reported always using new needles, 20%-39% of IVDUs reported increased use of bleach for cleaning drug-injection equipment (Table 1). Eleven percent to 43% of IVDUs reported consistent use of bleach.

Regular condom use with a steady sex partner increased in three cities to 12%-16% (Table 2). Regular condom use with multiple sex partners increased in four cities to 10%-27%. Reported by: MY Iguchi, PhD, School of Osteopathic Medicine, Univ of Medicine and Dentistry of New Jersey, Camden, New Jersey. J Watters, PhD, Univ of California, San Francisco; P Biernacki, PhD, Youth Environment Study Corporation, San Francisco, California. CB McCoy, PhD, DD Chitwood, PhD, Univ of Miami, Florida. W Wiebel, PhD, Univ of Illinois, Chicago. J Liebman, MS, L Kotranski, PhD, Philadelphia Health Management Corporation, Pennsylvania. M Williams, PhD, Affiliate Systems Corporation, Houston, Texas. BS Brown, PhD, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration. Office of the Director, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: IV-drug use is an important factor in the transmission of HIV (2). Of the 117,781 persons with acquired immunodeficiency syndrome (AIDS) reported in the United States in 1989, 36,356 (30.8%) are in a risk-behavior category directly or indirectly related to IV-drug use (3).

IVDUs are difficult to reach and influence with traditional public health education and other prevention interventions (4). Although drug-treatment centers can serve the dual purpose of drug treatment and HIV prevention, an estimated 80% of active IVDUs are not in treatment (National Association of State Alcohol and Drug Abuse Directors, unpublished data). New approaches and more effective strategies for reaching IVDUs not in drug treatment are needed to decrease drug use and stem the HIV epidemic.

These preliminary results, which show an overall reduction in high-risk behaviors of IVDUs, suggest that participation in outreach and intervention programs can influence entry into drug-treatment programs and reduce drug-injection behaviors associated with increased risk for HIV transmission. The lowest rates for IVDUs entering drug-treatment programs were in Miami and Houston, where capacities of publicly funded drug-treatment programs are limited. Stronger evidence of the considerable impact that this approach could have if implemented nationwide would be provided if the results at other sites prove to be consistent with these preliminary results.

A related study in San Francisco (5) suggests that outreach programs affect even the behaviors of IVDUs in the community who did not participate directly in the interventions. Cross-sectional samples of approximately 500 IVDUs recruited at 6-month intervals during 1986 and 1989 revealed that the introduction of outreach programs to IVDUs in 1986 corresponded with the start of communitywide increases in bleach use (from 3% in 1986 to 86% in 1989).

The Health Behavior Projects in Newark and Jersey City, New Jersey, have shown that IVDUs can be recruited directly from the street and community to enter drug-treatment programs when drug treatment is made more accessible. In these projects, 49% of 1884 IVDUs who participated in intake interviews subsequently entered 21- or 90-day methadone treatment programs at no charge (M.Y. Iguchi, unpublished data, 1990).

The results reported here reflect the effectiveness of street outreach combined with additional behavior-change interventions such as HIV counseling and testing. An additional strength of the projects may be the use of nontraditional outreach workers to recruit IVDUs into treatment. As in other studies (4), reported reductions in drug-use risk behaviors were larger than reductions in sexual risk behaviors.

Recruiting drug users into and keeping them in well-managed, effective drug-treatment programs can reduce risk behaviors for HIV infection (6). This strategy is essential to all HIV-prevention programs for drug users. Additional strategies are needed to reach drug users not in treatment programs. Since peers may influence former drug users to use drugs, drug-treatment and HIV-prevention programs need to provide long-term, repeated contacts with IVDUs who have returned to the community after drug treatment.

Street/community outreach is an important element of a comprehensive program to reach IVDUs in a variety of settings (including drug-treatment centers, public health clinics, free-standing HIV counseling and testing programs, correctional facilities, and health-care facilities such as hospitals and emergency rooms) and is best coordinated at the community level to assure maximum coverage and effectiveness (7). Project TRUST in Boston (8) and South Carolina's survey of clients in alcohol- and drug-treatment centers (9) are efforts to meet the specific needs of IVDUs for HIV prevention. Continuous reassessment is important in determining how outreach can be most effectively used in HIV and drug-treatment programs.

References

1. CDC. Risk behaviors for HIV transmission among intravenous-drug users not in drug treatment--United States, 1987-1989. MMWR 1990;39:273-6.

2. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, January 1990:9.

3. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, July 1990:8.

4. Turner CF, Miller HG, Moses LE, eds. AIDS sexual behavior and intravenous drug use. Washington, DC: National Academy Press, 1989.

5. Watters JK, Cheng Y, Segal M, Lorvick J, Case P, Carlson J. Epidemiology and prevention of HIV in intravenous drug users in San Francisco, 1986-1989 (Abstract). Vol 2. VI International Conference on AIDS. San Francisco, June 20-24, 1990:116.

6. Hartel D, Selwyn PA, Schoenbaum EE, Klein RS, Friedland GH. Methadone maintenance treatment (MMTP) and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users (IVDUs) (Abstract). Book 2. IV International Conference on AIDS. Stockholm, June 12-16, 1988:395.

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

8. CDC. Counseling and testing intravenous-drug users for HIV infection--Boston. MMWR 1989;38:489-90,495-6.

9. CDC. Characteristics of clients in alcohol- and drug-treatment centers--South Carolina, 1989. MMWR 1990;39:519-20.

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