A Comprehensive Approach

PPRREVENTEVENTIINNGG BBLLOO OOD- B O R N E

IINNFECTIONFECTIONSS AMAMONGONG

IINJECNJECT ION DRUDRUGG UUSESERSRS

ACADEMY FOR EDUCATIONAL DEV ELOPMENT

WITH FU NDI NG PROVIDED B Y CE NTER S F OR D ISEASE CONTROL & PREVENTION DIVISION OF HIV/AIDS PREVENTION

DECEMBER 2 000

IDU HIV P R E V E N T I O N This document was prepared by the Academy for Educational Development’s (AED) Center for Community-Based Health Strategies, under contract to the Centers for Disease Control and Prevention (Contract #200-97-0605, Task 018), to provide technical assistance to CDC-funded prevention partners to assist in reducing infection of HIV, sexually transmitted diseases, and blood-borne pathogens among injection drug users (IDUs), their sexual pa rt ners, and their chil d r en by promoting a comprehensive approa c h to preven t i o n .

The Academy for Educational Development, founded in 1961, is an independent, non- profit organization committed to solving critical social problems in the U.S. and throughout the world through education, social marketing, research, training, policy analysis, and innovative program design and management. Major areas of focus include health, education, youth development, and the environment. Foreword

Injection drug users (IDUs) play a key role in the continuing epidemics of HIV and other blood-borne infections, primarily viral hepatitis. Addressing the role that IDUs play in these epidemics is a challenge because it necessitates coordinated action on two of our most complex public health problems —AIDS and drug addiction. In the past, prevention planners, public health agencies, community organizations, and providers tended to focus on one aspect or another of the problem: improving the quality of substance abuse treatment, encouraging HIV prevention education efforts, or helping IDUs who continue to inject to obtain sterile syringes. Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach takes a different tack, one that many in the prevention arena recognize and are acting on. No one provider or approach can do it all. To help IDUs reduce their sexual and drug-use risks of transmission, communities and organizations must embrace a broad approach that incorporates a variety of pragmatic strategies addressing IDUs’ differing life circumstances, cultures and languages, behaviors, and readiness to change. This technical assistance document describes eight complementary strategies that, together, can make a real difference for HIV prevention for IDUs. Services and interventions for IDUs don’t take place in a vacuum, however. They are carried out within a complex, often contentious social, political, and legal environment. Potential partners in the effort to reduce infection among IDUs may not agree on everything, but they do need to find ways to work together so that a critical mass of IDUs can obtain sufficient, high-quality services. A Comprehensive Approach discusses this environment and lays out some principles that can help community groups, agencies, and providers begin — or continue— to collaborate. The challenges are substantial, but so are the rewards, for reducing infections among IDUs will translate into a substantial public health benefit for the whole community. We hope this document will help move the field in that direction by providing new ways of thinking about this problem and about IDUs and by encouraging dialogue, collaboration, and constructive action.

Helene Gayle, MD, MPH Director National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention ii F O R E WO R D Acknowledgments

Preventing Blood-borne Infections Among Injection • Community Anti-Drug Coalitions • Katherine Marconi, Health Reso u rc e s Drug Users: A Comprehensive Approach refle c t s of Ame r i c a and Services Administration the efforts of many health dep a rt m e n t s , • Join Together • Da vid Metzger, University of community-based organizations, researchers, • Health Bridge Pennsylvania/VA Medical Center and providers who work with injection drug • HI V / A I D S , TB and Infectious Diseases • Alan Neaigus, National Devel o p m e n t users (IDUs). Pulling together the many Cross-Training: The Alcohol and Other and Rese a rc h Institutes, Inc. threads that make up this technical assistance Dr ug Abuse Connection • Denise Paone, Chemical Depe n d e n cy document was a complex undertak i n g, and • New York Harm Reduction Institute, Beth Israel Medical Center we wish to acknowledge the valu a b le help Educators, Inc. (NYHRE) • Tim Purrington, Tapestry Health Systems we rec e i ved from a wide variety of pe o p l e . • Partners in Community Health Proj e c t • Joyce Rivera, St. Anne’s Corner of • River Region Human Services AIDS Ha r m Redu c t i o n First, we thank the following individuals Ou t re a c h Program • Terry Ruef li, New York Harm and their staffs from the eight state and one • Taking It to the Street s Reduction Educators, Inc. city health departments, who assisted us in • The ARRIVE Program of • Susan Rusche, National Families collecting information on the availability of Exponents, Inc. in Action various services and interventions for IDUs • The Miami Coalition • Anne Spaulding, Rhode Island and assessing technical assistance needs • The Statewide Partnership for Dep a r tment of Co r rec t i o n s and priorities. Their insights and experi­ HIV Education in Recovery • Marie Sutton, Georgia Department of ence helped us refine the elements of the Environments (SPHERE) Health Resources comprehensive approach and develop the • Well-Being Institute • Peter Whit i c a r , Hawaii Depa r tment conceptual framework for the document. • Women and Infants Demonstration of Hea l t h • Melissa Beaupierre, Florida Dep a rt m e n t Pro j e c t s We are particularly indebted to the of Hea l t h Ma n y expe r ts took time to review sections advice and suggestions of the following • Casey Blass, Texas Depa r tment of He a l t h of the document and supporting materials. individuals who reviewed the final draft • Carol Christmyer, Maryland Department Their thoughtful comments and advice of the entire document: of Health and Mental Hygiene im p ro ved the document immeasurably. • Brenda Crowder-Gaines, • Jack Stein, National Institute on No r th Carolina Depa rtment of • Ma r cia Andersen,Well-Being Institute Dru g Abus e Health and Human Servic e s • Terje Anderson, National Association of • Beth Weinstein, Connecticut • John Egan , New York City Depa rt m e n t People with AIDS D ep a rtment of Public Health of Hea l t h • Brad Austin, Center for Substance Abuse • Linda Wright-De Agüero, CDC • Maria Favu z z i , New York City Treatment Fi n a l l y, we wish to acknowledge the effo rt s Department of He a l t h • La r ry Brown, Addiction Rese a rc h and of those who developed and wrote the • Chet Kelly, Illinois Department of Health Treatment Corpor a t i o n document. From CDC: T. Stephen Jone s , • Harold Rasmussen, Califo rn i a • Scott Burris, Temple University School Abu Abdul-Quader, John E. Anderson, Department of He a l t h of Law Beth Dillon, Kellie Lartigue, John Miles, • Mark Schr a d e r , Georgia Depa r tment • Alan Clear, Harm Reduction Coalition Kevin O’Connor, Ted Pestorius, David of Hea l t h • Susan Coyle, National Institute on Drug Pu r cell, Michael St. Louis, Jenn i f er Taus s i g, • Candace Vonderwahl, Colorado Abu se and Richa r d Wolitski. From AE D : Ca ro l Department of He a l t h • Pam DeCarlo, Center for AIDS Schechter, James Bender, Sharon Novey, Prevention Studies, University of We also would like to recognize the staff Anne Marie O’Keef e, and Susan Roger s . California at San Fran c i s c o and clients of the prog rams feat u r ed in From Macro International: Bi l l y Jones. • Glen Fischer, Management Chapter 3. Thank you for sharing your Assistance Corpor a t i o n Anne Brown Rodgers was the senior writer experiences and expe rtise with us. Your • Samuel R. Friedman, National and editor. Dan Banks and the grap h i c stories have done much to bring the com­ Development and Research Institutes, Inc. designers at Fathom Creative, Inc. designed prehensive approach to life. • Donna Gold, Health Systems Research and produced the document. • Brooklyn Treatment Court • Theo d o r e Hammett, Abt Associates, Inc. • Community AIDS Reso u r ces and • Zita Lazzarini, University of Education (C.A.R.E.) Co n n e c t i c u t

A C K N OW L E D G M E N T S iii Table of Contents

INTRODUCTION AND OVERVIEW ...... 1

CHAPTER 1: Injection Drug Users Play a Key Role in the Transmission of HIV and Other Blood-borne Infections...... 3 Risk Behaviors Associated with Infection by HIV and Other Blood-borne Infections...... 5 Dr ug Practices ...... 5 Se xual Behavi o r s ...... 6 The Context of High-risk Drug and Sexual Practices ...... 6 Drug Use Settings ...... 6 Social Network s ...... 6 Membership in Groups with Especially High Risks ...... 7 Ge o g raphic Differe n c e s ...... 8 Income and Social Fact o r s ...... 8 Conclusion...... 8 References ...... 9

CHAPTER 2: The Legal, Social, and Policy Climate Limits Prevention Options for IDUs ...... 13 Negative Attitudes and Stigma Toward IDUs Persist Despite a New Understanding of Addiction ...... 13 Negative Attitudes Toward IDUs on Public Policy and Treatment Approaches ...... 14 Conclusion ...... 18 References...... 19

CHAPTER 3: A Comprehensive Approach is a More Effective Approach ...... 21 Guiding Principles ...... 23 En s u re Coordination and Collaboration ...... 23 En s u re Covera g e, Access, and Quality ...... 23 Recognize and Overcome Stigma ...... 24 Tailor Services and Progr a m s ...... 26 Key Strategies...... 26 Substance Abuse Trea t m e n t ...... 26 Community Outrea c h ...... 27 Interventions to Increase IDUs’ Access to Sterile Syringes ...... 29 Interventions in the Criminal Justice System...... 30 Strategies to Prevent Sexual Tran s m i s s i o n ...... 32 HIV Counseling and Test i n g , Partner Counseling and Refer ral Services, and Prevention Case Manageme n t ...... 32 Coordinated Services for IDUs Living with HIV/AIDS ...... 34 Pr i m a r y Drug Preven t i o n ...... 36 Next Steps for Communities ...... 36 Conclusion ...... 38 References ...... 39

APPENDIX A: Key Strategies for Preventing Blood-borne Pathogen Infection Among Injection Drug Users ...... A1

APPENDIX B: Index of Articles and Reports Cited in Appendix A, Organized by Comprehensive Approach Strategy ...... B1

T A B L E O F C O N T E N T S v ID U HIV P R E V E N T I O N Introduction and Overview

Since 1981, 733,374 cases of AIDS have been reported to the Centers for Disease Control and Prevention (CDC). In 1999, 46,400 new cases were reported. It is estimated that 650,000 to 900,000 Americans are now living with HIV, and that approximately 40,000 new infections occur each year. Approximately 1 to 1.25 million Americans are chronically infected with hepatitis B virus (HBV), and since 1995, approximately 185,000 new infections have occurred each yea r. An estimated 2.7 million Americans are chronically infec t e d with hepatitis C (HCV).

These blo o d - b o r ne infections are transmit­ transmission of blo o d - b o r ne infec t i o n s . • coordinated services for IDUs living with ted primarily through two routes—sharing However, we focus on injection drugs in HIV/AIDS; and contaminated syringes, needles, and other this document because of the key role they • primary drug preven t i o n . drug injection equipment, and having unpro­ play in the intersection of addiction and tected sex with infected individuals. Through infection and because of the myriad ways in These eight strategies are supported by both types of risk behaviors, injection drug which communities and providers can work four cross-cutting principles: users (IDUs) are an important factor in the with injection drug users to reduce their risk • Ensure coordination and collaboration. continuing evolution of these epidemics. and burden of infection. A coordinated and collaborative approach Women who become infected with HIV The core of the comprehensive approach is to serving IDUs, their sex partners, and through sharing needles or having sex with a group of pragmatic strategies. These their children is essential because no one an infected IDU can also transmit the virus strategies recognize that services and inter­ provider or institution can or does deliver to their babies before or during birth or ventions for IDUs must be organized so all requ i r ed services. The comprehensive through breastfeeding. that prevention and behavior change mes­ approach outlined in this document To address this critical public health issue, sages can be delivered and reinforced across requires action by many sectors. Providers program man a g ers and staff, policy makers , various settings, populations, life circum­ must work toget h e r , sharing their vari o u s HIV prevention community planners, and stances, patterns of drug use, and stages of expe r tises and outlooks, recognizing and others in the public health community must behavior change. Though many kinds of overcoming their philosophical differences, focus attention on ways in which they can services and interventions can be directed building on existing relationships, and mo r e effect i vel y reac h and influence IDUs toward IDUs and the issues of drug use reaching out to groups with whom they and must intensify efforts to develop and and disease, eight strategies are included ma y not have work ed before. carry out prevention and treatment strategies here. They are: • Ensure coverage, access, and quality. directed to IDUs and their sex partners and • substance abuse trea t m e n t ; Programs and interventions will not be children. This technical assistance document ef fec t i ve if they do not reac h a critical is designed to help staff, planners, and • community outreach; mass of people who can be helped, if policy makers accomplish this goal. It first • interventions to increase access to sterile IDUs cannot or will not use them, or if describes the complex problems facing pro- syringes; they are of poor quality. If they hope to grams and professionals who work with the • interventions in the criminal justice system; truly reach and help IDUs, agencies and issue of pr eventing bloo d - b o r ne infec t i o n s providers must consider ways to effectively in IDUs and then proposes a comprehensive • strategies to prevent sexual transmission; deal with these issues as they plan, deliver, approach to ameliorating these problems. • counseling and testing, partner counseling and monitor programs and services. We recognize that other drugs besides and referral services, and prevention case injection drugs are also important in the management;

I N T RO D U C T I O N A N D O V E RV I E W 1 • Recognize and overcome stigma. Many This document describes in more detail More effective and comprehensive prevention people fear and disapprove of injection the need for and characteristics of the approaches for IDUs will clearly benefit drug use and consider IDUs to be bad comprehensive approach. It is divided into injection drug-using men and women and or weak people whose addiction results th r ee cha p t e r s : their partners and chil d ren. The benefits from moral failure. IDUs live in an envi­ have important implications for society as a Chapter 1: Injection Drug Users Play a ronment of high risk and are frequently whole as well, for reducing the transmission Key Role in the Transmission of HIV ostracized. Many, though not all, are poor of HIV and other blood-borne infections in and Other Blood-borne Infections. This this population means reducing transmission chapter provides epidemiologic detail on in the broader population. The results will the importance of injection drug use in be a smaller impact on and costs for health the epidemics of HIV and other blood- and social services, reduced crime, and a borne infections and describes the drug mo re prod u c t i ve society. Many indivi d u a l s , The comprehensive use and sexual behaviors that place IDUs or ganizations, and agencies have reco g n i z e d at risk of infection. approach consists of the importance of the issue of HIV and 8 pragmatic strategies Chapter 2: The Legal, Social, and Policy other bloo d - b o r ne infections among IDUs supported by 4 cross- Climate Limits Prevention Options for and are acting in innovative ways to address cutting principles. IDUs. This chapter describes the context them. We hope this document provides the within which prevention programs with vision and impetus for other program staff IDUs must work—the existing stigmas and and policy makers to take the steps neces­ biases that characterize man y public and sa r y to effect iv ely address the preven t i o n provider attitudes toward IDUs, even in the and care needs of injection drug users. face of current knowledge about the nature and live on the margins of society. If of addiction, and the policy, legal, and IDUs are to be successfully engaged in service provision climate that has emerged prevention efforts and ifpublic policy is fr om these attitudes. to move forward, these negative attitudes Chapter 3: A Comprehensive Approach and misconceptions must be recognized More effective and is a More Effective Approach. This chap­ and addressed. Addiction is now known comprehensive prevention ter briefly describes the component strate­ to be a treatable, chronic brain disease. and treatment approaches gies and principles of the comprehensive Making this understanding of addiction approach. Vignettes about selected programs will clea r ly benefit IDUs, more generally known and accepted is are included throughout this chapter to their partn e r s and children, key to overcoming stigma. illustrate the ways in which the strategies and society as a whole. • Tailor services and programs. IDUs are and principles are being applied in diverse tremendously diverse. They have different communities and settings. la n g u a g es, cultures, sexual orientations, This document also includes two li fe circumstances, behaviors, and require­ Appendixes. Appendix A provides greater ments for services. In planning and deliv­ detail on each of the eight key strategies, ering interventions, programs and including findings from programs and providers must take into account the fac­ research and discussions of issues and tors that characterize IDUs—who they barriers faced by agencies and providers ar e, wher e they are, what they do, what in each of these areas. Appendix B is a motivates them, and with whom they matrix of the many research studies and socialize. Tailoring services and pro gr a m s reports cited in Appendix A, organized by and involving IDUs in their planning, strategy so that readers have easy access to implementation, and monitoring will this rich literature. ma k e them more effect i ve.

2 I N T RO D U C T I O N A N D O V E RV I E W ID U C HAP T E R ONE HIV P R E V E N T I O N Injection Drug Users Play a Key Role in the Transmission of HIV and Other Blood-borne Infections

Since 1981, 733,374 cases of AIDS have been reported to the CDC (CDC, 1999a). At least 430,441 of these Americans have died. It is estimated that 650,000 to 900,000 Americans are now living with HIV, and that approximately 40,000 new infections occur each year (CDC, 1999b). HIV infection and AIDS is concentrated in large urban areas, primarily along the East and West Coasts, in the south, and in Puerto Rico. In the late 1980s and early 1990s, AIDS incidence increased in all regions of the country, with the most dramatic increases in the South. Since then, incidence has declined in all regions except the South, where it has remained stable (CDC, 1999b). CDC surveillance data show that injection drug use is directly or indi­ rectly associated with about one-third of all AIDS cases (CDC, 1999a).

Of the 46,400 new cases of AIDS heavy impact of the HIV/AIDS epidemic Within these continuing high numbers, reported in 1999, almost 14,000 were on racial and ethnic minority populations however, there appear to be some promising IDU-associated: and on women, youth, and children. The trends. Partly because of prevention efforts data suggest three inter related issues play a targeting those at highest risk, the epidemic • 7,207, or 52 percent of these IDU- role in this—disparities in socioeconomic has slowed considerably since its earliest associated cases, were heterosexual status, the nation’s inability to substantially days (CDC, 1999b). HIV seroincidence in male IDUs; reduce substance abuse, and the intersec - injection drug users has declined over the • 2,931, or 21 percent, were female IDUs; tion of substance abuse and the epidemics past several years in the largest drug-using ofHIV and other STDs. There is no communities, including New York, northern • 1,806, or 13 percent, were men who have question that drug use plays a major role New Jersey, and Los Angeles (Des Jarlais et sex with men and were IDUs; in the spread of the epidemic of HIV and al., 2000; Ho l m b e r g, 1996). These declin e s • 1,790, or 13 percent, were heterosexual other blood-borne infections among can be attributed to changes in IDUs’ risk sex partners of IDUs; and African Americans and Hispanics, both behaviors, including greater use of sterile through the direct impact of injection drug • 99, or less than 1 percent, were children use and indirectly through sex with an whose mothers were IDUs or the sex IDU or through the exchange of sex for pa r tners of IDUs. drugs or money (CDC, 1999a; CDC, Injection drug use These numbers for IDU-associated AIDS 1999b). In 1998, IDU-associated AIDS is a major force in cases in 1999 are minimum estimates, as cases represented almost 40 percent of all HIV/AIDS: 11,209 of the 46,400 cases (24 percent) cases among African Americans and 43 1 were cla s s i f ied as “other/risk not reported percent of all cases among Hispanics • about ⁄3 of or identified . ” Some of these cases were (CDC, 1999b). In 1998, the IDU-associ­ adult AIDS cases ID U - a s s o c i a t e d . ated infection rate was five times higher are related to among Hispanics than among whites and Data from prevalence surveys and case injection drug use more than ten times higher among African surveillance continue to demonstrate the Americans than among whites (CDC, 1999c).

I D U S A N D T R A N S M I S S I O N O F H I V 3 needles, more disinfection of drug prepa­ The transmission of other bloo d - b o rn e 1999). However, hepatitis C is a major ration equipment, shifts from injection to diseases, primarily hepatitis B and hepa t i t i s cause of cirrhosis and liver cancer, and snorting, and stopping using drugs. C, through unsafe sex and sharing needles, HCV-related end stage liver disease is the sy r i n ges , and drug preparation equipment, leading reason for liver transplantation in The shift from injecting to snorting drugs such as filters, water, and cookers, is another the U.S. The estimated annual incidence of is documented by information on drug use important concern for public health agencies hepatitis C remained relatively stable through tren ds gath e red by the National Institute and service providers. Appr oxi m a t e l y 1 to mu c h of the 1980s. However, based on on Drug Abuse’s (NIDA) Community 1.25 million Americans are chronically sentinel surveillance for acute viral hepatitis Epidemiology Work Group (CEWG, infected with hepatitis B virus (HBV), and conducted in four U.S. counties, the CDC 1998). CEWG contributors report that since 1995, approxim a t e l y 185,000 new estimates that the aver a g e number of ne w ly although heroin use indicators continue to infections have occured each year. The CDC ac q u i re d HCV infections has declin e d increase in 12 cities monitored by CEWG, reports that the incidence of HBV infec­ from 180,000 in 1984 to 40,000 in 1998 in those cities in which high-purity white tion increased through the mid-1980s, then (Alter and Moyer 1998, CDC unpubli s h e d powder heroin is available, heroin snorting declined through 1994. A small portion of data). The risk of expo s u r e to HCV from has become much more prevalent and is this decline is attributed to the wider use transfused blood has declined dramatically in spreading to new and younger users. recent years with improvements in screening However, this may be a short-lived trend, blood donations. In contrast, ille gal drug as many of these snorters may shift to use currently accounts for about 60 per - injecting if the purity of available heroin IDUs are also cent of HCV transmission, while sexual drops. It is also known that many drug users important in exposures account for 20 percent (Alter, who begin by snorting heroin eventually the hepatitis C 1999). Studies have consistently shown move to injecting it (Irwin et al., 1996). epidemic: that injection drug use is the single most The findings on declining seropr evale n c e • illegal drug use and important risk factor for hepatitis C virus have been supported by other recent work, infection (Alter et al., 1999; Alter and including an examination of temporal trends high-risk sex are the Moyer, 1998; Garfein et al., 1998; Thomas in HIV seroprevalence in New York from factors most strongly et al., 1995). Among IDUs, hepatitis C 1991 to 1996 (Des Jarlais et al., 1998). associated with vi r us infection is extre m e l y preval e n t — in New York has between 170,000 to over hepatitis C infection studies conducted worldwide, from 50 to 200,000 IDUs and almost 50,000 cases among those 17-59 95 percent of IDUsare infected (Garfein et of diagnosed AIDS among IDUs and their al., 1998). This high prevalence persists even pa r tners and chil d r en (Des Jarlais et al., years old in populations in which the prevalence of 1 1998). New York City accounts for almost • ⁄2 of hepatitis C cases HIV is relatively low (van Beek et al., 1998). one-fourth of the IDU AIDS cases in the in the U.S. are directly This may be because HCV has a higher U.S. and almost one-tenth of all AIDS cases aver a g e transmission effici e n c y than does in the U.S. During the first half ofthe or indirectly linked to HIV (Coutinho, 1998; Crofts et al., 2000). 1990s, the city saw a steady decline in HIV illegal drug use In addition, HIV may be transmitted on seroprevalence. The authors attribute the equipment such as swabs, spoons, and rinse decline in number of seropositive IDUs to water that may be commonly shared by two major factors. The first is the death of of vaccine among healthcare workers. It is IDUs even if they do not share syringes1 many HIV-positive IDUs who became hypothesized that a significant portion of (C o u t i n h o , 1998; Crofts et al., 2000). infected early in the epidemic. Others may this decline was the result of reduced high- Another reason why HCV is of p a rt i c u l a r have become too ill to engage in the activities risk practices following the introduction of co n c e r n is that infection appears to be needed to obtain and use drugs. The second HIV prevention messages. ac q u i re d rela t i vel y soon after drug injecting factor is the adoption of risk reduction is initiated (one study reported that 50 to An estimated 2.7 million Americans are behaviors as a result of community out- 80 percent of new IDUs became infected chronically infected with hepatitis C. Most reach efforts, syringe exchange programs, within 6 to 12 months of first injecting are unaware of their infection because some and other contributing factors. [G a r f ein et al., 1996]). However , more in d i viduals experience no symptoms for recent studies are suggesting that IDUs are 20-30 years after infection (Alter et al., getting infected at a slower rate (Garfein et

1The term “syringe” is used throughout this document to refer to the needle and all other parts of the syringe.

4 I D U S A N D T R A N S M I S S I O N O F H I V al., 2000). There is however a very large After injecting the drug, the IDU rinses the for example, when several IDUs pool their reservoir of potentially infectious indivi d u ­ syringe with water to prevent any remaining money to purchase drugs toget h e r . The als, whic h provides multiple opportunities blood from clo t t i n g . This contaminates the en t i r e amount of dr ug is dissolved during for transmission to occur (Alter and rinse water. Drug injection may take place a shared preparation process. The preparer Mo yer , 1998). in locations with little access to water, so draws all the drug and water solution into rinse water may be reused and therefore a syringe through the cotton. Using the Risk Behaviors Associated become increasingly contaminated. In many calibrations on the syringe, the preparer with Infection by HIV and Other cases, this water is used for dissolving drugs then transfers individual doses of the drug Blood-borne Infections to be injected as well as for rinsing. In the into the syringes of the other users. After D RU G P R A C T I C E S absence of a sufficient supply of new sterile injecting the drug, users rinse their syringes sy r i n g es, IDUs must reuse their syringes . with water. Though syringes themselves are The process of preparing and injecting Di s i n f ecting used syringes with blea c h is not used by more than one person in indirect dru gs and the various items of eq u i p m e n t recommended as a risk reduction measure, sh a r i n g, they still become contaminated used provide many opportunities for con­ but even if done correctly, it is not as safe with blood because of contact with con­ tamination with and transmission of HIV as using a new, sterile syringe. In reality, the taminated ancillary paraphernalia. or other blood-borne viruses (AED, 1997). multiple steps involv ed in the blea ch i n g Other practices associated with indirect procedure and the difficulty of ad e q u a t e l y To be injected, drugs such as heroin must sharing can also transmit infection, including cleaning the hard-to-reach internal spaces be dissolved in water. Heat is sometimes (K oester and Hoffer, 1994): used to speed the process. This is typically of a syringe mean that many IDUs are done in a spoon or a bottle cap, called a un a b le to prop e rl y disinfect their used • Sq u i r ting the drug solution from a previ­ “cooker.” The drug and water solution is sy r i n g es. (Gershon, 1998; Glegho r n et al., ously blood-contaminated syringe into the then drawn into a syringe through a filter 1994; McCoy et al., 1994). cooker or spoon and then drawing it into another syringe. or a “cotton,” which prevents small particles The patterns of cocaine and heroin use in the solution from clogging the narrow present particular viral transmission risks • Using the plunger from a previously gaug e needle. (Koester et al., 1996). The desire and need blood-contaminated syringe to mix the Before injecting intravenously, an IDU must for cocaine mean that users of this drug dr ug with wate r . inject freq u e n t l y, multiplying the opportu­ de t e r mine whether the needle is in a vein . • Returning the drug solution from a nities for transmission of bloo d - b o rn e To do so, he or she pulls back the syringe pr evi o u s l y blood-contaminated syringe to vi r uses. Heroin injectors make fewer injec­ plunger to see if blood enters the syringe. the shared cooker or directly to another tions per day, but their risks are multiplied This is called “r egi s t e r i n g .” If blood regi s­ sy r i n g e. This occurs when the user draws because of their overwhelming physical and ters, the needle is in a vein. Regi s t e r i n g up more than his or her allotted share of emotional need to avoid the withdrawal contaminates the entire syringe with bloo d : the drug. needle, hub, barrel, and plunger (Koester, syndrome. Their objective is to inject as 1998; Normand et al., 1995). soon as possible after obtaining the drug, • “B e a t i n g ,” or pres s i n g, a used cotton whic h means they may use what e ver syringe (or several cottons) to retr i e ve any drug Once the user registers that the needle is in or equipment is closest to hand, whether remaining in the cotton from a previous a suitable vein, the drug is injected directly. or not that presents viral infection trans- injecting session. To ensure that all the drug is injected, the mission risks (Koester et al., 1996). IDU may pull the plunger back several • “Kicking out a taste” by putting a part of times, drawing blood into the syringe eac h Transmission of HIV and other blood- the drug/water solution from a previously time, and then re-injecting it. This technique, borne viruses can occur through either blood-contaminated syringe back into the called “booting ,” increases the presence of di r ect or indirect sharing of co n t a m i n a t e d cooker or into another IDU’s syringe so residual blood in the syringe (Koester, 1998; equipment. Direct sharing involves injecting that another or several other IDUs can Normand et al., 1995). drugs with a syringe already used by another get some of the drug. injector. Indirect sharing occurs when injec­ • Drawing up the water for dissolving the HIV survives in the residual blood in used tors prepare their own drugs but use injection drug by using another injector’s used and sy r i n ges , even if it has been rinsed with paraphernalia, such as water, cookers, cottons, in a d e q u a t e l y disinfected syringe. water. A recent study showed that HIV in and spoons, that others have used, or when used syringes remained viable and infectious injectors jointly prepare and share drugs Another attribute of drug use that con- at room temperature for more than 4 weeks (K oester and Hoffer, 1994). This occurs, tributes to the risk of viral transmission is (Abdala, 1999).

I D US A N D T R A N S M I S S I O N O F H I V 5 the use of more than one drug. For example, ulcerative lesions. These high-risk drug and D RUG U S E S E T T INGS IDUs often use alcohol, cigarettes, and sexualbehaviors intersect in a variety of ways Drug use takes place in a variety of locations marijuana in addition to the drug they inject to increase risk. For example, sex partners that allow people to inject by themselves (A E D , 1997). “S p e e d b a l l , ” a combination of HIV-infected IDUs may begin injecting or in small groups. These locations include of heroin and cocaine is favor ed by some drugs themselves (Ouellet et al., 1998). apartments or homes, bars, massage parlors, injectors, and has been highly correlated Dr ug injectors who also freq u e n t l y smoke social clubs, residential hotels, abandoned with HIV infection (Battjes et al., 1994). crack cocaine tend to spend time in crack buildings, public bathrooms, and “shooting Common reasons for this polydrug use houses or other places with other drug- gall e r i e s ” (AE D , 1997; Des Jarlais et al., include the need to counteract the effects injecting cocaine users (Friedman et al., 1993; IOM, 1995; Latkin et al., 1996a). of one drug with another, the desire to 1995). Crack use is associated with high- In some settings, users rent out needles and experience the effects of more than one risk sexual activities, possibly because of the other equipment for a small fee or a portion drug, and the need to substitute when the disinhibiting effect of the drug or because of the user’s drug, which is paid to the dealer drug of choice is too difficult or costly to of the addicted person’s need to obtain the operating the gallery. The needles are then obtain. Polydrug use can increase the risk dru g , whic h leads to exchan ge s of se x for returned and used by the next injector. In of HIV and other bloo d - b o r ne disease crack or for money to buy crack (Edlin et al., other settings, sharing drugs or equipment transmission in several ways. For exam p l e , 1994). Many IDUs, both men and women, occurs without payment of drugs or money. the situations and people with whom an trade sex for drugs or money to buy drugs Key components of this context are the IDU uses drugs may vary depending on or engage in commercial sex or hustling to number of drug users in the setting and the the drug. These differing contexts may generate income for their habits and this riskiness of the behaviors. When a setting expose the individual to a variety of high- in c r eases their transmission risks (AED, brings together multiple individuals who risk situations. Furth e rm o re, intoxi c a t i o n 1997; Kail et al., 1995; Rietmeijer et al., prepare and inject drugs in risky ways (with with one drug may lessen an indivi d u a l ’ s 1998; Schilling et al., 1992). few syringes and widespread direct and ability or desire to reduce risks associated in d i rect sharing) or who have high-risk sex, with the use of another drug. The Context of High-risk Drug and Sexual Practices transmission of HIV and other blood-born The degree of risk associated with injecting vi ruses can spread rapidly and effici e n t l y drugs is determined in part by the physical from one user to others (Latkin et al., 1994). setting in which it takes place and the people High-risk drug use with whom a user injects. An understanding SOCI A L NETW O R KS behaviors and high-risk of the contexts in which drug use occurs is These are groups of users linked by various sexual behaviors particularly important because they help to relationships and bonds. Networks differ are often linked, explain the ways drug use takes place and based on the number of members and how they help define individual users and the further increasing stable the relationships are, the types of other people with whom they spend time, relationships among members, the degree risk of transmission. buy drugs, inject drugs, and have sex. This to whic h the group is open to inclu d i n g knowledge, in turn, illuminates the ways in new members, the kind of social activity which infection is transmitted from one that occurs within it, and the types of drug individual to another, as well as from small used and how they are used (Friedman et al., S E X U A L B E H AV I O R S high-seroprevalence groups to the larger 1997; Needle et al., 1995). In addition, net- community (Des Jarlais et al., 1993; works may be defined by race or ethnicity, High-risk drug use behaviors and high-risk Friedman et al., 1995; Friedman et al., 1997; gender, sexual orientation, social class, and sexual behaviors are often linked, further Needle et al., 1995). Armed with these the presence of kinship among members. increasing the risk of HIV and other blood- insights, policy makers and service providers borne diseases being transmitted from one can develop prevention interventions that The nature of the relationships among person to another (Chu et al., 1998). These are tailored to the characteristics and needs members and the interpersonal and group risky sexual behaviors include unprote c t e d of spe c i f ic groups of injection drug users dynamics of the network direc t l y affects a anal, vaginal, or oral sex; multiple partners; (AED, 1997; Bourgois, 1998; IOM, 1995). member’s drug-use and sexual behaviors and and lack of treatment of sexually transmitted The following sections discuss several key therefore are highly influential in determining diseases (STDs), especially those with social contexts for drug use. that person’s risk of infection (Friedman

6 I D U S A N D T R A N S M I S S I O N O F H I V et al., 1997; Latkin et al., 1996b; Needle et ME MBERSHIP IN G R O U P S the Bureau of Justice Statistics shows that al., 1995). For example, some networks are WI T H ESPECI ALL Y in 1996, 24,881 inmates in state and fed­ small, consisting of a close group of drug- HIGH RISKS eral prisons were kno wn to be infec t e d using or sex partners. These individuals may with HIV (Hammett et al., 1999). HIV- Certain groups of injection drug users have increased risk because they may be less positive inmates comprised 2.4 percent of warrant particular attention because their likely to use condoms or sterile syringes, the state prison population in 1996 and occupations or behaviors lead to drug- and which may conflict with the intimacy and 1.0 percen t of the federal prison popula­ sexually-related transmission risks that trust developed in the relationships. Oth e r tion. Between 1991 and 1996, the number appear to be higher than they are for other types of networks are characterized by a of HIV-positive inmates grew at about the populations. They can experience consid­ la r ger , more open membership, and the same rate as the overall prison population erable societal stigma to begin with because level of risky behavior engaged in by mem­ (both increased by about 42 percent). of these occupations and behaviors, and bers is influenced by the settings in which their drug use compounds this problem and Female sex workers and female IDUs who drug use takes place and the closeness ofthe contributes to their higher transmission risk. have sex with other women are particularly ties that bind members (Trotter, 1995). A For example, many IDUs have coe xi s t i n g vulnerable to infection because many are member who has close links with other problems, such as mental illness, phys i c a l poor and homeless and addicted to alcohol drug injectors in the network is more likely illness, homelessness, and incarc e r a t i o n . as well as drugs. Female IDUs who trade to engage in high-risk practices, such as As many as 30 percent of homeless adults sex for money or drugs are more likely to sharing syringes or injecting in shooting may be substance abusers. (NIDA, 1990; share needles than are female injectors galleries, than are drug injectors who are Schutt et al., 1992). Overall, homeless who do not engage in sex trading, and are only peripherally connected to other network adults have higher HIV rates than do the less likely to use new needles or to clean members (Friedman et al., 1997). Further- general population, particularly in high old ones (Kail et al., 1995). Female drug- more, those members with the most material prevalence areas. A recent survey of home- injecting partners of male IDUs may be reso u r ces are at the top of the networ k ’ s less adults using a storefront medical clinic more likely to inject after the man and hi e r a r chy. When sharing drugs, they will found that more than two- t h i r ds were at therefore be exposed to greater risk. shoot first, which may make it more likely risk of HIV infection from various sources, that they will use a sterile syringe and including unprotected sex with multiple equipment. In contrast, the newest members partners, injection drug use, sex with an of the network or those with the fewest IDU partner, or exchanges of sex for money material and other reso u r ces command the Key contexts of or drugs (St. Lawrence and Brasfield, 1995). least respect and exist on the margins of high-risk behaviors: Some homeless also have mental illness the network. They often must engage in and violent and unstable living situations, • drug use settings the riskiest drug and equipment sharing and because of this they find it dif ficult to practices, such as collecting used cottons • social networks form the safe, intimate relationships that to extract any drug remaining in them could help them reduce their risk. Limited • membership in groups (B o u r gois, 1998; Bourgois, unpublished). availability of or access to mental health with high risk Social networks are a critically important services increases this problem. co n t e xt for understanding drug use and its • geography Men and women in prisons and jails also intersection with the transmission of HIV suffer disproportionately high rates of • income and social factors and other blood-borne pathogens because of drug abuse as well as of HIV infection. their role in maintaining an epidemicwithin Recent data from the National Center on the group and in providing a starting poi n t Addiction and Substance Abuse (CASA) for rapid transmission beyond the group Regardless of the origin of their risks, these show a direct or indirect connection between (Friedman et al., 1997). They are also a wome n often exist in a subordinate and substance abuse and the incarceration of cr i t i c a l ly important context when consider­ physically dependent relationship to the nearly 80 percent of those in federal, state, ing prevention efforts because these same men with whom they interact, and these and local prisons and jails (Belenko, 1998); dynamics also may be used to introduce and power imbalances make it dif ficult for 60-80 percent of inmates have serious reinforce norms that support risk reduction them to change their behaviors in ways substance abuse problems (Leshner, 1999). and to develop effect iv e channels of co m­ that might reduce risk (AED, 1997; Another recent report, published by the munication with members (Latkin, 1995). Bourgois, unpublished). National Institute of Justice, CDC, and

I D U S A N D T R A N S M I S S I O N O F H I V 7 Young injection drug users are another heroin. Mexican black tar heroin also has injection equipment (Bluthenthal et al., group who require increased attention recently reappeared in Atlanta (CEWG, 1999a; Bluthenthal et al., 1999b; Case et because the contexts in which they inject 1998). Black tar heroin is less pure than al., 1998). For these IDUs, any chan ge in frequently increase their risk of transmission. the white powder form (39 percent) and financial or social circumstances can have a Young IDUs may be runaways or peripheral has a consistency somewhere between tar significant impact on their risk profile. A members of drug-using social networks. and wax. Its difficult texture makes it hard case in point is the 1997 federal decision to If they lack money to buy drugs, they may to snort and users are therefore more likely cease Supplemental Security Income (SSI) be forced to trade sex for drugs or money. to inject it, which exposes them to the benefit payments to individuals whose drug potential transmission risks associated with or alcohol addiction is considered a con­ Men who have sex with men (MSM) and injection practices. The combination of the tributing factor to their disability. Data inject drugs also face increased risks of texture and the drug’s cost (in San Francisco, from a 1995 study of IDUs living in six transmission. For example, recent evidence it is commonly sold in $20 units about San Francisco area communities showed from CEWG shows that methamphetamine the size of pencil eraser) also increases the that benefits for SSI recipients contributed use, once largely restricted to the West, is chances that IDUs who are short of money to the overall stability of their lives and to now spreading into other parts of the will share the drug. This involves dissolving a lower risk of acquiring or transmitting country and gaining in popularity among the drug and dividing it into portions infection because they were less likely to be MSM. Methamphetamines can be admin­ equivalent to the money each person homeless, were less reliant on illegal income, istered in several ways but the injection contributed to the purchase of the drug. used drugs less often, and shared syringes route appears to be increasingly common. This procedure increases the risk of infection less often than did IDUs who did not This method of administration incre a s e s through shared needles and ancillary para­ receive benefits (Lorvick et al., 1997). A a user’s chances for engaging in high-risk phernalia (Bourgois, unpublished; Koester follow-up study showed that those who sexual and non-sexual behaviors, thus and Hoffer, 1994). lost SSI benefits as a result of the ruling increasing the risk of acquiring or trans­ were more likely to participate in ille gal mitting infection (NIDA, 2000). INCO ME AND activities, more likely to share syringes, SOCI AL F A C T O R S and injected drugs more often than did G E O G R A P H I C those who retained benefits (Bluthenthal DIFF ER E N C E S Many IDUs have jobs and health insurance et al., 1999b). (Eisenhandler and Drucker, 1993; SAMH­ Location often influences the types of SA, 1999). Others are less involved in the drugs available, and this in turn dictates the Conclusion ma i n s t re am economy and must reso rt to a method of administration (e.g., injected, Toda y, a major force behind the epi d e m i c variety of tactics to support their habits, smoked) and the level of risk experienced of HIV and other bloo d - b o r ne illnesses is including panhandling, scavenging, day labor, by users (Sullivan et al., 1998). For example, in f ections among IDUs, their sex partne r s , sex work, and petty theft. As noted already, the two major sources of heroin in the and their ch i l d ren. IDUs engage in a the relative social status of IDUs has a direct United States today are South America and number of drug-use and sexual practices in flu ence on the degree of risky behavio r Mexico. South American heroin is distributed that signific a n t l y increase their risk of co n ­ necessary for survival. Those who begin with primarily to cities on the East Coast and tracting HIV and hepatitis and of pa s s i n g higher social status and more secure income, is a high purity, white powder form of the them on to others. The next chapter of this housing, and support networks may be more drug. Because of this high purity (60-70 document fur ther describes the probl e m ab le to control their risks of tr a n s m i s s i o n . percent), an increasing number of users are facing programs and professionals as they Poorer IDUs, those with concomitant health resorting to snorting the drug rather than ad d r ess the complex prevention needs of or mental problems, and those with unstable injecting it (CEWG, 1998). In contrast, IDUs: the envi ronmen t of stigma and living and social circumstances may have the major forms of heroin available on the bi as — the “j u n k i ep h o b i a ” — in whic h difficulty obtaining sterile syringes or be West Coast, Texas, and some Midwestern ma n y IDUs live and the policy, legal, and more susceptible to legal penalties for syringe cities, such as Chicago and St. Louis, are service provision climate that has emerged possession, and thus may be more likely Mexican black tar and brown powdered from these attitudes. to pursue risky behaviors, such as sharing

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10 I D U S A N D T R A N S M I S S I O N O F H I V Latkin CA, Mandell W , Vl a h o v D, Oziemkowska M, Celentano Ouellet LJ, Rahimian A, Wiebel WW. The onset of drug injection DD. The long-term outcome of a personal network- among sex partners of injection drug users. AIDS Education oriented HIV prevention intervention for injection and Preven t i o n 19 9 8 ; 1 0 ( 4 ) : 3 4 1 - 3 5 0 . drug users: the SAFE study. American Jou rn al of Rietmeijer CA, Wolitski RJ, Fishbein M, Corby NH, Cohn DL. Community Psycho l o g y 19 9 6 b ; 2 4 ( 3 ) : 3 4 1 - 3 6 4 . Sex hustling, injection drug use, and non-gay identifica­ Latkin CA, Mandell W , Vlahov D. A personal network approach tion by men who have sex with men: associations with to AIDS prevention: an experimental peer group inter­ high-risk sexual behaviors and condom use. Sex u a l l y vention for street-injecting drug users: the SAFE study. Transmitted Diseases 19 9 8 ; 2 5 ( 7 ) : 3 5 3 - 3 6 0 . In: Needle RH, Coyle SL, Genser SG, Trotter RT, editors. Schilling R, Serrano Y, Faruque S, el-Bassel N, Wei-Huei Sun F, Na tional Institute on Drug Abuse rese a r ch monograph 151: social Edlin B, Irwin K, Ludwig D. Predictor variables of ne t wo rk s, drug abuse, and HIV tran s m i s s i o n . Rockville (MD): trading sex among male drug users in Harlem. National Institute on Drug Abuse; 1995. NIH In t e r national Conferen ce on AIDS. 1992 July 19- Pu b lication No. 95-3889. 24;8(2):C352 (abstract no. PoC 4659). Latkin CA, Mandell W , Vlahov D, Oziemkowska M, Knowlton A, Schutte RK, Garret GR. Responding to the homeless: policy and prac t i c e . Celentano D. My place, your place, and no place: behavior New York: Plenum; 1992. settings as a risk factor for HIV-related injection practices of drug users in Baltimore, Maryland. American Jour nal of St. Lawrence JS, Brasfield TL. HIV risk behavior among homeless Community Psychology 1994;22(3):415-430. adults. AIDS Education and Prevention 1995;7(1):22-31. Leshner A. Why shouldn’t society treat substance abusers? Substance Abuse and Mental Health Services Administration Los An ge les Ti m e s . June 11, 1999. (SAMHSA). Worker drug use and workplace policies and programs: results from the National Household Survey on Lorvick J, Bluthenthal R, Kral AH. The withdrawal of SSI disability Drug Ab u s e . September 8, 1999. benefits for drug and alcohol addiction. Ha rm Redu c t i o n www.samhsa.gov/PRESS/99/990908hl.htm Communication. New York (NY): New York Harm Reduction Educators, Inc. Fall 1997. Su l l i van PS, Nakashima AK, Purcell DW , Ward JW. Geogra p h i c www.harmreduction.org/news/ssi.html differences in noninjection and injection substance use among HIV-seropositive men who have sex with men: Mc C o y CB, Rivers JE, McCoy HV, Shapshak P, Weat h e r b y NL, west e r n United States versus other regions. Supplement Chitwood DD, Page JB, Inciardi JA, McBride DC. to HIV/AIDS Surveillance Study Group. Jou r nal of Compliance to bleach disinfection protocols among Ac q u i red Immune Deficiency Syndromes and Human Retr ovi ro l o g y injecting drug users in Miami. Journal of Ac q u i red Immune 19 9 8 ; 1 9 ( 3 ) : 2 6 6 - 2 7 3 . Deficiency Syndromes and Human Retrovirology 1994;7:773-776. Thomas DL, Vlahov D, Solomon L, Cohn S, Taylor E, Garfein R, National Institute on Drug Abuse (NIDA). AIDS and intravenous Nelson KE. Correlates of hepatitis C virus infections drug use: future directions for community-based pr evention among injection drug users. Medicine (Baltimore) research. Washington (DC): NIDA; 1990. 19 9 5 ; 7 4 ( 4 ) : 2 1 2 - 2 2 0 . National Institute on Drug Abuse (NIDA). Community drug alert Trotter RT, Bowen AM, Potter JM Jr. Network models for HIV bulletin: methamphetamine. Washington (DC): NIDA; 2000. outreach and prevention programs for drug users. In: www.nida.nih.gov/methalert/methalert.html Needle RH, Coyle SL, Genser SG, Trotter RT, editors. Needle RH, Coyle SL, Genser SC, Trotter RT, editors. National Na tional Institute on Drug Abuse rese a r ch monograph 151: social Institute on Drug Abuse research monograph 151: social networks, ne t wo rk s , drug abuse, and HIV tran s m i s s i o n . Rockville (MD): drug abuse, and HIV tran s m i s s i o n . Rockville (MD): National National Institute on Drug Abuse; 1995. NIH Institute on Drug Abuse; 1995. NIH Publication Pu b lication No. 95-3889. No . 95-3889. van Beek I, Dwyer R, Dore GJ, Luo K, Kaldor JM. Infection No r mand J, Vl a h o v D, Moses LE, editors. (National Rese a rc h with HIV and hepatitis C virus among injecting drug Council and Institute of Medicine). Pr eventing HIV tran s- users in a prevention setting: retro s p e c t i ve cohort study. mission: the role of sterile needles and bleach. Washington (DC): British Medical Jou rn a l 19 9 8 ; 3 1 7 ( 7 1 5 6 ) : 4 3 3 - 4 3 7 . National Academy Press; 1995.

I D U S A N D T R A N S M I S S I O N O F H I V 11 ID U CHAPTER TW O HI V P R E V E N T I O N The Legal, Social, and Policy Climate Limits Prevention Options for IDUs

The AIDS epidemic and the public health importance of other blood-borne illnesses, primarily hepatitis B and hepatitis C, have introduced a new dimension to the issue of injection drug use and increased the urgency of finding effec t ive and appro p r i ate interventions for IDUs. Numerous studies have examined issues related to the nature of addiction, the reasons why individuals begin and continue to use addictive drugs, and the factors that help them change their behaviors so as to stop using drugs. Despite this growing body of s c i e n t i fic knowledge, many myths, negative stereotypes, and biases persist about drug users and their lives, the health and safety risks they take, and their ability to overcome addiction. These stereotypes and beliefs profoundly influence the service, policy, and legal environment affecting IDUs and the scope and quality of health and social services provided to them (Friedman, 1998). They also constrain efforts to reduce the spread of blood-borne pathogens among IDUs and ach i eve the nat i o n’s ultimate goal, whi ch is to substantially reduce or even eliminate drug use. To design and deliver effective interventions for IDUs, prevention providers, program staff, and policy makers must better understand the lives and issues faced by IDUs, address the biases they and society have toward this pop­ ulation, and work to ameliorate the stigma caused by such biases. They must also explore ways to surmount the profound differences in philosophy and approach that exist among various types of providers and that all too often hinder collaboration and limit effective solutions.

Negative Attitudes and Stigma Many IDUs are marginalized, without full condition or a lack of access to adequate, Toward IDUs Persist Despite a participation in the economic, social, or comprehensive treatment (Des Jarlais et al., New Understanding of Addiction cultural life of their community. For those 1993; Leshner, 1997). They are regarded Negative attitudes and biases about addiction IDUs who are infected with HIV or other somehow as alien figures, as one of “them,” and drug users are pervasive and derive blood-borne illnesses or who have associated not one of “us.” Their addiction or result­ from experience and deeply felt moral and mental illness or other conditions, the ing infection with HIV or hepatitis is “their philosophical beliefs. These attitudes, stigmatization and marginalization are fault.” IDUs are incor rectly perceived to wi d e s p r ead among the general public and further increased (Des Jarlais et al., 1993). be unwilling to change their behaviors or unable to respond to education, outreach, many policy makers, are prevalent even In the eyes of many, IDUs, at best, ar e or treatment interventions (Jones and among service providers and health profes­ seen as victims of their addiction. At worst, Anderson, 1999). These negative and sionals (Cole and Slocumb, 1993; they are viewed as criminals or as weak and dehumanizing attitudes toward IDUs even McGrory et al., 1990; Wall a c k, 1991; bad people whose chaotic lives and inability extend to the providers and programs that Yedidia et al., 1993; Yedidia et al., 1996). to overcome addiction result from moral work with them. These professionals and IDUs are stigmatized, seen as less valuable failure rather than from a legitimate medical citizens than others in the population. organizations are also seen as having lower

T H E L E G A L , S O C I A L, A N D P O L I C Y C L I M AT E 13 social value than those working with including heroin, cocaine, marijuana, alcohol, physical and social consequences (Leshner, mainstream populations and are often and nicotine, also activate this reward system 1997; NIH, 1997). stigmatized for serving IDUs (AED, by causing an extra release of dopamine Another concept that is key to the current 1999; Friedman, 1998). into the pathway. Initially, an individual understanding of drug addiction is that it uses a drug because of the pleasurable “Junkiephobia” is a term that has been used is not an acute illness, but rather a chronic, effects on mood, perception, and psycho- to encapsulate this complex of stereotypes, relapsing condition that is treatable. Like logical state. Prolonged drug use, however, stigma, and negative attitudes toward IDUs other chronic illnesses, such as diabetes, causes fundamental and long-lasting (Jones and Anderson, 1999). Like “racism” asthma, or hypertension, appropriate treat­ changes in the brain. At some point, these and “homophobia,” “ j u n k i ep h o b i a ”c overs ment must be focused more on effective changes throw a metaphorical “switch” in a number of social and individual factors management over the long term rather the brain. Once the swit c h is thrown, the underlying these attitudes. For example, a individual moves from a state of voluntary lack of knowledge about addiction and drug use to a state of addiction in which ignorance of the lives and cultures of IDUs drug seeking and use are uncontroll a bl e is a factor leading to stereotyping and Overall, treatment for and compulsive. In the addicted state, the stigmatization. Fear of the addictive capacity pleasurable effects of the drug may be addiction is as successful of drugs and of addicts themselves is minimized or absent altogether. as treatment of other another factor. Reluctance to support policies that might appear to promote or The compulsion to use some drugs, like chronic conditions, condone drug use, such as syringe exchange, such as asthma, diabetes, is a third powerful factor. Lack ofspecific and hypertension. provider training and education also hamper Addiction is no longer those in service agencies from providing empathetic, responsive, and appropriate defined so much by services and education to IDUs. the element of physical than on a permanent cure (Leshner, 1997). Treatment compliance and relapse rates in These attitudes persist among the public, dependence, but is drug addiction are about the same as in policy makers, and service providers increasingly described as these other chronic medical conditions despite advances in the neurosciences and compulsive drug seeking (O’Brien and McLellan, 1996). the behavioral sciences that have transformed and use that come to the understanding of drug abuse and dominate a drug addict’s Negative Attitudes Toward addiction. It is now known that the roots life, even in the face of IDUs Affect Public Policy and of addiction lie in a series of complex Treatment Approaches terrible physical and biochemical changes that occur in the Public and provider attitudes and perce p­ brain over time, causing alterations in social consequences. tions about drug use and users color brain function. The result is a chro n i c attitudes toward appropriate responses and relapsing, but treatable, disease with to the problem of injection drug use. intertwined biological, behavioral, and heroin, is partly driven by the need to ward The substantial investment in prisons and social components. off the withdrawal syndrome, which occurs criminal justice institutions, the relatively Studies over the last 20 years have revealed when use is stopped or reduced. This syn­ limited public support for substance abuse that all drugs have the same effects on a drome is characterized by nausea and treatment, and laws and regulations limiting single pathway deep inside the brain, the vomiting, muscle cramps, sweating, agitation, sterile syringe sales and syringe exchange mesolimbic dopamine system (Childress and depression. Because these symptoms programs appear to reflect a national incli­ et al., 1999; Koob , 1996; Koob , 1992; can be managed with medications and nation to respond to drug users in a punitive NI D A/Hospital Practice, 1997; Volk ow because not all addictive drugs result in and dehumanizing fashion. For example, et al., 1993). When activated in response to this syndrome (cocaine, for example, does active drug users are disqualified from the natural rewards, such as food, water, sex, and not), addiction is no longer defined so much federal Supplemental Security Income nurturing, this pathway provides pleasurable by the element of physical dependence, program if their addiction is considered to feelings. These pleasurable feelings cause the but is increasingly described as compulsive be a contributing factor to their disability individual to repeat the behavior to reactivate drug seeking and use that come to dominate (Bluthenthal et al., 1999; Lorvick et al., the reward pathway. All addictive drugs, a drug addict’s life, even in the face of terrible 1999), and welfare recipients are tested for

14 T H E L E G A L , SO C I A L, A N D P O L I C Y C L I M AT E drug use and may lose their benefits if the This, combined with the criminal activities local regulations and funding mecha nisms test is positive (though in some areas they that many IDUs pursue to maintain their that limit provi d e r s ’ ability to providethe may retain food and rent vouchers) addictions, means that they are frequently continuum of services necessary to meet the (Friedman, 1998). Pregnant drug-using ar res t e d and imprisoned. This tends to complex substance abuse treatment, medical, women still face barriers in obtaining treat­ reinforce the public’s perception of them as and social service needs of injection drug ment and, should they be incarcerated, in “bad” people and of drug use as a crime users (AED, 1999; NIH, 1997). obtaining prenatal care and retaining custody rather than a medical and behavioral problem. Community resistance to substance abuse of their child after delivery (Breitbart et ◆ Funding priorities. The federal govern­ treatment facilities and programs— the al., 1994; GAO, 1999). ment currently spends nearly twice as much “not-in-my-backyard” (NIMBY) factor — The impact of these public and personal on programs to stop drugs from entering also plays an important role in limiting the attitudes on current laws, regulations, and the U.S. as on programs to reduce the availability of tre atment and other servi c e s policies can be seen in several ways: demand for drugs. In 1998, two-thirds of for IDUs. Common objections to these the $16.18 billion federal drug control facilities are that they contribute to an ◆ Emphasis on criminal penalties rather budget was allocated for “supply reduction” increase in crime in the area, attract unde­ than treatment. With several notable activities, such as border control efforts, and sirable groups of people, and import the exceptions (alcohol and tobacco use by one-third for “demand redu c t i o n ”a c t iv i t i e s , drug culture. As a result, treatment facilities adults), the use of addictive drugs is illegal such as prevention and treatment programs are often located in industrial or run-down (ONDCP, 1999 in Amaro, 1999). The parts of town to avoid the presence of drug control budget for fiscal year 2000 is residential neighbors and diminish the expected to increase by over $1.6 billion, possibility of community resi s t a n c e . Legal and public but the proportion dedicated to demand Treatment program counselors also may policy results reduction will be only slightly augmented routinely patrol the area around their facility (A m a r o, 1999). to ensure that clients do not loiter and of attitudes cause problems with neighbors. and stigma: ◆ Limited substance abuse treatment services. It is clear that the people who During 1999, a number of prominent voices • emphasis on need substance abuse treatment far out- spoke out on these issues and in favor of criminal punishment number the people who are able to receive major increases in the funding and attention over treatment it. For example, data from the Substance de voted to substance abuse trea t m e n t : Abuse and Mental Health Services • General Barry McCaffrey, Director of the • differences in Administration’s (SAMHSA) National Office of National Drug Control Policy funding priorities Household Survey on Drug Abuse (ONDCP), proposed a new strate gy of (NHSDA) show that in 1996, more than • limited drug integrating drug testing and substance 5.3 million people with severe substance abuse treatment into almost every phase treatment services abuse problems needed treatment services. of the criminal justice process, from However, only 37 percent received such • restrictive syringe arrest to the return to community after treatment (Epstein and Gfroerer, 1998). prescription and prison. Gen. McCaffrey outlined this Of the estimated 600,000 opiate-dependent strategy at a “National Assembly on paraphernalia laws individuals in the U.S., only about Drugs, Alcohol Abuse and the Criminal and regulations 115,000 (19.2 percent) are in methadone Offender,” which was sponsored by the maintenance treatment (NIH, 1997). Par t • a fragmented and ON D C P , the Depa r tment of Justice, and of this results from a lack of funding. the Department of Health and Human polarized atmosphere Other contributing issues include a shortage Services to bring together 900 law enforce­ of physicians and other health care profes­ ment, prison, and public health specialists sionals who are trained and able to provide from around the country to discuss ways treatment; complex federal regulations that to break the seemingly unbreakable link and users are subject to arrest and incar­ limit the flexibility and responsiveness of between substance abuse and crime. The ceration. Punitive laws for drug possession treatment programs; limitations in health assembly advocated better collaboration and dealing channel users and IDUs into insurance coverage for treatment; and an between substance abuse, public health, and prison rather than substance abuse treatment. existing patchwork of federal, state, and

T H E L E G A L , S O C I A L, A N D P O L I C Y C L I M AT E 15 criminal justice, much greater relianceon injection drugs. They fall into several hypodermic equipment only for medical substance abuse treatment to address the major categor i e s : purposes (AED, 1997). cause of most involvement with criminal • Drug paraphernalia laws in many states • Ph a r macy reg u l a tions or practice guidelines in 23 justice, and better programs to ease inmates’ make it illegal to distribute or possess jurisdictions restrain pharmacists from return to their home communities after any equipment intended for injecting, selling sterile syringes or impose addi­ prison (Wren, 1999). smoking, or otherwise consuming ille gal tional requirements on customers for • Dr. Alan Leshner, Director of the National substances (AED, 1997; Case et al., their purchases. In addition, some drug Institute on Drug Abuse (NIDA), made 1998; Gostin, 1998; Koester, 1994). stores have corporate or individual policies the case that as a society we should no Currently, 44 states have such laws. that limit over-the-counter sales of longer focus on unanswerable questions syringes (Jones and Taussig, 1999). • Prescription laws require that a person about the morality of treating versus wishing to buy syringes have a valid medical Other related laws and restrictions include punishing those addicted to drugs, but prescription for syringes. In addition, some the Mail Order Drug Paraphernalia Act, instead should focus on the practical states require that syringe purchasers show which permits federal enforcement against benefits to individuals and society as a individuals who knowingly sell or distribute whole of treating drug addiction. “If we syringes to IDUs, and a Congressional are ever going to significantly reduce the prohibition against federal funding for tremendous price that drug addiction Differences syringe exchange programs (SEPs) exacts from every aspect of our society, among providers (Gostin, 1998). drug treatment for all who need it must be of services a core element of our society’s strategies” to IDUs are ◆ A fragmented and polarized atmosphere. (Leshner, 1999). Cu r rent public policies and rest r i c t i ve laws caused by: and regulations are an important fact o r • Dr. Hortensia Amaro of Boston University constraining efforts to develop compre­ School of Medicine argued that limited • lack of knowledge hensive and effective interventions for IDUs. funding for substance abuse treatment is about issues beyond Another critical factor is the profound an expe n s i ve long-term policy. She noted one’s expertise differences in training, experience, attitude, that the federal governm e n t ’ s policy of and approach among the various profes­ spending nearly twice as much on reducing • specific training sionals who provide services to IDUs (for the supply of drugs as on reducing the and educational example, those working in infectious disease demand for them through prevention and perspectives pr evention, substance abuse trea t m e n t , treatment programs is “ p e rp l ex i n g ”g iven • attitudes toward users mental health, criminal justice, and primary that treatment has been shown to be more care). These philosophical and practical effective than law enforcement and incar - • personal experience gulfs foster an atmosphere of po l a r i z a t i o n , ceration in reducing the demand for illegal with addiction and work against a coordinated, collaborative drugs. “Providing treatment to all in recovery ap p ro a c h, and hinder system-wide efforts need could save more than $150 billion to reach IDUs. The gulfs emerge from lack over the next 15 years, at a price tag of just • experience working of knowledge about issues outside of one’s $21 billion in treatment costs. Funding with IDUs own expertise, specific training and education treatment for persons addicted to drugs pe r s p e c t i ves, attitudes held toward users, is prudent fiscal policy: every dollar personal experience with addiction and invested in drug treatment generates $7 in recovery, and experience working with IDUs. savings of future costs” (Amaro, 1999; identification and provide their name, California Department of Alcohol and address, and other identifying information One example of these differences is the Drug Programs, 1994; Rydell and (AED, 1997). Until recently, eight states debate over the relative merits of various Everingham, 1994). had prescription statutes (Gostin, 1998). substance abuse treatment approaches. In 2000, New York, Rhode Island, and Recovery from addiction is a day-by-da y, ◆ Restrictive syringe prescription and New Hampshire partially or completely minute-by-minute, sometimes precarious paraphernalia laws and regulations. In the removed their prescription laws. In the balancing act in which the user makes in t e r est of limiting drug use, a number of states in which these laws are in effect, repeated, sequential decisions not to use. laws restrict the purchase and possession of p hysicians are allowed to pre s c r i b e Relapse can be common. Traditional equipment used to prepare and administer

16 T H E L E G A L , SO C I A L, A N D P O L I C Y C L I M AT E substance abuse treatment models have sequent benefits of reduced transmission emphasizing bleach disinfection for IDUs focused exclusively on abstinence as the of HIV and other blood-borne infections who do not have sterile syringes; and pro­ only acceptable short- and long-term out- and reduced criminal activity (NIH, 1997). viding alcohol swabs to clean injection sites come. A person or program that appears The effectiveness of this approach is to help prevent abscesses and other infections. to tolerate any use of drugs is seen as dependent on a number of issues, including A recent analysis of the laws in the 50 enabling the user to continue his or her adequate dosage, the length and continuity states, the District of Columbia, and addiction. Treatment approaches that oftreatment, and the presence of associated Puerto Rico found that physicians in focus on abstinence from alcohol and psychosocial support services. Though nearly all of these jurisdictions may legally drug use include detoxification programs, considerable research supports the effec­ prescribe sterile syringe equipment to prevent inpatient and outpatient programs, and tiveness of methadone maintenance treatment peer-based residential treatment settings and it is a legally sanctioned treatment in (called therapeutic communities). These most states, its use is very highly regulated by Risk reduction approaches are usually complemented by federal and state agencies, it is still contro­ self-help or “12-Step” programs, such versial, and less than 20 percent of op i a t e - approaches: as Alcoholics Anonymous, Narcotics de pendent indivi d u a l s have access to it • substance abuse Anonymous, or Cocaine Anonymous (NIH, 1997). treatment (AED, 1997). All have the ultimate goal Another perspective on working with IDUs, of helping an individual achieve and main­ • referrals to HIV- called risk reduction or harm redu c t i o n , tain a drug-free recovery (to become sees the fundamental problem as the adverse antibody testing, “clean and sober”). consequences of continued drug use (Des medical care, and Jarlais et al., 1993). This approach is based social services on a recognition that many IDUs and other • providing education drug users are initially unwilling or unable to stop drug use and that many things can about ways to manage Traditional be done to help protect them, their families, drug use and gain substance abuse and society from the harmful consequences control over daily treatment of the drug use until they are able to stop life issues using. Because HIV, hepatitis B, and hepatitis approaches: C infections are transmitted through shared • reduction in risky • detoxification injection equipment, it is possible for active injection practices users to reduce the risk of or prevent • inpatient/outpatient infection (Des Jarlais et al., 1993). Primary • access to sterile programs HIV-related risk redu c t i o n approaches syringes • methadone maintenance include a range of interventions, such as • working with injectors substance abuse treatment to reduce or who choose to attempt • peer-based residential stop drug use; referrals to HIV-antibody treatment settings testing and medical care services; referrals abstinence to social su p p o r t services; education about • self-help programs • focusing on “treatment ways for IDUs to increase control over readiness” when , how often, wher e, and with whom they inject; and ef forts to encourage active users to switch to non-injection forms of disease transmission and that pharmacists drug use. For those IDUs who are unable or in most states have a clear or reasonable Another approa c h, methadone maintenance unwilling to stop injecting, risk reduction legal basis for filling the prescription. While treatment, has been used for more than interventions also focus specifically on physician prescription will likely not result 30 years to treat tens of thousands of injection practices — providing access to in widespread access to sterile syringes, it individuals addicted to opiates. Consistent sterile syringes through exchange programs may have an important beneficial impact participation in methadone maintenance or over-the-counter sales from pharmacies; among individual IDUs who cannot or programs over time diminishes and often emphasizing the need to never share syringes, will not stop injecting (Burris et al., 2000). eliminates use of other opiates, with con- water, or drug preparation equipment;

T H E L E G A L , S O C I A L, A N D P O L I C Y C L I M AT E 17 All of these approaches have strong funding for syringe exchange pro gr a m s example, IDUs are advised to enter substance advocates as well as fierce opponents. highlights the polemics involved in the abuse treatment and, if they continue to De f enders of ab s t i n e n c e - o n l y interven t i o n s debate over approaches to working with inject, to use only sterile syringes. argue that tolerating any drug use is unac­ IDUs and illustrates some of the attitudinal However, insufficient substance abuse ceptable because it allows users to continue and philosophical perspectives described treatment capacity and syringe laws that their self-destructive behavior and prevents earlier in this chapter (U.S. House of make it illegal to obtain or possess sterile them from achieving a “drug-free” status. Representatives, 1998): injection equipment often make it dif ficult Specifically, they express concerns that or impossible to car ry out this public “Mr. Goodlatte. Not only are needle exchange pro- promoting syringe exchange programs and health advice. grams inconsistent with federal law, the results of safer injection practices ser ve to encourage community-based needle exchange program have been This climate presents a multi-layered continued drug use, that methadone main­ disastrous. Needle exchange programs have resulted challenge for program staff, policy makers, tenance programs merely substitute one in communities with higher crime, communities and others in the public health community. addicting drug for another, and that support that are littered with used drug paraphernalia, and Many types of services and inter ventions for risk reduction approaches is an opening communities that are magnets for drug addicts and currently exist to serve the complex drug- wedge for the eventual legalization of drugs. the high-risk behavior that accompany them….I urge related, medical, and social circumstances Many advocates of abstinence-based sub- my colleagues to support this legislation, oppose the of IDUs and their families. More of these stance abuse treatment are former drug use of needle exchange programs, and make sure services and interventions are clearly needed, users for whom this approach was essential that we continue the fight on drugs in a sensible but if they are to be successful, publichealth to recovery. Their experience is the foun­ way by cracking down on drug traffickers and program staff, service providers, and policy dation of their conviction that abstinence educating people in the country about the dangers leaders need to design them with this exist­ is the only valid strategy for helping IDUs of using illegal drugs. ing social, legal, and policy climate in mind. to stop using drugs. This is because the social attitudes and Ms. Woolsey. Maintaining the ban [on federal structural factors described here often sub­ Defenders of methadone maintenance funding for needle exchange programs] will not help st a n t i a l l y limit prog ram activities and con- treatment cite its effectiveness in reducing sa ve our chi l d r en or anyone else. In fact, the ban on tribute to a fragmented service delivery dependence on illegal drugs and in helping needle exchan g e actually threa tens lives….In 1995, system that does not ensure the availability users become productive members of society. needle exchan g e prog r ams were found to reduce the of a full range of high-quality services that spread of AIDS and not to lead to increased drug use. Defenders of risk reduction cite as com­ IDUs can easily obtain. Services and pro- pelling reasons for pursuing their approach This bill would ignore the science by denying public grams need to be or ganized and delivered the limited number of substance abuse health experts a tool in the fight against AIDS, a in such a way that prevention messages and treatment slots available, the fact that many tool that has been proven to slow the spread of this public health strategies can be reinforced users are unable or unwilling to permanently deadly disease. And those of my colleagues who are across IDUs’ various circumstances, patterns and completely stop their drug use, the worried that free needles increase drug usage have of drug use, stages of change of risk importance of injection drug use in the to stop and think. We have to be reassured that behaviors, and across the many community HIV and hepatitis epidemics, and the knowing that the positive step by a drug user to and institutional settings where they ar e im p o r tance of injection drug use in other choose clean needles is actually a first step in a very found. At the same time, individual services health problems such as abscesses and positive way towards their recovery. Just think about need to be supported by a philosophical en d o c a r ditis. Another strength, they say, is it. This is an opportunity to begin the healing process.” framework that moves beyond the stigma risk redu c t i o n ’s underlying principle of surrounding IDUs, reduces the cur rent beginning any efforts with users at the Conclusion polarization among different approaches to place wher e they are, whi c h then allows As seen in this chapter, the social, legal, working with IDUs, and ensures that col­ providers to help them move to a new and and public policy climate surrounding drug laboration is integral to the provision of better place wher e risk is redu c e d . use creates structural and environmental services. The next chapter provides further barriers that limit the ability of IDUs to detail on this vision of a comprehe n s i ve A 1998 U. S. House of Repre s e n t a t i ves stop their drug use and reduce their risks of approach to preventing HIV and other de bate on legislation to prohibit fede r a l acquiring or transmitting infection. For blood-borne pathogens among IDUs.

18 T H E L E G A L , S O C I A L, A N D P O L I C Y C L I M AT E References Academy for Educational Development. Comprehensive HIV preven t i o n Des Jarlais DC, Friedman SR, Ward TP. Harm reduction: services for injection drug users: an assessment of state and local a public health response to the AIDS epidemic technical assistance issues and priorities. Washington (DC): among injecting drug users. Annual Reviews of Public AED; August 1999. Prepared for the Centers for Health 1993;14:413-450. Disease Control and Prevention. Epstein J, Gfroerer J. Changes affecting NHSDA estimates of Academy for Educational Development. HIV prevention among treatment need for 1994-1996. Rockville (MD): Office drug users: a resource book for community planners and program of Applied Studies, Substance Abuse and Mental managers. Washington (DC): Academy for Educational Health Services Administration, Janu a ry 1998. Development; 1997. Funding provided under Centers www.samhsa.gov/oas/nhsda/chngs96/index.htm for Disease Control and Prevention contract number Friedman SR. The political economy of drug-user scape­ 200-91-0906. goating — and the philosophy and politics of resistance. Amaro H. An expensive policy: the impact of inadequate Drugs: Education, Prevention, and Policy 1998;5(1):15-32. funding for substance abuse treatment. [editorial] Gostin LO. The legal environment impeding access to sterile American Jour nal of Pu b lic Health 19 9 9 ; 8 9 : 6 5 7 - 6 5 9 . syringes and needles: the conflict between law Bluthenthal RN, Lorvick J, Kral AH, Erringer EA, Kahn JG. enforcement and public health. Journal of Acquired Collateral damage in the war on drugs: HIV risk Immune Deficiency Syndromes and Human Retrovirology. behaviors among injection drug users. The International 1998;18(Suppl 1):S60-S70. Journal of Drug Policy 1999;10:25-38. Jones TS, Anderson T. “Junkiephobia”: a new concept to capture Breitbart V, Chavkin W , Wise P. The accessibility of drug treatment the stigma and ostracism of drug users and limitations for pregnant women: a survey of programs in five cities. on HIV prevention for drug users. Poster presented at American Journal of Public Health 1994;84(10):1658-1661. National HIV Prevention Conference, Atlanta (GA), August 29–September 1, 1999. Burris S, Lurie P, Abrahamson D, Rich JD. Physician prescribing of sterile injection equipment to prevent HIV infection: time Jones TS, Taussig J. Should pharmacists sell sterile syringes to for action. Annals of Internal Medicine 200;133:218-226. injection drug users? Journa l of the American Pharma c e u t i c a l As s o c i at i o n 19 9 9 ; 3 9 ( 1 ) : 8 - 1 0 . California Department of Alcohol and Drug Programs. Evaluating recovery services: The California Drug and Alcohol Koester SK. Copping, running, and paraphernalia laws: contextual Treatment Assessment. Sacramento (CA): California and needle risk behavior among injection drug users in Department of Alcohol and Drug Programs; 1994. De n ver . Human Organi z at i o n 19 9 4 ; 5 3 : 2 8 7 - 2 9 5 . Case P, Meehan T, Jones TS. Arrests and incarceration of injection Koob GF. Drugs of ab use: anatomy, pharma c o l o g y, and function dru g users for syringe possession in Massachus e t t s : of reward pathways. Trends in Pharmacological Sciences. implications for HIV prevention. Journ al of Ac q u i re d 19 9 2 ; 1 3 : 1 7 7 - 1 8 4 . Immune Deficiency Syndromes and Human Retr ovi ro l o g y Koob GF. Drug addiction: the yin and yang of hedonic homeo­ 1998;18(Suppl 1):S71-S75. statis. Neuron. 1996;16(5):893-896. Childress AR, Mozley PD, McElgin W, Fitzgerald J, Reivich M, Leshner A. Why shouldn’t society treat substance abusers? O’Brien CP. Limbic activation during cue-induced cocaine Los An g eles Ti m e s . June 11, 1999. craving. American Journal of Psychiatry 1999;156(1):11-18. Leshner AI. Addiction is a brain disease and it matters. Sc i e n c e Cole FL, Slocumb EM. Nurses’ attitudes toward patients with 19 9 7 ; 2 7 8 : 4 5 - 4 7 . AI D S. Jour nal of Ad vanced Nursi n g 19 9 3 ; 1 8 : 1 1 1 2 - 1 1 1 7 .

T H E L E G A L , SO C I A L, A N D P O L I C Y C L I M AT E 19 Lorvick J, Bluthenthal R, Kral AH. The withdrawal of SSI dis­ U.S. House of Representatives. Prohibiting the expenditure of ability benefits for drug and alcohol addiction. Ha r m federal funds for distribution of needles or syringes for Reduction Communicatio n . New York (NY): New York hypodermic injection of illegal drugs. Congressional Harm Reduction Educators, Inc; Fall 1997. Record–House. April 29, 1998, H2445-H2478. www.harmreduction.org/news/ssi.html Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, McGrory BJ, McDowell DM, Muskin PR. Medical students’ Schulyer D, Dewey S, Wolf AP. Decreased dopamine attitudes towar d AIDS, homosexual, and intraven o u s D2 recep tor availability is associated with redu c e d dru g - a b using patients: a re-evaluation in New York City. frontal metabolism in cocaine abusers. Sy n a p s e Ps y chosomatics 19 9 0 ; 3 1 ( 4 ) : 4 2 6 - 4 3 3 . 19 9 3 ; 1 4 : 1 6 9 - 1 7 7 . National Institute on Drug Abuse (NIDA) and Hospital Practice. Wallack JJ. AIDS and the health care professional: evolving atti­ New understanding of drug addiction. Proceedings from a tudes and strategies to effect change. Psychiatric Medicine symposium cosponsored by the National Institute on 1991;9(3):483-501. Drug Abuse (NIDA) and Hospital Practice. Minneapolis Wren C. Top U.S. drug official proposes shift in criminal justice (MN): McGraw Hill Healthcare Information Progr a m s ; po l i cy . The New York Ti m e s . December 9, 1999. April 1997. Yedidia MJ, Barr, JK, Berry CA. Phys i c i a n s ’ attitudes toward National Institutes of Health (NIH). Eff ec t i ve medical trea tment of AIDS at different career stages: a comparison of op i a te addiction. NIH Consensus Statement. 1997, in t e r nists and surgeons. Journ al of Health and Social Behavio r No vember 17-19;15(6):1-38. 19 9 3 ; 3 4 : 2 7 2 - 2 8 4 . O’Brien CP, McLellan AT. Myths about the treatment of addiction. Yedidia MJ, Berry CA, Barr, JK. Physicians’ attitudes toward AIDS La n c e t 19 9 6 ; 3 4 7 : 2 3 7 - 2 4 0 . during residency training: a longitudinal study of medical Rydell CP, Everingham SMS. Controlling cocaine: supply versus sc hool graduates. Journal of Health and Social Behavi o r demand programs. Santa Monica (CA): RAND 19 9 6 ; 3 7 : 1 7 9 - 1 9 1 . Co rpora tion; 1994. U.S. General Accounting Office (GAO). Women in prison: issues and challenges co n f ro nting U.S. correctional systems. Wash i n g t o n (DC): GAO; 1999. GAO Report No.: GGD-00-22. www.gao.gov

20 T H E L E G A L , S O C I A L, A N D P O L I C Y C L I M AT E IDU CHAPTER THREE HIV P R E V E N T I O N A Comprehensive Approach is a More Effective Approach

P revention planners, pro g ram staff, policy makers, community-based organizations, and others who work with IDUs must deal with several significant and interrelated problems: • the high risk of infection with HIV and other blood-borne pathogens, particularly hepatitis B and C; • a ran ge of s ex and drug use behav i o rs that maintain the epidemics and facilitate their transmission to n o n - i n fected IDUs as well as to the larger population of s ex part n e rs, ch i l d ren, and other adults who do not inject drugs; • attitudes of bias and stigma that margi n a l i ze and dehumanize IDUs and that limit options for prevention through their negative influence on laws, regulations, social policies, and access to services; and • profound and deeply held differences of philosophy and orientation among providers and organizations, whi ch cause polarization and fra g m e n t ation, hinder cooperative wo rking re l at i o n s h i p s, and ultimat e l y, limit the effectiveness of services and interventions for IDUs. These pro blems are hard to solve. Their complex i t y, interc o n n e c t e d n e s s, and deep - rooted nat u re re q u i re a comprehensive and multifaceted approach. This chapter proposes and describes such a comprehensive approach.

Though many services and interven t i o n s Figure 1 action that will allow communities, agen­ can be used to help IDUs, this approach EN S U R E COORD I N AT I ON & COLLA B ORAT I O N cies, and providers to come together and focuses on eight specific strategies and four substance community criminal act more effec t i vel y. un d e r lying principles. Figure 1 il l u s t r a t e s abuse outreach justice treatment system The remainder of this chapter defines and the compreh e n s i ve approa c h and shows interventions describes the four supporting principles how its components are linked. The eight and the eight key strategies for preventing st r a t e gies, clus t e red around the concept of access to sterile IDU C&T, blood-borne diseases among IDUs. HIV prevention for IDUs, are supported syringes PCRS, PCM Accompanying these descriptions are and framed by the cross-cutting principles of HIV P R E V E N T I O N vignettes about selected programs around collaboration, tailoring, overcoming stigma, strategies services primary the country that are working with IDUs. and ensuring coverage, access, and quality. to prevent for IDUs drug sexual living with prevention Although many of these programs provide A range of strategies are included because transmission HIV/AIDS similar types of services and all employ a single type of service or program (sub- multiple components of the comprehe n s i ve E N S U R E C O V E R AG E , A C C E S S, & Q U A L I T Y stance abuse treatment, HIV prevention approach, the vignettes are intended to high- education, access to sterile syringes) is not light one or another strategy or principle enough. Multiple services and programs community organizations who plan, deliver, and show the way in which each program’s delivered in multiple settings are needed. and monitor them must consciously focus unique approach, content, or philosophy The supporting principles are included not only on “what” to pursue but also on brings that particular principle or strategy because if the strategies are to succeed, “why” and “how” they will be pursued. to life. Many other exemplary programs the providers, health departments, and Each principle contains the seeds of positive throughout the country are inc o rp o r a t i n g

A CO M P R E H E N S I V E A P P RO A C H 21 C R O S S - T R A I N I N G Cross-Training for HIV/AIDS, Infectious Diseases, and Substance Abuse Providers: A Novel Idea Becomes a Nationwide Trend

In 1996, the Georgia Department of Health received funding from worked with clients, created collaborations, and led to requests for the Center for Substance Abuse Treatment (CSAT) of the federal further trainings. Since then, several other series of cross-training Substance Abuse and Mental Health Services Administration workshops in Georgia have helped participants develop new (SAMHSA) to develop and deliver a series of workshops to bring approaches to dealing with issues such as substance abuse treatment together staff from the state’s public health and substance abuse planning, harm reduction, and confidentiality. treatment agencies. CDC also participated by providing technical In 1998, CSAT, CDC, and the Health Resources and Services assistance and oversight. The genesis of this project was the fact Administration (HRSA) developed an interagency agreement to that the shift of the epidemic toward IDUs and disadvantaged and expand the cross-training concept. This initiative, called “HIV/AIDS, minority populations meant, increasingly, that providers were TB and Infectious Diseases: The Alcohol and Other Drug Abuse working with clients who had multiple problems. Having providers Connection,” provides training and technical assistance to state focus only on a client’s substance abuse problem, or STD, or high- infectious disease and substance abuse health care delivery systems risk sexual behaviors was clearly not adequate. But significant barriers so that they can more effectively serve individuals who have or are at prevented these professionals from providing more comprehensive high risk of having concurrent conditions. During FY99 alone, 13 services. Staff from public health or substance abuse treatment cross-training workshops were held in 6 states. In addition, trainers didn’t know what questions to ask to assess a client’s problems in the have responded to 40 requests for cross-training information and other arena, or felt it wasn’t appropriate to ask those questions. technical assistance from states and federal agencies. Federal confidentiality protections precluded substance abuse treatment and public health staff from discussing a client who Many components and principles of the early cross-training experi­ was being seen at both types of facilities. Longstanding patterns ences have been applied in the current initiative: of limited communication between the different agencies created • Reflect the diversity of the epidemic. Because success in one an additional barrier. area is dependent on addressing others, the workshop now covers Clearly, something was needed to help break down these barriers prevention, treatment, and care issues for the various substance and foster collaboration. Staff needed an opportunity to learn about abuse and infectious disease topics (HIV, STDs, TB, hepatitis). each other’s subject areas, client assessment procedures, and treat­ Workshop planners and participants include representatives from ment options. More than that, they also needed an opportunity to mental health and criminal justice as well as from infectious diseases make personal connections across agency disciplines, cultures, and and substance abuse. Planners report that this greater diversity bureaucracies — connections that would allow them to develop in the cross-training helps participants more easily appreciate and mutual respect and a common vocabulary, foster a willingness to understand other points of view and approaches than does a hear each other’s point of view, and understand the realities of workshop with more restricted representation or content. each agency’s funding and policy requirements. The desired out- • Tailor to the local community. Before a workshop is held, come? Collaborative working relationships, strong channels of regular planners research the disease issues in the community to ensure communication, and ultimately, system-wide positive change. that topics and skills building exercises reflect and are tailored to Over a 7-month period in 1997, 24 2-day workshops were held the needs, cultures, and languages of the community. Participant across the state. About 1,100 nurses, counselors, social workers, lists reflect the particular needs and existing service delivery sys­ clinicians, and epidemiologists participated. The first part of each tems of the community. Planners also select workshop trainers workshop focused on one of the biggest difficulties — lack of knowl­ with this principle in mind. edge. The trainers provided the public health participants with a • Build local commitment and capacity. Although a request “Substance Abuse 101”; the substance abuse treatment participants for a cross-training workshop may come from one agency or received the same for STDs. The entire group received an update on organization, all the potential partners must agree to support and the HIV/AIDS and TB epidemics. The remainder of the workshop participate in the training. They are also part of the planning group, emphasized skills-building so that participants could conduct more select the participants, and identify local co-trainers. All of these comprehensive prescreening, risk assessment, and counseling with activities help to build local capacity for further training and clients. Throughout the workshop, participants were encouraged to encourage widespread institutional commitment to improving talk with each other, share experiences, and learn about the day- prevention, treatment, and care systems. to-day realities and challenges faced by others. • Follow up. An essential element of the initiative is long-term An essential element in the success of the workshops was including follow up to track changes that result from workshops (Are all the involved parties in planning and implementation. Before the trainings being replicated? How many QSOAs have been signed? workshops, high-level administrators and front-line staff from the Have other types of collaborative activities developed?) and to public health and substance abuse treatment agencies met to discuss provide necessary technical assistance to states. existing barriers to collaboration, needed tools and skills, and goals and objectives for the workshops. They also discussed Qualified For more information: HIV/AIDS, TB and Infectious Diseases Cross- Service Organization Agreements (QSOA), which would allow Training: The Alcohol and Other Drug Abuse Connection. substance abuse treatment and public health provider agencies to www.treatment.org/Topics/infectious.html share limited information about clients within the legal constraints of federal confidentiality protections. The response to the workshops was immediate, powerful, and posi­ tive. They changed attitudes, altered the way that many participants

22 A C O M P R E H E N S I V E A P P RO A C H these same approaches and philosophies and orientation espoused by various organi­ those needing substance abuse trea t m e n t in their work with IDUs. Readers also are zations, philosophies, and providers, and ac t u a l l y rece i ve those services (Epstein and encouraged to read Appendix A, which pro­ the resulting reluctance of agencies and Gf r oerer, 1998). Similarly, pharmacies and vides expanded discussions of the eight key providers to work together for IDUs con- sy r i n g e excha n ge prog rams help a growin g st r a t e gies, including findings from rese a r ch tributes to the fragmented service delivery number of IDUs who continue to inject to and programs and descriptions of issues system and leads to policies, laws, and and barriers facing providers and agencies regulations that can be inconsistent, contra­ as they seek to accomplish their goals. dictory, and sometimes at cross-purposes. Providers, agencies, and policy makers must Guiding Principles collaborate, sharing their various skills, per­ A comprehensive E N SUR E COORDI N A T I O N spectives, and experiences, building on prior approach rests on AND COLLABORAT I O N relationships, and reaching out to groups 4 basic principles with whom they may not have worked Current medical care, social service, and before. Partners in this effort need not • ensure coverage, access, HIV and drug use prevention and treatment agree on everything, but they do need to find and quality systems are complex and governed by a ways to cooperate so as to achieve the larger • ensure coordination patchwork of federal, state, and local goals of reducing HIV and viral hepatitis and collaboration funding arrangements and regulatory envi­ infection in injection drug users and reducing ronments (AED, 1999). Service providers substance abuse. • overcome stigma report frustrations with the barriers these • tailor services and multiple systems create and the ways in E N S U R E C O V E R AG E , which they limit providers’ ability to provide a A C C E S S , A N D Q U A L I T Y programs continuum of services to meet the complex needs of injection drug users (AED, 1999). Pro g rams and intervent ions will not be If interventions with IDUs are to succeed, effective if they do not reach a critical ma s s agencies and providers must find ways to of people who need them, if IDUs cannot or will not use them, or if they are of poor work within these systems to coordinate obtain sterile syringes. However, these pro- quality. The first of these elements, coverage, their efforts. grams often fall short of reaching all those co n c e r ns whether services or interven t i o n s who desire to reduce their transmission This principle also embodies another ar e reac hing a sufficient number of IDUs risks by obtaining and using sterile syringes idea — collaboration. The profound and to make a real difference. For example, it is (Lurie et al., 1998; Remis et al., 1998). often conflicting differences in approach estimated that only a small percentage of

S P H E R E One-stop Shopping to Help Programs Work Better

The Statewide Partnership for HIV Education in Recovery risk of or infected with HIV and other blood-borne pathogens. By Environments (SPHERE) develops and delivers training to substance holding cross-trainings and educational workshops and conducting abuse treatment providers, AIDS service organizations, and com­ outreach to HIV/AIDS, substance abuse, syringe exchange, mental munity-based health centers in HIV/AIDS prevention and substance health, primary care, and other providers, SPHERE hopes to create abuse issues and related topics such as capacity building, policy a synergy among providers so that they can learn with and from each development, organizational development, and coordination and other, share best practices, and overcome philosophical barriers. collaboration. Increasingly, programs are calling SPHERE for help In addition to its trainings and efforts to foster collaboration, SPHERE in developing long-term training and development plans and this has developed a number of tools and forms that have been adopted contributes to system-wide positive change. by many organizations and service providers in the state. Among Funded by the Massachusetts Department of Health’s AIDS bureau these are new standardized intake and record release forms and a and its substance abuse treatment bureau, SPHERE’s primary goal is comprehensive HIV risk assessment tool and a program satisfaction to foster and support interdisciplinary collaboration across the many and evaluation tool. groups that work with substance abusing populations and those at For more information: SPHERE, Brockton, MA, 800/530-2770.

A CO M P R E H E N S I V E A P P ROA C H 23 The second concern, access, relates to issues Thaca, 1997). This creates powerful feelings Ifagencies and providers hope to truly help such as the number and location of pre­ of mistrust and alienation and a strong IDUs, they must consider ways to effectively vention and care services and programs, reluctance to seek out or participate in deal with these key issues of coverage, access, whether they are free or not, whether IDUs programs and services. and quality as they plan, deliver, and monitor need a referral to use them, and whether programs and services. The third issue, quality of care provided IDUs know about their availability. to IDUs, covers a host of issues such as Problems with access stem from the very RECOGNIZE AND the training and competency of service nature of IDUs’ lives as well as from the O V E RCOME S T IGMA providers, the adequacy ofmedications way in which the services and programs prescribed (for example, are IDUs receiving If IDUs are to be successfully engaged in are organized and delivered. IDUs may not a more effective dose of 80-100 mg of pr evention effor ts and if pu b lic policy is kn o w what services are avai l a b le to them, methadone per day [Strain et al., 1999] or to move forward, the negat iv e attitudes, how to get to them, or how to use them. only 30 mg per day?), and the provision stereotypes, and stigma attached to injection Frequently, their lives are so dominated of all necessary services (for example, are drug users and their addiction must be by the demands of their addiction that substance abuse treatment services accom­ recognized and overcome. It is all too easy pa r ticipation in organized interventions panied by needed primary medical care or for IDUs to be dehumanized, to become is beyond their capability. Further, when psychosocial services?). The ability of IDUs “t h e m , ” not “u s . ” In fact, IDUs are “u s” IDUs do attempt to use care systems or to comply with treatment regimens, main­ — they are fami l y members, neighbors, programs, they report that some procedures tain or improve their health, and reduce friends, colleagues, patients. A willingness and staff are insensitive and demeaning, their risks of acquiring or transmitting to put a human face on the problem, to confidentiality is not protected, and agency HIV and other blood-borne pathogens is attempt to understand the disease of drug policies effec t i vel y pose barrie r s to care directly related to the quality of the preven­ addiction, and to consider IDUs as full (NYHRE, 1998; Rogers et al., 1998; tion and care services they receive. human beings is a critical step to moving

NEW Y O RK HAR M R EDUCTI ON E D U C A T O RS (NYH RE) Focusing on Coverage, Access, and Quality

NYHRE is the largest harm reduction program in New York State. and hangs his diploma on one of them. We do all our services on Now in its ninth year, its services also include outreach, HIV/AIDS the street. Everything. Whatever need you have, you can get it met prevention education, psychotherapy, treatment advocacy, referrals to in this program in one way or another.” health care, syringe exchange, and training for service providers. The As part of its efforts to improve service quality and increase coor­ ways in which it plans and provides its services and programs provide dination among providers, NYHRE conducts harm reduction training a useful perspective on the issues of coverage, access, and quality. programs. These workshops increase participants’ awareness of About 35,000 people are enrolled in NYHRE programs and the staff the difficulties that IDUs face in obtaining high-quality services and sees about 8,000 individuals each year. In the last three years, NYHRE provide training in the principles and practices of harm reduction. has doubled in size and budget and the number of staff has tripled. These trainings help providers learn to respect the ethnic and street Reaching a critical mass of those who need help is a long-term and cultures from which their clients come, which, in turn, helps them often difficult process, particularly in a city like New York, which has understand drug users, what makes sense to them, how they inter­ an extremely large IDU population. However, NYHRE’s philosophy pret the world, how they expect to be treated, and what kinds of of reaching as many users as possible “where they are,” providing interventions will be most effective. as many different types of services as possible, and creating linkages Located in one of the poorest urban communities in the nation — the among a myriad of services and service providers are good ways to Hunts Point section of the Bron x — NYHRE has worked hard to address existing gaps in coverage. collaborate with others on a variety of projects whose needs are “We understand that there are reasons why people use drugs and defined by the community itself. Ruefli explains that NYHRE is “part good reasons why they are not connected to services. We take that of the process by which IDUs see that there’s light at the end of the as our point of departure,” says Terry Ruefli, NYHRE’s executive tunnel. They’re not condemned to die of AIDS, to be homeless, to director, in describing the ways in which NYHRE helps IDUs break be mentally ill. We are one of the ways in which people can climb down barriers to obtaining services. For example, says Ruefli, out of that.” NYHRE provides traditional services in a nontraditional way. “We have a psychotherapist, but he doesn’t sit in his office and wait for For more information: New York Harm Reduction Educators, Inc., patients to come to him. He sets up two chairs on the sidewalk, Bronx, NY, 718/842-6050.

24 A C O M P R E H E N S I V E A P P R O A C H N I D A Working to Change Attitudes on a National Scale

Stigma toward IDUs and other drug users results from individual to tell NIDA what kind of information they need to better deal experiences with drug use or drug users, but it is also generated with drug problems in their community. in large measure from broader societal attitudes toward drug use. • Taking information to the people. If research findings and Changing social attitudes is one way to affect change on an individual scientific facts are to have an impact and be useful, they need to level. The National Institute on Drug Abuse (NIDA), a component of be used. A big focus of NIDA’s information dissemination effort, the National Institutes of Health (NIH), supports over 85 percent of therefore, is creating a wide range of publications and other mate- the world’s research on the health aspects of substance abuse and rials that are appealing, user-friendly, and pragmatic. For example, addiction and it is working on a number of fronts to disseminate NIDA’s recent publication, Principles of Drug Abuse Treatment: the results of its research. This dissemination effort is helping to A Research-based Guide synthesizes 25 years of research into a improve the nation’s understanding of addiction and, as a result, series of practical principles that communities can use to develop change attitudes about drug addiction and people who use drugs. effective substance abuse treatment programs. NIDA has also These various activities include: produced numerous educational booklets, slide shows, and other • Being clear on the terminology. NIDA carefully crafts the materials for parents, youth, and teachers. language it uses to talk about addiction and individuals who use • Harnessing the power of partnerships. NIDA has developed drugs so that it reflects current scientific knowledge and is clearly collaborative relationships with many different organizations and understandable. These words and phrase s — “addiction is a brain agencies, from Hollywood’s Entertainment Industries Council, to disease,” for example — are used repeatedly and in multiple the American Medical Association and other professional associa­ contexts so that, eventually, they can become a permanent part tions, to other federal agencies such as the Department of Justice of the way that society talks about this issue. and the Office of National Drug Control Policy (ONDCP), to • Fostering dialogue with communities. Since 1996, NIDA has community coalitions such as Join Together and Community hosted a series of 1-day Town Meetings in communities across the Anti-Drug Coalitions of America (CADCA). NIDA works through country to help bridge “the great disconnect”— the dichotomy these partnerships to promote wide distribution of information, between the public’s perception of drug addiction and the scientific ensure that depictions of drug use and addiction are accurate, and facts. These meetings, which are tailored to meet local interests create a better and more thorough understanding of drugs and and needs, give NIDA the chance to provide communities with their effects on the brain and body. the latest findings from drug abuse prevention and treatment research. They also give communities — local civic leaders, health For more information: National Institute on Drug Abuse (NIDA), care providers, parents, teachers, concerned citizens — a chance Bethesda, MD, www.nida.nih/gov.

A R R I V E Overcoming Stigma Through Investing in Human Capital

The ARRIVE Program of Exponents, Inc. is designed to improve the Started in 1988, ARRIVE now trains over 900 substance users a year, quality of life of traditionally underserved minorities affected by 60 percent of whom are HIV-positive. It has maintained an 83 percent drugs, HIV/AIDS, incarceration, and poverty. Serving clients from the retention rate over the last decade. As Ms. Josepher explains, the entire New York City area, Exponents’ programs intervene with program is based on the premise that investing in human capital not detainees, recently released inmates, people living with HIV/AIDS, only works, but is cost-effective. “We see people go through a trans- and substance users and their families. The ARRIVE curriculum covers formation within 2 months,” she says. ARRIVE costs about $1,000 harm reduction, relapse issues, HIV care and prevention strategies, per person for more than 60 hours of education, support groups, and health education, infection control, and nutrition. HIV counseling, counseling. For $1,000 you have a person who is literally transformed, referrals to much-needed services, and peer-led support groups motivated, and renewed.” reinforce classroom information and help clients amplify their Ms. Josepher illustrates this with the following story: “One of my strengths and resources to meet their health and social challenges. staff is a woman who was in and out of prison for prostitution, for Communications and presentation classes help clients transform drugs, for burglary. She would get off drugs but couldn’t stay off. personal experience into marketable skills. She didn’t have that ability. She was a heroin IDU for 20 years and on methadone for two. She came into the ARRIVE program. She ARRIVE is based on a “corporate social work model,” says deputy saw people like herself training, counseling, and becoming part of the executive director, Maria (Sam) Josepher. “It was begun by people solution. Then we put her on a computer. She just started soaking who were corporately aware as well as people who had been in it up like a sponge. She became a volunteer, our first part-time the substance abuse field for more than 30 years. We used a lot of employee. She never went back to drugs. The last time she was in what we learned from the business world to teach addicts — the prison was about 9 years ago. Two years ago she bought a house. importance of information, communication skills, respect, cleanliness — When she announced this at a staff meeting, there wasn’t a dry eye all of this is given to the client. On the social work side, the clients in the place.” receive a lot of therapeutic peer support. We acknowledge the incremental steps that people make. We notice when people are For more information: The ARRIVE Program of Exponents, Inc., dressing better, acting better, making more out of their lives.” New York, NY, 212/243-3434 www.exponents.org.

A CO M P R E H E N S I V E A P P ROA C H 25 beyond the stigma. Overcoming stigma is will increase their effectiveness. Involving also, fundamentally, a pragmatic necessity, IDUs in planning, delivering, and evaluating for without it, the job of helping IDUs services and interventions is one important Substance abuse overcome their addiction and prevent dis­ way to make sure that they are appropri­ treatment—why ease will not be accomplished. ately tailored. include it? T A I LO R SE RV IC E S Key Strategies • it helps users stop A N D P RO G R A M S using drugs S U B S T ANCE ABU S E IDUs have diverse languages, cultures, sexual T R E AT M E N T • it helps prevent orientations, life circumstances, behaviors, transmission because and requirements for services. One size does Drug addiction is a chronic illness charac­ users reduce drug- not fit all. In planning and delivering inter­ terized by compulsive, uncontrollable vent i o n s , providers must take into account drug craving, seeking, and use, even in the and sex-related the factors that differentiate IDUs— who face of enormous ne gative consequences. risk behaviors they are, where they are, what they do, Though nearly all addicts believe initially • it has major positive what motivates them, who they socialize that they can stop on their own, most of with. Programs and pr oviders must also their attempts fail to achieve long-term effects on a user’s life account for the fact that the behaviors or abstinence (NIDA, 1999). Substance abuse • it’s cost effective occupations of certain groups of IDUs, treatment provides the medical, psychological, such as the mentally ill, the homeless, and behavioral support necessary for • it’s a good way to commercial sex workers, and those in prisons i n d ividuals to stop using drugs and to reach IDUs with and jails, put them at particularly high risk allow their brain processes to ret u rn to other messages of acquiring and transmitting infection. pre-addiction functioning (see Chapter 2 and interventions Tailoring interventions to the particular for more detail on the changes in brain characteristics and service needs of recipients function that occur during addiction).

W E L L-BEIN G INSTI TUT E Tailoring Interventions for a Specific Population of IDUs

Well-Being Institute is a drop-in day treatment center located in “In the course of 9 months, we got her housing, got her primary Detroit’s inner city. It works primarily with HIV-infected, substance- health care needs met, and made sure she kept going to her health abusing women who are mentally ill. These women tend to fall care appointments. We got her into a substance abuse treatment between the cracks of the existing health care delivery system, which program so she was getting herself off drugs. We made sure she took is not well suited for creating and maintaining long-term relationships her HIV meds and her meds to reduce her mental illness symptoms. with such a high-risk population. The program locates eligible women I ran into her 3-4 months ago and she looked great. For public policy through street outreach, nursing staff contacts with case managers purposes, notice how she is no longer really an infection risk to any in Detroit’s HIV care network, and referrals. Through its own model other person. She is a thousand-fold less drain on public resources. of individualized nursing care, Well-Being staff help clients achieve No one will have to pick her body out of an alley somewhere. Simply three primary objectives: access — overcoming barriers to obtain­ getting her to take her meds and getting her to show up for regular ing care for their HIV disease, substance abuse problem, or mental health care appointments is a far more cost-effective way of dealing illness; retention — maintaining relationships with care providers with her health problems than her showing up in an ER somewhere over the long-term; and adherenc e — sticking with treatment with her problems like an out-of-control train wreck. The kind of regimens over time. interventions that can prevent the train wrecks can save the public health care systems enormous amounts of money, not to mention To illustrate the specific and broader pay-offs of tailoring interventions preventing a lot of human suffering. When I talked to her, the client to the needs and circumstances of particular IDUs, Geoffrey Smereck, wanted to get into community college and into the workplace. If Well Being’s director, tells the story of a mentally ill woman who we can get someone to stop soaking up resources, let alone to was also homeless, an IDU, a victim of domestic violence, and had start contributing….” an HIV-related cancer: For more information: The Well-Being Institute, Detroit, MI, 734/913-4300.

26 A C O M P R E H E N S I V E A P P RO A C H Often, because of the complexity of the social benefits have been emphatically theft by $4 to $7. The average cost of 1 disease and the frequency of relapse to drug demonstrated (Gerstein and Harwood, year of methadone maintenance treatment use, treatment requires multiple episodes 1990; Hubbard et al., 1989; Metzger et is $4,700 per person. The cost of 1 year over a long period of time. al., 1998; NIDA, 1999; NIH, 1997a; of imprisonment per person is about Pickens et al., 1991). Successful treatment $18,400. When health care savings are For injection drug users, substance abuse can have a major positive impact on many added in, total savings can exceed costs by treatment is a powerful disease prevention areas of a person’s life, helping him or her a ratio of 12 to 1 (NIDA, 1999). strategy. Drug injectors who do not enter improve family life, employment and treatment are up to six times more likely to health, and decrease involvement with Substance abuse treatment programs also become infected with HIV than are injectors crime. Overall, treatment for addiction is reach drug users and their partners with who enter and remain in treatment as successful as treatment of other chronic other HIV prevention messages and inter­ (NIDA, 1999). Because substance abuse conditions, such as asthma, diabetes, and ventions. Participation in these interventions treatment helps users reduce or eliminate hypertension (NIDA, 1999; O’Brien and offered in the treatment setting is associated the number of drug injections, it lowers McLellan, 1996). with reduced drug- and sex-related risk the risk of infection with HIV or hepatitis behaviors (Calsyn et al., 1992; El-Bassel that might occur through unsafe injection and Schilling, 1992; Malow et al., 1994; practices, such as multi-person use of McCusker et al., 1993). syringes or sharing of drug injection Overall, treatment for equipment (Thiede et al., 2000). It also addiction is as successful COMMUN I T Y O U T REAC H prevents or reduces other harmful conse­ as treatment of other Many IDUs are not engaged by conven­ quences of drug use, such as abscesses and chronic conditions, endocarditis (inflammation of the lining tional service systems that provide treatment of the heart). Further, because drug use such as asthma, diabetes, and prevention services or medical, mental impairs rational decision making, which and hypertension. health, or social welfare services. This is due can lead to high-risk behavior, substance partly to funding and capacity limitations abuse treatment can reduce the risk of on the part of the service systems. It is also due to IDUs’ own attitudes and life HIV and hepatitis infection that can Substance abuse treatment makes financial ci rcum stances. The over whel ming priorities occur through high-risk, unprotected sex. sense as well. Every $1 invested in substance of obtaining and using drugs often prevent abuse treatment reduces the costs of drug- In the last decade, the effectiveness of IDUs from seeking out services, such as HIV related crime, criminal justice costs, and substance abuse treatment and its broader prevention, that may seem abstract or

R IVER REGIO N H U MAN SERV I C E S In Substance Abuse Treatment, Be Persistent and Accept Small Victories

River Region Human Services AIDS Outreach Program, located in Gross. “Once you get one good one with all the connections, they Jacksonville, Florida, focuses on providing substance abuse treatment will work with you and get their buddies into treatment.” services to high-risk IDUs. Additional services include HIV, STD, and Persistence and patience are key elements. “You have to address the TB testing; group support meetings; referrals to mental health and substance abuse problems first,” says Gross. “The other issues can substance abuse treatment services; sexual risk reduction education come later. If the person isn’t interested in treatment, don’t give up. and condom distribution; and counseling and education. Over time, Keep after them, eventually they will come. It’s not a fast process.” it has developed links and collaborative relationships with a variety of other agencies that provide substance abuse treatment, case In addition to working in the community, River Region is the sub- management, and medical services. River Region recently assumed stance abuse treatment provider for the Jacksonville jail, and has management of a 40-bed supportive housing facility. recently added an HIV testing and education component to these services. Its numerous links with community-based agencies and River Region is unusual in that outreach is an integral component of service providers ensure continuity and consistency for inmates its services. River Region goes out into the community to find IDUs once they return to the community. and offer them substance abuse treatment, HIV testing, and other services. By working in the neighborhoods with IDUs, they’ve been For more information: River Region Human Services AIDS Outreach able to develop trust and credibility. “We’ve been doing it so long, Program, Jacksonville FL, 904/359-6088. www.rrhs.com we are recognized and have a good rep,” says director Marc

A CO M P R E H E N S I V E A P P ROA C H 27 unimportant in comparison. In addition, the recovering drug users returning from stigma and negat i ve attitudes expe r i e n c e d substance abuse treatment and those by many IDUs when they have worked returning to the community after time Community with service providers leads them to mistrust spent in prison or jail. outreach— why gover nment agencies and conven t i o n a l Community outreach is typically carried out include it? service systems and be reluctant to obtain in settings where drug users gather — on se rvices . Thus, to effect i vel y provide pre­ • it reaches IDUs the street, in homes, in shooting galleries vention, treatment, and care services to IDUs, who don’t use or are and crack houses, and in housing projects, it is essential to bring the services to IDUs in missed by conve n t i o n a l emergency rooms, laundromats, and parks. the settings in which they live and socialize. Ideally, the messages and services are delivered service systems Community outreach programs can make by people with whom the drug user is • it provides services a valuable contribution to preventing familiar and likely to trust, such as peers in settings that are blood-borne infections (Wiebel et al., 1996). who live in the community. Many commu­ These practical and relatively low-cost nity outreach workers are recovering IDUs familiar to IDUs approaches are designed to reach high-risk themselves. A typical outreach encounter • it helps create a cul­ IDUs and present and reinforce preven t i o n in vol v es face - t o - f ace communication that is ture of risk reduction messages in a community setting . They intended to assist IDUs in changing their can be the first step in developing a rela­ high-risk drug use and sexual behaviors. in the community tionship with drug users and ultimately Outreach workers may give out literature • it uses peers who linking them with services. Because they are on HIV and how to prevent it or provide are likely to be trusted both an individual- and community-level information on avai l a b le services. They also by IDUs intervention, they help create a culture of distribute condoms and bleach kits for risk reduction among drug users, their decontaminating injection equipment and • it’s relatively low cost families, friends, and neighbors. This culture they help IDUs obtain other services in of risk reduction also helps to support the community, such as housing assistance

T A K I N G IT T O THE S T REETS A Science-based Community Outreach Program

Located in the heart of Detroit’s Empowerment Zone, Taking It Taking It to the Streets is research-based, incorporating approaches to the Streets’ target population is low-income, underserved, at- and specific strategies that have been shown to work. For example, risk and HIV-infected African American substance users. It provides it was one of the first programs in the state to use OraSure for HIV health education, HIV risk reduction counseling and testing, and testing, a quick, relatively noninvasive technology with proven reliable syringe exchange services, and collaborates closely with six of the results. Project Respect is the counseling model employed by the area’s largest chemical dependency treatment centers. program because, according to Simpson, “The results of their research showed that people who had gone through a two-session Taking It to the Streets was based in part on a National AIDS contact had pretty much the same outcome as those in longer sessions. Demonstration Research Project supported by NIDA that looked at After we implemented the Project Respect Model, our return rate effective outreach to injecting drug users. The program has pioneered increased from 40 percent to more than 80 percent.” the indigenous leader outreach approach. It operates on the diffusion model, which focuses on the spread of ideas and practices throughout Simpson stresses that the mobility of the program is also key to its a social system from person to person. Harry Simpson, former success. His staff work out of specially outfitted vans that some have executive director of the Community Health Awareness Group that called “prevention on wheels.” Simpson says, “These vans let us oversees the program, describes the staff as “individuals who share take the service to those who need it most, rather than waiting for the demographic characteristics as well as the life experiences” of them to come to us.” the people they serve. “They walk the walk, and they talk the talk. Because they are often in recovery themselves, they are seen as For more information: Taking It to the Streets, Detroit, MI, credible role models.” Simpson says also that community involve­ 313/872-2424 ment is the “central theme in our program’s design, development and implementation, and monitoring and evaluation.”

28 A C O M P R E H E N S I V E A P P RO A C H or mental health treatment. Outreach also individuals who continue to inject drugs. stop injecting drugs. Many jurisdictions are involves working with drug users’ social and pursuing efforts to sustain and expand syringe Most states restrict the sale, distributi o n , drug-using networks to diffuse prevention excha n ge programs, which provide IDUs with and possession of sterile syringes: 44 states messages and build risk reduction skills. free sterile syringes and a way to safely have drug paraphernalia statutes, 5 states Ou t re a c h can also be used to recr uit drug dispose of blood-contaminated used have syringe prescription statutes, and 23 users to other activities, such as confidential sy r i n ges . Many of these syringe exchan ge states have pharmacy regulations or prac­ risk assessments, HIV testing and counsel­ programs also provide additional servic e s , tice guidelines. These restrictions present ing, and substance abuse treatment, and to such as education and counseling, primary si g n i f icant barriers to the sale of syringes to distribute sharps containers for safe disposal medical services, and referrals to substance IDUs by pharmacists, the prescription of of used syringes. ab use treatment and social servic e s . sterile syringes to IDUs by physicians, the In i t i at ives with pharma c i s t s pr ovide education operation of syringe excha n g e progr a m s , I N T E RVEN T IONS T O about the role of sterile syringes in reducing the safe disposal of bloo d - c o n t a m i n a t e d INCREASE IDUS’ A C C E S S the transmission of bloo d - b o r ne pathogen s used syringes, and ultimately, to the efforts T O STERILE SYR I N G E S such as HIV and viral hepatitis, address by IDUs to reduce their risks of ac q u i r i n g pharmacist concerns and questions about Cl e a r ly, the best solution for injecting drug or transmitting bloo d - b o r ne pathogens sy r i n ge sales and disposal, and encourage users is to stop injecting and enter substance (Gostin, 1998). chan ges in pharmacy policy and practice. abuse treatment. However, many drug users Three types of interrelated interventions are either cannot get into substance abuse An individual IDU makes approximately now being pursued in the U.S. to increase treatment programs or will not stop inject­ 1,000 injections each year, which even in IDUs’ access to sterile syringes. Several ing drugs. Even those injectors who are in a moderate-size city adds up to millions states and municipalities are working on treatment may relapse to injecting drugs. of syringes and millions of injections a policy efforts to allow increased pharmacy Given these realities, several governmental year (Lurie et al., 1998). Given this fact, sales of syringes, remove criminal penalties bodies and institutions1 ha ve reco m m e n d e d ach i e ving the recommendation of the for syringe possession, and include language consistent, one-time-only use of st e r i l e one-time-only use of sterile syringes will in laws stating that preventing HIV and syringes as a central strategy in the effort require the coordination of all of these other blood-borne pathogens is a “legitimate to reduce the transmission of HIV and interventions so that every IDU who cannot medical purpos e ” for prescribing sterile other bloo d - b o r ne pathogens among those or will not stop injecting will be able to sy r i n g es to IDUs who cannot or will not

1This includes the U.S. Public Health Service, the Institute of Medicine of the National Academy of Sciences, and the U.S. Prevention Services Task Force.

I N C REAS ING IDUS ’ A C C E S S T O STER ILE SYRI NG ES Changing Connecticut’s Syringe Laws Results in Increased Pharmacy Sales of Syringes to IDUs

In 1992, in response to a growing AIDS epidemic largely fueled by Connecticut was able to successfully change the state syringe laws injection drug use, Connecticut modified its syringe laws to partially because of collaborative efforts between the state health department remove the legal barriers to pharmacy sales of syringes to IDUs. and the Department of Consumer Affairs, the state’s pharmacy regu­ These changes included repealing the state prescription law to allow latory body. Since 1992, there have been several collaborative efforts the purchase of up to 10 syringes without a prescription and modi­ between the health department and pharmacy schools and organi­ fying the paraphernalia law to allow possession of up to 10 syringes zations to educate pharmacists about the changes in the law and the without drug residue. important role pharmacists can play in helping active IDUs obtain sterile syringes, and to encourage pharmacists to sell syringes to An evaluation of the effect of changing Connecticut’s syringe laws IDUs to help prevent transmission of HIV and other blood-borne revealed substantial increases in pharmacy sales of syringes in high pathogens. Other states, including Maine, Minnesota, and Washington, injection drug use areas compared with areas of minimal injection and very recently New York, Rhode Island, and New Hampshire, drug use. Furthermore, a large number of IDUs reported that they have used Connecticut’s experience as a model in their efforts to had shifted their primary source of syringes from “the street” to change laws and regulations restricting syringe sales. “the pharmacy” and reported substantially reduced rates of syringe sharing after the new laws went into effect. For more information: Groseclose et al., 1995; Valleroy et al., 1995.

A CO M P R E H E N S I V E A P P RO A C H 29 obtain and safely dispose of a sufficient work to reduce legal and regulatory barriers that 81 percent of state inmates, 80 percent number of sterile syringes to prevent the that restrict access, expand availability of of federal inmates, and 77 percent of lo c a l acquisition or transmission of bloo d - substance abuse treatment, and improve jail inmates had some type of drug abuse bo r ne pathogens . options for safe disposal of syringes problem (Belenko, 1998). In 1996, an esti­ (NASTAD, 1999). This statement builds mated 250,000 state prison inmates had In October 1999, the American Medical on previous similar policies adopted by the injected drugs, including 120,000 who had Association (AMA), the American APhA in 1999, the AMA and NASTAD shared needles. Some 14,000 federal prison Pharmaceutical Association (APhA), the in 1997, and ASTHO in 1995. inmates had injected drugs, including 6,000 Association of State and Territorial Health who shared needles (Belenko, 1998). Officials (ASTHO), the National I N T E RV ENTION S I N Association of Boards of Pharmacy At the same time, inmates in prisons and THE CRI MINAL J U S T ICE (NABP), and the National Alliance of State jails have disproportionately high rates of S YS T E M and Territorial AIDS Directors (NASTAD) HIV infection and other STDs, hepatitis, issued a joint statement urging state leaders Because injection drugs are illegal and drug and other health problems. At the end of in medicine, pharmac y, and public health users often resort to crime to support 1996, 2.3 percent of male and 3.5 percent to coordinate action to improve IDUs’ access their drug addiction, IDUs are frequentl y of female state and federal prison inmates to sterile syringes through pharmacy sales. arrested and imprisoned. A recent study were known to be infected with the HIV They encouraged public health leaders to on substance abuse and prisoners found virus (Hammett et al., 1999). AIDS was

B R O O K L Y N T R E A T M E N T C O U R T An Innovative Approach to Working with IDUs Within the Court System

Since the early 1990s, 400 jurisdictions have established drug courts of Nursing, in collaboration with the Brooklyn Hospital, provides with the idea that a different approach was needed. In the drug primary health care services. The Human Resources Administration court model, the emphasis shifts from incarceration with occasional provides assistance with welfare, food stamps, and Medicaid. The treatment, to treatment with (hopefully) only occasional incarcera­ BTC also provides acupuncture and short-term drug education and tion. In most drug courts, substance abusing defendants who have intervention through its Treatment Readiness Program. The BTC’s been charged with nonviolent offenses are screened for eligibility. If Project Connection has relationships with many local organizations, eligible, the defendant will be offered a deferred prosecution or the which helps clients return to their communities after treatment and opportunity to plead guilty to the charges with the promise that if he promotes enhanced court-community relations. BTC also works or she complies with court-mandated substance abuse treatment, with attorneys to advocate for women involved in child custody the court will vacate the plea and dismiss the charges. If the defendant cases and collaborates with the Family Court and the Administration refuses treatment or fails to fully comply, the case will be prosecuted for Children’s Services to coordinate case management of women in the usual fashion. Defendants who choose treatment regularly who are involved in the criminal justice and Family Court systems. report back to the court on their progress. A central component of In describing BTC’s approach and philosophy, Valerie Raine, BTC’s the model is monitoring of drug use through frequent drug tests. The project director, says, “What we have tried to do here is bring as court uses escalating sanctions for drug use and rewards for many services on site to the courthouse, so this population is not progress to create incentives for the defendant’s recovery. tossed around and referred out. You lose them the minute you refer The Brooklyn Treatment Court (BTC) has taken this model a few them even across the street. A lot of what we’re trying to do is to steps further. What it has tried to do is recognize the myriad needs integrate services. Because, especially in New York, services are so and situations of substance abusing individuals who come into the frequently fragmented in a way that doesn’t effectively meet the needs criminal justice system. These men and women are not just addict­ of the population. If you only meet one need and not the others, they ed to drugs. They have serious health problems as well as employ­ are probably going to fail — to recidivate, to start using again.” ment, housing, and social service needs. Women drug users have par­ The Brooklyn Treatment Court has been in operation since 1996. ticularly complex situations; many have experienced physical or sex­ It has placed more than 1,525 people in treatment; more than 500 ual abuse and many have child custody issues. are still in treatment and about 374 have “graduated.” It enjoys a To accommodate these needs, the BTC has developed a broad high retention rate — about 60 percent. network of on-site and off-site collaborative services. For example, the New York City Department of Health provides screening, testing, For more information: Brooklyn Treatment Court, Brooklyn, NY, and education for HIV, TB, STDs, and pregnancy. The NYU Division 718/243-2639. www.drugcourttech.org

30 A C O M P R E H E N S I V E A P P RO A C H diagnosed in 0.5 percent of all inmates, education interventions to inmates not only others in ways they never believed possible a rate six times higher than that of the benefits them and their overall health but (Hammett et al., 1999). U.S. population. The high-risk behaviors can also improve the health of the commu­ Prevention services cur rently offered to responsible for the transmission of HIV nities to which the vast majority of inmates inmates vary widely across state, county, and other blood-borne illnesses among return (Hammett et al., 1999). and city jails and prisons. They include inmates include high-risk sexual activity, One of the most important types of inter­ instructor-led and/or peer-led HIV sharing of needles and other drug injection ventions in prisons and jails is education education, pre- and post-test counseling , equipment, and tattooing with impr ovised and prevention efforts led by inmates them- multi-session prevention counseling, the tools and materials (Calzavara et al., 1997; selves. These programs can be cost-effective use of audiovisual materials, and the Dolan et al., 1996; Mahon, 1996; and they have a credibility that programs distribution of written materials. Most Struckman-Johnson et al., 1996). led by outsiders cannot match. Peer-led correctional systems provide HIV antibody In light of the many IDUs who are in the programs also provide significant benefits testing, although testing policies differ criminal justice system and the large numbers to the peer educators themselves. Throu g h widely. Few systems routinely screen inmates of at-risk and infected individuals, this pa r ticipating in the prog rams, peer leaders for STDs and only limited viral hepatitis setting is a crucial venue for HIV- and can develop a positive focus in their lives, prevention and treatment services are a vail­ hep a t i t i s - r elated interventions and servic e s . regain a sense of purpose and empowerment, able. A very few systems make condoms Pro viding a range of health and preven t i o n and realize that they are able to influence available to inmates.

THE W O M E N A N D I N F A N T S D EMONS TR A T ION PRO J E C T S Preventing the Sexual Transmission of HIV at the Community Level

Currently, the number of AIDS cases are increasing faster among Several other activities supported these stories — a peer network of women than among men; heterosexual transmission is responsible volunteers was formed to provide HIV prevention information and for a growing percentage of these cases (38 percent of cases among distribute the stories and condoms; small businesses and neighbor- women in 1997, as compared with 14 percent in 1987). Using a hood organizations and agencies were recruited as distribution sites condom is the principal way to prevent heterosexual transmission, for the stories and other HIV prevention information and as sites for but its use is relatively low among the male partners of women at workshops or other activities; each intervention city also hired four risk and is partner-specific, meaning that rates of use are lower full-time outreach workers to provide individualized HIV prevention with main partners than with other partners. information and condoms to women in the community. The Prevention of HIV in Women and Infants Demonstration Projects The WIDP reached large numbers of at-risk women with HIV pre­ (WIDP) was a 5-year, multi-site intervention designed to increase vention messages and it was well received by community leaders, positive attitudes, behaviors, and community norms around condom businesses, and residents. It was also effective in encouraging use among women at risk of HIV infection. Using the stages of women to talk with their main partners about using condoms and change theory, social learning theory, and the diffusion-of-innovation to begin using them. There was a similar, though not statistically theory, the WIDP built on strategies previously applied in CDC’s significant, positive change in condom use with other partners as AIDS Community Demonstration Projects to see whether a variety well. One final and notable finding was that intervention effects of HIV prevention activities focusing on the need to use condoms began to appear only after the WIDP had been active for 2 years. with main and other partners would increase the use of condoms. In combination with the other findings, this suggests that to be This 1991-1996 intervention took place in two public housing commu­ effective in low-income, higher-risk neighborhoods, interventions nities in Pittsburgh, a low-income neighborhood in West Philadelphia, need to address the particular social, economic, and cultural issues and a group of inner-city neighborhoods in Portland, Oregon. that affect the target population and they need to be sustained Several other communities served as a comparison group. over the long term. The centerpiece of the intervention consisted of a series of culturally For more information: Lauby et al., 2000. specific role-model stories that were developed for use in each community. In each story, the main character moved from one stage in the stages-of-change theoretical model to the next. In each community, 33 to 48 stories, each of which were based on inter- views with women in the community, were developed and widely distributed as fliers, brochures, posters, and newsletters.

A CO M P R E H E N S I V E A P P RO A C H 31 New antiviral and combination therapies casual sexual relationships than with their HIV COUNS E LING ar e widely avai l a b le in correctional faci l i t i e s pr i m a r y sexual partners (CDC/ACD P , A N D T E S T I N G , P A RT N E R (Hammett et al., 1999). However, a number 1999; Friedman et al., 1994; Friedman et COUNSEL I N G AND of factors, including the high cost of the al., 1999) or with sexual partners who do REFERRAL SERV I C E S , regimens, inmate reluctance to seek testing not inject illicit drugs (Friedman et al., AND P R EV E NTION CASE and treatment, uneven clinical quality of 1994; Friedman et al., 1999; Vanichseni et M A NA G E M E N T services, and a lack of uniform treatment al., 1993). The reluctance to use condoms A comprehe n s i ve approa c h to preven t i n g standards means that the availability of with main partners may be due to concerns HIV and other blood-borne infections must comprehensive care for infected inmates that doing so violates the intimacy and trust include the opportunity for individuals to that involves case management, psychosocial de veloped in the rela t i o n s h i p . discover whether they are infected, and if treatment in conjunction with medical To date, distributing condoms and infor­ they are, to help them inform their partners. services, hospice care, substance abuse treat­ mation has commonly been used to help If they are not infected but engage in high- ment, and continuity of services between IDUs reduce their risk of sexual transmis­ risk practices, the approach can also help prison and the community, may be limited sion. These materials are given out for free IDUs begin or sustain behavior changes (Hammett et al., 1999). by most outrea ch work ers, syringe exchan g e that will reduce their risk of acquiring or and other risk reduction programs, drug transmitting the infection. Three interrelated S T R A T EG I E S TO PR EV E N T us e r s ’ organizations, and some substance services are designed to meet these objectives: S E X U A L TRANS MISSI O N abuse treatment programs. One-on-one • HIV prevention counseling and testing; Se xual transmission of HIV and hepa t i t i s sexual risk reduction counseling and group involving IDUs is an important factor in interventions are also conducted by peers to • partner counseling and referral services; and the continuing epidemics of these diseases address skills building and rehearsal, inter- • prevention case management. in the U.S. In 1997, 11 percent of the new personal communication, problem-solving, AIDS cases reported that year were among situational analysis, and self-managem e n t Because these services are one-on-one and men and women whose sex partners were st r a t e gies. Strategies for female drug users focused around the needs of the client, they IDUs. Twel v e percent were among male and sexual partners of drug users have have the potential to address the complex IDUs who also reported having sex with stressed the importance of building lives and circumstances of IDUs and more other men (CDC, 1998a). High-risk sexual self-esteem, social supports, and sexual effectively influence their risk behaviors than be h a vior is also stron g ly associated with negotiation skills to encourage safer sex can more limited and diffuse interventions. hepatitis B transmission (CDC, 1999). practices with partners. In addition, partner counseling and refe rr a l As described in Chapter 1, high-risk drug se r vices and prevention case managem e n t In developing strategies to reduce sexual behaviors and high-risk sexual behaviors are have the potential to provide the continuity transmission among IDUs, agencies and often linked (Chu et al., 1998). For example, of care that is so important to successful organizations should design them with a large portion of IDUs use alcohol and/or outcomes with IDUs. sp e c i f ic target groups (for example, in- cr a c k cocaine, whi c h are often associated treatment versus out-of-treatment drug HIV counseling and testing (C&T) is a prevention with increased frequencies of un s a f e sexu a l users) and specific goals (for example, pre- intervention that provides HIV antibody behavior (Edlin et al., 1994) and number venting acquisition of infection in unin­ testing and individual client-centered of sex partners (Corby et al., 1988). Some fected IDUs and preventing transmission counseling. The counseling is focused on IDUs support their drug habits by exchang­ from infected IDUs to others) in mind. working with the client to identify his or ing sex for money or drugs. Therefore, the These strategies should also take into her risk behaviors and then to develop an extent to whi c h IDUs cha n g e their sexu a l c o nsideration the determinants of sexual individualized risk reduction plan. It pro­ behaviors in response to these diseases is transmission, including the consistency of vides a private and confidential way for critical. This is partic u l a rl y true in light of condom use, the presence of co n c u r ren t in d i viduals to learn their HIV seros t a t u s the fact that although IDUs will make large STDs, the presence of concurrent injection and get further help, whatever the results of chan ges in their injection risk behavior in drug and crack use, and the extent of sexual the testing. A number of C&Tapproaches response to concerns about AIDS, changes ac t i vity while high. Interventions designed ha ve been developed that are well suited to in sexual behavior are generally more modest for the sexual partners of IDUs are an IDUs, including new, rapid HIV antibody (Des Jarlais, 1995; Friedman et al., 1993). important complementary element of tests that allow a person to be tested and In addition, it appears that IDUs are more ove rall strategies for reducing sex u a l receive their results in one visit (CDC, likely to reduce sexual risk behaviors with t r a n smission among IDUs. 1998b), other new tests that allow testing

32 A C O M P R E H E N S I V E A P P RO A C H O U T R E A C H - A S S ISTED MODEL O F P A R T NER NOT I F I C A T I O N Helping HIV+ IDUs Tell Their Partners

Despite the benefits of HIV testing, many people find it difficult to workers do not know the identity of the infected IDU. In the course complete the process because of worries related to being possibly of their regular duties, the outreach workers will locate partners infected. Fear of partner retaliation; stigma; and future health, employ­ and inform them of their possible exposure. ment, and insurance problems all may prevent a person from discov­ This model has a number of benefits. For one thing, it offers ering his or her HIV infection status and disclosing it to others. community-based testing and counseling in a non-threatening and IDUs face all these concerns and more. For example, the formality familiar environment by counselors and outreach workers who and perceived hostility of the health care system discourage IDUs are trusted by and can communicate with those who live in the from seeking testing. If they do get tested and find they are infected, neighborhood. The outreach workers’ thorough knowledge of the finding and notifying partners may be difficult. Users may not know neighborhood and its social networks makes it possible for more the names of their partners, know only street names, or lack adequate partners to be located and informed than if outsiders were to do it. locating information. IDUs may be involved in illegal activities with In addition, because the outreach workers are in the neighborhood partners and that makes them reluctant to reveal names. Given these all the time and often talking with individuals, their presence does realities, alternative models of providing counseling, testing, and not automatically indicate that they are there for partner notification. partner notification services clearly are needed. Thus, it provides a measure of privacy and protection for partners who are notified. One such model is the Outreach-Assisted Model of Partner Notification, an intervention of the Partners in Community Health This model was tested on Chicago’s west side over the course Project, located on Chicago’s west side. This model expands tradi­ of a year. During this time, the project recruited 386 IDUs. Almost tional community outreach activities to include counseling and testing all — 376 — returned to get their results and of these, 60 IDUs tested and partner notification. As part of their regular HIV/AIDS prevention positive. All but one were willing to identify their partners to the HIV and education responsibilities, trained indigenous outreach workers, counselor. Rather than seeing notification by others as intrusive or who are already familiar figures in the community, talk to high-risk unwanted, the majority — 82 percent — welcomed the help and IDUs and their drug-using and sex partners about the benefits of asked that the outreach staff notify one or more partners. One con­ voluntary HIV testing and partner notification. Confidential testing cern that is often expressed about HIV testing and partner notification is offered at the intervention’s neighborhood storefront office. An is that notification can lead to violence, but fortunately this did not HIV counselor provides pre- and post-test counseling to IDUs who occur. Moreover, recruitment for testing continues successfully come in for testing and works with infected individuals to determine in neighborhoods where notification has occurred. These results how partners will be notified. If an infected IDU prefers to notify suggest that expanding traditional community outreach to include partners, the counselor will help prepare the person for these counseling, testing, and partner notification is a viable HIV prevention conversations. The IDU can also request that the outreach workers strategy among IDUs. notify the partners. In this case, the counselor provides the locating and identifying information to the outreach workers; the outreach For more information: Levy and Fox, 1998.

T H E C . A . R .E. PRO G R A M Using C&T, PCRS, and Case Management as an Entry Point to Reach IDUs with Multiple Services

In 1988, Austin’s Community AIDS Resources and Education (C.A.R.E.) This worker stays in touch with the inmate, works with the cor­ Program first began offering services to IDUs and their drug-using and rectional facility medical staff to ensure that the inmate receives sex partners. The program offers four major types of services — medical care, and develops a case management plan for that person counseling, testing, and partner notification; early intervention services; that includes provisions for continuity of care and HIV medications street and community outreach; and case management. In addition, once the inmate is released. This worker also makes sure that the C.A.R.E. offers TB screening, client advocacy, acu-detox (a 15-point street outreach team is aware of any inmates who may be released acupuncture procedure for stress reduction and relapse prevention), from jail earlier than expected, which helps to ensure that the per- and a Journey program (outpatient substance abuse treatment son stays linked to the help he or she needs. C.A.R.E. also provides designed specifically for individuals living with HIV). education and early intervention services to all inmates at correctional facilities. In 1999, the program educated 3,443 men and women in C.A.R.E. provides free, no-appointment-needed confidential and jails about HIV and STD prevention, safer sex practices, hepatitis C anonymous counseling and testing at its clinic, at two Travis County prevention, and harm reduction. correctional facilities, and at each of the publicly funded drug treatment programs. These services are the “entry point” for 85 percent of C.A.R.E. receives its funding from a variety of sources, including the C.A.R.E.’s clients and they lead directly into the program’s other Texas Department of Health, the Texas Commission on Alcohol and highly integrated services. C.A.R.E.’s work with jail inmates shows Drug Abuse, Ryan White Title III, and the City of Austin. how this operates. Individuals who test positive for HIV while in jail are linked immediately with a C.A.R.E. community outreach worker. For more information: C.A.R.E., Austin, TX, 512/473-2273 x 108.

A CO M P R E H E N S I V E A P P RO A C H 33 to be conducted with oral fluids rather provide an opportunity for agencies to notify as substance abuse, STDs, mental health than blood, and C&T settings designed to the partn e r s ofinfected individuals of their problems, and social and cultural factors. attract IDUs (CDC, 1989). exposure to HIV and, potentially to viral Because it has the potential to address a hepatitis also. If already infected, the part­ wide range of social problems and risk Partner counseling and referral services (PCRS), ners’ prognosis can be improved through behaviors, PCM is particularly suited for formerly known as “p a r tner notific a t i o n , ” earlier diagnosis and treatment. If not individuals like IDUs, who have or are likely begin when a person seeks HIV counseling infected, the partners can be assisted in to have difficulty initiating or sustaining and testing. If the test is positive for HIV, changing their risk behavior, thus reducing practices that reduce or prevent HIV he or she is given the opportunity to receive the likelihood of acquiring the virus. From transmission and acquisition. PCM strives PCRS at the earliest appropriate time. an epidemiological standpoint, following the to develop an ongoing relationship with During the initial PCRS interview, the chains of transmission from one infected each client to provide an environment of counselor will discuss with the client his or individual to another within and across trust and understanding within which her responsibilities to sex and drug-use part­ social networks permits public health inves­ prevention counseling can take place. ners and available options for notifying them tigators to chart the course of the epidemic of the clie n t ’ s infection. The HIV-infected and reach individuals at very high risk. C O O R D I N A TED SERV I C E S client is encouraged to voluntarily and F O R IDU S LIVI N G W I T H confidentially disclose identifying, locating, Prevention case management (PCM) is an intensive, H I V / A I D S and exposure information for each partner. ongoing, client-centered HIV prevention The PCRS provider and client together activity designed to help individuals with Because HIV disease is a chronic and com­ formulate a plan and set priorities for complex lives and circumstances adopt and pl e x condition with freq u e n t ly cha n g i n g n o t ifying partners. maintain HIV risk-reduction behaviors. It recommendations for treatment regi m e n s , provides counseling, support, and help in f ected IDUs and their families requ i r e PCRS can have important benefits for with services to address the relationship close monitoring and a constantly chan g i n g individuals and communities in that they between HIV risk and other issues such array of services in their homes, in the

H E A L T H B R IDGE Coordinated Services Improve the Health and Quality of Life of IDUs Living with HIV

Working in upper Manhattan and the South Bronx, Health Bridge’s and two case managers provide care, support, and referrals to goal is to engage, link, and provide continuous care to HIV-infected housing, case management, and other services at the SRO hotels. men and women who have fallen through the cracks and are lost A fundamental element of the Health Bridge model is recognizing to follow-up within the traditional medical care delivery system. that disenfranchised individuals, such as HIV-infected IDUs, need According to Debbie Indyk, director of Health Bridge, the key is to support through various phases of engagement and retention in care. “identify strategic sites for reaching people who are not reached For example, clients may be willing to meet with Health Bridge staff elsewhere, and engage them for whatever they need to be engaged but not come to the clinic for care; they may be ready to take AZT for. We have lots of people with HIV who know their status but aren’t to reduce the risk of perinatal transmission, but not want to begin in care and lots of people who don’t even know their status. But we treatment for their own HIV disease. Through a model derived from can reach these people if we think strategically about where to find the stages of change theory and using sustained outreach to reach them and establish linkages and infrastructure. Through outreach individuals “where they are,” Health Bridge staff have built a safety you find crises, but subsequently, you can also deal with stabilization net that can quickly identify people in crisis as well as those ready and growth and development.” to be engaged in medical care, substance abuse treatment, and other Working closely with the Mount Sinai Jack Martin Fund Clinic and care and support services. other New York City programs for IDUs, Health Bridge staff provide Since its inception in 1998, Health Bridge has reached well over 100 holistic care to HIV-infected individuals who live in single room occu­ people living in three SRO hotels. Over one-half are African American pancy (SRO) hotels. Through their “home visiting” approach and and about two-thirds are men. Recognizing the very great need in consistent presence in the hotels, Health Bridge staff are able to this part of New York, Health Bridge is actively trying to expand its successfully engage clients and provide various services, including capacity and linkages so that it can serve increased numbers of wound care, urgent care, entry into substance abuse treatment, and infected and at-risk individuals. stage-based links to primary care. For those clients who are not ready to come into the clinic for care, a Health Bridge team consisting of a For more information: Health Bridge, New York, NY 212/241-7863. physician assistant, a part-time attending physician, a medical assistant,

34 A C O M P R E H E N S I V E A P P RO A C H hospital or health care faci l i t y , and in the on themselves and others. HIV-infected complex and fragmented for them to navigate community (Keenan, 1990). With appro­ drug users who are in substance abuse and often too remote geographically, socially, priate and high-quality services and med­ tr eatment and are rece i ving other health and culturally. Some prog rams proh i b i t ications, IDUs living with HIV can lead services are more likely to comply with se r vices to active drug users, whic h pres e n t s fulfilling, prod u c t i ve lives. HIV/AIDS drug treatment regimens and formi d a bl e barriers for IDUs. Negat i ve to reduce their sex and drug risk-related attitudes by staff toward IDUs’ behaviors Many IDUs continue to engage in high-risk behaviors (Booth et al., 1999). and life circumstances further exac e r b a t e be h a viors after they learn they are infect e d the situation. IDUs living with HIV/AIDS with HIV and, thus, place others at risk of As a marginalized population, IDUs can be therefore need a full complement of services, HIV infection and themselves at risk for less connected to the AIDS service delivery delivered in a setting geared to attract IDUs collateral health problems (CDC, 1996; system than are other infected individ u a l s . from the community and retain them. Case HRSA, 1994; Kwia t k owski et al., 1998; Like non-IDU consumers, many IDUs do ma n a g ers and prevention case managers Me t s c h et al., 1998). When HIV-infected not know where to go to obtain services or should offer risk reduction counseling and IDUs are actively engaged in health care, what services are appropriate for different prevention services to these individuals and ho wever , they can be fol l o wed to identify people at different stages of the disease. assist them with managing their chronic and renewed high-risk sex or drug use and The service delivery system can be too acute health care needs, including taking counseled about the effects of these behaviors

P R I M A R Y D R U G P R E V E N TION Community Coalitions Are Powerful Agents for Change

Over the last 25 years, many community groups and coalitions have and training, public policy initiatives, media strategies and marketing sprung up to respond to a variety of social problems in the U.S. programs, and conferences and special events. The President’s Among the most powerful are coalitions that have worked to prevent Drug Advisory Council founded CADCA in 1992 and it is currently alcohol and drug use among youth and to achieve drug-free com­ funded by The Robert Wood Johnson Foundation, the Knight munities. These coalitions recognize that primary prevention is not Foundation, the Samuel Newhouse Foundation, the Annie E. so much a specific program – though those are important — but a Casey Foundation, and the K-Mart Corporation. process over time in which a variety of individuals and groups come • The Miami Coalition, which is a broadly-based community together to study and then address the problem of drug abuse and organization dedicated to reducing the problems of drug abuse, related issues (Rusche, 1995). The results include strengthened addiction, and directly related social issues. The Coalition serves organizations, more consistent policies, shared understanding of as a convener and facilitator, bringing together diverse local insti­ different viewpoints, changed social attitudes, and reduced drug tutions and organizations to determine how Miami-Dade County use. Three good examples of community coalitions are: can collectively tackle this major criminal justice and health crisis. • Join Together founded in 1991, which supports community- These groups have included law enforcement, medicine, education, based efforts to reduce, prevent, and treat substance abuse across business and commerce, the corporate workplace, the faith the nation. In 1996, Join Together broadened its scope to include community, media, the banking industry, neighborhoods, youth, gun violence prevention because of its belief that communities and families. The Coalition, which was founded by Dade County’s need to employ comprehensive strategies that respond to the corporate and civic leadership in 1988, spent much of its founding harms related to substance abuse. Join Together produces reports, year in a strategic planning process that resulted in a detailed newsletters, and community action kits; supports a National analysis of community needs and resources related to the local Leadership Fellows program; sponsors public policy panels that drug problem and the formation of task forces assigned to address examine and recommend changes in public policies and practices specific goals. This same process of analysis and response has related to substance abuse; provides technical assistance designed been continued and refined each year since then. to link people nationwide so that they can share information and resources; and conducts surveys to measure and define the For more information: Join Together, Boston, MA, 617/437-1500, community movement against substance abuse. Join Together is www.jointogether.org; Community Anti-Drug Coalitions of America, funded by a grant from The Robert Wood Johnson Foundation Alexandria, VA, 703/706-0560, www.cadca.org; The Miami Coalition, to the Boston University School of Public Health. Coral Gables, FL, 305/284-6848, www.miamicoalition.org. More information on primary drug prevention can also be obtained from • Community Anti-Drug Coalitions of American (CADCA), National Families in Action, a national drug education, prevention, which creates and strengthens the capacity of new and existing and policy center founded in 1977. NFIA, Atlanta, GA, 404/248-9676, coalitions to build safe, healthy, and drug-free communities. www.emory.edu/NFIA. CADCA supports its 4,300 members with technical assistance

A CO M P R E H E N S I V E A P P RO A C H 35 anti-HIV medication and opportu n i s t i c demic failure, violence, thefts, motor vehicle the extent and nature of the community’s in f ection prop h ylaxis as recommended. In crashes, homicides, injuries, suicides, and HIV, hepatitis, and injection drug use addition, a full range of co m p l e m e n t a r y, risky sexual behaviors (Ary et al., 1999; problems; a limited understanding of the af ford a b le, and accessible services should Berger and Levin, 1993; Cohen et al., 1997; community’s IDU populations; or polarized be made available, including substance abuse Donovan et al., 1988; Farrell et al., 1992; political and philosophical viewpoints tr eatment services, mental health servic e s , Osgood et al., 1988). among different organizations and providers. and help with other basic needs such as What can communities do to adjust their food, housing, child care, and job training. Next Steps for Communities programs to overcome these realities? This chapter has described the elements of a comprehensive approach to preventing the One important step that communities can P R I M A RY D R U G continued transmission of bloo d - b o rn e take is to assess existing IDU-related pre­ P R E V E N T I O N pa t h o ge ns among IDUs — eight strategie s vention needs, services, interventions, and Pr i m a ry drug prevention is a key strategy su p p o r ted by four essential principles. ba r riers in light of the compreh e n s i ve in a compreh e n s i ve approa ch to preven t i n g Health departments, community planning ap p ro a c h. The process of gathering this bloo d - b o r ne diseases among IDUs and groups, community-based organi z a t i o n s , information does not have to involve a reducing the spread to others. By helping health care and social service provi d e r s , formal or lengthy needs assessment. Health individuals avoid drug use and drug injection correctional facilities, policy makers, and d ep a rtment staff, service providers, and altogether, these programs help eliminate the others who work with IDUs are already other interested local groups may already risk of in j e c t i o n - r elated bloo d - b o r ne virus carrying out many of these elements and know much of this information or have transmission. Primary drug prevention pro- working in creative ways to enhance the ongoing working relationships with those grams, which are conducted in a variety of impact and reach of their efforts. who do. An important group to include in settings, including schools, families, and this process is IDUs themselves, for they At the same time, communities and com­ community-based organizations and through have a unique perspective on the programs munity planning groups must deal with a variety of channels, such as the media, are and services that are designed for them. various realities that hamper their ability to largely aimed at youth to encourage them Various reports have been written that also bring individual efforts together into a truly to avoid or delay the age of first use of pr ovide valu a ble backgro und information comprehensive approach. These realities can alcohol, tobacco, marijuana, inhalants, and and expe r t consensus on effec t i ve interven­ include limited funding; restrictive laws and other drugs. Avoiding or delaying substance tions (NIH, 1997b). regulations; community opposition; a lack of use can help youth prevent many problems trained staff; insufficient knowledge about The foll o wing questions, organized arou n d associated with it, including truancy, aca­ the four principles that guide the compre-

P R I M A R Y D R U G P R E V E N T I O N Learning What Makes A Program Effective

A number of primary drug prevention programs have been rigorously Indicated programs, which target people who are already experi­ evaluated and are recommended. They fall into several categories: menting with drugs or who exhibit other risk-related behaviors — Universal programs, which are designed to reach a general • Reconnecting Youth Program (Eggert et al., 1994; Eggert population, such as all students in school — et al., 1995) • Project Star (Pentz, 1995; Pentz et al., 1989) • Life Skills Training Comprehensive programs, which include several interventions Program (Botvin et al., 1990; Botvin et al., 1995a; Botvin et al., to reach the general population, groups at risk, or those already 1995b) • Adolescent Alcohol Prevention Trial (Donaldson et al., using drugs — 1994) • Seattle Social Development Project (Hawkins et al., 1992) • Adolescent Transitions Program (Dishion et al., 1998) • Adolescents Training and Learning to Avoid Steroids (Goldberg et al., 1996a; Goldberg et al., 1996b) • Project Family (Spoth, 1998) For more information: Drug Strategies, 1999; NIDA, 1997. Selective programs, which target groups at risk or other subsets of the general population — • Strengthening Families Program (Kumpfer et al., 1996) • Focus on Families (Bry et al., 1998)

36 A C O M P R E H E N S I V E A P P R O A C H he n s i ve approa c h, provide a framework for ENS URE COV E R AG E , • Are IDUs able to obtain services or communities to generate the inform a t i o n A C C E S S , AND QUALITY participate in inter ventions for a suffi­ ne c e s s a ry for this assessment. cient length of time (e.g., substance Assessing services and programs from abuse treatment that extends beyond these three perspectives will provide valuable ENSURE COO R D I N A T I O N initial detoxification)? insight into the strengths of existing pro- AND COLL A B O RAT I O N grams and services and the ways in which • Do the services obtained by IDUs com­ Successfully reaching IDUs must involve communities can build on these stren g t h s . plement and reinforce each other (e.g., a range of services and inter ventions. By This exercise can also shed light on the assistance with basic living needs provided definition, this means that different agencies, barriers that individuals face as they attempt along with substance abuse treatment, risk health and social services providers, health to obtain or participate in them and reveal reduction counseling that covers sexual risk professionals, and others active in the gaps or weaknesses in programs that must behaviors as well as drug use behaviors)? community must work together to plan, be addressed. carry out, manage, and monitor these efforts. R E COGNIZE AND Coverage Understanding ongoing efforts as well as O V E RC O M E STI GMA the attitudes of key players toward coordi­ • Which of the eight key strategies are In addition to collecting facts about services, nation is an essential first step to building being carried out at present? At whom programs, and interventions, it will be and maintaining effective collaborations. are they directed and how are they im p o r tant for those participating in the being implemented? • What kinds of collaborations and coor­ assessment to examine the community’s atti­ dination curren t ly exist among health • Ho w many IDUs rece i ve whic h servi c e s tudes toward IDUs, including the attitudes d ep a rtment staff, community planning and interventions (e.g., are there multiple of the general public, providers, and policy groups, community organizations, health outreach teams to cover the multiple makers. An important element of this task and social services providers, correc t i o n a l neighborhoods that have injection drug will be to exp l o r e the community’s legal , institutions, policy makers, and others use problems)? po l i cy , and social envi ro nment and how it who work with IDUs? affects the services and programs available Access • How might these collaborations be to IDUs. For example, one community may strengthened or new ones created? • Do IDUs know which prevention and have laws that penalize IDUs for carrying c a re services and interventions are syringes and an outspoken citizen group that • What barriers to coordination and available to them? opposes syringe excha n g e prog rams. Thes e collaboration exist (e.g., philosophical clearly are barriers to IDUs in their attempts • Wher e are services and interven t i o n s di f fer ences, organizational char a c t e r i s t i c s to obtain sterile syringes and reduce trans- located (e.g., in a central location only, in of service delivery systems, funding limi­ mission risks. Another community may have multiple “storefront” locations across the tations, legal or regu l a t o r y barriers, lack laws allowing possession of a certain number community)? of communication)? of sterile syringes and a strong outreach • How might these barriers be overcome? • What must IDUs do to obtain the services initi a t i ve with active peer-led education or interventions (e.g., get a referral, fill groups that are successful in helping IDUs • Do the various providers who work out forms, be on a waiting list, pay a fee, chan g e their behaviors. Learning about with IDUs (such as those in substance attend week l y sessions)? attitudes and environments and how they abuse treatment, public health, primary inhibit or encourage successful implemen­ care, criminal justice, mental health, and • What sort of barriers to these requir e­ tation of programs and services is critical. social services) have opportunities to ments exist and how can they be learn about each others’ issues and treat­ ameliorated? • How has the community responded to ment approaches and philosophies (e.g., effo r ts to establish and expand servi c e s Quality through cross-training, site visits, formal and programs for IDUs (e.g., substance or informal networking)? • Do IDUs obtain services and medica­ abu se treatment prog rams or drop - i n tions in appropriate and recommended clinics for IDUs)? • Are IDUs involved in planning, quantities (e.g., sufficient daily doses designing, and car rying out services • Is the current concept of addiction as a of methadone, psychosocial support and interventions? brain disease known and understood by services in tandem with substance providers and the public? abuse treatment)?

A CO M P R E H E N S I V E A P P RO A C H 37 • How have current attitudes about • What perce n t a ge of the IDUs in the Conclusion IDUs and resulting laws and policies community are homeless? Mentally ill? Preventing Blood-Borne Infections Among helped or hindered prevention and Have other serious medical conditions? Injection Drug Users: A Compreh e n s i ve Approach treatment initiatives? In what demographic, racial, or ethnic has described a critically important public groups do they belong? • What are the current laws and regulations health problem now facing our nation. The regarding sale, distribution, and possession • Do providers and service agencies have intersecting epidemics of injection drug use of sterile syringes? su ff icient staff who are culturally and and blood-borne pathogen infection present li n g u i s t i c a l l y capable of working with the multiple, long-term challenges that demand • Do syringe excha n ge progr ams operate co m m u n i t y ’ s IDU populations? immediate action. If this problem is to be in the community? Under what legal and effectively addressed, many different groups, organizational auspices do they operate? • Are IDUs involved in planning, designing, or ganizations, and individuals must work and carrying out services or interventions? singly and together to focus on both T A I LOR S E RVICES Because it may not be financially possible or epidemics. We hope that the comprehensive AND P RO GRAMS organizationally feasible for a community ap p ro a c h presented here provides some To effectively plan and deliver prevention to implement all eight of the strategies new ways of thinking about the problem and care services, providers and organizations described in this chapter, agencies, organi­ and about IDUs, some starting points need to understand the particular character­ zations, and providers will need to mak e for dialogue and collaboration, and some istics and risk profiles of the various IDU choices and trade-offs. The information that avenues for construc t i ve action. Injection populations in the community. Generating emerges from answering the questions listed drug users, their sex partners, and their this information will help providers to more above can help communities, community children have much to gain from this effectively reach those at highest risk. planning groups, and health departments new thinking, collaboration, and action. set priorities and plan programs because Neighborhoods, communities, and the • What are the demographic, language, it will reveal gaps in services, needs for nation also have a major stake in the and cultural characteristics of the IDUs expanded or new services, and existing success of these efforts, for reduced drug in the community? duplication of services and interventions. use and reduced HIV and viral hepatitis • Ar e there specific groups at partic u l a r ly The assessment also can be useful in helping transmission have concrete and long-lasting high risk of acquiring or transmitting organizations match high priority needs benefits — safer streets, healthier people, bloo d - b o r ne pathogens? with potential areas of collaboration as and a more productive society. they plan activities and determine how • Ifso, what are their particular patterns of funding, staff, and other resources are to drug use and sexual behavior and how do be allocated. these behaviors increase transmission risk?

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42 A C O M P R E H E N S I V E A P P RO A C H Appendix A Key Strategies for Preventing Blood-borne Pathogen Infection Among Injection Drug Users

Substance Abuse Treatment ...... A2

Community Outreach ...... A3

Interventions to Increase IDUs’ Access to Sterile Syringes ...... A4 Policy Efforts to Increase IDUs’ Access to Sterile Syringes ...... A6 Syringe Exchange Programs ...... A6 Initiatives with Pharmacists ...... A7

Interventions in the Criminal Justice System ...... A8

Strategies to Prevent Sexual Transmission ...... A9

HIV Counseling and Testing, Partner Counseling and Referral Services, and Prevention Case Management ...... A10 HIV Prevention Counseling and Testing ...... A10 Partner Counseling and Referral Services ...... A11 Prevention Case Management ...... A13

Coordinated Services for IDUs Living with HIV/AIDS ...... A14

Primary Drug Prevention ...... A14

References ...... A15

A P P E N D I X A A1 This Appendix details the eight key strate­ because of the complexity of the disease with lower HIV risk behaviors as well as gies of the comprehe n s i ve approa ch. Each and the freq u e n c y of relapse to drug use, lo wer rates of HIV serop re valence and section describes the service or intervention treatm ent req u i r es multiple episodes over a seroincidence (Abdul-Quader et al., 1987; and explains its importance, provides findings long period of time. Successful treatment Avins et al., 1997; Ball et al., 1988; Blix from research and programs, and describes can have a major impact on many areas of a and Gronbladh, 1991; Booth et al., 1996; the issues and barriers facing providers and person’s life, helping him or her improve Brown et al., 1988; Caplehorn and Ross, agencies in that area. family life, employment and health, and 1995; CDC, 1984; Friedman et al., 1995; decrease involvement with crime. Meandzija et al., 1994; Metzger et al., Substance Abuse Treatment 1998; Metzger et al., 1993; Moss et al., Treatment services differ in their approaches For injection drug users, substance abuse 1994; Novick et al., 1990; Orr et al., and components. They are generally divided treatment is a powerful disease prevention 1996; Serpelloni et al., 1994; Shoptaw et into five major kinds of programs (AED, st r a t eg y. Drug injectors who do not enter al., 1997; Williams et al., 1992). treatment are up to six times more likely to 1997; NIDA, 1999): Methadone is the medication most frequently become infected with HIV than are injectors • detoxification; who enter and remain in treatment (NIDA, provided to IDUs in substance abuse treat­ 1999). Substance abuse treatment helps • inpatient; ment because it is the most widely available and because many IDUs inject heroin or a users reduce the number of drug injections • therapeutic communities; and, thus, lower the risk of infection with combination of heroin and cocaine (Battjes HIV or hepatitis that might occur through • outpatient; and et al., 1991; Hahn et al., 1989; Haverkos, 1998; NIH, 1997). Methadone redu c e s unsafe injection practices, such as multi- • methadone maintenance. person use of syringes or sharing of drug p a t i e n t s ’c r avings for heroin and blocks its injection equipment. It also prevents or In addition, many drug users also partici­ effects , thereby enabling patients to redu c e reduces other harmful consequences of pate in self-help or 12-Step progr a m s , he r oin use and live more prod u c t iv e lives. dr ug use, such as abscesses or endocardi t i s . su c h as Narcotics Anonymous, Cocaine The effect iv eness of methadone trea t m e n t Fu rt h e r , because drug use impedes rational Anonymous, or Smart Reco very . By provid­ is dependent on many factors, inclu d i n g decision making, which can lead to high- ing a crucial support network of peers adequate dosing, a sufficient duration and risk behavio r , substance abuse trea t m e n t who are going through similar experiences, continuity of treatment, and the presence of can reduce the risk of HIV and hepa t i t i s these programs can reinforce and extend complementary services, such as psychosocial transmission through high-risk, unprotected more formal types of treatment services and medical support, counseling, and voca­ se x. Substance abuse treatment has broa d e r (NIDA, 1999). tional training (NIH, 1997). Some patients st a y on methadone indefin i t e l y; others social benefits as well because it can lead In the last decade, the overall effect i ven e s s progress to abstinence with decreasing doses to reduced health care costs, reduced drug- of substance abuse treatment has been of methadone. Several other medications can related crime and associated criminal justice demonstrated (Gerstein and Harwoo d , be used to treat opiate addiction, including costs, reduced interpersonal conflicts and 1990; Hubbard et al., 1989; NIDA, 1999; levo-alpha-acetylmethadol (LAAM) and d ru g - related injuries, and improved work- NIH, 1997; Pickens et al., 1991). A number naltrexone, but they have not been in exis­ place prod u c t i vity (NIDA, 1999). of studies have shown that persons who tence as long as methadone and are not as receive treatment reduce their alcohol and Drug addiction is a complex and chronic, wi d e ly used (NIDA, 1999; NIH, 1997). but trea t a b le, illness characterized by com­ drug use and improve their legal, employ­ pulsive, uncontrollable drug craving, seeking, ment, family, social, psychiatric, and medical Substance abuse treatment makes financial and use, even in the face of enormous neg­ situations (Anglin et al., 1989; Ball et al., sense as well. Every $1 invested in substance ative consequences. Though nearly all addicts 1988; DeLeon, 1984; Hubbard et al., 1989; abuse treatment reduces the costs of drug- believe initially that they can stop on their McLellan et al., 1994; Moos, 1974; Moos related crime, criminal justice costs, and own, most of their attempts result in failure et al., 1990; Simpson and Savage, 1980). theft by $4 to $7. The average cost of 1 to achi ev e long-term abstinence (NIDA, Overall, treatment for addiction is as year of methadone maintenance treatment 1999). Substance abuse treatment provides successful as treatment of other chronic is $4,700 per person. The cost of 1 year the medical, psychological, and behavi o r a l conditions, such as asthma, diabetes, and of imprisonment per person is about support necessary for an individual to stop hypertension (NIDA, 1999; O’Brien and $18,400. When health care savings are using drugs and for their brain processes to McLellan, 1996). Studies of me t h a d o n e added in, total savings can exceed costs by retu r n to pre-addiction functioning. Often, maintenance treatment have shown that a ratio of 12 to 1 (NIDA, 1999). participation in treatment is associated

A2 A P P E N D I X A Another compelling reason for provid i n g intake processes can discourage drug users to IDUs in the settings in which they live substance abuse treatment is that these from seeking treatment. Many communities and socialize. programs are a good way to reach drug st re n u o u s l y resist the introduction of drug Community outreach programs can make a users and their partners with other HIV treatment facilities in their neighborhoods, valu a ble contribution to HIV prevent i o n pr evention messages and interven t i o n s . and this limits the availability of treatment (Wiebel et al., 1996). These practical and Participation in these interventions offered for many IDUs. State and federal funding of rela t i vel y low-cost approa c hes are designed in the treatment setting is associated with substanceabuse treatment is insufficient to to reach IDUs at high risk of HIV and reduced drug- and sex-related risk behaviors make treatment avail a b le to all who need it. other bloo d - b o r n infections who are not (Calsyn et al., 1992; El-Bassel and Schilling, The effect i veness of substance abuse trea t ­ in conventional service systems. They can 1992; Malow et al., 1994; McCusker et al., ment depends on many factors, including its be the first step in developing an ongoing 1992). One of the most consistent findings goals, the length of time treatment lasts, the relationship with these drug users and ulti­ of both behavioral and serologic studies is doses of medications that may be prescribed, mately linking them with services. For those that early entry and longer duration of treat­ links to other services, and the characteristics users who are linked to conventional serv­ ment are associated with protection from of the user. Limitations in all of these areas ice systems, outreach is an important way HIV infection (Metzger et al., 1998). ma y pose significant barriers. For exam p l e , to reinforce educational and preven t i o n For example, twenty years of data collected an IDU in a methadone maintenance pro- me s s a g es and strategies. Because they are in the Bronx, New York, show that longer gram may rece i ve adequate medication but an individual- and community-level inter­ time in treatment is associated with a lower not the behavioral counseling or the case vention, they help create a community likelihood of HIV infection (Hartel and ma n a g ement and referral to other medical, culture of risk reduction among drug users, Schoenbaum, 1998). The strongest protective psychological, and social services that are their families, friends, and neighbors. This associations against HIV in this popula­ necessary for full and effective treatment. Or, culture of risk reduction also helps to sup- tion were early entry and continuous stay in he or she may receive lower methadone doses, port recovering drug users returning from methadone treatment plus higher methadone which compared to doses of 80-100 mil­ substance abuse treatment and those return­ doses (80 milligrams or higher per day). ligrams, are less effective (Strain et al., 1999). ing to the community from prison or jail. Despite clear evidence regarding the utility Community outreach is typically carried out and effect i veness of substance abuse trea t ­ Community Outreach in areas where drug users congregate — on ment in helping users reduce or eliminate Many IDUs do not participate in conven­ the street, in shooting galleries and crack their drug use and helping them address tional service systems that provide treatment houses, and in housing projects, emergency a host of other problems, significant bar­ and prevention services or medical, mental rooms, laundromats, and parks. The mes­ riers remain for IDUs to fully obtain health, or social welfare services. This is due sages and services are delivered by people these services. For example, data from the partly to funding and capacity limitations with whom the drug user is familiar and Substance Abuse and Mental Health on the part of the service systems and partly likely to trust, such as peers who live in the Services Administration’s (SAMHSA) to barriers that limit IDUs’ ability to use co m m u n i t y . This personal contact betwee n National Household Survey on Drug these systems. IDUs’ own attitudes and life outreach worker and IDU is an important Abuse (NHSDA) show that in 1996, circumstances also determine the extent to reason why community outreach can be more than 5.3 million people with severe which they use or are reached by conven­ influential in helping IDUs. Many commu­ substance abuse problems needed treatment tional service systems. The overwhelming nity outreach work ers are reco vering IDUs se rvices. However, only 37 percent rece i ved priorities of obtaining and using the drugs th e m s e l v es. A typical outreac h encounter such treatment (Epstein and Gfroerer, 1998). they are addicted to often prevent IDU s in vol ves fac e - t o - f ace communication that is Less than 20 percent of op i a t e - d ep e n d e n t from seeking services, such as HIV preven­ intended to assist IDUs in changing their individuals are in methadone maintenance tion, that may seem abstract or unimportant high-risk drug use and sexual behaviors. (NIH, 1997). Many IDUs cannot afford in comparison. In addition, the stigma and Ou t re a c h work ers may give out literature pr i vat e l y-funded services, and limitations nega t i ve attitudes of se rvice providers that on drug use, substance abuse treatment, in funding restrict the number of publicly are experienced by many IDUs leads them and HIV and how to prevent it, and provide funded slots. Even for those IDUs who are to mistrust government agencies and con­ information on available services. They al s o in treatment, the processes and proc e d u re s ventional service systems and be reluctant to di s t r i bu te condoms and blea c h kits for associated with participation may be daunt­ obtain services. Thus, to effectively provide decontaminating injection equipment and ing. For example, waiting lists, delays in prevention, treatment, and care services to help IDUs obtain services in the community, admissions and lengthy and cumbersome IDUs, it is essential to bring the services

A P P E N D I X A A3 such as housing assistance or mental health • needle disinfec t i o n ; IDUs and the peer outreach workers may tr eatment. Outrea c h also involv es work i n g af fect how messages are rece i ved. Thes e • entry into substance abuse treatment; and with drug users’ social and drug-using differences may also make it more difficult networks to extend and reinforce prevention • condom use. for the workers to establish trusting rela­ me s s a ges and build risk reduction skills. tionships with IDUs. A number of researchers have demonstrated Outreach can also be used to recruit drug the effectiveness of peer-delivered inter­ Environmental and structural factors also users to other activities, such as confidential ventions conducted by community health may hamper the effectiveness of community risk assessments, HIV testing and counsel­ outreach workers who were formerly active outreach efforts. For example, community ing, and substance abuse treatment, and to drug users, and peer-dr iv en interven t i o n s , outreach can face active opposition in the distribute sharps containers for safe disposal whic h are conducted by out-of-trea t m e n t community from powerful individuals such of used syringes . IDUs who are provided with guidance as neighborhood political leaders or local Ou t re a c h interventions were one of th e and struc t u r ed incentives and play an active drug dealers. The limited capacity of many earliest HIV prevention strategies designed role in their social networks in HIV pre­ substance abuse treatment programs means to reach high-risk IDUs. Results of a num­ vention. Overall, these studies suggest that IDUs may not be able to enter treat­ ber of studies and prog rams have shown that peers, whether former or active drug ment even if they are referred by an outreach that this approach, in fact, works. It can be users, can be ef fective in reaching large and worker. Further, existing laws and regula­ used to identify and contact IDUs and it diverse communities of out-of-treatment tions, such as restrictions on the sale of creates an atmosphere in which IDUs are users (Broadhead et al., 1998; Carlson and sterile syringes in pharmacies or prohibitions co m fo rt a b le talking about HIV preven t i o n . Needle, 1989; Cottler et al., 1998; Friedman against syringe exchange programs or criminal Community outrea c h is effect i ve in gett i n g et al., 1993; Jose et al., 1996; Latkin et al., penalties for possession of syringes, make IDUs to accept HIV-prevention literature, 1998; Neaigus, 1998; Sufian et al., 1991). it hard for outrea ch work ers to disseminate risk reduction materials, and referral serv­ They also suggest that peers are ef fective crucial prevention messages, such as the need ices, and outreach workers have played an role models for promoting reductions in to consistently use sterile syringes and make important role in providing condoms to dru g - r elated HIV risk behaviors with active it hard for IDUs to follow such advice. high-risk populations (Anderson et al., drug users, but less effective in changing Fi n a l l y, the rel a t i vel y unstruc t u r ed and 1996; Anderson et al., 1998). Follow-up sexual risk behaviors (Coyle et al., 1998). un s t a n d a r dized nature of community assessments have shown that IDUs have Although community outrea c h is cle a r ly an outreach work may make it difficult for regularly reported reductions in five major important element in any overall strategy to pr oviders to identify consistently effect i ve risk behaviors after participating in com­ reach IDUs, it has its challenges. By its very strategies. It also may be hard to measure munity outreach interventions (APA, 1996; na t u re , it is clie n t - c e n t e r ed and less formal the outreach process and control for extra­ CDC/ACDP, 1999; Coyle et al., 1998; and struct u r ed and therefore can be more neous factors, and attrition can skew research Semaan et al., 1998; Sumartojo et al., difficult to supervise and monitor. Outreach results. Cohort effects may promote socially 1997). These inclu d e : work is demanding and workers must con- desirable responses among those who return • stopping drug injection; tend with freq u e n t l y difficult conditions, for follow-up, making self-reports less in c luding unsafe neighborhoods, incle m e n t valid measures of in t e r vention effect s . • reducing freq u e n cy of in j e c t i o n ; weat h e r , and, for those work ers who have • reducing multi-person reuse of sy r i n ges ; had drug problems, situations that may Interventions to Increase IDUs’ challenge their own recovery. Outreach staff Access to Sterile Syringes • reducing multi-person reuse of ot h e r need reinforcement, training, and support Clearly, the best way for injecting drug equipment, such as cookers, cotton, and to avoid burnout and the risk of relapse to users to avoid the problems of drug use rinse wate r ; and drug use and to help them understand the and blood-borne infection is to stop • reducing crack use. li f estyles or cultures of pa r ticular IDUs injecting and enter substance abuse treat­ (AED, 1999). Another issue in community ment. However, many drug users either They also have reported increases in outreach strategies that use peers is defining cannot get into substance abuse treatment three protective behaviors (APA, 1996; who a “p e e r ” rea l l y is. Some current IDUs programs or will not stop injecting drugs. CDC/ACDP, 1999; Coyle et al., 1998; may not consider a former user to be their Even those injectors who stop drug use Semaan et al., 1998; Sumartojo et al., 1996): pe e r . Demographic differ ences between the through substance abuse treatment may

A4 A P P E N D I X A relapse to injecting drugs. Given these In essence, IDUs are in a Catch-22 situation. approximately 1,000 injections each year, realities, several governmental bodies and They are advised to enter substance abuse which even in a moderate-size city adds up in s t i t u t i o n s 1 have recommended consistent, treatment and, if they continue to inject, to to millions of injections a year (Lurie et one-time-only use of sterile syringes to use only sterile syringes, but major structural al., 1998). Therefore, achieving the recom­ prepare and inject drugs as a central strategy and environmental factors—insufficient sub- mendation of the one-time-only use of in a comprehensive effort to reduce the stance abuse treatment capacity and syringe sterile syringes will require the coordination transmission of HIV and other blood- laws that make it illegal to obtain or possess of all of these interventions so that IDUs borne pathogens among those individuals sterile injection equipment—effectively who continue to inject will be able to obtain who continue to inject drugs. reduce IDUs’ ability to carry out this advice. and safely dispose of a sufficient number of sterile syringes to prevent the acquisition or Currently, IDUs obtain syringes in Three types of in t e rven tions are now being transmission of blood-borne pathogens. several ways: pursued in the U.S. to ameliorate the second of these two structural barriers and increase The magnitude of this challenge to adequate • th r ough illegal or “black marke t ”s o u rc e s , IDUs’ access to sterile syringes. Several states coverage is illustrated by Montreal, a city such as street drug dealers (individuals who and municipalities are engaged in policy efforts that has made major strides in ensuring that sell drugs and syringes to IDUs), needle to change existing syringe laws and regulations to IDUs can obtain sterile syringes (it does not dealers (individuals who sell syringes to allow increased pharmacy sales of syringes, pr ohibit the sales of sy r i n g es without pre­ IDUs), “shooting galleries,” or friends, remove criminal penalties for syringe pos­ scription, it encourages pharmacy sales, injection partners, or diabetics — these session, and include language in laws stating and it has active and well-supported syringe sy r i n g es may have been used and contam­ that preventing HIV and other blood-borne exchange programs). An analysis estimated inated with blood; some dealers “reseal” pathogens is a “legitimate medical purpose” that in 1994 Montreal’s 10,000 IDUs used syringes in their packaging to make for prescribing sterile syringes. Many juris­ injected 10,683,000 times (Remis et al., them appear to be new (Des Jarlais et al., dictions are carrying out efforts to sustain 1998). About 338,000 sterile syringes 1985; Glegh o r n et al., 1995; Gros e cl o s e and expand syringe exchange programs,which were distributed through pharmacy sales et al., 1995); provide IDUs with free sterile syringes and a and syringe exchange programs. This • by purchase from pharma c i es — thi s way to safely dispose of blood-contaminated meant that only 3.2 percent of the need ensures that the syringes are sterile; and used syringes. Initiatives with pharmacists also for sterile syringes was being met. Based on are underway to provide education about these results, the Montreal Regional Public • th r ough syringe exchan ge programs the role of sterile syringes in reducing the Health Department removed the quota of (S E P s) — this ensures that the syringes transmission of blood-borne pathogens, 15 syringes that could be exchanged at one ar e sterile. address pharmacist concerns and questions time and drafted an action plan to expand Most states have legal and regulatory about syringe sales and disposal, and encour­ the number of sites for syringe distribution restrictions on the sale and distribution age changes in pharmacy policy and practice. th rou gh community organizations, health of sterile syringes: 47 states have drug para­ centers, and pharmacies, with a target of All of these interventions are closely phernalia statutes, 8 states have syringe more than 1 million syringes distributed interrelated and the success of one partly prescription statutes, and 23 states have by 1997. In 1996, 500,000 syringes were depends on the success of the others. The pharmacy regulations or practice guidelines. di st ributed. Though this represented signifi­ effectiveness of interventions that encourage These restrictions present a significant cant progress, the number distributed in pharmacists to sell syringes to IDUs, for barrier to the sale of sterile syringes to 1996 was still far short of the number of example, is enhanced when laws and regu­ IDUs by pharmacists, the prescription of sterile syringes needed. lations that limit pharma cy sale of sy r i n ge s sterile syringes to IDUs by physicians, the and that prohibit possession of syringes In October 1999, the American operation of syringe exchange programs, are repealed. Similarly, for IDUs to openly Medical Association (AMA), the American the safe disposal of blood-contaminated participate in syringe exchange programs, Ph a r maceutical Association (APhA), used syringes, and ultimately, to the efforts the public health implications of laws that the Association of State and Terri t o r i a l by IDUs to reduce their injection-related ma k e possession of sy r i n g es a crime should Health Officials (ASTHO), the National risks of acquiring or transmitting blood- be reviewed. An individual IDU makes Association of Boards of Pharmacy (NABP), borne pathogens (Gostin, 1998).

1This includes the U.S. Public Health Service, the Institute of Medicine of the National Academy of Sciences, and the U.S. Prevention Services Task Force.

A P P E N D I X A A5 and the National Alliance of State and (Groseclose et al., 1995; Valleroy et al., various stakeholders (Beckett et al., 1998): Territorial AIDS Directors (NASTAD) 1995). In 1993, Maine changed its laws • surveying pharmacies to identify current issued a joint letter urging state leaders in so as to allow anyone aged 18 or older to syringe sale policies, practices and barriers; medicine, pharmac y, and public health to purchase from a pharmacy any quantity of coordinate action to improve IDUs’ access syringes (Beckett et al., 1998). In January • building coalitions to work for legislative to sterile syringes through pharmacy sales. 1997, the Maine state legislature adopted action to modify or repeal criminal penal- They encouraged public health leaders to rules to permit legal syringe exchange and ties for possession of sy r i n g es; and work to reduce state-level legal and regula­ to remove the criminal penalties for pos­ • conducting conferences and other aware­ tory barriers that restrict access, expand sessing 10 or fewer syringes. Other states ness-building events among a wide variety availability of substance abuse treatment, have tried other approaches. For example, ofinterest groups (pharmacists, substance and improve options for safe disposal of some state legislatures have given health abuse specialists, law enforcement officers, syringes (NASTAD, 1999). This statement departments the power to establish SEPs legislators, HIV prevention providers, builds on previous similar policies adopted and to exempt them from drug parapher­ drug users, and advocates of drug users) by the APhA in 1999, the AMA and nalia and syringe prescription statutes. Five to discuss relevant issues and necessar y NASTAD in 1997, and ASTHO in 1995. states (Hawaii, Maryland, Massachusetts, action steps. New York, and Rhode Island) and the POLICY E FFOR TS T O District of Columbia have carved out S Y R I N G E E X C H A N G E I N CRE ASE IDUS’ A C C E S S an exemption in their drug paraphernalia P RO G R A M S TO S T ER I L E SYRINGES laws for SEP staff and participants. Three states have specifically exempted SEPs Syringe exchange programs (SEPs) are a As described above, most states prohibit from their prescription laws (Connecticut, second important strategy for increasing IDUs from possessing or carrying sterile Massachusetts, Rhode Island). In California, IDUs’ access to sterile syringes. SEPs syringes and many states bar their sale legislation went into effect in January 2000 allow IDUs to exchange their used needles without a valid medical prescription. The that permits the use of public funds for and syringes for new, sterile injection equip­ result of these restrictions is that even if SEPs after a local agency has declared a ment at no cost. By collecting used injection IDUs are legally able to acquire sterile health emergency for hepatitis C and AIDS. equipment, SEPs remove blood-contaminated syringes, they often do not want to carry However, the city or county must renew the syringes from circulation and allow for safe and are unable to safely dispose of them state of emergency every 14 days to keep the disposal of equipment that may have been because of the potential for arrest and new law in effect. New legislation exempts contaminated with HIV or hepatitis. SEPs criminal prosecution (Bluthenthal, Kral et cities and public employees from criminal were first introduced in the United States al., 1999; Bluthenthal, Lorvick et al., 1999; prosecution if the SEP is operating under a in the late 1980s. By 1997, there were 123 Koester, 1994; Springer et al., 1999). This declared public health emergency. programs in 33 states, the District of environment serves to increase transmission Columbia, Puerto Rico and Guam (CDC, risk because IDUs who are concerned about Results from states that have changed their 1998a). These programs exchanged over being arrested for obtaining or car rying laws have been positive. For example, after 17 million syringes in 1997, but two- syringes are more likely than other IDUs Connecticut parti a l l y repealed its syringe thirds of these were exchanged by the 10 to share syringes and injection supplies laws, most pharmacies in the state (about largest programs. One-half of the SEPs (Bluthenthal, Kral et al., 1999; Bluthenthal, 87 percent) began to sell nonpres c r i p t i o n distribute fewer than 50,000 per program Lorvick et al., 1999). syringes, though in limited numbers (Valleroy per year. SEPs in the U.S. are able to cover et al., 1995; Wright-De Agüero et al., 1998). Although widespread negative opinions only a small percentage of the need for As a result, fewer IDUs bought syringes on of drug users and a reluctance to appear sterile syringes. the street, syringe sharing decreased, and su p p o rt i ve of dr ug use make it difficult to police repo r ted fewer needlestick injuries IDUs are drawn to SEPs because they get chan g e syringe laws and regulations, severa l (Groseclose et al., 1995). fr ee syringes. This “p a s s i ve outreach” str a t­ states have done so. In 1992, Connecticut egy has an added benefit because it gives partially repealed its laws and regulations Those in Maine who worked for success­ programs an efficient way to reach IDUs that limited pharmacy sales of syringes ful policy changes to improve access to with additional services and interven t i o n s . and made possession of syringes a crime. sterile syringes attribute their success to These services include HIV/AIDS educa­ This allowed pharmacy sales of up to 10 the following actions, which were focused on tion and counseling; condom distribution syringes without a prescription and legalized building an environment of collaboration to prevent sexual transmission of HIV; the possession of up to 10 clean syringes and a sense of common purpose among the

A6 A P P E N D I X A primary medical services; referrals to sub- Despite their success, syringe exchan g e Ev en in states that have partia l l y or com­ stance abuse treatment and other medical programs face continuing chal l e n ges. Thes e pletely repealed laws and regulations banning and social services; bleach distribution for in c lude legal and regu l a t o r y rest r i c t i o n s , the sale of sterile syringes, however, sales may disinfecting injection equipment; distribution precarious funding, and, in some locations, be hampered by specific pharmacy store of alcohol swabs to help prevent abscesses community opposition. While some com­ policies restricting the sale of sy r i n g es to and other bacterial infections; on-site HIV munities welcome SEPs, others strenu o u s l y IDUs, the personal reluctance of individual testing and counseling; crisis intervention; reject them. This opposition comes from p h a rm a cy managers or pharmacists to sell and screening for tuberculosis,hepatitis B, local leaders, the general public, or residents syringes to IDUs, or other factors that create hepatitis C, and other infections. SEPs vary of the neighborhoods in which they woul d ba r riers to buying syringes. For exam p l e , widely in their locations (fixed versus rov­ be located. Some objections relate to beliefs p h a rm a cy practice regulations that require ing sites), hours of operation, the number that SEPs will increase drug use among purchasers to show identification, sign a of syringes allowed for exchange, and participants and attract youth or new indi­ register of sy r i n g e purchasers, and confirm other policies. viduals to drug use. Other objections are that the syringes sale is for a “l eg i t i m a t e ” that SEPs will threaten the safety of the purpose, reduce IDUs’ ability or willingness Because of the controversy associated with community because they will foster an to come into the pharmacy and buy syringes. SEPs, a great deal of research has been con­ increase in illicit drug sales in the area and These policies and attitudes are partly due ducted on their effects and outcomes. This result in people discarding contaminated to store managers’ and pharmacists’concerns work has shown that SEPs have significant syringes in the community. However, a recent that IDUs will discard contaminated syringes positive effects on preventing adverse health study examining the potential effect of SEPs around their businesses and in the commu­ consequences associated with injection drug on the formation of drug-using social net- nity (Case et al., 1998; Gleghorn et al., 1998; use and that SEPs do not increase drug use works found that this was unlikely to occur Singer et al., 1998; Wright-De Agüero et or promote the initiation of injection drug (Junge et al., 2000). al., 1998). Another reason may be the use (Des Jarlais et al., 1996; Hagan et al., limited amount of training and academic 1995; Heimer, 1998; Heimer et al., 1994; I N I T I A TIVES W I T H material on addiction and the rela t i o n s h i p Kaplan and Heimer, 1992; Lurie et al., P H A R M AC I S T S be t w een injection drug use and bloo d - 1993; Vlahov and Junge, 1998; Vlahov et al., borne pathogens provided by schools of 1997; Watters et al., 1994). Other benefits The Public Health Service recommenda­ p h a rm a cy to their students. of SEPs are that they can facilitate the entry tion that IDUs who cannot or will not of IDUs into substance abuse trea t m e n t stop injecting should consistently use Some states are carrying out interven t i o n s and other services that can reduce the sterile syringes to prevent transmission of with pharmacy managers and pharmacists in risk of HIV infection (Heimer, 1998). blood-borne infections provides a legitimate conjunction with efforts to repeal restrictive SEPs have also been shown to successfully medical foundation for the sale of st e r i l e laws and regulations that limit pharmacy engage IDUs as peer outreach workers syringes to IDUs. Pharmacies, therefore, can sales of sy r i n g es. For example, several state to create new exchangers and increase the play a crucial role because they are a reliable health departments are working with state number of syringes exchanged (Whiticar source of sterile syringes. Pharmacies are pharmacy associations, medical societies, and and Smetka, 1999). conveniently located in most neighborhoods, bo a r ds of ph a r macies to raise aware n e s s and often have extended hours of operation. about the barriers to the purchase of sterile Results showing higher HIV incidence Many are open 24 hours a day. In addition, sy r i n g es and to review current laws and among IDUs using SEPs in Vancouver they are staffed by trained, licensed pro­ regulations. In Connecticut, Minnesota, and (Strathdee et al., 1997) and Montreal fessionals who are able to provide sound Maine, where laws prohibiting the purchase (Bruneau et al., 1997) have been interpreted medical advice and to make referrals for a or possession of syringes have been partially by some to suggest that SEPs may contribute variety of related services, including HIV repealed, partnerships between health to the spread of HIV. However, investigators testing and counseling, substance abuse d ep a rtments and pharmacies have been in these cities have shown that SEPs are not treatment, health care, and other community formed, education has been conducted to ca u s a l l y associated with HIV transmission services. They also provide a safe environ­ ad d r ess pharma c i s t s ’ con c e r ns, and phar­ and that this association was confou n d e d ment for IDUs to make their purchases and macists have been encouraged to sell syringes by the fact that SEPs attract higher-risk some degree of anonymity for those IDUs to IDUs. Results from one peer education users (Archibald et al., 1996; Schechter et who do not want to self-identify by going program for pharmacists in Connecticut al., 1999). Both Canadian cities have con­ to an SEP. Some pharmacies accept used demonstrate that pharmacists can become tinued to expand their SEP services. syringes for disposal. ac t i ve participants in AIDS preven t i o n

A P P E N D I X A A7 ac t i vities; pharmacies, schools of ph a rm a c y crime for whic h they were in correc t i o n s ; Risk reduction strategies have not been and local health depa r tments can devel o p committed their offense to get money for widely adopted in U.S. correctional systems. co l l a b o r a t i ve linkages to carry out HIV drugs; had a history of alcohol abuse, or For example, only two state prison systems prevention for IDUs; and professional peer sh a r ed some combination of these char a c­ and four city/county jail systems make con­ education for pharmacists can be effective teristics (Belenko, 1998). In 1996, an esti­ doms avail a b le to inmates. However , most in expanding prevention services for IDUs mated 250,000 state prison inmates had correctional systems provide HIV antibody (Weinstein et al., 1998). injected drugs, including 120,000 who had testing, although testing policies differ widely. sh a r ed needles. Some 14,000 federal prison Few systems rout i n e l y screen inmates for Despite this prog ress, states and organi z a­ inmates had injected drugs, including6,000 STDs and only limited viral hepatitis pre­ tions face a number of si g n i f icant chal­ who shared needles (Bel e n k o, 1998). vention and treatment services are available. lenges as they work with pharmacists to change policies related to selling sterile At the same time, inmates in prisons and The few systems that provide an inte­ sy r i n g es to IDUs. One important chal l e n g e jails have disprop o rt i o n a t e l y high rates of grated continuum of care for at-risk is attitudinal. Pharmacists are trained to HIV infection and other STDs, hepa t i t i s , and HIV-infected inmates provide the distrust IDUs and drug users, who may try and other health problems. At the end of foll o wing services: to use bogus prescriptions or rob the phar­ 1996, 2.3 percent of male and 3.5 percent • sc r eening and identification of me d i c a l macy. They may also fear that an increase of female state and federal prison inmates and psychosocial problems; in sales of sy r i n ges to IDUs might attract were known to be infected with HIV dr ug users to the neighborhood and crea t e (Hammett et al., 1999). Confirmed AIDS • case management, including the use of a sa fe ty and littering problems. cases were found in 0.5 percent of all medical treatment plan; inmates, a rate six times higher than that Sales of sterile syringes also raise issues • substance abuse trea t m e n t ; of the total U.S. population. The high-risk related to safe disposal of used syringes. be h a viors res p o n s i b le for the transmission • provision of antiretroviral medications and Community options for safe disposal of used of HIV and other bloo d - b o r ne illnesses prophylaxis of opportunistic infections; syringes are often limited. The public worries among inmates include high-risk sexual that IDUs will discard syringes in their • mental health servi c e s ; activity, sharing of needles and other drug neighborhoods without recognizing that injection equipment, and tattooing with • hospice care; diabetics who use insulin contribute a sub­ im p ro vised tools and materials (Calzavara stantial number of used syringes (Macalino • discharge planning; and et al., 1997; Dolan et al., 1996; Mahon, et al., 1998). Further, pharmacists may 1996; Struckm a n - J ohnson et al., 1996). • continuity of care and community linkages mistakenly equate the pharmacy sale of when prisoners are rele a s e d . sy r i n g es to IDUs with syringe excha n g e in Given the large numbers of IDUs involved the pharma c y. with the criminal justice system and the large Although few HIV prevention programs in numbers of at-risk and infected individuals, correctional settings have been rigorously Interventions in the Criminal this setting is a crucial venue for HIV- and evaluated, limited evidence suggests that Justice System hep a t i t i s - r elated interventions and servic e s . they can be successful in reaching this high- Because the possession and sale of il l i c i t Providing a range of health and prevention risk population with practical risk-reduction drugs and syringes are crimes and drug users education interventions to inmates not only messages (Hammett et al., 1999). For are often involved in crimes to support their benefits them and their overall health, but example, several innovative models of prison- drug addiction, IDUs are frequently arrested can improve the health of the communities based substance abuse treatment programs or in prison or jail. A recent study on sub- to which the vast majority of inmates return that use a therapeutic community approach stance abuse and prisoners found that 81 (Hammett et al., 1999). have resulted in reduced rates of return to percent of state inmates, 80 percent of the correctional system and sustained drug Pr evention services current l y offered to federal inmates, and 77 percent of local jail abstinence and condom use at follow-up in c a r cerated populations vary widely acros s inmates had used an illegal drug regularly; (Field, 1989; Inciardi, 1996; Wexler et al., state, county, and city jails and prisons. They been incarcerated for drug selling or pos­ 1994). These innovative programs include include instructor-led and/or peer-led HIV session, driving under the influence of New York State’s Stay’n Out, Oregon’s education, pre- and post-test counseling, alcohol (DUI) or another alcohol abuse Cornerstones program, and Delaware’s multi-session prevention counseling, the use violation; were under the influence of alco­ Crest Outreach Center program. Jail-based ofaudiovisual materials, and the distribution hol or drugs when they committed the methadone maintenance has shown positive of printed materials (Hammett et al., 1999).

A8 A P P E N D I X A results among participants, including low­ also lacking for HIV-infected IDU inmates. the frequent movement of inmates within ered rates of drug use and criminality Ma n y HIV seronega t i ve and seropo s i t iv e and between facilities disrupts the continuity after release (Magura et al., 1993). inmates leaving the system, including those of educational progr a m m i n g , counseling, using antiretroviral drug therapy for HIV and care. Requ i r ements that prisoners be One of the most important types of inter­ infection, still do not receive appropriate dis­ escorted by guards to meetings with health ventions in prisons and jails is education and charge planning or continuity of su b s t a n c e and HIV prevention staff may rest r i c t prevention efforts led by inmates themselves. abuse treatment and medical services after in m a t e s ’ par ticipation in counseling and These prog rams can be cost-effec t i ve and release. Without planning and support, many education initiatives and significantly threaten flexible, and they have an added cred i b i l i t y ex-prisoners are arrested and jailed again. confidentiality protections. The prohibition that programs led by outsiders cannot match. against condom distribution because they Pee r-led pro grams also provide signifi­ These gaps occur for a variety of reasons. A are considered contraband closes off a major cant benefits to peer educators themselves. primary reason is financial. HIV prevention risk reduction intervent i o n . Through participating in the progr a m s , and treatment services, particularly treatment these inmates can develop a positive focus services, can be costly and the issue of Finally, HIV education programs face in their lives, regain a sense of purpose and who should pay has not been adequately challenges in working with diverse inmate empowerment, and realize that they are addressed. Because inmates are legally wards populations having different cultures, lan­ able to influence others in ways they never of the government correctional system, guages, and literacy levels or who may be believed pos s i b le (Hammett et al., 1999). health and substance abuse agencies (for incarcerated for only a short time. The careful selection of peer trainers and example, Medicaid) do not pay for services open support of corrections staff are among inside prisons and jails. At the same time, Strategies to Prevent Sexual the factors contributing to the success of most correctional systems have limited Transmission such innovative programs as the peer pro- budgets to address issues related to preventing Se xual transmission of HIV and hepa t i t i s gram at Louisiana State Peni t e n t i a r y in and treating substance abuse, blood-borne involving IDUs is an important factor in the An go la, the AIDS Counseling and Trus t diseases, and mental health issues. spread of these diseases in the U.S. In 1999, program at Louisiana’s Avoyelles Correctional 13 percent of the new AIDS cases repo rt e d A second major reason relates to differences Ce n t e r , the peer prog rams in California’s that year were among men and women whose between the philosophies, perspectives, and state prisons at San Quentin, Frontera, and se x partners were IDUs. Thi r teen percen t priorities of pu b lic health and correc t i o n a l Vacaville, and the AIDS Video Project and were among male IDUs who also reported agencies. When these differences are not Peer HIV Education Project in the Los having sex with other men (CDC, 1999a). se n s i t i vely addressed, they can make collab­ An g eles County Juvenile System. Severa l High-risk sexual behavior is also strongly oration difficult because they undermine in n o vat i ve models of in s t ru c t o r -led HIV/ associated with hepatitis B transmission respect by public health staff for the skills AIDS education and prevention programs (CDC, 1999b). High-risk drug behaviors and expertise of correctional medical staff also have evolved in correctional systems. and high-risk sexual behaviors are often and other cor rectional staff and they pro- These include the Forensic AIDS Proj e c t linked (Chu et al., 1998). For example, a mote obstruction and lack of cooperation conducted in the San Francisco jails and the large portion of IDUs use alcohol and/or on the part of correctional staff Corrections AIDS Prevention Program con­ cr a c k cocaine, whic h are often associated (Hammett, 1998). ducted at Rikers Island in New York City with increased frequencies of unsafe sexual (Hammett et al., 1999). A third cha l l e n g e facing efforts to redu c e behavior (Edlin et al., 1994). Some IDUs HIV and other blood-borne illnesses among su p p o r t their drug habits by exchan g i n g Although many correctional systems in the IDUs in prisons and jails is the primary need se x for money or drugs. For these reas o n s , U.S. have instituted HIV prevention serv­ for correctional systems to maintain security the extent to which IDUs change their sexual ices, numerous gaps in covera g e still exis t and to control inmates. Administrators of behaviors in response to these diseases is for IDUs, both for those in the system and correctional systems often do not want to critical. This is parti c u l a r ly true in light of those leaving jail or prison to return to their acknowledge that HIV risk behaviors, such evidence showing that although IDUs will home communities. Gaps for those in the as men having sex with men or injection drug ma k e large chan ge s in their injection risk system can be found in insufficient num­ use, are occurring in their facilities. Prisoners behavior in response to concerns about bers of i n s t ru c t o r-led and peer-based HIV also may not want to acknowledge these AI D S , chan g es in sexual behavior are gen­ education and prevention programs. For all behaviors for fear of sanctions. In addition, erally more modest. All studies that have inmates, there is a lack of co m p re h e n s i ve sp e c i f ic security measures limit the effec­ compared changes in injection risk behavior substance abuse treatment and mental health ti veness of pre vention efforts. For exam p l e , with changes in sexual risk behavior found services. Supervised medical care services are

A P P E N D I X A A9 greater chan g es in injection risk behavi o r (CDC/ACDP, 1999), the use of a problem- test results and the person’s history of risk (Friedman et al., 1993). In addition, it solving therapy model in a male detention behavior and other factors determine whether appears that IDUs are more likely to change center (Magura et al., 1994), and a condom he or she is referred to the other servic e s . sexual risk behaviors (reduce number of giveaway program at an outpatient sub- Because these three types of services are partners, increase use of condoms) with stance abuse treatment program (Calsyn clie n t - c e n t e r ed and one-on-one, they have casual sexual partners than with their pri­ et al., 1992). the potential to address the complex lives mary sexual partners (CDC/ACDP, 1999; and circumstances of some IDUs and more In developing strategies to reduce sexual Friedman et al., 1994; Friedman et al., effectively influence their risk behaviors transmission, agencies and organi z a t i o n s 1999) or with sexual partners who do not than can more limited and diffuse inter­ should tailor them to specific high-risk inject illicit drugs (Friedman et al., 1994; ventions. In addition, these services have groups (for example, in-treatment as well as Friedman et al., 1999; Vanichseni et al., the potential to provide the continuity of out-of-treatment drug users) and to specific 1993). The reluctance to use condoms care that is so important to successful out- goals (for example, preventing acquisition of with main partners may be partly due to comes. Each of these services is discussed infection in uninfected IDUs and preventing concerns that such action violates the inti­ in greater detail below. transmission from infected IDUs to others). macy and trust developed in the relationship. These strategies should also take into HIV PREV E N T ION Di s t r i b uting condoms and information consideration the determinants of sexual C O U NSELI N G AND ha ve been an important means of he l p i n g transmission, including the consistency of T E ST I NG (C& T ) IDUs reduce their risk of sexual transmis­ condom use, the presence of co n c u r ren t sion. These materials are given out for free STDs, the presence of concurrent injection HIV C&T is a prevention intervention by most outreach workers, syringe exchange drug and crack use, and the extent of sexual that provides HIV antibody testing and and other risk reduction programs, drug activity while high. Interventions designed individual, client-centered risk reduction users’ organizations, and some substance for the sexual partners of IDUs are an counseling. It provides a private and confi­ abuse treatment programs. One-on-one im p o r tant element of these strategi e s . dential way for individuals to learn their HIV sexual risk reduction counseling and group serostatus and get further help, whatever interventions are also conducted by peers to HIV Counseling and Testing, Partner the results of the testing. address skills building and rehearsal, inter- Counseling and Referral Services, HIV antibody testing is provided to individ­ personal communication, problem-solving, and Prevention Case Management uals who seek, either through private care situational analysis, and self-manageme n t A compreh e n s i ve approa c h to preven t i n g providers or publicly funded programs, to st r a t e gies. Intervention strategies for fema l e HIV and other bloo d - b o r ne infect i o n s determine if they are living with the HIV drug users and sexual partners of drug users among IDUs must include the capacity virus. If the results of the test are positive, ha ve stressed the importance of buil d i n g to allow individuals to discover whether they can be referred to clinical care and self-esteem, social supports, and sexu a l they are infected, and if they are, to help case management. If the results are negative, negotiation skills to encourage safer sex them inform their partners. If they are not they can receive counseling and suppor t practices with partners. infected but engage in high-risk practices, the approach can also help IDUs begin or for risk reduction ef forts and referrals for Se veral approaches to sexual risk redu c t i o n sustain behavior chan ges that will redu c e needed services. in t e r ventions have had partic u l a r ly good their risk of acquiring or transmitting the The counseling element, a short- t e r m results. For example, skills-building interven­ in f ection. Three services are designed to in t e r vention involving two brief ses s i o n s tions that target sexual risk reduction have meet these objectives: (one before and one after the antibody sh o wn more positive effects in improvin g test), has several functions, including: drug users sexual risk reduction than have • HIV prevention counseling and interventions that try to target risk reduction testing (C&T); • offering information on HIV testing and in general (Beardsley et al., 1996; El-Bassel • partner counseling and referral servi c e s helping a client make a decision about and Schi l l i n g , 1992; Schilling et al., 1991). (PCRS); and being tested; Other interventions that have been effec­ • helping clients understand their resp o n s i­ tive in sexual risk reduction with drug • prevention case management (PCM). bility, if their HIV test results are positive, users have included the AIDS Community HIV counseling and testing services are for ensuring that sex and drug-use partners Demonstration Projects in five U.S. cities gene r a l ly the first step. The HIV antibody ar e infor med of their possible exposure,

A10 A P P E N D I X A and for referring their partners to HIV second visit to receive results can be difficult HIV medical care, case management, and prevention counseling, testing, and other to manage. Another possibility that could support services. Finally, and most impor - su p p o r t services; be used effec t i vel y with IDUs is oral flui d tant for IDUs, publicly funded HIV C&T testing kits, which allow antibody testing does not now include counseling, testing, • reviewing all avai l a b le options for partne r without the need for a blood sample. This and treatment for other blood-borne counseling and referral services (PCRS); permits HIV testing to be carried out in out- infections that have a significant impact • helping assess a clie n t ’ s risk of ac q u i r i n g reach settings, making it much easier to reach on IDUs, particularly viral hepatitis. or transmitting HIV; a larger number of IDUs with this service. P A RTNER COUNSE LING • helping clients develop a realistic and incre­ Research conducted among IDUs and other AND RE F ERR AL SERV I C E S mental plan for reducing their risk; and drug users has shown that HIV C&T has ( P C R S ) resulted in some beneficial behavior changes, • offering referrals to clients for substance including positive impacts on both drug- PC R S, also known as partner notifica t i o n , abuse treatment or other interventions, such related and sexual practices (Gibson et al., is a public health activity that evolved from as prevention case management (PCM), 1999). As with general at-risk populations, “contact tracing” ac t i vities developed earli­ for more intensive risk reduction services C&T has produced a more positive effect er in the 20th century for the control of if needed. with HIV-infected drug users than with sexually transmitted diseases, parti c u l a r ly Given that many IDUs mistrust conven­ HIV-negative or untested IDUs (Weinhardt syphilis. Public health workers conduct tional health service systems or are unable et al., 1999; Wolitski et al., 1997). Studies confidential interviews with newly identified to obtain services, agencies and providers with general at-risk populations and IDUs infected persons to find out the names of must offer C&T services in settings where have shown that both standard, 2-session and tracing information for recent sexual IDUs are already found (such as substance and enhanced, 4-session counseling inter­ or drug contacts who are at high risk of abuse treatment or criminal justice) and ventions significantly increased participants’ also being infected and to make confidential deliver them in ways that are tailored to the condom use (Kamb et al., 1998). Compared efforts to locate them, recruit them for specific circumstances of the IDUs who will to standard interventions, enhanced HIV diagnostic tests, and provide treatment as receive them. For example, in November C&T has had a greater effect on IDUs’ needed (Bayer and Toom e y , 1992; Cates 1987, the City of Boston’s Department of needle risk behaviors (Siegal et al., 1995) and Toom e y , 1990). Health and Hospitals, the Division of than on their sexual risk behaviors PCRS can have important benefits for indi­ Drug Rehabilitation of the Massachusetts (M c C u s k er et al., 1993). vidual IDUs and their communities. PCRS Department of Public Health, and the A number of chal l e n g es limit the potential provides an opportunity for agencies to Massachusetts Center for Disease Control impact and benefits of counseling and testing notify the sexual and drug-use partners of established Project TRUST (Teaching, services. Perhaps the most important issue in f ected individuals of their expo s u re to Referral, Understanding, Support, and is that C&T is a short- t e r m intervent i o n HIV and, potentially to viral hepatitis also, Testing) at Boston City Hospital. The project and therefore would be expected to have to counsel them, and potentially to offer offered anonymous HIV testing in conjunc­ a relatively limited impact on risk behav­ longer-term follow-up. If already infec t e d , tion with a range of related prevention, iors. Individuals frequently go through a the partn e r s ’ prognosis can be improved education, referral, and social su p p o r t relatively long cognitive and behavioral through earlier diagnosis and treatment. If services. A number of factors helped attract process, including several cycles of attempted not infected, the partners can be assisted in IDUs and increase the numbers of pe o p l e change and relapse, before achieving lasting changing their risk behavi o r , thus redu c i n g of fered counseling and testing, inclu d i n g behavioral change (Prochaska, 1989). In the likelihood of acquiring the virus. From the range of fr ee services avai l a b le without many cases, individuals must come to a an epidemiological standpoint, following a need for appointments, staff who included testing site twice, once to have the test the chain of transmission from one HIV- recovering IDUs, location in a neighbor- performed and once to receive their results infected individual to another within and hood with a visible drug-user presence, and a week later. Many persons who are tested across social networks permits public health anonymity (CDC, 1989). New, rapid HIV do not return to receive their HIV antibody investigators to chart the course of the an t i b o d y tests are being developed that will test results, especially those who are tested epidemic and conduct more effective pre­ allow a person to be tested and receive their in STD clinics. Further, some individuals vention planning. Epidemiologists suspect results in one visit (CDC, 1998b). This may who test positive have difficulty being inte­ that recently infected persons account for a be attractive to many IDUs, for whom a grated into more intensive services, such as substantial prop o r tion of tr a n s m i s s i o n ,

A P P E N D I X A A11 either because they have higher viral loads • contract-referral in whic h the provid e r To date, no research has been conducted than those who have been infected longer informs the partner only if the client on the effect i veness of pa r tner notific a t i o n and are therefore more infectious, or because does not notify the partner within a in helping partners adopt safer behavi o r s they have more sex partners, or both (West negotiated time period. or preventing new infections. Rese a rc h has and Stark, 1997). Identifying and trea t i n g focused on the process and its effec t i ven e s s During the notification process each infected partners early may reduce HIV in reaching partners, testing them, and partner is: transmission by reducing the number of identifying seropo s i t i vity rates (Macke et po t e n t i a l l y infectious contacts (Fenton and • informed of po s s i b le expo s u re to HIV al., 1999). Most HIV-i n fe cted indivi d u a l s Pete r man, 1997). and other STDs or bloo d - b o rn e who take part in HIV C&T willingly par­ pa t h o ge ns; ticipate in PCRS (West and Stark, 1997), PCRS also can yield important eval u a t i o n although the rates of participation have been information for HIV prevention programs. • pr ovided with accurate inform a t i o n found to vary considerably across existing If conducted in conjunction with social about HIV transmission and prevention; state programs (Crystal et al., 1990; Landis ne t w ork methods, it can aid in identifying • informed of the benefits of knowing et al., 1992; Pavia et al., 1993; Spencer et networks with priority prevention and treat­ on e ’ s serostatus; al., 1993; Wykoff et al., 1991). One study, ment needs and insight on how to access conducted with IDUs in Utah, showed a them. In addition, partners can be inter- • assisted in obtaining counseling, testing, participation rate of 93 percent (Pavia et viewed about their past experience with and other support services; and al., 1993). Further research is needed to pr evi o u s l y used prevention services and the • cautioned about the possible negative improve partner notification procedures and effe c t i veness of those services in helping consequences of revealing their own or tailor them to specific populations, to under- them reduce risk. ot h e r s ’ ser ostatus to anyone else. stand the impact of new testing technologies PCRS begins when an IDU seeks HIV on partner notification, and to understand Ma n y HIV-in f ected drug users are critical prevention C&T. If the HIV test is posi­ the consequences of pa r tner notific a t i o n of par tner referral interventions expe r i­ tive, he or she is given the opportunity to for individuals and their partners (Macke enced in the past (Rogers et al., 1998). receive PCRS at the earliest appropriate et al., 1999). These opinions are based on a mistrust time. During the initial PCRS interview, of gover nment agen c y invol v ement and HIV-infected individuals who take part in the counselor will discuss with the client concerns about confidentiality and potential PCRS name approxim a t e l y three partne r s , his or her responsibilities to sexual and discrimination in disclosing informa t i o n although this has also varied considerably drug-use partners and available options for related to their behaviors and their partners. ac r oss state prog rams. Of the partn e r s notifying them of the client’s infection sta­ However, the few studies on HIV partner named, the majority are sex rather than drug- tus. The HIV-infected client is encouraged referral with drug users provide some insights use partners. Of those partners named, state to voluntarily and confidentially disclose into the kind of intervention that may work program records indicate that 60 to 80 the identifying, locating, and exposure best with them (Levy and Fox, 1998; Rogers percent are located (Crystal et al., 1990; information for each partner. The PCRS et al., 1998). One innovative approach to Landis et al., 1992; Pavia et al., 1993; provider and client together formulate a pa r tner referral with drug users builds on Spencer et al., 1993; Wykoff et al., 1991). plan and set priorities for notifying part­ the success of community outreach methods Pr ovider referral has resulted in the notifi­ ners. Partner referral options include: by adding contact tracing and partner refer­ cation of more partners than has patient • client referral in whi c h the HIV-infected ral to the role of ou t re a c h staff. With the referral (Jones et al., 1990; Landis et al., person agrees to personally inform part­ understanding that IDUs often can be more 1992). Those index clients with the most ners about possible expo s u re and refer read i ly reac hed using community-based past sex partners are least likely to attempt them to servi c e s ; in d i g enous staff members, the Outreach- to notify any partner (Marks et al., 1992). Assisted Model of Partner Referral uses If located, sex partners are generally receptive • provider referral in whic h the provid e r , indigenous outreach workers in a more active to confidential notification of their potential us u a l l y health depa r tment staff, with the role delivering street-based HIV counseling, exposure to HIV by the client or the health consent of the client, takes resp o n s i b i l i t y te s t i n g, and partner referral (Levy and Fox, department and usually seek HIV testing for contacting/referring partners; 1998). The expanded outreach model offers (West and Stark, 1997). • dual-referral in which the HIV-infected testing to IDUs in an environment that is PCRS also has been effec t i ve in uncoveri n g person infor ms the partner of hi s / h e r more comfo rt a ble and community oriented pr evi o u s l y undiagnosed HIV infect i o n s . HIV infection in the presence of the than those IDUs generally experience in IDU partners who are tested have shown pr ovi d e r ; and using public health HIV testing services.

A12 A P P E N D I X A higher rates of HIV infection than have his or her partners (West and Stark, 1997). PCM includes the foll o wing seven pa r tners with other known routes of tr a n s- Health departments are often viewed with components: mission (Waldron et al., 1995). suspicion, and their ability to keep personally • client recruitment and engagement; identifying information confidential is fre­ Partner referral faces several challenges, qu e n t l y questioned. Efforts are needed to • sc r eening and compreh e n s i ve assessment pa rt i c u l a r ly when agencies attempt to find en s u r e that community HIV preven t i o n of HIV and STD risks, medical and partners of IDUs. One reason is that the needs are met, misconceptions about PCRS psychosocial service needs, including STD success of pa r tner referral depends heavi l y practices and policies are corrected, and evaluation and treatment, and partic i p a­ on the disclo s u r e of names of contacts by le gitimate concerns about confid e n t i a l i t y tion in substance abuse treatment; the HIV-infected client. IDUs may be par­ and discrimination are addressed. ticularly unwilling to reveal the names of or • de velopment of a clie n t - c e n t e r ed other information about partners partially pr evention plan; PREVE NTION CASE because the drug culture discourages reveal­ M A N A GEMENT ( PCM) • HIV risk-reduction counseling over ing information about others. Other barriers multiple sessions; to disclo s u re can include fear of losing a PCM is an intensive, ongoing, client- p a rt n e r, of losing support and, especially centered HIV prevention activity with the • ac t i ve coordination of se r vices with for women, fear of violence (North and fundamental goal of helping indivi d u a l s foll o w-up; Roth e n b e r g, 1993; Norwood, 1995; with complex lives and circumstances adopt • monitoring and reassessment of clie n t s ’ Rothenberg et al., 1995). However, studies and maintain HIV risk-reduction behaviors. needs, risks, and progress; and have found that when an infected individual For those who are living with HIV, preven­ reveals his or her infection to a main partner, tion case management helps in obtaining • discharge from PCM when the client the disclo s u r e does not result in sepa r a t i o n and adhering to treatment for HIV. It attains and maintains his or her risk- or disruption of the relationship (Nabais provides counseling, support, and service reduction goals. et al., 1996; Padian et al., 1993). assistance to address the relationship between Case management is often offered as part HIV risk and other issues such as substance Even when a client discloses drug-use part­ of a larger care system and this makes it abuse, STDs, mental health problems, and ners’ names, it is often difficult to locate difficult to assess its effects apart from other social and cultural factors. PCM staff closely these IDUs because the client may know se rvices . In partic u l a r, it has been diffic u l t collaborate with Ryan White CARE Act them only by a nickname or street name to assess prevention case management with case managers to provide information and (Rogers et al.,1998). The long incubation HIV seronegative drug users and determine referrals for secondary prevention needs of period of HIV and anonymous partne r s the most effec t i ve approa ch es to use with persons living with HIV or AIDS. PCM is of clients are other reasons why it may be IDUs because of the high drop-out rate of also useful for HIV seronegative persons, or difficult to locate IDU partners. participants even when the required number those of unknown HIV serostatus who are of sessions with a prevention case manager Because PCRS activities often require the either engaging in high-risk behavior within is reduced (Falck et al., 1994). Other diffi­ no t i f ication of ma n y partners, they can be communities with moderate to high sero­ culties in evaluating PCM have been small labor intensive and costly. The cost to prevalence rates of HIV infection or are sample size; the lack of ability to control counsel and refer one sex partner to needed otherwise at heightened risk of infection. for disease progression, which can cause a services ranges from $100 to $2,260 and Because it has the potential to address a wide de c r ease in sexual activity; the fail u re to from $810 to $3,205 to identify one HIV- ra n g e of social prob lems for persons with collect behavioral data in the time between infected partner through provider referral multiple and complex HIV risk-red u c t i o n HIV testing and the first case management (Pavia et al., 1993; Peterman et al., 1996). situations, PCM is partic u l a rl y suited for appointment; and the fail u r e to collect Although partner notification for STDs is individuals like IDUs, who have or are likely data on the serostatus of program partic i - gene r a l l y regarded as ethically accept a bl e , to have difficulty initiating or sustaining p a n t s ’p a rtners. ethical concerns about the role of HIV practices that reduce or prevent HIV trans- At present, five CDC-funded demonstra­ partner notification as a prevention strategy mission and acquisition. PCM strives to tion projects are being carried out to test ha ve been voiced (Fenton and Pete rm a n , develop an ongoing relationship with each the effectiveness of PCM on reducing the 1997). Community representatives often client to provide an environment of trust transmission of HIV from HIV-infected perceive HIV PCRS to be an intrusive and understanding within which prevention persons. One intervention in California is activity that is unlikely to protect the confi­ counseling can take place. being conducted within early interven t i o n dentiality of the HIV-in fe cted person or

A P P E N D I X A A13 program (EIP) sites and employs a risk and retain them. Case managers and preven­ Women living with HIV disease face reduction specialist who uses behavior tion case managers need training in issues particular educational, cultural, economic, chan ge theory in the context of clie n t - sp e c i f ic to IDUs, whi c h should help them ps y chological, physical, and social barri e r s ce n t e re d counseling and/or short- t e rm , offer risk reduction counseling and preven­ in accessing and using care (Weissman et al., so l u t i o n - f ocused counseling techn i q u e s . tion services to these individuals and assist 1995; Weissman and Brown, 1995). Most them with managing their chronic and acute are either active or recovering injection drug Another chal l e n g e for PCM services is health care needs, including taking anti-HIV or crack users who have a history of sexual/ their greater cost compared to other HIV medication and opportunistic infection pro­ physical abuse, psychological distress and pr evention activities, whic h can employ phylaxis as recommended. In addition, a d ep ression, and lack of social support. peers or paraprof essionals to reac h larger full range of complementary affordable and In c r eased funding for services will help to numbers of people with less time-intensive, accessible services should be made available, address these barriers, but other changes st a ff - i n t e n s i ve risk reduction strategi e s . including substance abuse treatment services, are also needed, including: mental health services and assistance with Coordinated Services for IDUs • expanded outreach to women with HIV; Living with HIV/AIDS other basic needs such as food, housing, Because HIV disease is a complex chronic chil d c a r e, and job training. • chan ges in substance abuse trea t m e n t policies and procedures that do not favor condition, infected IDUs and their fami l i e s A major barrier to providing comprehensive women (for example, those that do not requ i r e a changing arra y of se r vices in their se rvices for HIV-i n fe cted IDUs is inade­ ad e q u a t e l y address issues of preg n a n t homes, in the hospital or health care facility, quate funding. HIV-infected IDUs have women and women with children); and in the community (Keenan, 1990). In high levels of need that are only partially addition, anti-HIV medication regi m e n s being addressed by the current service system • efforts to build peer networks and in vol v e multiple medications with differ i n g (HRSA, 1994). While acute medical services on g oing support struc t u res ; sc hedules and req u i r ements. Fail u re to fol­ are generally accessible, other health serv­ • im p ro vements in HIV counseling and low recommendations can lead the virus to ices (dental, home care, hospice, long-term testing proc e d u res to ensure that wome n develop resistance to anti-HIV medications. residential drug treatment) and ancillary understand the testing and services needed; However, with appropriate and high-quality services (shelter, food, stable living condi­ services and medications, IDUs living with tions, vocational training, long-term therapy) • cro ss-training of pr oviders in wome n ’s HIV can lead healthy, prod u c t i ve lives. often are not adequately provided. issues; and Many IDUs continue to engage in high-risk As a marginalized population, IDUs can be • enhanced advoca cy for women livi n g be h a viors after they learn they are infec t e d less connected to the AIDS-related service with drug abuse and HIV disease with HIV and, thus, place others at risk delivery system than are other infected indi­ (Weissman and Brown, 1995). of HIV infection and themselves at risk viduals. For example, HIV-i n f ected IDUs, for collateral health problems (CDC, 1996; in c luding those rece n t l y incarcerated, with- Primary Drug Prevention HRSA, 1994; Kwia t k owski and Booth, out clinical disease who have less contact Primary drug prevention is a centrally 1998; Metsch et al., 1998). When HIV- with health care providers, have not been important strategy in a comprehensive infected IDUs are actively engaged in health receiving optimal care (Celentano et al., approach to preventing blood-borne diseases care, however, they can be followed to 1998). Like non-IDU consumers, many among IDUs and reducing the spread to identify renewed high-risk sex or drug use IDUs do not know where to go to obtain others. By helping individuals avoid drug and counseled about the effects of these services or what services are appropriate use and drug injection altogether, these behaviors on themselves and others. HIV- for different people at different stages of programs help to eliminate the risk of infected drug users who are in substance the disease. The service delivery system is in j e c t i o n - r elated bloo d - b o r ne virus trans- abuse treatment and are receiving other too complex and fragmented for them to mission. Primary drug prevention programs, health services are more likely to comply navigate and often too remote geographi­ which are conducted in a variety of settings, with HIV/AIDS drug treatment regimens cally, socially, and culturally. Some programs including schools, families, and community- and to reduce their sex and drug risk-related prohibit services to active drug users and based organizations and through a variety behaviors (Booth et al., 1999). those who are HIV-infected and this of channels, such as the media, are largely aimed at youth to encourage them to avoid IDUs living with HIV/AIDS need a full presents formidable barriers for IDUs. or delay the first use of alcohol, tobacco, complement of services, delivered in a setting Negative attitudes by staf f toward IDUs’ marijuana, inhalants, and other drugs. geared to attract IDUs from the community behaviors and life circumstances exacerbate the situation. Avoiding or delaying substance abuse can

A14 A P P E N D I X A help youth prevent many problems associ­ • developing personal social and refusal skills; movement within communities has been ated with it, including truancy, academic instrumental in reducing regular drug use • teaching that drug use is not the norm failure, violence, thefts, motor vehicle among adolescents and young adults by among young people; crashes, homicides, injuries, suicides, and two-thirds between 1979 and 1992 (Rusche, risky sexual behaviors (Ary et al., 1999; • promoting bonding to schools and to personal communication, September 3, Berger and Levin, 1993; Cohen et al., 1997; co n s t ru c t i ve role models; and 19 9 9) — the r e are still some limitations Donovan et al., 1988; Far rell et al., 1992; that must be addressed. Many of the tested • using interactive methods of de l i very . Osgood et al., 1988). pr i m a r y drug prevention prog rams are Successful primary prevention pro gr a m s sc hool-based and their effect i veness with Rese a r ch has identified effec t i ve primary also include a variety of components and ou t - o f - s c hool youth, who may be at higher prevention programs that target all forms of characteristics, such as: risk, is not clear. Some school-based pro- substance abuse and reach all populations grams whose effectiveness has not been (Drug Strategies, 1999; NIDA, 1997; • media campaigns; co n cl u s i vely demonstrated continue to be ONDCP, 1998). Successful programs • consistent anti-drug messages across po p u l a r . Furth e rm o re, school-based inter­ incorporate messages and strategies that components and settings; ventions have been designed and tested are tailored to respond to the specific nature ma i n l y with middle school students; pro­ ofdrug use in the community and the level • environmental and policy initiatives, such gramming for younger students and older of risk in the audience. In addition, they are as raising the minimum age to buy alcohol; teens is limited. Prog ress in eval u a t i o n age-specific, developmentally appropriate, • a parent / c a r egi vers component; research in this area has also been hampered and culturally sensitive. by methodological limitations, such as lim­ • training and support to ensure that inter­ Successful programs also are designed to ited curriculum assessment that does not ventions are delivered as intended; and enhance “protective fac t o r s ” and redu c e consider the multiple requirements teachers “risk fact o r s ” by: • “booster sessions” over the long term to must address in the classroom, and a paucity reinforce original prevention goal s . of medium- and long-term follow-up • raising aware ness of exte r nal pres s u re s , studies of in t e r ven t i o n s . su c h as peer pres s u r e and media effec t s , Although primary drug prevention has and internal pres s u r es, such as grou p been shown to have clear benefits — many identity; professionals feel that the primary prevention

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A P P E N D I X A A21 Schechter MT, Strathdee SA, Cornelisse PGA, Currie S, Patrick Springer KW, Sterk CE, Jones TS, Friedman L. Syringe disposal DM, Rekart ML, O’Shaughnessy MV. Do needle options for injection drug users: a community-based exchan g e prog rammes increase the spread of HI V perspective. Substance Use and Misuse 1999;34(13): among injection drug users? An invest i gati on of th e 1917-1934. Vanc o u v er outbreak. AI D S 19 9 9 ; 1 3 ( 6 ) : F 4 5 - F 5 1 . Strathdee SA, Patrick DM, Currie SL, Cornelisse P, Rekart M, Schilling RF, El-Bassell N, Schinke SP, Gordoin K, Nichols D. Montaner J, Schechter MT, O’Shaughnessy M. Needle Building skills of recovering women drug users to reduce excha n ge is not enough: lessons from the Vanc o u ve r heterosexual AIDS transmission. Public Health Reports injecting drug use study. AI D S 19 9 7 ; 1 1(8 ) : F 5 9 - F 6 5 . 19 9 1 ; 1 0 6 ( 3 ) : 2 9 7 - 3 0 4 . Strain EC, Bigelow GE, Liebson IA, Stitzer ML. Moderate- vs high- Semaan S, Des Jarlais DC, Sogolow ED, Ramirez G, Sweat M, dose methadone in the treatment of opioid dependence: Norman LM, Needle RH. A meta-analysis of the a randomized trial. JAMA 1999;281:1000-1005. impact of HIV risk reduction interventions on safer sex Struckman-Johnson C, Struckman-Johnson D, Rucker L, Bumby K, be h a viors of dr ug users. In t e rn a tional Conferen ce on AI D S Donaldson S. Sexual coercion reported by men and (G e n e va, Switzerland). 1998;12:232 (abstract no. women in prison. Journal of Sex Research 1996;33(1):67-76. 25 3 / 1 4 2 5 0 ) . Sufian M, Friedman SR, Curtis R, Neaigus A, Stepherson B. Serpelloni G, Carriere MP, Rezza G, Morganti S, Gomma M, Or ganizing as a new approa c h to AIDS risk redu c t i o n Ginkin N. Methadone treatment as a determinant of for intravenous drug users. Journal of Ad d i c t iv e Diseases HIV risk reduction among injecting drug users: a nested 19 9 1 ; 1 0 ( 4 ) : 8 9 - 9 8 . case controlled study. AIDS Care 1994;6(2):215-220. Sumartojo E, Carey JW, Doll LS, Gayle H. Targeted and general Sh o p t a w S, Fros c h DL, Rawson RA, Ling W. Cocaine abus e population interventions for HIV prevention: towards a counseling as HIV prevention. AIDS Education and comprehensive approach. AIDS 1997;11(10):1201-1209. Pr eve n t i o n 1997;9(6):511-520. Vall e r oy LA, Weinstein B, Jones TS, Gros e cl ose SL, Rolfs RT, Siegal HA, Glack RS, Carlson RG, Wang J. Reducing HIV Kassler WJ. Impact of increased legal access to needles needle risk behaviors among injection drug users in the and syringes on community pharmacies needle and midwest: an evaluation of the efficacy of standard and sy r i n g e sales — Connecticut, 1992-1993. Jour nal of enhanced interventions. AIDS Education and Prevention Ac q u i re d Immune Deficiency Syndromes and Human Retr ovi ro l o g y 1995;7(4):308-319. 1995;10(1):73-81. Simpson D, Savage L. Drug abuse treatment readmissions and Vanichseni S, Des Jarlais DC, Choopanya K, Friedmann P, Wenston outcomes: three - y ear foll o w-up of DARP patients. J, Sonchai W, Sotheran JL, Rakthan S, Carballo M, Arc hives of Ge n e r al Psychiatry 1980;37(8):896-901. Friedman SR. Condom use with primary partners among Singer M, Baer HA, Scott G, Horowitz S, Weinstein B. Pharmacy injecting drug users in Bangkok, Thailand and New York access to syringes among injecting drug users: follow-up City, USA. AIDS 1993;7(6):887-891. findings from Hartford, Connecticut. Pu b lic Health Reports Vlahov D, Junge B. The role of needle exchange programs in HIV 1998;113(Suppl 1):81-89. prevention. Public Health Reports 1998;113(Suppl 1):75-80. Spencer NE, Hoffman RE, Raevsky CA, Wolf FC, Verson TM. Vlahov D, Junge B, Brookmeyer R, Cohn S, Riley E, Armenian H, Partner notification for human immunodeficiency Beilenson P. Reductions in high risk drug use behaviors virus infection in Colorado: results across index case among participants in the Baltimore needle exchange groups and costs. International Journal of STD and AIDS program. Jour nal of Ac q u i red Immune Deficiency Syndromes 1993;4(1):26-32. and Human Retr ovi ro l o g y 1997;16(5):400-406.

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A P P E N D I X A A23 Appendix B Index of Articles and Reports Cited in Appendix A, Organized by Comprehensive Approach Strategy

Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

Abdul-Quader ● et al., 1987

AED, 1999 ●

AED, 1997 ●

Anderson ● et al., 1996

Anderson ● et al., 1998

Anglin et al., ● 1989

APA, 1996 ●

Archibald ● et al., 1996

Ary et al., 1999 ●

Avins et al., ● 1997

Ball et al., 1988 ●

Battjes et al., ● 1991

Bayer and ● To omey, 1992

Beardsley et al., ● 1996

Beckett et al., ● 1998

Belenko, 1998 ●

Berger and ● Levin, 1993

Blix and ● Gronbladh, 1991

Bluthenthal, ● Kral et al., 1999

Bluthenthal, ● Lorvick et al., 1999

Booth et al., ● 1999

Booth et al., ● 1996

Broadhead ● et al., 1998

A P P E N D I X B B1 Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

Brown et al., ● 1988

Bruneau et al., ● 1997

Calsyn et al., ● ● 1992

Calzavara et al., ● 1997

Caplehorn and ● Ross, 1995

Carlson and ● Needle, 1989

Case et al., ● 1998

Cates and ● To omey, 1990

CDC, 1999a ●

CDC, 1999b ●

CDC, 1998a ●

CDC, 19998b ●

CDC, 1996 ●

CDC, 1989 ●

CDC, 1984 ●

CDC/ACDP, ● ● 1999

Celentano ● et al., 1998

Chu et al., ● 1998

Cohen et al., ● 1997

Cottler et al., ● 1998

Coyle et al., ● 1998

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B2 A P P E N D I X B Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

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A P P E N D I X B B3 Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

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B4 A P P E N D I X B Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

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A P P E N D I X B B5 Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

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B6 A P P E N D I X B Author Substance Community Access to Criminal Sexual C&T, Services for Primary Abuse Outreach Sterile Justice System Transmission PCRS, PCM IDUs Living Drug Treatment Syringes Interventions with HIV/AIDS Prevention

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