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National Institute on Drug Abuse
National Institutes of Health
Research Synthesis Symposium on the Prevention of HIV in
Drug Abuse
Northern Arizona University
August 3-5, 1997
SUMMARY
Meeting Sponsors:
National Institute on Drug Abuse
NIH Office of AIDS Research
Northern Arizona University
Meeting Purpose:
The two and one-half day Symposium was the first meeting in the history
of the HIV epidemic to be exclusively devoted to the prevention of HIV
in injection and noninjection drug users. The Symposium brought together
national and international leaders from the fields of drug abuse and HIV
prevention research to:
- review the effectiveness of community-based interventions designed
to reduce risk behaviors and prevent the spread of HIV in injection and
noninjection drug users
- translate science-based findings into prevention principles that can
be applied on a world- wide basis by prevention planners and practitioners,
and
- formulate emerging strategies and discuss future directions for the
prevention of HIV transmission among drug abusers
Meeting Process:
The agenda included presentations on the history and evolution of HIV
prevention research; the human experience of HIV; triumphs and tribulations
in HIV prevention; and what we have learned, have done, and haven't done
in 15 years of HIV prevention. State-of-the-art synthesis papers and unpublished
findings were presented by researchers over the next two days on the following
themes:
- community-based outreach interventions to prevent the spread of HIV
among drug abusers
- syringe exchange programs and access to sterile injection equipment
- drug abuse treatment as an HIV prevention strategy
- social network roles in diffusing risk reduction messages and mediating
HIV transmission
- international HIV prevention interventions
- biological and behavioral prevention interventions, and
- bridges from HIV research to prevention and to practice
In responding to the challenges of the changing dynamics of drug abuse
and the spread of HIV/AIDS and other infectious diseases, researchers supported
by the National Institute on Drug Abuse (NIDA) have developed and implemented
interventions to change risk behaviors to prevent the spread of HIV infection.
Throughout the Symposium, the origins, evolution, and current status of
the scientific knowledge base of NIDA's HIV research and intervention program
were discussed. Each panelist examined the current scientific literature
findings and presented them in conjunction with their own research results
on the effectiveness of behavioral interventions in changing high risk
drug-using behaviors (unsafe sexual behaviors and unsafe injection practices)
related to HIV transmission.
Content:
The following HIV prevention principles emerged from the Symposium and
were determined to be effective for guiding practitioners and policy makers.
These include:
- start HIV prevention interventions early in the epidemic, or
as soon as possible
- implement multiple intervention strategies, such as outreach
to active drug users, recruitment and referral to treatment, risk behavior
reduction and other elements of comprehensive HIV programs including the
use of sterile injection equipment by those who will not stop drug use,
and drug abuse treatments which have been shown to be effective in reducing
risk behaviors for injection drug users and preventing the spread of HIV
- implement interventions at multiple levels (policy, legal, institutional,
community, network, and individual levels) to alter community behavioral
norms and risk behaviors to create opportunities for at-risk individuals
to make and sustain behavior change in a supportive environment
- implement interventions in multiple settings to reach as many
of the at-risk population and subgroups as possible, e.g.,
- streets, mobile vans, storefront offices, and other places where drug
users congregate, such as shooting galleries
- health-related settings, such as clinics, pharmacies, drug treatment
centers
- target multiple risk behaviors simultaneously, including drug
use, needle risk, and sexual practices
- provide access to multiple means (intervention components) for behavior change, including:
- risk reduction information and
- risk reduction supplies, including bleach, sterile water, and related
injection hygiene materials, and condoms (male and female), and
- HIV antibody testing with pre- and post-test counseling
- create opportunities for increased exposure to interventions
through booster sessions to reinforce skills and knowledge learned in the
initial intervention to further increase the effectiveness of interventions
- recognize that populations at risk for HIV are in various stages
of readiness to participate in an intervention and need to be engaged
appropriately in order to maintain them in the interventions by using
motivational techniques, contingency management, cognitive strategies,
and/or peer-driven interventions,
- be assured that risk reduction is an appropriate, realistic outcome
of HIV interventions; the ultimate goal is the elimination of select risk
behaviors
Next Steps:
The researchers at the symposium concluded that more systematic analysis
of currently available data is necessary to:
- describe intervention components
- develop contextual information about the intervention
- determine the impact of the intervention on risk behaviors and disease
transmission
- interpret how an intervention contributed to observed effects, and
- determine the effects of interventions, sustain behavior change, and
prevent the further spread of HIV
Future research needs to address both intervention assessment issues
and methodological issues. Suggested new areas include:
Intervention Issues:
- assessment of the relationship of intervention dose (amount and duration
of intervention services received), content (types of intervention services
delivered), and outcome
- assessment, characterization, and evaluation of the effectiveness of
interventions in sustaining behavior change and averting HIV incidence
- differential responses to interventions by gender, age, and ethnicity
in low, moderate, and high HIV prevalence communities
- decision making processes and risk assessments
- better specification of drug abuse treatment in terms of services that
address the physiological effects of drug abusing behaviors as well as
the psychosocial consequences of drug abuse and the factors that lead to
sustained drug abuse rather than modality per se
- characterization of those not being reached by existing interventions:
e.g., active users, women, and those at the highest and lowest levels of
HIV risk
- assessments of comprehensive, multiple interventions on behavior change
and prevention of HIV
Methodological Issues:
- improved measures of risk, e.g., length of followup, clinical vs. statistical
changes due to interventions
- development of designs that are acceptable alternatives to randomized
trials
- process measures of quality of implementation of interventions over
time
- use of new technologies for collecting, analyzing, and reporting data
more quickly
Products/Future Activities
The meeting made it clear that it was necessary to systematically examine
all interventions and their effects on behaviors as we work toward the end
goal of preventing HIV. As a result, the following future activities are
planned:
- A special supplemental issue of Public Health Reports is anticipated
for the Spring of 1998. Scientific papers presented at the Research
Synthesis Symposium on Prevention of HIV in Drug Abusers will be developed
and peer reviewed for inclusion in the Journal. The supplemental issue
is intended to be a resource for the public health, research, and practitioner
communities on empirically-based prevention principles and programs, as
well as on emerging priority areas in drug abuse and HIV research and program
development.
- The first formal Global Research Network on Drug Abuse and HIV Transmission
Meeting (25 global HIV prevention network researchers will make presentations)
is tentatively planned for June 26, 1998 as a research satellite to the
1998 World AIDS Conference, Geneva. Potential co-sponsors for the network
include the NIH Office on AIDS Research, NIH, WHO Programme on Substance
Abuse, and UNAIDS. In addition to the face-to-face meeting proposed for
June 1998, multiple strategies for electronic communication are being considered,
including the establishment of a List Serv to link members electronically
in a series of "virtual" meetings as well as informal chat sessions
