HIV/AIDS and Drug Abuse Treatment Services - Part A

Literature Review
September, 1998

Barry S. Brown, Ph.D.
University of North Carolina at Wilmington

Hyperlinks to sections within this text:

Part A:
Executive Summary
Introduction
The Response of Drug Abuse Treatment: Implementing New Initiatives
The Response of Drug Abuse Treatment: New Initiatives Available for Implementation

Part B:
Special Populations
Staffing Issues
Recommendations for Service Delivery and Research
References

Engagement and retention in drug abuse treatment have been widely recognized as effective AIDS prevention strategies. At the same time, recognition of the special needs and concerns of the HIV-infected client and the importance of HIV prevention has prompted the development of new initiatives in drug abuse treatment and the modification of existing drug abuse practices. Treatment intake procedures now embrace an expanded concern with diagnosing a range of infectious diseases and providing HIV prevention services in conjunction with available HIV testing. Moreover, the efforts of community-based organizations offering AIDS prevention outreach and needle exchange have resulted in increased demand for treatment services, suggesting the need for drug abuse treatment programs to work collaboratively with these organizations on behalf of a common concern about the health and well-being of their clients. The special needs of the HIV-infected drug treatment client have further emphasized the importance of primary care and highlighted gaps in the provision of that care to drug abuse clients generally and to HIV-infected clients specifically.

Strategies important to the continuing refinement of drug abuse treatment have particular relevance for HIV prevention. Because treatment retention is significantly related to lower rates of seroprevalence, initiatives effective in encouraging early retention through such strategies as role induction and contingency management are important to HIV prevention efforts and to broader rehabilitative objectives. Relapse prevention/aftercare efforts, with their capacity to reduce relapse to regular drug use and related risk behaviors posttreatment, have significance for AIDS prevention programming as well.

Because methadone treatment is the modality most directly targeting the injection drug user, it has the greatest capacity for reducing HIV risk behaviors. Efforts to increase the reach of methadone or opiate replacement therapies to serve an increased number of clients include the expanded use of LAAM, medical maintenance, 180-day detoxification, mobile vans, and interim methadone.

Partners of injection drug users, non-injection drug users who are sexually active, drug abuse clients with comorbid psychiatric disorder(s), and drug users entering the criminal justice system all may be at risk for HIV infection. Whereas a number of programs specific to the HIV prevention needs of criminal justice clients have been developed and tested, little comparable activity has been initiated on behalf of drug users with psychiatric comorbidity and virtually none with partners of drug users.

Special issues exist for treatment staff working with populations at risk for AIDS. The risk and the reality of HIV infection for drug abuse clients has implications for the recruitment, retention, and training of treatment staff. Program responses range from basic AIDS training programs for staff to the development of staff support groups.

In addition to reviewing the research in the areas described above, the paper contains suggested interventions based on existing research, as well as issues that require further study. A strategy needs to be developed to permit the effective transmission of research findings to the treatment community. The significance of making information and models available to treatment staff is obvious. The difficulty involved in making that information available in a structure and format to induce individual and organizational change should not be minimized.

The number of AIDS cases has long since ceased to amaze. The tragedy of AIDS has quite simply become too routine to sustain a sense of amazement. Nonetheless, the size of those numbers reflects only the passage of AIDS from crisis to epidemic. The most recent report of AIDS cases (Centers for Disease Control and Prevention [CDC], 1996a) indicates that more than a half million American men, women, and children have contracted the disease and that more than 60%—343,000 people—have died, all in the course of a decade and a half. Use of injection drugs and/or sex with injection drug users is associated with 36% of all AIDS cases and, by extension, is responsible for the deaths of nearly 125,000 people. The number of deaths from AIDS contracted in association with injection drug use is greater than the number of opiate clients admitted to drug abuse treatment in 1980, and well above the number of Americans killed in the Korean and Vietnam Wars combined. Just as the number of AIDS cases climbs inexorably higher, the percentage accounted for by injection drug use has risen from a low of approximately 25% in 1983 (Miller, Turner, & Moses, 1990) to the current rate of 36%.

Although data on AIDS are limited to the relationship between disease and injection drug use, there is now a considerable body of findings on the relationship between high-risk behavior and use of noninjectable cocaine. Crack use has been linked to sexually transmitted disease (Fullilove, Fullilove, Bowser, & Gross, 1990; Guinan, 1989; Rolfs, Goldberg, & Sharrar, 1990), to number of sexual partners (Wolfe, Vranzian, Gorter, Cohen, & Moss, 1990), and to number of injection drug-using sexual partners (Schoenbaum, Hartel, & Friedland, 1990). Consistent with these findings, ethnographic study has documented instances of trading sex for crack both within crack houses (Inciardi, Chitwood, & McCoy, 1992) and outside those settings (Birch & Davis Associates, 1991). It is not surprising, then, that high rates of HIV infection have been found among women using crack but not injectable drugs (Sterk, 1988; Trapido, Lewis, & Comerford, 1990) as well as among people injecting cocaine (Chaisson et al., 1989; Chaisson et al., 1988; Des Jarlais & Friedman, 1988). In association with these findings, the National Academy of Sciences considered an "outbreak" of HIV infection among adolescent and adult cocaine users to be a significant concern (Coyle, Boruch, & Turner, 1991).

The latter findings point to an additional issue important to the interpretation of data regarding the threat of AIDS to the drug-using population. Unlike findings for the prevalence of AIDS, a disease reportable to the CDC, rates of HIV infection can only be estimated. HIV infection is neither reportable nor always known to its carrier. The number of individuals with HIV infection, who are thereby rendered vulnerable to AIDS, has been estimated to be between 650,000 and 950,000 (CDC, 1996b; Karon et al., 1996), far exceeding the number who have progressed to AIDS. In short, findings with regard to the prevalence of AIDS provide an obviously important measure of disease, but risk underestimating its threat to the population just as the emphasis on injecting drugs risks underestimating the significance of all drug use for AIDS and HIV infection.

Much of the responsibility for responding to the AIDS crisis as it affects the drug user has devolved to community-based drug abuse treatment programs. The extent of responsibility felt and, in part, the way in which that responsibility has been discharged varies with the extent to which AIDS is a concern to the community affected. Thus, methadone programs in high HIV seroprevalence areas become involved in a range of sometimes apparently unrelated activities such as providing traditional rehabilitative counseling, arranging primary care for infected clients, making funeral arrangements, providing grief counseling, and assisting families through the process of loss. These programs, which sometimes have as many as 50% of clients infected with HIV/AIDS, may have full-time AIDS coordinators on staff who have responsibility for accessing and coordinating the services required in association with HIV/AIDS infection and prevention (Maslansky & Leguillow, in press). Programs in lower prevalence communities face far less pressure to get involved with providing for the needs of infected clients. However, they may find themselves facing comparable challenges in terms of preventing HIV transmission, training staff, and maintaining the morale of a counseling staff whose concerns have been client growth and rehabilitation and who now find themselves involved in protecting their clients from lethal disease—or helping their clients cope with that disease.

This paper describes the treatment initiatives that have been undertaken in response to HIV/AIDS and the research findings with regard to those new initiatives. The paper covers issues of diagnosis, prevention, the development of novel treatment forms, and the adaptation of traditional forms to meet the threat AIDS poses to clients. Because treatment programs are caught up in the twin tasks of HIV/AIDS prevention and the care of individuals already infected with HIV/AIDS, initiatives designed to respond to both of these concerns are explored. In addition, programming for drug users in the criminal justice system is examined. Finally, program and research recommendations are developed consistent with earlier findings and efforts.

HIV infection has dramatically challenged drug abuse treatment. The risk of infection to clients and the appearance of disease in some has led to the need to develop new initiatives at the program site and to seek additional services from community agencies. Moreover, the process of program elaboration and change has been initiated during a period of declining resources for treatment response at a time in which managed care initiatives threaten additional reductions in the length and comprehensiveness of treatment—despite findings that the length and comprehensiveness of treatment are tied to program effectiveness (McLellan, Arndt, Metzger, Woody, & O'Brien, 1993; Simpson, 1981).

As described by Cooper (1989), several investigators have pointed to the capacity of long-term methadone treatment to insulate injection drug users against HIV infection. Thus, Ball, Lange, Myers, and Friedman (1988) describe dramatic increases in rates of injection (and, by inference, in risk of HIV infection) for individuals leaving methadone treatment as compared to those remaining in treatment. Similarly, length of time in methadone treatment is negatively related to frequency of injection, use of shooting galleries, and sharing of injection paraphernalia with others (Abdul-Quadar et al., 1987; Longshore, Hsieh, Danila, & Anglin, 1993). Perhaps most important, as reported in several reviews (Miller et al., 1990; Normand, Vlahov, & Moses, 1995; Office of Technology Assessment, 1990), a number of investigators have reported a relationship between treatment retention and low rates of HIV incidence. In a recent study comparing rates of HIV incidence for injection opiate users in the community and injection drug users continuously in methadone treatment, it was found that at 18 months 3.5% of methadone clients continuously in treatment had contracted HIV compared to 22% of out-of-treatment opiate users, and at 36 months 8% of methadone clients continuously in treatment had seroconverted compared to 30% of opiate users not in treatment (McLellan et al., 1996; Metzger et al., 1993). Thus, many view drug abuse treatment—and more particularly methadone treatment—as an essential component to any HIV prevention strategy targeting the drug-using community.

Although the value of long-term retention is unquestioned, concerns with preventing HIV infection have focused attention on the real capacity of programs to achieve that long-term retention and, indeed, to attract and modify the behaviors of drug abuse clients. In that spirit, it is apparent, first, that long-term retention, although a goal for all clients, is a reality only for some. Findings from the Treatment Outcome Prospective Study (TOPS) (Hubbard et al., 1989) indicate that well over half of residential and outpatient drug-free clients and one-third of methadone maintenance clients leave treatment within the first 3 months (i.e., receive clearly subtherapeutic dosages of treatment). Even with methadone maintenance, only a little more than half of treatment admissions (52%) are retained for 6 months or more. In short, the insulating effects of long-term treatment are available to a distinct minority of drug abuse clients.

Second, drug abuse treatment is not uniformly successful even among those retained for extended periods. Thus, although the relationship between length of retention and positive behavior change is clear (Simpson, 1981), it is not uniform, and relapse, when it occurs, can involve engaging in risk behaviors that make the individual and members of his or her community vulnerable to contracting AIDS. Given the threat of lethal disease to client and community, additional services that respond to the danger of relapse and associated risk behaviors can be seen as warranted.

Third, the capacity of drug abuse treatment to reduce risk associated with needle use has not extended to risk associated with sexual activity (Becker & Joseph, 1988; Brettle, 1991; Watkins, Metzger, Woody, & McLellan, 1994). Thus, additional services may be warranted to limit the risk of infection for injection opiate users and, perhaps even more significantly, for the crack and injection cocaine users who now dominate drug abuse treatment rolls.

Fourth, drug abuse treatment is not chosen by all drug users at risk for HIV infection. In a nationwide study of out-of-treatment injection drug users, more than 40% of individuals contacted had never been in drug treatment in spite of an average of more than 10 years of injecting drugs (Brown & Needle, 1994; Liebman, Knezek, Coughey, & Hua, 1993). To the extent drug abuse programming accepts a view of itself as fulfilling a public health role, it becomes important to assume responsibility for that population in need of services but lacking either access to those services or the will to gain access. Once the out-of-treatment drug user is defined as a population of concern, the task becomes one of developing and testing a system of service delivery for accessing and modifying behaviors in that population.

Finally, HIV prevention is not an option for all clients. Although varying markedly by geographic region, HIV seroprevalence rates of up to 59% have been reported for admissions to methadone programs (Battjes, Pickens, & Amsel, 1991; Battjes, Pickens, Haverkos, & Sloboda, 1994). Where HIV infection already exists, the clients’ certain need for medical services and likely need for social services mandate additions to existing treatment programming and treatment providers.

The unsurprising finding that drug abuse treatment is not uniformly successful in retaining and rehabilitating clients has  focused particular attention on diagnostic and HIV prevention efforts early in treatment. The finding that substantial proportions of injection drug users do not enter treatment has led to extra-treatment efforts to engage those users and modify their behaviors. The appearance of HIV-infected drug abuse clients has led to an increased concern with providing primary care and implementing case management initiatives.

Diagnostic Procedures

Diagnosis is an obvious and essential strategy for determining the presence and extent of HIV, as well as other diseases, and responding appropriately. To that end, diagnostic materials specific to HIV infection have been prepared for use by drug abuse treatment programs (Barthwell, 1993, 1995). As described by Selwyn (1996), injection and other drug users are vulnerable to a range of infectious diseases including HIV, tuberculosis, sexually transmitted disease, and viral hepatitis. Consequently, it has been recommended that drug users be screened routinely at intake for the presence of disease (Barthwell, 1993, 1995; Brown, Nurco, & Tims, 1996). It has been further recommended that drug users who refuse initial HIV testing be encouraged to obtain testing "as soon as feasible" after intake (Barthwell, 1993) and that those testing seronegative be encouraged to obtain retestings at 3 months if risk behaviors were present at time of program entry and at 6 to 12 months thereafter depending on risk behaviors shown (Barthwell, 1995). In that regard, it is emphasized that HIV antibodies typically will be present 6 weeks after infection but may not appear for up to 12 months.

It also should be emphasized that the client must give his or her permission for HIV testing, and it has been recommended that informed consent be obtained prior to testing (Barthwell, 1993). Testing may be either confidential (i.e., identifying information on the testee is available) or anonymous (i.e., no identifying information is collected, and the client is given a number that he or she presents to get test results). Testing may be offered at the treatment program or through referral to a community public health agency. In all instances, testing must be accompanied by pretest and posttest counseling to allow the client to understand issues in the transmission of HIV and protective measures the client can take, as well as to have an opportunity to discuss the meaning of test findings and to plan future behaviors. The significance of accurate diagnosis for treatment planning has led both the National Institute on Drug Abuse (NIDA) and the CDC to urge HIV testing and counseling in drug abuse populations (CDC, 1994; Leshner, 1995).

Work with drug abuse treatment clients suggests that high rates of consent for HIV testing are feasible (Carlson & McLellan, 1987; Weddington & Brown, 1988 ). In reviews of studies on the capacity of HIV testing and associated counseling to reduce risk behaviors among treatment clients, Higgins and colleagues (1991) report that "overall, these studies document improvements in needle use behavior and some reductions in sexual behavior." Changes in needle use behaviors typically involved reductions in frequency of injecting and in sharing paraphernalia. Changes in sexual behavior—which were less consistent across studies—typically involved a decrease in numbers of sexual partners and an increase in the use of condoms. Rates of change for clients learning they were seronegative were comparable with those for clients learning they were seropositive (Higgins et al., 1991). Watters (1996) provides a review of studies confirming behavior change associated with routine HIV testing and counseling.

In spite of recommendations and generally positive findings, it is not clear that large numbers of treatment programs are providing HIV testing. In a survey of outpatient drug treatment programs conducted in 1990, approximately 40% of methadone programs and less than 10% of outpatient drug-free programs reported conducting HIV testing (Price & D'Aunno, 1992a). Moreover, although these figures reflect a doubling of the number of methadone programs providing HIV testing since 1988, they reflect a diminution in the number of outpatient drug-free programs conducting testing since 1988. The response of programs to HIV issues has been a rapidly changing phenomenon as the data for HIV testing in methadone programs suggest; consequently, in this and other areas of programming, it would be useful to monitor the nature of HIV-related services provided.

HIV Prevention/Education Counseling

Relatively little study has involved the comparison of different strategies of HIV prevention/education administered to treatment admissions. As noted, findings from the several studies of HIV testing and counseling have been associated with significant change, particularly with regard to needle use behaviors. However, the effects of testing and counseling may be viewed as confounded by the effects of the drug abuse treatment regimen of which the HIV prevention efforts are a part (Higgins et al., 1991). One study compared injection drug users randomly assigned to (a) drug abuse treatment with AIDS education only, (b) drug abuse treatment with AIDS education plus opportunity for testing and counseling, and (c) a waiting list with AIDS education plus opportunity for testing and counseling. No differences were found between groups, and all showed marked reductions in needle-using behaviors and increases in condom use during the first months of treatment (Calsyn, Saxon, & Freeman, 1992). The study controls for the effect of treatment on behaviors, although placement of oneself on a waiting list (i.e., the commitment to change behaviors) is itself associated with short-term positive behavior change (Brown, Hickey, Chung, Craig, & Jaffe, 1989).

Additional studies exploring the comparative effectiveness of differing strategies of HIV education/prevention counseling would be useful on two counts. On the one hand, there is the frequently cited finding that needle use behaviors are far more likely to be modified by existing strategies than are sexual risk-taking behaviors. Development of effective AIDS prevention strategies targeting sexual behaviors is of obvious significance to the treatment of not only injection drug users, but also crack and other noninjection cocaine users. In addition, the effectiveness of AIDS prevention strategies with drug abusers who drop out of treatment early (i.e., who receive subtherapeutic dosages of treatment) could be studied. Posttreatment follow-up might explore the capacities of different strategies to protect the treatment dropout from needle and/or sexual risk taking. Among issues specific to HIV education/prevention counseling that could be resolved by additional study would be the impact of on-site as opposed to off-site testing and counseling regimens, the importance of skills building as opposed to educational techniques, the utility of contingency management strategies, and the effectiveness of medical professionals as opposed to peer counselors.

Outreach/Needle Exchange Strategies and Linkages to Treatment

Efforts to reach injection drug users in the community for AIDS education/prevention, although typically initiated by community-based groups not allied with treatment, have positive implications for treatment entry and engagement. Outreach efforts to locate and counsel injection drug users about HIV prevention were initiated in the late 1980s. Whereas outreach efforts in the 1960s and 1970s were offered by treatment programs and focused on getting out-of-treatment drug users into drug abuse treatment programs (Hughes, 1977; Hughes & Jaffe, 1971), outreach in the 1980s was offered primarily by community-based organizations to limit behaviors associated with the risk of contracting and spreading HIV infection. Treatment usually was offered as the most effective mechanism for limiting risk; however, it was not presented as the only mechanism. Outreach workers and programs were willing to tolerate continuing drug use as long as it involved safer administration of drugs than the individual had used formerly (Brown, Beschner, & National AIDS Research Consortium [NADR], 1993; Normand, Vlahov, & Moses, 1995).

Outreach programs distributed condoms, vials of bleach to clean needles, and sometimes a new cotton and cooker. Price and D'Aunno (1992b) reported that only 14% of a 1988 national sample of outpatient treatment programs were engaged in outreach involving bleach and condom distribution, and 35% of program supervisors gave "unqualified support" to the distribution of bleach, condoms, and/or needles. The distancing of treatment from outreach activities involving safer injection practices is indicative of the conflict between views of drug abuse treatment as the only appropriate behavior change strategy and of harm reduction as a legitimate and necessary alternative (Brown, 1996; DuPont, 1996). Nonetheless, studies of outreach initiatives found that half or more of outreach clients reduced their frequency of injection and other drug use and rates of borrowing, renting, and lending needles; reduced selected measures of sexual risk (e.g., nonuse of condoms, number of sexual partners) (NIDA, 1994; Stephens, Simpson, Coyle, McCoy, & NADR, 1993); and increased their use of drug abuse treatment (Brown & Needle, 1994). Thus, 33% of injection drug users entered drug abuse treatment within 6 months of being contacted by an outreach worker, and 25% of injection drug users who had never before been in drug abuse treatment enrolled after being contacted by outreach workers (Leibman et al., 1993).

Outreach programming enabled drug users to learn and practice attributes of the clients’ role in the safe (i.e., known) surroundings of their communities. Thus, HIV prevention programs can prepare the drug user to become a drug treatment client (Brown & Needle, 1994).

Outreach programs stretched the reach and responsibility of drug abuse treatment programming. The programs were concerned with harm reduction — reducing the extent of harm individuals could do to themselves and their communities. Effectiveness was measured in reduced levels of HIV risk taking. Although treatment entry was desirable (as the best protection against HIV risk), it was not a criterion of outreach programming success (Watters, 1994). If outreach and bleach distribution pushed the limits of drug abuse programming, needle exchange programs appeared to some to lie beyond those limits (DuPont, 1996). In making available the implements of drug taking, needle exchange programs were viewed as reducing, if not removing, societal sanctions against drug use. The response of those championing the harm reduction strategy was that rehabilitation, although a laudable goal, was impossible in the absence of the client’s survival. In their argument, the spread of HIV infection constituted a clearly emergent situation demanding a response that went beyond treatment as usual.

As detailed by Normand and colleagues (1995), a review of the effectiveness of needle exchange programs was requested by the U.S. Congress in 1991 and carried out by the General Accounting Office (GAO) through review of existing study findings and a limited number of site visits to needle exchange programs. The GAO analysis and report (1993) gave qualified support to needle exchange programs, concluding that some of the U.S. and foreign studies reviewed suggested reductions in needle risk behaviors and no increase in recruitment into injection drug use. The one U.S. program included in the analysis and two of the additional eight programs reported making referrals to drug abuse treatment programs.

A second report developed for the U.S. government dealing with the effectiveness of needle exchange programming was issued in 1993. The report identified and reviewed nearly 2,000 U.S. and foreign studies and ranked them on a five-point scale of research quality to determine their influence on report conclusions and recommendations. This effort involved site visits and data collection at 33 needle exchange sites in 15 cities (Lurie et al., 1993). The authors concluded that needle risk behavior was dramatically diminished without evidence of negative outcomes in terms of increased injection or other drug use in the communities served and found no evidence of other public health dangers. Moreover, 17 of 18 U.S. and Canadian needle exchange programs reported making referrals to area drug abuse treatment programs (Lurie et al., 1993). One program, located in New Haven, found that needle exchange resulted not only in reduced HIV risk behavior, but also to entry into drug abuse treatment (Kaplan, 1993).

Findings from studies of both outreach and needle exchange programs suggest the importance of coordinating treatment programming with community initiatives that provide health services to drug users. In the instance of HIV prevention programs, significant health concerns associated with individuals’ continuing drug use likely reinforce messages regarding availability of drug abuse treatment and concerns about drug use and lifestyle. In the currently popular Stages of Change model (Prochaska, DiClemente, & Norcross, 1992), the arousal of health concerns may facilitate movement from contemplation to preparation and ultimately to action.

Needle exchange programs developed independently of one another; therefore, they tend to differ in their commitment to treatment referral. However, needle exchange programs provide a means to link injection drug users to health services, including drug treatment (Carvell & Hart, 1990). In their review of U.S. and Canadian needle exchange programs, Sorensen and Lurie (1993) identified several bridges used to facilitate entry into substance abuse treatment. Although the definition of referral was not always consistent, ranging from personally escorting an individual to passively mentioning treatment, the programs offered insights into the process. Three of the programs described referred 33% to 40% of their injection drug users to drug treatment. When sufficient funding was available, staff members referred additional clients to treatment.

Other opportunities to encourage linkage to treatment were described by Sorensen and Lurie (1993). As preparation for entering drug abuse treatment, injection drug users have an opportunity to build trusting relationships with program staff. Depending on the organization of services, needle exchange programs may be integrated within the existing public health system and be located such that physical access to treatment services encourages engagement.

Contingency management interventions have been used to promote entry into and continued participation in drug treatment programs. Incentives such as coupons and vouchers are common referral mechanisms used by needle exchange programs (Sorensen and Lurie, 1993). As long as treatment slots are available, the use of incentives such as coupons or vouchers can motivate treatment entry by removing financial considerations and circumventing waiting lists. In most cases, incentives can be integrated into existing treatment programs. Although all of the variables have not been explored, a review of five needle exchange program studies indicates that incentives appear to be successful in linking injection drug users to treatment (J. L. Sorensen, personal communication, June 9, 1998).

The primary barrier to linking needle exchange clients to treatment is the lack of available or effective treatment in many communities (Sorensen & Lurie, 1993). Insufficient treatment slots and long waiting lists discourage even those drug users motivated to seek treatment. Needle exchange programs often are open during times that drug treatment programs are closed. Referrals are less effective when treatment programs are located at a distance from the needle exchange program or if clients are sent to a treatment site rather than accompanied by a supportive staff member. Adjacent drug treatment facilities are rare (Sorensen & Lurie, 1993).

Linkages to Primary Care

Although linkages between drug abuse treatment and community-based HIV prevention programs have been forged slowly, at least in part due to the novelty of HIV prevention programs, the same rationale cannot be applied to the often poor liaison between drug abuse treatment and well-established primary care units (Brown, 1991). As reported by Selwyn (1996), rather than using private physicians or outpatient clinics, drug users have long used emergency rooms and acute care hospital facilities as their primary care providers. HIV-infected drug users have made less use of outpatient medical facilities than HIV-infected gay men (Mor, Fleishman, Dresser, & Piette, 1992). That difference was found to be significantly associated with race, with whites more likely to use outpatient services (Piette, Mor, Mayer, Zierler, & Wachtel, 1993). Not surprisingly, outpatient visits were also found to be tied to insurance status (Solomon, Frank, Vlahov, & Astemborski, 1991). Perhaps most ominous, HIV-infected drug users, as well as women and people of color, were less likely to receive antiretroviral medications than HIV-infected gay men (Piette, Fleishman, Stein, Mor, & Mayer, 1993).

The needs of drug users for community health and other services have been well documented. Mental health problems, job training, housing, and family assistance have long been described as concerns requiring attention (Piette, Fleishman, et al., 1993). Moreover, health needs are not restricted to HIV. In particular, drug users are at heightened risk for sexually transmitted disease in association with the behaviors employed to finance drug use as well as the disinhibiting effects of those drugs (Nelson, Vlahov, & Cohn, 1991). Drug users are at heightened risk, as well, for tuberculosis (Selwyn et al., 1989) and viral hepatitis (Neshin, 1993). In addition, Selwyn (1996) reports that drug-using women are at risk for complications from pregnancy, past infections, cervical dysplasia, and/or cancer. A recent publication of the Center for Substance Abuse Treatment (CSAT) describes screening practices for HIV and other infectious diseases (Barthwell, 1993), while additional volumes explore primary care issues embracing medical treatment for those who have become infected (Brown, 1995b; Selwyn & Batki, 1995).

Serving the primary care needs of drug abuse clients requires both diagnostic/preventive care and medical treatment. Four models have been described for the delivery of those services (Selwyn, 1996): (a) on-site primary care services in which the core activity is the delivery of drug abuse treatment, (b) referral systems to primary care, (c) drug treatment services in the primary care setting in which the core activity is the delivery of medical services, and (d) comprehensive care service systems in which the core activity is the delivery of a range of social and health services. As described by Selwyn (1996), the best evidence to date of effectiveness in terms of assuring medical care is obtained with on-site services in which primary care is provided in the drug treatment setting. That is, to encourage effective use of medical services, it is preferable to bring those services into settings primarily concerned with the delivery of drug abuse treatment. Those initiatives do not rely on the capacity of clients to follow through on referrals on the one hand and make use of drug treatment counselors and an existing regimen of drug treatment sessions on the other.

As compared to those programs affiliated with hospital facilities, stand-alone treatment programs are typically at a disadvantage in making primary care services available. The medical resources available through a hospital association obviously make the provision of primary care more feasible. Nonetheless, even under these conditions there are likely to be policy and programmatic issues requiring resolution. Resources, although more abundant at the hospital site, are still finite. Moreover, the behavior of drug abuse clients may make them less desirable hospital patients and thereby may make necessary the training of hospital staff, or cross-training of hospital and drug treatment staffs, to guarantee sympathetic and effective service delivery. Sorensen, Batki, Good, and Williamson (1989) have described a primary care services model that was delivered with a high level of program compliance to seropositive drug treatment clients in a hospital-affiliated methadone program (i.e., a program that was concerned primarily with drug abuse treatment and that provided on-site medical care).

Second, referral systems to provide primary care make use of existing community health and social service facilities through the development of cooperative relationships between the drug abuse treatment program and those agencies. The services negotiated may rely on informal arrangements based on joint concerns of the drug abuse and public health communities, a common administrative structure, personal relationships, contractual arrangements, or some combination of these. Again, these efforts may suffer from a general paucity of community resources, difficulties in drug users gaining access to those services, or the unwillingness and/or inability of clients to adhere to the regimens set by community agencies. As described by Selwyn (1996), for referral to be effective, the drug treatment program and community agency must jointly monitor client movement. Despite potential obstacles, initiatives to make medical services available to drug abuse clients have been successful, especially the provision of antiretroviral medications to seropositive clients (O’Connor, Molde, Henry, Shockfor, & Schottenfeld, 1992).

A third model for providing primary care services involves the provision of drug abuse treatment in the primary care setting. As described by Selwyn (1996), efforts to respond to drug use problems in primary care settings have chiefly involved screening and referral to specialized drug treatment programs rather than the assumption of that responsibility by the primary care facility. Consistent with the findings reported above regarding the limited use of primary care facilities by drug users, those users who seek out primary care tend to be younger and less invested in a drug use career than clients entering drug treatment facilities (Genser & Schlenger, 1993). It should, however, be noted that Weisner and Schmidt (1995) found that drug users were more likely to be seen in the complex of health care, social service, and criminal justice agencies than in drug abuse treatment programs.

The much discussed and little implemented comprehensive care center (i.e., "one-stop shopping") is an appropriate resource for serving drug abuse clients' multiple needs and, thereby, for protecting the health and well-being of the individual and the community. The development of such centers, designed to serve defined catchment areas, has long been seen as a strategy capable of increasing the cooperation of the several agencies necessary to meet client needs and promote rehabilitation and as a means to make those agencies more accessible. Nonetheless, "one-stop shopping" remains the exception.

Constituency Group Statements

Concerns about the issues for drug abuse treatment presented by HIV infection and the threat of infection have led to the development of policy statements on differing aspects of treatment by several organizations. As reviewed by Normand and colleagues (1995), a number of service provider organizations have recommended expanded treatment opportunities as well as increased efforts to provide HIV prevention. Several give full or qualified support to outreach and needle exchange programs. Of particular interest are the policy statements issued by two groups relating to HIV counseling and testing and to primary care.

At its October 1994 meeting, the Board of the American Society of Addiction Medicine (ASAM) adopted a series of policy statements regarding drug abuse treatment (ASAM, 1995a, 1995b, 1995c, 1995d). These statements emphasize (a) the role that drug abuse treatment programs can play in "organizing and providing medical care to drug dependent individuals" and the need to provide that coordinated care; (b) the especial need to respond to the increasing evidence of tuberculosis among drug abuse clients; (c) the availability of HIV testing for all drug abuse clients who are deemed to be at risk for contracting AIDS, with appropriate attention to pretest and posttest counseling and client confidentiality; (d) HIV education and prevention for all clients; (e) staff education in HIV issues; and (f) the encouragement of needle exchange programming "in all communities with injection drug users."

At a March 1995 consensus conference on drug abuse treatment and AIDS/HIV infection organized under NIDA auspices, a series of policy statements was adopted by a panel of 22 members representing "the several treatment modalities, the treatment research community, state drug abuse authorities, criminal justice programming, and ... those involved primarily or exclusively in AIDS prevention with drug users and their sexual partners" (Brown et al., 1996). Those statements emphasize that treatment programs should (a) admit all qualified applicants irrespective of HIV status, (b) broadly assess clients’ medical and social status and provide or obtain needed medical and social services, (c) provide HIV prevention services and the opportunity for HIV testing in both drug abuse treatment and criminal justice facilities, and (d) provide in-service staff training about HIV issues. Additional policy statements emphasize the importance of making HIV prevention information and/or counseling available to clients’ sexual partners, of developing early retention strategies, and of the role to be played by the criminal justice system in both treatment and HIV prevention. In addition, the conference participants took note of the fact that guidelines can and should be developed to inform the delivery of HIV prevention services for drug abuse clients.

In general, drug abuse professionals agree with statements calling for the expansion of treatment opportunities, for modest efforts to provide HIV prevention, for attention to the medical and social service needs of clients, and for the compassionate care of HIV-infected individuals. These activities represent the expansion of treatment services necessary to provide prophylaxis on the one hand and to serve the client in need on the other, without modifying the delivery of core drug abuse treatment. Additional efforts, being explored in several settings, involve significant changes in existing service delivery.

Issues for Treatment Entry and Retention

The limited availability of public treatment programming, and in particular of methadone and residential treatment "slots," has given rise to the development of strategies designed to increase the availability of treatment services to those at greatest risk for HIV infection where feasible and to develop alternative services where increase in treatment availability is infeasible. Increasing the availability of treatment can include (a) increasing the number of treatment slots and (b) facilitating entry or removing barriers to drug abuse treatment.

Increasing the number of treatment slots may be pursued through a use of funding sources additional to those normally available to support drug abuse treatment. Sorensen and Miller (1996) describe the use of Ryan White CARE funds to support treatment for HIV-infected drug users. In addition, a jurisdiction may institute regulatory change to increase treatment availability to selected populations. McCarty, LaPrade, and Botticelli (1996) describe a process that successfully revised state regulations governing substance abuse treatment to increase treatment availability to injection and other drug users by prioritizing drug users’ access to outpatient alcohol and drug treatment slots, redefining detoxification services to include a range of medical diagnostic services, and modifying the fee structure. In addition to creative funding strategies and the modification of existing regulations, communities have the option of prioritizing within the drug-using population for access to scarce outpatient and residential drug-free treatment.

In short, drug abuse programs must accept a particular responsibility for populations whose care has special implications for the health of the community (Lampinen, 1991). It can be argued that the risks injection drug users pose to themselves and to others is justification for those applicants to be given preference over noninjectors for scarce treatment slots. Reasons not to give injectors preferential admission are (a) applicants may be seen as rewarded for being injectors, (b) the motivation noninjectors may bring to the treatment program is overlooked, and (c) noninjectors’ risk through sexual activity is underestimated.

Strategies for facilitating treatment entry have been concerned with rapid entry to treatment (i.e., treatment on demand) and role induction strategies to permit client engagement. Strategies for removing barriers to treatment entry have focused attention on economic impediments to entry.

Treatment on demand, as described by Wenger and Rosenbaum (1994), has occasioned considerably more rhetoric than action. Nonetheless, the two studies conducted in this area both suggest greater retention of rapid-entry clients than those admitted only after the more customary steps of induction (Bell, Caplehorn, & McNeil, 1994; Rosenberg, McKain, & Patch, 1972).

In contrast to the limited efforts to explore treatment-on-demand strategies, there have been several attempts to develop and assess early retention initiatives involving role induction strategies. Those strategies recognize and respond to client ambivalence about drug abuse treatment and/or ignorance or misconceptions about the process of treatment. Thus, role induction strategies involve clarification at the outset of treatment regarding the structure and functioning of the treatment program; client and staff roles, responsibilities, and expected activities; and exploration of potential areas of treatment stress as well as advantages. Ample time is given for the client to raise issues and concerns needing resolution. Role induction strategies have been particularly effective in increasing retention with residential treatment clients (De Leon, 1991; Goldapple & Montgomery, 1993; Ravndal & Vaglum, 1992).

An additional early retention strategy that has implications for HIV risk reduction is that of contingency management. Contingency management strategies have been used to encourage not only retention, but also program compliance such as attending scheduled counseling sessions and adhering to medication schedules. Thus, retention involves attendance sufficient to avoid dropout; compliance involves adherence to the treatment regimen. To the extent adherence to the treatment regimen is consonant with the ability to derive program benefit, strategies that encourage compliance may be expected to produce greater evidence of positive behavior change generally and of risk reduction specifically. In that regard, it is noteworthy that contingency management initiatives have been associated with increased program compliance of methadone clients even when simple rewards were used and when rewards were delayed up to 3 months (Rowan-Szal, Joe, Chatham, & Simpson, 1994). Use of contingency management also increased compliance in psychologically disturbed drug users (Carey & Carey, 1990).

The importance of developing and implementing early retention initiatives, as typified by role induction strategies and contingency management initiatives, is heightened by concerns with halting the spread of HIV infection (Brown, 1991; Sorensen & Miller, 1996). Increasing client motivation for behavior change is associated not only with important goals of rehabilitation, but also with urgent goals of client survival and community safety.

As noted, strategies to reduce barriers to treatment entry have placed a particular emphasis on the removal of financial impediments to access to drug abuse treatment. The provision of vouchers for free detoxification has consistently led to large numbers of opiate users requesting redemption of those vouchers to gain entry into treatment (Bux, Iguchi, Lidz, Baxter, & Platt, 1993; Jackson, Rotkiewicz, Quinones, & Passannante, 1989; Sorensen, Constantini, Gibson, & Wall, 1993), with more vouchers redeemed for 90- than 21-day detoxification (Bux et al., 1993) and with a substantial minority (28%) of those given 21-day vouchers opting for a longer stay (Jackson et al., 1989). Moreover, in a comparison of methadone clients randomly assigned to no-fee and nominal-fee groups, clients assigned to the no-fee group were significantly more likely to be retained in treatment for 1 year or longer (Maddux, Parihoda, & Desmond, 1994). Given the cost to society of law enforcement, incarceration, and health care for injection and other drug users, the insistence on recovering payments from drug abuse clients appears to be misguided economic and social policy.

Modifying Methadone Treatment

As described above, methadone maintenance has been associated with continuing seronegativity among opiate clients; however, methadone treatment slots have been in short supply. Strategies for making methadone more available have taken four differing paths: (a) a use of medical maintenance, (b) mobile methadone dispensing vans, (c) 180-day detoxification programs, and (d) interim methadone for waiting-list clients. A fifth medication strategy would involve use of an alternative opiate substitute—l-"-acetylmethadol (LAAM). It should be noted that only interim methadone has been designed specifically to respond to the AIDS crisis, although all these strategies have implications for HIV prevention.

Medical Maintenance

Medical maintenance involves the provision of 28 days of take-home methadone through the use of medical facilities in the community. Typically, the medical maintenance client has been in treatment a minimum of 3 to 5 years and has a lengthy history of responsible use of take-home medication and of effective psychosocial functioning with specific regard to drug and alcohol use, criminal activity, and employment. The medical maintenance client receives one observed dose at time of monthly pick-up (to confirm continuing tolerance) and gives a urine specimen. Counseling is provided on an as-needed basis only (Novick, Joseph, et al., 1988; Novick, Pascarelli, et al., 1988). In a study of 40 clients assigned to medical maintenance for periods of 12 to 55 months, 33 (83%) were retained in medical maintenance while an additional 6 (15%) either requested or were assigned (in association with cocaine use) to routine maintenance. Only one client used heroin (and only for a brief period) during the time assigned, and there were only four instances of lost medication over 1,381 months (Novick & Joseph, 1991). Medical maintenance holds promise as a strategy for permitting appropriate clients to be referred to alternative medical facilities, freeing up space at oversubscribed methadone treatment programs. However, it is unclear how many clients can qualify under the stringent guidelines in place, whether those guidelines might be relaxed somewhat without risk to the client or community, and to what extent community medical facilities (e.g., doctors’ offices) can be made available to an opiate-using clientele.

Mobile Vans

The use of mobile vans to deliver methadone (and counseling) to community members has the obvious potential of increasing the number of opiate users admitted to methadone treatment without increasing traffic at existing community facilities. Mobile vans present the added advantage of recruiting a client population that might otherwise find it inconvenient or undesirable to enter treatment. Use of vans also precludes the need to negotiate with communities often hostile to the addition of free-standing methadone programs. To date, methadone vans have been developed in Amsterdam, Boston, and Baltimore. The Boston program has expanded services to Boston residents and permitted service delivery to be initiated in several Boston suburbs (Center for Addictive Behaviors, 1994; McCarty et al., 1996). The Baltimore program was designed as a research project and has produced somewhat mixed results; that is, the mobile program is obtaining significantly higher rates of opiate- and cocaine-positive urines than a comparison stationary methadone program while obtaining significantly lower rates of attrition from treatment (Brady, 1993a, 1993b).

180-Day Methadone Detoxification

The use of 180-day methadone detoxification provides the potential for prolonged methadone treatment to those opiate users who are put off by the prospect of becoming maintenance patients and choose instead to see themselves as detoxifying from heroin. Quite simply, it is unknown how many—if any—of the 40% of long-time opiate users who do not choose to enter treatment (Liebman et al., 1993) would elect this detoxification regimen. However, it is known that methadone is viewed negatively in much of the target community (Murphy & Irwin, 1992) and that 180-day detoxification offers the client the opportunity to view himself or herself—and to describe himself or herself to others—as someone in the process of detoxifying rather than as someone who must continue on methadone indefinitely. At the same time, the long-term detoxification client is able to benefit from a range of psychosocial services that would be pointless with a short-term detoxification client. Long-term detoxification is available to opiate users of both short and long duration (i.e., a range of services is available to opiate users who are eligible only for detoxification [DHHS, 1989]). Although the 180-day detoxification program appears to be little implemented, it has been found to limit opiate use, reduce craving, and reduce anxiety and depression in clients. Moreover, these treatment effects were sustained at 6-month follow-up, with 55% of detoxification clients in drug abuse treatment at time of follow-up (Banys, Tusel, Sees, Reilly, & DeLucchi, 1993; Reilly, Banys, Tusel, & Sees, 1993; Tusel, Reilly, Banys, Sees, & DeLucchi, 1993).

Interim Methadone

Interim methadone has excited far greater controversy than medical maintenance, mobile methadone vans, or 180-day detoxification and has had even less application (Peyser, Newman, Friedmann, & Des Jarlais, in press). Interim methadone involves the administration of daily methadone (with Sunday take-home) to applicants for methadone treatment who cannot immediately be admitted and must be placed on a waiting list. In addition to methadone administration, waiting-list clients are given HIV prevention/education, crisis counseling, and referral to community agencies appropriate to client needs, but they do not receive sustained counseling or other services as provided to regularly enrolled methadone patients. Studies of interim methadone treatment have found that clients receiving methadone while on a waiting list showed significantly lower rates of heroin use than waiting-list clients who were not provided methadone (Yancovitz et al., 1991). Moreover, significantly more interim methadone clients (72%) were admitted to treatment than comparison clients (56%) over a 16-month study period, and rates of retention for 1 year did not differ between interim methadone clients and an additional sample of clients admitted directly into methadone maintenance (Friedmann et al., 1994).

In spite of these findings—and in spite of legislation tying federal funding for treatment to a requirement that injection drug-using clients on waiting lists for 2 or more weeks receive interim methadone—no jurisdiction provides interim methadone (Peyser et al., in press). Opposition to interim methadone employs two arguments: use of a minimalistic treatment approach will fail and prove destructive to the capacity to provide comprehensive treatment (Rangel, 1989; Webb, 1990), and use of a minimalistic treatment approach will be attractive to policymakers and budgeteers and prove destructive to the capacity to provide comprehensive treatment (Finklestein, 1990; Primm, 1989). Missing from these arguments is an acknowledgment that interim methadone is not suggested (or legislated) as a treatment form, but as a strategy for permitting clients to remain available to comprehensive treatment without doing irreparable harm to themselves or their communities. Again, client rehabilitation is impossible in the absence of that client's survival.

LAAM

A fifth strategy for increasing the availability of treatment to opiate clients involves the administration of LAAM. LAAM, a long-acting form of methadone, provides the client and treatment program an alternative to methadone that extends the period of stabilization from the 1 day obtained with methadone to 3 days. Thus, the opiate client can be maintained on medication without the necessity of daily visits (CSAT, 1995). For the program that has concerns about use of take-home medication, LAAM provides an alternative that can permit the clinic to treat an increased number of clients. For the program that provides take-home medication, LAAM may be viewed as an attractive alternative to methadone, since its administration at the clinic provides protection against both diversion and overdose. Drug abuse treatment involving LAAM has been as effective as treatment using methadone (Ling & Blaine, 1979; Ling, Charuvastra, Kaim, & Klett, 1976; Ling, Klett, & Gillis, 1978). However, opiate clients assigned to LAAM at treatment entry were somewhat more likely to drop out of treatment early than were those started on methadone (Ling et al., 1976; Ling et al., 1978). This suggests the importance of careful selection of clients for LAAM and/or the use of LAAM as a replacement medication for methadone after pharmacological and psychosocial stabilization on methadone has been achieved.

Relapse Prevention/Aftercare and HIV Prevention

Although the use of relapse prevention strategies is typically initiated as a part of drug abuse treatment, the strategy, like aftercare, is designed specifically to counter community pressures to resume drug use. As with early retention strategies, relapse prevention/aftercare strategies were viewed by some as an important treatment issue before the advent of concerns regarding HIV infection. Nonetheless, the association of relapse to contracting and spreading a lethal disease further elevates the importance of relapse prevention/aftercare. A number of strategies have, in fact, been effective in reducing client drug use and maintaining or extending treatment gains in psychosocial functioning (Carroll, Rounsaville, & Gawin, 1991; Carroll, Rounsaville, & Keller, 1991; Hawkins, Catalano, Gillmore, & Wells, 1989; Hawkins, Catalano, & Wells, 1986; McAuliffe, 1990; McAuliffe & Chien, 1986). In that context, it is a particular concern that a limited number of treatment programs have incorporated aftercare as a service they provide (Hubbard et al., 1989).

When Worlds Collide: Treatment Concerns and Harm Reduction Concerns

Relapse prevention and aftercare, like early retention and the administration of LAAM, represent the use of additional treatment initiatives. Their limited use to date may reflect a lack of financial and/or human resources, lack of information, insecurity about implementation of these initiatives, or simple inertia. However, unlike outreach/bleach distribution, needle exchange, and interim methadone—as the latter has been interpreted by much of the treatment community—these initiatives break no new ground in terms of the ideology of treatment. Other than these three, each approach discussed to date can be seen as geared to traditional rehabilitative ends. The three initiatives that appear to lie outside usual approaches have been isolated from drug abuse treatment practice. Interim methadone has been converted to a nonissue through disuse whereas outreach/bleach distribution and needle exchange are tolerated as nontreatment initiatives conducted by nontreatment staffs. As described above, these latter initiatives are seen as capable of moving the field closer to harm reduction (i.e., as threatening to rehabilitation objectives). Other initiatives that appear tied to harm reduction have received less attention but are perhaps capable of exciting equal or greater controversy.

Training Clients in "Safer" Drug Injection

Given dropout rates from methadone treatment of more than 30% at 3 months and nearly half of clients (48%) at 6 months — with far higher rates for other treatment modalities (Hubbard et al., 1989) — it can be argued that AIDS prevention programming should include instruction in safer drug injection. Thus, although retention in drug abuse treatment can be accurately seen as the most effective AIDS preventive, many clients are not retained for extended periods or for periods long enough to achieve continuing behavior change. In this regard, Conviser and Rutledge (1989) describe the teaching of needle sterilization strategies to drug abuse clients as a promising AIDS prevention strategy. They report that staff members at New Jersey outpatient drug-free programs thought that instruction in safer drug use was inconsistent with treatment efforts to discourage drug use, but that methadone staff were more receptive to that strategy. However, the authors provide no data in support of their conclusions. Sorensen and Miller (1996) report that counselors in their treatment program are "grilled" by clients regarding effective needle-cleaning strategies, suggesting that such information is not made routinely available and is a continuing area of both concern and confusion for drug abuse clients. The importance of taking steps to protect the health, indeed the life, of the client who will drop out can be viewed as jeopardizing the rehabilitation of the client who will be retained. The concern with avoiding the suggestion of treatment failure can be viewed as jeopardizing the survival of the client who will drop out.

Retaining Clients Who Continue to Use Illicit Drugs

Historically, programs have monitored clients' behavior both for counseling purposes and for the sanctioning of inappropriate behaviors. The ultimate sanction involved discharge for the client whose repeated misbehavior suggested that he or she was not yet ready for treatment. Prominent among those misbehaviors was an inability or unwillingness to contain the use of illicit drugs in spite of the counseling and supportive services provided by the program. As described by Sorensen and Miller (1996), some believe that it is more desirable for the HIV-infected injection drug user to be using drugs occasionally in treatment than to be untreated and at risk in—and to—the community. One could argue as well that the injection drug user who refrains from injecting while in treatment—even if using other noninjection drugs—poses less of a threat to public health while in treatment than if discharged into the community. The dilemma for treatment is apparent. The retention of clients who continue to use drugs, albeit noninjection drugs, may give a message to other clients and to the community of a diminished concern with the traditional goal of rehabilitation. That is, the retention of drug-using individuals changes the nature of drug abuse treatment. Again, the conflict between concerns regarding rehabilitation vis-à-vis concerns about protecting the client and community from disease reflects the dispute over the role for harm reduction in drug abuse treatment programming. Although these concerns are not mutually exclusive, the emphasis on one or the other can lead to differing courses of action.

Minimalist Versus Comprehensive Treatment

Perhaps nowhere is the conflict between harm reduction and rehabilitation better delineated than in the dispute regarding proposals to increase the availability of methadone treatment through a narrowed conception of that treatment, typically described as the provision of methadone with a near absence of support services and implemented by some European providers (Hartgers, van den Hoek, Krijnen, & Coutinho, 1992; Sorensen & Miller, 1996). As noted above, the response to a minimalist services program for injection drug users placed on waiting lists (interim methadone) has been to deny the availability of that intervention. Not surprisingly, there has been no rush to embrace minimalist methadone treatment for injection drug users who are admitted to treatment in the United States. Moreover, a study by McLellan and colleagues (1993), indicating a relationship between diminution in the delivery of psychosocial services and both use of illicit drugs and evidence of psychopathology in methadone clients, has been widely cited as evidence for the necessity of comprehensive treatment to achieve the several objectives of drug abuse treatment. Nonetheless, it seems clear that many methadone programs, driven by economic rather than ideological considerations, have taken giant steps in the direction of minimalist methadone treatment. Thus, one complex of methadone programs serving more than 8,000 clients provides daily methadone and once-monthly counseling (Richman, 1996). Although it is unclear to what extent that experience is widespread, it is noteworthy that the majority (51%) of clients in the 29 sampled Drug Abuse Treatment Outcome Study (DATOS) methadone maintenance programs reported receiving 10 or fewer counseling sessions during the first 3 months of treatment; 65% reported receiving no psychosocial services other than drug abuse counseling; and treatment services were dramatically reduced from 10 years earlier (Etheridge, Craddock, Dunteman, & Hubbard, 1995). In short, the concern with retaining comprehensive methadone treatment may reflect more wish than reality. The pretense that the emperor remains fully clothed may be more easily maintained by those who seek to influence drug abuse policy than by those who must live under it.

Working with Clients' Sexual Partners

Family counseling long has been viewed as an important and underprovided service (see, for example, Hubbard et al., 1989). Etheridge and colleagues (1995) found that family services were the most frequently cited need by clients in both outpatient and residential drug-free programs (68.9% and 77.5% of clients, respectively). The need for family services was also cited by 54.4% of methadone clients (the largest proportion of methadone clients—56.6%—cited medical needs). At the same time, only 20.2% of residential clients, 8.3% of outpatient drug-free clients, and 2.0% of methadone clients reported receiving family services. In short, there is no tradition of providing family services to drug abuse clients. Again, the HIV epidemic and its impact on drug users has focused attention on the relative absence of those services. Because the vast majority of drug abuse clients generally, and injection drug users specifically, are male (NIDA & National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1992), sexual partners at risk for HIV infection are typically female. Thus, 68% of female AIDS cases are attributable to injection drug use, either the individual's own use (44%) or as the consequence of sex with an injection drug user (24%), and 54% of pediatric AIDS cases are attributable to the mother's injection drug use (37%) or sex with an injection drug user (17%) (CDC, 1996a). Although the threat to female partners of male injection drug users is readily apparent, the risk to male partners of female injection drug users, to male partners of female injection drug users, and to gay and lesbian partners of injection drug users needs to be acknowledged as well.

For the most part, the effort by treatment programs to limit the risk of sexual partners contracting AIDS has consisted of HIV prevention counseling and/or the dispensing of information and literature to clients with the intent that the materials provided and the risk reduction strategies obtained through counseling be shared with the partner (Brown, 1991; Sorensen & Miller, 1996). Friedman, Des Jarlais, Ward, and Jose (1993) have argued for greater effort by programs to counsel clients about sexual risk taking and risk reduction with sexual partners. Schilling and colleagues (1991, 1993) and El-Bassel and Schilling (1992) found that female methadone clients exposed to a group-oriented, skills-building strategy were more likely to use condoms, to discuss sexual behaviors with their partners, and to feel better able to reduce their risk for contracting HIV than clients receiving information only.

The effort to reach the sexual partners of drug abuse clients is limited by concerns about both client confidentiality and the availability of resources to support that activity. Although the guarantee of client confidentiality must be a concern, it is noteworthy that more than 90% of injection drug-using clients reported a willingness to share HIV test results with both a partner and a personal physician, while a majority (58%) would share findings with public health agencies (Calsyn, Freeman, Saxon, & Whittaker, 1990).

Two types of resources are needed to support a sexual partner program. First, dollars are needed to permit staffing adequate to carry out the contacting and counseling of partners. Second, information is needed to guide the development of effective programs. Sadly, both types of resources are lacking. Certainly, there is little evidence of a concern with reaching sexual partners as would be reflected in a body of studies being undertaken in this area. At the same time, there is little enthusiasm for using public health agencies to conduct "contact tracing" in the absence of available drug treatment staff (Brown & Beschner, 1989). Indeed, there is considerable ambivalence about whether treatment programs have any role in the area of partner counseling (Carroll, in press). Still, the vulnerability of partners and their offspring impels greater clinical and research efforts in this area. In that regard, Wermuth (1995) provides a useful review of issues and potential strategies for involving sexual partners in HIV prevention activities with the treatment client's active assistance and support.

As with the out-of-treatment drug user, community-based organizations often have taken a larger role in locating and counseling sexual partners than have treatment programs. Outreach to community facilities at which sex partners might be found (beauty parlors, public housing projects, launderettes, etc.) by indigenous workers led to substantial reductions in several areas of sexual risk behaviors. Twenty percent of female sexual partners (N = 1127) reported always using condoms at 6-month follow-up compared to 5% at baseline, while 24% of male sex partners (N = 510) reported always using condoms at follow-up compared to 9% at baseline. Similarly, the proportion of female sexual partners reporting two or more sex partners declined from 42% to 32%, and the proportion of females reporting two or more injection drug-using partners declined from 15% to 8% over the 6-month study period. The proportion of male partners reporting two or more partners declined from 72% to 51%, and the proportion of males reporting two or more injection drug-using partners declined from 37% to 15% (NIDA, 1994). Given the difficulty typically reported in reducing sexual risk taking, these figures offer both a basis for further refinement and an optimism for future efforts.

Perinatal Transmission

The effort to prevent perinatal transmission of HIV emphasizes the importance of working with female sexual partners as well as indicating some of the special issues that need to be addressed in working with female drug users of child-bearing age. Approximately 25-30% of infants born to HIV-infected mothers are infected (Normand et al., 1995), suggesting the importantce of early diagnosis and the need for treatment programs to emphasize counseling on sexual risk reduction. Early diagnosis provides an opportunity to consider continuing or terminating the pregnancy, to prepare the mother for the birth of an infected child, and to limit the risk of HIV transmission through breast-feeding where advisable.

The need for sexual risk counseling is underscored by the greater likelihood that female injection drug users will become pregnant than will their noninjecting peers (Normand et al., 1995). This finding suggests increased sexual activity and/or diminished use of condoms by female injection drug users, either of which increases the risk of infection and perinatal transmission of HIV.