Frequently Asked Questions: 2

• How effective is a comprehensive HIV/AIDS prevention approach?
• What role does the community-based outreach worker play in comprehensive HIV prevention for drug users?
• Is comprehensive HIV prevention for drug users cost-effective?

How effective is a comprehensive HIV/AIDS prevention approach?

Comprehensive HIV/AIDS prevention, which includes the strategies and components of community-based outreach, drug abuse treatment, and sterile syringe access programs -- all in combination with testing and counseling for HIV and other infections -- currently is the most effective approach for preventing the spread of HIV, other blood-borne infections, and STDs in drug-using populations.

Community-based outreach. More than 15 years of research on HIV/AIDS prevention interventions with IDUs, crack cocaine users, and many of their sex partners has shown that community-based outreach is effective for all types of drug-using risk groups, in a range of local settings. Cumulative research from a 23-site study that followed 18,144 drug users (13,164 IDUs and 4,980 non-injecting crack users) reports that 3 to 6 months after participating in the intervention, 72 percent of the IDUs either stopped injecting drugs or reduced their frequency of injection. Of those who continued to inject, nearly 60 percent either stopped or reduced reusing or sharing their syringes. Twenty-six percent of the crack cocaine users, including 8,184 IDUs who also used crack and 4,980 non-injecting crack users, had stopped using crack cocaine at follow-up. Nearly 25 percent of the 18,144 drug users who participated in the study had entered drug abuse treatment at follow-up, many for the first time.

Drug abuse treatment. Studies have consistently shown that participation in drug abuse treatment is associated with lower rates of drug injection. For example, a 3-year study of drug use patterns among male IDUs participating in methadone maintenance treatment reported that 71 percent of 388 patients who had remained in treatment for 1 year or more had stopped injecting drugs. By contrast, in a second group of 105 IDUs who had dropped out of treatment, 82 percent had relapsed to injecting drug use within a year. Another study found that opiate addicts who were recruited by street outreach workers and offered free methadone maintenance treatment were significantly more likely to enter and remain in treatment, even if they had never been in treatment before or claimed not to want treatment (4).

Research has also shown that participating in methadone maintenance treatment is linked to lower rates of HIV infection. In one study, for example, drug users who remained out of treatment were nearly six times more likely to become infected than those who remained in treatment (5).

Sterile syringe access programs. When implemented as part of a comprehensive HIV/AIDS prevention strategy, sterile syringe access programs play a unique role in engaging hard-to-reach populations at high risk for HIV infection in meaningful prevention interventions and treatment opportunities. Evaluations of these programs indicate that they are an effective part of a comprehensive strategy to reduce the injection drug use-related spread of HIV and other blood-borne infections. In addition, they do not encourage the use of illicit drugs. For example, one study in New York City showed a 70 percent decrease in HIV incidence attributed to sterile syringe access programs (6). By comparison, international investigators found that in 29 cities with established sterile syringe access programs, HIV prevalence decreased an average of 5.8 percent per year but increased an average of 5.9 percent per year in 51 cities without such programs (7).

The cumulative research shows that sterile syringe access programs are effective in reducing the further spread of HIV among IDUs, their sexual partners, and their children. Furthermore, these programs help to:

• increase the number of drug users who enter and remain in detoxification and drug treatment programs if they are available to them;


• disseminate HIV risk reduction information, materials for behavioral change, and referrals for HIV testing and counseling and drug treatment services;


• reduce injection frequency and needle-sharing behaviors;


• reduce the number of contaminated syringes in circulation in a community; and


• increase the availability of sterile injection equipment, thereby reducing the risk that new infections will spread.

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What role does the community-based outreach worker play in comprehensive HIV prevention for drug users?

Community-based outreach workers are on the front line in the local community, and they know where, when, and how to contact even the most difficult-to-reach drug users in their neighborhoods. As a trusted and recognized source of information, an outreach worker can help drug users understand their personal risks for HIV and other blood-borne diseases and identify the preventive steps they need to take. As a peer, the indigenous outreach worker can encourage drug users to stop or reduce using and injecting drugs and enter drug abuse treatment. They can provide referrals to drug users for drug-abuse treatment, for testing and counseling for HIV/AIDS and other infectious diseases, and for sterile syringe access programs. Outreach workers are a vital link to:

• educational and risk-reduction information on HIV/AIDS, HBV, HCV, and other STDs;


• information and materials for behavioral change, including the HIV/AIDS risk-reduction hierarchy, bleach kits to disinfect injection equipment, condoms for safer sex, and instructions for proper condom use and disposal; and


• services for testing and counseling for HIV, HBV, HCV, and other STDs; drug abuse treatment; and other community health, prevention, and social programs.

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Is comprehensive HIV prevention for drug users cost-effective?

Research has shown that the three complementary approaches that make up comprehensive HIV prevention for drug users — community-based outreach, drug abuse treatment, and sterile syringe access programs — are cost-effective. Comprehensive HIV prevention permits ongoing contact with drug users who may otherwise not be reached and provides them with information and opportunities to stop using drugs, to enter drug-abuse treatment, and to reduce their drug- and sex-related risks for HIV and other blood-borne infections.

Cost-effectiveness studies have reported that, by preventing HIV infections, community-based outreach interventions help avert future medical costs associated with the care and treatment of HIV/AIDS (8). Similarly, drug abuse treatment programs are cost-effective in reducing drug use and its associated health and social costs, especially when compared to not treating addicts or to incarcerating them (2). Evaluations of sterile syringe access programs have demonstrated that by lowering the frequency of injections with used needles these programs help prevent the spread of new HIV infections and save medical-care costs for each averted infection (9).

Sustained, well-designed strategies of comprehensive HIV prevention also can lead to substantial reductions in health-care and social-service costs associated with the treatment and care of people with HIV/AIDS and other infectious diseases. Comprehensive HIV prevention is most cost-effective when its strategies are implemented early in the epidemic (10), when the prevalence of HIV is low and the greatest number of potential new infections in the population can be averted.

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References

1. Centers for Disease Control and Prevention (CDC), Center for Substance Abuse Treatment (SAMHSA), NIDA Prevention Bulletin. U.S. Department of Health and Human Services, Public Health Service. April 1993.


2. NIDA. Principles of Drug Addiction Treatment: A Research-Based Guide. NIH Publication No. 99-4180, Oct. 1999.


3. CDC. Revised guidelines for HIV counseling, testing, and referral. Oct. 2000.


4. Kwiatkowski, C.; Booth, R.E.; and Lloyd, L.A. The effects of offering free treatment to street-recruited opioid injectors. Addiction 95(5):697-704, 2000.


5. Metzger, D.S.; Woody, G.E.; McLellan, A.T.; O'Brien, C.P.; Druley, P.; Navaline, H.; et al. Human immunodeficiency virus seroconversion among in- and out-of-treatment intravenous drug users: An 18-month prospective follow-up. J Acquir Immune Defic Syndr (6):1049-1056, 1993.


6. Des Jarlais, D.C.; Marmor, M.; Paone, D.; Titus, S.; Shi, Q.; Perlis, T.; et al. HIV incidence among injecting drug users in New York City syringe-exchange programs. Lancet 348(9033):987-991, 1996. /li>
   
7. Hurley, S.F.; Jolley, D.J.; Kaldor, J.M. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet 349(9068):1797-1800, 1997.


8. Pinkerton, S.; Holtgrave, D.; DiFranceisco, W.; Semaan, S.; Coyle, S.L.; and Johnson-Masotti, A.P. Cost-threshold analyses of the National AIDS Demonstration Research HIV prevention interventions. AIDS 14(2):1257-1268, 2000.


9. Kahn, J.; and Haynes-Sanstad, K. The role of cost-effectiveness analysis in assessing HIV prevention interventions. AIDS and Public Policy Journal 12(1):21-30, 1998.


10. Des Jarlais, D.C.; Hagan, H.; Friedmann, P.; et al. Maintaining low HIV seroprevalence in populations of injecting drug users. JAMA 274(15):1226-1231, 1995.

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