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A Comprehensive Approach: Appendix A: Key Strategies for Preventing Blood-borne Pathogen Infection Among Injection Drug Users This Appendix details the eight key strategies of the comprehensive approach. Each section describes the service or intervention and explains its importance, provides findings from research and programs, and describes the issues and barriers facing providers and agencies in that area. For injection drug users, substance abuse treatment is a powerful disease prevention strategy. Drug injectors who do not enter treatment are up to six times more likely to become infected with HIV than are injectors who enter and remain in treatment (NIDA, 1999). Substance abuse treatment helps users reduce the number of drug injections and, thus, lower the risk of infection with HIV or hepatitis that might occur through unsafe injection practices, such as multi-person use of syringes or sharing of drug injection equipment. It also prevents or reduces other harmful consequences of drug use, such as abscesses or endocarditis. Further, because drug use impedes rational decision making, which can lead to high-risk behavior, substance abuse treatment can reduce the risk of HIV and hepatitis transmission through high-risk, unprotected sex. Substance abuse treatment has broader social benefits as well because it can lead to reduced health care costs, reduced drug-related crime and associated criminal justice costs, reduced interpersonal conflicts and drug-related injuries, and improved workplace productivity (NIDA, 1999). Drug addiction is a complex and chronic, but treatable, illness characterized by compulsive, uncontrollable drug craving, seeking, and use, even in the face of enormous negative consequences. Though nearly all addicts believe initially that they can stop on their own, most of their attempts result in failure to achieve long-term abstinence (NIDA, 1999). Substance abuse treatment provides the medical, psychological, and behavioral support necessary for an individual to stop using drugs and for their brain processes to return to pre-addiction functioning. Often, because of the complexity of the disease and the frequency of relapse to drug use, treatment requires multiple episodes over a long period of time. Successful treatment can have a major impact on many areas of a person's life, helping him or her improve family life, employment and health, and decrease involvement with crime. Treatment services differ in their approaches and components. They are generally divided into five major kinds of programs (AED, 1997; NIDA, 1999):
In addition, many drug users also participate in self-help or 12-Step programs, such as Narcotics Anonymous, Cocaine Anonymous, or Smart Recovery. By providing a ecrucial support network of peers who are going through similar experiences, these programs can reinforce and extend more formal types of treatment services (NIDA, 1999). In the last decade, the overall effectiveness of substance abuse treatment has been demonstrated (Gerstein and Harwood, 1990; Hubbard et al., 1989; NIDA, 1999; NIH, 1997; Pickens et al., 1991). A number of studies have shown that persons who receive treatment reduce their alcohol and drug use and improve their legal, employment, family, social, psychiatric, and medical situations (Anglin et al., 1989; Ball et al., 1988; DeLeon, 1984; Hubbard et al., 1989; McLellan et al., 1994; Moos, 1974; Moos et al., 1990; Simpson and Savage, 1980). Overall, treatment for addiction is as successful as treatment of other chronic conditions, such as asthma, diabetes, and hypertension (NIDA, 1999; O'Brien and McLellan, 1996). Studies of methadone maintenance treatment have shown that participation in treatment is associated with lower HIV risk behaviors as well as lower rates of HIV seroprevalence and seroincidence (Abdul-Quader et al., 1987; Avins et al., 1997; Ball et al., 1988; Blix and Gronbladh, 1991; Booth et al., 1996; Brown et al., 1988; Caplehorn and Ross, 1995; CDC, 1984; Friedman et al., 1995; Meandzija et al., 1994; Metzger et al., 1998; Metzger et al., 1993; Moss et al., 1994; Novick et al., 1990; Orr et al., 1996; Serpelloni et al., 1994; Shoptaw et al., 1997; Williams et al., 1992). Methadone is the medication most frequently provided to IDUs in substance abuse treatment because it is the most widely available and because many IDUs inject heroin or a combination of heroin and cocaine (Battjes et al., 1991; Hahn et al., 1989; Haverkos, 1998; NIH, 1997). Methadone reduces patients' cravings for heroin and blocks its effects, thereby enabling patients to reduce heroin use and live more productive lives. The effectiveness of methadone treatment is dependent on many factors, including adequate dosing, a sufficient duration and continuity of treatment, and the presence of complementary services, such as psychosocial and medical support, counseling, and vocational training (NIH, 1997). Some patients stay on methadone indefinitely; others progress to abstinence with decreasing doses of methadone. Several other medications can be used to treat opiate addiction, including levo-alpha-acetylmethadol (LAAM) and naltrexone, but they have not been in existence as long as methadone and are not as widely used (NIDA, 1999; NIH, 1997). Substance abuse treatment makes financial sense as well. Every $1 invested in substance abuse treatment reduces the costs of drug-related crime, criminal justice costs, and theft by $4 to $7. The average cost of 1 year of methadone maintenance treatment is $4,700 per person. The cost of 1 year of imprisonment per person is about $18,400. When health care savings are added in, total savings can exceed costs by a ratio of 12 to 1 (NIDA, 1999). Another compelling reason for providing substance abuse treatment is that these programs are a good way to reach drug users and their partners with other HIV prevention messages and interventions. Participation in these interventions offered in the treatment setting is associated with reduced drug- and sex-related risk behaviors (Calsyn et al., 1992; El-Bassel and Schilling, 1992; Malow et al., 1994; McCusker et al., 1992). One of the most consistent findings of both behavioral and serologic studies is that early entry and longer duration of treatment are associated with protection from HIV infection (Metzger et al., 1998). For example, twenty years of data collected in the Bronx, New York, show that longer time in treatment is associated with a lower likelihood of HIV infection (Hartel and Schoenbaum, 1998). The strongest protective associations against HIV in this population were early entry and continuous stay in methadone treatment plus higher methadone doses (80 milligrams or higher per day). Despite clear evidence regarding the utility and effectiveness of substance abuse treatment in helping users reduce or eliminate their drug use and helping them address a host of other problems, significant barriers remain for IDUs to fully obtain these services. For example, data from the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Household Survey on Drug Abuse (NHSDA) show that in 1996, more than 5.3 million people with severe substance abuse problems needed treatment services. However, only 37 percent received such treatment (Epstein and Gfroerer, 1998). Less than 20 percent of opiate-dependent individuals are in methadone maintenance (NIH, 1997). Many IDUs cannot afford privately-funded services, and limitations in funding restrict the number of publicly funded slots. Even for those IDUs who are in treatment, the processes and procedures associated with participation may be daunting. For example, waiting lists, delays in admissions and lengthy and cumbersome intake processes can discourage drug users from seeking treatment. Many communities strenuously resist the introduction of drug treatment facilities in their neighborhoods, and this limits the availability of treatment for many IDUs. State and federal funding of substance abuse treatment is insufficient to make treatment available to all who need it. The effectiveness of substance abuse treatment depends on many factors, including its goals, the length of time treatment lasts, the doses of medications that may be prescribed, links to other services, and the characteristics of the user. Limitations in all of these areas may pose significant barriers. For example, an IDU in a methadone maintenance program may receive adequate medication but not the behavioral counseling or the case management and referral to other medical, psychological, and social services that are necessary for full and effective treatment. Or, he or she may receive lower methadone doses, which compared to doses of 80-100 milligrams, are less effective (Strain et al., 1999). Many IDUs do not participate in conventional service systems that provide treatment and prevention services or medical, mental health, or social welfare services. This is due partly to funding and capacity limitations on the part of the service systems and partly to barriers that limit IDUs' ability to use these systems. IDUs' own attitudes and life circumstances also determine the extent to which they use or are reached by conventional service systems. The overwhelming priorities of obtaining and using the drugs they are addicted to often prevent IDUs from seeking services, such as HIV prevention, that may seem abstract or unimportant in comparison. In addition, the stigma and negative attitudes of service providers that are experienced by many IDUs leads them to mistrust government agencies and conventional service systems and be reluctant to obtain services. Thus, to effectively provide prevention, treatment, and care services to IDUs, it is essential to bring the services to IDUs in the settings in which they live and socialize. Community outreach programs can make a valuable contribution to HIV prevention (Wiebel et al., 1996). These practical and relatively low-cost approaches are designed to reach IDUs at high risk of HIV and other blood-born infections who are not in conventional service systems. They can be the first step in developing an ongoing relationship with these drug users and ultimately linking them with services. For those users who are linked to conventional service systems, outreach is an important way to reinforce educational and prevention messages and strategies. Because they are an individual- and community-level intervention, they help create a community culture of risk reduction among drug users, their families, friends, and neighbors. This culture of risk reduction also helps to support recovering drug users returning from substance abuse treatment and those returning to the community from prison or jail. Community outreach is typically carried out in areas where drug users congregate on the street, in shooting galleries and crack houses, and in housing projects, emergency rooms, laundromats, and parks. The messages and services are delivered by people with whom the drug user is familiar and likely to trust, such as peers who live in the community. This personal contact between outreach worker and IDU is an important reason why community outreach can be influential in helping IDUs. Many community outreach workers are recovering IDUs themselves. A typical outreach encounter involves face-to-face communication that is intended to assist IDUs in changing their high-risk drug use and sexual behaviors. Outreach workers may give out literature on drug use, substance abuse treatment, and HIV and how to prevent it, and provide in formation on available services. They also distribute condoms and bleach kits for decontaminating injection equipment and help IDUs obtain services in the community, such as housing assistance or mental health treatment. Outreach also involves working with drug users' social and drug-using networks to extend and reinforce prevention messages and build risk reduction skills. Outreach can also be used to recruit drug users to other activities, such as confidential risk assessments, HIV testing and counseling, and substance abuse treatment, and to distribute sharps containers for safe disposal of used syringes. Outreach interventions were one of the earliest HIV prevention strategies designed to reach high-risk IDUs. Results of a number of studies and programs have shown that this approach, in fact, works. It can be used to identify and contact IDUs and it creates an atmosphere in which IDUs are comfortable talking about HIV prevention. Community outreach is effective in getting IDUs to accept HIV-prevention literature, risk reduction materials, and referral services, and outreach workers have played an important role in providing condoms to high-risk populations (Anderson et al., 1996; Anderson et al., 1998). Follow-up assessments have shown that IDUs have regularly reported reductions in five major risk behaviors after participating in community outreach interventions (APA, 1996; CDC/ACDP, 1999; Coyle et al., 1998; Semaan et al., 1998; Sumartojo et al., 1997). These include:
They also have reported increases in three protective behaviors (APA, 1996; CDC/ACDP, 1999; Coyle et al., 1998; Semaan et al., 1998; Sumartojo et al., 1996):
A number of researchers have demonstrated the effectiveness of peer-delivered interventions conducted by community health outreach workers who were formerly active drug users, and peer-driven interventions, which are conducted by out-of-treatment IDUs who are provided with guidance and structured incentives and play an active role in their social networks in HIV prevention. Overall, these studies suggest that peers, whether former or active drug users, can be effective in reaching large and diverse communities of out-of-treatment users (Broadhead et al., 1998; Carlson and Needle, 1989; Cottler et al., 1998; Friedman et al., 1993; Jose et al., 1996; Latkin et al., 1998; Neaigus, 1998; Sufian et al., 1991). They also suggest that peers are effective role models for promoting reductions in drug-related HIV risk behaviors with active drug users, but less effective in changing sexual risk behaviors (Coyle et al., 1998). Although community outreach is clearly an important element in any overall strategy to reach IDUs, it has its challenges. By its very nature, it is client-centered and less formal and structured and therefore can be more difficult to supervise and monitor. Outreach work is demanding and workers must contend with frequently difficult conditions, including unsafe neighborhoods, inclement weather, and, for those workers who have had drug problems, situations that may challenge their own recovery. Outreach staff need reinforcement, training, and support to avoid burnout and the risk of relapse to drug use and to help them understand the lifestyles or cultures of particular IDUs (AED, 1999). Another issue in community outreach strategies that use peers is defining who a "peer" really is. Some current IDUs may not consider a former user to be their peer. Demographic differences between the IDUs and the peer outreach workers may affect how messages are received. These differences may also make it more difficult for the workers to establish trusting relationships with IDUs. Environmental and structural factors also may hamper the effectiveness of community outreach efforts. For example, community outreach can face active opposition in the community from powerful individuals such as neighborhood political leaders or local drug dealers. The limited capacity of many substance abuse treatment programs means that IDUs may not be able to enter treatment even if they are referred by an outreach worker. Further, existing laws and regulations, such as restrictions on the sale of sterile syringes in pharmacies or prohibitions against syringe exchange programs or criminal penalties for possession of syringes, make it hard for outreach workers to disseminate crucial prevention messages, such as the need to consistently use sterile syringes and make it hard for IDUs to follow such advice. Finally, the relatively unstructured and unstandardized nature of community outreach work may make it difficult for providers to identify consistently effective strategies. It also may be hard to measure the outreach process and control for extraneous factors, and attrition can skew research results. Cohort effects may promote socially desirable responses among those who return for follow-up, making self-reports less valid measures of intervention effects. Interventions to Increase IDUs' Access to Sterile Syringes Clearly, the best way for injecting drug users to avoid the problems of drug use and blood-borne infection is to stop injecting and enter substance abuse treatment. However, many drug users either cannot get into substance abuse treatment programs or will not stop injecting drugs. Even those injectors who stop drug use through substance abuse treatment may relapse to injecting drugs. Given these realities, several governmental bodies and institutions¹ have recommended consistent, one-time-only use of sterile syringes to prepare and inject drugs as a central strategy in a comprehensive effort to reduce the transmission of HIV and other blood-borne pathogens among those individuals who continue to inject drugs. Currently, IDUs obtain syringes in several ways:
Most states have legal and regulatory restrictions on the sale and distribution of sterile syringes: 47 states have drug paraphernalia statutes, 8 states have syringe prescription statutes, and 23 states have pharmacy regulations or practice guidelines. These restrictions present a significant barrier to the sale of sterile syringes to IDUs by pharmacists, the prescription of sterile syringes to IDUs by physicians, the operation of syringe exchange programs, the safe disposal of blood-contaminated used syringes, and ultimately, to the efforts by IDUs to reduce their injection-related risks of acquiring or transmitting blood-borne pathogens (Gostin, 1998). In essence, IDUs are in a Catch-22 situation. They are advised to enter substance abuse treatment and, if they continue to inject, to use only sterile syringes, but major structural and environmental factors insufficient substance abuse treatment capacity and syringe laws that make it illegal to obtain-possess sterile injection equipment-effectively reduce IDUs' ability to carry out this advice. Three types of interventions are now being pursued in the U.S. to ameliorate the second of these two structural barriers and increase IDUs' access to sterile syringes. Several states and municipalities are engaged in policy efforts to change existing syringe laws and regulations to allow increased pharmacy sales of syringes, remove criminal penalties for syringe possession, and include language in laws stating that preventing HIV and other blood-borne pathogens is a "legitimate medical purpose" for prescribing sterile syringes. Many jurisdictions are carrying out efforts to sustain and expand syringe exchange programs, which provide IDUs with free sterile syringes and a way to safely dispose of blood-contaminated used syringes. Initiatives with pharmacists also are underway to provide education about the role of sterile syringes in reducing the transmission of blood-borne pathogens, address pharmacist concerns and questions about syringe sales and disposal, and encourage changes in pharmacy policy and practice. All of these interventions are closely interrelated and the success of one partly depends on the success of the others. The effectiveness of interventions that encourage pharmacists to sell syringes to IDUs, for example, is enhanced when laws and regulations that limit pharmacy sale of syringes and that prohibit possession of syringes are repealed. Similarly, for IDUs to openly participate in syringe exchange programs, the public health implications of laws that make possession of syringes a crime should be reviewed. An individual IDU makes approximately 1,000 injections each year, which even in a moderate-size city adds up to millions of injections a year (Lurie et al., 1998). Therefore, achieving the recommendation of the one-time-only use of sterile syringes will require the coordination of all of these interventions so that IDUs who continue to inject will be able to obtain and safely dispose of a sufficient number of sterile syringes to prevent the acquisition or transmission of blood-borne pathogens. The magnitude of this challenge to adequate coverage is illustrated by Montreal, a city that has made major strides in ensuring that IDUs can obtain sterile syringes (it does not prohibit the sales of syringes without prescription, it encourages pharmacy sales, and it has active and well-supported syringe exchange programs). An analysis estimated that in 1994 Montreal's 10,000 IDUs injected 10,683,000 times (Remis et al., 1998). About 338,000 sterile syringes were distributed through pharmacy sales and syringe exchange programs. This meant that only 3.2 percent of the need for sterile syringes was being met. Based on these results, the Montreal Regional Public Health Department removed the quota of 15 syringes that could be exchanged at one time and drafted an action plan to expand the number of sites for syringe distribution through community organizations, health centers, and pharmacies, with a target of more than 1 million syringes distributed by 1997. In 1996, 500,000 syringes were distributed. Though this represented significant progress, the number distributed in 1996 was still far short of the number of sterile syringes needed. In October 1999, the American Medical Association (AMA), the American Pharmaceutical Association (APhA), the Association of State and Territorial Health Officials (ASTHO), the National Association of Boards of Pharmacy (NABP), and the National Alliance of State and Territorial AIDS Directors (NASTAD) issued a joint letter urging state leaders in medicine, pharmacy, and public health to coordinate action to improve IDUs' access to sterile syringes through pharmacy sales. They encouraged public health leaders to work to reduce state-level legal and regulatory barriers that restrict access, expand availability of substance abuse treatment, and improve options for safe disposal of syringes (NASTAD, 1999). This statement builds on previous similar policies adopted by the APhA in 1999, the AMA and NASTAD in 1997, and ASTHO in 1995. POLICY EFFORTS TO INCREASE IDUS' ACCESS TO STERILE SYRINGES As described above, most states prohibit IDUs from possessing or carrying sterile syringes and many states bar their sale without a valid medical prescription. The result of these restrictions is that even if IDUs are legally able to acquire sterile syringes, they often do not want to carry and are unable to safely dispose of them because of the potential for arrest and criminal prosecution (Bluthenthal, Kral et al., 1999; Bluthenthal, Lorvick et al., 1999; Koester, 1994; Springer et al., 1999). This environment serves to increase transmission risk because IDUs who are concerned about being arrested for obtaining or carrying syringes are more likely than other IDUs to share syringes and injection supplies (Bluthenthal, Kral et al., 1999; Bluthenthal, Lorvick et al., 1999). Although widespread negative opinions of drug users and a reluctance to appear supportive of drug use make it difficult to change syringe laws and regulations, several states have done so. In 1992, Connecticut partially repealed its laws and regulations that limited pharmacy sales of syringes and made possession of syringes a crime. This allowed pharmacy sales of up to 10 syringes without a prescription and legalized the possession of up to 10 clean syringes (Groseclose et al., 1995; Valleroy et al., 1995). In 1993, Maine changed its laws so as to allow anyone aged 18 or older to purchase from a pharmacy any quantity of syringes (Beckett et al., 1998). In January 1997, the Maine state legislature adopted rules to permit legal syringe exchange and to remove the criminal penalties for possessing 10 or fewer syringes. Other states have tried other approaches. For example, some state legislatures have given health departments the power to establish SEPs and to exempt them from drug paraphernalia and syringe prescription statutes. Five states (Hawaii, Maryland, Massachusetts, New York, and Rhode Island) and the District of Columbia have carved out an exemption in their drug paraphernalia laws for SEP staff and participants. Three states have specifically exempted SEPs from their prescription laws (Connecticut, Massachusetts, Rhode Island). In California, legislation went into effect in January 2000 that permits the use of public funds for SEPs after a local agency has declared a health emergency for hepatitis C and AIDS. However, the city or county must renew the state of emergency every 14 days to keep the new law in effect. New legislation exempts cities and public employees from criminal prosecution if the SEP is operating under a declared public health emergency. Results from states that have changed their laws have been positive. For example, after Connecticut partially repealed its syringe laws, most pharmacies in the state (about 87 percent) began to sell nonprescription syringes, though in limited numbers (Valleroy et al., 1995; Wright-De Agüero et al., 1998). As a result, fewer IDUs bought syringes on the street, syringe sharing decreased, and police reported fewer needlestick injuries (Groseclose et al., 1995). Those in Maine who worked for successful policy changes to improve access to sterile syringes attribute their success to the following actions, which were focused on building an environment of collaboration and a sense of common purpose among the various stakeholders (Beckett et al., 1998):
Syringe exchange programs (SEPs) are a second important strategy for increasing IDUs' access to sterile syringes. SEPs allow IDUs to exchange their used needles and syringes for new, sterile injection equipment at no cost. By collecting used injection equipment, SEPs remove blood-contaminated syringes from circulation and allow for safe disposal of equipment that may have been contaminated with HIV or hepatitis. SEPs were first introduced in the United States in the late 1980s. By 1997, there were 123 programs in 33 states, the District of Columbia, Puerto Rico and Guam (CDC, 1998a). These programs exchanged over 17 million syringes in 1997, but two-thirds of these were exchanged by the 10 largest programs. One-half of the SEPs distribute fewer than 50,000 per program per year. SEPs in the U.S. are able to cover only a small percentage of the need for sterile syringes. IDUs are drawn to SEPs because they get free syringes. This "passive outreach" strategy has an added benefit because it gives programs an efficient way to reach IDUs with additional services and interventions. These services include HIV/AIDS education and counseling; condom distribution to prevent sexual transmission of HIV; primary medical services; referrals to substance abuse treatment and other medical and social services; bleach distribution for disinfecting injection equipment; distribution of alcohol swabs to help prevent abscesses and other bacterial infections; on-site HIV testing and counseling; crisis intervention; and screening for tuberculosis, hepatitis B, hepatitis C, and other infections. SEPs vary widely in their locations (fixed versus roving sites), hours of operation, the number of syringes allowed for exchange, and other policies. Because of the controversy associated with SEPs, a great deal of research has been conducted on their effects and outcomes. This work has shown that SEPs have significant positive effects on preventing adverse health consequences associated with injection drug use and that SEPs do not increase drug use or promote the initiation of injection drug use (Des Jarlais et al., 1996; Hagan et al., 1995; Heimer, 1998; Heimer et al., 1994; Kaplan and Heimer, 1992; Lurie et al., 1993; Vlahov and Junge, 1998; Vlahov et al., 1997; Watters et al., 1994). Other benefits of SEPs are that they can facilitate the entry of IDUs into substance abuse treatment and other services that can reduce the risk of HIV infection (Heimer, 1998). SEPs have also been shown to successfully engage IDUs as peer outreach workers to create new exchangers and increase the number of syringes exchanged (Whiticar and Smetka, 1999). Results showing higher HIV incidence among IDUs using SEPs in Vancouver (Strathdee et al., 1997) and Montreal (Bruneau et al., 1997) have been interpreted by some to suggest that SEPs may contribute to the spread of HIV. However, investigators in these cities have shown that SEPs are not causally associated with HIV transmission and that this association was confounded by the fact that SEPs attract higher-risk users (Archibald et al., 1996; Schechter et al., 1999). Both Canadian cities have continued to expand their SEP services. Despite their success, syringe exchange programs face continuing challenges. These include legal and regulatory restrictions, precarious funding, and, in some locations, community opposition. While some communities welcome SEPs, others strenuously reject them. This opposition comes from local leaders, the general public, or residents of the neighborhoods in which they would be located. Some objections relate to beliefs that SEPs will increase drug use among participants and attract youth or new individuals to drug use. Other objections are that SEPs will threaten the safety of the community because they will foster an increase in illicit drug sales in the area and result in people discarding contaminated syringes in the community. However, a recent study examining the potential effect of SEPs on the formation of drug-using social networks found that this was unlikely to occur (Junge et al., 2000). The Public Health Service recommendation that IDUs who cannot or will not stop injecting should consistently use sterile syringes to prevent transmission of blood-borne infections provides a legitimate medical foundation for the sale of sterile syringes to IDUs. Pharmacies, therefore, can play a crucial role because they are a reliable source of sterile syringes. Pharmacies are conveniently located in most neighborhoods, and often have extended hours of operation. Many are open 24 hours a day. In addition, they are staffed by trained, licensed professionals who are able to provide sound medical advice and to make referrals for a variety of related services, including HIV testing and counseling, substance abuse treatment, health care, and other community services. They also provide a safe environment for IDUs to make their purchases and some degree of anonymity for those IDUs who do not want to self-identify by going to an SEP. Some pharmacies accept used syringes for disposal. Even in states that have partially or completely repealed laws and regulations banning the sale of sterile syringes, however, sales may be hampered by specific pharmacy store policies restricting the sale of syringes to IDUs, the personal reluctance of individual pharmacy managers or pharmacists to sell syringes to IDUs, or other factors that create barriers to buying syringes. For example, pharmacy practice regulations that require purchasers to show identification, sign a register of syringe purchasers, and confirm that the syringes sale is for a "legitimate" purpose, reduce IDUs' ability or willingness to come into the pharmacy and buy syringes. These policies and attitudes are partly due to store managers' and pharmacists'concerns that IDUs will discard contaminated syringes around their businesses and in the community (Case et al., 1998; Gleghorn et al., 1998; Singer et al., 1998; Wright-De Agüero et al., 1998). Another reason may be the limited amount of training and academic material on addiction and the relationship between injection drug use and blood-borne pathogens provided by schools of pharmacy to their students. Some states are carrying out interventions with pharmacy managers and pharmacists in conjunction with efforts to repeal restrictive laws and regulations that limit pharmacy sales of syringes. For example, several state health departments are working with state pharmacy associations, medical societies, and boards of pharmacies to raise awareness about the barriers to the purchase of sterile syringes and to review current laws and regulations. In Connecticut, Minnesota, and Maine, where laws prohibiting the purchase or possession of syringes have been partially repealed, partnerships between health departments and pharmacies have been formed, education has been conducted to address pharmacists' concerns, and pharmacists have been encouraged to sell syringes to IDUs. Results from one peer education program for pharmacists in Connecticut demonstrate that pharmacists can become active participants in AIDS prevention activities; pharmacies, schools of pharmacy and local health departments can develop collaborative linkages to carry out HIV prevention for IDUs; and professional peer education for pharmacists can be effective in expanding prevention services for IDUs (Weinstein et al., 1998). Despite this progress, states and organizations face a number of significant challenges as they work with pharmacists to change policies related to selling sterile syringes to IDUs. One important challenge is attitudinal. Pharmacists are trained to distrust IDUs and drug users, who may try to use bogus prescriptions or rob the pharmacy. They may also fear that an increase in sales of syringes to IDUs might attract drug users to the neighborhood and create safety and littering problems. Sales of sterile syringes also raise issues related to safe disposal of used syringes. Community options for safe disposal of used syringes are often limited. The public worries that IDUs will discard syringes in their neighborhoods without recognizing that diabetics who use insulin contribute a substantial number of used syringes (Macalino et al., 1998). Further, pharmacists may mistakenly equate the pharmacy sale of syringes to IDUs with syringe exchange in the pharmacy. Interventions in the Criminal Justice System Because the possession and sale of illicit drugs and syringes are crimes and drug users are often involved in crimes to support their drug addiction, IDUs are frequently arrested or in prison or jail. A recent study on substance abuse and prisoners found that 81 percent of state inmates, 80 percent of federal inmates, and 77 percent of local jail inmates had used an illegal drug regularly; been incarcerated for drug selling or possession, driving under the influence of alcohol (DUI) or another alcohol abuse violation; were under the influence of alcohol or drugs when they committed the crime for which they were in corrections; committed their offense to get money for drugs; had a history of alcohol abuse, or shared some combination of these characteristics (Belenko, 1998). In 1996, an estimated 250,000 state prison inmates had injected drugs, including 120,000 who had shared needles. Some 14,000 federal prison inmates had injected drugs, including 6,000 who shared needles (Belenko, 1998). At the same time, inmates in prisons and jails have disproportionately high rates of HIV infection and other STDs, hepatitis, and other health problems. At the end of 1996, 2.3 percent of male and 3.5 percent of female state and federal prison inmates were known to be infected with HIV (Hammett et al., 1999). Confirmed AIDS cases were found in 0.5 percent of all inmates, a rate six times higher than that of the total U. S. population. The high-risk behaviors responsible for the transmission of HIV and other blood-borne illnesses among inmates include high-risk sexual activity, sharing of needles and other drug injection equipment, and tattooing with improvised tools and materials (Calzavara et al., 1997; Dolan et al., 1996; Mahon, 1996; Struckman-Johnson et al., 1996). Given the large numbers of IDUs involved with the criminal justice system and the large numbers of at-risk and infected individuals, this setting is a crucial venue for HIV- and hepatitis-related interventions and services. Providing a range of health and prevention education interventions to inmates not only benefits them and their overall health, but can improve the health of the communities to which the vast majority of inmates return (Hammett et al., 1999). Prevention services currently offered to incarcerated populations vary widely across state, county, and city jails and prisons. They include instructorl-ed and/or peer-led HIV education, pre-and post-test counseling, multi-session prevention counseling, the use of audiovisual materials, and the distribution of printed materials (Hammett et al., 1999). Risk reduction strategies have not been widely adopted in U.S. correctional systems. For example, only two state prison systems and four city/county jail systems make condoms available to inmates. However, most correctional systems provide HIV antibody testing, although testing policies differ widely. Few systems routinely screen inmates for STDs and only limited viral hepatitis prevention and treatment services are available. The few systems that provide an integrated continuum of care for at-risk and HIV-infected inmates provide the following services:
Although few HIV prevention programs in correctional settings have been rigorously evaluated, limited evidence suggests that they can be successful in reaching this high-risk population with practical risk-reduction messages (Hammett et al., 1999). For example, several innovative models of prison-based substance abuse treatment programs that use a therapeutic community approach have resulted in reduced rates of return to the correctional system and sustained drug abstinence and condom use at follow-up (Field, 1989; Inciardi, 1996; Wexler et al., 1994). These innovative programs include New York State's Stay'n Out, Oregon's Cornerstones program, and Delaware's Crest Outreach Center program. Jail-based methadone maintenance has shown positive results among participants, including lowered rates of drug use and criminality after release (Magura et al., 1993). One of the most important types of interventions in prisons and jails is education and prevention efforts led by inmates themselves. These programs can be cost-effective and flexible, and they have an added credibility that programs led by outsiders cannot match. Peer-led programs also provide significant benefits to peer educators themselves. Through participating in the programs, these inmates can develop a positive focus in their lives, regain a sense of purpose and empowerment, and realize that they are able to influence others in ways they never believed possible (Hammett et al., 1999). The careful selection of peer trainers and open support of corrections staff are among the factors contributing to the success of such innovative programs as the peer program at Louisiana State Penitentiary in Angola, the AIDS Counseling and Trust program at Louisiana's Avoyelles Correctional Center, the peer programs in California's state prisons at San Quentin, Frontera, and Vacaville, and the AIDS Video Project and Peer HIV Education Project in the Los Angeles County Juvenile System. Several innovative models of instructor-led HIV/ AIDS education and prevention programs also have evolved in correctional systems. These include the Forensic AIDS Project conducted in the San Francisco jails and the Corrections AIDS Prevention Program conducted at Rikers Island in New York City (Hammett et al., 1999). Although many correctional systems in the U.S. have instituted HIV prevention services, numerous gaps in coverage still exist for IDUs, both for those in the system and those leaving jail or prison to return to their home communities. Gaps for those in the system can be found in insufficient numbers of instructor-led and peer-based HIV education and prevention programs. For all inmates, there is a lack of comprehensive substance abuse treatment and mental health services. Supervised medical care services are also lacking for HIV-infected IDU inmates. Many HIV seronegative and seropositive inmates leaving the system, including those using antiretroviral drug therapy for HIV infection, still do not receive appropriate discharge planning or continuity of substance abuse treatment and medical services after release. Without planning and support, many ex-prisoners are arrested and jailed again. These gaps occur for a variety of reasons. A primary reason is financial. HIV prevention and treatment services, particularly treatment services, can be costly and the issue of who should pay has not been adequately addressed. Because inmates are legally wards of the government correctional system, health and substance abuse agencies (for example, Medicaid) do not pay for services inside prisons and jails. At the same time, most correctional systems have limited budgets to address issues related to preventing and treating substance abuse, blood-borne diseases, and mental health issues. A second major reason relates to differences between the philosophies, perspectives, and priorities of public health and correctional agencies. When these differences are not sensitively addressed, they can make collaboration difficult because they undermine respect by public health staff for the skills and expertise of correctional medical staff and other correctional staff and they promote obstruction and lack of cooperation on the part of correctional staff (Hammett, 1998). A third challenge facing efforts to reduce HIV and other blood-borne illnesses among IDUs in prisons and jails is the primary need for correctional systems to maintain security and to control inmates. Administrators of correctional systems often do not want to acknowledge that HIV risk behaviors, such as men having sex with men or injection drug use, are occurring in their facilities. Prisoners also may not want to acknowledge these behaviors for fear of sanctions. In addition, specific security measures limit the effectiveness of prevention efforts. For example, the frequent movement of inmates within and between facilities disrupts the continuity of educational programming, counseling, and care. Requirements that prisoners be escorted by guards to meetings with health and HIV prevention staff may restrict inmates' participation in counseling and education initiatives and significantly threaten confidentiality protections. The prohibition against condom distribution because they are considered contraband closes off a major risk reduction intervention. Finally, HIV education programs face challenges in working with diverse inmate populations having different cultures, languages, and literacy levels or who may be incarcerated for only a short time. Strategies to Prevent Sexual Transmission Sexual transmission of HIV and hepatitis involving IDUs is an important factor in the spread of these diseases in the U.S. In 1999,13 percent of the new AIDS cases reported that year were among men and women whose sex partners were IDUs. Thirteen percent were among male IDUs who also reported having sex with other men (CDC, 1999a). High-risk sexual behavior is also strongly associated with hepatitis B transmission (CDC, 1999b). High-risk drug behaviors and high-risk sexual behaviors are often linked (Chu et al., 1998). For example, a large portion of IDUs use alcohol and/or crack cocaine, which are often associated with increased frequencies of unsafe sexual behavior (Edlin et al., 1994). Some IDUs support their drug habits by exchanging sex for money or drugs. For these reasons, the extent to which IDUs change their sexual behaviors in response to these diseases is critical. This is particularly true in light of evidence showing that although IDUs will make large changes in their injection risk behavior in response to concerns about AIDS, changes in sexual behavior are generally more modest. All studies that have compared changes in injection risk behavior with changes in sexual risk behavior found greater changes in injection risk behavior (Friedman et al., 1993). In addition, it appears that IDUs are more likely to change sexual risk behaviors (reduce number of partners, increase use of condoms) with casual sexual partners than with their primary sexual partners (CDC/ACDP,1999; Friedman et al., 1994; Friedman et al., 1999) or with sexual partners who do not inject illicit drugs (Friedman et al., 1994; Friedman et al., 1999; Vanichseni et al., 1993). The reluctance to use condoms with main partners may be partly due to concerns that such action violates the intimacy and trust developed in the relationship. Distributing condoms and information have been an important means of helping IDUs reduce their risk of sexual transmission. These materials are given out for free by most outreach workers, syringe exchange and other risk reduction programs, drug users' organizations, and some substance abuse treatment programs. One-on-one sexual risk reduction counseling and group interventions are also conducted by peers to address skills building and rehearsal, interpersonal communication, problem-solving, situational analysis, and self-management strategies. Intervention strategies for female drug users and sexual partners of drug users have stressed the importance of building self-esteem, social supports, and sexual negotiation skills to encourage safer sex practices with partners. Several approaches to sexual risk reduction interventions have had particularly good results. For example, skills-building interventions that target sexual risk reduction have shown more positive effects in improving drug users sexual risk reduction than have interventions that try to target risk reduction in general (Beardsley et al., 1996; El-Bassel and Schilling, 1992; Schilling et al., 1991). Other interventions that have been effective in sexual risk reduction with drug users have included the AIDS Community Demonstration Projects in five U. S. cities (CDC/ACDP, 1999), the use of a problem-solving therapy model in a male detention center (Magura et al., 1994), and a condom give away program at an outpatient substance abuse treatment program (Calsy net al., 1992). In developing strategies to reduce sexual transmission, agencies and organizations should tailor them to specific high-risk groups (for example, in-treatment as well as out-of-treatment drug users) and to specific goals (for example, preventing acquisition of infection in uninfected IDUs and preventing transmission from infected IDUs to others). These strategies should also take into consideration the determinants of sexual transmission, including the consistency of condom use, the presence of concurrent STDs, the presence of concurrent injection drug and crack use, and the extent of sexual activity while high. Interventions designed for the sexual partners of IDUs are an important element of these strategies. HIV Counseling and Testing, Partner Counseling and Referral Services, and Prevention Case Management A comprehensive approach to preventing HIV and other blood-borne infections among IDUs must include the capacity to allow individuals to discover whether they are infected, and if they are, to help them inform their partners. If they are not infected but engage in high-risk practices, the approach can also help IDUs begin or sustain behavior changes that will reduce their risk of acquiring or transmitting the infection. Three services are designed to meet these objectives:
HIV counseling and testing services are generally the first step. The HIV antibody test results and the person's history of risk behavior and other factors determine whether he or she is referred to the other services. Because these three types of services are client-centered and one-on-one, they have the potential to address the complex lives and circumstances of some IDUs and more effectively influence their risk behaviors than can more limited and diffuse interventions. In addition, these services have the potential to provide the continuity of care that is so important to successful outcomes. Each of these services is discussed in greater detail below. HIV PREVENTION COUNSELING AND TESTING (C&T) HIV C&T is a prevention intervention that provides HIV antibody testing and individual, client-centered risk reduction counseling. It provides a private and confidential way for individuals to learn their HIV serostatus and get further help, whatever the results of the testing. HIV antibody testing is provided to individuals who seek, either through private care providers or publicly funded programs, to determine if they are living with the HIV virus. If the results of the test are positive, they can be referred to clinical care and case management. If the results are negative, they can receive counseling and support for risk reduction efforts and referrals for needed services. The counseling element, a short-term intervention involving two brief sessions (one before and one after the antibody test), has several functions, including:
Given that many IDUs mistrust conventional health service systems or are unable to obtain services, agencies and providers must offer C&T services in settings where IDUs are already found (such as substance abuse treatment or criminal justice) and deliver them in ways that are tailored to the specific circumstances of the IDUs who will receive them. For example, in November 1987, the City of Boston's Department of Health and Hospitals, the Division of Drug Rehabilitation of the Massachusetts Department of Public Health, and the Massachusetts Center for Disease Control established Project TRUST (Teaching, Referral, Understanding, Support, and Testing) at Boston City Hospital. The project offered anonymous HIV testing in conjunction with a range of related prevention, education, referral, and social support services. A number of factors helped attract IDUs and increase the numbers of people offered counseling and testing, including the range of free services available without a need for appointments, staff who included recovering IDUs, location in a neighborhood with a visible drug-user presence, and anonymity (CDC, 1989). New, rapid HIV antibody tests are being developed that will allow a person to be tested and receive their results in one visit (CDC, 1998b). This may be attractive to many IDUs, for whom a second visit to receive results can be difficult to manage. Another possibility that could be used effectively with IDUs is oral fluid testing kits, which allow antibody testing without the need for a blood sample. This permits HIV testing to be carried out in outreach settings, making it much easier to reach a larger number of IDUs with this service. Research conducted among IDUs and other drug users has shown that HIV C&T has resulted in some beneficial behavior changes, including positive impacts on both drug-related and sexual practices (Gibson et al., 1999). As with general at-risk populations, C&T has produced a more positive effect with HIV-infected drug users than with HIV- negative or untested IDUs (Weinhardt et al., 1999; Wolitski et al., 1997). Studies with general at-risk populations and IDUs have shown that both standard, 2-session and enhanced, 4-session counseling interventions significantly increased participants' condom use (Kamb et al., 1998). Compared to standard interventions, enhanced HIV C&T has had a greater effect on IDUs' needle risk behaviors (Siegal et al., 1995) than on their sexual risk behaviors (McCusker et al., 1993). A number of challenges limit the potential impact and benefits of counseling and testing services. Perhaps the most important issue is that C&T is a short-term intervention and therefore would be expected to have a relatively limited impact on risk behaviors. Individuals frequently go through a relatively long cognitive and behavioral process, including several cycles of attempted change and relapse, before achieving lasting behavioral change (Prochaska, 1989). In many cases, individuals must come to a testing site twice, once to have the test performed and once to receive their results a week later. Many persons who are tested do not return to receive their HIV antibody test results, especially those who are tested in STD clinics. Further, some individuals who test positive have difficulty being integrated into more intensive services, such as HIV medical care, case management, and support services. Finally, and most important for IDUs, publicly funded HIV C&T does not now include counseling, testing, and treatment for other blood-borne infections that have a significant impact on IDUs, particularly viral hepatitis. PARTNER COUNSELING AND REFERRAL SERVICES (PCRS) PCRS, also known as partner notification, is a public health activity that evolved from "contact tracing" activities developed earlier in the 20th century for the control of sexually transmitted diseases, particularly syphilis. Public health workers conduct confidential interviews with newly identified infected persons to find out the names of and tracing information for recent sexual or drug contacts who are at high risk of also being infected and to make confidential efforts to locate them, recruit them for diagnostic tests, and provide treatment as needed (Bayer and Toomey, 1992; Cates and Toomey, 1990). PCRS can have important benefits for individual IDUs and their communities. PCRS provides an opportunity for agencies to notify the sexual and drug-use partners of infected individuals of their exposure to HIV and, potentially to viral hepatitis also, to counsel them, and potentially to offer longer-term follow-up. If already infected, the partners' prognosis can be improved through earlier diagnosis and treatment. If not infected, the partners can be assisted in changing their risk behavior, thus reducing the likelihood of acquiring the virus. From an epidemiological standpoint, following the chain of transmission from one HIV-infected individual to another within and across social networks permits public health investigators to chart the course of the epidemic and conduct more effective prevention planning. Epidemiologists suspect that recently infected persons account for a substantial proportion of transmission, either because they have higher viral loads than those who have been infected longer and are therefore more infectious, or because they have more sex partners, or both (West and Stark, 1997). Identifying and treating infected partners early may reduce HIV transmission by reducing the number of potentially infectious contacts (Fenton and Peterman, 1997). PCRS also can yield important evaluation information for HIV prevention programs. If conducted in conjunction with social network methods, it can aid in identifying networks with priority prevention and treatment needs and insight on how to access them. In addition, partners can be interviewed about their past experience with previously used prevention services and the effectiveness of those services in helping them reduce risk. PCRS begins when an IDU seeks HIV prevention C&T. If the HIV test is positive, he or she is given the opportunity to receive PCRS at the earliest appropriate time. During the initial PCRS interview, the counselor will discuss with the client his or her responsibilities to sexual and drug-use partners and available options for notifying them of the client's infection status. The HIV-infected client is encouraged to voluntarily and confidentially disclose the identifying, locating, and exposure information for each partner. The PCRS provider and client together formulate a plan and set priorities for notifying partners. Partner referral options include:
During the notification process each partner is:
Many HIV-infected drug users are critical of partner referral interventions experienced in the past (Rogers et al., 1998). These opinions are based on a mistrust of government agency involvement and concerns about confidentiality and potential discrimination in disclosing information related to their behaviors and their partners. However, the few studies on HIV partner referral with drug users provide some insights into the kind of intervention that may work best with them (Levy and Fox, 1998; Rogers et al., 1998). One innovative approach to partner referral with drug users builds on the success of community outreach methods by adding contact tracing and partner referral to the role of outreach staff. With the understanding that IDUs often can be more readily reached using community-based indigenous staff members, the Outreach-Assisted Model of Partner Referral uses indigenous outreach workers in a more active role delivering street-based HIV counseling, testing, and partner referral (Levy and Fox, 1998). The expanded outreach model offers testing to IDUs in an environment that is more comfortable and community oriented than those IDUs generally experience in using public health HIV testing services. To date, no research has been conducted on the effectiveness of partner notification in helping partners adopt safer behaviors or preventing new infections. Research has focused on the process and its effectiveness in reaching partners, testing them, and identifying seropositivity rates (Macke et al., 1999). Most HIV-infected individuals who take part in HIV C&T willingly participate in PCRS (West and Stark, 1997), although the rates of participation have been found to vary considerably across existing state programs (Crystal et al., 1990; Landis et al., 1992; Pavia et al., 1993; Spencer et al., 1993; Wykoff et al., 1991). One study, conducted with IDUs in Utah, showed a participation rate of 93 percent (Pavia et al., 1993). Further research is needed to improve partner notification procedures and tailor them to specific populations, to understand the impact of new testing technologies on partner notification, and to understand the consequences of partner notification for individuals and their partners (Macke et al., 1999). HIV-infected individuals who take part in PCRS name approximately three partners, although this has also varied considerably across state programs. Of the partners named, the majority are sex rather than drug-use partners. Of those partners named, state program records indicate that 60 to 80 percent are located (Crystal et al., 1990; Landis et al., 1992; Pavia et al., 1993; Spencer et al., 1993; Wykoff et al., 1991). Provider referral has resulted in the notification of more partners than has patient referral (Jones et al., 1990; Landis et al., 1992). Those index clients with the most past sex partners are least likely to attempt to notify any partner (Marks et al., 1992). If located, sex partners are generally receptive to confidential notification of their potential exposure to HIV by the client or the health department and usually seek HIV testing (West and Stark, 1997). PCRS also has been effective in uncovering previously undiagnosed HIV infections. IDU partners who are tested have shown higher rates of HIV infection than have partners with other known routes of transmission (Waldron et al., 1995). Partner referral faces several challenges, particularly when agencies attempt to find partners of IDUs. One reason is that the success of partner referral depends heavily on the disclosure of names of contacts by the HIV-infected client. IDUs may be particularly unwilling to reveal the names of or other information about partners partially because the drug culture discourages revealing information about others. Other barriers to disclosure can include fear of losing a partner, of losing support and, especially for women, fear of violence (North and Rothenberg, 1993; Norwood, 1995; Rothenberg et al., 1995). However, studies have found that when an infected individual reveals his or her infection to a main partner, the disclosure does not result in separation or disruption of the relationship (Nabais et al., 1996; Padian et al., 1993). Even when a client discloses drug-use partners' names, it is often difficult to locate these IDUs because the client may know them only by a nickname or street name (Rogers et al.,1998). The long incubation period of HIV and anonymous partners of clients are other reasons why it may be difficult to locate IDU partners. Because PCRS activities often require the notification of many partners, they can be labor intensive and costly. The cost to counsel and refer one sex partner to needed services ranges from $100 to $2,260 and from $810 to $3,205 to identify one HIV-infected partner through provider referral (Pavia et al., 1993; Peterman et al., 1996). Although partner notification for STDs is generally regarded as ethically acceptable, ethical concerns about the role of HIV partner notification as a prevention strategy have been voiced (Fenton and Peterman, 1997). Community representatives often perceive HIV PCRS to be an intrusive activity that is unlikely to protect the confidentiality of the HIV-infected person or his or her partners (West and Stark, 1997). Health departments are often viewed with suspicion, and their ability to keep personally identifying information confidential is frequently questioned. Efforts are needed to ensure that community HIV prevention needs are met, misconceptions about PCRS practices and policies are corrected, and legitimate concerns about confidentiality and discrimination are addressed. PREVENTION CASE MANAGEMENT (PCM) PCM is an intensive, ongoing, client-centered HIV prevention activity with the fundamental goal of helping individuals with complex lives and circumstances adopt and maintain HIV risk-reduction behaviors. For those who are living with HIV, prevention case management helps in obtaining and adhering to treatment for HIV. It provides counseling, support, and service assistance to address the relationship between HIV risk and other issues such as substance abuse, STDs, mental health problems, and social and cultural factors. PCM staff closely collaborate with Ryan White CARE Act case managers to provide information and referrals for secondary prevention needs of persons living with HIV or AIDS. PCM is also useful for HIV seronegative persons, or those of unknown HIV serostatus who are either engaging in high-risk behavior within communities with moderate to high seroprevalence rates of HIV infection or are otherwise at heightened risk of infection. Because it has the potential to address a wide range of social problems for persons with multiple and complex HIV risk-reduction situations, PCM is particularly suited for individuals like IDUs, who have or are likely to have difficulty initiating or sustaining practices that reduce or prevent HIV transmission and acquisition. PCM strives to develop an ongoing relationship with each client to provide an environment of trust and understanding within which prevention counseling can take place. PCM includes the following seven components:
Case management is often offered as part of a larger care system and this makes it difficult to assess its effects apart from other services. In particular, it has been difficult to assess prevention case management with HIV seronegative drug users and determine the most effective approaches to use with IDUs because of the high drop-out rate of participants even when the required number of sessions with a prevention case manager is reduced (Falck et al., 1994). Other difficulties in evaluating PCM have been small sample size; the lack of ability to control for disease progression, which can cause a decrease in sexual activity; the failure to collect behavioral data in the time between HIV testing and the first case management appointment; and the failure to collect data on the serostatus of program participants' partners. At present, five CDC-funded demonstration projects are being carried out to test the effectiveness of PCM on reducing the transmission of HIV from HIV-infected persons. One intervention in California is being conducted within early intervention program (EIP) sites and employs a risk reduction specialist who uses behavior change theory in the context of clientcentered counseling and/or short-term, solution-focused counseling techniques. Another challenge for PCM services is their greater cost compared to other HIV prevention activities, which can employ peers or paraprofessionals to reach larger numbers of people with less time-intensive, staff-intensive risk reduction strategies. Coordinated Services for IDUs Living with HIV/AIDS Because HIV disease is a complex chronic condition, infected IDUs and their families require a changing array of services in their homes, in the hospital or health care facility, and in the community (Keenan, 1990). In addition, anti-HIV medication regimens involve multiple medications with differing schedules and requirements. Failure to follow recommendations can lead the virus to develop resistance to anti-HIV medications. However, with appropriate and high-quality services and medications, IDUs living with HIV can lead healthy, productive lives. Many IDUs continue to engage in high-risk behaviors after they learn they are infected with HIV and, thus, place others at risk of HIV infection and themselves at risk for collateral health problems (CDC, 1996; HRSA, 1994; Kwiatkowski and Booth, 1998; Metsch et al., 1998). When HIV-infected IDUs are actively engaged in health care, however, they can be followed to identify renewed high-risk sex or drug use and counseled about the effects of these behaviors on themselves and others. HIV-infected drug users who are in substance abuse treatment and are receiving other health services are more likely to comply with HIV/AIDS drug treatment regimens and to reduce their sex and drug risk-related behaviors (Booth et al., 1999). IDUs living with HIV/AIDS need a full complement of services, delivered in a setting geared to attract IDUs from the community and retain them. Case managers and prevention case managers need training in issues specific to IDUs, which should help them offer risk reduction counseling and prevention services to these individuals and assist them with managing their chronic and acute health care needs, including taking anti-HIV medication and opportunistic infection prophylaxis as recommended. In addition, a full range of complementary affordable and accessible services should be made available, including substance abuse treatment services, mental health services and assistance with other basic needs such as food, housing, childcare, and job training. A major barrier to providing comprehensive services for HIV-infected IDUs is inadequate funding. HIV- infected IDUs have high levels of need that are only partially being addressed by the current service system (HRSA, 1994). While acute medical services are generally accessible, other health services (dental, home care, hospice, long-term residential drug treatment) and ancillary services (shelter, food, stable living conditions, vocational training, long-term therapy) often are not adequately provided. As a marginalized population, IDUs can be less connected to the AIDS-related service delivery system than are other infected individuals. For example, HIV-infected IDUs, including those recently incarcerated, without clinical disease who have less contact with health care providers, have not been receiving optimal care (Celentano et al., 1998). Like non-IDU consumers, many IDUs do not know where to go to obtain services or what services are appropriate for different people at different stages of the disease. The service delivery system is too complex and fragmented for them to navigate and often too remote geographically, socially, and culturally. Some programs prohibit services to active drug users and those who are HIV-infected and this presents formidable barriers for IDUs. Negative attitudes by staff toward IDUs' behaviors and life circumstances exacerbate the situation.Women living with HIV disease face particular educational, cultural, economic, psychological, physical, and social barriers in accessing and using care (Weissman et al., 1995; Weissman and Brown, 1995). Most are either active or recovering injection drug or crack users who have a history of sexual/ physical abuse, psychological distress and depression, and lack of social support. Increased funding for services will help to address these barriers, but other changes are also needed, including:
Primary drug prevention is a centrally important strategy in a comprehensive approach to preventing blood-borne diseases among IDUs and reducing the spread to others. By helping individuals avoid drug use and drug injection altogether, these programs help to eliminate the risk of injection-related blood-borne virus transmission. Primary drug prevention programs, which are conducted in a variety of settings, including schools, families, and community-based organizations and through a variety of channels, such as the media, are largely aimed at youth to encourage them to avoid or delay the first use of alcohol, tobacco, marijuana, inhalants, and other drugs. Avoiding or delaying substance abuse can help youth prevent many problems associated with it, including truancy, academic failure, violence, thefts, motor vehicle crashes, homicides, injuries, suicides, and risky sexual behaviors (Ary et al., 1999; Berger and Levin, 1993; Cohen et al., 1997; Donovan et al., 1988; Farrell et al., 1992; Osgood et al., 1988). Research has identified effective primary prevention programs that target all forms of substance abuse and reach all populations (Drug Strategies, 1999; NIDA, 1997; ONDCP, 1998). Successful programs incorporate messages and strategies that are tailored to respond to the specific nature of drug use in the community and the level of risk in the audience. In addition, they are age-specific, developmentally appropriate, and culturally sensitive. Successful programs also are designed to enhance "protective factors" and reduce "risk factors" by:
Successful primary prevention programs also include a variety of components and characteristics, such as:
Although primary drug prevention has been shown to have clear benefits-many professionals feel that the primary prevention movement within communities has been instrumental in reducing regular drug use among adolescents and young adults by two-thirds between 1979 and 1992 (Rusche, personal communication, September 3, 1999)-there are still some limitations that must be addressed. Many of the tested primary drug prevention programs are school-based and their effectiveness with out-of-school youth, who may be at higher risk, is not clear. Some school-based programs whose effectiveness has not been conclusively demonstrated continue to be popular. Furthermore, school-based interventions have been designed and tested mainly with middle school students; programming for younger students and older teens is limited. Progress in evaluation research in this area has also been hampered by methodological limitations, such as limited curriculum assessment that does not consider the multiple requirements teachers must address in the classroom, and a paucity of medium- and long-term follow-up studies of interventions.
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