Research Synthesis Symposium on the Prevention of HIV in Drug Abuse

United States

Meeting Sponsors: National Institute on Drug Abuse, NIH Office of AIDS Research, Northern Arizona University

Purpose:

The two and one-half day Symposium was the first meeting in the history of the HIV epidemic to be exclusively devoted to the prevention of HIV in injection and noninjection drug users. The Symposium brought together national and international leaders from the fields of drug abuse and HIV prevention research to:

• review the effectiveness of community-based interventions designed to reduce risk behaviors and prevent the spread of HIV in injection and noninjection drug users
• translate science-based findings into prevention principles that can be applied on a world- wide basis by prevention planners and practitioners, and
• formulate emerging strategies and discuss future directions for the prevention of HIV transmission among drug abusers

Meeting Process:

The agenda included presentations on the history and evolution of HIV prevention research; the human experience of HIV; triumphs and tribulations in HIV prevention; and what we have learned, have done, and haven't done in 15 years of HIV prevention. State-of-the-art synthesis papers and unpublished findings were presented by researchers over the next two days on the following themes:

• community-based outreach interventions to prevent the spread of HIV among drug abusers
• syringe exchange programs and access to sterile injection equipment
• drug abuse treatment as an HIV prevention strategy
• social network roles in diffusing risk reduction messages and mediating HIV transmission
• international HIV prevention interventions
• biological and behavioral prevention interventions, and
• bridges from HIV research to prevention and to practice

In responding to the challenges of the changing dynamics of drug abuse and the spread of HIV/AIDS and other infectious diseases, researchers supported by the National Institute on Drug Abuse (NIDA) have developed and implemented interventions to change risk behaviors to prevent the spread of HIV infection. Throughout the Symposium, the origins, evolution, and current status of the scientific knowledge base of NIDA's HIV research and intervention program were discussed. Each panelist examined the current scientific literature findings and presented them in conjunction with their own research results on the effectiveness of behavioral interventions in changing high risk drug-using behaviors (unsafe sexual behaviors and unsafe injection practices) related to HIV transmission.

Content:

The following HIV prevention principles emerged from the Symposium and were determined to be effective for guiding practitioners and policy makers. These include:

• start HIV prevention interventions early in the epidemic, or as soon as possible
• implement multiple intervention strategies, such as outreach to active drug users, recruitment and referral to treatment, risk behavior reduction and other elements of comprehensive HIV programs including the use of sterile injection equipment by those who will not stop drug use, and drug abuse treatments which have been shown to be effective in reducing risk behaviors for injection drug users and preventing the spread of HIV
• implement interventions at multiple levels (policy, legal, institutional, community, network, and individual levels) to alter community behavioral norms and risk behaviors to create opportunities for at-risk individuals to make and sustain behavior change in a supportive environment
• implement interventions in multiple settings to reach as many of the at-risk population and subgroups as possible, e.g.,
  • streets, mobile vans, storefront offices, and other places where drug users congregate, such as shooting galleries
  • health-related settings, such as clinics, pharmacies, drug treatment centers
• target multiple risk behaviors simultaneously, including drug use, needle risk, and sexual practices
• provide access to multiple means (intervention components) for behavior change, including:
  • risk reduction information and
  • risk reduction supplies, including bleach, sterile water, and related injection hygiene materials, and condoms (male and female), and
  • HIV antibody testing with pre- and post-test counseling
• create opportunities for increased exposure to interventions through booster sessions to reinforce skills and knowledge learned in the initial intervention to further increase the effectiveness of interventions
• recognize that populations at risk for HIV are in various stages of readiness to participate in an intervention and need to be engaged appropriately in order to maintain them in the interventions by using motivational techniques, contingency management, cognitive strategies, and/or peer-driven interventions,
• be assured that risk reduction is an appropriate, realistic outcome of HIV interventions; the ultimate goal is the elimination of select risk behaviors

Next Steps:

The researchers at the symposium concluded that more systematic analysis of currently available data is necessary to:

• describe intervention components
• develop contextual information about the intervention
• determine the impact of the intervention on risk behaviors and disease transmission
• interpret how an intervention contributed to observed effects, and
• determine the effects of interventions, sustain behavior change, and prevent the further spread of HIV

Future research needs to address both intervention assessment issues and methodological issues. Suggested new areas include:

Intervention Issues:

• assessment of the relationship of intervention dose (amount and duration of intervention services received), content (types of intervention services delivered), and outcome
• assessment, characterization, and evaluation of the effectiveness of interventions in sustaining behavior change and averting HIV incidence
• differential responses to interventions by gender, age, and ethnicity in low, moderate, and high HIV prevalence communities
• decision making processes and risk assessments
• better specification of drug abuse treatment in terms of services that address the physiological effects of drug abusing behaviors as well as the psychosocial consequences of drug abuse and the factors that lead to sustained drug abuse rather than modality per se
• characterization of those not being reached by existing interventions: e.g., active users, women, and those at the highest and lowest levels of HIV risk
• assessments of comprehensive, multiple interventions on behavior change and prevention of HIV

Methodological Issues:

• improved measures of risk, e.g., length of followup, clinical vs. statistical changes due to interventions
• development of designs that are acceptable alternatives to randomized trials
• process measures of quality of implementation of interventions over time
• use of new technologies for collecting, analyzing, and reporting data more quickly

Products/Future Activities

The meeting made it clear that it was necessary to systematically examine all interventions and their effects on behaviors as we work toward the end goal of preventing HIV. As a result, the following future activities are planned:

• A special supplemental issue of Public Health Reports is anticipated for the Spring of 1998. Scientific papers presented at the Research Synthesis Symposium on Prevention of HIV in Drug Abusers will be developed and peer reviewed for inclusion in the Journal. The supplemental issue is intended to be a resource for the public health, research, and practitioner communities on empirically-based prevention principles and programs, as well as on emerging priority areas in drug abuse and HIV research and program development.
• The first formal Global Research Network on Drug Abuse and HIV Transmission Meeting (25 global HIV prevention network researchers will make presentations) is tentatively planned for June 26, 1998 as a research satellite to the 1998 World AIDS Conference, Geneva. Potential co-sponsors for the network include the NIH Office on AIDS Research, NIH, WHO Programme on Substance Abuse, and UNAIDS. In addition to the face-to-face meeting proposed for June 1998, multiple strategies for electronic communication are being considered, including the establishment of a List Serv to link members electronically in a series of "virtual" meetings as well as informal chat sessions