Treatment and Outreach Research on AIDS: Identifying and Treating Those at Risk

NIDA's drug abuse treatment and outreach research is taking the Institute's AIDS prevention mission onto the front lines of the battle against HIV infection. NIDA-supported researchers in these programs work face to face with drug abuse populations to learn and implement more effective ways to reduce the risk of contracting HIV and AIDS. An important component in both treatment and outreach programs has been the search for ways to reduce HIV risks related to drug-injection practices.

Treatment Research

NIDA's years of experience in developing and implementing drug abuse treatment programs have enabled the Institute to identify, study, and modify drug-use behaviors that increase HIV transmission risks among people who are in treatment.

The Institute's AIDS-related treatment research has three major goals: improving therapies and getting more addicts into treatment, integrating effective HIV risk-reduction tactics into existing treatment programs, and designing treatment and services for targeted at-risk subgroups. These subgroups include gay men who are also drug users, women who don't abuse drugs but who have sex with men who do, HIV-positive addicts, and drug abusers who are in prison or are otherwise involved with the criminal justice system.

NIDA-funded studies have shown repeatedly that injecting drug users who are in treatment programs are less likely to engage in high-risk sexual and drug-using behaviors than are comparable addicts who are not enrolled in treatment. For example, a 1988 study of methadone treatment programs for heroin addicts found that comprehensive drug abuse treatment is effective in reducing injection drug use and needle sharing among most heroin addicts.

Subsequent NIDA-funded studies have reinforced these initial findings. University of Pennsylvania researchers studying heroin addicts in Philadelphia found that out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. The 1993 study found that the addicts who did not receive treatment had a conversion rate to HIV-positive status that was six times higher than the rate among in-treatment injecting drug users who had been regularly exposed to risk-reduction education, counseling, and other strategies.

Unfortunately, HIV risk-reduction education and counseling, HIV testing, and AIDS risk behavior assessments have not yet been assimilated into many existing treatment programs for heroin and cocaine addicts. In response, NIDA is encouraging researchers who are developing and testing behavioral therapies for drug abuse and dependence to also develop HIV risk- reduction interventions that can be readily incorporated into existing drug-abuse treatment programs.

The Institute's behavioral therapies development program announcement has recently been expanded to specifically encourage behavioral research to develop HIV risk-reduction interventions. The program will identify, test, and introduce new behavioral therapies for drug abuse that ultimately can be used in community treatment clinics. Researchers will develop behavioral counseling, cognitive therapies, and other types of treatment designed to reduce the risk of HIV infection and will explore ways to improve treatment compliance, keep potential dropouts enrolled, and appeal to those who resist treatment.

Case Manager Andrea Coward (left) listens to a client describe his life in a culture of drug abuse. "Hearing themselves say things to another person, a light bulb will go on, and it helps them realize what they can do to help themselves," Ms. Coward says.

Another new effort will seek to expand basic behavioral research to develop models of behavior and behavior change relevant to HIV risk. These will include psychological, social, and biological approaches to explain and predict HIV-related behaviors among persons and groups in various settings. A significant aspect of this initiative will bring together researchers from different disciplines in a collaborative way to integrate scientific approaches in order to develop novel ways to address the HIV/AIDS problem.

Outreach Programs

Two landmark outreach programs, initiated by NIDA's Community Research Branch in collaboration with researchers around the country, have set the standard for investigations that shoulder the dual responsibility of AIDS prevention and drug abuse outreach and treatment.

The National AIDS Demonstration Research (NADR) Project, conducted from 1987 to 1992, funded 29 community-based HIV-prevention programs for out-of-treatment injecting drug users and their sexual partners. The followup Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program, launched in 1990, is currently evaluating the effectiveness of NADR intervention programs among different populations in different communities across the Nation, as well as looking at ways to expand the programs. As the examples cited below clearly illustrate, the interventions for out-of-treatment drug users undertaken in both programs accomplished statistically significant and clinically meaningful decreases in HIV-related risk behaviors.

NADR lived up to its description as an outreach program, reaching thousands of out-of-treatment drug users and their sexual partners during its 5-year life span. Reductions in risk behavior, from initial assessment to followup assessment at 6 months, were striking and encouraging. Followup data revealed that 46 per-cent of NADR participants reduced or stopped injecting drugs, 37 per-cent reduced or stopped sharing needles, 50 percent reduced or stopped borrowing needles, and 60 percent reduced or stopped sharing other injection equipment. In addition, a substantial minority of injecting drug users underwent treatment after intervention, many for the first time in their lives.

Although changes in high-risk sexual behaviors were less marked than changes in drug-use behavior, they did show substantial improvement. For example, the proportion of injecting drug users who always used condoms increased from 10 per-cent before intervention to 19 per-cent afterward. The decrease in the percentage of subjects who reported having two or more sexual partners dropped from 44 to 36 percent.

The Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program continues NADR's goals of preventing the further spread of HIV infection among drug users and their sexual partners. Like NADR before it, the program uses street-based, face-to-face outreach and risk-reduction interventions and pretest and post-test HIV anti counseling. The Cooperative Agreement takes NADR's research one step further, with controlled experimental research. Specific, well-defined populations have been recruited for intervention at multiple sites, and a standardized intervention is being used. The Cooperative Agreement is currently the only system of its kind that captures epidemiologic information on hard-to-reach, out-of-treatment drug-using populations.

Counselor James Gaines (left), Community Outreach Program in Long Beach, California, discusses risk reduction with patient. NIDA-funded studies show that injecting drug users in treatment programs are much less likely to engage in high-risk sexual and drug-using behaviors than are comparable users not in treatment.

As with research results from NADR, results from the Cooperative Agreement reveal a remarkable success story in reducing HIV risk behaviors. Examples of changes in risk behavior, from initial assessment to followup assessment at 6 months, include:

• a 41 percent reduction in frequency of injection, from 64 times in the past 30 days prior to intervention to 38 times in the past 30 days after intervention;
• a 54 percent reduction in reusing other persons' syringes, with 17 percent reusing another person's syringes before intervention and 8 percent at followup; and
• a reduction from 22 percent to 14 percent in the proportion of sexual partners who injected.

Outreach approaches are still being developed and evaluated. As the epidemiologic characteristics of the epidemic continue to change, becoming increasingly concentrated in hard-to-reach populations and subgroups, new techniques for monitoring the extent of HIV disease prevalence and for delivering effective interventions are critical in developing effective prevention strategies. NIDA is now funding new epidemiology studies to better define the communities and demographic subgroups in which HIV is spreading, to further identify the specific behavioral risk factors related to the spread of HIV in each subgroup, and to evaluate what has been learned about using effective risk-reduction messages tailored to the needs of these subgroups. Research will concern the unique health care needs of high-risk populations of drug users, seeking ways to better meet their medical and social service needs.

Needle Exchange and Hygiene

NIDA has taken the lead in fighting the spread of AIDS among injecting drug users by studying various strategies to reduce HIV risks related to needle use.

One such study, the first federally funded needle-exchange evaluation, tracked the use of syringes among injecting drug users in New Haven, Connecticut, over 3 years. Data from the locally operated project, which includes HIV testing and medical monitoring, show that after the needle-exchange service was provided, the proportion of needles that tested positive for HIV dropped significantly. Using these data, the New Haven researchers estimated that there would be a 33 percent reduction in new cases of HIV infection among injecting drug users as a result of the needle-exchange program. Significantly, they also have reported that 17 per-cent of the study subjects have been referred to drug abuse treatment. NIDA is now funding similar evaluations in six other cities.

NIDA's multisite observation of needle hygiene practices among injecting drug users in 1993 provided information about another HIV risk involved in injection drug use - indirect sharing, which can occur when water or cookers used to mix drugs, cotton swabs, or a drug solution that contacts the bleach of one injecting drug user is used by another in the process of preparing or injecting drugs. Indirect sharing also can occur with the transfer of drugs from one syringe to another before injection. NIDA researchers' data show that, despite reductions in the frequency of syringe sharing among users, indirect sharing remains a common practice, and some high-risk subgroups have not yet been targeted for risk-reduction interventions.

NIDA research in the 1980s suggested that common household bleach is more effective than most other readily available solutions such as alcohol and hydrogen peroxide in disinfecting needles and syringes used by injecting drug users. Bleach soon became the standard for use in needle hygiene programs, and small bottles of bleach and other HIV risk-reduction educational materials were widely distributed by outreach workers throughout the country. Because of wide disparities in bleach disinfection techniques by drug users, in 1993 NIDA issued a Director's Alert and later joined with the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment in issuing a bulletin on the most effective bleach disinfection procedures and urging the use of new or sterile equipment.

Now NIDA is recruiting re-searchers for a second generation of studies to examine strategies used in different injection risk-reduction projects - counseling, education, the crafting of messages targeting specific subgroups, linkages to drug treatment, and other variable components.

Sources

• National Institute on Drug Abuse. Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research Program, 1990-Present. Rockville, Md.: NIDA, 1995.
• National Institute on Drug Abuse. Outreach/Risk Reduction Strategies for Changing HIV-Related Risk Among Injection Drug Users. NIH Publication No. 94-3726. Rockville, Md.: NIDA, 1994.