Structural Interventions to Reduce HIV Infection among Injecting Drug Users
Don C. Des Jarlais, Ph.D.
[Slides not available.]
SUMMARY: Dr. Don Des Jarlais considered the conceptualization of structural interventions for reducing HIV transmission among IDUs, their implementation, and how they might be evaluated. He used the expansion of methadone maintenance treatment in Edinburgh, Scotland and the legalization and expansion of syringe exchange programs in New York as case studies for his presentation. Dr. Des Jarlais indicated that when properly implemented, structural interventions are expected to generate “herd immunity” effects. He examined implementation issues such as extent of coverage required before a structural intervention can be considered successfully implemented. Dr. Des Jarlais stressed that randomized clinical trials can almost never be used to evaluate structural interventions; potential criteria for assessing the effectiveness of a structural intervention include: (1) biological and behavioral plausibility, (2) temporal associations, and (3) large effect sizes.
Connect to Protect—ATN Protocols 016a, 016b, and 040
Jonathan Ellen, M.D.
SUMMARY: Dr. Jonathan Ellen’s presentation detailed the objectives of the Adolescent HIV Prevention Trials Network Connect to Protect (C2P) project. This project is an intervention aimed at mobilizing communities to take action against HIV incidence among its youth. Dr. Ellen argued that structural changes—changes in policies and leadership—can reduce the risk and incidence of HIV infection among adolescents and young adults in high prevalence communities and that partnerships are the first step in promoting change within those communities. The C2P project targets high-risk youth between 12 and 24 years old and addresses their needs through three phases, each of which has clear objectives that include assessment and recruitment of at-risk youth; developing partnerships between key community members and community organizations designed to reach at-risk youth; and evaluating the effectiveness of the project. The partnerships provide a means of “connecting” these youth to education and services, and health indicators are monitored and evaluated over a 5-year period through repeated cross-sectional, venue-based surveys.
HIV, Infectious Diseases, and Drug Use in Networks and Communities
Samuel Friedman, Ph.D.
SUMMARY: Data from 96 U.S. metropolitan areas suggest that economic variables such as unemployment rates, lower healthcare expenditures per capita, and per capita arrests for “hard drugs” are predictors of the population density of intravenous drug users in the population (IDUs per capita) and that the HIV prevalence rate among IDUs is positively associated with economic variables, lower healthcare expenditures per capita, and per capita arrests for hard drugs. In his presentation, Dr. Samuel Friedman argued that treatment centers and other programs for drug users should provide sexually transmitted infection (STI) prevention, education, and treatment for users, as well as hepatitis C (HCV) education and treatment. Surveys in New York City suggest that IDUs are active participants in the struggle against HIV; IDUs and other users may be core groups for spreading bloodborne viruses and STIs such as HSV-1 and -2 and syphilis; and that hepatitis B vaccinations are not reaching those who need them most. Dr. Friedman stressed that research and planning are needed to reach IDUs and other users who need HIV, hepatitis B, HCV, and HSV-2 vaccines; macrosocial issues of economics and policy may affect the availability of syringe exchange and drug treatment programs; and arrests for hard drug use may be counterproductive because IDUs and others can be actors for public health instead.
HIV in Ethnic Minority Populations
John B. Jemmott III, Ph.D.
SUMMARY: Dr. John Jemmott presented a summary of HIV infection risk factors among ethnic minority individuals, as well as the challenges in providing HIV prevention to these groups. Dr. Jemmott reported on a series of randomized, controlled trials that he and his colleagues conducted to test the “Be Proud! Be Responsible!” HIV/STD risk reduction intervention for African-American adolescents. The research examined program efficacy in regard to intervention development; cultural adaptability to diverse groups; behavior theory; the design, methodology, and implementation of HIV/STD prevention trials (particularly for adolescents); measurement of HIV/STD risk behavior; and reduction of attrition. The presentation also addressed research on disseminating the “Be Proud! Be Responsible!” curriculum, limitations of the research, and possible directions for future research.
Future Directions for HIV Prevention among Drug Users: the HPTN Agenda
David S. Metzger, Ph.D.
SUMMARY: Dr. David Metzger noted that while evaluations of prior interventions aimed at reducing HIV risk and infection among injection and noninjection drug-using populations have often lacked scientific rigor, there is a rich body of knowledge that can inform and guide future prevention efforts. For example, effective drug treatment, network-based interventions, and the use of sterile injection equipment have consistently been found to reduce HIV risk. Yet, due to policy, perceptions, and costs, many drug users are unable to become engaged in such services. Dr. Metzger provided an overview of the HIV Prevention Trials Network (HPTN)—its sites, priorities, and protocols. He stressed future research must be guided by the epidemiology of the epidemic to maximize its impact on the spread of HIV infection and that work needs to target those drug users at greatest risk, including HIV positive individuals and their drug-using and sexual partners, cocaine and stimulant users, drug-using gay and bisexual populations, and drug users unaffiliated with health efforts to increase access and acceptability of effective prevention strategies.
Drug Use and HIV among Men Who Have Sex with Men (MSM)
David W. Purcell, J.D., Ph.D.
SUMMARY: Dr. David Purcell’s presentation focused on the prevalence of substance use and abuse among men who have sex with men (MSM); the potential links between substance use and HIV infection for MSMs; and HIV prevention interventions that address the needs of substance-using MSMs. Dr. Purcell presented an in-depth look at the prevalence of substance use and HIV among MSMs, risk factors for HIV infection and drug abuse, associated health problems and intervention implications for treating dually diagnosed individuals, as well as HIV prevention approaches for substance-abusing MSMs. His studies revealed that although MSMs use more substances over their lifetimes than heterosexual men, there are fewer differences for recent use; other data also suggest more drug dependence among MSMs. While the causal links between substance use and risk behavior have been difficult to establish, Dr. Purcell concluded that substance use may play an important role in HIV for MSMs, and that there is a need for greater integration between substance abuse treatment and HIV prevention for this population.
HIV Prevention among Adolescents: Diffusion of Innovation in a Community Trial
Kathleen J. Sikkema, Ph.D.
SUMMARY: Dr. Kathleen Sikkema presented findings of a study that examined the effect of a multicomponent community intervention to reduce HIV risk among adolescents, diverse with respect to age and ethnicity. This randomized, controlled, multisite intervention was undertaken on a community level with adolescents (ages 12 to 17) living in 15 low-income housing developments in five U.S. cities. Baseline, short-term, and long-term followup risk assessments were carried out. Following matching, the youth were randomly assigned in equal number to each of three conditions; they were divided into state-of-the-science skills training workshops; an experimental, community-level intervention; and an education-only control group. At long-term followup, 83 percent of the adolescents who received the community-level intervention were more likely to delay onset of first intercourse than those in the control group (74%), while those in the workshop group (77%) did not differ from control condition adolescents. Adolescents in both the workshop and community-level interventions reported greater condom use than those in the control group.
Integrating Hepatitis C and Drug Treatment in a Community-Based Setting
Diana L. Sylvestre, M.D.
SUMMARY: Dr. Diana Sylvestre presented an overview of the O.A.S.I.S. (Organization to Achieve Solutions in Substance Abuse) Group Model of care for addressing addiction-related medical conditions. Preliminary data from O.A.S.I.S. HCV patients has shown that successful clinical outcomes can be achieved by integrating peer-based HCV services in a community setting that provides medical care for substance users. Dr. Sylvestre examined current data from an ongoing NIDA-sponsored trial that uses buprenorphine to bridge street-recruited heroin users to hepatitis C treatment in a community setting. Preliminary results suggest that this integrated approach is a useful strategy for engaging high-risk drug injectors with serious medical conditions, and that offering combined treatment services in a single setting that addresses multiple comorbidities can yield high levels of engagement and treatment success, even in the most challenging patients with active addictive disorders.