Background: In 1997, the National Institutes of Health (NIH) reviewed evidence of the effectiveness of HIV prevention programs for injection drug users (IDUs) and recommended that three types of interventions be implemented to prevent transmission of HIV among IDUs: 1) community-based outreach, 2) expanded syringe access (including needle exchange programs [NEP] and pharmacy sales), and 3) drug treatment. Progress on increasing the acceptance and feasibility of implementing these programs has been made at the national level, but their implementation has been varied at the local level.
Objective: To study the acceptance and implementation of the three interventions by communities and to identify the factors that contributed to the success or failure of communities to implement these programs on the local level.
Methods: Forty-three in-depth qualitative interviews were conducted with key informants in six U.S. cities. Informants included AIDS prevention providers, political leaders, activists, substance abuse and AIDS researchers, health department directors, and law enforcement officials. Cities were classified according to when they initiated interventions as 1) early adopters, 2) middle adopters, and 3) late or never adopters.
Results: Conditions that facilitated or deterred the adoption of interventions were identified. Coalition building and community consultation were key to the acceptance and sustainability of new interventions. Leadership from politicians, public health officials, and program directors provided necessary authority, legitimacy, and access to resources. Grassroots activists took initiative and risks in the face of opposition, but often lacked the resources to sustain their efforts. Researchers played an important role in initiating interventions and legitimizing them by providing access to the scientific information supporting their safety and effectiveness. Successful implementers worked with or avoided the opposition rather than creating polarized positions. Changes in funding and structure of publicly supported drug treatment programs have limited the implementation of new programs. Lack of leadership in the political and public health sectors, and, indeed, fear of adopting or even discussing needle exchange because of perceived political opposition, were the biggest barriers to implementation of syringe exchange programs.
Conclusion: Understanding the conditions under which communities accept and implement interventions can help guide effective strategies to foster the implementation of these interventions in areas where programs do not currently exist.