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The tools, templates and resources in this toolkit were compiled and developed by the CBR team at Access Alliance based on half a decade of implementing CBR projects. The CBR team at Access Alliance realized early on that having solid CBR training and tools was crucial to the success of its CBR projects. Thus, the team made it a priority to build CBR training and tools. In 2006, we created a part-time in-house researcher trainer position whose task was to develop innovative CBR training materials and tools and to deliver CBR training to peer researchers and other partners as per the need of our CBR projects. We also hired a consultant from the Catalyst Centre (Matthew Adams) to ground our CBR training and tools in a popular education framework.

These instruments were used to measure the effectiveness of the multisite INSPIRE Study (known as VOICE in San Francisco) and cover medication use and adherence, health care utilization, substance abuse, injection behavior, sexual behavior, partner relationships, and more. Instruments:

Scoring: N/A Reliability and/or validity: Purcell DW, Metsch LR, Latka M, Santibanez S, Gómez CA, Eldred L, Latkin CA, INSPIRE Study Group. Interventions for seropositive injectors—research and evaluation: an integrated behavioral intervention with HIV-positive injection drug users to address medical care, adherence, and risk reduction. J Acquir Immune Defic Syndr. 2004 Oct 1;37 Suppl 2:S110–8.

Does HIV Needle Exchange Work?

revised 12/98

Why do we need needle exchange?

More than a million people in the US inject drugs frequently, at a cost to society in health care, lost productivity, accidents, and crime of more than $50 billion a year.¹ People who inject drugs imperil their own health. If they contract HIV or hepatitis, their needle-sharing partners, sexual partners and offspring may become infected. It is estimated that half of all new HIV infections in the US are occurring among injection drug users (IDUs)². For women, 61% of all AIDS cases are due to injection drug use or sex with partners who inject drugs. Injection drug use is the source of infection for more than half of all children born with HIV.³ Injection drug use is also the most common risk factor in persons with hepatitis C infection. Up to 90% of IDUs are estimated to be infected with hepatitis C, which is easily transmitted and can cause chronic liver disease. Hepatitis B is also transmitted via injection drug use.⁴ Needle exchange programs (NEPs) distribute clean needles and safely dispose of used ones for IDUs, and also generally offer a variety of related services, including referrals to drug treatment and HIV counseling and testing.

Why do drug users share needles?

The overwhelming majority of IDUs are aware of the risk of the transmission of HIV and other diseases if they share contaminated equipment. However, there are not enough needles and syringes available and even these are often not affordable to IDUs. Getting IDUs into treatment and off drugs would eliminate needle-related HIV transmission. Unfortunately, not all drug injectors are ready or able to quit. Even those who are highly motivated may find few services available. Drug treatment centers frequently have long waiting lists and relapses are common. Most US states have paraphernalia laws that make it a crime to possess or distribute drug paraphernalia “known to be used to introduce illicit drugs into the body.”⁵ In addition, ten states and the District of Columbia have laws or regulations that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. Concern with arrest for carrying drug paraphernalia has been associated with sharing syringes and other injection supplies.⁶ In July 1992, the state of Connecticut passed laws permitting the purchase and possession of up to ten syringes without a prescription and making parallel changes in its paraphernalia law. After the new laws went into effect, the sharing of needles among IDUs decreased substantially, and there was a shift from street needle and syringe purchasing to pharmacy purchasing.⁷ However, even where over-the-counter sales of syringes are permitted by law, pharmacists are often unwilling to sell to IDUs, emphasizing the need for education and outreach to pharmacists.

What’s being done?

Around the world and in more than 80 cities in 38 states in the US, NEPs have sprung up to address drug-injection risks. There are currently 113 NEPs in the US. In Hawaii, the NEP is funded by the state Department of Health. In addition to needle exchange, the program offers a centralized drug treatment referral system and a methadone clinic, as well as a peer-education program to reach IDUs who do not come to the exchange. Rates of HIV among IDUs have dropped from 5% in 1989 to 1.1% in 1994-96. From 1993-96, 74% of NEP clients reported no sharing of needles, and 44% of those who did report sharing reported always cleaning used needles with bleach.⁸ Harm Reduction Central in Hollywood, CA, is a storefront NEP that targets young IDUs aged 24 and under. The program provides needle exchange, arts programming, peer-support groups, HIV testing and case management and is the largest youth NEP in the US. Over 70% of clients reported no needle-sharing in the last 30 days, and young people who used the NEP on a regular basis were more likely not to share needles.⁹

Does needle exchange reduce the spread of HIV? Encourage drug use?

It is possible to significantly limit HIV transmission among IDUs. One study looked at five cities with IDU populations where HIV prevalence had remained low. Glasgow, Scotland; Lund, Sweden; New South Wales, Australia; Tacoma, WA; and Toronto, Ontario, all had the following prevention components: beginning prevention activities when levels of HIV infection were still low; providing sterile injection equipment including through NEPs; and conducting community outreach to IDUs.¹⁰ A study of 81 cities around the world compared HIV infection rates among IDUs in cities that had NEPs with cities that did not have NEPs. In the 52 cities without NEPs, HIV infection rates increased by 5.9% per year on average. In the 29 cities with NEPs, HIV infection rates decreased by 5.8% per year. The study concluded that NEPs appear to lead to lower levels of HIV infection among IDUs.¹¹ In San Francisco, CA, the effects of an NEP were studied over a five-year period. The NEP did not encourage drug use either by increasing drug use among current IDUs, or by recruiting significant numbers of new or young IDUs. On the contrary, from December 1986 through June 1992, injection frequency among IDUs in the community decreased from 1.9 injections per day to 0.7, and the percentage of new initiates into injection drug use decreased from 3% to 1%.¹² Hundreds of other studies of NEPs have been conducted, and all have been summarized in a series of eight federally funded reports dating back to 1991. Each of the eight reports has concluded that NEPs can reduce the number of new HIV infections and do not appear to lead to increased drug use among IDUs or in the general community.^13-15 These were the two criteria that by law had to be met before the federal ban on NEP service funding could be lifted. This is a degree of unanimity on the interpretation of research findings unusual in science. Five of the studies recommended that the federal ban be lifted and two made no recommendations. In the eighth report the Department of Health and Human Services decided that the two criteria had been met, but failed to lift the ban. The Congress has since changed the law, continuing to ban federal funding for NEPs, regardless of whether the criteria are met.

Is needle exchange cost-effective?

Yes. The median annual budget for running a program was $169,000 in 1992. Mathematical models based on those data predict that needle exchanges could prevent HIV infections among clients, their sex partners, and offspring at a cost of about $9,400 per infection averted.¹⁶ This is far below the $195,188 lifetime cost of treating an HIV-infected person at present.¹⁷ A national program of NEPs would have saved up to 10,000 lives by 1995.¹³

What must be done?

Efforts to increase the availability of sterile needles must be a part of a broader strategy to prevent HIV among IDUs, including expanded access to drug treatment and drug-use prevention efforts. Although the US federal government has acknowledged that NEPs¹⁵ reduce rates of HIV infection and do not increase drug use rates, it still refuses to provide funding for NEPs. Therefore, advocacy activity at the state and local community level is critical. However, the federal government should play a more active role in advocating for NEPs publicly, even if it doesn’t fund them. States with prescription laws should repeal them; those with paraphernalia laws should revise them insofar as they restrict access to needles and syringes. Local governments, Community Planning Groups and public health officials should work with community groups to develop comprehensive approaches to HIV prevention among IDUs and their sexual partners, including NEPs and programs to increase access to sterile syringes through pharmacies.

Says who?

1. Rice DP, Kelman S, Miller LS. Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988 . Public Health Reports. 1991;106:280-92. 2. Holmberg SD. The estimated prevalence and incidence of HIV in 96 large US metropolitan areas . American Journal of Public Health. 1996;86:642-654. 3. CDC. HIV/AIDS Surveillance Report . 1998;9:12. 4. Alter MJ, Moyer LA. The importance of preventing hepatitis C virus infection among injection drug users in the United States . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998; 18(Suppl 1):S6-10. 5. Gostin LO, Lazzarini Z, Jones TS, et al. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: a national survey on the regulation of syringes and needles . Journal of the American Medical Association. 1997;277:53-62. 6. Bluthenthal RN, Kral AH, Erringer EA, et al. Drug paraphernalia laws and injection-related infectious disease risk among drug injectors. Journal of Drug Issues. (in press). 7. Groseclose SL, Weinstein B, Jones TS, et al. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993 . Journal of Acquired Immune Deficiency Syndromes. 1995;10:82-89. 8. Vogt RL, Breda MC, Des Jarlais DC, et al. Hawaii’s statewide syringe exchange program . American Journal of Public Health. 1998;88:1403-1404. 9. Kipke MD, Edgington R, Weiker RL, et al. HIV prevention for adolescent IDUs at a storefront needle exchange program in Hollywood, CA. Presented at 12th World AIDS Conference, Geneva, Switzer-land. 1998. Abstract #23204. 10. Des Jarlais DC, Hagan H, Friedman SR, et al. Maintaining low HIV seroprevalence in populations of injecting drug users . Journal of the American Medical Association. 1995;274:1226-1231. 11. Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection . Lancet. 1997;349:1797-1800. 12. Watters JK, Estilo MJ, Clark GL, et al. Syringe and needle exchange as HIV/AIDS prevention for injection drug users . Journal of the American Medical Association. 1994; 271:115-120. 13. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA . Lancet. 1997;349:604-608. 14. Report from the NIH Consensus Development Conference. February 1997. 15. Goldstein A. Clinton supports needle exchanges but not funding. Washington Post. April 21, 1998:A1. 16. Lurie P, Reingold AL, Bowser B, et al. The Public Health Impact of Needle Exchange Programs in the United States and Abroad . Prepared for the Centers for Disease Control and Prevention. October 1993. 17. Holtgrave DR, Pinkerton SD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1997;16:54-62.

Prepared by Peter Lurie, MD MPH*,** and Pamela DeCarlo** *Public Citizen’s Health Research Group **CAPS Updated December 1998. Fact Sheet #5Er

Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © December 1998, University of California

¿Pueden los proveedores de salud ayudar en la prevención del VIH?

(revisado 4/99)

¿son los trabajadores de salud importantes en la prevención?

Sí. Los proveedores de salud tienen muchas oportunidades para promover los cambios de comportamiento necesarios para detener nuevas infecciones de VIH. En los EEUU en 1996, el adulto promedio visitó al médico 3 veces al año. 82% de las visitas fueron en consultas médicas y 10% en salas de emergencia.¹ Las visitas médicas proveen oportunidades para que el paciente pueda expresar su propria experiencia con respecto al riesgo sexual y el uso de drogas. Los proveedores de salud que trabajan en areas con altos índices de pacientes de alto-riesgo-como en salas de emergencia, clínicas de enfermedades transmitidas sexualmente (ETS), clínicas de mantenimiento con metadona y clínicas en cárceles o prisiones-juegan un papel crítico en la prevención del VIH. Por ejemplo, hombres, mujeres, y adolescentes que han sido encarcelados tienen altos índices de VIH, ETS, y tuberculosis, así como problemas de alcoholismo y narco-dependencia, y se beneficiarían de información preventiva y servicios médicos.² En una encuesta nacional de adultos en los EEUU, solamente un 20% de los pacientes había discutido su riesgo relacionado con el VIH con su médico. Solamente 21% de los que sí habían hablado del tema con su médico reportaron que el médico había iniciado el tema. Y solamente 23% de los que reportaron un riesgo con respecto a el VIH había hablado con su médico sobre el SIDA.³

¿cuáles son las barreras para hablar del VIH?

La prevención del VIH requiere la habilidad de hablar abiertamente sobre la sexualidad y las drogas-lo cual puede ser incómodo. Los proveedores de salud necesitan entrenamiento sobre como iniciar discusiones, saber manejar los temas incómodos, responder a temores y expectativas, estimular respuestas del paciente y comprender al paciente. Hay varios formas de enseñar estas técnicas incluyendo practicar discusiones en las cuales los instructores juegan el papel del paciente y se graba la sección en video para que el proveedor pueda criticar su actuación.⁴ La falta de tiempo puede ser un gran obstaculo para discutir los riesgos del VIH. Muchos proveedores de salud practican la prevención en muchas otras áreas de la salud como la nutricion y el ejercicio, fumar, depresión, diabetes, enfermedades del corazón y cáncer. Con una cantidad de tiempo programado para cada paciente, proveedores de salud pueden sentir que no hay suficiente tiempo para discutir temas tan delicados como la sexualidad o el uso de drogas.

¿qué pueden hacer?

La evaluación de los comportamientos de riesgo relacionados con el VIH debe ser parte habitual de la evaluación inicial con cada nuevo paciente. No todos los pacientes requieren educación preventiva intensiva. Sin embargo, los proveedores de salud deben preguntarle a todo paciente sobre el uso de condones, número de parejas sexuales, orientación sexual y uso de drogas inyectables para evaluar el riesgo de contraer el VIH. Los que no tienen tiempo o no se sienten cómodos discutiendo estos temas pueden canalizar a sus pacientes a líneas informativas gratuitas o programas comunitarios de salud pública. Los proveedores de salud pueden proveer consejería sobre el VIH y proveer o recomendar la prueba de detección del VIH a pacientes de alto riesgo para el VIH. Esto incluye pacientes con ETS, especialmente adolescentes, usuarios de drogas inyectables (UDI), mujeres cuyas parejas pueden ser UDIs y pacientes que no saben si su pareja es VIH- o VIH+. Los proveedores de salud pueden tener un efecto profundo en la vida del paciente cuando demuestran interés en sus pacientes que usan drogas y alentarlos a empezar un programa para el alcoholismo o la narco-dependencia. Recaer en el uso de alcohol o drogas ocurre frecuentemente al tratar adicción. Es importante que en dichos casos los proveedores de salud no demuestren una actitud prejuiciosa hacia el paciente.⁶ Los proveedores de salud que trabajan con pacientes VIH+ pueden prevenir la transmisión de VIH ayudándoles a evaluar sus comportamientos de riesgo y aconsejándoles que reduzcan dichos comportamientos.⁷ Esto es de suma importancia con los nuevos tratamientos efectivos contra el VIH. Por ejemplo, pacientes VIH+ pueden creer que tener un conteo bajo o indetectable del virus impide la transmitir del virus. Los momentos oportunos para ofrecer consejería son: en el diagnóstico, al inicio de los síntomas y al empezar un nuevo tratamiento.⁸

¿el tratamiento puede promover la prevención?

Sí. El diagnóstico y tratamiento de ETS tales como la sífilis y la gonorrea pueden proteger contra la transmisión del VIH. La detección temprana y el tratamiento de ETS puede ser crucial ya que las infecciones de ETS facilitan la infección y la transmisión del VIH. En zonas y poblaciones con altos índices de ETS y bajos índices de infecciones de VIH, el tratamiento de ETS es una forma eficaz de prevenir infecciones de VIH.⁹ En años recientes, ha habido muchos adelantos en la prevención de la transmisión del VIH de madre a hijo. Los proveedores de salud deben ofrecer la prueba del VIH a toda mujer embarazada. El tratamiento con AZT a madres VIH+ y sus bebés ha reducido la transmision en dos-tercios. A las madres VIH+ también se les debe ofrecer consejería sobre los riesgos al amamantar así como alternativas a la leche materna si fuera necesario.¹⁰ PEP es un método que potencialmente prevendría la transmisión del VIH al administrar AZT y otras drogas anti-VIH en las primeras 72 horas después de haber estado expuesto al virus.¹¹ Estudios ocupacionales han encontrado que la transmisión de VIH puede ser prevenida con el tratamiento pos-exposición, y ahora es recomendado por los Centers for Disease Control and Prevention (CDC) para los trabajadores del sector de salud que accidentalmente han estado expuestos al virus. Actualmente, se hacen estudios sobre el uso de PEP para exposición a través del sexo o uso de drogas inyectables, incluyendo asalto sexual. El CDC todavía no ha aprobado el uso de PEP en estos casos ya que no hay datos sobre su efecto en las exposiciones de este tipo.¹²

¿qué se está haciendo?

Los proveedores de salud necesitan acceso a entrenamiento y a información médica actualizada. Proveedores de salud en áreas rurales recibieron entrenamiento sobre VIH/SIDA. Aprendieron información básica, como evaluar el riesgo, los adelantos en tratamientos, y como ser sensibles a las poblaciones diversas. El entrenamiento más eficaz para los proveedores de salud en áreas rurales fue un folleto auto-didáctico que ayudó a incrementar la prevención, a intervenir temprano y a promover salud en el área rural. Dicho folleto está disponible gratuitamente en la Internet. Entrenamientos interactivos por medio de teleconferencias y entrenamiento de personal por medio de educadores también fueron eficaces.¹³ Los proveedores de salud tienen que prestar atención a las múltiples necesidades de sus pacientes. En Bangalore, India, se estableció la Clínica de la Mujer Sana como parte de un programa de control del VIH. Mujeres de bajos ingresos, en su mayoría prostitutas, habían sido indebidamente atendidas, tenían altos índices de ETS y tenían alto riesgo de contraer el VIH. Debido a que las mujeres están condicionadas a ignorar o tolerar problemas de salud, las pacientes de la Clínica automáticamente reciben pruebas de detección de ETS sin tener que admitir ningún síntoma.¹⁴ Los proveedores de salud deben utilizar los servicios disponibles en sus comunidades. El Hospital de Niños de Los Angeles colaboró con organizaciones de prevención de la comunidad para proveer un modelo de cuidado integral para jóvenes con/o en riesgo de contraer el VIH. El modelo ofrece una clínica de medicina general y servicios psicosociales tales como consejería y manejo de casos. Educadores del mismo grupo también proveen reclutamiento extensivo en los sitios donde se reúnen jóvenes de alto riesgo. El programa desarrolló un sistema de canalización de servicios locales para jóvenes que puede obtenerse en la Internet.¹⁵

¿es suficiente incrementar la participación de proveedores de salud?

Incrementar la participación de proveedores de salud es solamente uno de los aspectos de un plan de prevención amplio. Una estrategia completa utiliza múltiples elementos para proteger del VIH a la mayor cantidad de personas posible. La prevención del VIH no se logra de un “solo golpe”; es un proceso contínuo que requiere la participación de varios sectores de la sociedad. Esto incluye doctores, enfermeras, educadores de salud, terapeutas, dentistas y otros proveedores de salud a quienes la poblacion consulta sobre como mantener la salud.

¿quién lo dice?

1. Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996 . Vital and Health Statistics. 1998;134:1-37. 2. Hammett TM, Gaiter JL, Crawford C. Reaching seriously at-risk populations: health interventions in criminal justice settings . Health Education and Behavior. 1998;25:99-120. 3. Gerbert B, Bleecker T, Bernzweig J . Is anybody talking to physicians about acquired immunodeficiency syndrome and sex? A national survey of patients. Archives of Family Medicine. 1993;2:45-51. 4. Epstein RM, Morse DS, Frankel RM, et al. Awkward moments in patient-physician communication about HIV risk. Annals of Internal Medicine. 1998;128:435-442. 5. American Medical Association. Physician Guide to HIV Prevention. June 1996. 6. Herman M, Gourevitch MN. Integrating primary care and methadone maintenance treatment: implementation issues . Journal of Addictive Diseases. 1997;16:91-102. 7. Gerbert B, Brown B, Volberding P, et al. Physicians’ transmission assessment and counseling practices with their HIV-seropositive patients. AIDS Education and Prevention. In press. 8. Gerbert B, Love C, Caspers N et al. “ Making all the difference in the world”: how physicians can help HIV-seropositive patients become more involved in their healthcare . AIDS Patient Care and STDs. 1999;13:29-39. 9. Centers for Disease Control and Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases-United States . Morbidity and Mortality Weekly Report. 1998;47(RR-12):1-25. 10. Centers for Disease Control and Prevention. Update: perinatally acquired HIV/AIDS-United States, 1997 . Morbidity and Mortality Weekly Report. 1997;46:1086-1092. 11. Centers for Disease Control and Prevention. Management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis . Morbidity and Mortality Weekly Report. 1998;47(RR-7):1-33. 12. Centers for Disease Control and Prevention. Management of possible sexual, injecting drug-use, or other non-occupational exposure to HIV, including considerations related to antiretroviral therapy . Morbidity and Mortality Weekly Report. 1998;47(RR-17):1-14. 13. Martin SJ. HIV/AIDS prevention, early intervention and health promotion: results of training for rural health care providers. Presented at the 9th National AIDS Update Conference, San Francisco, CA. March 19, 1997. 14. Baksi CM, Harper I, Raj M. A `Well Woman Clinic’ in Bangalore: one strategy to attempt to decrease the transmission of HIV infection . International Journal of STDs & AIDS. 1998;9:418-423. 15. Schneir A, Kipke MD, Melchior LA, et al. Children’s Hospital Los Angeles: a model of integrated care for HIV-positive and very high risk youth. Journal of Adolescent Health. 1998;23(2Suppl):59-70. Computerized referral system:www.caars.net

Preparado por Pamela DeCarlo*, Barbara Gerbert, PhD y el Center for Health Improvement and Prevention Studies; *CAPS Traducido por Sandra Gálvez, CAPS Septiembre 1999. Hoja Informativa 6SR.