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Howdy, Partner! Using the PARTNER Tool to Track and Analyze Community Partnerships
Self-Report Adherence to Medications
This questionnaire was developed by the AIDS Clinical Trials Group (ACTG) Recruitment, Adherence, and Retention Subcommittee, Margaret A. Chesney, PhD, and Jeannette Ickovics, PhD, co-chairs. Please read the two abstracts on adherence in clinical trials and practice. Instruments:
Scoring: N/A Reliability and/or validity: Chesney MA, Ickovics JR, Chambers DB, Gifford AL, Neidig J, Zwickl B, and Wu AW (2000). “Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG).” AIDS Care 12(3): 255–66.
Club drugs
How do club drugs impact HIV prevention?
What are club drugs?
Club drugs are illegal drugs that are often, although not exclusively, used at dance clubs, raves and circuit parties. Drugs often referred to as club drugs include: MDMA (ecstasy), methamphetamine (crystal meth, speed), GHB (liquid X), Ketamine (special K) and less often, Viagra and amyl nitrites (poppers)1. These drugs also are often used outside of clubs and parties. Raves are large parties featuring house or techno music and visual effects. Mostly younger people attend raves. Circuit parties are a series of large, predominantly gay parties lasting several days and nights in a row that are frequented mostly by younger and older middle-class white men. They occur annually in different cities.2 Some of the physical and psychological effects of club drugs include: elevated mood, increased empathy, altered vision, sensations and emotions, increased alertness, decreased appetite, relaxation, increased physical energy and/or self-confidence. Many people use drugs recreationally with few or no immediate repercussions. Misuse of club drugs can lead to problems with toxicity (from the drugs themselves or from interactions with other drugs), with legal issues and sometimes with addiction. Persons using one or more club drugs during sex often report engaging in extremely high HIV risk behaviors.3 Club drugs can cause a variety of non-HIV-related health risks. This fact sheet will focus on sexual and drug-using HIV risk behaviors that can occur with club drug use.
Who uses club drugs?
Most of the research on club drugs has been with gay men, mainly because HIV prevalence and risk of infection are high among gay men. Use of club drugs varies by different populations and by geography.4 A survey of gay male circuit party attenders in San Francisco found that 80% used ecstasy, 66% ketamine, 43% methamphetamines, 29% GHB, 14% Viagra and 12% poppers during their most recent out-of-town weekend party. Half (53%) used four or more drugs.5 A study of rave attenders in Chicago found that 48.9% had used any club drugs, 29.8% used LSD, 27.7% ecstasy and 8.5% methamphetamine. Rave attenders used club drugs with other drugs such as marijuana (87%), alcohol (65.2%) and cocaine/crack (26.1%).6
What is the risk?
There are many negative physical and psychological side effects of club drugs. The reason club drugs present a potential HIV risk is because they can lower inhibitions, impair judgment, increase sexual endurance and encourage sexual risk-taking. With injected drugs, there is also a potential risk from sharing injection equipment. The risk for HIV occurs mainly when drug use occurs during sexual activity. For example, methamphetamine is often used to initiate, enhance and prolong sexual encounters, allowing individuals to have sexual intercourse with numerous partners. Poppers are used for receptive anal sex, to relax the anal sphincter. Speed is also dehydrating, which may make men and women more prone to tears in the anus, vagina or mouth, and therefore more prone to HIV/STD infections.3,7 In one study, HIV- heterosexual methamphetamine users reported an average of 9.4 sex partners over two months. The number of unprotected sexual acts in two months averaged 21.5 for vaginal sex, 6.3 for anal sex and 41.7 for oral sex. Most users (86%) reported engaging in “marathon sex” while high on methamphetamine. Over one-third (37%) of users reported injecting, and of those, almost half had shared and/or borrowed needles.7 Unprotected sex with a partner whose HIV status is unknown is a high-risk activity. A survey of gay men found that 21% of HIV+ and 9% of HIV- men reported unprotected anal sex with a partner of unknown status at their most recent circuit party.5 A study of gay men at raves in New York City found that about one-third (34%) used ecstasy at least once a month. Men who used ecstasy were more likely to report recent unprotected anal intercourse than men who used other drugs, including alcohol.8
Why do people use club drugs?
For many people, straight or gay, drug use and sex are a natural occurrence at raves and circuit parties, and one of the appeals of these parties. These parties are popular social activities for some groups of youth and gay men, and there can be strong peer pressure to use drugs and be sexually active. While circuit parties and raves may not themselves cause drug use, they may attract persons who are more inclined to use drugs.10 People use club drugs for many reasons. Some people use club drugs to have fun, dance and loosen inhibitions. Others use them to escape their problems and to counter feelings of depression or anxiety. Parental drug use, childhood sexual abuse and depression are some of the factors that may lead to drug use.4
What’s being done?
A drug treatment program for gay methamphetamine users in Los Angeles, CA, sought to reduce drug use and HIV-related sexual risk behaviors. Treatment options included: 1) cognitive behavioral therapy, a 90-minute group session delivered three times a week; 2) contingency management, a behavioral intervention that offered increasingly valuable vouchers for abstinence from drug use; and 3) cognitive behavioral therapy culturally tailored to gay issues. All men reduced their drug use, and those using contingency management reduced drug use longer. The highest reduction in sexual risk-taking occurred in men who used the culturally tailored program.11 DanceSafe promotes health and safety within the rave and nightclub community, with local chapters throughout the US and Canada. DanceSafe trains volunteers to be health educators and drug abuse prevention counselors at raves and nightclubs. They use a harm reduction approach and primarily target non-addicted, recreational drug users. DanceSafe offers information on drugs, safer sex and staying healthy, and in some venues offers pill testing to make sure drugs do not contain harmful substitutes.12 Twelve Step programs such as Crystal Meth Anonymous (CMA), Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) are for people for whom drug use has become a problem. Twelve Step advocates abstinence from crystal meth, alcohol and other illicit drugs. Twelve Step meetings occur in many cities across the US.13 The PROTECT project at the South Florida Regional Prevention Center aims to reduce club-drug use among young gay men. PROTECT trains police officers, teachers and other community stakeholders on club drugs, particularly ecstasy. They also developed a web site with a chat room monitored by peer counselors.14 Stepping Stone, in San Diego, CA, is a residential drug treatment facility for gay men and lesbians. Most of their clients are poly drug users and most are dually diagnosed with psychiatric disorders. They address sexual behaviors and mental health issues in the context of drug abuse treatment. Stepping Stone sponsors a harm reduction social marketing campaign to increase awareness of the dangers of club drugs and alcohol.15
What needs to be done?
Several organizations are currently addressing the negative effects of club drugs at raves and parties across the country. More education is needed about the toxicity of club drugs, poly drug use and the connection between drug use and unsafe sex. Referrals for mental health counseling should also be made available at these venues. The gay community needs to address the very real pressures in some sub-communities to party and be highly sexually active, and ask the question “is drug use worth the risks men are taking?”3 It is not enough to attempt to reduce drug use and abuse at circuit parties without also addressing the powerful sexual motivations to using drugs.3,9 When prescribing Viagra, physicians should counsel men on safer sex and the harmful effects of combining Viagra with methamphetamines, poppers and ecstasy. Physicians should inquire about club drug use among their HIV+ patients and counsel them on the danger of combining them with HIV treatment drugs.16 Physicians should be aware that club drug use can affect adherence to HIV drugs.
Says who?
1. Freese TE, Miotto K et al. The effects and consequences of selected club drugs. Journal of Substance Abuse Treatment. 2002;23:151-156. 2. Swanson J, Cooper A. Dangerous liaison: club drug use and HIV/AIDS. IAPAC Monthly. 2002;8:1-15. 3. Halkitis PN, Parsons JT, Stirratt MJ. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. Journal of Homosexuality. 2001;41:17-35. 4. Stall R, Paul JP, Greenwood G et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96:1589-1601. 5. Colfax GN, Mansergh G, et al. Drug use and sexual risk behavior among gay and bisexual men who attend circuit parties: a venue-based comparison. Journal of Acquired Immune Deficiency Syndromes. 2001;28:373-379. 6. Fendrich M, Wislar JS, Johnson TP et al. A contextual profile of club drug use among adults in Chicago. Addiction. 2003;98:1693-1703. 7. Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addictive Behavior. 2004;29:807-810. 8. Klitzman RL, Pope HG, Hudson JI. MDMA (“ecstacy”) abuse and high-risk sexual behaviors among 169 gay and bisexual men. American Journal of Psychiatry. 2000;157:1162-1164.10. Adlaf EM, Smart RG. Party subculture or dens of doom? An epidemiological study of rave attendance and drug use patterns among adolescent students. Journal of Psychoactive Drugs. 1997;29:193-198. 11. Shoptaw S, Reback CJ. Drug and sex risk behavior reductions with behavioral treatments for methamphetamine dependence among gay/bisexual men. Presented at the National HIV Prevention Conference, Atlanta, GA. 2003. Abstract #T3-D1004. 12. www.dancesafe.org 13. www.crystalmeth.org, www.na.org, www.aa.org 14. Rothaus S. Workshop targets young gays with a penchant for club drugs. Miami Herald. July 16, 2003. 15. Johnson SB. Stepping Stone: a catalyst for change. Presented at Methamphetamine Use and Gay Men Meeting. Sacramento, CA. April 24, 2003. 16. Romanelli F, Smith KS, Pomeroy C. Use of club drugs by HIV-seropositive and HIV-seronegative gay and bisexual men. Topics in HIV Medicine. 2003;11:25-32.
Other internet resources:
www.tweaker.org www.crystalrecovery.com www.freevibe.com www.crystalneon.org
Prepared by Mike Pendo*, Pamela DeCarlo** *San Francisco Department of Public health, **CAPSJuly 2004. Fact Sheet #55E Special thanks to the following reviewers of this Fact Sheet: Michael Thomas Angelo, Grant Colfax, Viva Delgado, Paul Galatowitsch, Rob Guzman, Perry Halkitis, Manuel Laureano-Vega, Gary Leigh, Phil Reichert, Frank Romanelli, Mike Siever, Steve Shoptaw, Steven Tierney, Dan Wohlfeiler. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2004, University of CA.
Prevention in health care settings
How can HIV prevention be integrated into health care settings?
Prepared by Carol Dawson-Rose RN PhD, Janet Myers PhD MPH, and Karen McCready MA; CAPS Fact Sheet 68, July 2010
Why is HIV prevention important in health care settings?
HIV prevention is an important part of health care for all individuals. It is particularly key for those at risk of becoming infected, as well as for those who are already infected, who can then avoid transmitting HIV to others and stay healthy themselves. Many strategies can be used in health care settings to optimize HIV prevention, including: assessing HIV risk; enhancing access to HIV testing; providing HIV-infected patients with disclosure and partner services; screening and treating patients for problem drinking, drug use and sexually transmitted infections (STIs); and providing the best possible care to HIV-infected individuals including access to anti-retroviral therapy (ARVs) and adherence counseling.
Do health care settings have a role in finding new infections?
Health care settings are important sites for providing access to HIV testing and prevention messages, for finding new infections and for linking infected individuals into HIV care. In 2006, the CDC issued guidelines for primary health care providers suggesting expanded access to HIV testing for all patients 13 to 64 years old.1 Providing HIV testing as a routine part of care has been most productive in emergency room and labor and delivery settings,2,3 although community health centers have also provided important new access.4 Testing programs have also proven effective in helping pregnant women to not transmit HIV to their babies.3 One key strategy for expanding testing is rapid test technology.5 Rapid tests allow providers to perform a test and deliver the results in under an hour, although a confirmatory test is required for positive rapid test results. Appropriate follow-up care can be planned before the patient leaves the health care facility. Especially when HIV testing is newly introduced, providers in health care settings need to learn how to integrate HIV testing into regular care, and to refer patients for additional support services if needed. Providers should also be trained in documenting test results to ensure they are shared with other health care providers and to maintain the confidentiality of client information. Providers must ensure that HIV-infected persons get the care and support they need. Linkage to care is an important and often overlooked piece of integrating HIV testing into health care. Individuals who are just finding out they are infected often need a great deal of help and support to find an HIV provider, to make an appointment and to show up at that appointment. Intensive case management models show promise in enhancing linkages to care for newly-diagnosed individuals.6
What other HIV prevention strategies work in health care settings?
Risk assessment. Assessing HIV risk behaviors should be a standard part of new patient intake, regardless of HIV status. In-depth HIV prevention education is not necessary for every patient. However, health care providers should ask all patients about their sexual behavior, condom use, number of sexual partners, and alcohol and illicit drug use to assess a patient’s risk for acquiring or transmitting HIV. These quick questions may lead to longer discussions and counseling about safer sex or alcohol and drug use practices.7 Drug treatment. Helping patients get into alcohol or drug treatment can be an effective HIV prevention tool and can help HIV-infected persons stay healthy. Health care providers can have a profound effect on patients’ lives by showing an interest in drug-using patients and encouraging willing patients to enter drug or alcohol treatment programs. Because relapse is common in treating addictions, health care providers should use a non-judgmental approach. Screening and treating for STIs. Providers should encourage screening for STIs. They should also provide STI education, emphasize the link between HIV and STIs, and encourage screening for partners.9
How does positive prevention work in health care settings?
Prevention counseling. Brief prevention counseling delivered in health care settings at every visit has been shown to decrease the likelihood that HIV-infected individuals transmit HIV to others, particularly if interventions are tailored to sub-populations of HIV-infected patients.10 Important messages include: helping people understand the relative risks of their actions and the effectiveness of different prevention strategies such as using condoms; disclosing HIV status to sex and drug using partners; and understanding their responsibility with regard to prevention. Formal provider training is important to facilitate these approaches.11,12 Viral suppression. A unique component that health care settings play in HIV prevention is helping HIV-infected persons find and adhere to an effective ARV regimen to help keep their viral load low. Some research has demonstrated that keeping the viral load below a threshold that is detectable with lab tests can help prevent up to 60% of new STIs.13 New research suggests that effective detection of HIV and treatment to reduce the viral load could reduce the overall community viral load and have a population-level impact on HIV transmission.14
How can HIV prevention capacity be increased in health care settings?
Risk assessment. Knowing how to assess risk among patients is key to HIV prevention of any kind. Having risk assessment tools and training providers to use them is critical. Written protocols. It is important to make sure that procedures are in place to guide testing efforts in health care settings.15 Having a “prevention plan” tailored to the clinic size, the service delivery model, the types of providers and the patient population is critical. Leadership. Successful clinic programs often have identified staff leaders who function as counselors or team leaders for positive prevention.16 Training. Underlying all of these important components is training. Training can facilitate buy-in from clinic providers and can address provider attitudes and beliefs about risk reduction and counseling.17 Training should outline staff responsibilities and anticipate changes to clinic flow.16
What are effective models for use in health care settings?
Positive STEPs17 is a training intervention to help HIV care providers deliver prevention counseling to their patients. The model was effective in improving provider attitudes, comfort, self-efficacy and frequency of delivering prevention counseling. Partnership for Health18 is an EBI (CDC’s Effective Behavioral Intervention) for providers in HIV clinics. Medical providers are trained to deliver brief risk-reduction counseling to their patients. All clinic staff are trained to integrate prevention messages into the clinic setting, and counseling is supplemented with written information for all patients. The intervention was effective in reducing unprotected intercourse by 38% among patients who had two or more sexual partners. Positive Choice19 is an interactive “Video Doctor.” Patients at HIV clinics completed an in-depth computerized risk assessment and received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed educational worksheet. Providers received a Cueing Sheet on reported risks for discussion during the clinical encounter. Provider-Delivered Counseling.10,16 In a large federal demonstration project, brief counseling messages delivered by primary care providers in clinic settings were most effective in reducing risk among HIV-infected patients, although there were also benefits in programs delivered by prevention specialists and HIV-infected peers.
What needs to be done?
Health care providers need more and repeated training on how HIV prevention can be integrated into the care they deliver. There are still significant misperceptions among health care providers about who should be tested for HIV and when to implement rapid testing. Provider attitudes, beliefs and self-efficacy can affect whether or not they address prevention through HIV testing or by providing risk-reduction counseling. Methods that enhance provider uptake of HIV prevention in health care delivery settings need attention and further research. Leaders in health care settings can establish written protocols that guide HIV prevention practices, including HIV testing in their clinics. Establishing protocols, documentation and quality assurance practices can enhance testing and prevention practices in all types of health care settings.
Says who?
1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.Morbidity and Mortality Weekly Report. 2006;55:1-17. 2. Haukoos JS, Hopkins E, Byyny RL, et al. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Annals of Emergency Medicine. 2008;51:303-309. 3. Tepper NK, Farr SL, Danner SP, et al. Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study. American Journal of Obstetrics and Gynecology. 2009;201:31-36. 4. Myers JJ, Modica C, Bernstein C, Kang M, McNamara K. Routine rapid HIV screening in six Community Health Centers serving populations at risk. Journal of General Internal Medicine. 2009;24:1269–1274. 5. Branson BM. State of the art for diagnosis of HIV infection. Clinical Infectious Diseases. 2007;15:S221-225. 6. Christopoulos K, Koester K, Weiser S, et al. A comparative evaluation of the development and implementation of three emergency department HIV testing programs (forthcoming) 7. Schechtel J, Coates T, Mayer K, et al. HIV risk assessment: physician and patient communication. Journal of General Internal Med. 1997;12:722-723. 8. Bruce RD. Methadone as HIV prevention: High volume methadone sites to decrease HIV incidence rates in resource limited settings. International Journal of Drug Policy. 2010;21:122-124. 9. McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. Journal of Antimicrobial Chemotherapy. 2006;57:163-166. 10. Myers JJ, Shade S, Dawson Rose C, et al. Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV. AIDS and Behavior. 2010;14:483-492. 11. Gilliam PP, Straub DM. Prevention with positives: A review of published research, 1998-2008. Journal of the Association of Nurses in AIDS Care. 2009;20:92-109. 12. Harder & Co. Community Research. Prevention with positives: Best practices Guide. Prevention with Positives Workgroup. 2009. 13. Porco TC, Martin JN, Page-Shafer KA, et al. Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS. 2004;18:81-88. 14. Das M, Chu PL, Santos G-M, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE. 2010;5:e11068. 15. Myers JJ, Steward, WT, Koester KA, et al. Written procedures enhance delivery of HIV “prevention with positives” counseling in primary health care settings. Journal of AIDS. 2004;37:S95-S100. 16. Koester KA, Maiorana A, Vernon K, et al. Implementation of HIV prevention interventions with people living with HIV/AIDS in clinical settings: Challenges and lessons learned. AIDS and Behavior. 2007;1:S17-S29. 17. Thrun M, Cook PF, Bradley-Springer LA, et al. Improved prevention counseling by HIV care providers in a multisite, clinic-based intervention: Positive STEPs. AIDS Education and Prevention. 2009;21:55-66. 18. Richardson J, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: A multi-clinic assessment. AIDS. 2004;18:1179-1186. 19. Gilbert P, Ciccarone D, Gansky SA, et al. Interactive “Video Doctor” counseling reduces drug and sexual risk behaviors among HIV+ patients in diverse outpatient settings. PLoS One. 2008;3.
Special thanks to the following reviewers of this Fact Sheet: Lucy Bradley-Springer, Kimberly Carbaugh, Mark Cichocki, Renata Dennis, Josh Ferrer, Mark Molnar, Quentin O’Brien, Jim Sacco. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©July 2010, University of CA. Comments and questions about this Fact Sheet may be e-mailed to [email protected].
Structural interventions
What is the role of structural interventions in HIV prevention?
What are structural interventions?
Most HIV prevention interventions deal with individuals, one by one. Many of these interventions have been very successful. However, they often require a lot of staff time and reach a limited number of persons. Furthermore, those who do receive interventions may face pressures to continue high-risk behaviors from their peers who do not receive the intervention. Structural interventions change or influence social, political, or economic environments in ways that help many people all at onceperhaps without their even knowing it.1 The term “structural interventions” means many things. Structural interventions include programs that change legal environments (often with community pressure or input) to make safer behavior easier, such as allowing syringes to be sold over the counter. They can also target the immediate social context of sexual or injection behaviors by changing the physical or normative environments within which they occur. Examples include Thai brothels that require condom use or European public health safer injection rooms. Structural interventions also include programs to reduce or abolish income inequality, racism, and other inequities and oppressions which create vulnerability to HIV/AIDS.
What structures create risk?
How can we know what social, political or economic structures or processes need changing? Generally, we learn this by studying naturally-occurring variation among areas or groups, or naturally-occurring experiments in which conditions change for reasons other than HIV-related interventions. Studies of naturally-occurring variation have shown that: 1) poor countries are more likely to have generalized HIV epidemics; 2) countries with more income inequality have higher HIV rates; 3) policies matter: localities where syringes can be bought legally have lower rates of HIV prevalence and incidence among injection drug users (IDUs).2 Studies of natural experiments indicate that: 1) otherwise-positive social and political transitions like the end of apartheid in South Africa in the 1990s, the break-up of the Soviet Union in the 1990s, and the ending of the dictatorship in Indonesia in the late 1990s were followed by large HIV outbreaks; 2) wars cause the spread of HIV, STDs, prostitution, rape, sexual bondage and high-risk substance use and lead to increased numbers of sexual partners and rates of sexual partner change.3
Why structural interventions?
Structural interventions often address issues that seem to be unrelated to HIV. When people think about preventing HIV, they don’t normally consider eliminating income inequalities or stopping war. But these social, political and economic realities greatly influence high-risk behaviors. Issues that are not directly related to HIV often create conditions that encourage the spread of HIV, making structural interventions necessary. For example, the New York City government closed fire stations in poor minority sections of the city in the 1970s. As a result, uncontrolled fires destroyed many buildings. The social lives of building residents were severely traumatized. Great overcrowding took place in surrounding poor minority areas. Injection drug use (and later crack), alcoholism, sex trading, gangs and demoralization spread widelyfollowed later by outbreaks of STDs, HIV, tuberculosis and many other ills.4 The governments of wealthy countries, including the USA, as well as banks, corporations and other economic elites have aggressively pursued an organized global policy of social welfare cutbacks, privatization and competition. This has led many developing countries into massive debt, and increased income inequality and the growth of massive cities based around giant slums. Also, International Monetary Fund-imposed “structural adjustment programs” have forced large-scale cuts in health and education services in many African, Asian and Latin American countries. These policies and progams have greatly hampered these countries from providing effective prevention interventions and/or antiretroviral therapy or other medical care for their infected populations.5,6
Examples of structural interventions
In many countries, sex workers have high rates of HIV and other STDs. Thailand and the Dominican Republic have instituted “100% condom” campaigns mandating that brothel owners enforce the use of condoms during all sex acts. These campaigns enlist the support of brothel owners and sex workers and, when possible, their customers. These programs have reduced HIV and STD transmission considerably by changing the immediate social context of sexual behaviors to reduce unprotected sex.7,8 Most US states have laws that make it a crime to possess or distribute needles and many have laws that require a prescription to buy a needle and syringe. Consequently, IDUs often do not carry syringes for fear of police harassment or arrest. To address this on a legal level, the Connecticut legislature passed a partial repeal of needle prescription and drug paraphernalia laws. This resulted in dramatic reductions in needle sharing, and increases in pharmacy purchase of syringes by IDUs. Sharing dropped from 52% to 31% after the new laws, pharmacy purchase rose from 19% to 78%, and street purchase fell from 74% to 28%.9
How can we impact harmful policies?
It is not easy to avoid or end wars, urban development policies that hurt the poor and minorities and repressive sexual and drug policies that create underground environments. However, individuals and communities can make a difference. Grassroots or community-based movements are often a necessary step to larger structural interventions. The formation of such movements can sometimes be a structural intervention if this leads to changes in power relationships or group norms. “Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, offered workshops on community organizing and mobilization techniques. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.10 Community organizations and individuals began operating needle exchange programs (NEPs) in many states with high rates of HIV among IDUs. The NEPs were often illegal and unsupported. The people working at NEPs and other politically active groups worked with public officials to invoke “state of emergency” policies to allow NEPs to exist legally in many states.11 Calcutta sex workers were aided by public health authorities to organize a community union that has enabled them to insist upon condom use. HIV prevalence among Calcutta sex workers has remained lower than in other Indian cities.12
What still needs to be done?
The relationship between structural factors such as economic, political and social marginalization and behaviors that place persons at risk for contracting or spreading HIV/AIDS and STDs cannot be ignored.13,14 Nor can high-risk behaviors be seen as operating outside of social, political and economic contexts. A more focused discussion of these issues is sorely needed in HIV/AIDS circles. One way to reduce the likelihood of negative repurcussions when structural factors change, is to legally mandate that economic, urban development and foreign policy programs conduct scientific “HIV/AIDS impact statements.” A first step might be for HIV prevention agencies to produce and publicize such HIV/AIDS impact statements themselves.15 Funders need to take into account the broad range of activities that constitute HIV prevention. Many community-based organizations find themselves responding to all issues affecting HIV, including ones that may seem unrelated. Addressing these larger issues of war, poverty, restrictive laws and social inequalities such as racism and homophobia is a part of what many agencies do on a daily basis. Helping organize and support these efforts may lead to needed structural HIV prevention interventions.
Says who?
1. Friedman SR, O’Reilly K. Sociocultural interventions at the community level.AIDS. 1997; 11:S201-S208. 2. Friedman SR, Perlis T, Lynch J, et al. Economic inequality, poverty, and laws against syringe access as predictors of metropolitan area rates of drug injection and HIV infection. 2000 Global Research Network Meeting on HIV Prevention in Drug-Using Populations. Third Annual Meeting Report. Durban, South Africa, July 5 -7, 2000. 147-149. 3. Hankins CA, Friedman SR, Zafar T, et al. Transmission and prevention of HIV and STD in war settings: implications for current and future armed conflicts.AIDS. 2002:16(17):2245-52. 4. Wallace R. Urban desertification, public health and public order: ‘planned shrinkage’, violent death, substance abuse and AIDS in the Bronx. Social Science and Medicine. 1990;31:801-813. 5. Lurie P, Hintzen P, Lowe RA. Socioeconomic obstacles to HIV prevention and treatment in developing countries: the roles of the International Monetary Fund and the World Bank. AIDS. 1995;9:539-546. 6. Farmer P. Infections and Inequalities: the Modern Plagues. University ofCalifornia Press: Los Angeles. 1999. 7. Celentano DD, Nelson KE, Lyles CM, et al. Decreasing incidence of HIV and sexually transmitted diseases in young Thai men: evidence for success of the HIV/AIDS control and prevention program. AIDS. 1998;12:F29-F36. 8. Roca E, Ashburn K, Moreno L, et al. Assessing the impact of environmental-structural interventions. Presented at the International AIDS Conference,Barcelona, Spain. 2002. Abst #TuPeC4831. 9. 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. 10. The STOP AIDS Project. Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790 x303 11. Gostin LO. The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health. Journal of Acquired Immune Deficiency Syndromes. 1998;18:S60-70. 12. Piot P, Coll Seck AM. International response to the HIV/AIDS epidemic: planning for success. Bulletin of the World Health Organization. 2001;79:1106-1112. 13. Diaz RM, Ayala G, Marin BV. Latino gay men and HIV: risk behavior as a sign of oppression. Focus. 2000;15:1-5. 14. Friedman SR, Aral S. Social networks, risk potential networks, health and disease. Journal of Urban Health. 2001;78:411-418. 15. Friedman SR, Reid G. The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy. (in press).
Prepared by Sam Friedman*, Kelly Knight** *National Development and Research Institutes, ** CAPS January 2003. Fact Sheet #46E Special thanks to the following reviewers of this Fact Sheet: Abu Abdul-Quader, Sevgi Aral, Judith Auerbach, Kim Blankenship, John Encandela, Mindy Fullilove, Carl Latkin, Peter Lurie.
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]. © January 2003, University of California