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Young injection drug users (IDU) are at high risk for viral infections, such as HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV), due to frequent injecting, needle/syringe and other drug preparation equipment sharing, high numbers of sexual partners, and exchange of sex for money or drugs. Street youth who inject have high unemployment, poor education, and mental health issues. In San Francisco, young IDU are typically homeless runaways who often are involved in an illegal street economy, including prostitution, drug sales, theft, panhandling, pornography and selling stolen property. They experience a large number of negative and traumatic events prior to leaving home. Many fear and mistrust authority and consequently avoid or delay contact with the public health system. The combination of youth, drugs, survival sex and disenfranchisement make this group extremely vulnerable to multiple negative health outcomes.

Substance use among youth and young adults continues to pose a variety of public health challenges. Young people who use opiates (heroin) and methamphetamine are more likely to have high risk sexual and injection practices, as well as more likely to be HIV+. Drug use among youth may be associated with a variety of problems including family trauma, academic difficulties, mental and physical health problems, sexual abuse, incarceration, poor peer relationships and violence. Youth in Northern California who are at risk for drug use, HIV and related health problems need to be better understood and targeted for prevention programs.

Correctional facilities concentrate populations that are at risk for HIV infection: persons of color, persons with substance abuse histories, and persons living in poverty.1,2 As a result, the prevalence of HIV among US incarcerated populations is five to seven times that of the general US population.3,4 Furthermore, about 25% of people living with HIV in the US have been incarcerated.5 These statistics support the need for access to effective means of HIV prevention and harm reduction strategies in correctional facilities. Condoms are highly effective at preventing the transmission of HIV.6 Despite the fact that there is a growing consensus that in-custody HIV transmission is not trivial,7 condoms are made available to only a minute fraction of the US prisoner population. The manner in which condoms are currently made available to prisoners in California varies widely. In the Los Angeles County Jail, the Center for Health Justice distributes condoms to a segregated gay male population only, one condom per week by request. In San Francisco, prior to this project, condoms were distributed by request through the Forensic AIDS Project’s public health staff in one-on-one health counseling sessions, one per person, per request.

CAPS and Centerforce, a community-based organization that has been providing services to prisoners and their families for thirty years, have been collaborating since 1993 to design and evaluate HIV prevention interventions for incarcerated men and their female partners. Our previous work with male prisoners includes the evaluation of a peer-led HIV education orientation for arriving prisoners; development and evaluation of a prerelease intervention for men leaving prison; development and evaluation of a health promotion intervention for HIV+ prisoners preparing for release;3 and a multi-site study to conduct formative research and develop and test an HIV, STD and hepatitis intervention for young men preparing for release from prison. Early in the course of these studies, men expressed a need for HIV prevention interventions specifically tailored for the needs of the women with whom they were in romantic and sexual relationships. In response, we conducted formative research with women visiting men imprisoned in a California state prison and we piloted a single session intervention designed for this population that was taught by a peer educator. Our formative work with women visiting incarcerated men indicated that it was feasible to engage women in intervention and research evaluation activities. However, a single-session intervention did not have a measurable effect on the HIV risk behavior of study participants. We decided to develop a multi-component intervention targeting the specific needs of women with incarcerated male partners. We designed and evaluated Health Options Mean Empowerment (HOME), an intervention to reduce HIV risk among women whose male partner was being released from state prison.

HIV+ persons confront a unique set of challenges and chronic stressors, including stigmatization, alienation from family and friends, complex treatment regimens, and, often, debilitating side effects as they attempt to manage the psychologic and physiological consequences of their condition. For persons living with HIV, elevated distress and low social support take on added importance because they can accelerate disease progression. Helping HIV+ people to reduce stress and adhere to their medical care may in turn help to reduce their risky behavior. The ability to cope successfully with a chronic illness such as HIV disease is influenced by a number of social and psychological factors. Stress and coping theory provides a framework for studying these factors and for intervention. Coping research draws attention to the co-occurrence of positive and negative psychological states and recognizes the importance of encouraging coping processes that help to sustain positive psychological states in the context of stress. We evaluated a coping intervention, Coping Effectiveness Training (CET), designed to assist HIV+ gay men in sustaining psychological health despite the ongoing stress associated with HIV infection. The study was a randomized clinical trial of an innovative, theory-based coping intervention. The research questions addressed the problems of maintaining intervention effects, evaluating intervention effects on quality of life, health care utilization and adherence to medical care, and testing new advances in stress and coping theory.