Preventing HIV Among Drug Injectors: A Summary of the Past Eighteen Years of NIDA-Supported Interventions in Denver

1. Preventing HIV Among Drug Injectors: A Summary of the Past Eighteen Years of NIDA-Supported Interventions in Denver Robert E. Booth, Ph.D. University of Colorado School of Medicine Division of Substance Dependency

2. Project Safe • 1987-1990 Demonstration Project: • Can street outreach & intervention be done? • 1990-1995 Cooperative Agreement: • Is the intervention effective? • 1995-2000 Treatment Inducement: • Can further gains be achieved? • 2000-2005 Further Treatment Inducement: • Can improvements be made?

3. The Indigenous Leader Outreach Model (ILOM) • Goal: To reduce the spread of HIV among injection drug users and their sex partners. • Primary objectives: • gain access to target group members • increase HIV awareness • help clients assess their personal risk and provide alternatives to high risk behavior • reinforce behavior change • encourage prevention advocacy

4. Street Outreach Methods • Targeted sampling is used in which the number of drug users in each census tract is estimated based upon drug indicators (e.g., drug-related arrests) • Outreach is conducted on foot, at tables, from cars, on bikes, and in bars • Time of day and type of outreach varies depending on the area being targeted • Posted flyers and paid gatekeepers are also used

5. Street Outreach Approach • Free condoms are offered as an ice breaker • If condoms are accepted, a flyer describing the project is offered and a brief description is given. Different flyers are designed to appeal to different people, including the general population, users and friends of users • Clients interested in participating in the study are informed of the eligibility requirements and scheduled for an interview appointment

6. 1987-1990 Demonstration Project:Can street outreach/intervention be done? • Myths about drug addicts: • You can’t find them • They won’t tell the truth • You can’t keep track of them for follow-up interviews • They won’t change their behavior

7. Risk behavior change according to site Booth RE & Wiebel W, Am. J. Add. 1992;1:277-287.

8. 1987-1990 Demonstration Project Conclusions- Can street outreach/intervention be done? • We can locate out of treatment IDUs • They will tell us about highly personal and illegal behavior they engage in • We can keep track of them over time • They will change their behavior -at least when the intervention is implemented as designed • Further gains in behavior change are possible with sustained intervention

9. 1990-1995 Cooperative Agreement: Is the intervention effective? • Yes, but many injectors continued to engage in risky behaviors • Additional strategies were required to further reduce HIV-related risk behaviors.

10. Objective: To compare the effects of various interventions on reduced drug use and criminal behavior • Including: • Street outreach intervention • HIV testing and counseling • Enhanced intervention (outreach intervention and HIV testing) • Drug treatment Booth RE, Crowley TJ, Zhang Y, Drug Alc Dep. 1996;42:11-20.

11. Which strategy works best? • On every variable assessed, including self-reported frequency of heroin, cocaine and speedball injection, crack smoking, and urine results for opiates and cocaine, individuals who entered treatment had 2.5-3.0 times the reduction in drug use as those who did not enter. No other intervention strategy was nearly as effective.

12. The effect of treatment on injections

13. The effect of treatment on heroin use

14. What predicts treatment entry?

15. 1995-2000 Treatment inducement:Can further gains be achieved? • Can we increase the percentage of street-recruited injectors who enter treatment? • What predicts who will enter treatment? • Does treatment reduce HIV risk behaviors?

16. Intervention Strategies • Risk Reduction stresses safer drug use in order to reduce HIV risk behaviors. • Motivational Interviewing, based on the Stages of Change model, stresses an increased commitment to lifestyle changes leading to drug abstinence.

17. Getting injectors to enter treatment: Greasing the skids • Steps to facilitate treatment entry • contact through street outreach • schedule the treatment intake appointment • provide rapid intake • provide transportation to intake appointment • wave the treatment intake fee • offer free treatment (50%)

18. Treatment Entry by Assignment

19. Treatment Retention (90 Days) by Assignment (for All Subjects)

20. Predictors of Treatment Entry

21. Does treatment reduce HIV risk behaviors? Booth RE & Kwiatkowski CF, HIV Prevention Research Conference, Flagstaff, Aug, 1997.

22. 2000-2005 Further Treatment Inducement:Can Improvements be Made? • Enhancements to intervention efforts • Stage-based Motivational Interviewing where the length of the intervention is based on the individual’s readiness to change behaviors • Strength-based Case Management emphasizing individual empowerment in developing skills to quit drug use

23. Treatment Entry p <.05

24. Treatment Retention p <.10

25. Injection Frequency

26. Number of Needle-Related Risk Behaviors (0-5)

27. Summary: the last eighteen years • Street outreach/intervention can be done • drug injectors can be found and followed-up and they will reduce their risk behaviors • Outreach intervention is effective • but education is not enough, treatment facilitation is also needed • Further gains can be achieved • free treatment, stage of change, case management predict treatment entry, which leads to reduced risk