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Strategies for Reducing Blood Borne Infections Among Injection-Drug Users Back to Course Index

 

                                     

STRATEGIES FOR REDUCING BLOOD BORNE INFECTIONS AMONG INJECTION-DRUG USERS

 

 syringe

 

                                               

INTRODUCTION

 

Most of the material presented in this continuing education course was selected from the Center of Disease Control website www.cdc.gov/idu/pubs.  Some of the material was used almost verbatim, whereas other parts were edited for applicability to this course.  Additional information was added to some sections to augment the information presented in the CDC website.

 

GENERAL INFORMATION

 

Injection-drug use over a long period can cause profound changes in brain structure and chemistry and result in uncontrollable compulsive drug craving, seeking and use.  Frequently, when an individual is experiencing strong cravings they have a tendency to let their guard down and get involved in high risk activities such as sharing of drug related paraphernalia, sex with multiple partners, criminal activity and other anti-social behaviors.  It follows that injecting-drug use is a risk factor for acquired immunodeficiency syndrome (AIDS), as well as for hepatitis.  As a matter of note, research data from 1994 through 2000 indicates that approximately twenty-five percent of new AIDS cases occurred among injecting drug users.  IDUs become infected with human immunodeficiency virus (HIV) through sharing injecting drug equipment with HIV-infected persons or by engaging in other risk behaviors such as having unprotected sex.

 

Because IDUs and their sex partners represent approximately one third of persons infected in the HIV epidemic and continue to be at risk for transmitting of HIV, prevention efforts targeting IDUs and their sex partner should be enhanced.  This story is similar for hepatitis; however, it is less publicized due to the time (sometimes up to 20 years) from exposure to the hepatitis virus to diagnosis of the disease.  Oftentimes a hepatitis-infected person is diagnosed and treated as a flu patient and not as a hepatitis patient.  Consequently, some of the hepatitis cases progress to severe liver disease before a proper diagnosis is made.

 

 Many individuals, including IDUs themselves, have a mistaken belief about drug addiction and recovery from addiction.  Two of the most pervasive myths are that a person can get off drugs alone and that most addicts can become permanently drug-free.   These ideas stem in part form notions that continued drug use is voluntary and that a persons inability to overcome addiction stems solely from character flaws or a lack of willpower.

 

The highly addictive nature of cocaine and other injectable drugs and the difficulties associated with stopping use are understood and generally accepted in the treatment community.  Quitting often requires repeated attempts and the help of substance abuse professionals as well as therapeutic aids such as anti-depressants and the administration of other similar, less potent drugs.  Only a small percentage of those who try to quit on their own each year succeed.  The potential for relapse after treatment for drug addiction is generally recognized and accepted; however, societal reactions when a person relapses to injection drug use are usually highly negative.

 

REDUCING BLOOD BORNE PATHOGEN INFECTION BETWEEN INJECTING DRUG-USERS

 

Currently, there are several strategies for preventing (or reducing) the spread of blood-borne pathogen infections between Injecting-Drug Users (IDUs).  The following sections describe some of the major interventions; provides findings from research as to the effectiveness (relative to reducing cross-infection) of the interventions; and describes some of the barriers facing providers and agencies chartered with the responsibility for implementation of the various interventions.

 

SUBSTANCE ABUSE TREATMENT

 

The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) by the American Psychiatric Association states that drug addiction is a complex and chronic illness that is characterized by compulsive, uncontrollable drug craving, seeking, and use, even in the face of enormous negative consequences.  The good news is that drug addiction is treatable through substance abuse treatment and other interventions.

Analysis of outcomes data proves that Substance abuse treatment is a powerful disease prevention strategy for IDUs.  Drug injectors who are not in substance abuse treatment are approximately six times more likely to become infected with HIV or hepatitis than are IDUs who enter and remain in treatment (NIDA, 1999).   They are also broader social benefits associated with substance abuse treatment as it can lead to reduce health care costs, reduced drug-related crime and associated criminal justice costs, reduced interpersonal conflicts and drug-related injuries, and improved workplace productivity.  Also, one of the major improvements is in family relationships with an attendant reduction in spouse and family abuse and neglect.  Its not unusual for families with an addicted individual to move from crisis-to-crises and completely ignore other basics family issues.  I think the least desirable characteristic of an addicted individual is that they are often self-centered and have a tendency to elevate the needs to supply their habit above any and all other considerations even including their own health.  This leads many IDUs to go through very pronounced blame and shame cycles as they recognize and reflect on the damage they are causing to themselves and others.

 

A focus item during substance abuse treatment is education to help the IDUs to better understand the risks associated with drug use.  Specifically, the health risk associated with sharing of syringes (and other drug related equipment) with others who may be infected with either HIV or hepatitis or both.  Another objective of treatment is to help users reduce the frequency of use (injections) and thereby lower the risk of infection.  The aforementioned risks are primarily associated with unsafe injection practices such as multi-person use of syringes or sharing of other drug injection equipment or the engagement in unsafe sex practices.  The premise is   increased knowledge regarding drugs and the consequences of their use will lead to reduced use with corresponding less exposure to infections.  The ultimate goal of treatment is total abstinence that would essentially eliminate the risk of cross-infection.  Total abstinence is desired because one of the major characteristics of drug use is that it impedes rational decision-making that in turn, can lead to high-risk behaviors.

 

In general substance abuse treatment provides the medical, psychological and behavioral support essential for individuals to obtain and sustain abstinence.  Extended substance abuse treatment enables the users chemical composition to return to pre-addiction functioning.  It must be remembered that addiction is a disease of the brain and that long-term use results in an altered chemical state of the brain.  Consequently, when an addicted individual stops using, the brain continues to want (crave) the substance and the vicious addiction cycle continues.  Some individuals explain their craving, as being like a weight that they must hold above their head.  The task is easy in the beginning but increases with time and does not completely goes away.  When one understands the process of addiction and the physical changes (primarily in the brain) it is easier to understand the concept of craving and compulsive use.  The level and severity of addiction is unique to the individual.  It follows that a successful treatment program can have a major impact on many areas of a persons life, helping him or her to improve family life, employment, health, and decrease involvement with crime.

 

Treatment services are generally divided into the followings programs:

Detoxification:  Detoxification is the first step in treatment for drug abuse.  It refers to the detoxifying of the residual toxins in the body as a result of talking drug(s).  Drug detoxification from a medical prospective, is the process of medically managing the body’s withdrawal from drug (s) to minimize the possible side effects and prevent potentially harmful consequences. 

 

Inpatient:  Medically managed inpatient treatment is an organized service, staffed by designated addiction physicians or addiction credentialed clinicians.  It involves a planned regimen of 24-hour medically directed evaluation, care and treatment of substance-related disorders in an inpatient setting.  Such a service functions under a defined set of policies and procedures and has permanent facilities that include hospital beds.  It requires an interdisciplinary staff to care for patients whose acute biomedical, emotional and behavioral problems are severe enough to require primary medical and nursing services.  Treatment is provided 24 hours a day, and the full resources of a general care hospital or psychiatric hospital are available.  This treatment is specific to substance dependence disorders; however, the skills of the interdisciplinary team and the availability of support services allow the conjoint treatment of any coexisting biomedical and emotional/behavioral conditions that need to be addressed and that could jeopardize recovery.

 

Outpatient:  Outpatient treatment encompasses organized services, which may be delivered in a wide variety of settings.  Addiction treatment personnel or addiction-credentialed clinicians provide professionally directed evaluation, treatment and recovery services to persons with substance related disorders.  Such services are provided in regularly scheduled sessions of usually fewer than 9 hours per week.  These services function under a defined set of policies and procedures.   Outpatient services are designed to treat the individuals level of illness, severity and to achieve permanent changes in an individuals drug use.  To accomplish this, the service must address major lifestyle, attitudinal and behavioral issues that have the potential to undermine the goals of treatment or to inhibit the individuals ability to cope with major life tasks without the non-medical use of other drugs.

 

Methadone maintenance (see discussion below)

 

Many patients also participate in self-help or 12-step programs, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or Cocaine Anonymous (CA).  Individuals appear to be strengthened by association with a network of peers, who are going through similar experiences, these programs can reinforce and extend more formal types of treatment services.

 

Methadone is the medication most frequently provided to IDUs in substance abuse treatment because it is the most widely available and because many IDUs inject heroin or a combination of heroin and cocaine.  Methadone reduces the craving for heroin and blocks its effects, thereby enabling addicts to reduce heroin use and live more productive lives. 

 

Studies of methadone maintenance treatment have also shown that participation in treatment is associated with lower rates of HIV and hepatitis infections.  

 

The advantages of substance abuse treatment are clear regarding the effectiveness in helping users reduce or eliminate their drug use; however, IDUs are not fully utilizing these services.  For example, data from the Substance Abuse and Mental Health Services Administrations (SAMSHA) shows that in the mid-nineties there was more than 5 million people with severe substance abuse problems that needed treatment services.  This data also reveals that less than 35% received treatment and less than 25% of opiate-dependent individuals were in methadone maintenance programs.   For those IDU’s who are in treatment, the processes and procedures associated with participation can be cumbersome.  They often encounter waiting lists, delays in admission and lengthy intake processes.  In essence, the treatment delivery system can become so complex that it inhibits the timing and application of effective treatment and tends to discourage some drug users from seeking treatment.  Also, some communities put up barriers as they strenuously resist the introduction of drug treatment facilities in their neighborhoods and this limits the availability of treatment for many IDUs.  Also, funding of substance abuse treatment is insufficient in many communities especially in communities where most of the IDUs live.

 

The effectiveness of substance abuse treatment is also linked to length of time in treatment as well as many other factors, such as goals (treatment and individual), medications prescribed, and characteristics/motivation of the user.  Limitations in any of these areas may reduce the effectiveness of treatment.  For example, adequate medication but not the behavioral counseling or the lack of psychological and social services that are necessary for full and effective treatment can significantly reduce program effectiveness.  In essence, all aspects (social, community, family, employment, health, etc.) must be taken into consideration to effectively design and administer a comprehensive treatment program. 

 

I would be remiss if I did not point out some of the barriers to treatment.  Some of the more prevalent ones are:

 

Irrational thinking:  Most addicts believe they can stop on their own; however, most of their attempts to stop using result in failure to achieve long-term abstinence;

Denial: Most addicts blame someone or something else for their addiction other than themselves.  Consequently, one of the major challenges to any treatment program is help the addicted individual to break through denial and to accept the fact that they have a problem;

Lack of funding.

 

POLICY EFFORTS TO INCREASE IDUS ACCESS TO STERILE SYRINGES

 

Most states prohibit individuals IDUs from purchasing or processing syringes whereas other states bar their sale without a valid prescription.  This environment serves to increase the risk of transmission, as IDUs who are concerned about being arrested for obtaining and carrying syringes are more likely than other IDUs to share syringes and injection supplies. 

 

Syringe laws and regulations are difficult to change as widespread negative opinions of drug users persist.  However, several states have made some progress in changing the law. For example, Connecticut partially repealed its laws and regulations that limited sales of syringes and that also made possession of syringes a crime.  They legalized the sale of up to 10 syringes without a prescription and also legalized the possession up to 10 sterile syringes.  Also, Maine changed its laws so as to allow anyone aged 18 and older to purchase any quantity of syringes.  Maine also adopted rules to permit legal syringes exchange (turn in a used syringe and it is replaced with a new syringe) and to remove the criminal penalties for possessing 10 or fewer syringes.  Other states have tried other approaches.  For example, some state legislatures have given health departments the authority to establish syringes exchange programs (SEPs) and to exempt them from drug paraphernalia and syringe prescription statutes. 

 

Results from states that have changed their laws have been positive.  For example, In Connecticut:

Over 80% of pharmacies began to sale nonprescription syringes

Fewer IDUs bought syringes on the street

Syringe sharing decreases

Fewer needle stick injuries occurred

Other states have reported similar results as those documented in Connecticut.

 

SYRINGE EXCHANGE PROGRAMS (SEP)

 

SEP’s are an important strategy for increasing IDUs access to sterile syringes.  The SEP’s allow IDUs to exchange used syringes for new ones at no cost and no accountability requirements.  The SEP’s also help reduce the overall spread of blood-borne infections by helping remove contaminated syringes from circulation and allow for safe disposal of ones that may have been contaminated with HIV or hepatitis.

 

Drug uses are generally positive toward SEP’s as they receive free syringes.  The SEP’s also have an added benefit in that additional services may be offered to the addict.  These services may include HIV/AIDS education and counseling, condom distribution, medical services, referrals to substance abuse treatment programs, screening for tuberculosis; screening for hepatitis type B and type C and other infections.

 

SEP’s are controversial; consequently, a large amount of research has been conducted as to their effectiveness as well as the negative consequences of the programs.  For example, many view these programs as an indication of permissiveness toward drug use.  In any case, the research data show that SEPs have a positive impact on preventing negative health consequences associated with injection drug use and that SEPs do not significantly increase drug use or promote the initiation of injection drug use.

 

Despite their success, syringe exchange programs face strong legal and regulatory restrictions as well as community opposition (in some locations).  Some objections are based on the belief that SEPs will increase drug use and attract new individuals to drug use due to increased availability and societal permissiveness.  Other objections are related to community safety in that they think the SEPs will foster an increase in illicit drug activity in the area and result in people discarding contaminated syringes in the community.  Research indicated these concerns are unlikely to occur.

 

PHARMACY PATICIPATION

 

Helping professionals recommend if an IDU is unable or unwilling to stop injecting they should consistently use sterile syringes to prevent transmission of blood-borne infections.  This health consideration provides a viable medical foundation for the sale of syringes to IDUs; consequently, if the ultimate decision is to authorize the sale of syringes to IDUs then pharmacies can play a key role in distribution of syringes as they are a primary source and often have extended hours of operation (generally open 24 hours per day).  Another positive consideration is that the pharmacies are staffed by trained, licensed professionals who are able to provide medical advice and to make referrals for related services (substance abuse treatment, health care, HIV testing and counseling and other similar items).  The pharmacies also present a non-threatening environment for IDUs to make their purchase with some degree of anonymity.  Also, some pharmacies accept used syringes and dispose of them safely.

 

Some states are working with pharmacies in an effort to repeal restrictive laws that limit sales of syringes.  For example, health departments in several states are working with pharmacy associations to reduce the barriers that inhibit the purchase of sterile syringes and to review current laws and regulations.  In one state the laws prohibiting the purchase or possession of syringes have already been partially repealed.  Results to date indicate that pharmacies can become active participants in AIDS prevention activities and health departments can develop collaborative linkages to carry out HIV prevention efforts for IDUs.

 

Even in states where it is legal to sale syringes to IDUs, pharmacy sales may be limited by store policies restricting the sale of syringes to IDUs or the personal reluctance of individual pharmacy mangers.  Another issue is that some pharmacies require purchasers to show identification, sigh a register of syringe purchases and verify the syringes sale is for a legitimate purpose.  This accountability, although necessary, reduces the IDUs willingness to buy syringes.  The pharmacy policies and attitudes are partly based on concerns that IDUs will discard contaminated syringes around their business and in the community.

 

Despite this progress, states and organizational still face significant challenges as they work to change policies related to selling syringes to IDUs.  One of the most important is attitudinal.  Pharmacists inherently distrust IDUs and drug users in general.  The pharmacist suspects them to try to use bogus prescriptions or rob the pharmacy.  They also fear an increase in sales of syringes to IDUs might attract drug users to the neighborhood and create safety and littering problems.

 

Safe disposal of used syringes is also a concern.  Community options for safe disposal are often limited and the public worries that IDUs will not discard syringes in a safe manner. 

 

CRIMINAL JUSTICE SYSTEM

 

The possession and sale of illicit drugs and syringes are illegal in most states.  Also, drug users are often involved in other criminal activity to support their drug addiction; consequently, IDUs are frequently arrested on drug related charges.  A recent study indicated that over 80 percent of state and federal inmates had used an illegal drug regularly; been incarcerated for drug selling or possession, driving under the influence or alcohol (DUI) or another alcohol abuse violation; were under the influence of alcohol or drugs when they committed the crime for which they were incarcerated; committed their offense to get money for drugs; had a history of alcohol abuse; or had some combination of these characteristics.  For IDUs, it was estimated (in 1996) that about 350,000 state prison inmates had injected drugs, including 120,000 who had shared syringes.  At the same time, approximately 14,000 federal prisoners had injected drugs, including approximately 6,000 who shared syringes.

 

Prevention services currently offered to the incarcerated populations vary widely across state, county and city jails and prisons.  Some include HIV/AIDS education and counseling, substance abuse counseling, self-help groups (12-step programs) such as AA/NA/CA while other locations offer very little or no rehabilitate support.  Also, risk reduction strategies have not been widely adopted in the U.S. correctional system.  Some institutions offer condoms while other provide HIV testing although testing polices differ widely.  A few institutions screen inmates for sexually transmitted diseases (STDs) and provide very limited viral hepatitis prevention and treatment services.  The correctional institutions that provide an integrated continuum of care for at risk and HIV-infected inmates focus on the following services:

Screening and identification of medical problems;

Substance abuse treatment; 12 step support groups

Provide medications (typically antiretroviral)

 

Metal health services

 

Continuity of care an community linkages upon release.

 

Inmate led educational and preventative interventions are important types of interventions in prisons and jails.  These programs have added credibility over programs that are led by outsiders.  These programs are successful and help inmates to develop a positive focus in their lives, retain a sense of purpose and empowerment, and realize that they are able to influence others in ways they never believed possible. 

 

Many correctional institutions in the U.S. have instituted HIV prevention strategies for IDUs; however, they are not as efficient as desired in that there is an insufficient number of peer-based providers who are willing to contribute to the programs.  This deficiency is also evident in substance abuse and mental health outreach programs. 

 

Another major inhibitor to effective treatment in the correctional system is lack of funding.  For example, HIV treatment services can be costly and the issue of the payer source has not been adequately addressed.  Inmates are legally wards of the government correctional system; consequently, health and substance abuse agencies typically do not pay for services inside prisons and jails.  The correctional systems ability to pay is limited as they operate on a limited budget and their budgets are seldom adequate when it comes to funding issues related to treating substance abuse, blood-borne disease and mental health issues.

 

Another challenge is the primary need for correctional systems to maintain security and to control inmates.  Administrators do not want to acknowledge that HIV risk behaviors are occurring in their facility.  Prisoners are also reluctant to acknowledge these behaviors for fear of reprisal.  Also, in some cases, security measures limit the effectiveness of prevention efforts.  For example, the continuity of educational programming can be disrupted due to movement of inmates.  Also, some institutions prohibit the distribution of condom that in turn prohibits a major risk reduction intervention.

 

STRATEGIES TO PREVENT STD TRANSMISSION

 

Sexual transmission of HIV, hepatitis and other sexual related infections is an important factor in the spread of these diseases among IDUs.  For example, in 1999 over 10 percent of the new AIDS cases reported were among men and women whose sex partners were IDUs.  Also, approximately 13 percent were among male IDUs who also reported having sex with other men (CDC, 1999).  High-risk sexual behavior is also strongly associated with hepatitis B transmission.  It follows that high-risk drug behavior and high-risk sexual behaviors are often linked.  For example, a large percentage of IDUs use alcohol and/or cocaine, which are often associated with increases frequencies of unsafe sexual behavior.  It is also well known that some support their drug habits by exchanging sex for money or drugs.  For these reasons, the extent to which IDUs change their sexual behaviors in responses to these diseases is critical.  This is particularly true in light of evidence showing that although IDUs will make large changes in their injection risk behavior in response to concerns about AIDS, changes in sexual behavior are generally more modest.  It appears that IDUs are more likely to change sexual risk behaviors with casual sexual partners than with their primary sexual partners.  The reluctance to use condoms with main partners may be partly due to concerns that such action violates the intimacy and trust developed in the relationship.  Intervention strategies for female drug users and sexual partners of drug users have stressed the importance of building self-esteem, social supports, and sexual negotiation skills to encourage safer sex practices with partners.

 

Skill-building interventions that target sexual risk reduction have shown greater positive affects than have interventions that try to target risk reduction in general.  Other interventions that have been effective are:

AIDS education and counseling

Employment of problem-solving therapy

Condom give away programs

 

Strategies to reduce sexual transmission should be tailored to specific high-risk groups and to specific risk-reduction goals.  These strategies should take into consideration the determinants of sexual transmission, including the use of condoms, the presence of concurrent STDs, the presence of concurrent injection drug and use and the extent of sexual activity while under the influence of the drug.  Interventions targeted for the sexual partners of IDUs are an important element of these strategies.

 

COUNSELING AND REFERRAL SERVICES

 

The composite strategy for preventing HIV and other blood-borne infections must include the following:

Capacity for an individual to determine whether they are infected or not;

If infected, help them to communicate with their partner and to undergo medical treatment;

If not infected, but admit engaging in high-risk practices the strategy to help them begin or sustain behavior changes that will reduce their risk of acquiring or transmitting the infection.

 

The following services were designed to achieve these objectives:

HIV related counseling and testing (C&T);

Partner counseling and referral services (PCRS);

Prevention case management (PCM).

 

The first step is usually counseling and testing.  The HIV test results and the individuals history of risk behaviors will guide the referral to the other services if required.  The services are client-centered and have the potential to address the complex circumstances of IDUs and influence their risk behaviors than can be accomplished by less intrusive interventions.  They can also provide a continuity of care that is essential for successful outcomes.

 

COUNSELING AND TESTING (C&T)

 

C&T provides HIV testing and individual client-centered counseling.  The sessions are private and provide a confidential way for an individual to learn their HIV status and to obtain information on recommended medical treatment, if required.  The testing is provided to individuals who want to determine if they are a carrier of the HIV virus.  If the results of the test are positive, they can be referred to appropriate medical services.  If the results are negative, they can undergo counseling for risk reduction and referrals for other services as needed.

 

The counseling is generally brief (one session before testing and one post test).  The counseling provides the following information:

Provides information on HIV testing and helps the client make a decision as to whether to undergo testing or not.

Promotes client responsibility to sex and drug-use partners.  If test results are positive the client has the responsibility to inform. 

Perform risk assessments to identify clients high-risk behaviors.

Develop a risk reduction plan

Make referrals to substance abuse treatment or other interventions as appropriate

 

IDUs generally mistrust conventional health services and in many cases are unable to obtain services; consequently, agencies and providers must offer C&T services in settings where IDUs are already found and deliver them in ways that are tailored to the specific circumstances of the IDUs who will receive them.  Performing C&T in conjunction with substance abuse treatment is one of the most expedient and successful delivery options.  Also, a number of factors help attract IDUs to specific programs. The most effective ones are:

The range of free services available without a need for an appointment.

Diversified staff (including recovering IDUs);

Location in a neighborhood with a visible presence of drug activity;

 

Anonymity

 

Other items that are promising for IDUs include:

Rapid HIV antibody tests that will allow a person to receive results in one visit;

Oral fluid testing kits that allow testing without the need for a blood sample. 

 

Research conducted among IDUs and other drug users has shown that HIV C&T has resulted in some beneficial behavior changes, including positive impacts on both drug-related and sexual practices.  However, a number of challenges limit the potential impact and benefits of C&T services.  By design, it is a brief intervention; consequently, it functions more like a case management tool (coordination of treatment activities) than to deliver long-term behavior changes in the IDUs.  It follows that an extended substance abuse treatment program is beneficial to augment the C&T effort.  Finally, and probably more important for the IDU, is that public funded HIV C&T does not now include counseling, testing and treatment for other blood-borne infections that have a significant impact on IDUs, particularly viral hepatitis.

 

PARTNER COUNSELING AND REFERRAL SERVICES (PCRS)

 

PCRS is primarily a public health activity that evolved form contact tracing activities for the control of syphilis.  Confidential interviews are conducted with newly infected persons to find out the names of and tracing information for recent sexual or drug contacts who are at high-risk of also being infected and to make confidential efforts to locate them, recruit them for diagnostic testing and to provide treatment as required.

 

PCRS provides an opportunity for agencies to notify the sexual and drug-use partners of infected individuals to inform them of their exposure to HIV and potentially to viral hepatitis.  It also opens up counseling opportunities as well as for longer-term follow-up.  As indicated earlier, if an individual is already infected, the partners prognosis can be improved through earlier diagnosis and treatment.  If not infected, the partners can be assisted in changing their risk behavior, thus reducing the likelihood of acquiring the virus.  From an epidemiological prescriptive, following the chain of transmission from one HIV-infected individual to another within and across social networks permits public health investigations to determine the course of the epidemic and perform more effective prevention planning.

 

PCRS begins when an IDU seeks HIV prevention C&T.  If the test is positive, he or she is given the opportunity to receive PCRS at the earliest appropriate time.  During the initial PCRS interview, the counselor will discuss with the client his or her options for notifying his or her partners regarding his or her infection status.  The HIV-infected client is encouraged to voluntarily and confidentially disclose the identifying, locating and exposure information for each partner.  Partner referral options include:

 

Client:  HIV-infected person informs partners;

Provider:  Usually the health department staff (with consent of the client) takes responsibility for contacting partners;

Dual:  HIV-infected person informs partner of his or her infection in the presence of the health care provider;

Contract:  Provider informs the partner only if the client does not notify the partners within a negotiated period.

 

Partner referrals encounter several challenges, particularly when agencies attempt to find partners of IDUs.  One reason is that the success of partner referral depends heavily on the disclosure of names of contacts by the HIV-infected individual.  IDUs may be particularly unwilling to reveal the names of or other information about partners partially because the drug culture discourages revealing information about others.  Even when a client discloses drug-use partners names it is often difficult to locate the IDUs because the client may know them only by a nickname or street name.  Also, the long incubation period of HIV and anonymous partners of clients are other reasons why it may be difficult to locate IDU partners.

 

Although partner notification for STDs is generally regarded as ethically acceptable, ethical concerns about the role of HIV partner notification as a prevention strategy have been voiced.  Community representatives often perceive HIV PCRS to be an intrusive activity that is unlikely to protect the confidentiality of the HIV-infected person or his or her partners.  Efforts are needed to ensure that community HIV prevention needs are met, misconceptions about PCRS practices and policies are corrected, and legitimate concerns about confidentiality and discrimination are addressed.

 

 

PREVENTION CASE MANAGEMENT (PCM)

 

PCM is a HIV prevention activity with the fundamental goal of helping individuals adopt and maintain HIV risk-reduction behaviors.  For those who are living with HIV, it helps in obtaining and adhering to treatment for HIV.  PCS includes the following components:

 

Client recruitment;

Screening and assessment of HIV and STD risks;

Development of a prevention plan;

Extended HIV risk-reduction counseling;

Coordination of services with follow-up;

Monitoring and reassessment of clients needs and progress;

Discharge planning.

Case management is often offered as part of a larger care system; consequently, it is difficult to assess its effectiveness apart from other services.  The major challenge for PCS is the greater cost compared to other HIV prevention activities, which may employ peers or paraprofessionals to reach larger numbers of people with less time-intensive, staff-intensive risk reduction strategies.

 

References and Recommended Reading

 

www.CDC.com

 

United Nations, HIV Prevention Among Young Injecting Drug Users, 2003

 

Robertson, Roy, Management of Drug Users in the Community:  A Practical Handbook,

 

Thornton, Neil,  Injecting Drug Users and HIV/AIDS:  A Counseling Manual, Department of Health, 1991