This study assesses the effectiveness of innovative community-based outreach intervention/prevention programs for reducing HIV-related risk behaviors of injection drug users (IDUs) and their sexual partners. Under the sponsorship of the National AIDS Demonstration Research (NADR) Project, the outreach programs offer information about HIV infection, strategies for reducing the risk, counseling, support groups, and training in cognitive and social skills. Significant increases are found in the use of new rather than reused needles, bleach for cleaning injection equipment, and condoms--all behaviors that reduce HIV risk. Study findings are so noteworthy that a permanent program has been created.
This study sought to assess the effectiveness of community-based outreach programs to curtail high-risk behaviors leading to HIV infection. The outreach programs were designed and sponsored by the National AIDS Demonstration Research Project, a demonstration program striving to reduce the risk of HIV infection among intravenous drug users and their sexual partners.
As of 1995, about 0.4 percent of the U.S. population are estimated to be infected with HIV. Innovative strategies are needed to reach elusive populations and motivate them to change their high-risk behaviors. Educational campaigns and the mass media have increased awareness about the dangers of HIV transmission through shared injection equipment. While some IDUs have changed behaviors, many continue to share their injection equipment and engage in high-risk sexual behaviors, which places them, their sexual partners, and their infants at risk. Knowledge of effective interventions was so limited that many public officials doubted that IDUs would participate in AIDS prevention programs and were reluctant to spend public funds to reach them.
In 1987, the Community Research Branch of the National Institute on Drug Abuse (NIDA) initiated the NADR Project as a demonstration program. The program was restricted to IDUs who were not currently in drug treatment programs and to their sexual partners. Its purpose was to design and implement innovative outreach intervention/prevention strategies and to determine program effectiveness through a built-in evaluation component.
The NADR Project was discontinued in 1992, but it was a model for the inauguration of a formal program of cooperative agreements to communities to help them curb risky behaviors of IDUs that lead to HIV infection.
Interventions at each of the 28 sites studied by NOVA Research Company varied somewhat but shared key elements. Community outreach workers, often former IDUs, contacted and recruited IDUs and their sexual partners to participate. Participants were offered voluntary HIV testing and received counseling and education that was culturally relevant. The counseling was delivered and reinforced by a credible source who also provided skills training and/or material resources.
The program collected and analyzed data on 13,475 IDUs and 1,637 sexual partners of IDUs. Investigators used a before/after design, collecting information at baseline and comparing it to that obtained at 6-month followup. Standardized baseline and followup assessment instruments were used to collect comparable data across all sites. Clients were assigned--either randomly or through systematic sampling--to a standard or enhanced intervention at most sites. The standard intervention generally included education and referral for needed community services. The enhanced intervention included a variety of more intensive services, such as couples counseling, development of peer networks, and social skills training.
Three summary risk scales were developed for use as outcome measures: needle risk behavior, sex risk behaviors, and total frequency of drug injection. Specific behaviors such as cleaning needles with bleach or using condoms were used for assessing the impact of the intervention.
Analyses focused on the participants' demographic characteristics, their behaviors and knowledge before and after interventions, the relationship of the type and intensity of intervention modalities to HIV-related risk behaviors, and other risk factors related to the level of risk. Analysis indicated that participants reliably reported demographic factors, injection drug use, and use of alcohol and marijuana. The reliability of reported needle use and sexual behaviors was more difficult to measure.
IDUs reported significant decreases in HIV-related risk behaviors after interventions. Significant increases were observed in the use of new needles, bleach for cleaning injection equipment, and condoms. Changes in needle-related behaviors of IDUs were more dramatic than changes in sexual behaviors.
The enhanced interventions were slightly more effective than standard interventions in reducing risk. However, this difference was not uniform across all sites and was related to the duration, format, and content of the enhanced intervention at each site. Specific components that were important to reducing risk were providing condoms and/or bleach and demonstrating the proper use of both. Around 33 percent of IDUs entered drug treatment during the followup period, thus reducing their risk for HIV and drug-related illnesses. At followup, subjects who were long-time IDUs, Hispanic, previously in drug treatment, unemployed, and heroin injectors reported greater use of injected drugs than did other IDUs.
The analysis at 17 sites revealed increased use of condoms, reduced number of sex partners, and reduced use of noninjected drugs. Average sex risk scale scores were not significantly different between the standard and enhanced interventions.
While both IDUs and their sexual partners began with high levels of AIDS-related knowledge, the project further enhanced this knowledge. AIDS knowledge levels were significantly higher among white than among African-American or Hispanic IDUs and sex partners. Females scored higher than males on sex risk knowledge, general risk knowledge, and total knowledge. No significant differences were revealed in knowledge scale scores between subjects in the standard and enhanced interventions.
Use of Results
This evaluation provides evidence that IDUs and their sexual partners can successfully take advantage of education and counseling to reduce the risk of becoming infected with HIV. The interventions were found to be so effective that they have been incorporated into formal programs administered by NIDA.
The study contained numerous suggestions for further research. Since the interventions varied across sites and had different impacts on subgroups, greater use of process measures was recommended for future research to document intervention exposure and to relate exposure to changes in behavior. Further investigation is needed into the efficacy of specific components dealing with bleach and condoms over more costly enhanced interventions. Methods to improve response rates at followup need further development. Long-term analysis of the data is needed to assess lasting impact on risk reduction.
NIDA, the NIDA/NADR research consortium, and individual project sites are disseminating the results through articles in refereed journals, training manuals and videotapes, and national database tapes for secondary data analysis.
National Institutes of Health
Richard Needle, Ph.D., M.P.H.
Community Research Branch
Division of Epidemiology and Prevention Research
National Institute on Drug Abuse
National Institutes of Health
5600 Fishers Lane, Room 9A-42
Rockville, MD 20857
(301) 443-6720 Fax: (301) 443-2636
NOVA Research Company, Bethesda, MD