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Redefining HIV prevention for drug-using populations
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Redefining HIV prevention for drug-using populations
Research on HIV prevention in drug users has evolved in response to the dynamic nature of the co-occurring epidemics of drug use, HIV and other blood-borne diseases. Over time, as the accrual of empirical findings on HIV prevention in drug users has increased, new opportunities have arisen to refine, replicate, and test key principles of effective behavioural interventions in a variety of risk populations. It has been necessary to adapt or tailor behavioural interventions to the needs of the target group or population. The principles, listed below, have withstood the test of time and researchers have demonstrated that consideration of these principles during development and implementation of behavioural intervention programs for drug users will increase the likelihood of desired outcomes.
? <B>A community must start HIV prevention programming as early as possible </B>
Even when HIV is well established, HIV prevention programming can have significant impact on the further spread of HIV/AIDS. Early prevention efforts have been successful in maintaining low levels of seroprevalence in local settings. In areas where HIV is well established, effective strategies can be introduced to prevent the spread of HIV to uninfected people.
? <B>HIV risk reduction for drug-users is an achievable goal</B>
The first objective of any contact with drug users is to make them stop using drugs. Recovery from drug addiction can be a long-term process and relapse may occur even among persons in drug treatment. To prevent the spread of HIV, drug users must reduce or eliminate behaviours that place them and others at risk.
? <B>Effective prevention requires a comprehensive range of coordinated services</B>
Drug users and their sex partners at risk for HIV are diverse and no single prevention strategy will work for everyone. Moreover, specific individuals often require multiple interventions and prevention services. Comprehensive strategies are most effective for individuals and communities and they should include services like community outreach, HIV testing and counselling, prevention case management, drug abuse treatment, sterile syringe access, and service delivery through community health and social service providers. Careful attention must be paid to the coordination of services.
? <B>Prevention programs must be based on an assessment of local community needs</B>
There is variation across the United States and worldwide in the nature and extent of drug abuse and the profile of the AIDS epidemic. Prevention strategies must be adapted to local community needs and resources.
? Prevention services are most effective in reaching at-risk populations when they are available in several locations </B>
Drug users are dispersed throughout communities and have varying lifestyles. Thus, reaching at-risk populations requires providing HIV prevention services in a wide range of settings, including community health and social service agencies, hospitals and clinics, and drug treatment and correctional facilities.
? <B>Infected drug users and their sex partners are important target groups</B>
Infected persons need special efforts to help them gain access to treatments that can prevent progression of HIV disease. Research has also demonstrated that infected drug users can make major behaviour changes to protect their injecting and sex partners.
? <B>Prevention efforts must target not only individuals</B>
Risk behaviours typically occur within small or large groups, and community-based outreach interventions that engage small and larger groups can be effective. Behavioural norms within a local drug-using community that permit sharing of needdles also need to be modified. Relying on opinion leaders in groups can be an effective strategy to influence the drug-using behaviours of risk networks.
? <B>Community-based outreach is an essential HIV prevention component </B>
Drug abuse is usually a covert activity, making drug users and their sex partners difficult to access through traditional health and social service agencies. Indigenous outreach workers who are familiar with drug use subcultures in their communities have proved particularly effective agents of behaviour change. Peer outreach workers can act as referral sources to service agencies and drug treatment facilities, distribute HIV/ AIDS information and risk-reduction technologies, and provide skills-building demonstrations, such as syringe cleaning or condom application. They serve as opinion leaders who educate their peers to reduce risks for HIV and increase behavioural self-efficacy.
? <B>Prevention interventions must be personalized. </B>
Persons at risk must be engaged in a personalized assessment of their own risk behaviours, assisted in identifying barriers to and resources available to help them change their behaviour, and helped to formulate specific and achievable strategies to protect themselves and others.
? <B>Drug users and their sex partners must be treated with dignity and respect</B>
Successful engagement of at-risk populations in interventions requires that they recognize that concern for them is genuine and that they are seen as capable of undertaking behavioural change. Outreach approaches must be socially and culturally appropriate.
? <B>Sterile injection equipment must be available to IDUs </B>
Individuals are at high risk for HIV and other infections if they share someone else?s syringe and other injection equipment (including cookers, cotton, and rinse water). Research has shown that access to syringe exchange and pharmacy syringe distribution programs, as part of comprehensive HIV prevention programming, is effective in reducing syringe sharing and in preventing the spread of HIV.
? <B>Interventions targeting injection risk must address all injection equipment. </B>
Although sharing of other injection equipment is less risky for transmitting HIV than sharing syringes, it presents a potential route of infection for HIV and other diseases (e.g., hepatitis B and C) and must be addressed.
? <B>Risk-reduction information is necessary, but not sufficient to achieve behaviour change</B>
In addition to offering accurate and up-to-date information on risky behaviours, effective programs focus on enhancing motivation to change behaviour patterns, teach concrete strategies and behavioural skills for reducing risk, provide tools for risk reduction, and offer reinforcements for initial behaviour change.
? <B>Prevention efforts must address sexual transmission risks as well as risks associated with drug injection </B>
Many non-injecting drug users and their partners are at risk for HIV infection and its transmission because of unsafe behaviours associated with drug use, such as engaging in unprotected sex. For all sexually active individuals, drug and alcohol use may reduce inhibitions and increase the likelihood of unsafe sexual behaviours.
? <B>HIV intervention programs must be sustained over time</B>
Although brief interventions have shown they significantly reduce HIV risk among substantial numbers of drug users, they are seldom sufficient. Sustained and repeated interventions are usually needed.
? <B>Community-based prevention is cost-effective</B>
Sustained, well-designed prevention programs are cost-effective and can lead to substantial reductions in health care and social service costs associated with the treatment and care of persons with HIV/AIDS and other infectious diseases.
<B>Dr Fayzal SULLIMAN</B>
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