A Comprehensive Approach to
Preventing Blood-Borne Infections
Among IDUs

Injection Drug Users are Important in the Transmission of HIV and Other Blood-borne Diseases

Since 1981, 753,907 cases of AIDS have been reported to the Centers for Disease Control and Prevention (CDC). It is estimated that 650,000 to 900,000 Americans are now living with HIV and that about 40,000 new infections occur every year.

The figures on hepatitis are equally impressive: Between 1 and 1 1/4 million Americans have active hepatitis B; 130,000 to 320,000 new infections occur every year. Nearly 3 million Americans have active hepatitis C.

Injection drug users (IDUs) are an important force in the continuing epidemics of these devastating diseases. IDUs become infected and transmit the viruses to others in two, often interconnected, ways:

• high-risk drug use—sharing blood-contaminated syringes and injection paraphernalia such as water, cookers, and cottons
• high-risk sex—unprotected sex, sex with many partners, failure to treat STDs

Women who become infected with HIV through sharing needles or having sex with an infected IDU can also transmit the virus to their babies before or during birth or through breastfeeding.

More effective prevention approaches will help IDUs. Society as a whole will benefit as well, because reduced transmission among IDUs means reduced transmission among their sex partners, their children, and ultimately, among the general population.

The Legal, Social, and Policy Environment Limits Options for IDUs

Many health departments, community-based organizations, agencies, and providers are working hard to reach and work with IDUs to help them change their behaviors and reduce or eliminate their risk of acquiring or transmitting infection.

The problem of injection drug use and transmission of blood-borne disease persists, however. Solutions are hampered by society's pervasive negative attitudes toward IDUs, a lack of understanding of drug addiction as a treatable biomedical and psychological disease, limited funding for prevention and treatment, restrictive laws and regulations, and polarized philosophical viewpoints among various organizations and providers.

The Solution: A Comprehensive Approach to Working with IDUs

If organizations and providers, public health staff, and prevention planners are to succeed in effectively reducing the transmission of HIV and other blood-borne infections, they must consider a comprehensive approach to working with IDUs. Such a comprehensive approach, now being advocated by the Centers for Disease Control and Prevention (CDC), incorporates a range of pragmatic strategies that take into account IDUs' various life circumstances, cultures and languages, behaviors, and readiness to change. It also incorporates several basic principles that serve as a framework for action.

THE PRINCIPLES

Ensure coordination and collaboration. No single provider or institution can or does deliver all required services to IDUs, their sex partners, and their children. Coordination and collaboration are essential. Providers must work together, sharing their various expertise and outlooks, recognizing and overcoming their philosophical differences, building on existing relationships, and reaching out to groups with whom they may not have worked before.

Ensure coverage, access, and quality. Interventions will not be effective if they do not reach a critical mass of people, if IDUs cannot or will not use them, or if they are of poor quality. If they hope to truly reach and work with IDUs, agencies and providers must consider ways to effectively deal with these issues as they plan, deliver, and monitor programs and services.

Recognize and overcome stigma. Injection drug use is regarded with disapproval and fear, and a user's addiction is considered to be a moral failing. To successfully engage IDUs in prevention efforts and to advance public policy, these negative attitudes and misconceptions must be addressed. Addiction is now understood to be a treatable brain disease. This concept should be more widely known and accepted.

Tailor services and programs. IDUs are diverse populations with different languages, cultures, sexual preferences, life circumstances, behaviors, and requirements for services. Many, though not all, are poor and live high-risk lives on the margins of society. In planning and delivering interventions, programs and providers must take into account the factors that characterize IDUs - who they are, where they are, what they do, what motivates them, and with whom they socialize. Tailoring services and programs and involving IDUs in their planning, implementation, and monitoring will make them more effective.

THE STRATEGIES

Substance Abuse Treatment — Why include it?

• most drug users cannot stop using without it
• treatment prevents transmission because it helps users reduce drug- and sex-related risk behaviors
• it has major positive effects on a user's life
• treatment is cost effective
• providers can reach IDUs with other messages and interventions during treatment
• society benefits from reduced drug use and associated crime

Community Outreach — Why include it?

• it reaches IDUs who don't participate in conventional service systems
• it provides services in settings that are familiar to IDUs
• outreach interventions help create a culture of risk reduction in the community, which helps to reinforce prevention messages
• peers, who are often used in community outreach, are likely to be trusted by IDUs
• it's relatively low cost

Access to Sterile Syringes — Why include it?

• the U.S. Public Health Service and other agencies and institutions recommend consistent, one-time only use of sterile syringes obtained from a reliable source as a central risk reduction strategy for IDUs who cannot or will not stop injecting
• the use of a sterile syringe every time helps ensure that IDUs who continue to inject will not acquire or transmit infection
• existing laws, regulations, and public and pharmacists' attitudes hamper IDUs' ability to obtain and safely dispose of syringes and therefore promote multi person use of syringes
• access to sterile syringes does not increase drug use or attract new people to drug use
• ensuring access to sterile syringes involves working with pharmacists; addressing existing syringe laws and regulations; and syringe exchange programs

Services in the Criminal Justice System — Why include them?

• many IDUs are in jail or prison because of their drug use
• inmates have disproportionately high rates of HIV infection, STDs, and hepatitis
• high-risk sex and drug-use behavior occurs in jails and prisons
• interventions benefit inmates and the communities to which almost all will return

Strategies to Prevent Sexual Transmission — Why include them?

• IDUs are an important source of sexual transmission of HIV and hepatitis B
• high-risk drug use and sex behaviors are often linked

Counseling and Testing Services, Partner Counseling and Referral Services, and Prevention Case Management — Why include them?

• they allow IDUs to find out whether they are infected with HIV
• they allow infected IDUs access to counseling and medical care and other services
• they help infected IDUs inform sex and drug-use partners
• they help public health officials follow the chains of transmission and reach those at high risk
• they help uninfected but high-risk IDUs reduce their risk behaviors

Services for IDUs Living with HIV/AIDS — Why include them?

• they can help infected IDUs reduce high-risk drug and sex behaviors
• IDUs should have access to comprehensive and quality health care
• HIV disease management is complex and long-term, requiring close monitoring
• infected IDUs who receive substance abuse treatment and other health services are more likely to comply with medication regimens

Primary Drug Prevention — Why include it?

• preventing first use of alcohol, marijuana, inhalants, and other drugs among youth can reduce the risk that they will go on to use injection drugs
• preventing injection drug use eliminates injection-related blood-borne virus transmission
• preventing alcohol and drug use and associated crime and injuries benefits society