NIH Publication No. 02-4733

Printed March 2002

Principles of HIV Prevention 

in Drug-Using Populations

A Research-Based Guide

National Institute on Drug Abuse

National Institutes of Health

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
PRINCIPLES OF HIV PREVENTION

IN DRUG-USING POPULATIONS

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 1

1

2

3

4

Reducing the risk of HIV/AIDS in

drug users is an achievable goal.

To prevent the spread of HIV and

other blood-borne infections, drug

users must reduce or eliminate those

behaviors that place them and others

at risk. Research has shown that

appropriately designed prevention

programs can reduce transmission 

of not only HIV but of other bloodborne diseases (e.g., hepatitis B [HBV],

hepatitits C [HCV], and other sexually

transmitted diseases [STDs]) as well.

A community must start HIV/AIDS

prevention programs as soon as 

possible. Even when HIV/AIDS is well

established in a community, prevention

programs can significantly limit the 

further spread of HIV/AIDS.

Effective prevention programs

require a comprehensive range 

of coordinated services. Given the

diversity of drug users and their sexual 

partners, no single prevention strategy

will work for everyone. A comprehensive approach that can readily adapt 

to changing needs and circumstances

is the most effective approach for 

preventing HIV/AIDS and other

5

blood-borne infections in drug users,

their sexual partners, and their communities.This approach should include

such services as community outreach,

HIV testing and counseling, drug abuse

treatment, access to sterile syringes,

and services delivered through 

community health and social service

providers. Services must be carefully

coordinated within a community.

Prevention programs should work

with the community to plan and

implement interventions and 

services. Involving the local community

increases the likelihood of developing

and implementing culturally appropriate

HIV/AIDS prevention strategies that 

the community accepts and that 

can effectively reach drug users 

and their sexual partners in their 

natural environments.

Prevention programs must be

based on a thorough, continuing

assessment of local community

needs, and the effectiveness and

impact of these programs must be

continually assessed. Because the

nature and extent of drug abuse and

the HIV/AIDS epidemic vary widely,
2 Principles of HIV Prevention in Drug-Using Populations PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 3

6

7

8

9

prevention strategies must be adapted

to local community needs and

resources. Local drug use and HIV/AIDS

risk-behavior patterns must be tracked

to refine program approaches over time

and to evaluate program outcomes.

Prevention services can most 

effectively reach drug-using 

populations when they are available

in a variety of locations and at 

a range of operating times. Drug

users are dispersed throughout 

communities and have varying

lifestyles.Thus, reaching them requires

providing HIV/AIDS prevention services

in a wide range of settings, including

community health and social service

agencies, hospitals and clinics, and 

drug abuse treatment and correctional

facilities. Coordinating these services 

in various community settings and at 

a range of operating times enhances

the impact of interventions and reduces

the unnecessary duplication of services.

Prevention and treatment efforts

should target drug users who

already have the HIV infection, 

as well as their sex partners. 

People who have the HIV infection may

need help gaining access to services

and adhering to treatments that can

prevent HIV from progressing to AIDS.

Research has demonstrated that HIVpositive drug users are able to make

major behavioral changes to protect

their injecting and sex partners from

contracting the infection.

Prevention efforts must target not

only individuals, but also couples,

social networks, and the broader

community of drug users and 

their sex partners. Risky behaviors

typically occur in the context of social

groups. Community-based outreach

interventions that engage these groups

can be highly effective in reducing risks

and preventing the spread of infection.

Behavioral norms that permit drug

users to share injection equipment

also need to be modified within the

community. Relying on opinion leaders

within these groups can be an effective

strategy to influence the drug-using

behaviors of individuals and their

social networks.

Community-based outreach is an

essential component of HIV/AIDS

prevention and must be directed 

to drug users in their own 

neighborhoods. Drug abuse is usually

a covert activity, making it difficult 

to contact drug users and their sex

partners through traditional health

and social service agencies. Indigenous

outreach workers who are familiar

with the drug use subcultures and local

neighborhoods in their communities

have been shown to be effective agents

10

11 13

12

of behavioral change and referral

sources to service agencies and drug

abuse treatment facilities.

Prevention interventions must be

personalized for each person at risk.

Effective prevention entails discussing

the many behavioral changes a drug

user must make to reduce his or her

risks for HIV/AIDS. It may require

showing drug users and their sex 

partners how to assess their own risk

behaviors. It may also require helping

people identify barriers that keep

them from changing their behavior,

informing them about available

resources to help them make those

changes, encouraging them to seek

voluntary HIV testing and counseling,

and teaching them how to develop

specific, achievable strategies to 

protect themselves and others from

contracting HIV and other infections.

Drug users and their sex partners

must be treated with dignity and

respect and with sensitivity to 

cultural, racial/ethnic, age, and

gender-based characteristics. 

To successfully engage drug-using 

populations in interventions, it is

important that outreach workers 

and service providers show that their

concern for drug users is genuine and

that they believe that drug users are

capable of changing their HIV-related

risk behaviors. Outreach workers and

service providers should use socially

and culturally appropriate, nonjudgmental approaches to engage 

drug users and their sex partners.

As part of a comprehensive HIV

prevention program, injection drug

users should have ready access to

sterile injection equipment to reduce

their use of previously used injection

equipment. Individuals who inject

drugs are at high risk for HIV and

other infections if they share or reuse

someone else’s syringe and other

injection equipment, including cookers,

cottons, and rinse water. Research has

shown that access to sterile syringes,

one component of a comprehensive

HIV prevention approach, effectively

reduces syringe sharing and prevents

the spread of HIV.

In a comprehensive program, 

interventions that target injection

risk must address sharing other

injection equipment in addition 

to syringes. Sharing other injection

equipment, including cookers, cottons,

and rinse water, and drug solutions

that have been prepared for injection,

presents another potential route of

infection for HIV and other bloodborne diseases. Sharing drug solutions

(drugs mixed with water in preparation

for injection) is a significant, but 
4 Principles of HIV Prevention in Drug-Using Populations

14

15

16

17

frequently overlooked, HIV transmission

risk.Targeted interventions can help

drug users reduce these associated risks.

While necessary, risk reduction

information alone cannot help

drug users and their sex partners

make lasting behavioral changes. 

In addition to offering accurate and

up-to-date information on risky 

behaviors, effective HIV/AIDS prevention

programs focus on enhancing individuals’

motivation to change their behavioral

patterns, teaching concrete strategies

and behavioral skills to reduce risk,

providing tools for risk reduction, and

reinforcing positive behavior change.

Prevention efforts must address the

risks of transmitting HIV and other

infections sexually as well as

through drug injection. Drug and

alcohol use may reduce inhibitions and

increase the likelihood of engaging in

unsafe sexual behaviors. Injecting and

non-injecting drug users, their sexual

partners, and people who exchange

sex for drugs or money are at risk for

sexually transmitting HIV, STDs, and 

other infections.

HIV/AIDS risk-reduction 

interventions must be sustained

over time. Although research has

shown that brief interventions have

significantly reduced risks for HIV and

other infections among substantial

numbers of drug users and their sex

partners, brief interventions are typically

not sufficient. Sustained and repeated

interventions are usually needed.

Community-based prevention 

is cost-effective. Sustained, welldesigned prevention programs are

cost-effective and can substantially

reduce health care and social service

costs associated with treating and 

caring for people with HIV/AIDS 

and other infectious diseases.

CONTENTS

1 Principles of HIV Prevention in Drug-Using Populations

7 Preface

9 Acknowledgments

11 Introduction

13 Frequently Asked Questions

13 How can drug users reduce their risks for HIV/AIDS?

14 What is the best HIV/AIDS prevention strategy for drug users?

15 What are the components of a comprehensive HIV/AIDS prevention approach?

16 How effective is a comprehensive HIV/AIDS prevention approach?

19 What role does the community-based outreach worker play 

in comprehensive HIV prevention for drug users?

19 Is comprehensive HIV prevention for drug users cost-effective?

23 Research on Preventing HIV/AIDS and Other Infections 

in Drug-Using Populations

28 Resources

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 5
PREFACE

During the past 15 years, the National

Institute on Drug Abuse (NIDA) has

sponsored a comprehensive research

program in response to the dynamic

nature of the co-occurring epidemics of

drug abuse and HIV/AIDS.This research

has yielded a set of scientifically based

principles that should prove useful to

community planners, policymakers,

service providers, and medical practitioners as they develop and implement

programs to prevent the spread of HIV

and other infections among injecting

and non-injecting drug users and their

sexual partners.To foster widespread

use of these principles, NIDA is pleased

to provide this research-based guide:

Principles of HIV/AIDS Prevention in 

Drug-Using Populations.

Pages 1–4 of the guide summarize 

the basic overarching principles that

characterize effective HIV/AIDS 

prevention in drug-using populations.

Pages 13–21 elaborate on these 

principles by providing answers to 

frequently asked questions. Pages

23–27 describe the epidemiology of

HIV/AIDS risk behaviors.This section

also provides an overview of major

research programs that NIDA has 

supported since the mid-1980s to

gauge the effectiveness of outreachbased interventions in preventing 

the spread of HIV/AIDS and other 

diseases among drug users and their

sex partners.

Although research has shown clearly

that HIV/AIDS can be prevented in

drug-using populations, the epidemic

continues to spread.We must take

every opportunity to meet this public

health threat, not only by advancing our

research efforts but also by ensuring

that our research findings on HIV/AIDS

prevention are adapted for use within

diverse drug-using groups and their

communities.We hope that this guide

will be an important contribution to

our ever-expanding prevention toolbox.

Glen Hanson, Ph.D., D.D.S.

Acting Director

National Institute on Drug Abuse

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 7
ACKNOWLEDGMENTS

The National Institute on Drug Abuse

wishes to thank the following individuals

for their contributions to the 

development of this publication.

Robert J. Battjes, D.S.W.

Friends Research Institute, Inc.

Baltimore, Maryland

Robert Booth, Ph.D.

University of Colorado Health

Sciences Center

Denver, Colorado

Sherry Deren, Ph.D.

NDRI, Inc.

New York, New York

Don C. Des Jarlais, Ph.D.

Beth Israel Medical Center

New York, New York

Antonio L. Estrada, Ph.D.

University of Arizona

Tucson, Arizona

T. Stephen Jones, M.D., M.P.H.

Centers for Disease Control 

and Prevention

Atlanta, Georgia

Clyde B. McCoy, Ph.D.

University of Miami 

School of Medicine

Miami, Florida

David Metzger, Ph.D.

University of Pennsylvania

Philadelphia, Pennsylvania

Rafaela R. Robles, Ed.D.

Addiction Technology Transfer Center

Bayamon, Puerto Rico

Salaam Semaan, Dr.P.H.

Centers for Disease Control 

and Prevention

Atlanta, Georgia

Harry Simpson

Community Health Awareness Group

Detroit, Michigan

Merrill Singer, Ph.D.

Hispanic Health Council

Hartford, Connecticut

Wendee Wechsberg, Ph.D.

Research Triangle Institute

Research Triangle Park, North Carolina

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 9
INTRODUCTION

In the mid-1980s, the National Institute

on Drug Abuse (NIDA) launched 

an extensive research program to

develop, implement, and evaluate the

effectiveness of a range of intervention 

strategies to reduce risk behaviors 

and prevent the spread of HIV/AIDS,

particularly among injection drug users

(IDUs), their sex partners, and crack

cocaine users. Cumulative findings

from these efforts show that it is 

possible to prevent the transmission 

of HIV in drug-using populations.

These studies have shown that comprehensive HIV prevention strategies,

in the absence of a vaccine or a cure

for AIDS, are the most cost-effective

and reliable approaches for preventing

new HIV infections in diverse populations of drug users and their communities. Comprehensive HIV prevention

includes a variety of complementary

components—community-based 

outreach, drug abuse treatment, and

sterile syringe access programs—to

help drug-using populations increase

their protective behaviors and reduce

their risks for HIV/AIDS as well as

other blood-borne infections, such as

hepatitis B (HBV) hepatitis C (HCV),

and other sexually transmitted diseases

(STDs). In combination with HIV testing

and counseling, each major component

has proven somewhat effective in

reducing HIV-related risk behaviors.

However, no single strategy has proven

sufficient by itself to prevent the 

further spread of HIV/AIDS.

In August 1997, after more than a

decade of HIV prevention research,

NIDA sponsored the “Research

Synthesis Symposium on the Prevention

of HIV in Drug Abusers” to review

and translate research conducted 

by NIDA on HIV/AIDS prevention

strategies for drug users and their 

sex partners. Less than a year later,

NIDA published a special issue of

Public Health Reports (1) that featured

selected papers from the Symposium

on the origins, current status, and

future prospects of HIV prevention 

in drug-using populations.The special

issue also provided an initial set of

overarching principles to help guide

HIV prevention planning efforts.

As a follow-up to both the Symposium

and the special issue, NIDA held a

workshop on “HIV Prevention in

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 11

Mark Williams, Ph.D.

University of Texas-Houston

Houston,Texas

This publication was prepared 

by Elizabeth Y. Lambert, M.Sc. and 

Helen K. Cesari, M.Sc. of NIDA’s

Center on AIDS and Other Medical

Consequences of Drug Abuse;

Richard H. Needle, Ph.D., chief of NIDA’s

Community Research Branch from

1992 to 1999; and Jack B. Stein, Ph.D.,

deputy director of NIDA’s Office of

Science Policy and Communications.

Alan I. Leshner, Ph.D., was the director

of NIDA until November 30, 2001.

We are grateful for his stewardship,

support, and contributions to the

development of this guide.

All materials in this volume are in the

public domain and may be used or

reproduced without permission from

the Institute or the authors. Citation 

of the source is appreciated.

The U.S. government does not endorse

or favor any specific commercial 

product or company. Trade, proprietary,

or company names appearing in this 

publication are used only because they

are considered essential in the context

of the studies described here.

10 Acknowledgments

The cover photograph is of a painting by 

Community Health Outreach Worker Craig Lasha.

Called “Reaching Out: Preventing HIV/AIDS in Our

Community,” the painting depicts outreach workers

talking to people on the streets of San Francisco’s

Tenderloin District. It was painted in 1989.

NIH Publication No. 02-4733

Printed March 2002
FREQUENTLY ASKED QUESTIONS

• If you continue to inject drugs,

take the following steps to reduce 

personal and public health risks:

– Never re-use or “share”

syringes, water, or drug 

preparation equipment.

– Use only sterile syringes 

obtained from a reliable source 

(e.g., a pharmacy or a syringe 

access program).

– Always use a new, sterile syringe 

to prepare and inject drugs.

– If possible, use sterile water to 

prepare drugs; otherwise use 

clean water from a reliable 

source (e.g., fresh tap water).

– Always use a new or disinfected 

container (“cooker”) and a new 

filter (“cotton”) to prepare drugs.

– Clean the injection site with 

a new alcohol swab before 

injecting drugs.

– Safely dispose of syringes after 

one use.

As the hierarchy shows, drug injectors

can best reduce their risks by stopping

all drug use. If they inject drugs, they

should always use sterile supplies and

never share them.When this is not

possible, cleaning and disinfecting 

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 13

Drug-Using Populations: Research

Outcomes and Principles of Effective

Behavioral Interventions” in January

2000.The workshop sought to 

(a) review the scientific literature on

the principles of effective behavioral

interventions to prevent HIV/AIDS

among drug users, (b) refine a set 

of prevention principles that is both

comprehensive and representative 

of the best science available, and 

(c) translate the principles so that 

they could be widely applied and

implemented in diverse community

settings.The workshop coincided with

NIDA’s development of a manual on

the NIDA Outreach Model, released

in September 2000 (2).The manual

discusses the principles of HIV prevention for drug users and their sex partners, includes step-by-step instructions

for conducting community-based 

outreach, and provides information for

program managers to use in designing

outreach risk reduction programs in

their communities (for more information, see “Resources” on page 28).

Available resources, social and cultural

factors, and local conditions and policies

will influence how, when, where, and

to what extent HIV/AIDS prevention 

programs can be implemented to

ensure that even the most difficult-toreach drug users have access to the

services that they need.The research12 Introduction

based principles described in this 

publication can be a useful tool for

communities to use in planning and

implementing a comprehensive

HIV/AIDS prevention program.

Coordination and effectiveness of 

the various services called for in a

comprehensive approach can be

improved through partnerships 

among researchers, drug abuse and

HIV/AIDS prevention and treatment

providers, and local civic leaders. Once

HIV/AIDS prevention programs are

adapted to the individual community,

they should be assessed continually 

to determine whether they are 

successfully achieving program 

objectives and whether they should 

be modified or adapted in response

to other blood-borne diseases.

References

1. NIDA. HIV Prevention With 

Drug-Using Populations: Current 

Status and Future Prospects.

Public Health Reports 113 

(Suppl. 1), 1998.

2. NIDA. A Manual to Reduce the 

Risk of HIV and Other Blood-Borne 

Infections in Drug Users:The NIDA 

Community-Based Outreach Model.

NIH Pub. No. 00-4812.

Washington, DC: U.S. Govt.

Print. Off., Sept. 2000.

1

How can drug users reduce

their risks for HIV/AIDS?

Drug users should be advised that

stopping all drug use, including drug

injection, is the most effective way 

to reduce their risks for contracting

HIV/AIDS and other blood-borne 

diseases, including hepatitis B and 

hepatitis C. However, not every drug

user is ready to stop using drugs, and

many of those who stop may relapse.

A variety of HIV/AIDS prevention

strategies to protect against becoming

infected are available for individuals

who may be considering or already

injecting drugs.These are described in

a hierarchy of HIV/AIDS risk-reduction

messages, beginning with the most

effective behavioral changes that 

drug users can make:

• Stop using and injecting drugs.

• Enter and complete drug 

abuse treatment, including 

relapse prevention.
32

What are the components of

a comprehensive HIV/AIDS

prevention approach?

The comprehensive HIV/AIDS prevention approach for drug users includes

three complementary approaches:

community-based outreach, drug abuse

treatment, and sterile syringe access

programs. Each of these also includes

HIV testing and counseling.

Community-based outreach is an

effective approach for contacting drug

users in their local neighborhoods to

provide them with the means to change

their risky drug- and sex-related

behaviors.This approach relies on 

outreach workers who typically reside

in the local community and are familiar

with its drug use subculture. As a

result, they are in a unique position 

to educate and influence their peers

to stop using drugs and reduce their

risks for HIV and other blood-borne

infections. Outreach workers distribute

HIV/AIDS educational information,

bleach kits for disinfecting injection

equipment when sterile equipment is

not available, and condoms for safer

sex.They also provide drug users with

referrals for drug treatment, syringe

access and exchange programs, and HIV,

HBV, and HCV testing and counseling.

Drug abuse treatment is HIV prevention. Drug users who enter and continue in treatment are more likely than

those who remain out of treatment to

reduce risky activities, such as sharing

needles and injection equipment or

engaging in unprotected sex. Drug

abuse treatment can be conducted 

in a variety of settings (e.g., inpatient,

outpatient, residential) and often

involves various approaches, including

behavioral therapy, medications, or a

combination of both.The best treatment programs offer their clients HIV

testing and counseling and referral 

to other services.

Sterile syringe access programs

complement community-based 

outreach and drug abuse treatment 

by providing drug users who will not

or cannot seek treatment, or who are

in treatment but continue to inject

drugs, with access to sterile syringes

and other services.These programs

help remove potentially contaminated

needles from circulation.They also

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 15

techniques should be considered. Fullstrength bleach is the most effective

disinfectant when safer options are

not available. However, sterile, unused

injection equipment is safer than 

previously used injection equipment

disinfected with bleach (1). Drug users

should never share their other injection

equipment, such as cookers, cottons,

rinse water, and drug solutions prepared

for injection. Sharing these materials

presents an important but often 

overlooked HIV transmission risk.

In addition to learning how to make

the behavioral changes described in

the hierarchy, drug users and their sex

partners should be counseled about

sexual risks for HIV and other STDs

and the importance of avoiding

unprotected sex.

Community-based outreach workers,

treatment providers, and other public

health professionals should use any

contact with a drug user as an opportunity to convey these important

HIV/AIDS risk-reduction messages.

The messages should be delivered

along with referrals for testing and

counseling services for HIV and other

blood-borne infections, drug abusetreatment programs, and other services.

14 Frequently Asked Questions

What is the best HIV/AIDS

prevention strategy for

drug users?

Given the diversity of drug users and

their sex partners, no single HIV/AIDS

prevention strategy will work effectively

for everyone. A comprehensive

approach is the most effective strategy

for preventing HIV/AIDS and other

blood-borne infections in drug-using

populations and their communities. A

comprehensive approach readily adapts

and responds to changing patterns of

drug use and HIV/AIDS risk behaviors,

to the characteristics of the local setting,

and to the varied service needs of

drug users and their sex partners.

At every contact with a drug user,

outreach workers, interventionists, and

counselors deliver drug- and sex-related

risk-reduction messages and provide

the means to reduce or eliminate 

their risks for transmitting HIV 

and other blood-borne infections.

A comprehensive approach 

is the most effective strategy 

for preventing HIV/AIDS and

other blood-borne infections 

in drug-using populations and

their communities.

Comprehensive HIV prevention

programs can help drug users

stop using drugs, change their

risk behaviors, and reduce

their risks for acquiring or

transmitting the HIV infection.
4

based outreach is effective for all types

of drug-using risk groups, in a range of

local settings. Cumulative research from

a 23-site study that followed 18,144

drug users (13,164 IDUs and 4,980

non-injecting crack users) reports that

3 to 6 months after participating in

the intervention, 72 percent of the

IDUs either stopped injecting drugs 

or reduced their frequency of injection.

Of those who continued to inject,

nearly 60 percent either stopped 

or reduced reusing or sharing their

syringes.Twenty-six percent of the

crack cocaine users, including 8,184

IDUs who also used crack and 4,980

non-injecting crack users, had stopped

using crack cocaine at follow-up.

Nearly 25 percent of the 18,144 drug

users who participated in the study

had entered drug abuse treatment at 

follow-up, many for the first time.

Drug abuse treatment. Studies have

consistently shown that participation

in drug abuse treatment is associated

with lower rates of drug injection. For

example, a 3-year study of drug use

patterns among male IDUs participating

in methadone maintenance treatment

reported that 71 percent of 388

patients who had remained in treatment

for 1 year or more had stopped

injecting drugs. By contrast, in a second

group of 105 IDUs who had dropped

out of treatment, 82 percent had

relapsed to injecting drug use within a

year. Another study found that opiate

addicts who were recruited by street

outreach workers and offered free

methadone maintenance treatment

were significantly more likely to enter

and remain in treatment, even if they

had never been in treatment before

or claimed not to want treatment (4).

Research has also shown that participating in methadone maintenance

treatment is linked to lower rates of

HIV infection. In one study, for example,

drug users who remained out of

treatment were nearly six times more

likely to become infected than those

who remained in treatment (5).

16 Frequently Asked Questions PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 17

serve as a bridge to active and out-oftreatment drug users by providing

them with HIV/AIDS information and

materials (e.g., bleach kits and condoms)

to reduce their risks, by offering

opportunities for HIV testing and

counseling, and by providing referrals

for drug abuse treatment and other

social services. Hence, it is important

that drug abuse treatment and other

services are available and accessible to

drug users referred by sterile syringe

access programs.

How effective is a 

comprehensive HIV/AIDS

prevention approach?

Comprehensive HIV/AIDS prevention,

which includes the strategies and 

components of community-based 

outreach, drug abuse treatment, and

sterile syringe access programs—all in

combination with testing and counseling

for HIV and other infections—currently

is the most effective approach for 

preventing the spread of HIV, other

blood-borne infections, and STDs in

drug-using populations.

Community-based outreach. More

than 15 years of research on HIV/AIDS

prevention interventions with IDUs,

crack cocaine users, and many of their

sex partners has shown that communityTesting and Counseling

Services for HIV and Other

Blood-Borne Infections

HIV testing and counseling services

are an important part of comprehensive HIV prevention programs.

These services are most effective

when a range of anonymous and

confidential testing options are

available in diverse, accessible 

settings (e.g., mobile clinics) and 

at nontraditional times.The most

current, rapid testing technologies

can be especially useful.These allow

drug users and others at risk to

learn their test results as soon as

they are available, plan a course 

of action to stop using drugs and

reduce their risk of transmitting

HIV to others, and get a referral to

appropriate drug abuse treatment

and other health services (2). HIV

testing and counseling staff also

can inform drug users about their

potential risks for contracting HBV

and HCV and explain why it is

important to be tested for these

and other blood-borne and sexually transmitted infections. Staff are

trained to help people who test

positive for HIV and/or other

infections to inform their drug 

use and sex partners about their

potential risks for infection and

the importance of getting testing

and counseling (3).

More than 15 years of research

have shown that communitybased outreach is effective 

for all types of drug-using 

risk groups, in a range of 

local settings.

Drug users who enter and 

continue in treatment are

more likely than those who

remain out of treatment to

reduce risky activities.
5

6

What role does the 

community-based 

outreach worker play 

in comprehensive HIV 

prevention for drug users?

Community-based outreach workers

are on the front line in the local 

community, and they know where,

when, and how to contact even the

most difficult-to-reach drug users in

their neighborhoods. As a trusted and

recognized source of information, an

outreach worker can help drug users

understand their personal risks for HIV

and other blood-borne diseases and

identify the preventive steps they need

to take. As a peer, the indigenous 

outreach worker can encourage drug

users to stop or reduce using and

injecting drugs and enter drug abuse

treatment.They can provide referrals

to drug users for drug-abuse treatment,

for testing and counseling for HIV/AIDS

and other infectious diseases, and 

for sterile syringe access programs.

Outreach workers are a vital link to:

• educational and risk-reduction 

information on HIV/AIDS, HBV,

HCV, and other STDs;

• information and materials for 

behavioral change, including the 

HIV/AIDS risk-reduction hierarchy,

bleach kits to disinfect injection 

equipment, condoms for safer 

sex, and instructions for proper 

condom use and disposal; and

• services for testing and counseling 

for HIV, HBV, HCV, and other STDs;

drug abuse treatment; and other 

community health, prevention, and 

social programs.

Is comprehensive HIV 

prevention for drug users

cost-effective?

Research has shown that the three

complementary approaches that make

up comprehensive HIV prevention 

for drug users—community-based

outreach, drug abuse treatment, and

sterile syringe access programs—are

cost-effective. Comprehensive HIV

prevention permits ongoing contact

with drug users who may otherwise

not be reached and provides them

with information and opportunities 

to stop using drugs, to enter drugabuse treatment, and to reduce their

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 19

Sterile syringe access programs.

When implemented as part of a 

comprehensive HIV/AIDS prevention 

strategy, sterile syringe access programs

play a unique role in engaging hard-toreach populations at high risk for HIV

infection in meaningful prevention

interventions and treatment opportunities. Evaluations of these programs

indicate that they are an effective part

of a comprehensive strategy to reduce

the injection drug use-related spread of

HIV and other blood-borne infections.

In addition, they do not encourage the

use of illicit drugs. For example, one

study in New York City showed a 

70 percent decrease in HIV incidence

attributed to sterile syringe access

programs (6). By comparison, international investigators found that in 

29 cities with established sterile syringe

access programs, HIV prevalence

decreased an average of 5.8 percent

per year but increased an average 

of 5.9 percent per year in 51 cities

without such programs (7).

18 Frequently Asked Questions

The cumulative research shows that

sterile syringe access programs are

effective in reducing the further

spread of HIV among IDUs, their 

sexual partners, and their children.

Furthermore, these programs help to:

• increase the number of drug users 

who enter and remain in detoxification and drug treatment programs

if they are available to them;

• disseminate HIV risk reduction 

information, materials for 

behavioral change, and referrals 

for HIV testing and counseling 

and drug treatment services;

• reduce injection frequency and 

needle-sharing behaviors;

• reduce the number of contaminated

syringes in circulation in a community; and 

• increase the availability of sterile 

injection equipment, thereby 

reducing the risk that new 

infections will spread.

Outreach workers are in a

unique position to educate and

influence their peers to stop

using drugs and reduce their

risks for HIV and other bloodborne infections.
drug- and sex-related risks for HIV

and other blood-borne infections.

Cost-effectiveness studies have reported

that, by preventing HIV infections,

community-based outreach interventions help avert future medical costs

associated with the care and treatment

of HIV/AIDS (8). Similarly, drug abuse

treatment programs are cost-effective

in reducing drug use and its associated

health and social costs, especially when

compared to not treating addicts or

to incarcerating them (2). Evaluations

of sterile syringe access programs have

demonstrated that by lowering the

frequency of injections with used 

needles these programs help prevent

the spread of new HIV infections 

and save medical-care costs for each

averted infection (9).

20 Frequently Asked Questions

Sustained, well-designed strategies of

comprehensive HIV prevention also

can lead to substantial reductions in

health-care and social-service costs

associated with the treatment and care

of people with HIV/AIDS and other

infectious diseases. Comprehensive

HIV prevention is most cost-effective

when its strategies are implemented

early in the epidemic (10), when the

prevalence of HIV is low and the

greatest number of potential new

infections in the population can 

be averted.

References

1. Centers for Disease Control and 

Prevention (CDC), Center for 

Substance Abuse Treatment 

(SAMHSA), NIDA Prevention 

Bulletin. U.S. Department of 

Health and Human Services,

Public Health Service. April 1993.

2. NIDA. Principles of Drug Addiction 

Treatment: A Research-Based Guide.

NIH Publication No. 99-4180,

Oct. 1999.

3. CDC. Revised guidelines for HIV 

counseling, testing, and referral.

Oct. 2000.

4. Kwiatkowski, C.; Booth, R.E.; and 

Lloyd, L.A.The effects of offering 

free treatment to street-recruited 

opioid injectors. Addiction

95(5):697-704, 2000.

5. Metzger, D.S.;Woody, G.E.;

McLellan, A.T.; O’Brien, C.P.;

Druley, P.; Navaline, H.; et al.

Human immunodeficiency virus 

seroconversion among in- and 

out-of-treatment intravenous drug 

users: An 18-month prospective 

follow-up. J Acquir Immune Defic 

Syndr (6):1049-1056, 1993.

6. Des Jarlais, D.C.; Marmor, M.;

Paone, D.;Titus, S.; Shi, Q.; Perlis,T.;

et al. HIV incidence among injecting

drug users in New York City 

syringe-exchange programs.

Lancet 348(9033):987-991, 1996.

7. Hurley, S.F.; Jolley, D.J.; Kaldor, J.M.

Effectiveness of needle-exchange 

programmes for prevention 

of HIV infection. Lancet

349(9068):1797-1800, 1997.

8. Pinkerton, S.; Holtgrave, D.;

DiFranceisco,W.; Semaan, S.;

Coyle, S.L.; and Johnson-Masotti, A.P.

Cost-threshold analyses of the 

National AIDS Demonstration 

Research HIV prevention interventions. AIDS 14(2):1257-1268, 2000.

9. Kahn, J.; and Haynes-Sanstad, K.

The role of cost-effectiveness 

analysis in assessing HIV prevention

interventions. AIDS and Public Policy

Journal 12(1):21-30, 1998.

10. Des Jarlais, D.C.; Hagan, H.;

Friedmann, P.; et al. Maintaining low 

HIV seroprevalence in populations 

of injecting drug users. JAMA

274(15):1226-1231, 1995.

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 21

Comprehensive communitybased HIV prevention

approaches help avert future

medical costs associated with

the care and treatment of

HIV/AIDS.
RESEARCH ON PREVENTING HIV/AIDS AND

OTHER INFECTIONS IN DRUG-USING POPULATIONS

Epidemiology of 

Risk Behaviors

Reusing and sharing syringes, needles,

and other drug injection equipment

exposes injecting drug users (IDUs) to

the risk of contracting or transmitting

HIV and other blood-borne infections

(e.g., hepatitis B (HBV) and hepatitis C

(HCV). In addition to injecting drug

use, unprotected sexual contact with

infected individuals is a major way that

these and other sexually transmitted

diseases (STDs) are transmitted.

During the course of the HIV/AIDS

epidemic, the major groups at risk for

HIV in the United States have been

men who have had sex with men,

IDUs, the sexual partners of IDUs, and

people who have blood transfusions.

Today, however, the boundaries

between the major risk groups are

less distinct. Considerable mixing

occurs among different at-risk populations who engage in multiple types of

drug use, high-risk needle practices,

and unsafe sex. A disproportionate

number of HIV/AIDS cases, most of

which are associated with injecting

drug use, have occurred among racial

and ethnic minority populations of both

genders.These changes reflect the

dynamic interactions of the epidemic

and simultaneous risk-taking behaviors,

including injecting and non-injecting

drug use, unprotected sex with multiple

partners, and the exchange of sex for

drugs or money (1).

IDUs have one of the highest HBV

incidence rates among all risk groups,

and at least half of all new HCV cases

occur among IDUs. Studies have shown

that infection with HBV and HCV 

frequently occurs soon after an 

individual begins injecting drugs.

Prevalence rates vary considerably,

but have been reported as high as 

50 percent for HBV and 65 percent

for HCV among people who have

injected drugs for less than a year.

Co-infections of HBV, HCV, and HIV

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 23

Prevalence rates have been

reported as high as 50 percent

for hepatitis B virus and 65

percent for hepatitis C virus

among people who have

injected drugs for less than 

a year.
and experiences gained through the

NADR program.When crack cocaine

emerged in the mid-1980s, it was

quickly identified as a major risk factor

for unsafe sex, other drug use, and

HIV transmission, and the CA program

expanded the target population 

to include non-injecting crack 

cocaine users.

Community-based outreach was a

central intervention strategy in both

the NADR and CA programs, and

was shown to be a highly effective

approach for contacting and engaging

out-of-treatment drug users (4). Early

in the HIV/AIDS epidemic, a prevailing

belief was that IDUs and their sex

partners would not or could not

modify their behaviors in response 

to the threat of infection. However,

findings from the NADR and CA 

programs demonstrated that, with 

the help of well-designed prevention

programs, drug users can stop using

drugs, change their risk behaviors,

and reduce their risks for acquiring 

or transmitting the HIV infection (4,5).

Following is a brief overview of 

each program.

National AIDS Demonstration

Research (NADR) Program

The NADR program was conducted

from 1987 to 1992 in 29 sites across

the United States.The program investigated the effectiveness of outreachbased interventions in reducing HIV

risks among out-of-treatment injection

drug users and the non-injecting

female sex partners of male IDUs.

During the study, outreach workers

from the local communities were 

sent to contact members of the target

population and begin risk-reduction

activities in places where IDUs tend to

gather.The outreach workers provided

drug users with information on how

HIV/AIDS is transmitted, prevented,

and treated and materials to reduce

risks for infection, such as condoms

and bleach kits to disinfect injection

equipment. Outreach workers also

provided referrals to drug users for

locally available services, including 

drug abuse treatment and medical

care for HIV/AIDS.The communitybased outreach intervention often

included follow-up activities, such as

confidential HIV testing and counseling

and individual risk assessment.

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 25

have been found to cluster in IDUs

and, in some geographic regions, are

endemic among long-term IDUs. HCV

is now considered an opportunistic

infection in HIV-positive people,

according to the U.S. Public Health

Service and the Infectious Diseases

Society of America (2). Although a

vaccine is not yet available for HIV or

HCV, data on the HBV vaccine indicate

that it is possible to immunize injecting

and non-injecting drug users successfully.

The strong epidemiologic association

between HIV and other STDs also has

been recognized since the HIV/AIDS

epidemic began. Some studies have

reported a two- to five-fold increased

risk for HIV among people who have

other STDs (3). Shifts in the HIV/AIDS 

epidemic in the United States highlight

the important cofactor effects of STDs.

The notable increase in heterosexual

HIV transmission among young women,

especially young African-American

women, has been linked in part to the

disproportionate rate of other STDs

in this group (3), as well as to the 

mixing of drugs (including the noninjecting use of heroin, crack cocaine,

amphetamines, and other substances),

alcohol, and unprotected sex. Moreover,

pregnant women who use drugs or

24 Research on Preventing HIV/AIDS and Other Infections in Drug-Using Populations

are the sex partners of IDUs risk

transmitting one or more infections to

their infants. Because the proportion

of asymptomatic STDs is higher

among women than among men, many

women are unaware that they have 

an infection and do not seek routine

screening examinations.Therefore,

testing and counseling for HIV and

other blood-borne and sexually transmitted infections, including routine

screening for asymptomatic STDs,

are critically important for controlling,

preventing, and treating these infections.

Research Programs on

HIV/AIDS Prevention in

Drug-Using Populations

NIDA initiated two national multisite

intervention programs—the National

AIDS Demonstration Research

(NADR) program and the Cooperative

Agreement (CA) for HIV/AIDS

Community-Based Outreach/

Intervention Research Program—to

study the effectiveness of HIV/AIDS

prevention approaches among injecting

drug users and their sex partners.

The NADR program began in 1987.

In 1990, NIDA established the CA

program, which built on the findings
Cooperative Agreement (CA) Program

The CA program was carried out in

23 sites (21 in the United States, and

one each in Puerto Rico and Brazil)

from 1990 to 1999. It was designed 

to advance the knowledge base gained

through the NADR program. Successful

elements of the NADR program were

incorporated into the CA program,

and the study design was refined based

on its scientific results and insights.

Community-based outreach workers

contacted out-of-treatment IDUs and

crack cocaine users to participate 

in the intervention.These individuals

were assigned to basic or “enhanced”

intervention services, but they had

access to the same basic services at 

all study sites.The basic intervention

involved community-based outreach 

as a prelude to two education and

counseling sessions.The sessions were

organized around optional HIV testing

and counseling, which was provided 

to help drug users learn whether they

had tested positive or negative for 

HIV and what behavioral changes they

needed to make to reduce their HIV

transmission risks.

26 Research on Preventing HIV/AIDS and Other Infections in Drug-Using Populations

References

1. Rothenberg, R.B.; Long, D.; Sterk, C.;

Pach, A.; Potterat, J.J.; Muth, S.; and 

Baldwin, J.A.The Atlanta Urban 

Network Study: A blueprint for 

endemic transmission. AIDS 

14:2191-2200, 2000.

2. Centers for Disease Control 

and Prevention (CDC). 1999 

USPHS/IDSA Guidelines for 

the Prevention of Opportunistic 

Infections in Persons Infected 

with HIV: U.S. Public Health Service 

(USPHS) and Infectious Diseases 

Society of America (IDSA).

MMWR 48(RR-10), 1999.

3. CDC. HIV prevention through early

detection and treatment of other 

sexually transmitted disease—

United States recommendations 

of the advisory committee 

for HIV and STD prevention.

MMWR 47(RR-12):1-24, 1998.

4. Coyle, S.L.; Needle, R.H.; and 

Normand, J. Outreach-based HIV 

prevention for injecting drug users:

A review of published outcome 

data. Public Health Reports

113(Suppl 1):19-30, 1998.

5. Stephens, R.C.; Simpson, D.D.;

Coyle, S.L.; McCoy, C.B.; and 

the National AIDS Research 

Consortium. Comparative 

effectiveness of NADR interventions.

In: Brown, B.S.; and Beschner, G.M.,

eds. Handbook on Risk of AIDS.

Westport, CT: Greenwood Press,

pp. 519-556, 1993.

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 27
RESOURCES

General Inquiries:

NIDA Public Information and 

Liaison Branch, 301-443-1124

NIDA’s HIV Prevention

Research Activities: 

Center on AIDS and Other Medical

Consequences of Drug Abuse 

(CAMCODA), 301-443-1801

NIDA’s Web Site:

www.drugabuse.gov

Selected NIDA Educational 

Resources on HIV Prevention

in Drug-Using Populations

The following publications are available

from the National Clearinghouse 

on Alcohol and Drug Information

(NCADI) at 1-800-729-6686,

or online at www.drugabuse.gov.

28 Resources

The NIDA Community-Based

Outreach Model: A Manual To

Reduce the Risk of HIV and Other

Blood-Borne Infections in Drug

Users. (2000) Provides principles of

HIV prevention for out-of-treatment

drug-using populations, information 

on community-based HIV prevention,

a discussion of the roles of effective

community-based outreach workers,

instructions for conducting communitybased outreach, information for 

program managers for designing an

outreach risk-reduction program in

their communities, and cue cards 

to use during counseling sessions.

NIH Publication No. 00-4812, or 

available at the NIDA Web site at

www.drugabuse.gov.

HIV Prevention With Drug-Using

Populations: Current Status and

Future Prospects. Public Health Reports

(1998); 113(Suppl 1). Provides a 

historical perspective on the current

status of the knowledge base on 

prevention of HIV in drug-using 

populations, and includes sections 

on community-based outreach 

risk-reduction interventions, syringe

exchange/access programs, drug abuse

treatment, social networks and their

roles in preventing HIV in drug users,

and future directions for HIV prevention

research. For sale by the U.S.

Government Printing Office,

ISBN 0-16-049601-2.

Integrating Cultural, Observational,

and Epidemiological Approaches in

the Prevention of Drug Abuse and

HIV/AIDS. (1999) Provides a historical

and future perspective on the integration of qualitative and quantitative

methods approaches for the collection,

analysis, and interpretation of data on

drug abuse and HIV/AIDS, and shows

how combining epidemiological and

ethnographic methods informs the

development of effective HIV prevention interventions for drug users.

NIH Publication No. 99-4565, or 

available from the NIDA Web site 

at www.drugabuse.gov.

Preventing Drug Use Among

Children and Adolescents: 

A Research-Based Guide. (1997)

Provides an overview of research on

the origins and pathways of drug abuse,

the basic principles of drug abuse 

prevention, and the development and

application of research-based programs

for the prevention of drug abuse

among children and adolescents.

NIH Publication No. 99-4212, or 

available from the NIDA Web site 

at www.drugabuse.gov.

Principles of Drug Addiction

Treatment: A Research-Based Guide.

(1999) Summarizes basic overarching

principles that characterize effective 

treatment, describes types of treatment,

and presents examples of scientifically

based and tested treatment components. NIH Publication No. 99-4180,

or available from the NIDA Web site

at www.drugabuse.gov.

Research Monographs

Qualitative Methods in Drug 

Abuse and HIV Research (Research

Monograph 157). (1995) Describes

advances in the use of qualitative

research methods for the study of

drug abuse and HIV/AIDS, including 

a review of qualitative methods, their 

appropriateness for different populations and settings, and their strengths

and limitations. NIH Publication 

No. 95-4025, or available from the

NIDA Web site at www.drugabuse.gov.

Social Networks, Drug Abuse, 

and HIV Transmission (Research

Monograph 151). (1995) Explores

the roles of social networks and 

network characteristics on patterns 

of risk behaviors and the transmission

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 29
of HIV/AIDS, including the use of 

network analysis techniques for 

developing and implementing strategies

to prevent HIV transmission among

drug-using populations. NIH Publication

No. 95-3889, or available from the

NIDA Web site at www.drugabuse.gov.

The Collection and Interpretation

of Data From Hidden Populations

(Research Monograph 98). (1990)

Examines the use of qualitative

approaches in the analysis and understanding of complex human behavior,

including the use of ethnographic

methods for contacting hard-to-reach

and hidden populations of drug users

and other at-risk individuals. DHHS

Publication No.(ADM)90-1678, or

available from the NIDA Web site 

at www.drugabuse.gov.

Additional Information

NIDA’s 5-Year Strategic Plan.

NIDA's overarching goal for the next

5 years is to significantly reduce the

health and social consequences of

drug abuse and addiction. Using input

from Congress, the Institute's staff, its

advisory groups, and its constituents,

NIDA has developed three broad

strategies and several priority areas

30 Resources

within each that will be pursued to

fulfill this goal. Information on the

strategies and priority areas, in addition

to NIDA's basic, clinical, prevention,

epidemiological, and services research

areas, is available from the NIDA 

Web site at www.drugabuse.gov/

StrategicPlan/Index.html.

Global Research Network (GRN) 

on HIV Prevention in Drug-Using

Populations. In 1998, NIDA 

collaborated with the Office of AIDS

Research at the National Institutes 

of Health, the Joint United Nations

Programme on HIV/AIDS (UNAIDS),

and the World Health Organization

(WHO) to hold the inaugural meeting

of the GRN in Geneva, Switzerland.

The GRN was established to facilitate

international cooperation and collaboration on research to prevent HIV and

other blood-borne diseases among

drug users, to increase understanding

of HIV in drug-using populations, and

to report on new research findings at

both the regional and country levels.

The second annual meeting of the

GRN was held in Atlanta, Georgia,

in August 1999, and the third annual

meeting was held in Durban, South

Africa, in July 2000. For inquiries about

the GRN and the GRN’s proceedings

from the 1998 and 1999 meetings, call

NIDA’s CAMCODA at 301-443-1801.

HIV/AIDS and Drug Abuse Treatment

Services. HIV/AIDS and Drug Abuse

Treatment Services Literature Review.

Barry S. Brown, Ph.D., University 

of North Carolina at Wilmington,

September 1998. Available at NIDA’s

Web site; search for “HIV” or go 

to 165.112.78.61/HSR/da-tre/

BrownHIV.html.

Community Epidemiology 

Work Group (CEWG) Publications.

Participant Observation Study of

Indirect Paraphernalia: Sharing/HIV

Risk in a Network of Heroin Injectors.

Available at NIDA’s Web site; search

for “HIV” or go to 165.112.78.61/

CEWG/ethno.html.

Funding Opportunities

For information on funding opportunities at NIDA, including NIDA’s list of

program announcements, requests 

for applications, and research training 

sites, and for information on grants

and contracts, application guidelines

and policies, forms, and answers to

frequently asked questions, go to 

www.drugabuse.gov/Funding.html.

Other Resources

Center for Substance Abuse

Prevention (CSAP). CSAP, part of the

Substance Abuse and Mental Health

Services Administration, is responsible

for providing national leadership in 

the Federal effort to prevent alcohol,

tobacco, and illicit drug problems that

are intrinsically linked to other serious

national problems, including HIV/AIDS.

CSAP publications are available

through the National Clearinghouse

for Alcohol and Drug Information at

1-800-729-6686. Additional information

about CSAP can be found on its 

Web site at www.samhsa.gov/csap.

Center for Substance Abuse

Treatment (CSAT). CSAT, part of the

Substance Abuse and Mental Health

Services Administration, is responsible

for supporting treatment services

through block grants and developing

knowledge about effective drug abuse

treatment, disseminating the findings to

the field, and promoting the adoption of

these treatments. CSAT also operates

the National Treatment Referral 

24-hour HOTLINE (1-800-662-HELP),

which offers information and referrals

to people seeking treatment programs

and other assistance. CSAT publications

are available through the National

Clearinghouse for Alcohol and Drug

PRINCIPLES OF HIV PREVENTION IN DRUG-USING POPULATIONS 31
Information at 1-800-729-6686.

Additional information about CSAT

can be found on its Web site at

www.samhsa.gov/csat.

The National Clearinghouse for

Alcohol and Drug Information

(NCADI). NIDA publications and 

prevention materials along with 

publications from other Federal agencies

are available from this information

source. Staff provide assistance in

English and Spanish and have TDD

capability. Phone: 1-800-729-6686.

Web site address: www.health.org.

Centers for Disease Control and

Prevention (CDC). CDC is responsible

for promoting health and quality of life

by preventing and controlling disease,

injury, and disability. CDC’s programs

include support for State and local 

disease prevention activities; a national

public information network; education

programs in the Nation’s schools;

disease monitoring; and laboratory,

behavioral, and epidemiologic studies

designed to identify the most effective

interventions to combat HIV. CDC’s

Web site is www.cdc.gov.

32 Resources

Joint United Nations Programme

on HIV/AIDS (UNAIDS). Established

in January 1996, UNAIDS brings

together the United Nations Children’s

Fund, United Nations Development

Programme, United Nations Population

Fund, United Nations International Drug

Control Programme, United Nations

Economic and Social Council,World

Health Organization (WHO), and the

World Bank in leading and supporting

a worldwide effort to prevent HIV

and alleviate the impact of the AIDS

epidemic. UNAIDS’Web site is

www.unaids.org.