AIDS and

Intravenous

Drug Use:

Future Directions

for

Community-Based

Prevention

Research

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • National Institutes of Health
AIDS and Intravenous Drug Use:

Future Directions for CommunityBased Prevention Research

Editors:

C.G. Leukefeld, D.S.W.

R.J. Battes, D.S.W.

Z. Amsel, Sc.D.

Division of Clinical Research

National Institute on Drug Abuse

NIDA Research Monograph 93

1990

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

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For sale by the Superintendent of Documents, U.S. Government Printing Office

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NIDA Research Monographs are prepared by the research divisions of the

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NB Associates Health Sciences

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KARST J. BESTEMAN

Alcohol and Drug Problems Association

of North America

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Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph D.

The Johns Hopkins Unversity School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph D.

Washington University School of

Medicine

St Louis, Missouri

MARY L. JACOBSON

National Federation of Parents for

Drug Free Youth

Omaha, Nebraska

REESE T. JONES, M. D.

Langley Porter Neuropsychiatric Institute

San Francisco, California

DENISE KANDEL, Ph.D.

College of Physicians and Surgeons of

Columbia Universitv

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Yale University School of Medicine

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New Jersey State Department of Health

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NIDA Research Monograph Series

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Director, NIDA

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Acting Associate Director for Science, NIDA

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
AIDS and Intravenous Drug Use:

Future Directions for CommunityBased Prevention Research
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from a technical

review on AIDS and intravenous drug abuse that took place on

February 25 and 26, 1988, in Rockville, MD. The review meeting was

sponsored by the Division of Clinical Research, National Institute on

Drug Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from

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material as noted in the text. Further reproduction of this

copyrighted material is permitted only as part of a reprinting of the

entire publication or chapter. For any other use, the copyright

holder’s permission is required. All other material in this volume

except quoted passages from copyrighted sources is in the public

domain and may be used or reproduced without permission from the

Institute or the authors. Citation of the source is appreciated.

Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the National

Institute on Drug Abuse or any other part of the U.S. Department of

Health and Human Services.

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 reported herein.

National Institute on Drug Abuse

NIH Publication No. 94-3714

Formerly DHHS Publication No. (ADM) 89-1627

Printed 1990 Reprinted 1994

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics Index,

BioSciences Information Service, Chemical Abstracts, Current

Contents, Psychological Abstracts, and Psychopharmacology Abstracts.

iv
Contents

Page

Introducing the Concept “Community Prevention”. . . . . . . . vii

Zili Amsel

Communication and Health Education Research:

Potential Sources for Education for Prevention

of Drug Use . . . . . . . . . . . . . . . . . . . . . . 1

Nathan Maccoby

The Puerto Rican Intravenous Drug User. . . . . . . . . . . 24

Yolanda Serrano

AIDS Prevention for Non-Puerto Rican Hispanics . . . . . . . . 35

Barbara V. Marin

Black Intravenous Drug Users: Prospects For

Intervening in the Transmission of Human

lmmunodeficiency Virus Infection . . . . . . . . . . . . . . 53

Lawrence S. Brown, Jr.

Community-Based AIDS Prevention Interventions:

Special Issues of Women Intravenous Drug Users. . . . . . . 68

Josette Mondanaro

Preventing AIDS: Prospects for Change in White Male

Intravenous Drug Users . . . . . . . . . . . . . . . . . 83

James L. Sorensen

Sexual Minority Needle Users . . . . . . . . . . . . . . . 108

A. Silly S. Jones

v
Risk Behavior of Intravenous Cocaine Users:

Implications for Intervention . . . . . . . . . . . . . . . . 120

Dale D. Chitwood, Clyde B. McCoy, and Mary Comerford

An Ethnographic Approach to Understanding HIV

High-Risk Behaviors: Prostitution and Drug Abuse. . . . . . . 134

Michele G. Shedlin

The Role of Schools in Community-Based Approaches to

Prevention of AIDS and Intravenous Drug Use. . . . . . . . . 150

Lewayne D. Gilchrist

The Role of Drug Abuse Treatment Programs in AIDS

Prevention and Education Programs for Intravenous

Drug Users: The New Jersey Experience . . . . . . . . . . 167

Joyce F. Jackson, Leslie G. Rotkiewicz, and

Robert C. Baxter

Lost Opportunity to Combat AIDS: Drug Abusers in the

Criminal Justice System . . . . . . . . . . . . . . . . . 187

Eric D. Wish, Joyce O’Neil, and Virginia Baldau

The Homeless Intravenous Drug Abuser and the

AIDS Epidemic . . . . . . . . . . . . . . . . . . . . . 210

Herman Joseph and Hilda Roman-Nay

HIV-Related Disorders, Needle Users, and the

Social Services. . . . . . . . . . . . . . . . . . . . . 254

Lawrence C. Shulman, Joanne E. Mantell,

Charles Eaton, and Stephen Sorrell

Accessing Intravenous Drug Users via the

Health Care System . . . . . . . . . . . . . . . . . . . 277

Patricia E. Evans

Community Prevention Efforts to Reduce the Spread

of AIDS Associated With Intravenous Drug Abuse . . . . . . . 288

Robert J. Battjes, Carl G. Leukefeld, and

Zili Amsel

List of NIDA Research Monographs. . . . . . . . . . . . . 300

vi
Introducing the Concept

“Community Prevention”

Zili Amsel, SC. D.

The impact of the acquired immunodeficiency syndrome (AIDS) on

intravenous (IV) drug abusers is only beginning to be assessed.

According to the surveillance system of the Centers for Disease

Control (CDC), over 25 percent of all reported adult and adolescent

cases of AIDS in the United States are attributed to IV drug abuse,

and the percentage is growing (Centers for Disease Control 1988).

However, the effect of AIDS on IV drug abusers has been even

greater than indicated by AIDS case data. Many IV drug abusers

have died of AIDS-related conditions. AIDS among heterosexual IV

drug abusers has been reported in all 50 States, the District of

Columbia, and Puerto Rico, and is heavily concentrated along the East

Coast. For women with AIDS, IV drug abuse is the primary risk

factor, accounting for 52 percent of adult and adolescent female

cases. Finally, 11 percent of gay AIDS cases also have IV drug abuse

as a risk factor.

Ethnic groups, overrepresented among IV drug abusers, are also

overrepresented among heterosexual IV drug abusers with AIDS.

Whereas blacks account for 12 percent of the U.S. population, blacks

make up 51 percent of heterosexual IV drug abusers with AIDS.

Similarly, while 6 percent of the general population are Hispanic,

over 30 percent of the heterosexual IV drug abusers with AIDS are

Hispanic.

According to reports from the National Institute on Drug Abuse

(NIDA), there are an estimated 1.1 to 1.3 million IV drug abusers in

the United States (Centers for Disease Control 1987). Various studies

(Lange et al. 1988; Des Jarlais et al. 1988a) report that between

70 percent and nearly 100 percent of IV drug abusers share the use

vii
of injection equipment, with resulting high risk for contracting and

transmitting AIDS.

The effects of AIDS are not limited to IV drug abusers, but extend

also to their sexual partners and children. About 70 percent of those

born in the United States and reported to the CDC as having AIDS

attribute their infection to heterosexual contact with an IV drug

abuser. About 75 percent of perinatal transmission (from mother to

child during pregnancy or childbirth) has been attributed to children

of IV-drug-using women or to women who were the sexual partners

of IV drug abusers (Chamberland et al. 1987; Oxtoby, personal

communication, 1987).

Preventing the AIDS epidemic associated with IV drug abuse requires

a broad program that includes multiple strategies. This effort must

include interventions designed to alter high-risk behaviors among IV

drug abusers and their sexual partners and to educate the public

about the infection so that when a vaccine or therapeutic intervention becomes available, mechanisms are in place to reach those

with the greatest need.

Risk-reduction programming needs to extend beyond medical and drug

abuse treatment facilities to also reach IV drug abusers who are not

in treatment and their sexual partners. These efforts need to include

all sexual partners of IV drug abusers, not only spouses. lt seems

that AIDS prevention programs should separate components that

disseminate information from those that are designed to change

behaviors. Each of these approaches addresses different objectives,

but they are interdependent, one approach reinforcing the other.

For the first approach, factual information about infection with the

human immunodeficiency virus (HIV) and AIDS is provided through

one or more channels, such as electronic media, written materials, or

information sessions. For some people, information dissemination is

sufficient to alter attitudes and behaviors. Usually, these are

individuals who hold values and beliefs that are compatible with the

messages being transmitted. The social networks of these individuals

also support these messages and the associated behavior change. In

most cases, those most readily affected by media messages are highly

educated and mainstream members of the population. For any largescale health promotion effort, however, messages channeled through

media provide the structural support for more intensive behaviorchange programs. Continued messages reinforce the norms of the

community for the desired behaviors.

viii
For harder-to-reach populations, particularly those not in the

mainstream of society, such as addicted, needle-using persons,

additional strategies are necessary. These strategies need to be

tailored to address the special parameters of the target population.

These parameters include perceptions of AIDS, its transmission, and

its relative importance in the lives of the population, as well as

existing levels of involvement in high-risk behaviors. Barriers and

enhancers to the initiation and maintenance of desired behaviors also

should be identified and addressed.

However, most educational programs directed towards AIDS prevention

among IV drug abusers are concerned with information dissemination.

Community outreach workers or professional workers intervene in

one-on-one relationships and through informal contact and counseling

to address the individual drug user’s attitudes and behaviors. Many

of these program activities are not standardized or well documented,

making their assessment difficult to conduct.

Early studies conducted in New York and San Francisco have

indicated that high levels of knowledge about AIDS exist among IV

drug abusers (Des Jarlais et al. 1988b). Yet, knowledge alone does

not appear to be sufficient incentive for individual behavior change.

In interviews with 59 methadone patients in Manhattan regarding

their knowledge of AIDS and their use of protective behaviors,

Friedman and associates found that more than 90 percent were

knowledgeable about AIDS (Friedman et al. 1986). However, only 54

percent reported any change in their drug injection practices.

In conjunction with a seroprevalence study conducted in 1984 and

1985 in New Jersey, an assessment was made of knowledge of AIDS

and self-reported protective behaviors among IV drug abusers in

treatment. Facts about AIDS, how HIV is transmitted, and its

symptoms were well known to these IV drug abusers. However,

knowledge was not related to behavior change, and only about onethird of those interviewed knew how to sterilize injection equipment.

Furthermore, about a third incorrectly believed that those infected

with HIV necessarily show signs and symptoms of infection. Finally,

slightly more than half were aware that HIV could be transmitted

sexually or perinatally (Ginzburg et al. 1986).

Educational programs have had some success in changing drug

injection behavior and in enrolling abusers in drug treatment

programs. For example, in San Francisco, local health outreach

workers are distributing small bottles of bleach and instructions for

ix
cleaning injection equipment. During the period prior to the

program, 3 percent of IV drug abusers interviewed as part of an

evaluation study reported that they used bleach for this purpose.

One year later, 67 percent reported that they did so (Watters et al.

1987). In New Jersey, outreach workers developed a voucher system

for treatment programs for those IV drug abusers who could not pay

for such services. The vouchers served three purposes: (1) to

measure contacts on the street, (2) to describe the characteristics of

those reached, and (3) to facilitate entry into treatment. lt was

found that 80 percent of the first 1,000 vouchers were redeemed at

detoxification programs. Of those redeeming vouchers, 40 percent

had not previously been enrolled in treatment. After detoxification,

over 200 individuals went on to longer treatment programs (Jackson

et al., in press).

These reports indicate that providing information about AIDS risk

factors alone has not been effective in altering high-risk behaviors.

Thus, intervention programs must go beyond just providing facts and

include behavior-change strategies that not only encourage the

initiation of risk reduction, but also the maintenance of these

behaviors. However, AIDS prevention strategies for IV drug abusers

will not be directly comparable to those used for other AIDS risk

groups, such as gay men and hemophilia and transfusion patients.

Components from these programs, as well as from other types of

programs such as those directed to smoking cessation, seat belt use,

family planning, and cardiovascular disease and cancer prevention, can

be incorporated into a comprehensive intervention model.

IV drug use is not a problem of one group but includes people from

all social classes, educational levels, ethnic groups, religions, and

geographic areas. The possession of drugs for nonmedical purposes is

illegal throughout the United States, and possession of injection

equipment is also illegal in most States. IV drug abuse has been

found to be associated with other illegal or deviant behaviors (Des

Jarlais et al. 1986; Des Jarlais et al. 1988a; Agar 1973). It should be

recognized that for some persons and groups, drug abuse is intertwined with their economic and social lives. Furthermore, sexual

behavior, independent of IV drug use, is defined by group norms and

individual sexual identity. Therefore, many personal, social, and

cultural barriers must be addressed in order to alter high-risk drug

use and sexual behaviors.

Because of the special needs of IV drug abusers and their sexual

partners, an AIDS intervention program designed for this population

x
should address multiple objectives and requires multilevel, highly

integrated interventions. lt is suggested here that the intervention

should be community based to be effective in reaching the greatest

numbers of the target population, particularly any hidden population

such as the IV drug abuser not in drug abuse treatment programs.

Such interventions should be designed to: (a) prepare various

members of the community for forthcoming AIDS preventive efforts,

(b) overcome barriers to high-risk-behavior change, and (c) bring

about high-risk-behavior change among those in the community.

Community support for AIDS-prevention programming suggests

strategies that use multiple community channels, such as broadcast

and print media. The media could be used to increase knowledge

levels about HIV transmission and perceptions of susceptibility among

residents. Messages for the general population should be clear,

simple, to the point, and repeated. Human-interest stories about HIV

infection could be presented to demonstrate that the problem is not

limited to stereotypical drug abusers, but affects various people, their

sexual partners, and their children, with whom drug abusers can

identify. Eliminating the barrier between “them” and “us” will

increase perceptions of individual susceptibility and familiarity, and

redefine the AIDS problem as “our problem.” A media program could

be developed not just to reach drug abusers but also those around

them to create an environment that encourages and reinforces

behavior change. To assure support from the community,

participation by leaders with broad constituencies is recommended,

including religious groups, labor organizations, and political figures,

as well as the involvement of local community leaders on active task

forces and work groups.

Results of the Stanford and North Karelia cardiovascular disease

prevention programs (Fortmann et al. 1988; Puska et al. 1983) suggest

that behavior-change interventions should not only build on media

support but also should focus on small group and individual

interventions based on a theoretical framework. Printed or

audiovisual materials along with personal discussions provide

instructions for skills needed for behavior change as well as answer

questions that arise in response to the educational messages.

Furthermore, group sessions provide the social and psychological

support needed for initiating and reinforcing such changes. It is

suggested that groups identified with broad health, social, and

community issues be used to help increase effectiveness. Finally, to

xi
reach those who are more self-directed or who have no social

supports, interventions should include “one-on-one” strategies such as

hotlines and counseling services.

A key resource that can fit within the context of a community-based

prevention and intervention program is drug treatment, with aftercare

components to reinforce the decision to give up drug use. Facilities

for HIV testing and counseling, with followup and medical care, also

must be available.

To identify and describe innovative ways for preventing and reducing

the spread of HIV among drug abusers, their sexual partners, and

their children, NIDA convened a technical review meeting in February

1988. The aim of the meeting was to propose recommendations for

future directions for community-based prevention research within the

context presented here. “Community,” for the technical review, was

defined as “any set of formal or informal group relationships that has

some established criteria for membership.” The chapters in this

volume examine communities from two perspectives: (1) having one

or more demographic characteristics, and (2) formal institutional

membership. Each author was asked to describe current knowledge

about HIV infection in a selected community; community factors or

characteristics that support or hinder performance of protective and

preventive behaviors (e.g., cultural, social, economic, psychological, or

functional); any available documented community experiences specific

to the target group with other related preventive behaviors; anecdotal

experiences specific to the target group with behaviors associated

with HIV transmission as well as other related preventive behaviors;

suggestions for intervention models for the target groups; and

suggestions for associated research initiatives.

Communities represented here include IV drug abusers who are black,

Puerto Rican, and members of other Hispanic groups; white males;

gays; users of nonopiate drugs; and prostitutes. Also incorporated are

institutional settings, including schools, drug abuse treatment

facilities, the criminal justice system, shelters for the homeless, the

social service system, and the health care system.

Based on the papers presented, participants at the technical review

meeting considered future directions in community AIDS prevention in

two concurrent discussion groups focused on intervention models and

research methodology. The recommendations of these groups are

presented as the final chapter in this book.

xii
REFERENCES

Agar, M.H. Ripping and Running: A Formal Ethnography of Urban

Heroin Addicts. New York: Seminar Press, 1973. 79 pp.

Centers for Disease Control. Acquired immunodeficiency syndrome

(AIDS). Weekly Surveillance Report, June 20, 1988.

Centers for Disease Control. A Review of Current Knowledge and

Plans for Expansion of HIV Surveillance Activities: A Report to

the Domestic Policy Council. November 30, 1987. 48 pp.

Chamberland, M.; White, C.; Lifson, A.; and Dondero, T.J. AIDS in

heterosexual contacts: A small but interesting group of cases.

Presented at the Third International Conference on AIDS,

Washington, DC, June 1-5,1987.

Des Jarlais, D.C.; Friedman, S.R.; Sothern, J.L.; and Stoneburner, R.

The sharing of drug injection equipment and the AIDS epidemic in

New York City: The first decade. In: Battjes, R.J., and Pickens,

R.W., eds. Needle Sharing Among intravenous Drug Abusers:

National and International Perspectives. National Institute on Drug

Abuse Research Monograph 80. DHHS Pub. No. (ADM)88-1567.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988a.

pp. 160-174.

Des Jarlais, D.C.; Friedman, S.R.; and Stoneburner, R.L HIV

infection and intravenous drug use: Critical issues in transmission

dynamics, infection outcomes, and prevention. Rev Infect Dis

10:151-158, 1988b.

Des Jarlais, D.C.; Friedman, S.R.; and Strug, D. AIDS among

intravenous drug users: A socio-cultural perspective. In: Feldman,

D.A., and Johnson, T.A., eds. Social Dimensions of AIDS: Methods

and Theory. New York: Praeger Publishing Company, 1986.

pp. 11-126.

Fortmann, S.P.; Haskell, W.L; Williams, P.T.; Varady, A.N.; Hulley,

A.B.; and Farquhar, J.W. Community surveillance of cardiovascular

disease in the Stanford Five-City Project: Methods and initial

experience. Am J Epidemiol 123(4):656-669, April 1986.

Friedman, S.R.; Des Jarlais, D.C.; and Sothern, J.L. AIDS health

education for intravenous drug users. Health Educ Q 13:383-393,

1986.

Ginzburg, H.M.; French, J.; Jackson, J.; Hartsock, P.I.; MacDonald,

M.G.; and Weiss, S.H. Health education and knowledge assessment

of HTLV-III diseases among intravenous drug users. Health Educ Q

13:373-382, 1986.

Jackson, J.; Rotkiewicz, L.G.; Quinones, M.A.; and Passannante, M.R.

A coupon program: Drug treatment and AIDS education. Int J

Addict 24, in press.

xiii
Lahge, W.R., et al. Geographic distribution of human immunodeficiency virus markers in parenteral drug abusers. Am J Public

Health 78(4):443-446, April 1988.

Oxtoby, M.J. Centers for Disease Control, personal communication,

1987.

Puska, P.; Salonen, J.A.; Nissinen, A.; Tuomilehto, J.; Vartiainen, E.;

Korhonen, H.; Tanskanen, A.; Rönnqvist, P.; Koskela, K.; and

Huttunen, J. Change in risk factors for coronary heart disease

during 10 years of a community intervention programme. (North

Karelia Project) Br Med J 287: 1840-1844, 1988.

Watters, J.K. Preventing human immunodeficiency virus contagion

among intravenous drug users: The impact of the street-based

education on risk behavior. Presented at the Third International

Conference on AIDS, Washington, DC, 1987.

AUTHOR

Zili Amsel, Sc.D.

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A16

5600 Fishers Lane

Rockville, MD 20857

xiv
Communication and Health

Education Research:

Potential Sources for Education

for Prevention of Drug Use

Nathan Maccoby

INTRODUCTION

In this paper, research conducted during the last 20 years is briefly

described that has been applied to reduction of disease risk in communities. Most of the work reported is based on the Stanford Center

for Research In Disease Prevention’s work in communities. Included

are experiences from the Three Community Study (TCS), the still ongoing Five City Project (FCP), and the work done in schools. The

hope is that some of this experience may suggest methods and ideas

that might be successful in preventing or reducing behavior that may

contribute to high risk of acquired immunodeficiency syndrome (AIDS)

infection.

BACKGROUND

Chronic disease, especially cardiovascular disease (CVD) and, to a lesser extent, cancer, became the largest contributors to death and disability in this and other highly developed countries by the middle of

this century. Risk factors for heart disease had been identified

through the long-term Framingham study and other epidemiological

investigations (Dawber 1980). The three major risk factors are smoking, high blood pressure, and blood cholesterol. As blood pressure

and blood cholesterol could be controlled through diet, exercise, and

drugs, it was seen that behavior changes needed to take place to

reduce the risk of heart disease.

To address the prevention of CVD, John W. Farquhar and Stanford

Medical School co-researchers Peter D. Wood, Byron W. Brown, Jr.,

William Haskell, and Michael Stern joined in a decision in early 1970

to develop a research plan to explore efficient means of risk

1
reduction in the population at large and to participate in clinical

trials. In Farquhar’s view, such a plan would require a broad interdisciplinary team of biomedical and social scientists to address the

wide range of questions raised by the research problem. This led him

to reach beyond medical science and to consult with Nathan Maccoby,

the Department of Communication, and other behavioral scientists.

This group began to assess how best to design a public education

program in CVD risk reduction.

Since the primary risk factors of smoking, diet, and high blood pressure were distributed across large segments of the total adult population, techniques that would reach large numbers of people were called

for. At this point, the idea of intervening in total communities

through mass media was introduced. After reviewing the projected

limitations in resources and manpower, the decision was reached to

limit the target population to all adults aged 35 to 59.

As a result of interaction between the communication researchers,

psychologists, communication specialists, and others, Farquhar and the

biomedical scientists made a basic change in the research plan. They

turned from a medical model, concerned with high-risk populations

and key health-professional opinion leaders, to a more complex but

potentially more effective community model, relying principally on

communication as the basic intervention tool.

The role of mass media in achieving behavior change is complex.

Steve Chaffee, in a 1982 review of the evidence arguing that interpersonal sources of information are by nature more persuasive than

media, points out that the evidence varies greatly (Chaffee 1982).

Furthermore, mass media interact in complex ways with other sources

of communication. Media information may lead one to seek interpersonal confirmation; the reverse is also true. For example, when

people heard of the J.F. Kennedy assassination from others, they

checked the truth of the rumor by consulting radio, TV, and

newspapers.

Diffusion of information and practices takes place partly through

mass media (“everybody is doing it”), and partly through institutions

and organized groups. Communities can take on major tasks like prevention, using a myriad of facilities to organize activities. Schools,

worksites, churches, clubs, and families can all serve as agents of a

communitywide effort to achieve changes in behavior that puts people

at risk or to prevent such behavior from being learned and

performed.

2
The environment can be altered in ways that are likely to reduce the

incidence of risky activities. Cigarette machines kept away from minors or abolished; smoking banned in worksites and public places; cigarette advertising banned or heavily restricted; more healthful foods

supplanting disease-promoting ones in schools, restaurants, fast-food

places, and food-dispensing machines all help to reduce the incidence

of smoking and high-cholesterol diets. In addition, exercise opportunities can be made readily available to the public.

Since the media campaign was to be directed at entire communities,

random assignment of individuals to the treatment or control condition was not feasible. An equally rigorous experimental method,

treating a large number of entire, geographically defined populations

as single units and randomly assigning some of these communities to

treatment and some to control conditions, was not administratively

possible (Farquhar 1978). We concluded that the most realistic compromise between feasibility and rigor was a quasi-experimental research approach using a small number of communities as experimental

units.

After considering the powerful cultural forces that reinforce and

maintain the health habits we wished to change, and in view of past

failure of health education campaigns, we designed a heretofore untested combination of extensive mass media with a considerable

amount of face-to-face instruction. We chose the latter method not

so much because it was potentially widely applicable, but because it

was judged most likely to succeed (Maccoby and Alexander 1979). It

was then possible to compare mass media, a more generally applicable

though less promising treatment with a sound approach. Therefore,

another community was selected in which treatments were administered via mass media alone. Three strategies not usually incorporated

in health campaigns were used in our approach:

(1) the mass media materials were devised to teach specific behavioral skills, as well as to perform the more usual tasks of

offering information and affecting attitudes and motivation;

(2) both the mass media and, in particular, the face-to-face instruction were designed to embody many previously validated methods

of achieving changes in behavior and self-control training

principles; and

3
(3) the campaign was designed on the basis of careful analysis of

the specific needs and the media consumption patterns of the

intended audiences. Our goal was to devise and evaluate

methods for effecting changes in smoking, exercise, and diet

that would be both cost effective and applicable to large population groups.

THE STANFORD THREE COMMUNITY STUDY (TCS)

Three roughly comparable communities in northern California were

selected for the study. Tracy was chosen as a reference town because it was relatively distant and isolated from media in the other

two communities. Gilroy and Watsonville, the other two communities,

share some media channels (television and radio), but each town has

its own newspaper. Watsonville and Gilroy received different strategies of health education over a period of 2 years. Both received

health education through the mass media, but in Watsonville face-toface was added using a randomized design with a sample of persons

at high levels of risk for cardiovascular disease. Two-thirds of this

group received the face-to-face instruction, while the remaining

people in this group were exposed only to media health education.

The intensive instruction program was composed of education and

persuasion in the context of social learning and self-control training

procedures designed to achieve the same changes in cholesterol and

fat consumption, body weight, cigarette smoking (Meyer et al. 1977),

and physical exercises that were advocated in the media campaign.

The instruction was conducted by a team of graduate students in

communication, medical students, and health educators trained in behavior modification techniques. The protocols were pretested in a

controlled setting before being applied in the field. The basic sequential strategy was to present information about the behavior that

influences risk of coronary heart disease, stimulate personal analysis

of existing behavior, and demonstrate desired skills (e.g., food selection and preparation), using such channels as TV spots and bus cards.

The mass media component consisted of a broad range of materials,

including about 50 different television spots, 3 hours of television

programming, over 100 different radio spots, several hours of radio

programming, weekly newspaper columns, newspaper advertisements

and stories, billboards, printed material sent via direct mail to participants, posters, and other assorted materials. Because of the sizable

Spanish-speaking population in the communities, the campaign was

4
presented in both Spanish and English. The Spanish media programs

were designed to be culturally relevant.

The dominant characteristic of the mass media campaign was organizational. The campaign was an integrated information system with

primary functions that included the creative transformation of the

medical risk-reduction messages into media events, the formative

evaluation of those events, their distribution in coordinated packages

over time, and their cumulative effectiveness in promoting change.

The management of this system was put into operation by a process

of continuous monitoring of the target audience’s existing knowledge,

beliefs, attitudes, risk-related behavior, and media use. The media

campaign began 2 months after an initial survey and continued for

9 months in 1973; stopped during a second survey; continued for

9 more months in 1974; then continued on a very reduced basis in

1975 (Farquhar et al. 1977, Maccoby et al. 1977).

At the onset of the campaign, decisions were based primarily on data

gathered at the initial survey, from the pretesting on local audiences

of various media productions, and on the practical considerations

arising from the likely availability of privately owned mass media.

While the campaign was under way, further guidance was obtained

from the second annual survey and from a series of systematic but

informal small-scale information-gathering efforts designed to provide

media planners with immediate feedback on the public’s awareness and

acceptance of specified sets of media events, as well as to gauge the

progress to date. Thus, the total campaign could be seen as a set of

phased media events where the information obtained from monitoring

was used to refocus priorities, reset directions, and modulate the

course of the campaign in the desired direction.

The intensive instruction program content was designed to guide the

individual through tentative practice of the skills mentioned above,

and gradually withdraw instructor participation. The expectation was

that the behavior would be maintained in the group setting without

the instructor. During the initial stage, intensive instruction was

conducted in group classes and home counseling sessions. During the

second year, the frequency and amount of contact was successively

reduced. A less intensive educational campaign was conducted in the

summer months of the third year.

The results of the education program, over a 2-year period, demonstrated a surprisingly large decrease in a composite risk score

5
for CVD. This risk score is an adaptation of one used in the

Framingham longitudinal study (Farquhar et al. 1977). This decrease

was about 25 percent for those exposed to only the mass-media

campaign and about 30 percent for those who also received intensive

instruction. The risk reduction in the community provided with mass

media education was comprised almost equally of contributions from

blood pressure reduction, blood cholesterol reduction, and decreased

cigarette use. Among the individuals who received additional intensive instruction, a larger proportion of change was due to decreased

cigarette use. Changes were reasonably well maintained during a

third year of decreased education, especially for the intensively

instructed group (Meyer et al. 1980; Williams et al. 1981).

Therefore, it appears that the amount of education provided, as described, was sufficient to produce impressively large decreases in predicted future risk of CVD in an adult population. The change when

relying only on media education was especially surprising, given the

generally poor results of prior media-based health campaigns

(Robertson et al. 1974). Although no fixed standard of comparison is

available, due to a combination of the difficulty in quantifying the

amount of education and a general lack of well-evaluated health

education studies, it does appear that, in areas of generally high

public interest, a reasonably small amount of well-designed printed,

television-based, and radio-based health education combined with a

small amount of community organization and personal influence can

produce substantial changes in knowledge, behavior, and physiological

states that confer risk (Farquhar et al. 1977; Maccoby et al. 1977).

The experimental design involved development and application of a

mass media and face-to-face instruction campaign. These communication efforts were designed to overcome deficiencies of previous

unsuccessful campaigns to change behavior. Each campaign was intended to produce awareness of the probable causes of coronary

disease and of the specific behaviors that may reduce risk. The campaigns also aimed at providing the knowledge and skills necessary to

accomplish recommended behavior changes. Last, the campaigns were

designed to help the individual become self-sufficient in maintaining

new health habits and skills. Dietary habits recommended for all

participants were those that, if followed, would lead to a reduced intake of saturated fat, cholesterol, salt, sugar, and alcohol. We also

urged reduction in body weight through caloric reduction and increased physical activity. Cigarette smokers were educated on the

need and methods for ceasing or at least reducing their daily rate of

cigarette consumption.

6
For the mass media campaign, a coordinated set of messages was

prepared for the audiences in Gilroy and Watsonville. Over time,

these basic messages were transformed for a variety of media. The

TCS demonstrated that mass media, when appropriately used, can increase knowledge and help people improve their health habits. The

results led us to believe, however, that the power of this method

could be enhanced considerably if we employed the media to stimulate

and coordinate face-to-face instructional programs in natural community settings (e.g., schools, workplaces, community organizations).

Thus, the TCS led to further investigation designed to test these

ideas.

THE STANFORD FIVE CITY PROJECT (FCP)

The FCP began in 1978 and will continue until 1991 (Farquhar et al.

1985). The FCP differs from the TCS in that the two communities

selected for education are much larger, the health education campaign

is aimed at benefiting the entire population, the communities are

more complex socially, the education program is more extensive, there

are three reference cities rather than one, the education program will

run for 6 years rather than 3, the effects of the intervention are

being monitored for a wider age range (12 to 74), changes in CVD

event rates (i.e., morbidity and mortality) are being measured, and a

community organization program is being devised to create a costeffective and lasting program of community health promotion.

There are two major hypotheses being tested in the FCP. The first

hypothesis is that communitywide education can achieve a lasting

reduction in the prevalence of CVD risk factors within a general

population, leading to substantial decline in the Framingham multiple

logistic measure of risk in a representative sample of persons age 12

to 74. The second hypothesis is that this risk decline will lead to a

decline in CVD morbidity and mortality in persons age 30 to 74, and

that this decline will be greater in the education cities than in the

reference cities.

The education program of the FCP was introduced after completion of

a baseline population survey. The effects of education on reducing

risk factors are being assessed by comparing the results of the four

independent sample surveys (cross-sectional) and cohort sample surveys (longitudinal) in the two treatment communities, with the results

of the same survey types in two of the three reference communities.

Epidemiologic surveillance of CVD morbidity and mortality is done in
all five cities and will continue beyond the education program

(Fortmann et al. 1986).

The education program has three goals. The first is to generate an

increase in the knowledge and skills of individuals and in the educational practices of organizations, such as providing for exercise facilities and/or heart-healthy food choices and a smoke-free environment,

to bring about risk factor reduction and decreased morbidity and

mortality. A second goal is to carry out the education program so

that a self-sustaining health promotion structure, embedded within the

organizational fabric of the communities will continue to function

after the project ends. The third goal is to derive a model for costeffective community health promotion from the experiences and data

accumulated in the TCS and this study that will have general applicability to other American communities.

The intervention itself consists of three components: broadcast

media, print media, and community interpersonal programs.

Broadcast Media Components

The primary goal of using broadcast media in the FCP is to encourage lasting behavior change that will result in risk factor modification and, ultimately, reduction in morbidity and mortality. Underlining this major goal are two subgoals: encouraging direct behavior

change and encouraging indirect change through support of community

events. Some broadcast media products are hybrids: for example, a

smoking cessation television show could encourage cessation as well

as recruiting individuals to the smoking cessation programs available

in the community. A wide variety of broadcast media programs are

used, including public service announcements, TV news series, radio

series and talk shows, and TV shows.

Print Media Programs

Print materials (e.g., newspapers, books, pamphlets, etc.) can usually

provide more information than television and radio and therefore better skills training. Print media can provide messages of higher information density than can broadcast media, and they can be read and

reread at the user’s own pace, providing a large amount of information in user-oriented format. Reading print media can be greatly

stimulated through the use of electronic media.

8
Print media products are distributed through direct mail and through

existing organizations such as worksites and medical care providers.

A variety of print media programs are used in the FCP. Big print is

intended to carry a major message over a relatively long period of

time. Media promotion print is any print piece whose primary objective is to motivate individuals to attend to the FCP’s media events.

Educational support print includes any pieces whose purpose is to

support classes or workshops and includes reinforcing the knowledge

and skills being taught in an educational program. The purpose of

local print is to satisfy the projects’ objectives of developing indigenous (i.e., community-owned) print materials.

Because of the large Spanish-speaking population in the intervention

communities, mass media have included Spanish language. Radio production, for example, concentrates on Spanish language programs,

since this is a major information source for this target group. In

addition, weekly newspaper columns in both English and Spanish are a

major part of the print media program.

Community Interpersonal Programs

The FCP community interpersonal programs are delivered through a

variety of organizations, including health departments, community colleges, schools, voluntary organizations, health professionals, worksites,

hospitals, and other nonprofit health service agencies. These programs include traditional strategies such as classes and lectures.

They also include more innovative efforts such as incentive-based

contests and use of lay leaders/role models.

Formative and Process Evaluation Methods

The program is being assessed by formative, process, and summative

evaluation methods. There are at least seven specific topics in which

formative evaluation assists in the design, development, production,

and distribution of the educational program. These include:

(1) audience needs analysis–understanding audience attitudes,

beliefs, self-efficacy, and knowledge;

(2) audience segmentation–identifying subsections of the community

with factors in common such as needs, risk, demographic characteristics, and media use;

9
(3)

(4)

(5)

(6)

(7)

program design–addressing questions such as the proper name,

location, and time for program and use of appropriate educational methods and materials;

program testing–testing an early version of an intervention with

relevant audiences;

message design pretesting–to improve the effectiveness of

specific mass media messages;

community event analysis–investigation of the factors that

motivate participants to attend an event, how they learn about

an event, what they thought about an event, and how this experience will influence their future participation and behavior

change attempts; and

media event analysis–analysis of community media events.

A variety of process evaluation strategies are employed. lt is essential to identify a number of steps in the process of community

change and to measure each step. For example, while the ultimate

outcome variable in these studies may be a change in morbidity and

mortality due to heart disease and stroke, it is also important to

measure intermediate stages such as success in community organization, knowledge, attitude change, skills learning, and performance and

maintenance of these skills. One needs to know who changed in response to interventions. lt is also important to evaluate the success

of achieving stable and meaningful change in community practices and

institutions as a measure of success in leaving behind a program that

runs partly or totally on its own energies. While one cannot guarantee a totally clear explanation of success or failure, the use of process evaluation strategies will provide some important clues for future

research and intervention.

Summative Evaluation Methods

The population surveys of health behavior on CVD risk factors are

conducted by full-time FCP staff at permanent survey centers in four

of the five cities. City directories of households, published by R.L.

Polk, provide a relatively complete listing of households in each community (approximately 97 percent complete) and are revised every 2

years. All individuals 12 to 74 years of age who reside in randomly

selected households at least 6 months of the year are eligible for the

10
surveys, are invited to participate, and are included in the denominator for calculation of participation rates (Farquhar et al. 1985).

There are two main types of samples included in the surveys: a cohort or longitudinal sample and an independent or cross-sectional

sample. In the initial year of the survey, 625 people in each community visited the survey centers, comprising the first independent

sample. These individuals were invited to participate in subsequent

surveys every 2 years, to study the process of change in CVD risk

and related behaviors over time. Second, third, and fourth independent samples will be selected over the last 6 years of the project to

study cross-sections of the community without the potential confounding effects of repeated measurements.

The chief sources of data on health-related behaviors are questionnaires and dietary measures. The core questionnaire consists of the

following components: demographic measures, attitude and opinion

measures, health knowledge assessment related to prevention of heart

disease and stroke, stress behavior, diet/nutrition and weight behavior, smoking behavior, physical activity behavior, communication media

use and interpersonal communication network analysis, and medical

history including medication use. Finally, a random 50 percent of the

participants are given a 24-hour dietary recall, aided by food models

to illustrate size, weight, or volume of foods.

A variety of physiologic measures are obtained, including weight,

nonfasting venous samples (for lipid, lipoprotein, and plasma thiocyanate analysis), expired air carbon monoxide as a measure of

cigarette use, blood pressure, urine samples (for urinary sodium, potassium, and creatinine measures), a low-level exercise test, and pulse

rates.

Community Organization

It was always assumed that community organization would play a significant role in both the initial success and the durability of our program. In accord with this assumption, our educational program is

conducted in a manner that encourages involvement from the outset

by local community groups and is designed to lead to local ownership

and control. Several assumptions underlie this approach.

(1) Mass media education alone is powerful, but its effects may be

augmented by community organization.

11
(2)

(3)

(4)

(5)

Interpersonal influence can be enhanced inexpensively through

community organization, and this can allow a multiplier effect to

occur that will increase behavior change.

Organizations can expand our educational program’s delivery system in ways that are lmportant for achieving communitywide

health education.

Organizations can help the process of community adoption of

risk reduction programs as their own, thus increasing the likelihood of continuing health education programs and maintained

behavior change.

Formation of new organizations can be catalyzed by our external

efforts to increase the array of groups concerned with health

education and health promotion.

FCP Results

The results of the FCP are not yet complete. There will be a fifth

independent sample and an additional cohort sample taken at the end

of 1989. The surveillance of morbidity and mortality, which is expected to lag behind changes in risk, will be carried on for several

more years.

Main interim results from the cohort sample indicate significant improvements in knowledge of CVD risk factors, reductions in blood

pressure (both systolic and diastolic), and a reduction in pulse rate.

Total risk, i.e., the multiple logistic function of CVD risk incorporating age, sex, plasma cholesterol, systolic blood pressure, relative

weight, and smoking used as a predictor of a cardiovascular event

within 12 years, was significantly lower in the cohort comparison.

Currently, the extension to self-help communities of programs of

disease prevention and health promotion is being carried by the

Kaiser Family Foundation with our staff serving as a resource center.

Summary of Community Studies

Findings indicate that the use of an interdisciplinary staff of cardiologists, epidemiologists, behavioral scientists, biostatisticians, and

communication specialists makes it possible to mount communitybased studies aimed at reducing the incidence and prevalence of

chronic disease, especially cardiovascular disease. Methodologically,

12
quasi-experimental designs involving the collection of a variety of

demographic, physiological, and behavioral data can serve as baselines

for prospective intervention studies and can assist in the design and

creation of such interventions.

The TCS provided substantial indications that risk factors in CVD

could be reduced through community education. The FCP is the attempt to replicate and extend these findings by additional means of

intervention. Through these interventions, it is hoped that changes

can be initiated and institutionalized with sufficient magnitude and

duration to provide a means for reducing risk of, as well as morbidity

and mortality due to, CVD.

THE STANFORD ADOLESCENT HEART HEALTH PROJECT

The Stanford Adolescent Heart Health Project is a 4-year, schoolbased research program conducted by investigators from the Stanford

Center for Research in Disease Prevention. The project is designed

to develop and test a multifactor cardiovascular risk reduction/prevention intervention for 15-year-old adolescents.

CVD begins early in life but might be prevented or delayed by primary prevention programs designed for children and adolescents

(Berenson 1980). Interventions that only delay onset may still reduce

the severity of the disease and the costs of medical care. Studies

providing data on the effectiveness of multifactor programs designed

to promote adolescent health behavior change in nonclinic settings

are limited. Research is needed that develops procedures to help

young people acquire and practice positive health behaviors and that

measures the effects of treatment over time and with multiple indices

of behavior change.

The Need for Early lntervention

Most researchers would agree that our modern lifestyle (cigarette

smoking, diets rich in animal fat, sedentary habits) contributes to the

development of CVD (Stamler 1980). Available evidence suggests that

behaviors associated with cardiovascular risk are acquired early in

life and may contribute to early onset of the disease (Berenson 1980;

Stamler 1980; Coates et al. 1981; Lauer and Shekelle 1980). Autopsy

studies on young soldiers (average age, 22) killed in the Korean war

revealed gross coronary atherosclerosis in 77 percent of these men

who had no known clinical evidence of coronary disease (Farquhar

1987). Elevated blood pressure, cigarette smoking, and sedentary

13
lifestyle in college students have been shown to predict both fatal

and nonfatal coronary heart disease (Paffenbarger et al. 1966; Thorne

et al. 1968). Between 10 percent and 25 percent of adolescents are

at least moderately overweight (Lauer et al. 1975). Sizeable numbers

of children and adolescents show evidence of elevations in blood

cholesterol (Lauer et al. 1975; Frerichs et al. 1976). Analyses of

children’s diets suggest that over 40 percent of the calories eaten are

from fat in concordance with adult eating patterns. Saturated fat

accounts for 15 percent to 18 percent of calories eaten, and dietary

cholesterol is well in excess of 300 mg per day. lt is well known

that smoking rates among teenagers escalate sharply beginning in

middle school and continue to rise into early adulthood (U.S. Office

on Smoking and Health 1988). As Berenson (1980) has stated, “If

today’s children grow up like their parents, 20 to 30 percent of them

will have hypertension as adults. Ninety percent will develop significant atherosclerotic lesions, and over 50 percent will die from hypertension and atherosclerosis.” Thus, there is a clear need for preventive efforts beginning prior to the appearance of manifest clinical

symptoms (Stamler 1980).

Advantage of a Multifactor Perspective

The Stanford Adolescent Heart Health Project is a natural outgrowth

of earlier work conducted by Stanford Center researchers on the efficacy of school-based smoking prevention programs (Killen 1985). In

this earlier work, senior high school students (aged 16 to 17) are

trained to conduct smoking prevention programs in middle school

(ages 12 to 13) settings. The high school students help to equip

their younger peers with coping skills enabling them to resist social

and cultural influences that promote cigarette smoking. This research

has shown that prevention programs based on empirically tested social

learning principles can help junior high school adolescents develop

new health behaviors and maintain them, once training is complete.

The intervention was administered through physical education departments as part of the regular physical education curriculum. All 10th

graders in each treatment school attended the experimental course

sessions 3 days each week.

Health Behavior Change Programs for High-School-Aged

Adolescents

Comparatively little health behavior change research has been conducted with adolescents 15 to 17 years of age. Successful smoking

14
prevention programs and weight loss treatments developed for

implementation in schools have been conducted in elementary and

middle schools. While it is often assumed that interventions with

younger children may prove more successful in achieving intervention

goals, prevention programs may need to be delayed in order to

coincide with developmental periods that favor skills acquisition and

performance (Johnson 1982) or periods in which strong social influences to engage in unhealthful behavior occur. Thus, older adolescents may benefit more from treatment because they possess cognitive

and behavioral competencies necessary to understand and act upon

new health and behavior change information (Johnson 1982). One aim

of this study (Killen et al. 1988) is to develop health behavior change

strategies that take into account the influence processes specific to

older adolescents.

Objectives

The Stanford Adolescent Heart Health Project includes the following

objectives:

(1)

(2)

(3)

(4)

(5)

(6)

to collect data on the prevalence of cardiovascular risk factors

in an adolescent population;

to develop procedures for building adolescents’ self-regulatory

skills and thus strengthen perceived competence in practicing

healthy lifestyle behaviors;

to test methods for increasing adolescents’ knowledge concerning

the role of lifestyle behaviors in the development of cardiovascular disease;

to decrease the cardiovascular risk factor behaviors of cigarette

smoking and excessive consumption of calories, saturated fats,

cholesterol, and salt;

to increase the cardiovascular risk-reduction behaviors of

aerobic exercise and complex carbohydrate consumption: and

to lower the risk factor variables of blood pressure and obesity.

Recruitment and Training of Teaching Staff

A 10-member teaching staff was recruited and trained to deliver the

educational program. The basic classroom instruction was provided by

15
eight full-time teachers. One additional staff person served as a

coordinator and backup teacher in each of the treatment schools.

The coordinator attended classroom sessions and had primary

responsibility for monitoring the intervention to ensure that

educational protocols were implemented correctly.

The core teaching staff was composed of young women and men in

their early twenties, on staff with the Center for Research in Disease

Prevention. All teachers had previous training in health studies

and/or previous experience in health care/health research settings. A

performance-based teacher training model was used to provide staff

with the skills necessary for successful administration of the educational protocols. The educational program was divided into four basic

modules. The teaching staff spent 3 days each week in the high

school classrooms delivering the intervention. Teachers spent 1 day a

week at Stanford preparing for the subsequent week’s activities.

During training sessions, teachers were first guided through the instructional protocols to acquaint them with the teaching objectives

and strategies for particular modules. The staff then broke into

smaller groups for rehearsal with feedback from group members. As

a third step, teachers enacted protocols for the larger group.

Theoretical Perspectives Guiding the Intervention

If students are to adopt healthy lifestyles, treatment programs must

build students’ perceived value of acquiring heart-healthy behaviors;

help them make immediate changes in current practices; help them

generalize new practices to family, work, and recreational settings;

and help them maintain new behaviors in the face of numerous personal and social inducements to return to old habits or to adopt less

healthful habits.

The goals of the Stanford Project, based principally on Bandura’s

social learning principles (Bandura 1986), are to train adolescents

with guided practice in which instructors first model appropriate

counters to inducements to smoke and then help students to invent

and use appropriate counters. The Stanford Project aims to provide

strengthened environmental context for our intervention, because in a

school-based program we are able to marshal environmental support

necessary to sustain behavioral change. The environment may play a

critical role in fostering maintenance by providing support and inducements for desired behaviors.

16
Education Components

The education program consists of 20 classroom sessions, each lasting

50 minutes. The 20 sessions are divided among five modules. Students in the education program receive an introductory module

acquainting them with the concept of a healthy lifestyle and surveying the major risk factor variables: smoking, high blood pressure,

and high blood cholesterol. This module discusses the benefits of

weight control, physical activity, stress management, nonsmoking, and

heart-healthy diet. A major goal of this module is to persuade students that various lifestyles may have important immediate effects on

life quality as well as potential long-term health consequences, and

thus to raise the incentive value of making lifestyle changes.

The emphasis on immediate consequences may be particularly critical

or behavior change in this age group. Our surveys suggest that adolescent interest in health issues stems, primarily, from concerns for

personal appearance and, to a lesser extent, physical conditioning.

Therefore, dietary and physical activity changes may be accomplished

most effectively by emphasizing relationships between health and personal appearance and condition. For example, dietary change may be

most effective for some students when embedded in weight management programs.

A second goal of this module is to introduce students to the concept

of self-regulation. This module demonstrates how self-regulatory

skills may be used to achieve control over behavior. Specifically,

students are shown how heart-healthy behavior change may be accomplished through the application of various self-regulatory techniques. Specific techniques include setting specific, proximal change

goals, monitoring progress toward proximal goals, problem solving, use

of self-instructional strategies, and applying self-managed incentive

systems.

Following the introductory module, students are guided through a

series of modules designed to provide them with detailed information

on risk factor behaviors and opportunities to assess their lifestyle

patterns. Thus, each module features information/demonstration and

self-assessment.

As part of the final sessions devoted to problem-solving training,

each student is required to carry out one self-change project

designed to improve heart health. Special features of the treatment

program include videodrama and role-play simulations.

17
Videodrama is designed to increase students’ receptivity to altering

risk factor behavior. Our previous work suggests that efforts to

build appreciation for a heart-healthy lifestyle must precede behavioral skills training. As a first step in achieving this objective, a

39-minute videodrama presenting the contemporary, dramatic story of

teenagers facing real-life situations and crises was developed. The

dramatization was designed to increase adolescents’ intentions to

adopt and practice heart-healthy behaviors by producing a shift in

their valuation of a heart-healthy lifestyle. Specific aims of the

videodrama are to:

(1)

(2)

(3)

(4)

(5)

strengthen students’ beliefs in the positive benefits accompanying practice of heart-healthy behaviors (e.g., regular aerobic

exercise);

strengthen students’ beliefs in the negative consequences associated with the practice of risky behaviors (e.g., cigarette

smoking);

reduce students’ beliefs in the negative consequences associated

with the practice of heart-healthy behaviors;

reduce students’ beliefs in the positive consequences associated

with the practice of risky behaviors; and

increase students’ beliefs in their ability to assume personal

control over their behavior.

Role-play simulations are designed to help students invent coping

strategies for managing high-risk situations. Skill acquisition and

performance are enhanced by rehearsal (Bandura 1986). Role-play

simulations enable students to prepare themselves to manage difficult

“real-life” situations and to devise and practice new behaviors under

nonthreatening conditions. Behavioral practice serves an important

role in the transfer of skills from school to home and recreational

environments by boosting perceived competence in performance

capability.

Evaluation

Measurements are obtained in school gymnasiums and cafeterias.

Males and females are separated. Approximately 100 to 120 students

are assessed during each 50-minute class period. Assessments

18
consist of self-report questionnaires and physiologic measurements.

Questionnaire and physiological data are collected for each classroom.

Two days are required to collect data from all 10th graders in one

school.

Two persons serve as monitors in each room. Monitors are trained

to administer the questionnaire and to keep order in the classroom.

Twenty measurement specialists are trained to collect the various

physiologic data. The measurement staff are divided into specialist

teams. Each team collects only one physiologic measure.

Preliminary findings suggest that the intervention has achieved a

relatively strong effect (Killen et al. 1988). Knowledge gains in the

treatment group are impressive. Changes in physical variables, particularly among females in the treatment group, may be indicative of

the effectiveness of the intervention in promoting behavior change as

well as increasing students’ knowledge of CVD risk factor concepts.

Along with the analyses of CVD risk factor data, the research project

has enabled us to make contributions in adolescent health areas outside our primary focus.

SUMMARY

Studies conducted by the Stanford Center for Research in Disease

Prevention have been carried out over the last 15 years. These

studies indicate that, with systematic planning by interdisciplinary

research teams, field research projects, based on appropriate theory,

can be mounted successfully both at the community level and in

schools for the study of adolescents and for adolescent children.

Both final and interim results are for the most part encouraging.

While all of the research reported here applies to health problems

completely different from AIDS, some useful suggestions may emerge.

For one thing, in both AIDS prevention and chronic disease prevention, the most effective measures to be taken appear to be behavioral. The research reported here is almost exclusively concerned with

developing and testing methods for assisting people to change their

behavior in ways that are likely to promote health and reduce risk of

disease. They involve education at a community level and in schools.

Perhaps education for AIDS prevention can follow similar lines with

some success.

19
Recently, several studies have been directed toward the prevention of

drug abuse habits being formed by schoolchildren. A 1994 Rand Corporation report summarizes a number of relevant studies and describes

models that have been applied (Polich et al. 1994). These programs

are aimed at nonuser adolescents who otherwise might become users.

It depicts four stages of experimental use of drugs: (1) nonuse–never

tried drugs, (2) experimental or episodic use, (3) regular or frequent

use, and finally (4) heavy use. Primary prevention is aimed at the

early stages of use. The methods used are essentially those described

above. Students need to be able to identify pressures to begin usage,

especially from peers. They then need to know the dangers and

problems arising from drug use. Next, and crucially, they need to

develop skills to resist such pressures and practice using the skills in

the presence of such pressure. Role-play situations can help in this

process. Project Star at the University of Southern California (not

yet published) has recently completed a large-scale seventh grade

study in Los Angeles junior high schools. They found the following

social approaches worked best in the prevention of drug abuse behavior. These approaches promoted group identification, explained the

nature of peer pressure, clarified the misinformation on the prevalence of drug use among peers, made clear the consequences of drug

use, and used role-playing techniques to teach resistance skills.

Results were assessed over a 3-year period and indicated success in

delaying the onset of tobacco, marijuana, and alcohol use. They did

not apply these methods to the prevention of hard drug use. Clearly

such research is badly needed.

In research concerned with reduction of risk of CVD, the Stanford

group elected to intervene at the level of the community for a

number of reasons. Since risk of CVD is so widespread and since

primary prevention was our goal, we sought to educate entire

communities on the behavior needed for risk minimization.

It is also the case that communities offer a number of opportunities

for such intervention. Organizations such as schools, media outlets,

worksites, local health departments, churches, local health organizations such as chapters of the American Heart Association, American

Lung Association, American Cancer Society, and many others offer

means of diffusion that can multiply the education program’s reach.

In this paper, such community studies have been described with a

special emphasis on youth via schools. It is our hope that this model

may have some applicability to problems of primary prevention of

drug abuse.

20
REFERENCES

Bandura, A. Social Foundations of Thought and Action. lnglewood

Cliffs, NJ: Prentice Hall, 1986. 497 pp.

Berenson, G.S. Cardiovascular Risk Factors in Children. New York:

Oxford University Press, 1980. 453 pp.

Chaffee, S.H. Inter/Media: Interpersonal communication in a media

world. In: Gumpert, G., and Cathcart, R., eds. Mass Media and

Interpersonal Channels: Competitive, Convergent or Complementary? New York: Oxford University Press, 1982. pp. 57-77.

Coates, T.J.; Perry, C.; Killen, J.D.; et al. Primary prevention of

cardiovascular disease in children and adolescents. In:

Prokop, C.K., and Bradley, L.A., eds. Medical Psychology

Contributions to Behavioral Medicine. New York: Academic Press,

1981. pp. 157-196.

Dawber, T.R. The Framingham Study–The Epidemiology of Atherosclerotic Disease. Cambridge, MA: Harvard University Press, 1980.

257 pp.

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Five-City Project: Design and methods. Am J Epidemiol

122(2):323-334, 1985.

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surveillance of cardiovascular diseases in the Stanford Five-City

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and triglycerides in 3446 children from a biracial community: The

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eds. Promoting Adolescent Health. New York: Academic Press,

1982. pp. 137-148.

Killen, J.D. Annotation: Prevention of adolescent tobacco smoking:

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Psychiatry 26(1):7-15, 1985.

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Killen, J.D.; Telch, M.J.; Robinson, T.N.; Maccoby, N.; Taylor, C.B.;

and Farquhar, J.W. Cardiovascular disease risk reduction for tenth

graders: A multiple factor school based approach. JAMA

260(12): 1728-1733,1988.

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disease risk factors in school children: The Muscatine Study. J

Pediatr 86:697-706, 1975.

Lauer, R.M., and Shekelle, R.B. Childhood Prevention of Atherosclerosis and Hypertension. New York: Raven Press, 1980. 484 pp.

Maccoby, N., and Alexander, J. Reducing heart risk using the mass

media comparing the effects on three communities. In: Munot,

R.F.; Snowden, L.R.; Kelley, J.G.; et al., eds. Social and

Psychological Research in Community Settings. San Francisco:

Jossey-Bass, 1979. pp. 69-100.

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cardiovascular disease. J Community Health 3:100-114, 1977.

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leadership in a cardiovascular health education campaign.

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cardiovascular health education campaign. J Consult Clin Psychol

48(2):129-142.1980.

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disease in former college students 1. Early precursors of fatal

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Controlling Adolescent Drug Use. Santa Monica, CA: Rand

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the effect of television messages on safety belt use. Am J Public

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Hypertension. New York: Raven Press, 1980. 484 pp.

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618 pp.

22
Williams, P.T.; Fortmann, S.P.; Farquhar, J.W.; et al. A comparison of

statistical methods for evaluating risk factor changes in communitybased studies: An example from the Stanford Three-Community

Study. J Chronic Dis 34:565-571,1981.

AUTHOR

Nathan Maccoby, Ph.D.

Stanford Center for Research on

Disease Prevention

Stanford University

1000 Welch Road

Palo Alto, CA 94304

23
The Puerto Rican Intravenous

Drug User

Yolanda Serrano

INTRODUCTION

Acquired immunodeficiency syndrome (AIDS) has come to represent

one of the major afflictions of modern times, with tremendous individual and social costs. The groups suffering the most profound

consequences of, and at greatest risk for, AIDS are ethnic minorities

with the lowest national incomes, limited health care knowledge, and

the poorest access to health care (Centers for Disease Control 1986;

Bakeman et al. 1987). Historically, minorities have had limited access

to quality care, primarily due to economic factors. Sociocultural

barriers such as language, social class, education, and nonmainstream

health-care beliefs have affected minority communities. A Puerto

Rican who develops AIDS might suffer from already existing impaired

health and might delay treatment until later in the progression of the

disease. Based upon the experience of this writer, the result is that

the number of persons with AIDS in the minority community is

underestimated, and many more people of color are dying.

DRUG USE

Any examination of AIDS and the ethnic community must take drug

use into consideration. The role of the addict is very important in

the AIDS epidemic in three ways: the addict’s contact with heterosexuals; the addict’s use of needles, syringes, and other drug

paraphernalia; and the risk of vertical transmission to the unborn

child (Drucker 1987). AIDS is spreading at a faster rate in minority

communities due to the progressive disease of addiction.

Compounding the disease of addiction is human immunodeficiency

virus (HIV) infection. Current estimates suggest that 1- to 11⁄2-

million people in the United States have been exposed to the AIDS

virus (Department of Health and Human Services 1987). When citing

24
the extent to which intravenous drug users (IVDUs) contribute in the

racial distribution of AIDS, the Centers for Disease Control (CDC)

report that although Hispanics are 8 percent of the national

population, they account for 14 percent of the U.S. AIDS cases

(Centers for Disease Control 1986). In addition, Hispanic women

account for 21 percent and children account for 22 percent of

reported cases (Bakeman et al. 1987). The statistics concerning

Hispanics and AIDS are grim. The Puerto Rican community in New

York is unknowingly being devastated. According to the 1980 census,

Hispanics comprise 19.9 percent of New York City’s population, yet

they represent 21 percent of the city’s adult cases of AIDS. The

New York City Department of Health indicates that 24 percent of all

cases of AIDS were among Hispanics. Of the 2,785 Hispanic men

with AIDS, 49 percent were IVDUs, 41 percent had sex with other

men, and 6 percent engaged in both behaviors. For 4 percent, the

risk category was unknown. Hispanics comprised 32 percent of adult

female AIDS cases. Of the 474 adult Hispanic women with AIDS,

59 percent used IV drugs, and 30 percent had sex with a man at risk.

Of the children with AIDS, 32 percent had Hispanic mothers (New

York City Department of Health 1988a).

In Brooklyn, New York, which has a large Puerto Rican community,

as of November 13, 1987, 274 (60 percent) of the total of 453

Hispanic males with AIDS were IV substance abusers; 133 (30 percent)

were gay, and 21 (5 percent) were both gay and IVDUs. Of the 102

total Hispanic females with AIDS in Brooklyn, more than half (66

percent) were IVDUs (New York City Department of Health 1987).

The number of cases, particularly heterosexual and pediatric AIDS

cases, is staggering. The infected IVDU transmits the virus to a sex

partner, who then passes it on to the unborn child, changing the

epidemic into a family disease in the Puerto Rican community. In the

United States, the New York City area has the highest seroprevalence

rate. The area also has the greatest number of AIDS cases among

IVDUs. Over 75 percent of IV drug use AIDS cases in the United

States have been from the States of New York and New Jersey.

Blacks and Hispanics constitute 39 percent of U.S. AIDS cases, but

52 percent of New York City’s AIDS cases (Des Jarlais 1987). In

addition, New York has reported half of all the female AIDS cases in

the United States. In New York City, which has reported over half

of all the pediatric AIDS cases, approximately 80 percent of AIDS

cases have been found in children of IVDUs. There are

approximately 100,000 to 120,000 women in New York City of childbearing age, and therefore contribute to more than 5,000 births per

25
year. The majority of these women are Hispanic and black, who do

not realize they are at risk or that their sexual partners currently

use or have ever used IV drugs.

PUERTO RICAN DRUG ABUSER

In explaining the plight of the Puerto Rican addict, a better understanding of the economic conditions that have existed and are major

factors in the incidence of drug use in the Puerto Rican community

must be examined. The problem of IV drug abuse has disproportionately affected Puerto Ricans in New York. Therefore, IV drug

abuse became a Puerto Rican problem. In a classic study of heroin

addiction, Chein et al. (1964) reported a high correlation among high

levels of drug abuse, low levels of education, and high levels of

family breakdown in poor Hispanic areas. The same study found a

relationship between those areas with fewer social and economic

problems and low rates of drug abuse. The pressures of growing

population, unemployment, poverty, overcrowding, massive

displacement of Puerto Ricans from their neighborhoods, and

continued dispersals in the city, combined with cultural and linguistic

differences, have contributed to the disintegration of the Puerto

Rican community. These factors place an enormous burden on the

survival of the Puerto Rican family. The family is the heart of the

Puerto Rican culture and the base of strength and support. The

Puerto Rican addict’s family is involved in most of his life, from

growing up to courtship, when a man must speak to the woman’s

parents to declare his intentions.

Between 1980 and 1987, the Puerto Rican population in the United

States grew by 35 percent, from 2 million to an estimated 2.7 million.

According to the 1980 U.S. census 1,107,129; or 55 percent, were born

in Puerto Rico and migrated to the mainland; 906,825, or 45 percent,

were born in the mainland to Puerto Rican parents. In addition,

about 43 percent of all Puerto Ricans in the United States (860,552)

were living in New York City in 1980 (U.S. Department of Commerce

1980).

While the number of Puerto Ricans increases sharply, economic

conditions worsen, relative to the rest of the Nation. Median family

income for Puerto Ricans, as a percentage of total U.S. income,

continues to decline. Whereas in 1959 the median family income for

Puerto Ricans was 65 percent of white median family income, in 1980

it was 54 percent of total U.S. family income. In 1987, median family

income was estimated at only 46 percent of all U.S. families.

26
Unemployment levels for all Puerto Ricans remained essentially

unchanged throughout the decade as the highest among Hispanics-14

percent in 1988, compared to rates last year of 10.6 percent for all

Hispanics, 5.5 percent for whites, and 12.8 percent for blacks.

Approximately 42 percent of all Puerto Rican families in the United

States are living below the poverty level. The urban tragedy that

has occurred in New York City, the destruction of housing by

burning, has contributed further to disorganization of families, along

with the myriad of other problems.

The family is a traditional way of coping with difficult situations. If

families are being torn apart by drugs, and there are no alternative

ways to deal with the problem, then the future does not look good

for Puerto Ricans. Puerto Rican addicts often speak of their families

and their desire to go back to the way they once were. This is most

apparent when entering a shooting gallery (places addicts go to inject

drugs). When entering a shooting gallery, there is always a reminder

of family life, with pictures, religious items, or other familiar objects.

Poverty and joblessness place an enormous burden on the family’s

survival, family health, and family relations and contribute to the

high incidence of drug abuse.

One way of attempting to reach the IVDU is by building bridges to

their subculture (Des Jarlais et al. 1985; Des Jarlais et al. 1988).

This contact can be achieved by culture brokers or outreach workers.

Such persons have experience and training in both worlds. Through

these informal networks, information can be transmitted to the IV

drug abuser in a culturally familiar and nonthreatening environment.

The culture brokers penetrate the addicts’ social circles and promote

behavior modification through frank and open discussion of HIV

infection. These outreach workers also provide information regarding

access to drug abuse treatment, medical services, and other social

services. In dealing with addicts, experience has shown that they

want treatment for their addiction, they are desperate to get off the

drugs, and they always state they are tired of life on the streets.

WOMEN

AIDS is killing women. In New York City, HIV infection among

IVDUs and their sexual partners continues to increase (New York

City Department of Health 1988a). Many of these women are Puerto

Rican. Addicted women are a special group. What has worked for

other groups is not necessarily going to be effective for women.

AIDS continues to affect women with the fewest resources, the

27
women who are not ready to deal with AIDS. This population is at

high risk for adolescent pregnancies. In New York City there are

approximately 60,000 IV-drug-using women of childbearing age,

according to the New York State Division of Substance Abuse

Services. Women who are IVDUs have been victimized, traumatized,

looked down upon, rejected by society and their own communities,

and even rejected by their families. In addition, most people assume

these women are prostitutes. These women are street addicts as well

as women who use drugs secretly at home (housewives and students).

There are also women in drug treatment programs who continue to

inject cocaine. Many women engage in prostitution to support their

drug habii.

An outreach program aimed at women and men in the sex industry

must be implemented to provide AIDS education and referrals to

health services and other agencies as needed. The program should be

aware of and sensitive to issues affecting those working in the

industry. Services should include referrals for general medical

checkups, pap smears, breast examinations, sexually transmitted

disease (STD) screening, full contraceptive services, pregnancy tests,

drug and alcohol counseling, health and welfare information, free

condoms, and other services. Literature for IV-drug-using women in

the sex industry must be developed, with close attention paid to the

Puerto Rican women. In view of the potential spread of AIDS, it

would seem prudent to increase the level of understanding at street

level as soon as possible. However, both prostitutes and their

clients, predominantly heterosexual males who control the nature of

the sexual contact and can transmit the virus to their families, must

be educated. Present services are not geared to meet the needs of

these groups. The greatest risks for contracting AIDS are multiple

sexual contacts and sharing needles, syringes, and other drug paraphernalia. Therefore, prostitutes and IVDUs are major risk groups.

In addition, clients of the prostitutes provide a pathway for the virus

to enter the general community. Both groups are criminal and

stigmatized and cannot be reached through regular channels. There

is a substantial crossover between the two groups because a significant number of people belong to both groups. They share the same

geographic locations and they are both exploited.

The problem’s scope is easily demonstrated. If 1,000 prostitutes work

in New York City (in the streets, brothels, parlors, escort services,

or privately), and each has six clients per day, this adds up to 6,000

men per day. lf each prostitute works 4 days per week (many work

28
7 days per week), then 24,000 men would have contact with a prostitute each week in New York City alone. These numbers are conservative. Through innovative and unique ways, IV-drug-using Puerto

Rican women are being reached in New York City. Effective

education on AIDS prevention and effective strategies for risk

reduction must penetrate informal networks. Entry is made into

shooting galleries, where women of all ages and all colors, pregnant

women, women who have recently delivered, HIV-positive women, and

women with AIDS-related complex (ARC) and AIDS are found. There

are women living in abandoned buildings and shooting galleries, after

becoming homeless when their sexual partners were incarcerated. The

women who are living in the streets of Williamsburg, Brooklyn, the

Lower East Side, Harlem, and the South Bronx are living a nightmare.

Many are sick with abscesses, open lesions, syphilis, gonorrhea, and

other STDs. Many are also pregnant and are not receiving prenatal

care, since they do not have insurance.

Addicted women who become pregnant can transmit HIV to their

unborn child. Most Hispanic children with AIDS are children of

addicted Puerto Rican women or of Puerto Rican women are the

sexual partners of IVDUs. IV-drug-using women and women in drug

treatment programs rarely seek counseling about AIDS. They do not

plan their pregnancies and do not participate in birth control. Many

IV-drug-using women do not menstruate regularly. Their options are

restricted when, at 4 months, they discover the pregnancy. Thus,

early prenatal care is unlikely. Many Puerto Rican women have been

turned away from drug treatment programs. In addition, many women

become upset with the stringent protocol for admission to a drug

treatment program. Addicted women also do not have a regular

physician, and they rely on hospital emergency rooms for their

medical care.

Clearly, there is a need to educate addicted women and women in the

sex industry about the dangers of HIV infection. Women can be

empowered to take control of their lives. Many women believe that

if they are using a certain type of birth control (oral contraception),

they are safe from HIV infection. The risk to Puerto Rican women

needs to be more prominently placed in the literature and the media,

emphasizing risk behavior and specific risk groups. Programs for

Puerto Rican women must focus on enabling women to become more

assertive in negotiating safer sex and condom use.

29
RELATED ILLNESS

A major concern for the Puerto Rican community is the dramatic

increase in syphilis among men and women in urban areas, rising

faster among black and Hispanic people. Nationwide, syphilis cases

are up 35 percent this year over last year, with most of the

increases in poorer areas of some major cities. The number of

syphilis cases has more than doubled in New York City. There is a

clear indication that the increase in syphilis among adults creates a

rise in congenital syphilis among infants in poor inner-city neighborhoods (New York City Department of Health 1988b).

HIV infection is causing a resurgence of tuberculosis (TB) in New

York City. This is evident due to the increase in TB cases among

the sex and age group containing the majority of New York City

AIDS patients (males 20 to 49 years of age). In recent years, TB

cases in New York City have increased 36 percent, or 593 cases (from

1,630 to 2,223 cases), an increase greater than that for the Nation as

a whole. TB increased 2 percent, or 513 cases (from 22,255 to

22,768) (New York City Department of Health 1988c; Stoneburner

et al. 1987).

CRIMINAL JUSTICE CONTACT

The incidence of AIDS and AIDS-related conditions among Puerto

Ricans and other ethnic groups who come in contact with the

criminal justice system in the State of New York is increasing. In

New York State, about 40,000 prisoners are incarcerated in State and

city prisons. Blacks and Hispanics comprise 80 percent of the

inmates, and Department of Correction officials have estimated that

70 percent of the State’s inmates, or 28,000 persons, have a history

of IV drug use (New York State Commission of Correction 1986). In

New York State, 46 percent of inmates who have died of AIDS were

Hispanics, 39 percent were black, and 15 percent were white. The

Correctional Association of New York, which has legislative authority

to inspect prisons, recently reported that inmates infected with HIV

appear to have a very low survival rate.

OUTREACH TO PUERTO RICAN DRUG ABUSERS

Since 1985, the Association For Drug Abuse Prevention and

Treatment, Inc. (ADAPT), an organization of recovering addicts and

health treatment professionals, has gone directly into IV-drug-use

neighborhoods and drug-injection sites (shooting galleries). Persons

30
from ADAPT describe HIV transmission and prevention and distribute

sterilization kits. In attempting to change behavior among addicts,

ADAPT has introduced three persons (facilitators) into the subculture

of the IVDU in Brooklyn, New York. These facilitators are exaddicts who are role models for active addicts and understand the

risks and problems. lt is hoped that one-on-one interventions can

lead addicts to take steps toward self-protection and behavior

modification.

A brief description of the facilitators’ work may give an idea of their

experiences. As the facilitators approach a particular city block,

they begin to feel the mood of the block. Every block has its own

mood, with a different population doing regular business and drug

business. Each block is very well organized, with an army to guard

and protect it. Lookouts signal the approach of any new person. A

yell might be heard from one doorway to the next “todo esta bien,”

(“all is well”) if the police are not in sight or a familiar face has

entered the area. lf a stranger enters the area, the word is spread

not to do business with this unfamiliar person. Lookouts, also known

as couriers and enforcers, will approach and threaten an unfamiliar

person. Discipline is maintained by street violence. Pushers, dealers,

and connections are all vital to the block’s existence, as is the flow

of drugs into the area. ADAPT facilitators have become known to

addicts as people who sincerely wish to provide help. Facilitators are

allowed access into the block and can stand near shooting galleries.

They are also allowed to enter galleries, participate in private

conversations, and, most important, facilitate behavior change.

Behavioral changes observed by ADAPT facilitators include decreases

in needle sharing and increased use of clean works. They also have

observed addicts giving accurate risk reduction information to other

IVDUs in shooting galleries or on the street. In addition, gallery

owners have come to ADAPT members to obtain sterilization kits and

referrals to drug treatment programs.

CONCLUSION

Minority communities, specifically Puerto Ricans, have been neglected.

The result is that these communities are devastated by illness and

death from HIV infection. There are hundreds of neighborhoods in

which HIV is spreading at an alarming rate. A real danger is that

HIV will become self-sustaining in the heterosexual community if we

do not immediately provide the necessary resources to curb it. lt is

already too late for those with AIDS, those who are infected, and

those children who will be born with AIDS. But it is not too late to

31
stop further infection of Puerto Rican women who may become infected through their sexual partners. It is not too late to prevent

further perinatal transmission to children. More weapons and

resources are needed to fight AIDS and to avoid further casualties.

To reach IVDUs effectively, the problems of treatment cost and

assuring fast treatment upon request must be addressed immediately.

By bringing addicts into drug treatment, AIDS education can be

offered and the process of behavior modification can begin. Treatment is prerequisite to behavior change. Addicts can change their

behavior, and they care about their health and their families, but the

disease of addiction is powerful. IV substance abusers and their

sexual partners will need considerable help to reduce effectively the

risks for contracting and transmitting HIV. To prevent AIDS within

minorities, community resources for dealing with the many complex

problems must be available. The family structure of minority communities must be utilized. There are particular strengths of black and

Hispanic families that can be used to communicate information about

behaviors that put IV drug users and their partners at risk for AIDS

(Marin and Marin 1987; Triandis et al. 1984).

The IVDU is a member of several well-defined communities. Knowledge on how IV drug abusers relate to their culture and its structure

and how these systems impact on IV drug use must be developed.

Effective messages for Puerto Rican IVDUs, including the use of

street jargon, must be developed. Community systems within each

community, the family as a prevention/education network, and other

relevant, culturally sensitive approaches can be utilized to reach the

IV drug abuser.

The threat of AIDS to our society is very real. The writer of this

paper has witnessed its devastation in minority communities. If you

were to come into these war zones, you would see the virus at work

and see its casualties. You would understand the urgency with which

this paper was prepared.

REFERENCES

Bakeman, R.; McCray, E.; Lumb, J.R.; Jackson, R.E.; and Whitley, P.N.

The incidence of AIDS among blacks and Hispanics. J Med Assoc

79(9):921-928, 1987.

Centers for Disease Control. Acquired immune deficiency syndrome

(AIDS) among blacks and Hispanics, United States. MMWR 35:665-

766, 1986.

32
Chein, I.; Gerard, D.L; Lee, R.S.; and Rosenfeld, E. The Reed to H:

Narcotics, Delinquincy and Social Policy. New York: Basic Books,

1964.

Department of Health and Human Services. Human lmmunodeficiency

Virus Infection in the United States: A Review of Current

Knowledge and Plans for Expansion of HIV Surveillance Activities.

November 30, 1987.

Des Jarlais, D.C. Intravenous drug use and heterosexual transmission

of HIV: Current Trends in New York City. NY State J Med

87(5):283-286, 1987.

Des Jarlais, D.C.; Friedman, S.R.; and Hopkins, W. Risk reduction for

the acquired immunodeficiency syndrome among intravenous drug

users. Ann Intern Med 103(5):755-759, 1985.

Des Jarlais, D.C.; Friedman, S.R.; and Strug, D. AIDS and needle

sharing within the IV drug use subculture. In: Feldman, D., and

Johnson, T., eds. The Social Dimensions of AIDS: Methods and

Theory III. New York: Praeger, 1986.

Drucker, E. AIDS: The eleventh year. NY State J Med 87(5):255-

257, 1987.

Marin, B., and Marin, G. Attitudes, expectancies and norms regarding

AIDS among Hispanics. Presented at the Meeting of the American

Psychological Association, New York, NY, August 1987.

New York City Department of Health. AIDS Surveillance Update,

AIDS Surveillance Division, November 13, 1987.

New York City Department of Health. AlDS Surveillance Unit

Monthly Statistical Report. February, 1988a.

New York City Department of Health. Remarks of Stephen Joseph,

M.D. Comments of the Presentation to the Council of Black and

Hispanic Caucus AIDS Briefing. March, 18, 1988b.

New York City Department of Health. Tuberculosis and Acquired

lmmunodeficiency Syndrome in New York City: Special AIDS Issue

#1. March 1988c.

New York State Commission of Correction. Acquired Immunodeficiency Syndrome: A Demographic Profile of New York State

Inmate Mortalities 1981-1985. March 1986.

Stoneburner, R.L; Des Jarlais, D.; Milberg, J.; Friedman, S.R.; and

Sotheran, J.L Evidence for a casual association between HIV

infection and increasing tuberculosis incidence in New York City.

Presented at the Third International Conference on Acquired

lmmunodeficiency Syndrome (AIDS), Washington, DC, June 1-5, 1987.

Triandis, H.C.; Marin, G.; Lisansky, J.; and Betancourt, H. Simpatia

as a cultural script of Hispanics. J Pers Soc Psychol 47:1365-1375,

1984.

33
U.S. Department of Commerce Bureau of the Census. 1980 Census of

Population and Housing, 1980.

AUTHOR

Yolanda Serrano, B.S.

ADAPT

85 Bergen Street

Brooklyn, NY 11201

34
AIDS Prevention for

Non-Puerto Rican Hispanics

Barbara V. Marin

INTRODUCTlON

This chapter develops a beginning framework for acquired immunodeficiency syndrome (AIDS) prevention in Hispanic communities, which

have not been as severely affected by the AIDS epidemic as the

Puerto Rican community. This group, referred to as non-Puerto

Rican Hispanics, includes Mexican-Americans, Cuban-Americans, and

other Hispanics of Central and South American origin living in cities

throughout the United States. It accounts for about 85 percent of

the U.S. Hispanic population. While the epidemiology of the AIDS

epidemic is very different for this group, many cultural issues, appropriate interventions, and research strategies will be similar for all

Hispanic groups, including Puerto Ricans.

EPIDEMIOLOGY

At the present time, it is not clear to what extent non-Puerto Rican

Hispanics are currently at risk of contracting AIDS. AIDS case incidence data indicate a lower prevalence of cases than the proportion

of Hispanics in the population for all areas outside the Northeastern

United States, except for males who are not intravenous drug users

(IVDUs) (Bakeman et al. 1987). Because of the lag time between infection and illness, these case data suggest that human immunodeficiency virus (HIV) infections were occurring at higher than expected

levels among homosexual non-Puerto Rican Hispanic men, but lower

than expected levels in other subgroups of this population several

years ago.

The limited data on current HIV infection rates suggest that the

epidemic has now spread to non-Puerto Rican Hispanic IVDUs,

35
although rates of infection do not approach those of Puerto Rican

IVDUs. Studies of IVDUs in San Francisco (Chaisson et al. 1987)

indicate that the proportion of Hispanics currently infected (14 percent) is far higher than the proportion of infected white nonHispanics (6 percent) in the drug treatment and IVDU population.

Although the potential exists for significant secondary spread of the

virus through Hispanic bisexual men, IV drug use and secondary infections to nonusing partners and to fetuses are likely to be the

major source of spread of the virus into the non-Puerto Rican Hispanic community.

CULTURAL FACTORS RELATED TO AIDS PREVENTlON

Hispanic culture represents a particular set of values and norms that

shape those reared in the culture (Hofstede 1980). The fundamental

aspects of the Hispanic worldview are similar for individuals from

different Latin American countries (Marin et al. 1987), even though

many of the outward signs of culture (food, national holidays, dress)

may be quite different. These cultural aspects must be studied carefully as they relate to AIDS prevention, to develop effective interventions. While these values are probably not easily changed, they

must be respected and understood for interventions to be effective.

Familismo

One of the most important cultural characteristics of Hispanics is

“familismo,” or the emphasis on the family as the primary social unit

and source of support (Marin and Triandis 1985; Sabogal et al. 1987).

The strong family orientation of Hispanic culture creates a number of

obligations as well as a source of perceived support in times of

trouble. Hispanics feel a strong need to consult with other family

members before making a decision, an obligation to help others in the

family economically and emotionally, and a strong sense of love and

nurturing toward their children.

Research on Hispanic smoking has revealed some of the power of

familismo. Hispanics are far more likely than white non-Hispanics to

express an intention to quit smoking because it sets a bad example

for their children and might affect their children’s health (Marin

et al., manuscript under review). The power of a family-oriented message might also be used to combat AIDS. The impact of AIDS on the

family and especially on the children could be a key motivating

factor in prevention campaigns. At the same time, the value of children to Hispanics suggests that many Hispanic women will become

36
pregnant and carry a pregnancy to term even after learning they are

infected with the AIDS virus (Gross 1987).

Simpatia

“Simpatia” has no direct translation in English, but refers to the importance of smooth social relations. This is a central cultural value

and social script (Triandis et al. 1984) that mandates politeness and

respect and shuns assertiveness, direct negative responses, and criticism. AIDS prevention activities that involve confrontation, such as

insisting on condom use with a sexual partner, seem inappropriate for

this group. Polite and culturally appropriate ways to negotiate new

sexual behaviors are needed for a Hispanic audience. The simpatia

script also requires that the Hispanic listener appear to agree with a

message, even though he or she has no intention of following the advice or did not understand it. This makes it crucial that intervenors

ask questions to assure that AIDS information and behavior change

messages have been correctly understood.

Another possible result of simpatia is that taboo topics are avoided in

polite conversation. Given that both drug use and sexuality are

taboo topics, these interventions will be more difficult.

Personalismo/Respeto

“Personalismo” refers to a preference by Hispanics for relationships

with others in their social group, and “respeto” is the need for

respect, especially for authority figures, in social relationships.

These two concepts must be understood and put into practice for

drug treatment and other prevention programs to be maximally effective. In practice, personalismo means that Hispanics may be more

likely to trust and cooperate with health care workers whom they

know personally, and with whom they have had pleasant conversations, often referred to as “la platica” by Mexican-Americans. The

implication of respeto is that drug abuse treatment will be rejected if

a Hispanic does not feel respected and valued. Another dimension of

respeto is that often clients will not question an authority, even if

they do not understand something that is said.

Although certain cultural attitudes common to Hispanics can hinder or

support AIDS prevention efforts, many are amenable to attitude

change efforts and intervention campaigns.

37
Sexuality

Sexuality appears to be even more intensely private and personal in

Hispanic culture than in white non-Hispanic culture. Anecdotal information suggests that sexual issues often are not discussed even

between sexual partners. Hispanic women may be very uncomfortable

when a condom is presented to them (Compagnet 1987). In traditional Hispanic culture, the “good” woman is not supposed to know about

sex, so it is inappropriate for her to bring up subjects like AIDS and

condoms. Amaro (1988) found that married Hispanic women in

Los Angeles had sexual relations infrequently and often perceived

them as not particularly enjoyable. There is also a fairly strong

double standard that allows men to have sex outside of marriage,

commonly with prostitutes. Given the higher rates of HIV infection

in Hispanic prostitutes found recently (Centers for Disease Control

1987), such a double standard is likely to result in additional spread

of the virus. When asked about abstinence, some Hispanic men felt

that not having sex would be nearly impossible as well as unhealthy

for them (Marin and Marin 1987).

In addition to a general reluctance to discuss sexuality, Hispanic culture includes a fairly powerful homophobic component. One indication of this is that a nonpejorative Spanish equivalent for the word

“gay” does not exist. Given this attitude, it is very common for Hispanic men who have sex with other men not to see themselves as

homosexual, meaning that messages directed specifically at “homosexuals” or “gays” may be ignored by a large proportion of those at

risk (Ronquillo 1987).

Machismo

“Machismo” is a complex phenomenon that may be both helpful and

hurtful to an AIDS prevention campaign. The majority culture view

of machismo as a negative, antifeminist phenomenon is not completely

correct, since machismo has a positive dimension that could facilitate

behavior change. Machismo incorporates the idea that the male has a

serious responsibility to provide for and protect his family, an attitude that could be extended, by an AIDS prevention campaign, to include protecting the family from the threat of AIDS. A dimension of

machismo that could create difficulties in AIDS prevention is the

need for the appearance that the man is in charge. A Hispanic

woman who challenges her partner because he won’t use condoms, for

example, may be setting herself up for rejection or possibly abuse

(Gross 1987).

38
Promotion of condom use is likely to be difficult among Hispanic men

who associate condoms with prostitutes. There is also a wmmon

belief that Hispanics will not use condoms because of the Catholic

Church’s prohibition against artificial contraception, but many Hispanics do use birth control (Potvin et al. 1968; Mann et al. 1981). Of

course, whenever parishes or churches are the channel for AIDS prevention messages, condoms can be mentioned only in a very limited

way (United States Catholic Conference 1987).

Other Cultural Attitudes

Some Hispanics in the United States, especially those who have recently arrived, use needles and syringes for activities other than drug

use, such as piercing ears and giving injections of vitamin B12 and

other medications (Compagnet 1987). This activity is partly due to

the fact that in most Latin American countries prescription medicines

(including injectables) are available over the counter. A recent study

in San Francisco found about 5 percent of the Hispanic respondents

occasionally injected medicines or vitamins in the home (Fairbank et

al. 1987). There is at least one case of family vitamin injections

spreading HIV infection (Koenig et al. 1986).

An assessment of information about AIDS transmission and prevention

among adolescents revealed that Hispanic teens knew less than other

groups (DiClemente et al. 1988). Some preliminary data suggest that

many Hispanics view AIDS as a problem almost exclusively of the

white homosexual community. When presented with the hypothetical

situation that their partner had been infected with HIV, our

San Francisco Hispanic sample often expected this situation to

produce chaos, total abstinence, or abandonment (Marin and Marin

1987). Hispanic men seem especially likely to say they would abandon

an infected partner, while women are more likely to say they would

remain. These Hispanic respondents did not often make a rational,

planning response to hypothetical news of an HIV infection in themselves or a partner (Marin and Marin 1987).

MODELS FOR SMOKING CESSATION AND PREVENTION

AMONG HISPANICS

Community-level interventions are used to reduce a number of health

risk behaviors, including cigarette smoking, alcohol use, and poor

dietary habits. These community interventions provide information

about the risk behaviors and how to change them, change community

39
attitudes and norms concerning those behaviors, and ultimately affect

the behavior of many individuals at high risk.

Currently, four large-scale intervention projects, funded by the

National Cancer Institute, are aimed at smoking behavior in the Hispanic community. All of these projects are in progress, however, so

conclusions cannot be drawn. Nonetheless, certain insights from

these projects may be useful in developing an AIDS prevention campaign in the Hispanic community.

The A Su Salud/To Your Health project is attempting to intervene in

two almost entirely Hispanic communities near the Mexican border.

Behaviors attacked include smoking, alcohol and drug use, inappropriate diet and consumption of fatty foods, and not receiving regular

medical checkups. This project is using a social learning approach in

which role models from the community are presented via radio, TV,

and newspapers, along with messages about how to carry out the behavior. In addition, lay counselors visit their neighbors to instruct

and motivate them. Initial evaluations have indicated promising early

trends (McAllister et al., submitted for publication).

A smoking prevention study in Boston/Hartford focuses on Puerto

Rican adolescents. Change is being produced through community involvement, including production of videotapes used for discussion,

contests, and school-based interventions. Anecdotal reports indicate

that rap contests, which have also been used in San Francisco for

AIDS prevention (Fullilove 1987), are quite popular among Puerto

Rican youth (Carrillo, personal communication, 1987).

A Life Skills Training curriculum has been developed for drug use and

smoking prevention specifically aimed at inner-city Hispanics. This

school curriculum is based on earlier work with mostly suburban

white adolescents: it teaches skills needed to resist peer pressure to

engage in drug use, in addition to teaching general social skills

(Botvin and Wills 1985). Preliminary results of the Hispanic curriculum are quite promising (Botvin, personal communication, 1987).

The Hispanic Smoking Cessation Research Project/Programs Latino

Para Dejar de Fumar is a research project to develop and test interventions intended to help Hispanics quit smoking. Based in

San Francisco, the project primarily serves Hispanics of Mexican and

Central American origin. The objectives are to lower the prevalence

of smoking in San Francisco Hispanics by (1) providing culturally

appropriate information about the negative effects of smoking and the

40
positive effects of quitting: (2) providing culturally acceptable techniques and services for quitting smoking; and (3) changing the community norms associated with smoking (Perez-Stable et al. 1987).

Pretesting of Interventions

Pretesting of all materials is essential to the development of effective

AIDS prevention interventions. Development of Spanish-language

printed or electronic media materials should be initiated by a

bilingual-bicultural team.

One example of this process is the Guide to Quit Smoking developed

and pretested for more than a year by the Hispanic Smoking Cessation Research Project. This process identified three general issues.

First, writing simply and clearly is very important. A recent study

of the reading level of 16 pieces of AIDS educational material

revealed that the average reading level was grade 14, that is, second

year of college (Hochhauser 1987). Such a reading level would be

beyond the educational attainment of 80 percent of 18-to-24-year-olds

and 74 percent of 25-to-34-year-olds (Hochhauser 1987). Thus, it is

imperative that written materials contain simple messages, written at

no more than fifth-grade level, which avoid regional variations in

Spanish.

Second, pretesting should be used for format as well as for content.

Our pretesting suggests that use of photographs of real people would

be highly desirable. Reactions to the printed product have confirmed

this–most people mention the beautiful photographs with Hispanic

faces. Parents have reported reading the Guide to their children,

which is almost certainly due to the large colorful photographs used.

Those developing AIDS materials must pretest to determine whether

testimonials, novellas, stories, family focus, scientific information, or

some combination are most appropriate for their target audience.

Given the importance of the family in Hispanic culture, some materials should be developed that could be used by the entire family.

Third, pretesting can enhance credibility. Some smoking cessation

techniques in our research were quite acceptable for white nonHispanics, yet were literally laughed at by our respondents. Others

had to be modified to be more in tune with the culture. Rather than

the “just say no” message used so often, respondents preferred to

make up an excuse for why they were refusing a cigarette, even if

the excuse was a lie. Saying no is rejected as too brusque and not

41
“simpatico.” lt is likely that some common AIDS prevention messages

will also encounter disbelief or seem inappropriate to Hispanics.

Multivariate Approach to Intervention

Anecdotal information from research with Hispanics as well as more

formal research on other groups has indicated that behavior changes

can be encouraged in large groups of people if health promotion campaigns use multiple channels to reach their audiences (Flay 1987).

Mass-media-based attitude and behavior change has been shown to be

effective, but high-frequency presentations and saturation are necessary for an effect. For AIDS prevention campaigns, a variety of

channels can be considered including TV, radio, leaflets, billboards,

posters, pamphlets, manuals, bus cards, hotlines, newspaper, community workers, volunteers, and community groups. These channels are

discussed in more detail below.

To be most effective, a health promotion campaign must utilize the

principles of social marketing (Frederiksen et al. 1984). In this

approach, specific messages and interventions are aimed at specific

subgroups in a community. In the case of AIDS prevention, specific

interventions might be developed for teens, adult men, adult women,

health care providers, Hispanic media, community leaders, persons at

risk, and family or friends of those at risk.

AN AIDS PREVENTlON MODEL

To prevent the spread of AIDS in the non-Puerto Rican Hispanic

community there are two primary target audiences to consider:

(1) IVDUs and their sexual partners, and (2) the community. The

types of interventions appropriate for each will be discussed briefly

below. Truly effective programs should include both of these components, since they will have a synergistic effect on each other.

When the principal target of prevention messages is the Hispanic

IVDU, the types of interventions considered tend to be individualized

and labor intensive. The objectives include decreased needle sharing,

increased needle cleaning, and increased drug treatment, as well as

safer sex practices. There are very little evaluation data on approaches designed to achieve these objectives among non-Puerto

Rican Hispanics, but the potential approaches include: distribution

and education about use of bleach, use of condoms, and needle exchange; provision of culturally appropriate drug treatment; and

42
education/counseling about AIDS for the IVDU and his or her sexual

partner.

Along with individualized strategies, there is a need for more general,

community-level prevention efforts. Such campaigns would be designed to create normative changes around AIDS prevention behaviors

through multichannel, multitarget, culturally appropriate community

efforts. Possible content, channels, and targets of such an Intervention are discussed below.

The content of messages must be clear, behaviorally specific, and culturally appropriate. In the case of AIDS prevention campaigns, there

are a multitude of possible informational, attitudinal, and behavioral

messages, but many may prove to be confusing or offensive to Hispanics. Research is urgently needed in this area.

McKusick et al. (1985) identified certain prerequisites of AIDS prevention behavioral change. The individual must believe that AIDS is

a dreadful disease, that he or she is personally at risk, that the

recommended prevention behaviors are manageable, that he or she can

actually perform those behaviors, and that the community and peers

support this behavior change. While almost everyone believes that

AIDS leads to death and there is no cure (Dawson et al. 1987), it is

likely that far fewer people in the non-Puerto Rican Hispanic community see themselves as personally at risk, intend to carry out the

prevention behaviors, or see others as encouraging those behaviors

An effective AIDS prevention campaign must provide simple messages

about a very complex subject. it has been suggested (Liskin et al.

1986) that the essential information to be transmitted should include:

(1) those who are infected with HIV do not necessarily look different

from anyone else or even know that they are infected, yet they are

capable of transmitting the virus; (2) the virus is transmitted through

needle sharing and intimate sexual activity: (3) the virus is not

spread by casual contact (this may seem unnecessary, but persons

who believe that it is spread casually are probably less likely to

believe they can prevent spread); (4) women infected with the virus

can transmit it to their unborn children during pregnancy; (5) a

stable, faithful relationship with an uninfected partner is best, but, at

the least, one should reduce the number of sexual partners; and

(6) condoms offer good protection from the virus.

43
In addition, when the target group includes IVDUs and their sexual

partners, it should be emphasized that a stable, faithful relationship

is not protective if one’s sexual partner is an IVDU.

Perhaps additional and somewhat controversial information might be

added. Analysis by Hearst and Hulley (in press) indicates that the

risk of infection from sexual intercourse with someone in a known

risk group is substantial even if condoms are used, suggesting the

wisdom of abstaining from sex with partners from known risk groups

and partners whose sexual and drug use histories are unknown.

A community AIDS prevention campaign should request the active involvement of the community in helping to alert those at greatest

risk. The majority of IVDUs live with at least one other family

member (Cervantes et al. 1987), and some authors have called for a

much more active involvement of the family in treatment (Sorensen

and Bernal 1987). Marin and colleagues (manuscript under review)

are currently attempting to identify which AIDS prevention behaviors

Hispanic family members or friends would be willing to talk about

with someone at risk and how they could broach the subject.

Community AIDS prevention intervention must utilize as many channels as possible, while tailoring messages for particular subgroups.

Of course, some channels will be more appropriate than others for

particular messages. Based on work with other community interventions for Hispanics as well as anecdotal information, it is possible to

identify the following areas.

Radio and television are excellent channels for many messages to the

Hispanic community. Radio is listened to almost as much as television is viewed, and most Spanish-language stations have popular

talk shows that serve as good forums for providing information. Our

experience with a 1-hour, once-a-month radio talk show about smoking has been very positive, especially when the format involved calls

from the community. Television stations should also be quite cooperative, considering the positive reception of the program about AIDS

produced in San Francisco, which included the videotape “Ojos que no

ven” (Eyes that do not see).

AIDS prevention videos have the advantage of being relatively inexpensive to produce and useful in a variety of contexts. They can be

used to promote group discussions. The greatest need is for Spanishlanguage information, but culturally sensitive English-language

information is also needed, especially for adolescents.

44
Posted media include posters, bus cards, flyers, and billboards, and is

certainly an often inexpensive way to achieve community saturation.

We have been told that some of the most effective advertising of

family planning services has been bus cards (Taplin, personal communication, 1987). San Francisco buses in Hispanic neighborhoods have

bus cards that proclaim “Use Condones” (Use Condoms). These are

simple messages in large print. However, in the Dominican Republic,

a psychologist involved in a major anti-AIDS campaign reported that

people were too embarrassed to read the posters (De Moya, personal

communication, 1987). However, information and ads in newspapers

were very helpful, because people could read them privately. Unless

posted media have messages about AIDS that can be read quickly and

easily from a distance, they may be ineffective in the Hispanic

community.

Printed media such as pamphlets, brochures, booklets, or manuals can

be printed and distributed widely. Articles and news releases should

appear frequently in newspapers. Our experience has been that

people in the Hispanic community tend to be quite unimpressed with

pamphlets unless they are produced with full-color photos to attract

attention.

Several cities in the United States and Latin America have Spanishlanguage hotlines for AIDS questions, which have had good success.

And the NIDA-sponsored 800 number for drug referrals also has

Spanish-language capability.

Word of mouth could be an essential channel for AIDS prevention

messages. The most believable people for Hispanics are their own

community leaders (Marin and Triandis 1985).

Physicians and other health care providers are also powerful sources

of information in the Hispanic community. Few health providers ask

patients about their sexual or drug use behavior (Lewis and Freeman

1987). This intervention, accompanied by written materials and referrals, may have powerful effects on Hispanics, given the great respect

that physicians command.

There are a variety of other activities that might be considered for

the Hispanic community, including AIDS prevention message contests,

rap contests, production of videos or murals around AIDS themes, organizing neighborhood meetings about AIDS, taking materials about

AIDS to friends and family members, talking to one’s children about

AIDS, volunteering for hotline service, or aiding and visiting persons

45
with AIDS. One way that attitude change occurs is when individuals

become personally lnvolved in an issue and begin to speak and act on

it (Bern 1972).

NEEDED RESEARCH

AIDS prevention research focused on non-Puerto Rican Hispanics is

needed. In addition, difficult methodological issues must be addressed. Specific research needs include the following:

Little is known about the sexual attitudes and behaviors of Hispanics, including frequency and types of prostitution, sexual practices and partners, sexual information given to children, or attitudes about sexuality and birth control. Accurate information

about sexual practices may be very difficult to obtain, given the

taboos surrounding this topic.

Few studies have focused on Hispanic drug abuse. A bibliography

of the literature available from the Spanish Speaking Mental

Health Research Center (Hispanic Health and Mental Health Database 1987) revealed that the majority of studies have focused on

the Puerto Rican population. Research is needed that is related to

drug use attitudes, current drug use, needle use, needle sharing

and cleaning, and the social context of drug use. Although the

Hispanic Health and Nutrition Examination Survey collected information on drug use in the Cuban, Puerto Rican, and MexicanAmerican populations, these data currently are not widely

available.

Little is known about Hispanic attitudes toward AIDS and AIDS

prevention, risk behaviors, normative pressures related to these

behaviors, and cultural differences between Hispanics and other

groups. Identifying the differences between those at risk who are

able to change their behavior and those who are unable to change

would be useful.

Research is needed to identify the aspects of AIDS prevention that

are culturally appropriate to Hispanics. This will include research

on willingness to perform the various prevention behaviors, barriers to performance, perceived positive and negative consequences

of these behaviors, and perceived approval of important others for

these behaviors. Fishbein’s Theory of Reasoned Action and

Triandis’ subjective culture approach should be helpful guides for

such research (Ajzen and Fishbein 1980; Triandis 1972). Findings

46
from Marin et al. (manuscript under review) revealed that important consequences of smoking and quitting were predicted by the

research team beforehand (e.g., smoking is seen as a bad example

to children); several others were surprising (e.g., cigarettes causing bad breath is a very powerful reason for Hispanics to quit).

Culturally appropriate methods for recruiting and treating nonPuerto Rican Hispanic drug addicts must be developed and evaluated. Work with Hispanic families in this area might build on

Sorensen and Bernal (1987) and Szapocznik et al. (1988).

Culturally appropriate methods for preventing drug abuse must be

developed and tested not only for those preteens and adolescents

who are in school, but also for those who have dropped out.

Approaches might build on the work of Santisteban and Stapocznik

(1982).

Culturally appropriate and effective programs to prevent delinquency, lower the rate of teen pregnancy, delay the onset of

sexual activity, and prevent cigarette and alcohol use in adolescents should be evaluated. Problem behaviors appear in clusters

and among friendship groups, so that effective programs addressing

any one behavior will have an indirect impact on others (Jessor

and Jessor 1977).

The Association of Drug Abuse Prevention and Treatment (ADAPT)

(Friedman et al. 1987) has been distributing bleach and AIDS education materials, and is attempting to set up a needle exchange

experiment. Efforts such as these need vigorous evaluation to

assist in future program planning.

Community AIDS risk reduction programs designed to inform the

community about AIDS, motivate the community to intervene with

those at risk, and motivate high-risk individuals to change their

behavior must be developed and tested. Specific questions to

enable effective programs include:

Which AIDS reduction behaviors are community members willing

to use themselves?

Which communication channels are most appropriate for AIDS

prevention messages?

47
What positive and negative consequences of AIDS prevention

behaviors are most relevant to this population?

Which persons are most likely to be able to influence the

behavior of high-risk individuals?

What is the social context of risky and safe behaviors?

METHODOLOGICAL ISSUES

In many cases, Hispanics cannot be identified, since only race is

reported in some national and large regional studies (Dawson et al.

1987). To understand the epidemiology and prevention of AIDS, all

large data sets, including the Centers for Disease Control AIDS case

surveillance, epidemiological data on risk behaviors and HIV infections, and drug use and drug treatment statistics should be coded for

Hispanic subgroup (i.e., Cuban, Mexican, Puerto Rican, Other). Future evaluations of community programs will depend in part on the

availability of adequate archival data from these large data sets.

Studies of research methods must begin to identify better methods of

questioning Hispanics about sensitive subjects such as sexual behavior

and drug use, so that data that are collected are correct and valid.

CONCLUSION

While AIDS cases among non-Puerto Rican Hispanic IVDUs are now

low, a disastrous epidemic is possible in this group unless culturally

appropriate prevention interventions are developed and evaluated.

Current knowledge indicates that Hispanic cultural characteristics will

have profound implications for interventions. These characteristics

include familismo, respeto, simpatia, and personalismo, as well as sexand drug-related attitudes and practices. Community-level prevention

interventions must further identify culturally relevant beliefs and

attitudes regarding AIDS prevention practices, as well as use a multimedia, multimessage, multitarget approach to saturate the community

and change attitudes, norms, and behaviors regarding AIDS prevention. Research to identify the most appropriate intervention components is urgently needed. Many aspects of a program developed for

non-Puerto Rican Hispanics may also prove effective for the Puerto

Rican Hispanic population and vice versa.

48
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Perez-Stable, E.J.; Marin B.; and Marin, G. A smoking cessation

intervention in Hispanics. National Cancer Institute grant

5 R18 CA 39260-03, 1987.

Potvin, R.; Westoff, C.F.; and Ryder, N.B. Factors affecting Catholic

wives’ conformity to their church magistirium’s position on birth

control. Journal of Marriage and the Family 30:263-272, 1968.

Ronquillo, Y. Prevention and Education in the Latino Community.

Presented at the National AIDS Conference, San Francisco,

November 4-7, 1987.

Sabogal, F.; Marin, G.; Ctero-Sabogal, R.; Marin, B.; and Perez-Stable,

E.J. Hispanic familism and acculturation. Hispanic J Behav Sci

9:397-412, 1987.

Santisteban, D., and Szapocznik, J. The Hispanic substance abuser:

The search for prevention strategies. In: Becerra, R.M.; Karno,

M.; and Escobar, J.I., eds. Mental Health and Hispanic Americans:

Clinical Perspectives. New York: Grune & Stratton, 1982. 232 pp.

Sorensen, J.L., and Bernal, G. A Family Like Yours: Breaking the

Patterns of Drug Abuse. San Francisco: Harper & Row, 1987.

194 pp.

51
Szapocznik, J.; Perez-Vidal, A.: Brickman, A.; Foote, F.; Santisteban,

D.; Hervis, 0.; and Kurtines, W. Engaging adolescent drug abusers

and their families in treatment: A strategic structural systems

approach. J Consult Clin Psychol 56(4):552-557, 1988.

Taplin, S. Personal communication, 1987.

Triandis, H.C. The Analysis of Subjective Culture. New York:

Wiley, 1972. 383 pp.

Triandis, H.C.; Marin, G.; Lisansky, J.; and Betancourt, H. Simpatia

as a cultural script of Hispanics. J Pers Soc Psychol 47:1368-1375,

1984.

United States Catholic Conference. The Many Faces of AIDS.

Washington, DC: United States Catholic Conference, 1987. 30 pp.

ACKNOWLEDGMENTS

Gerardo Marin, Ph.D., and Eliseo J. Perez-Stable, M.D., provided

critical review of an earlier draft of this manuscript.

This work was funded in part by U.S. Public Health Service grant

DA 04928 from the National Institute on Drug Abuse.

AUTHOR

Barbara V. Marin, Ph.D.

Assistant Research Psychologist

University of California, San Francisco

400 Parnassus Avenue, Box 0320

San Francisco, CA 94143

52
Black Intravenous Drug Users:

Prospects For Intervening in the

Transmission of Human Immunodeficiency Virus Infection

Lawrence S. Brown, Jr.

INTRODUCTlON

As we approach the closing decade of the 20th century, society finds

a very formidable public health challenge with the acquired immunodeficiency syndrome (AIDS). As monumental as AIDS might be for

the United States as a whole, its significance for black Americans is

even more acute. While whites comprise the largest portion of the

53,069 currently reported AIDS cases (Centers for Disease Control

1988), blacks account for a larger portion of AIDS case reports than

their percentage of the U.S. population. Indeed, although 12 percent

of the U.S. population are black, 25 percent of all reported cases of

AIDS are attributed to black Americans (U.S. Department of Commerce, Bureau of the Census 1980; Centers for Disease Control 1988).

For blacks, the human immunodeficiency virus (HIV) epidemic could

not have occurred with worse timing. AIDS adds insult to injury for

a subpopulation of the United States already sustaining an excessive

prevalence of illness and deaths due to cardio- and cerebrovascular

diseases, cancer, diabetes, and chemical dependency (U.S. Department

of Health and Human Services 1985). The human toll of the HIV epidemic among black Americans extends well in excess of the Centers

for Disease Control (CDC) case reports of AIDS. While an indepth

discussion of these issues is beyond the scope of this paper, it is

imperative to make two crucial points. First, the face, or scope, of

the HIV epidemic, even among black Americans, differs according to

the prevalence of behavior patterns known to be associated with HIV

transmission. Thus, significant geographic differences may and do

exist in the prevalence of AIDS among blacks in the United States

(Bakeman et al. 1986; Centers for Disease Control 1986).

53
Second, an equally important area of emphasis is that there are other

medical, public health, social, and economic dimensions of the epidemic that often escape discussion. The concurrent rise in the prevalence of mycobacteria tuberculosis among black Americans (Centers

for Disease Control 1987a; Centers for Disease Control 1987b) and the

increased demand on already limited health care resources in many

black communities are byproducts of the HIV epidemic. AIDS commonly claims the lives of individuals at ages most often associated

with the highest levels of productivity to a society. For black Americans, who often reside in economically disenfranchised areas, the

morbidity and mortality of HIV infection means further erosion in the

economic base of these communities.

In the absence of an effective vaccine or a cure, education and prevention of behaviors associated with known routes of HIV transmission represent the greatest prospects for intervention. The success

of these efforts has implications that extend beyond the medical consequences of HIV disease to the social and economic fabric of black

communities across the Nation.

INTRAVENOUS DRUG USE AND AIDS AMONG BLACKS

A number of investigators have commented upon the association between various routes of HIV transmission and the overrepresentation

of black Americans in the nationwide prevalence of AIDS (Hopkins

1987; Bakeman et al. 1987; Bakeman et al. 1986; Centers for Disease

Control 1986; Brown et al., in press; Brown and Primm, in press).

Although AIDS cases among black Americans have been distributed

among the same transmission categories (homosexual/bisexual, intravenous drug abuser, heterosexual, etc.) as those AIDS cases occurring

among the U.S. population as a whole, the tragic triad of intravenous

(IV) drug use, belonging to the black race, and HIV disease is a

recurrent theme in discussions of HIV infection in the United States.

Epidemiological evidence demonstrates quite clearly that IV drug use

occupies a prominent position in the prevalence of AIDS among

women and children. The strength of this association is even more

poignant for black Americans (Centers for Disease Control 1986;

Brown and Primm 1988).

As demonstrated in table 1, black IV drug users (IVDUs) comprise an

appreciable portion of the number of AIDS cases reported in the

United States as a whole and in New York City in particular. Admittedly, the data in table 1 underrepresent the total contribution of

injectable drug use because it does not include cases of AIDS that

54
TABLE 1. Cumulative AIDS case reports among IVDUs and nonIVDUs in New York City and the United States

Total AIDS Cases AIDS Cases Among Blacks

Non-IVDUs IVDUs Non-IVDUs IVDUs

United States 44,025 9,044 8,746 4,664

New York City 8,739 3,997 2,143 1,835

have been associated with both IV drug use and homosexual/bisexual

behaviors. Because the proportionate contribution of each transmission category and the racial/ethnic distribution of AIDS cases have

been rather stable during the time periods displayed in table 1, a

number of observations can be made. IV drug use alone is associated

with 17 percent of all AIDS cases and 35 percent of black AIDS

cases. Comparable figures for New York City are 31 percent and

46 percent. Viewed differently, AIDS cases among black IVDUs comprise 9 percent (or 4,664 of 53,069) and 14 percent (or 1,835 of

12,736) of AIDS cases in the United States and New York City, respectively (Centers for Disease Control 1988; New York City Department of Health 1988). The higher proportion of black IVDUs among

AIDS cases in New York underscores a point made earlier in this discussion. The face of the HIV epidemic in the New York metropolitan

area is largely influenced by the disproportionate prevalence of

IVDUs in this geographic area (Brown and Primm 1988). Because the

author is most familiar with the role of black IVDUs in the New York

City HIV epidemic, the remaining discussion will focus on this population. Much of the information to be presented is derived from a

number of seroepidemiologic surveys either published in the literature

or from investigations conducted at the Addiction Research and

Treatment Corporation (ARTC), a drug abuse treatment program that

provides services to 2,100 patients in the boroughs of Brooklyn and

Manhattan in New York City. In no way, however, is it implied that

these findings can be extrapolated to all IVDUs or to all black

IVDUs, whether in or outside of drug treatment.

BLACK IVDUS AND HIV SEROPREVALENCE STUDIES

Much of the information available on the rates of HIV infection in

serosurveys are the results of investigations conducted of IVDUs in

drug treatment. Very little seroprevalence information is available on

the larger population of IVDUs not in treatment. Nonetheless, the

55
expansion of HIV seroprevalence data among IVDUs has significantly

increased knowledge of the prevalence of HIV infection. One fairly

consistent finding across investigations has been the higher prevalence of HIV infection among black IVDUs as compared to their white

counterparts (Chaisson et al. 1987; Weiss et al. 1985; Lange et al.

1987; Marmor et al. 1987; Friedman et al. 1987; Robert-Guroff et al.

1986). In 1987, among the HIV serosurveys conducted at ARTC

(table 2), there was a trend toward higher prevalence of HIV infection among black IVDUs than for the entire IVDU population surveyed. This result was in contrast to results of surveys conducted in

the previous years (1985 and 1986).

TABLE 2. Trends in HIV seroepidemiology in ARTC for entire

IVDU population surveyed

Year Number Tested

Total Blacks

Seropositive

Total Blacks

(%) (%)

1985 469 184 255 (54) 101 (55)

1986 262 100 159 (61) 62 (62)

1987 222 99 132 (59) 64 (65)

In reviewing the AIDS case-report data and seroprevalence studies

among black IVDUs, a number of methodological issues must be considered. Particularly among seroprevalence investigations, closer

scrutiny is important with regard to the geographic region in which

these studies are conducted, the prevalence of drug use in these

areas, the prevalence of various patterns of drug use and sexual

behavior, and the laboratory screening and confirmation methods of

HIV infection.

Admittedly, problems also exist in making reliable estimates of the

number of IVDUs and the HIV infection rates among IVDUs. Regarding the former, advances in mathematical modeling are limited by the

incompleteness of the system for identifying IVDUs. The prevalence

of IV drug use is often estimated from information provided by law

enforcement agencies and single State agencies having authority for

drug treatment programs. It is important that the extent to which

IV drug abuse has implications for exposure to and/or transmission of

the HIV virus be clarified. While it might be inferred that IV drug

56
abuse implies a high potential for HIV transmission, the impact on

the HIV epidemic of those persons who infrequently use injectable

drugs is arguable. Thus, in the context of the role of IVDUs in the

HIV epidemic, information is limited by how we operationally define

an IVDU and by restricted ability to determine the number of individuals who meet this operational definition in any geographic region.

Conclusions about black IVDUs, like conclusions about IVDUs from

other ethnic/racial groups, will be affected by this limitation. lt is

not immediately clear whether the effect will be to overestimate or

underestimate the proportion to which black Americans participate in

intravenous drug use. This problem also has significant implications

for obtaining accurate information on the prevalence of HIV infection

among black IVDUs.

TRENDS AMONG BLACK IVDUS

Having laid the background, inclusive of some methodological issues

that affect research among black and nonblack IVDUs, questions remain concerning the extent to which ethnic/racial differences are associated with the prevalence of various HIV-exposing behaviors among

IVDUs. It is obvious that this information would be invaluable to

tailoring preventive efforts, should significant ethnic/racial differences exist. From the seroprevalence and ethnographic information

collected in connection with the data shown in table 2, we find the

following trends. Compared to the other ethnic/racial groups, black

IVDUs tended to have a greater consumption of tobacco and alcohol,

even in studies that controlled for age and duration of opiate use.

The frequency of injection or sharing of needles/works by black

IVDUs did not vary significantly from other ethnic/racial groups. In

these studies, black IVDUs, compared to their nonblack counterparts,

tended to have medical histories of a greater prevalence of clinical

mycobacteria tuberculosis, a lesser prevalence of serum hepatitis, and

an equal prevalence of endocarditis.

Because of the pivotal position of IVDUs in the heterosexual transmission of the HIV virus, ethnic/racial differences in the sexual

behaviors of IVDUs is also significant. The practice of HIV-exposing

sexual practices by IVDUs, in whom HIV infection rates are considerable, might explain why IVDUs serve as an important HIV transmission vehicle between the drug-abusing community and the general

population. Ethnic/racial differences in the frequency of unsafe

sexual behaviors, coupled with the ethnic/racial differences in HIV

infection rates derived from seroprevalence data, might explain the

overrepresentation by black Americans in AIDS case reports linked to

57
heterosexual HIV transmission. While knowledge of HIV infection is

limited, much less is known about the sexual behaviors of IVDUs.

From ARTC investigations, black IVDUs, in comparison to other

ethnic/racial groups, reported a higher average number of sex partners and of sex partners with whom sex was exchanged for money or

drugs. Compared to white IVDUs, black lVDUs also stated that a

greater percentage of their sex partners were non-IVDUs. One

sexual practice that has often been associated with HIV transmission

is the performance of anal intercourse. The findings of the ARTC

survey indicate that black IVDUs, in comparison to other IVDUs,

either participated less in this sexual act or were less likely to admit

to this activity. Interestingly, black IVDUs in our investigations

were more likely to use condoms, compared to their white or

Hispanic/Latino counterparts. Even the black IVDUs in these studies,

however, admitted to using condoms for only 10 percent of their

sexual encounters.

The literature (Eskola et al. 1978; Landmann et al. 1964; Glaser and

Kiecolt-Glaser 1988), in describing a role of stress in modulating the

immune system, stimulated our interest concerning the extent to

which HIV infection was associated with the occurrence of stressful

life events. One hypothesis is that stress-related events may place

IVDUs at greater risk of HIV exposure and/or may sufficiently impair

immunological responses, enhancing prospects for infection or the

clinical consequences following infection. Alternatively, these stressful life events may represent other sequelae of HIV infection or

disease. In the 1986 cohort described in table 2, we found statistically significant associations between HIV seropositivity and changes

in employment status (p=.05), drug treatment enrollment (p=.05), and

personal relationships (p=.004). Of particular interest was the finding

that seropositive IVDUs were more likely to be depressed (p=.006) and

lonely (p=.02). As far as black IVDUs are concerned, table 3 shows

those variables where blacks, in comparison to nonblacks, experienced

a greater occurrence of stressful events in their lives prior to enrollment in the seroprevalence study.

Perhaps the higher HIV seropositivity rates among black IVDUs

observed in HIV seroprevalence studies might be associated with the

greater occurrence of stressful life events. While the study design of

the 1986 investigation did not allow for an assessment whether these

events preceded HIV infection or were consequences of HIV infection,

the role of stress in HIV exposure or progression deserves further

study.

56
TABLE 3. Stressful life events occurring more frequently among

black IVDUs than nonblack IVDUs

Event

Confrontation on Job .041

Miscarriage or Stillborn Birth .007

Losing Custody of Child .043

Having to Get Welfare .033

Child Got into Trouble .047

Worrying Too Much .045

Feeling Hopeless .006

Loss of Sex Interest/Pleasure .031

Significance

(p value)

HEALTH PREVENTlON EFFORTS AND BLACK IVDUS

Based upon the foregoing, AIDS-related interventions aimed at black

IVDUs must effectively modify their sexual and drug-related behaviors. Stress reduction may also be beneficial in interventions targeted for black IVDUs. Unfortunately, there are many environmental

factors that reduce the probability of reaching black IVDUs and positively modifying their behaviors. The environmental factors often

associated with addiction promulgate its persistence and interfere

with preventive behaviors. For example, a large body of data associates poverty with addiction. The communities in which black IVDUs

reside are often the same impoverished ones in which their drug

addiction began and in which effective preventive or intervention

programs are not likely to exist.

Furthermore, the housing problem in New York City is a poignant

example of how a response to homelessness can reinforce continued

drug use. New York City’s response of placing the homeless in

shelters has resulted in many of these shelters becoming locations for

the use or sale of injectable drugs. Because of the often degrading

conditions of these facilities, many of the homeless commonly choose

to stay “on the streets.” In the experience of ARTC, the combined

effect of the disproportionate number of blacks represented among

the homeless and the large numbers of black IVDUs being homeless

has significantly reduced the potential offered by housing and

rehabilitating the drug addict. The rising prevalence of tuberculosis

is also an indirect consequence of New York City’s housing response.

59
Many municipal hospitals are experiencing a rise in tuberculosis

admissions of patients with the following profile: black, IVDU, and

occupant of a city shelter.

The response of many black community residents to black IVDUs can

be characterized as either aggressively supporting law enforcement

initiatives or passively encouraging continued sale or use of illicit

substances. Primary prevention efforts in the public school system

probably represent the most structured drug prevention programs in

many black communities. However, the long-term effectiveness of

these projects is unclear. School dropouts comprise the subpopulation

that are less likely to receive these school-based efforts and more

likely to engage in the illicit use of drugs.

Prominent in the black community is the church. On many occasions

in the past, the black church has been a significant and highly visible force for social change. When it comes to HIV disease, however,

the response of the black church has generally been silence and lack

of support of prevention efforts. The clear absence of an affirmative/

supportive response by the black church to the HIV epidemic is

attributable to religious attitudes toward behaviors associated with

HIV transmission. One such behavior is the use of illicit drugs.

Some leaders of the black church have characterized the HIV epidemic as God’s response to sinful behavior. The lack of support, underscored by such responses of black church leaders, represents another

environmental obstacle to successful preventive efforts for black

IVDUs.

With a notable exception, the preventive and health promotion efforts

of many public health authorities often unintentionally exclude the

participation of IVDUs. These efforts focus on facilities that IVDUs

are unlikely to attend or at institutions with insufficient sensitivity

to the problems of the drug addicted, white or black. From the experience of ARTC clients, hypertensive patients (an increasing number, given the rising mean age and overrepresentation of black

patients) are not likely to have access to private practitioners or

other nonemergency-room health care facilities for monitoring and

followup of their hypertension. The absence of concern for the primary medical care of IVDUs by many single state drug agencies and

the insufficient attention to the design of modest to large-scale

health prevention efforts (thus unintentionally excluding IVDUs) by

public health authorities has resulted in significant unmet health care

needs among IVDUs. For black IVDUs, already living in economically

impoverished communities with inadequate health care and human

60
resources, this insufficient availability of drug-addiction-sensitive

health care and social welfare services has been even more

detrimental.

The notable exception referred to previously is in the area of prenatal services for IVDUs. Many large municipal hospitals in New

York City have prenatal services specifically tailored for drugaddicted women. The facilities that are the most successful in reducing problems of noncompliance by the pregnant mother are those

that have the following ingredients. First, the design of the clinics

provides encouragement, education, and parenting skills particularly

aimed at problems of the addicted woman and her often femaleheaded household. This does not mean just adding pregnant addicted

women to a facility’s otherwise established high-risk clinic, but providing sufficient, necessary, auxiliary services. Second, a close and

intimate association has been established with the mother to reduce

the inconvenience of having to attend separate locations for services.

Having reviewed a number of obstacles to prevention and health promotion efforts for black IVDUs, one may view these as monumental

roadblocks. Nevertheless, these formidable challenges are not

insurmountable. Innovative approaches and improvisation are the

orders of the day. Important components of community-based interventions aimed at black IVDUs include: (1) the identification of the

targeted behaviors and the provision of appropriately tailored HIVrisk-reduction education/information intervention by persons with

sufficient rapport with black IVDUs, offered in locations with easy

and frequent access to black IVDUs; (2) available services or vehicles

to enable black IVDUs to translate acquired knowledge into immediate

and sustained behavior change; and (3) the enhancement of traditional

and innovative community institutions to provide support for positive

modifications of the behaviors of black IVDUs. Finally, responsible

program administrators of HIV risk reduction efforts must include

systems for evaluating the effectiveness of their programs. Evaluating effectiveness will not be easy. In fact, in many ways the successful recruitment and retention of sufficient numbers of black

IVDUs will mean a deemphasis on procedures or practices that attempt to identify the participants. The ability to truly determine the

impact of HIV risk-reduction efforts targeted for IVDUs will require

prospective studies with periodic behavior change assessments. Particularly among IVDUs, this will necessitate the collection of address

and locator information for the IVDU and his family, close friends,

and acquaintenances if loss-to-followup rates are to be minimized.

These identification procedures are often seen by IVDUs as

61
unwarranted invasions of privacy. Unfortunately, these same identification practices are key features of traditional evaluation methods.

Thus, the challenge of caregivers for black IVDUs is to develop a

range of innovative means to measure the effectiveness of their risk

reduction programs. If black IVDUs are to receive the sustained

support that they so desperately need, program administrators are

going to have to meet the challenge of the vast majority of American

society who demand evidence of accomplishment.

The scope of HIV risk reduction efforts for black IVDUs should range

from primary prevention in school-based and nonschool-based youth

programs to secondary and tertiary services (especially primary medical services) to be provided in drug treatment programs, public

assistance/social service/child welfare centers, hospital emergency

rooms, and the criminal justice system. While the latter locations

provide points of access to black IVDUs, there is still a critical need

for mobile vans and a cadre of “foot soldiers” to go into the shooting

galleries and shelters where HIV exposure behaviors take place. The

common theme is to bring the services (whether education, information, or primary medical or social services) to the black IVDUs.

Furthermore, caregivers should provide a positive and supportive

environment. Accordingly, continuous inset-vice training about drug

addiction and its pivotal role in HIV disease needs to be provided to

the service provider as part of the intervention.

As valuable as pure research is for mankind, research that effectively

fuels community-based, risk reduction efforts for black IVDUs must

be a high priority. There is a critical need to develop additional

data bases to improve our capability to determine the number of

IVDUs and to assess their primary medical and social service needs.

Development is needed of mathematical models to use more appropriately the information substrate provided by various data bases. There

is also a desperate need for research to assist program evaluation.

Studies are crucial to determine what process and outcome measures

(other than the diagnosis of AIDS/AIDS-related complex (ARC) or the

use of HIV serological testing) are sufficient surrogates for HIV infection. Ingenuity is required to create instruments that assess behavior change and associated factors that influence behavior change.

Creative ways to validate behavior modification are also in great

demand. While it is ethically unjustifiable to postpone HIV risk reduction interventions until research efforts provide an acceptable

volume of support in the foregoing areas, legitimate investigative

efforts (for problem identification/monitoring, program direction, and

evaluation) are critical if effective and sustained support is to be

62
provided for black IVDUs. Research, appropriately directed, has the

potential to be an important ally of caregivers in HIV-risk-reducing

efforts. Indeed, research provides the evidence to inform a largely

uninformed American public of the need to develop a more rational

response to drug addiction and its medical-social sequelae.

CONCLUSION

For black Americans, the AIDS epidemic has meant a further insult to

a previous state of excessive morbidity and mortality, a deteriorating

family structure, and an impoverished economic base. While the face

of the epidemic may vary in many geographic regions, IV drug use is

a significant and pervasive factor in HIV disease among black heterosexual men, women, and children.

There are a number of formidable obstacles to effective intervention

in IVDU-associated HIV transmission. Black community institutions,

public health authorities, single state drug abuse agencies and government agencies may all intentionally or unintentionally inhibit behavior modification efforts directed at black IVDUs. Despite these

environmental challenges, there are significant prospects for engendering community support, and there are multiple potential avenues to

modify the behaviors of black IVDUs so as to reduce HIV exposure.

The effect of numbers of current community-based outreach programs

testify to this.

Significant demand persists for more education/information efforts

and, more important, for health care and social services to halt the

transmission of HIV infection and its sequelae. To be successful,

future intervention efforts will need to be focused to follow two

parallel, but closely related pathways. One pathway is to have drug

abuse treatment mainstreamed into other health services. This will

mean the modification of the curriculum of health professional

schools and postgraduate training programs and modifying State

licensing and professional certifying examinations to more greatly

emphasize drug abuse and addiction. Admittedly, this is a long-term

goal and would represent a true acceptance by modern medicine and

society of drug abuse as a medical disease and a major public health

problem.

The second pathway and more short-term approach is to diversify

services within current programs of drug abuse treatment. Addiction

to or abuse of one agent is becoming increasingly rare such that

treatment facilities must have the capacity to respond to the

63
increasing prevalence of polydrug abuse. Many IVDUs admit to concurrent IV heroin and cocaine use. Additionally, many IVDUs are not

likely to be accessed through traditional medical settings, necessitating that primary medical services become an integral component of

drug abuse treatment programs. Funding mechanisms and drug treatment regulations should be reviewed and modified to encourage these

program changes. While mainstreaming the drug abuse response is

optimal, the reality is that the diversification of current treatment

mechanisms is probably more achievable, although not a forgone conclusion. Public debate and political maneuvering may very well lessen

the full potential benefits of either pathway.

Simultaneously, there is a need for further research on the identification and surveillance of HIV-exposing behaviors, on the validation

of self-report instruments of behavior change, and on evaluation

methods of current and future health promotion programs. Research

is also especially needed to identify potential surrogates for sexually

and parenterally transmitted HIV infection. Very little is known, for

example, as to how well rates of other sexually transmitted diseases

predict rates of sexual HIV transmission or how well hepatitis B infection rates are related to parenteral HIV infection rates. Presently,

the opportunity for these concerted intervention and research efforts

is great. Without these efforts, the price to be paid is too high.

Redefining the response to drug abuse for the American society is an

opportunity that occupies a central position in the HIV epidemic.

While taking advantage of this and other HIV-related opportunities is

crucial for black Americans and black IVDUs, its public health significance is also great for the American society as a whole.

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U.S. Department of Health and Human Services. Report of the

Secretary’s Task Force on Black and Minority Health. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.

Weiss, S.H.; Ginzberg, H.M.; Goedert, J.J.; Biggar, R.J.; Mohica, B.A.;

and Blattner, W.A. Risk of HTLV-III exposure and AIDS among

parenteral drug abusers in New Jersey. The International Confer

ence on the Acquired lmmunodeficiency Syndrome. Philadelphia,

PA, April 1985. (Abstracts)

ACKNOWLEDGMENTS

Drs. Robert Lange and Jerome Jaffe of the Addiction Research

Center, National Institute on Drug Abuse, assisted by performing the

HIV serological tests.

68
AUTHOR

Lawrence S. Brown, Jr., M.D., M.P.H.

Addiction Research and Treatment Corporation

22 Chapel Street

Brooklyn, NY 11201

and

Department of Medicine

Harlem Hospital Medical Center

College of Physicians and Surgeons

Columbia University

New York, NY 10037

and

Division of Health Administration

School of Public Health

Columbia University

New York, NY 10032

67
Community-Based AIDS Prevention

Interventions: Special Issues

of Women Intravenous Drug Users

Josette Mondanaro

lNTRODUCTlON

To date, women comprise 7 percent (3,653) of acquired immunodeficiency syndrome (AIDS) cases (Centers for Disease Control 1988).

However, the prevalence of AIDS among women is likely to increase,

since the incidence of AIDS attributed to heterosexual contact is

increasing. The Centers for Disease Control (CDC) estimates that

another 7,300 to 36,000 women have AIDS-related complex (ARC) and

that there are 50 to 80 times as many women who test positive for

the human immunodeficiency virus (HIV) antibody as there are women

with active cases of AIDS–at least 180,000.

According to figures from the CDC for 1988, women with AIDS come

from the following risk groups:

Group Number Percent

Intravenous drug users 1,843 50

Heterosexual contact 1,074 29

Transfusion recipients 395 11

Undetermined 251 9

Although intravenous drug users (IVDUs) comprise the largest group

of women at risk for AIDS, the sexual partners of IVDUs are the

second largest group at risk. CDC figures show that, of women who

were infected with AIDS as the result of heterosexual contact,

69 percent had their heterosexual contact with an IVDU and 16 percent with a bisexual man.

68
The fourth largest group of women with AIDS falls into the CDC

category of “undetermined.” lt is believed that the women who fall

into this category represent second-generation transmission; that is,

their partners may not themselves be in high-risk groups, but may

have had sex with others in a high-risk group. Many of the women

in this group may be partners of men who are covering up their

intravenous (IV) drug use, HIV-seropositive results, or sexual

practices.

Thus, while it is difficult to estimate the numbers of women IVDUs,

it is imperative to recognize that a successful AIDS prevention/

education effort must reach out aggressively to the following groups

of women:

(1) IVDUs in treatment;

(2) IVDUs not in treatment;

(3) Partners of IVDUs; and

(4) Workers in the sex industry (prostitutes).

IVDUs Not in Treatment

It is estimated that for every chemically dependent person in treatment, there are seven who are not in treatment. Women, especially

IVDUs, are underrepresented in traditional drug treatment programs.

Partners of IVDUs

It is reported that 80 percent of male IVDUs have their primary relationships with women who do not themselves use such drugs. As

Des Jarlais and associates have reported (Des Jarlais et al. 1984),

male IVDUs who become seropositive are typically not ready to disclose this information to their partners for fear of rejection and

withdrawal of support. This coverup on the part of the male partners poses significant risk to women.

The nondrug-using female partners of male IVDUs may well constitute

the largest “hidden” population of women at risk for AIDS. These

women may not know that their male partners are IVDUs. They will

be difficult to reach since they will not be associated with a treatment program.

69
Prostitutes

Women who work in the sex industry are at an increased risk of

exposure to the AIDS virus based on a number of factors, including:

(1) multiple sex partners;

(2) anonymous sex with partners who may be seropositive or who

may fall into one of the high-risk groups;

(3) high-risk sexual activity;

(4) IV drug use; and

(5) decreased vigilance about proper safe sex practices because of

their use of alcohol or drugs.

PROGRESSION FROM INFECTION TO DISEASE

Not everyone who is exposed to the AIDS virus will develop AIDS.

In fact, researchers believe that the virulence of the AIDS virus

depends on:

(1) specific modes of transmission, i.e., direct intimate contact with

bodily fluids;

(2) repeated exposures over time; and

(3) preexisting or concurrent conditions in the host (cofactors).

Unfortunately, many of the cofactors associated with AIDS are known

to exist in drug users. These cofactors include poor nutrition, use of

drugs known to suppress the immune system, repeated bouts of infection, and high stress.

Nutrition

Women heroin users frequently state that they use heroin to lose

weight. Poor nutrition secondary to drug use is not just a byproduct of poor eating habits, but actually results from the direct

appetite suppressant effect of the drug. In addition, alcohol is

known to exert a direct toxic effect on the gastrointestinal tract;

this leads to an impaired absorption of food. Malnutrition is further

70
exacerbated by inadequate assimilation of vitamins and amino acids

due to damaged liver cells.

In some women, chemical dependency coexists with anorexia nervosa

or bulimia. lt is not uncommon for women with eating disorders to

attempt to control their perceived weight problem through the combined use of drugs and starvation. Ultimately the body’s immune

system is compromised due to the chronic state of malnutrition.

Drugs

Drugs enhance an individual’s risk for developing AIDS in multiple

ways. Alcohol, nitrites (poppers), amphetamines, and marijuana are

all known to suppress the body’s immune system. Nitrites lead to a

depletion of the helper T-cells by direct injury to these cells; they

are also known as cofactors in the development of various forms of

cancer.

In addition, the use of drugs to enhance sex may make it difficult to

practice safe sex. Drugs which cause muscle relaxation and blood

vessel dilation may enhance the absorption of the virus into the

bloodstream. Decreased judgment and decreased pain sensitivity may

make the participants less aware of the trauma involved in certain

physical acts.

Repeated Bouts of lnfection

Women drug users complain of medical problems more often than do

men drug users. Indeed, it is often a medical complaint that precipitates a woman’s entrance into drug treatment. Chemically dependent

women are at increased risk for the following medical problems: infections, anemia, sexually transmitted diseases (STDs), hepatitis,

hypertension, diabetes, urinary tract infections, gynecological problems, and dental disease, including abscesses.

During drug treatment, women continue to experience more medical

problems than their male counterparts. While this may reflect a

sociocultural bias (i.e., that women, more than men, are permitted to

be medically ill), it may well also reflect the fact that drugs exert a

more toxic influence on women. There is growing evidence that this

is certainly the case for alcohol (Wilsnack and Beckman 1984). In

particular, these drug-dependent women appear to be vulnerable to

the traditional STDs of gonorrhea, trichomonas, and chlamydia, as

well as the sequelae of exposure to these infections, which include

71
pelvic inflammatory disease, chronic scarring of the fallopian tubes,

decreased fertility, and increased abnormal cervical Pap tests. As a

result of needle use or skin popping, IV-drug-using women also expose themselves to other infections, including abscesses, cellulitis,

endocarditis, and hepatitis (Mondanaro 1981 a; Mondanaro 1981 b).

High Stress

Chemically dependent women experience extremely high levels of

stress as compared with male drug users or nondrug-using women.

Areas of increased stress include: responsibility for children, living

alone, low income, low level of education, lack of financial resources,

partners who are more likely to use drugs, more dysfunction and

pathology in family of origin, higher levels of depression and anxiety,

and lower levels of self-esteem (Reed 1981).

In addition, chemically dependent women tend to score high on recent

life change events, which are other stressors.

PREVENTION MOTlVATlON

Much of the AIDS prevention to date has occurred in the homosexual/

bisexual male community. These prevention efforts appear to have

been highly successful. One prospective study reported that 80 percent of the respondents had substantially changed their sexual

behavior from November 1982 to May 1984 (Coates 1985). Included in

these changes are significant decreases in the following high-risk

behaviors: numbers of new contacts, number of partners, receptive

anal intercourse without condoms, oral-anal contact, and swallowing

semen.

In addition, the number of rectal gonorrhea cases have declined by

75 percent in San Francisco since 1982. The San Francisco AIDS

Foundation believes that this is a direct result of AIDS education.

Is it reasonable to expect similar prevention efforts to have such an

equally positive effect on women who are chemically dependent? The

response must be a resounding and pessimistic “No!” The demographics of the gay male population are diametrically opposed to the

demographics of the female IV-drug-using group. One report of

changes in sexual behavior of gay men in San Francisco studied 454

men with the following characteristics: some college (68 percent),

white collar or professional work (77 percent), a mean reported income of $24,000 (Coates 1985). In comparison, studies of chemically

72
dependent women demonstrate a level of unemployment that varies

from 81 to 98 percent. Most chemically dependent women in federally funded treatment programs have not completed a high school education; even after completion of treatment, 72 percent of the women

are still unemployed and lack the skills for gainful employment

(Sutker 1981). Furthermore, AIDS statistics underscore the fact that

ethnic minorities are overrepresented among women with AIDS

(72 percent), as compared to homosexual men (25 percent) and all

AIDS cases (39 percent). In fact, the cumulative incidence of AIDS

in black and Hispanic women is more than 10 times that found in

white women (Centers for Disease Control 1987a). These differences

must be acknowledged and understood so that a prevention program

can be developed that will be responsive to the unique needs of the

chemically dependent woman.

EMPOWERING

To be effective, strategies for AIDS prevention and education for

high-risk women must be based on empowering techniques. The process by which AIDS information is disseminated is as important as

the content. The fear of contracting a fatal disease such as AIDS

because of belonging to a high-risk group, coupled with the woman’s

sense of hopelessness and powerlessness, can be severely debilitating. Denying her vulnerability to AIDS or assuming the fatalistic

attitude that she will contract the disease no matter what precautions

she takes may be the woman’s only defenses.

Chemically dependent women often feel like second-class citizens and

are very sensitive to real or imagined messages that they are not

worthy of help. lt would be easy for such women to get the idea

from AIDS prevention programs that they are being seen as unclean,

potential spreaders of AIDS to more worthy members of society. lt

is important, therefore, to set any educational program about AIDS

within the context of genuine concern for the well-being of the

chemically dependent woman herself.

Didactic presentations will probably be the least effective method of

reaching these women and bringing about both an increase in their

knowledge and changes in their behaviors. Methods that involve

these women in the development and delivery of their own programs

are more likely to be successful. In every client and community

population, there are individuals who are highly respected and

recognized by other members of that identified group and make up an

informal network of indigenous community helpers. These individuals

73
can become an integral part of the community’s educational efforts

by bridging the gap between the formal organizations and the various

populations of high-risk women.

The techniques of activating clients and identifying natural helpers

can be utilized within the drug treatment programs, in jail and prison

settings, with groups of women who work in the sex industry, and

within the community at large. Information given by these trusted

individuals will carry more weight than information given by drug

treatment counselors, jail guards, or other people who may not be

perceived as having the woman’s well-being as their primary goal.

Natural helpers can be identified and selected from all the groups of

women that a program wishes to reach. Depending on the location

and situation, target groups may be broken down by drugs of choice

(i.e., IV speed users, IV heroin users), ethnicity, area of residence, or

any other grouping.

Formal drug programs and other community organizations can offer

space for meetings, printed educational material, resource lists, and

other tangible support for the informal networking being carried out

by the natural helpers.

“Coyote,” the national organization for women in the sex industry,

has written its own guidelines for AIDS prevention. In addition, it

holds open meetings called The Bad Girls Rap Group, during which

women can discuss their concerns and have their questions answered

in a supportive, nonthreatening environment. This type of organizing

builds on the strengths found in a particular group. For example,

women who work in the sex industry often practice safe sex and are

very knowledgeable about techniques for avoiding STDs. These skills

can be acknowledged and used to teach women who may not be quite

as familiar with safe sex practices.

It is imperative that programs assist women in taking control of their

own lives. lt should be remembered that the process by which a

program reaches women will make the difference between success

and failure.

EDUCATION AND OUTREACH

Education and outreach to prevent the transmission of AIDS will

require a multilevel approach, involving a variety of organizations

that provide services to women. Women at risk can be reached

through the following agencies: public health departments, family

74
planning clinics, social service agencies, city and county jails, State

prisons, women’s health centers, battered women’s shelters, women’s

crisis programs, and drug treatment programs.

Service agency staff and members of the at-risk groups should be

trained to give the training themselves (Mondanaro et al. 1982).

Specific strategies that have been used to reach women include:

outreach to health providers, development of an advocacy and

information network of women working on AIDS issues, direct media

advertising, use of existing community institutions including health,

social service, ethnic, religious, and other cultural organizations,

material development in appropriate languages incorporating AIDS

information into existing materials, and hotlines, mass-media

education, and multiethnic outreach (Shaw 1985).

Areas to be covered by any intervention approach used with women

should include safe sex practices, changing sexual behaviors, and

pregnancy.

Safe and Unsafe Sex Practices

In this culture, there are very few words with which to adequately

discuss sex and bodily parts. Vocabulary is limited to scientific

medical jargon, street-wise “dirty” words, or baby talk. lt is important that the words selected are understood by all and that street

talk not be avoided because of the discomfort of the educator. At

the same time, a sense of respect and dignity must be communicated

while using common terms. Most persons are often uncomfortable in

dealing with issues of sexuality, and specialized training should be

offered to prepare intervention staff properly.

Safe sex includes activities that involve only skin-to-skin contact,

where there are no breaks in the skin from sores, infections, or

wounds. These activities include: massages, hugging, body-to-body

rubbing, social (dry) kissing, voyeurism, exhibitionism, fantasy, touching one’s own genitals, and using one’s own sex toys.

Using condoms, latex gloves, and latex barriers to avoid exchanging

bodily fluids–semen, saliva, urine, feces, or blood–is safe as long as

they are used properly and do not come off or break. The proper

use of these protective devices will allow a couple to engage safely

in vaginal intercourse (with a condom), fellatio (with a condom), cunnilingus (with a latex barrier), and hand/finger-to-genital contact

(with latex gloves).

75
Changing Sexual Behaviors

Practicing safe sex may pose a substantial challenge for chemically

dependent women. These women are being asked to change both

their drug-taking behaviors and their sexual behaviors. Many chemically dependent women already experience difficulty in the area of

sexuality. For some women, sexuality is the only way they know to

experience intimacy. Intervention programs must appreciate the core

changes that are being demanded of these women. In addition,

women may be afraid to tell their partners that they need to change

their sexual practices. They may fear rejection and abandonment,

and their fears may not be unwarranted.

Despite a hardened exterior, these women are often exceptionally

passive as a result of strict sex-role socialization; they have learned

that to be feminine means to be passive and nonassertive. These

women often test at the extreme end of feminine, while their chemically dependent male partners test at the extreme end of masculine

(Mondanaro et al. 1982). The result is that the woman may be too

passive to exert herself and the man may not accept his

responsibility or cooperate in sexual risk reduction. The male partner

may see changes in sexual practices as unmasculine.

Intervention programs must assist chemically dependent women to

escape from this socially passive role. Women role models will be

extremely important in getting across the message that a woman must

take responsibility for her own body. Natural helpers can be of

great assistance in modeling assertive behavior and in giving the

women permission to do things differently.

Anticipating a woman’s hesitation and discomfort, providing support,

and creating opportunities for role playing will all help increase her

confidence. Warnings about AIDS could be misinterpreted to mean

that these women are not to have any fun or pleasure in their lives.

Frank discussion should take place about how to enjoy sex and keep

it safe at the same time. These sessions will be more believable if

presented by individuals who truly believe that safe sex can be fully

satisfying and enjoyable.

It is imperative that all women who are IVDUs, partners of IVDUs,

or prostitutes, or who have sex with anonymous or multiple partners

practice safe sex. Material regarding testing and seropositivity may

confuse the basic, simple message that all women in these high-risk

groups must practice safe sex.

76
Pregnancy and AIDS

According to the CDC, 80 percent of pediatric AIDS cases are attrib

uted to transmission from an infected parent (Centers for Disease

Control 1987b). In 90 percent of these cases, the babies’ mothers

either used drugs intravenously or had male sexual partners who used

IV drugs. Ethnic minority children comprise 80 percent of all pediatric AIDS cases (Centers for Disease Control 1986). The bulk of these

cases represent in utero transmission. Another potential source for

contracting the virus is artificial insemination. Lesbians and other

women who received donor semen are being followed in a San

Francisco study to see if they have developed antibodies to HIV.

Chemically dependent women have been told that they should be

tested for HIV prior to pregnancy. This is good advice, but ignores

the reality that most pregnant addicts have not planned their pregnancies. Amenorrhea, a result of heroin use, or decreased fertility as

a result of repeated bouts of pelvic inflammatory disease make some

chemically dependent women believe that they cannot get pregnant.

Other women are too preoccupied with drugs to even think about the

possibility or need for contraception.

Contraception information must be made a major component of any

AIDS prevention/education program for women. This should include

the evaluation of women who falsely believe that they cannot get

pregnant because they have scarring secondary to infections in the

fallopian tubes. These women may have diminished fertility because

of heroin use, but once they enter treatment and become abstinent

from heroin, their fertility increases.

Pregnancy is associated with suppression of immunity, particularly

cell-mediated immunity. This is especially true during the last 3

months of pregnancy and is evident up to 3 months after delivery. It

is known that this decreased immunity increases a woman’s susceptibility to certain infections, and it is believed that it can make a pregnant woman more vulnerable to developing AIDS, especially if she is

already seropositive (Centers for Disease Control 1985).

INFORMATION THAT ALL WOMEN SHOULD KNOW

There is some information that should be given to all women in highrisk groups, regardless of their HIV antibody status. The basic information about AIDS should include:

77
(1)

(2)

(3)

(4)

(5)

a fundamental description of AIDS;

the iceberg concept, which explains that AIDS represents only

the end of a continuum that also includes HIV seropositivity and

ARC;

the fact that healthy people can be carriers of AIDS and that

whether an IVDU is contagious for AIDS cannot be told by

his/her physical appearance;

how they can become infected, i.e., IV drug use, sharing of

needles, sex with IVDUs, sex with a man whose history is

unknown, and sex with multiple sex partners; and

AIDS is not spread by casual contact.

What women should know about pregnancy and AIDS includes:

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

73 percent of pediatric AIDS is attributed to maternal transmission during pregnancy;

a seropositive woman does not need to be sick with the disease

of AIDS to pass the disease on to her fetus;

50 to 60 percent of children born to seropositive mothers will

be infected;

there is no way to prevent the fetus from becoming

infected if the mother is infected;

infants and children of seropositive mothers must be carefully

monitored because the infection may not cause symptoms

immediately at birth;

pregnancy is a stress on the woman’s body and as such may

increase the chances of an infected woman developing

symptoms;

seropositive women should not get pregnant;

high-risk women should get an HIV antibody test prior to getting pregnant;

78
(9) the virus is passed in the breast milk, and seropositive women

should avoid breast feeding; and

(10) women in high-risk groups who do become pregnant should get

the HIV antibody test.

Women who are seropositive, but have no symptoms, should be told

that regular medical evaluations and followup are advised. They are

probably both infected for life and contagious for life and must act

as if they are contagious. They cannot assume they will or will not

develop AIDS. Any persons who have been exposed to the seropositive woman, i.e., sexual partners, children, and persons with whom

needles have been shared, should seek HIV testing. lt is still true

that repeated exposures to the virus may increase the chances of

developing AIDS; therefore, they should not have unsafe sex or share

needles with other seropositive individuals. Meanwhile, maintenance

efforts, including proper nutrition, abstinence and sobriety, stress

management, safe sex practices, and no sharing of needles may all

decrease the risk of seropositivity developing into ARC or AIDS.

They should not get pregnant and should use a reliable method of

birth control. Of course, they should not donate blood, plasma, body

organs, or other tissue. Further, when seeking medical or dental

care, they should inform health care providers of their positive antibody status, so that appropriate care can be given and precautions

taken to prevent transmission.

The seropositive woman can be assured that the virus is not spread

through casual contact such as coughing, sneezing, sharing cups, telephones, or toilets, nor will she “give AIDS” to anyone in the course

of normal housekeeping. Indeed, she may and should continue to hug

her kids. She can continue to cook and clean with normal attention

to safety. However, toothbrushes, razors, or other implements that

could become contaminated with blood should not be shared and, following incidents that result in bleeding, contaminated surfaces should

be cleaned with household bleach freshly diluted with 1 part bleach

to 10 parts water. In addition, tampons and sanitary napkins should

be carefully disposed of, since menstrual blood does contain the virus.

It is important to stress the hope inherent in this situation and the

control the women can exert to avoid moving along the continuum

from seropositivity to ARC to AIDS. Women must be made to realize

that the exposure to the virus as represented by a positive antibody

test does not mean that she will inevitably get the disease of AIDS.

There is much she can do to increase her health status. Support

79
groups should be initiated for women who are seropositive. Aside

from answering questions and providing emotional support, these

groups can focus on the tangible changes a woman can and must

make. Checklists, charts, diaries, or journals can be used to give the

woman a concrete record of the health maintenance and behavioral

changes she needs to make.

Weekly reviews of diaries will help these women stay on track and

provide immediate positive feedback, as well as immediate assistance

in problem areas. These should start with areas in which the women

can experience high rewards and low stress. More difficult issues

can then be addressed in a graduated, progressive way on this

positive base.

Women will need assistance in discussing their HIV status with partners. Anticipating their discomfort will assist the women in acquiring

new skills for coping with this sensitive area. Encouraging role playing and having women share how they have told their partners will

give the women opportunities to practice various approaches and find

out what feels most comfortable for them. The program should facilitate this communication by offering couple counseling and groups for

partners of seropositive clients.

CARE OF THE CHEMICALLY DEPENDENT WOMAN WITH AIDS

The primary care for the chemically dependent woman with AIDS may

be the responsibility of medical personnel and the hospital staff. The

drug treatment program will have to be integrated with the work of

a multidisciplinary team that involves many organizations, including

the hospital, child protective services, human resources agencies, and

public health departments.

Chemically dependent women will most likely not have the resources

to develop the strong support networks seen in the gay communities.

For this reason, formal organizations will be essential and primary

providers of support for these women. Plans must be made for

dependent children prior to the women becoming too debilitated to

properly care for them. Drug treatment programs and other agencies

may well serve as the lifeline for these women. It is imperative for

the well-being of these women, their children, and the rest of

society, that the women not slip through the cracks that exist

between various service providers.

80
REFERENCES

Centers for Disease Control. Recommendations for assisting in the

prevention of perinatal transmission of HTLV/LAV and AIDS.

MMWR 34(48):721-732, 1985.

Centers for Disease Control. Acquired immunodeficiency syndrome

(AIDS) among black and Hispanics–United States. MMWR 35(42):

655-666, 1986.

Centers for Disease Control. Antibodies to human immunodeficiency

virus in female prostitutes. MMWR 36(11):157-161, 1987a.

Centers for Disease Control. Unpublished data, March 9, 1987b.

Centers for Disease Control. Acquired lmmunodeficiency Syndrome

(AIDS) Weekly Surveillance Report. Atlanta: January 4, 1988.

Coates, Thomas J. The impact of AIDS on the sexual behavior of gay

men. Public Health Grand Rounds. Sacramento: California

Department of Health Services, July 11, 1985.

Des Jarlais, D.C.; Chamberland, M.E.; Yancovitz, S.R.; Weinberg, P.;

and Friedman, S.R. Heterosexual partners: A large risk group for

AIDS. Lancet 2(8415):1346-1347, 1984.

Mondanaro, J. Medical services for drug dependent women. In:

Beschner, G.M.; Reed, B.G.; and Mondanaro, J., eds. Treatment

Services for Drug Dependent Women. Vol. I. Rockville, MD:

National Institute on Drug Abuse, 1981 a. pp. 208-257.

Mondanaro, J. Reproductive health concerns for the treatment of

drug dependent women. In: Beschner, G.M.; Reed, B.G.; and

Mondanaro, J., eds. Treatment Services for Drug Dependent

Women. Vol. I. Rockville, MD: National Institute on Drug Abuse,

1981b. pp. 258-292.

Mondanaro, J.; Wedenoja, M.; Densen-Gerber, J.; Elahi, J.; Mason, M.;

and Redmond, A. Sexuality and fear of intimacy as barriers to

recovery for drug dependent women. In: Reed, B.G.; Beschner,

G.M.; and Mondanaro, J., eds. Treatment Services for Drug

Dependent Women. Vol. II. Rockville, MD: National Institute on

Drug Abuse, 1982.

Reed, B.G. Intervention strategies for drug dependent women: An

introduction. In: Beschner, G.M.; Reed, B.G.; and Mondanaro, J.

Treatment Services for Drug Dependent Women. Vol. I. Rockville,

MD: National Institute on Drug Abuse, 1981.

Shaw, N.S. California models for women’s AIDS education and

services. Presented at the American Public Health Association

Annual Meeting, Washington, DC, November 20,1985.

81
Sutker, P.B. Drug dependent women: An overview of the literature.

In: Beschner, G.M.; Reed, E.G.; and Mondanaro, J., eds. Treatment

Services for Drug Dependent Women. Vol. I. Rockville, MD:

National Institute on Drug Abuse, 1981.

Wilsnack, S.C., and Beckman, LJ., eds. Alcohol Problems in Women.

New York: The Guilford Press, 1984.

AUTHOR

Josette Mondanaro, M.D.

California School of Professional Psychology

5024 Thurber Lane

Santa Cruz, CA 95065

82
Preventing AIDS:

Prospects for Change in

White Male Intravenous

Drug Users

James L. Sorensen

INTRODUCTION

As 1988 began, it was clear that acquired immunodeficiency syndrome

(AIDS) among intravenous drug users (IVDUs) had become a serious

problem. Some 49,743 cases of AIDS had been diagnosed: 8,411

among heterosexual IV drug abusers (17 percent) and 3,689 among

homosexual/bisexual men (hereafter referred to as gay men) with a

history of IV drug abuse (7 percent) (Centers for Disease Control

1987). The National Institute on Drug Abuse estimates that there are

approximately 1.1 to 1.3 million IVDUs in the country, of which

200,000 are intermittent users. Of these, the Centers for Disease

Control (CDC) estimates that 335,000 are infected with the human

immunodeficiency virus (HIV) (Booth 1988).

It was also clear that AIDS among IV drug abusers is a problem not

limited to a single ethnic group. Of the 8,411 heterosexual IV drug

abusers diagnosed with AIDS, 4,303 (51 percent) are black, 2,394 (28

percent) are Hispanic, and 1,672 (20 percent) are white. In contrast,

of the 23,552 AIDS cases among gay men who were not drug abusers,

fully 79 percent were white. Bakeman et al. (1987) analyzed the CDC

AIDS cases to April 1987 and noted that the number of AIDS cases

among heterosexual black and Hispanic male patients using drugs

intravenously were 22.6 and 21.4 times higher than the corresponding

rate of white male IVDUs. The reasons for the higher rate of cases

among black and Hispanic communities are complicated and not fully

understood (Bakeman et al. 1986); however, clearly, in the area of

AIDS among IV drug abusers, black and Hispanic ethnic groups have

been affected disproportionately.

83
By 1991, some 270,000 people in the United States will have AIDS or

will have died from the disease; how many others will be infected is

uncertain, partly because the virus is spreading into the general

population at an unknown rate (Barnes 1986). The proportion of

AIDS cases who are IVDUs is expected to remain about the same,

with an increase in cases among their sexual partners.

The general public sees drug users as reservoirs of criminality,

medical problems, and social ills–a self-destructive lot with few

resources. Ginzburg (1984) points out, however, that they are

extremely heterogeneous. Preventive interventions are needed and

must address the needs of specific racial groups, ethnic backgrounds,

sexual preferences, and ages. One theme of this presentation,

however, is that the integrity of this constituency must be supported

by prevention efforts, not splintered. The hope for prevention lies in

unity, both among citizens who use drugs and among those who care

about their survival.

This paper focuses on white male heterosexual IVDUs. First, it

summarizes the knowledge of HIV infection and AIDS as it applies to

this group. Then it discusses community factors that support or

hinder the likelihood of performance of preventive behaviors by this

group. To document community experiences with related behaviors,

the paper comments on experiences with gay men and health promotion campaigns. It also presents anecdotal experiences with HIVrelated behaviors, both from the literature and from the author’s drug

treatment program in San Francisco. Several “second-generation”

AIDS prevention models are suggested, and suggestions are made for

associated research.

WHAT IS KNOWN ABOUT AIDS FOR DRUG USERS WHO ARE WHITE

MALES?

For purposes of this review, population characteristics are separated

from behavioral characteristics. The former are defined as factors

that describe most study groups, e.g., geographic area, ethnicity and

sex, while the latter we define as behaviors that the groups engage

in, e.g., needle sharing and drug use.

Population Characteristics

Region. Several studies have found regional variation in rates of

infection with HIV. The studies in different regions consistently

point to the urban Northeast as an area with an intense

84
concentration of HIV infection among IVDUs. Des Jarlais and

Friedman (1987) point out that the best single predictor of HIV

infection in IVDUs is geographic location. In New York City and

northern New Jersey, the rate of infection among IVDUs has been

estimated to be at least 50 percent (Drucker 1986; Booth 1988).

Studies in 1985 showed that a third of all patients in New Jersey

drug treatment programs tested positive for HIV antibodies (Alcohol,

Drug Abuse and Mental Health Administration 1985). A 1984 study by

Spira et al. (1984) found a seroprevalence rate of 58 percent among

86 lVDUs entering a drug detoxification program. In two studies

with predominantly black and Hispanic IVDUs in New York City,

Brown and Primm (1987) reported seroprevalence of 54 percent among

a group applying for admission to methadone, and 61 percent among a

group in drug treatment for more than a year.

On the West Coast and in most of the rest of the country, HIV is

less widespread among IVDUs. In a 1985 survey, Levy et al. (1986)

found a rate of infection of only 1.7 percent among 845 blood samples from IV drug users attending State-licensed treatment centers in

seven California counties. In a 1984 to 1985 survey in San Francisco,

Chaisson et al. (1987a) found 10 percent of 281 IVDUs recruited from

community-based settings were seropositive. By 1987, the rate of

seroprevalence had risen to 15 percent (Chaisson et al. 1987a). A

study reported by Watters and Cheng (1987) revealed a seroprevalence

rate of 9 percent in 401 IVDUs in San Francisco.

Race. Caucasians have shown lower rates of HIV infection than

ethnic minorities (principally blacks and Hispanics have been studied)

in Manhattan (Cohen et al. 1985; Marmor et al. 1987), the Bronx

(Schoenbaum et al. 1986), Queens (Robert-Guroff et al. 1986), and

San Francisco (Chaisson et al. 1987a). For example, the Chaisson

et al. sample included 51 percent whites and 54 percent men. Racial

differences appeared, as whites had a lower prevalence of seropositivity than blacks and Hispanics, and this finding persisted after

adjusting for needle sharing.

Table 1 presents published studies known to this author that specifically address differences in race and indicators of AIDS risk in their

samples. Ethnic differences appear in three of the six studies, in

each case with whites being less at risk.

Gender and Age. Where sexual differences have been examined,

statistically significant differences have not appeared among IVDUs

85
(table 1). Nor have studies shown consistent differences in seroprevalence among different age groups.

TABLE 1. Summary of published studies: Risk of AIDS among

white males relative to other groups

First Author Indicators of AIDS

of Study White Men Risks (HIV+, Needle

Year) (Percent) (Percent) Sharing, Drug Use)

Chaisson

(1987a)

51

Dolan

(1987)

Marmor

(1987)

47

29

Robert-Guroff 34

(1986)

Selwyn

(1987)

20

Watters

(1987)

51

54

100

74

70

53

65

HIV antibodies: less

infection in whites.

No sex differences in

infection. Needle

sharing: Fewer whites

shared, but those who

shared did so with

more people.

Needle sharing: No

race differences.

HIV antibodies: Five

racial groups, infected

at different rates.

Whites' rate = .42;

total sample rate = .51.

No sex differences.

HIV antibodies: Less

infection in whites.

No sex differences.

Knowledge of AIDS:

No race or sex differences.

Needle sharing: No

race or sex differences.

HIV antibodies: No

race or sex differences.

86
Behavioral Characteristics

lf every person infected with HIV were to stop engaging in behaviors

that spread body fluids, the progression of HIV infection would be

stopped completely. Behaviors must be modified to stop AIDS, and

behavior changes are crucial. Where IV drug use is concerned, a

series of behavioral defenses would stop AIDS. lf people want to

protect themselves, the best defense is to stop using drugs. A less

perfect defense is not to use needles when they take drugs; even less

perfect is always to use their own needles and never share: and a

last-ditch defense is always to clean the shared needle before using

it. A similar set of defenses exist against sexual transmission of

AIDS, ranging from abstinence to protecting oneself always with

condoms and spermicide. In this section, we examine what is known

about these and other behaviors that might put IVDUs at risk.

Injection of Drugs. More frequent injection has been associated with

HIV risk consistently in studies in the New York (Marmor et al. 1987)

and San Francisco areas (Chaisson et al. 1987a) and also in Dallas

(Black et al. 1986, Dolan et al. 1987).

Needle Sharing. Needle sharing seems to be the most important

HIV-transmitting behavior among IVDUs; it is implicated in study

after study of HIV infection. Needle sharing has been commonplace

among IVDUs, even in areas of low seroprevalence. For example,

Levy et al. (1986) found that 80 percent of his sample of 345 IVDUs

shared. In the Chaisson et al. study (1987b), increased risk of

seropositivity was found among addicts who reported regularly sharing

needles, especially with two or more people. The study of Brown and

Primm (1987) revealed that needle sharing and numbers of people

involved with sharing explained more variance in serostatus than race

or any other variable.

Because of the importance of needle sharing, several investigators

have attempted to understand what factors influence the decision to

share. A qualitative study by Des Jarlais et al. (1987b) has explained

many of the psychological, social, and cultural reasons that IVDUs

share needles. Bakeman et al. (1987) comment that the epidemiology

of AIDS may indicate that needle sharing is more widespread among

minorities. The evidence for this, however, is mixed. Dolan et al.

(1987) surveyed the needle-sharing habits of 224 intakes to a 30-day

inpatient drug program in Dallas from 1983 to 1985. Three variables

discriminated needle sharers (68 percent of the sample) from other

drug abusers: greater severity of drug use, multiple drug use, e.g.,

87
opiates and cocaine, and use of shooting galleries. Of the sample, 47

percent were white; race did not predict needle sharing. An earlier

study noted that sex roles may make men more likely to use needles

on their own (Howard and Borges 1972); needle sharing may be more

common among women (Rosenbaum 1981).

Needle Cleaning. Needle hygiene has recently received attention as a

“last-ditch” method for an IVDU to prevent HIV infection. Watters

and Cheng (1987) found that 87 percent of their sample cleaned

needles between sharing partners, but the typical cleaning used tap

water (which does not kill HIV) as the cleaning agent.

Obtaining Drug Treatment. In the study of Watters and Cheng (1987)

the seroprevalence rate of those out of treatment was about twice

that of those who were in treatment for drug use. Sorensen et al.

(1988) report large decreases in needle use among seropositive drug

abusers once they enter methadone maintenance. However, because

of variability in treatment retention, abused drugs, and clientele, it

would be naive to expect to see a strong and consistent relationship

between drug treatment and risk of contracting or spreading HIV.

For example, Hubbard et al. (1988) found that length of time in

treatment strongly affects a drug user’s AIDS risk.

Prostitution. Two studies in the United States have found that

prostitutes are more likely to be infected than other populations

(Schoenbaum et al. 1986; Des Jarlais et al. 1987c). On the other

hand, in the Chaisson et al. (1987a) study, no association was found

between HIV infection and history of prostitution.

Summary

In population characteristics, white male IVDUs living in the Northeast are more likely to be infected than those in other areas of the

country. Whites appear to be less likely than blacks or Hispanics to

be infected with HIV. Other population characteristics do not consistently predict either HIV infection or risky behaviors. Regarding

behavioral characteristics, frequent injection of drugs and needle

sharing have been consistently implicated in studies of seroprevalence.

FACTORS THAT AFFECT LIKEHOOD OF PREVENTION

Several community factors or characteristics may support or hinder

the performance of protective and preventive behaviors among white

males IVDUs. The factors examined here include cultural differences;

88
social supports; family background; economic, educational, and

psychological resources, and sex role expectations.

Cultural

To the extent that they are better educated, whites more than any

other group may benefit from preventive messages in the written

media, e.g., newspapers or brochures. Ginzburg et al. (1986) report

that in a 1985 New Jersey survey of 577 drug users, more than

two-thirds indicated that they had obtained information about AIDS

from newspapers, and whites gave positive responses most frequently.

Social Supports

IVDUs have less social support for AIDS risk reduction than do gay

males (Friedman et al. 1987). Moss (1986) points out that the drug

treatment and AIDS constituencies are almost totally separate, and

there has been little evidence of mobilization on the AIDS/IV drug

abuse issue anywhere outside the east coast. White males are not

thought to differ from other groups in the likelihood that social

factors will mitigate risk of HIV infection.

Family

To the extent that white males may be less involved with extended

family than are other ethnic groups, they may be more difficult to

reach with prevention messages. For males who have a great

dependence on their nuclear family, family members may be crucial

for AIDS prevention, both as an influence on the drug user and also

as targets of preventive information themselves. IVDUs are not

typically loners, but have close contacts with their families (Stanton

et al. 1982). The spouse and parents of the drug user seem to be the

most important significant others that may help in AIDS prevention

with white males.

Economic

At the community level, IVDUs generally have few economic resources. The community infrastructure that enabled the epidemic

among gay men to be treated with substantial volunteer resources is

almost totally lacking among IVDUs. The lack of economic resources

among IVDUs transcends ethnic and cultural groups and overshadows

the economic differences between races or sexes. The lack of

economic resources and community infrastructure appears to be the

89
greatest impediment to providing adequate treatment for IVDUs once

infection has occurred. Perhaps because whites and males have more

money than other IVDUs, they may be less likely to share needles.

Educational/Psychological

If a group is more aware of the threat of AIDS, its members may be

less likely to share needles. A study by Selwyn et al. (1987) found

that AIDS knowledge predicted less needle sharing among 261 IVDUs

in New York. Needle sharers were less likely than nonsharers to

have graduated from high school and had lower scores on the AIDS

knowledge questionnaire. Hochhauser (1987) evaluated the readability

of AIDS educational materials and found the average reading level to

be 14th grade, well beyond the comprehension of poorly educated

IVDUs. Knowledge may make a difference in AIDS risk. And to the

extent that white male IVDUs may be better educated than other

groups, they may benefit more from health education efforts.

IV drug use in white males may reflect greater psychological maladjustment relative to their cultural norms than is the case of

nonwhites. Thus, white males may be less able to make deliberate

changes than those whose drug use fits their cultural norm. This

appears to be one factor that predicts limited engagement of the

white male IVDU in preventive behaviors, the established premise that

the higher the social class of an addict, the more likely he or she is

suffering from psychopathology (Kaufman 1978).

Sex Roles

A male partner’s support may serve as an essential catalyst for safe

sexual practices. Men, like women, need social skills training on the

use of condoms to overcome any embarrassment they may have in

asking a new partner about her sexual practices. As women do, men

may believe that condoms remove the spontaneity from sexual activity

(Mantel et al., in press). Heterosexual men must learn new sexual

repertoires that incorporate condom use. In general, men may be

more able than women to determine the use of condoms (Wermuth

et al. 1988), because although women can influence condom use, men

can control it.

Summary

Some community factors for whites may improve AIDS risk reduction

and the benefits from accrued AIDS prevention messages. White

90
males’ psychological resources, however, may pose barriers to preventive activities. The special role heterosexual men play in the

decisions surrounding sexual encounters is crucial in preventing the

spread of AIDS to women. increasing the likelihood that male IVDUs

will use condoms merits serious study.

COMMUNITY EXPERIENCES WITH RELATED BEHAVIORS

Gay Men and AIDS

Experiences with gay men can provide a template for interventions

with IVDUs. A study by Stall et al. (1986) showed that use of drugs

and alcohol during sex, the number of drugs used during such activity, and the frequency of combining drugs and sex were all positively

associated with risky sexual activity for AIDS. In short, they found

a strong relationship between drug and alcohol use during sex and

noncompliance with safe-sex guidelines. As the group of gay men in

San Francisco has changed its norms, the outliers continue to be

those with drug and alcohol problems. This experience supports the

view of the general public that IVDUs will be unlikely to change

their behaviors.

Among gay men, significant changes have occurred in response to the

AIDS epidemic. The number of sexual partners and amount of unprotected receptive anal/genital contact have been significantly related

to risk of HIV infection (Winkelstein et al. 1987). Significant reductions in these risks have occurred, but risky behaviors have not been

eliminated. A survey spanning sexual behavior from 1982 to 1985

among gay men in San Francisco indicated that all forms of sexual

activity considered to be high risk for AIDS transmission and reception had decreased substantially (McKusick et al. 1985), but about 25

percent of the sample still reported engaging in at least one sexual

act capable of infecting themselves during the month prior to the

survey, and 28 percent reported engaging in at least one activity

capable of spreading the infection to others. A 1983 survey by

McKusick et al. (1985) revealed that gay men attending bathhouses

showed little change in number of sex partners, while men in lowrisk situations (with few partners or a steady partner) had

substantially lowered their frequency of sexual contacts. Knowledge

of health guidelines for reducing AIDS risk was quite high among gay

men in this study, but this knowledge showed no relation to sexual

behavior. In planning AIDS prevention activities among drug abusers,

it should be expected that risky behaviors may be lessened, but not

eliminated. Programs that increase knowledge of risks will help at

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first, but once the population is AIDS-aware, more than knowledge

will be required to change behaviors.

Further, a study of the determinants of behavioral risk reduction

among gay men at risk for AIDS showed that the availability of supportive peer norms was the only variable that was consistently, significantly, and positively related to reducing one’s risk of acquiring

AIDS (Joseph et al. 1987). Knowledge, perceived threat, and other

attitudes toward infection did not make a substantial difference. The

implication for IVDUs is that permanent behavior change may not

come until IVDUs see that their peer groups’ behavioral norms are

changing.

Health Promotion Campaigns

Brandt (1988) has pointed to the Federal Government’s attempts at

syphilis control for guidance in dealing with the AIDS epidemic. He

contends that a complicated interplay of forces influences diseases

and our social policies for coping with them. There is conflict

between the “moral” and the “instrumental” approaches, with the

advocates of each approach thinking the other approach promotes

infection. Brandt concludes that intensive education programs, widespread provision of condoms, and widespread voluntary confidential

testing were useful in fighting the epidemic of syphilis and may

provide some insights for contemporary approaches to combat AIDS.

Job (1988) pointed out that in health promotion campaigns the use of

fear is often ineffective in achieving the desired behavior change. If

a campaign attempts to use fear as part of a punishment procedure,

it is unlikely to succeed. To work well, a campaign that uses fear

needs to have several elements: (1) fear should occur before a

desired behavior is offered; (2) the event upon which the fear is

based should appear to be likely; (3) a specific desired behavior

should be offered; (4) the level of fear should only be such that the

desired behavior offered is sufficient to substantially reduce the fear;

and (5) fear offset should occur as a reinforcer for the desired

behavior, confirming its effectiveness.

Following these five steps, it can be seen that there are ways in

which AIDS prevention campaigns can benefit from this analysis.

(1) Fear comes first. As AIDS spreads, it seems likely that IVDUs

will fear AIDS; however, they do not fear needle sharing, which

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(2)

(3)

(4)

(5)

is common in the culture. Nor are they likely to believe fearpromoting health educators.

AIDS is likely. As Moss (1986) has pointed out, HIV

presents difficulties because of its slow progression from

infection to disease. By the time the first cases appear in

a community, the virus will have established a strong hold.

Unfortunately, until some cases appear in their neighborhood, it is unlikely that drug abusers will view getting

AIDS as a likely event.

Specific behavior is offered. In San Francisco, an early

approach was to give the message “Don’t Share,” which,

although accurate, may have not been specific. lt told

drug abusers what not to do, but did not offer a specific

desired behavior that drug abusers should perform. It was

a message of what not to do rather than an action that an

IVDU could take. Subsequently, the message has become

‘Clean your needles with bleach,” which is more specific.

Behavior sufficiently reduces fear. This is unfortunately

the opposite side of (3) above. In leading psychoeducational groups of current and former IV drug abusers, the

author sees that drug abusers will feel safe only if they

have been abstinent and HIV antibody negative for at least

6 months. Giving the message “Clean your needles with

bleach” gives them a specific activity to perform, but it

does not allay their anxiety (nor should it).

Fear should stop when the desired behavior is performed.

Because the symptoms of AIDS are slow in coming, health

promotion campaigns may be presenting the classic-conditioning desensitization paradigm, in which the IVDU is

repeatedly presented with a high-risk activity, e.g., sharing

needles, without any effective unconditioned stimulus, e.g.,

no visible signs of HIV infection. Such a scenario allows

the addict to discredit the campaign or to deny or

rationalize with thoughts such as “I must be immune” or “If

it hasn’t happened to me yet, it won’t.”

Summary

Pertinent experiences with the epidemic of AIDS among gay men and

with combating the syphilis epidemic imply that educational programs,

93
widespread provision of condoms (and perhaps needles), and widespread voluntary confidential antibody testing may contribute to the

prevention of AIDS. When contemplating such efforts, however, we

should weigh the moral as well as the instrumental viewpoints. AIDS

education campaigns that rely on fear seem unlikely to be effective,

and may even be counterproductive as they may desensitize their

audience to important messages. Planners need guidance in taking

advantage of the principles suggested by health education research.

EXPERIENCE WITH HIV-RELATED BEHAVIORS

Behaviors Associated with Transmission

Des Jariais et al. (1985a) point out that although there are considerable barriers to behavior change among addicts, drug users have

made some efforts to reduce their risk of acquiring or spreading

AIDS. Needle sharing has been an important part of the social context of drug use, especially in the initiation into IV drug use, sharing

with “running partners” or sexual partners, and sharing in “shooting

galleries” (Des Jarlais et al. 1986). The extent of involvement in

such needle-sharing behaviors may be directly related to the risk of

transmitting or contracting HIV infection.

The author’s impression is that AIDS-transmitting sexual activities of

drug abusers are more resistant to change than their needle sharing.

Like most of the U.S. population, the majority of IVDUs do not use

condoms consistently. Discussion in a recent workshop indicated that

the resistance of IV drug abusers to using condoms was considerably

greater than their resistance to cleaning needles. Those who are

sexually active are unlikely to protect their sexual partners from

infection. It may be that with male heterosexual IVDUs a better ap

proach is to recommend abstinence. When using opiates, the IVDUs’

sexual activity may be restricted anyway, and reinforcing this tendency toward sexual inactivity may become a successful way to prevent AIDS.

Behaviors Associated with Prevention

Des Jarlais and Friedman (1987) point out that many public officials

have concluded that drug users will not change. Yet, as early as

1984, a New York City study showed that drug users in New York

knew about AIDS and were more likely to use clean needles

(Friedman et al. 1987). Needle sellers reported an increase in demand

in 1985 (Des Jarlais et al. 1987c), and were holding bonus sales of

94
drugs to include a free syringe (Des Jarlais and Hopkins 1985). In

1985, Selwyn and colleagues further documented that methadone maintenance patients in New York knew about AIDS and had cut down on

their sharing of needles (Selwyn et al. 1987).

In San Francisco, Chaisson et al. (1987a) found that the likelihood

that needle sharers usually or always cleaned their needles with

bleach grew from 6 percent in 1985 to 47 percent in a 1987 survey.

Nonetheless, more than half were not regularly cleaning needles

before injecting. Watters (1987) documented an increase in the use

of bleach to clean syringes among addicts in San Francisco, from 5

percent in 1986 to 68 percent in 1987. Needle cleaning, though an

important component of AIDS prevention, is unlikely to be consistently adopted and is insufficient by itself to stop the further spread of

HIV. Nevertheless, it provides evidence that drug users will change

their behaviors in response to the threat of AIDS.

The author’s experience in a treatment setting has been similar,

showing that people only partially change their risk behaviors.

Sorensen et al. (1986) found that IVDUs with AIDS or AIDS-related

complex (ARC) had problems in the psychological, physical, social

support, and confidentiality areas while enrolled in methadone

maintenance; however, an evaluation showed drastic reductions in

drug usage from before methadone to 3 months into treatment

(Sorensen et al. 1988).

SUGGESTED INTERVENTION MODELS

Brandt (1988) points out that no single medical or social intervention

can adequately address the problem of the spread of HIV infection.

A range of interventions is needed. Table 2 presents possible preventive interventions to change both drug use and sexual behaviors.

Community efforts of the early 1980s to prevent youth from advancing to drug use may ultimately have an important preventive effect.

For those using drugs, interventions are listed that may reduce needle

use. For those using needles, interventions can aim at reducing the

likelihood that they will share needles. Finally, for those who share

needles, last-stand efforts are needed to encourage needle cleaning.

The same approach is presented for preventing the spread of AIDS

through sexual behaviors, ranging from interventions that encourage

abstinence to programs that will encourage the use of condoms and

spermicides–the last defense against AIDS transmission.

95
TABLE 2. Suggested intervention models to change HIVspading habits

Drug Use Sexual Behavior

Prevent Drug Abuse

Reduce Needle Use

Prevent progression to IV use

Make treatment available for IVDUs

Identify high-risks groups for

intervention

Deliver culturally appropriate

interventions

Encourage Abstinence

Family and school education

Encourage Monogamy*

Educate sexual partners of IVDUs

Use Condoms and Spermicides Properly

Educate IVDUs

Distribute condoms and spermicides

Reach out to users not in

treatment

Reduce Needle Sharing

Educate IVDUs

Distribute or exchange needles

Change the needles

Antibody testing

Increase Needle Cleaning

Educate IVDUs

Distribute bleach and teach

*It must be noted that monogamy does not offer protection for the regular sexual

partner of IV drug abusers.

A number of educational and organizing activities with drug users and

the health care network may also help (table 3).

TABLE 3. Organizational steps to implement interventions

IVDUs Health Care Network

Support development of self-help

groups

Send outreach workers to the streets

and galleries

Send outreach vans

Develop education in treatment

programs

Develop written materials

Videos, public service

announcements

Use drug treatment program staff

Use AIDS treatment program staff

Enlist staff in medical hospitals and

clinics

Enlist Narcotics Anonymous, Namnon

96
Marmor et al. (1984) suggest that some patients with AIDS have been

very willing to talk about their disease and their feelings about drug

abuse. They have sometimes been able to communicate the hazards

of drug abuse and AIDS more effectively than physicians or other

medical personnel. We should support the self-organization efforts

among IVDUs, if we are to have any hope of changing norms and

tapping volunteer resources. Likewise, sending outreach workers in

vans to the community may provide education that will not get out

through treatment programs.

Drug treatment programs can be centers for AIDS prevention among

drug abusers. To the extent that drug treatment reduces the likelihood that a person will share a needle, treatment is AIDS prevention. In addition, it is crucial to develop education in drug treatment

programs that provide the most frequent and most trusted contact

between social organizations and drug users.

The author’s approach has been to develop and evaluate psychoeducational interventions for IVDUs, e.g., 6 hours of group discussion that

covers psychological motives and barriers along with education about

AIDS. Other preventive activities in San Francisco drug treatment

programs have included such activities as supplementing the intake

physical examination with information about AIDS, providing bleach

and condoms, posting flyers and billboards, distributing brochures,

testing for HIV antibodies, showing videotapes, and holding AIDS

awareness days.

Although these treatment-based interventions are vital, Watters

et al. (1986) point out that policymakers should be sure that treatment programs are indeed focusing on AIDS prevention. Specific

funds should be allocated for AIDS prevention, rather than allowing

funds to trickle down to prevention only after all funding needs of

treatment programs have been fully met.

There is also a need to develop media efforts to reach drug users,

not just with written materials but with videotapes and public service

announcements. In the health care network, staff in drug treatment

programs need education about AIDS, and AIDS programs need to

prepare to treat drug abusers. In Boston and some other areas, there

has been effective liaison with self-help groups for former drug

abusers like Narcotics Anonymous or groups for family members, e.g.,

Naranon. These groups need education to reduce their risks of contracting HIV. They may also be used to educate others in their

97
communities, and they may in turn provide the social support that

will be so desperately needed.

First-Generation Interventions

lt is early in the AIDS epidemic among IVDUs. Creative interventions have been developed, including such activities as AIDS education, antibody testing, clean needle education, some efforts to

increase the availability of drug treatment, promotion of condoms,

and a limited number of brochures and audiovisual materials. But

these alone will not be sufficient.

HIV antibody testing has been suggested as a method not only to

track the spread of the epidemic, but to educate IVDUs about AIDS.

Carlson and McLellan (1987) point out that such screening is wellaccepted by IVDUs in drug treatment programs, and it can be helpful

in educating them about the behaviors that spread AIDS. Des Jariais

et al. (1986) found that simply conducting such testing in a treatment

program improved the clients’ awareness and knowledge of AIDS, even

if they did not take the antibody test.

More drug abuse treatment is needed, and more effective treatment is

needed, for reducing dependency on drugs. But Newman (1987) points

out that treatment needs to be much more available than it has been

if IVDUs are to have a realistic opportunity to give up the use of

the needle.

Another first-generation educational model is the needle-cleaning

education program in San Francisco (Newmeyer et al., in press:

Watters et al. 1986). The project team identified a neighborhood

where IV drug use was epidemic and identified the needle use patterns that spread HIV. Using that information, an intervention strategy was developed that involved reaching out to IVDUs in the community and teaching them about AIDS and how to clean their injection equipment. Subsequent studies have documented the degree to

which that approach “caught on” among IVDUs and spread to those

who had not received the outreach contact directly (Chaisson et al.

1987b; Watters 1987).

Second-Generation Interventions

Second-generation interventions aim at specific groups at risk of

acquiring or spreading AIDS, or coordinate first-generation approaches more effectively. Although the efficacy of first-generation

98
intervention techniques is unknown, because the AIDS epidemic is

moving so quickly, there is no choice but to develop these secondgeneration efforts before all the data are in.

Des Jarlais and Friedman (1987) emphasize three groups for prevention: (1) those who have not begun IV drug use; (2) those who are

willing to enter treatment to eliminate IV drug use; and (3) those

who are unwilling to enter treatment and/or for whom present forms

of treatment are unlikely to be successful. For those who have not

begun drug use, Marmor et al. (1984) pointed out that knowledge of

HIV infection rates among IVDUs may be an effective deterrent to

beginning the use of a syringe. Similarly, the attitude changes in

youth resulting from the parent movement and “just say no” to drugs

campaigns may have a long-term effect on the likelihood that future

generations will inject drugs. Des Jarlais et al. (1987a) investigated

the reasons that drug “sniffers” go on to IV use and have proposed a

program to prevent initiation into using needles.

Self-Organization. One model would change the social organization

of IV drug use and take advantage of it in interventions (Des Jarlais

and Friedman 1985). Self-organization may be the only long-term

solution, but it needs much more development before it will be feasible in most communities.

Coordinated Approaches. Moss (1985) has suggested that the combination of antibody testing with availability of drug treatment may do

a lot to prevent the spread of AIDS. Specifically, he suggests

screening people, finding the HIV positives, and attempting to divert

them out of the IV drug use population, or at least out of needlesharing, before the cases increase rapidly in a community. In short,

he recommends finding those people who are seropositive and treating

them to prevent spread of the virus, an epidemiologic treatment using

the model that worked in syphilis prevention. Such an approach

coordinates antibody testing with delivery of effective drug treatment.

The approach may be sound epidemiologically, as the provision of

treatment to those who test positive would give them something for

taking the test, and should be less likely to drive the epidemic

underground. The next step would be making treatment for AIDS

available to those who test seropositive, e.g., making AZT available to

those with an AIDS diagnosis, and perhaps making it available in

combination with drug treatment in methadone programs.

AIDS Treatment interventions. Des Jarlais et al. (1985b) point out

that AIDS will create a need for services centered around issues of

99
death and dying. As the number of drug abusers with AIDS increases, there will be a need for more AIDS treatment interventions

to deal with depression and grief, to provide more counseling that

takes into account neuropsychologicai deficits, and to offer services

for an increasingly ill and homeless population (Batki et al., in press).

SUGGESTIONS FOR ASSOClATED RESEARCH

The health care problems of the AIDS epidemic strongly suggest the

need to understand better how people’s health relates to their behavior. Moral exhortation will not be sufficient to slow the epidemic

appreciably. Research is needed to identify the most effective

approaches to educating groups at risk and changing their risky

behavior. Coates et al. (1987) point out that systematic psychosocial

research is essential to slow the spread of AIDS.

Ethnographic and Psychological Studies

The need for studies of risky behaviors, why they occur, and how to

modify them is well represented in other chapters of this monograph.

Such studies are needed of the heterosexual white male drug user as

well as with other special community populations. For example, how

often do heterosexual white male IVDUs use condoms? Under what

conditions do they not use condoms, and why? How can they reliably

be persuaded to use condoms consistently? Is it more likely that

they will respond to messages that promote abstinence? These kinds

of studies are needed for every community group, including white

heterosexual male IVDUs.

The following research recommendations apply to all groups of IVDUs,

and represent the author’s thinking about research that will prevent

the spread of HIV among white males and all other IVDUs.

Sample Systematically

Population-based representative studies will never be practical in the

underground drug-abusing community. However, improved sampling

strategies can be used. Virtually every study of seroprevalence in

treatment programs has been based on samples of convenience, rather

than on systematically selected groups. More refined methods are

needed to establish the degree to which the results of these studies

generalize to the treatment population. Similarly, there is a need for

studies across geographical areas, using identical methodologies, to

establish the degree to which HIV has taken hold in different communities.

100
Study the Development of Self-Organization

Using what we have learned in the gay community as a template, it

appears vital to study self-organization and then to try different

models within the IV drug-using community. Without community

change, individual change is not likely to be permanent.

Use Existing Educational Models

Preventive educational campaigns should be based upon what has been

learned from other health promotion efforts. The health belief model

(Rosenstock 1974) has been applied, but it is not clear how effective

it is for AIDS prevention. It would be wise to commission a review

of the efficacy of such campaigns, both the theory and the specific

examples, e.g., smoking and heart disease, and to disseminate this

information to health educators to use to prevent the spread of AIDS.

Sow Many Seeds: Develop and Test Interventions

It is vital to develop and test interventions that attempt to prevent

the spread of HIV, before infection becomes so widespread that the

efforts can focus only on treatment. It would be a mistake to delay

intervention studies until the intricacies of risky behavior are fully

understood. A range of interventions will need to be developed, then

tested rigorously and quickly. Only a few may prove efficacious, but

those will be worthy of cross-validation, replication, and immediate

dissemination.

Evaluate, Then Disseminate

The field is moving very rapidly, and mistakes are probably being

made. For example, there is a widespread assumption that condoms

and possibly spermicides can effectively prevent HIV infection, but

the evidence for this assumption is not very strong (Feldblum and

Fortney 1988). In the drug abuse area, similar mistakes could include

recommendations that drug abusers clean their needles with bleach.

Seroprevalence studies have not yet shown an association between

needle cleaning and avoidance of HIV infection. There is an existing

need for more studies on the efficacy of preventive measures and for

studies of ways to lengthen the life of those infected. However, it

would be a mistake to continue to disseminate purported prevention

efforts that have not been shown to be efficacious in objective

scientific trials.

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Prepare a Dissemination Research Plan

The dissemination/utilization research field should be reviewed to help

plan the most effective dissemination strategies. Research literature

exists on disseminating interventions (Fairweather and Tomatzky

1977; Glaser et al. 1983) and this should be tapped systematically.

Studies will be needed of ways to disseminate the most effective

AIDS prevention interventions, and those studies should be started

immediately. Dissemination methods should be sharpened now, so

they can be used effectively to spread the word about the AIDS

prevention techniques that are most effective.

CONCLUSlON

A sense of community is necessary to invoke planned social change.

In the effort to develop community-based prevention for various

groups, innovators should always be cognizant of the overarching goal

to prevent the spread of AIDS among IVDUs and from IVDUs to the

general population. In this regard, it is important to avoid dividing

prevention efforts so that unity gets lost in AIDS prevention

campaigns. The tasks of understanding communities, designing AIDS

prevention models, creating prevention strategies, evaluating them,

and disseminating them to the field provides a challenge for every

special community group, including white males. The ultimate

challenge will be changing the community norms for all community

groups, in concert.

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ACKNOWLEDGMENTS

This project was supported by U.S. Public Health Service grant

DA 04340 from the National Institute on Drug Abuse and grant

MH 42459 from the National Institute of Mental Health and National

Institute on Drug Abuse to the University of California, San

Francisco.

AUTHOR

James L Sorensen, Ph.D.

Adjunct Professor and

Chief, Substance Abuse Services

Department of Psychiatry

University of California, San Francisco

Substance Abuse Services -Ward 92

UCSF at San Francisco General Hospital

1001 Potrero Avenue

San Francisco, CA 94110

107
Sexual Minority Needle Users

A Billy S. Jones

INTRODUCTlON

Initially, the focus of this paper was to be on “gay IV drug users.”

However, the term “gay” is a term more often used to refer to men

who have exclusive relationships with men, thereby excluding bisexual

men and women, lesbians, and transpersons (transsexuals, transvestites, transgenders, crossdressers, and male or female impersonators).

Whereas “gay” is used by some to refer to men and women who prefer same-gender relationships, the term “sexual minority” is more

inclusive of diverse lifestyles and orientations that deviate from

heterosexuality.

The term “intravenous drug user” (IVDU) does not take into consideration the practice of skin popping and intramuscular injecting, which

are also high-risk activities for human immunodeficiency virus (HIV)

infection. Since addicts are often looking for ways to exclude themselves from HIV at-risk behaviors and ways to continue the use of

narcotics, it is important to use terms that are as inclusive of addict

subcultures as possible. Thus, “needle drug user” (NDU) may be a

more inclusive and appropriate term than “intravenous drug user.”

WHO ARE SEXUAL MINORITIES–GAYS?

While sexual minorities (gays) are by no means a homogeneous group,

they are a part of every ethnic, racial, socioeconomic, religious, and

community group. Like racial minority communities, sexual minority

communities are more prevalent and visible in large metropolitan

cities. Such cities contain diverse lifestyles, offer pluralistic social

settings, and assure civil and human rights protection to their

residents (Holloran 1970). New York, San Francisco, Los Angeles,

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Houston, the District of Columbia, Newark, Miami, and Chicago are

examples of cities that have the highest incidence of HIV infection

among needle users as well as a large population of sexual minorities.

Because of the often closed and secretive nature of subculture

communities, effective outreach is difficult.

Lesbians

In many cities, community health outreach workers have identified

1 to 3 percent of their contacts as self-identified lesbians or bisexual

women who are engaged in prostitution and may be substance abusers

sharing needles. Drug treatment programs see a small percentage of

lesbian/bisexual women concerned about HIV infection because they

are not far removed from a male relationship and have a history of

sharing needles. Alternative Test Sites note that some women receiving HIV-positive test results are self-identified lesbians or

bisexuals who are often recovering or practicing NDUs (Jones and

Izzo 1988).

Transpersons

While many transpersons do not identify themselves as gay or bisexual (in fact, research indicates that the majority of transvestites

and transsexuals are heterosexuals), this is a population that is often

overlooked or scorned by gay and nongay communities (Weinberg and

Williams 1974). In large metropolitan cities, community health outreach workers have found that it is not unusual to locate visible

subcultures of transpersons who are involved in prostitution and have

a history of needle drug use and needle sharing (Jones and Izzo

1988). There are also significant numbers of transpersons who are

enmeshed in mainstream subcultures and not readily identified. In

terms of social stigma and potential legal harassment, transpersons

may more closely identify with lesbian/gay communities (Raymond

1979).

Married

Lesbians, gays, bisexuals, and transpersons constitute an often

overlooked sexual minority who embrace heterosexual marriage and

may also be parents (Weinberg and Williams 1974). Although we have

no means of knowing how large this subculture may be or to what

extent this subculture may be involved in at-risk HIV-infection

activities, we do know, through the presence of lesbian/gay married

support groups, and bisexual support groups, that their numbers are

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significant. While some partners are aware of their spouse’s bisexuality, many are not (Wolff 1977). To what extent substance abuse

and, more specifically, needle sharing exist in these subcultures is not

known; however, acquired immunodeficiency syndrome (AIDS) education messages must be aimed at these persons who may more closely

identify with mainstream communities than with lesbian/gay

communities.

Situational Bisexuality

While many persons may admit to an occasional relationship or sexual

encounter with a person of the same gender, they may very readily

reject the clinical and social labels that define them as sexual minorities (Blackwood 1986), in much the same manner that persons who

occasionally are involved in needle drug use may reject labels of

“addict” or “IVDU.”

Men and Women Incarcerated or Otherwise lnstitutionalized

Incarcerated or institutionalized men and women may express their

sexuality through same-gender relationships while in these settings

but return to heterosexual relationships upon release. The sharing of

needles for drugs, tattoos, and ear piercing may be a part of these

bonding relationships. Although prohibited, drugs are smuggled into

institutionalized settings, and needle sharing becomes a part of the

bonding that bring gays and nongays together (Wooden and Parker

1982). It is not unusual to find homemade needles that are shared by

dozens of persons who have no means of acquiring new sets of works

and little knowledge of how to sterilize works in settings that do not

offer bleach, alcohol, or boiling water. And while institutionalized

gays and nongays may know that, barring abstinence, latex condoms

and waterbased lubricants are the best tools to protect oneself

against HIV infection, these tools are often prohibited in such

settings as prisons, detention centers, jails, mental institutions,

boarding schools, and residential drug programs (National Academy of

Sciences 1986).

Men and Women In Commercialized Sex Industries

(Prostitutes and Hustlers)

Participants in commercial sex may be involved in same-gender relationships and encounters as well as heterosexual relationships and

encounters. The labels “lesbian,” “gay,” or “bisexual” may never be

embraced, but many of the men and women involved in prostitution

110
state that some of their most meaningful and caring relationships

have come from persons of the same gender; yet they adamantly state

that they are heterosexuals. The observation of outreach workers is

that most persons in the commercialized sex industries are very aware

and conscientious about reducing their risk for HIV infection via

sexual activities but are not as aware or conscientious about reducing

their risk for HIV infection via drug needle sharing. While the overwhelming majority of prostitutes and hustlers identify themselves as

heterosexuals, some do identify themselves as lesbian, gay, or bisexual, but they may engage in heterosexual relationships and may be

sharing needles with heterosexual partners (Jones and lzzo 1988).

Sexual Minority Youth

Whereas a great amount of AIDS education and outreach is directed

toward youth, very seldom are sexual minority youth acknowledged.

Yet, we know that many youth get in touch with their sexuality and

experiment with sex and drugs at very early ages (Charna 1986).

Thus, we must focus on sexuality and substance abuse issues in ways

that will not isolate or stigmatize gay and lesbian youth. It is not

unusual to learn that persons involved in prostitution and IV drug

use/needle drug use began these activities when they were

adolescents. Because of the myth that gays are child molesters (in

fact, 90 percent of all child molestation is committed by heterosexual

males) (Tsang 1981), many sexual minority organizations will not

provide services (such as HIV antibody testing or treatment for

venereal disease) to persons under the age of 21 or 18.

Partners of Sexual Minority NDUs

Often, lesbians, gays, and transpersons are assumed to be “single.”

Or, because of the stigma attached to being a sexual minority,

partners of sexual minorities are often excluded from efforts to

educate partners of IVDUs/NDUs. To the same extent that efforts

must be made to educate heterosexual partners of IVDUs/NDUs about

risk factors for HIV infection, programs must be developed for

partners of sexual minorities. Many sexual minorities who have a

history of needle drug use have been in long-term relationships and

should be acknowledged as “couples” (and in cases of parenting

status, as “families”) to the same extent that we acknowledge

heterosexual couples and families (Finnegan and McNally 1987).

Since sexual minorities and NDUs are often not visible but are indeed

a part of every subculture, all AIDS education efforts must include

111
messages that focus on the behavior of sexual minorities and NDUs.

Gay communities must not only focus on mainstream gays who are

politically astute and comfortable with their sexuality, but must network with communities, agencies, and institutions to reach sexual

minorities who identify more closely with other subcultures.

Risk-reduction messages must have as much focus on safer needle and

drug paraphernalia use as on safer sex practices. To the same extent

that we assume that everyone “potentially” may have engaged in some

at-risk behavior for HIV infection, we must assume that every sub

culture “potentially” includes sexual minorities as well as current or

recovering NDUs (Hawley, unpublished manuscript).

INCIDENCE OF SUBSTANCE ABUSE IN THE LESBIAN/GAY

COMMUNlTY

While the Weekly Surveillance Report of the Centers for Disease

Control (CDC) shows that about 7 percent of persons diagnosed with

AIDS had dual transmission risk of homosexuality and needle drug use

(Centers for Disease Control 1988), a much higher incidence of other

forms of substance abuse may be contributing to the progression of

HIV infection. Thus, AIDS education efforts must acknowledge and

address nonneedle-using substance abuse as a possible cofactor within

sexual minority communities.

A 1975 survey by the Los Angeles Gay Community Services Center

revealed that persons patronizing lesbian and gay bars spend an

average of 80 percent of their social activities time in bars, discos,

and establishments where alcohol is served (Fifield 1975). Whereas an

updated survey in the eighties is likely to reveal that persons

patronizing lesbian and gay bars are spending less than 80 percent of

their time in such social settings, such a survey may also reveal that

the trafficking and use of other drugs (including cocaine, heroin,

dilaudid, methamphetamine, quaaludes, valium, and marijuana) is not

uncommon. In addition, it is not uncommon to observe patrons in

lesbian and gay social settings sharing drug paraphernalia.

Considering the social role of bars, taverns, and clubs in lesbian and

gay communities, it is not surprising that researchers (Morales and

Graves 1988) have found the incidence of alcohol dependence to be

higher (25 to 35 percent) among sexual minorities than in the general

population (10 percent). Beyond hypothesizing, very little research

has focused on the drug patterns of sexual minorities. The lack of

reliable information makes decisions about health and drug treatment

services for sexual minority communities difficult. Often,

112
conclusions have been made on the basis of assumptions and myths

about lesbians, gays, and transpersons that have little or no basis in

fact (Weathers 1981). The absence of information about drug use

among gay men can impede critical public health intervention efforts.

Because of the lack of baseline data, it is difficult to allocate funds

or develop appropriate drug treatment services for sexual minorities.

Based on the high incidence of alcoholism in the lesbian and gay

communities and the social settings of sexual minorities that embrace

drugs and alcohol, some researchers hypothesize that drug use may

actually be higher among lesbians and gays than has been documented

among their heterosexual counterparts (Caputo 1985). Drug treatment

programs that target sexual minorities (Weathers 1981; Morales 1988;

Ziebold 1980) have found a pattern of polydrug use, with alcohol

being the significant second substance of choice. The choice of

drugs among sexual minorities seems to be influenced by availability

and locale, by socioeconomic group, and by racial/ethnic group.

While the amphetamines and cocaine seem to be the most popular

drugs in lesbian and gay communities, a much higher use of heroin is

noted among sexual minorities who are street-oriented racial

minorities. It is the observation of outreach workers that sexualminority heroin addicts are more closely identified with the mainstream drug subculture than with the lesbian/gay community.

AlDS AWARENESS AMONG SEXUAL MlNORlTY IVDUs/NDUs

Because of the extensive focus on the gay community regarding AIDS

and the response of the gay community to the AIDS crisis, most gay

men are aware that certain sexual behaviors may put them at risk for

HIV infection. However, most of the AIDS education messages aimed

at the gay community focus on sexual transmission risk factors and

not needle drug use transmission factors. Very little AIDS education

is directed toward IVDUs/NDUs. Until 1986, CDC’s Weekly Surveillance Reports did not have a category for “homosexual male and

IV drug abuser”; thus, many persons did not recognize that they

might be engaging in multiple risk behaviors for HIV infection.

Many sexual minorities do not have access to services of the gay

community, especially if they do not live in a major metropolitan area

(Ziebold 1980). Others (especially racial minorities) may not identify

strongly with the gay community and may seldom read gay publications or attend gay political and social functions. While the gay

community as a whole has done an excellent job of reaching,

educating, and changing the attitudes and behaviors of those sexual

113
minorities who have close ties to the gay community, there remain

class, racial, gender, and social barriers that have rendered the gay

community’s outreach and education efforts ineffective for some

persons (Jones and Izzo 1988; Hawley, unpublished manuscript).

Many lesbians believe they are not at risk for HIV infection. Yet

outreach workers do identify women who are IVDUs/NDUs, engaged

in prostitution, or not very far removed from male relationships

(Jones and lzzo 1988). Sexual minorities in heterosexual marriages

and lesbian/gay youth have not been specifically targeted by most

AIDS prevention programs. The gay community still seems baffled

about how to reach those lesbians and gays who are also racial

minorities with strong emotional ties to black, Latina/Hispanic, Asian,

or Native-American communities.

Because there are social stigmas attached to being identified as a

sexual minority as well as to being identified as an IVDU/NDU, many

persons who may fit more than one at-risk category often do not

acknowledge one or the other until they are thoroughly familiar with

support services. Consider the social stigma regarding homosexuality

as opposed to drug use. Consider the strong belief in many communities that AIDS is a “gay disease” (initially, AIDS was referred to

as GRID–gay-related immune deficiency). In many subcultures, there

is less stigma attached to having a history of IV drug use/needle

drug use than a lifestyle and orientation of homosexuality. Thus,

many persons initially deny that they are gay or have ever engaged

in a same-gender relationship, but admit to IV drug use (some

persons with AIDS even “invent” histories of IV drug use, relationship

with a prostitute, or a blood transfusion years ago).

In the era of AIDS, many persons who are identified as gay may find

themselves banned from “oil joints” (drug shooting galleries or getoff joints) and distanced from heterosexual IVDUs/NDUs except to

“cop” or purchase drugs. Many gays are refused admission to residential drug treatment programs because of homophobia and/or AIDSphobia in addition to the false assumption that all gays have AIDS or

that HIV can be transmitted by casual contact. Persons identifying

themselves as gay or bisexual risk being distanced from their families

and losing support services. Thus, many IVDUs/NDUs seeking

services at social service agencies often do not initially identify

themselves as a sexual minority. Many gay and bisexual clients

seeking services at clinics and social service agencies do not initially

profess to a history of IV drug use or other substance abuse.

Service providers must take these attitudes into account and include

114
messages about sexuality and substance abuse in all messages to all

clients.

ATTlTUDES AND AWARENESS ABOUT RISK-REDUCTlON

MESSAGES

Many substance abuse counselors and administrators maintain

judgmental and restrictive attitudes toward sexual minorities.

Homosexuality is still viewed by many drug treatment professionals as

a pathology even though professional associations such as the

American Psychological Association, the American Psychiatric

Association, and the National Association of Social Workers have

repeatedly stated that homosexuality “per se” is not a pathology.

Such negative attitudes, even when disguise is attempted, seriously

hinder the recovery from drug addiction of sexual minorities.

Some residential drug treatment programs state that the client’s

sexual orientation is a major problem and make efforts to change the

person’s orientation rather than addressing negative behavior that

may hinder recovery. Thus, the sexual minority’s chances for

recovery may range from poor to nonexistent.

While there appears to be a national push for therapeutic drug

programs to test clients for HIV antibodies or HIV infection, many of

the residential programs wish to test clients for the negative purpose

of excluding those who are seropositive.

The gay community has been at the forefront of AIDS education

efforts to reduce HIV infection not only among gay men, but also

within the mainstream population. However, much of the emphasis of

AIDS education messages from gay groups is on sexual issues with

very little emphasis on the very real possibility of HIV infection via

shared drug paraphernalia. Risk-reduction messages regarding drug

paraphernalia have only recently begun to surface within the

subcultures of transpersons, youth, and prostitutes.

A survey (Jones 1988) conducted in 1987 by health educators at the

Whitman-Walker Clinic’s Sunnye Sherman AIDS Education Project

revealed that:

Of 250 persons applying to be volunteers (mostly middle-class

white gay men), 78 percent did not know that sharing cookers,

dirty water, and filters could be a transmission factor for HIV

infection; and

115
78 percent knew about the risks of sharing needles and syringes.

A survey (Jones 1988) of 375 men and women incarcerated in the

metropolitan Washington, DC, area revealed that prior to education

seminars:

89 percent did not know about the danger of sharing cookers,

water, and filters, but did know that sharing needles was risky;

11 percent said that they did not know that HIV infection was

possible from needles and syringes, but did know about sexual

risks;

24 percent insisted that only gay men were at risk for HIV

infection and only 2 percent thought that lesbians may be involved

in at-risk behavior for HIV infection;

17 percent of the male inmates admitted to having “gotten off”

with a man (usually stating that they were on the receiving end

of oral sex) over the last 10 years, while only 6 percent of the

male inmates professed to be gay or bisexual;

22 percent of the women professed to having “fooled around” with

another woman, and 9 percent professed to bisexuality. Yet, none

of the women in this survey defined themselves as a lesbian;

91 percent of the inmates had a history of drug use and/or

prostitution. However, the survey did not distinguish needle drug

use from nonneedle use:

Only 3 percent of the inmates knew about cleaning works with

bleach, while all of those inmates who professed to needle drug

use stated that they made some effort to clean their works

(flushing with water or alcohol);

51 percent of the inmates stated that they never shot up after

another person but would pass their works on to another NDU,

and only 8 percent stated that they would not pass their works to

another shooting partner;

92 percent of the inmates felt that, if they knew the symptoms of

AIDS, they could look at a person and tell if that person had

AIDS, while 97 percent believed that having AIDS and being HIV

infected meant the same thing: death; and

116
89 percent of the inmates surveyed revealed that if they

discovered that they had AIDS, AIDS-related complex (ARC), or

were HIV infected they would attempt suicide via overdose of

drugs.

CONCLUSION

The IV-drug-using/needle-drug-using communities are not going to be

easy to reach. Like the nongay IVDU/NDU, sexual minority IVDUs/

NDUs are neither monolithic nor homogeneous. HIV risk-reduction

programs (outreach, education, counseling and seminar services,

treatment) for sexual minority NDUs must recognize that needs may

differ along boundaries of race, socioeconomic class, marital/

relationship status, urban vs. rural settings, and degree of openness

about sexual orientation and lifestyle (overt vs. covert). To the same

extent that service providers must make efforts to work through

racism and sexism, efforts must be made to acknowledge and work

through homophobia.

Since IVDUs/NDUs communicate mainly by word of mouth, one-on-one

efforts to reach and teach sexual minority addicts must be

encouraged. There are needs for more subcultural outreach and

educational efforts; within given communities subcultures within

subcultures must be acknowledged. Thus, what works for the

transperson community may not work for the male hustler’s

community or the married bisexual living in the suburbs.

Drug paraphernalia laws that prohibit purchase of syringes and

needles and laws that incarcerate persons for being in possession of

drug paraphernalia should be examined. While risk-reduction messages

are saying one thing, legislation is imposing another. Persons are

addicts because of the substances they put into their bodies, but HIV

infection is a reality if addicts share needles, syringes, cotton, and

cookers.

To the same extent that partners of nongay IVDUs being at risk for

HIV infection are acknowledged, “significant others” of lesbians, gays,

and transpersons should also be acknowledged.

There is a need for residential drug treatment programs to have

treatment modalities specifically for sexual minorities. Currently,

there are no residential drug treatment programs for sexual minorities

and only three such programs for recovering alcoholics (Pride

Institute in Minnesota, Right Step in Oregon, and Mountain Wood in

117
Virginia). Until residential drug treatment programs are in place that

respect the emotional and cultural needs of sexual minorities who are

recovering addicts, existing drug treatment programs must make

efforts to confront and address homophobia and gender bias among

staff as well as clients.

REFERENCES

Blackwood, E. The Many Faces of Homosexuality: Anthropological

Approaches to Homosexual Behavior. New York: Harrington Park

Press, 1988.

Caputo, L. Dual diagnosis: AIDS and addiction. Social Work

Vol. 30, No. 4. NASW, July-August, 1985. pp. 361-364.

Centers for Disease Control. AIDS WeekLy Surveillance Report.

Atlanta: March 21, 1988.

Charna, K. Counseling Our Own: The Lesbian/Gay Subculture Meets

The Mental Health System. Renton, WA: Publication Services,

1986.

Fifield, L. On My Way To Nowhere: An Analysis of Gay Alcohol

Abuse and an Evaluation of Alcoholism Rehabilitation Services of

the Los Angeles Gay Community. Los Angeles: County of Los

Angeles, 1975.

Finnegan, D.G., and McNally, E.B. Dual Identities: Counseling

Chemically Dependent Gay Men and Lesbians. Center City, MN:

Hazelden Educational Materials, 1987.

Hawley, P. Epidemiology of AIDS in gay men and IV drug users.

February, 1988, unpublished manuscript.

Holloran, J. Understanding Homosexual Persons: Straight Answers

from Gays. Hicksville, NY: Exposition Press, 1970. pp. 65-70.

Jones, A.B.S. Volunteers’ Resistance to Working with Minorities and

Addicts. Washington, DC: Whitman-Walker Clinic, 1988.

Jones, A.B.S., and lzzo, J.A. Share a Needle and You Share AIDS.

Washington, DC: Whitman-Walker Clinic, 1988. 46 pp.

Morales, E.S., and Graves, M.A. Substance Abuse: Patterns and

Barriers to Treatment for Gay Men & Lesbians in San Francisco.

San Francisco: San Francisco Department of Public Health, 1988.

National Academy of Sciences. Confronting AIDS: Directions for

Public Health, Health Care, and Research. Institute of Medicine,

National Academy of Sciences. Washington, DC: National Academy

Press, 1986.

Raymond, J.G. The Transsexual Empire: The Making of the SheMale. Boston: Beacon Press, 1979. pp. 101-113.

Tsang, D. The Age Taboo. Boston, MA: Alyson Publishing, 1981.

118
Weathers, B. Alcoholism & the Lesbian Community. Washington, DC:

Whitman-Walker Clinic, 1981. 12 pp.

Weinberg, M., and Williams, C. Male Homosexuals, Their Problems

and Adaptations. New York City: Oxford University Press, 1974.

Wolff, C. Bisexuality: A Study. New York: Quartet Books, 1977.

pp. 93-98.

Wooden, W., and Parker, J. Men Behind Bars: Sexual Exploitation in

Prison. New York: Plenum Press, 1982. 284 pp.

Ziebold, T.O., and Mongeon, J.E. Ways to Gay Sobriety. Washington,

DC: Whitman-Walker Clinic, 1980.

ACKNOWLEDGMENTS

The contributions of Joseph A. lzzo, M.A., M.S.W., Health Educator,

and Claire Quigley, C.A.D.C., Director of Alcohol and Substance Abuse

Services, Whitman-Walker Clinic, are acknowledged.

AUTHOR

A. Billy S. Jones, M.S.W.

Health Educator, Counselor, and Trainer

Assistant Director, Sunnye Sherman AIDS

Education Services

Whitman-Walker Clinic

Suite 141

1407 S Street, N.W.

Washington, DC 20009

119
Risk Behavior of Intravenous Cocaine

Users: Implications for Intervention

Dale D. Chitwood, Clyde B. McCoy, and Mary Comerford

INTRODUCTlON

The primary aim of this chapter is to discuss specific characteristics

of intravenous (IV) cocaine use, which are relevant for programs to

reduce risk behavior for human immunodeficiency virus (HIV-1)

transmission and exposure.

Two phenomena, the acquired immunodeficiency syndrome (AIDS)

epidemic and IV cocaine use, have enormous consequences for IV drug

users (IVDUs). The AIDS epidemic is the most consequential event of

the 1980s and will continue to affect IVDUs for the foreseeable

future (Des Jarlais and Friedman 1987; Ginzburg et al. 1985; Ginzburg

1988; Morgan and Curran 1988). The increasing prevalence of cocaine

use among IVDUs also is important (Grabowski 1984; Kozel and Adams

1985), but has been overshadowed by the impact of AIDS. Although

each phenomenon would have occurred in the absence of the other,

these two major events effect each other. As the data presented in

this chapter illustrate, the IV use of cocaine contributes to the risk

behaviors for exposure to HIV-1 among many IVDUs, while at the

same time an awareness of AIDS is leading some individuals who

inject cocaine to change their needle/syringe and sexual behaviors.

PREVALENCE OF HIV-1

The use of cocaine has been found to be associated with serostatus

for antibodies to HIV-1. Chaisson et al. (1988) have reported that

IVDUs who use cocaine frequently are more likely to be positive for

HIV-1 than other IVDUs. In Miami, 255 IV cocaine users in drug

treatment who had injected cocaine during the past 12 months were

twice as likely (20.8 percent) to test positive for antibodies to HIV-1

120
as were 222 persona who had injected opiates only (9.5 percent).

Among the 255 IV cocaine users, 56 clients who injected only cocaine

were as likely to test positive (24.5 percent) as were the 199 IV

users who had injected cocaine and opiates (19.8 percent).

METHODOLOGY

Two types of information are presented in this chapter that deal with

the issues of AIDS prevention for IV cocaine users.

First, it is useful to have an understanding of the nature of the IV

use of cocaine as it existed when IV cocaine users were being

exposed to HIV but prior to anyone, including IV cocaine users, even

suspecting that AIDS existed. In order to do this, data are reported

from an investigation of patterns of cocaine use that were occurring

in the late 1970s and early 1980s. Between April 1980 and June 1981

a structured interview was administered to 75 IV cocaine users who

were a subgroup of 170 cocaine users in south Florida (Chitwood

1985). A subsample of those IV cocaine users also provided an openended interview, which was taped and transcribed (Morningstar and

Chitwood 1984). These data are reported to document characteristics

of IV cocaine use that are believed to increase risk behavior for

exposure to HIV-1, as well as to identify characteristics that should

be considered in prevention efforts.

A second data source was selected to document specific risk

behaviors that currently are practiced by IV cocaine users and

identify changes in these behaviors that users report have occurred

as a result of their efforts to avoid AIDS. The risk behavior data

reported here are baseline data from a longitudinal epidemiologic

investigation of HIV-1 infection among IVDUs in South Florida.

Between June 1987 and July 1988,722 IVDUs in drug treatment

programs in south Florida were interviewed about their drug use,

needle/syringe (works) behavior, and sexual behavior and were tested

for antibodies to HIV-1. Risk behavior data were reported for 255

triethnic men and women who were active IV cocaine users. Of the

255,199 participants had injected cocaine and opiates in the year

prior to baseline interview, either simultaneously, as speedball (a

mixture of cocaine and an opiate, usually heroin), or, less often,

serially. An additional 56 had injected only cocaine.

The majority of these 255 IV cocaine users were non-Hispanic white

(61.2 percent), while 26.7 percent were non-Hispanic black and 11.0

percent were Hispanic. Three persons (1.1 percent) were American

121
Indian or Oriental. Two-thirds (67.8 percent) of all respondents were

male.

There were no ethnic or gender differences between those who

injected only cocaine and others who injected both cocaine and

opiates. Approximately four out of every five non-Hispanic white

(76.6 percent), non-Hispanic black (83.9 percent), and Hispanic (82.1

percent) users injected both cocaine and opiates. Similarly, 79.2

percent of the men and 75.6 percent of the women injected cocaine

and opiates.

FlNDlNGS

The findings reported in this chapter are divided into three distinct

sections.

First, this chapter discusses specific characteristics of the IV use of

cocaine as determined from both structured interview schedules that

contained extensive items concerning drug history, IV behavior, and

sexual behavior, and open-ended interviews with cocaine users about

their views of the nature of IV cocaine use. The purpose of this

discussion is to identify elements of IV cocaine use that predispose

users to engage in high-risk behavior.

Second, specific high-risk behaviors of current IV cocaine users are

reported for the purpose of documenting high-risk behaviors that risk

reduction programs must target.

Third, specific changes in high-risk behaviors that IV cocaine users

said they initiated without involvement in a risk reduction program

are presented to illustrate areas where interventions might be

effective.

Characteristics That Potentiate High-Risk Behavior

IV cocaine use was studied in the early 1980s as part of a

comprehensive investigation of the patterns of cocaine use in south

Florida (Morningstar and Chitwood 1984; Chitwood and Morningstar

1985). Most of the 75 IV cocaine users in that study reported they

craved increasing quantities of cocaine but had inadequate resources

to fulfill that desire. Approximately two-thirds (68.0 percent) of the

75 IV cocaine users who participated in that study said they were

obsessed with the desire for cocaine. At the time of the interview, a

majority (61.3 percent) were using cocaine more frequently than they

122
had in their initial year of use (Chitwood 1985). Three-fourths (72.0

percent) had no personal limit on the amount of money they spent

for cocaine–if funds were available. Not surprisingly, 81.3 percent

of these IV cocaine users reported that they had money problems as

a consequence of their cocaine use.

Many IV cocaine users (61.3 percent) reported that they always

craved cocaine when it was present, and 4 out of 10 (44.0 percent)

never had refused cocaine, regardless of the setting and

circumstances under which it was offered to them.

When cocaine users were asked what patterns of cocaine use they had

observed, their own perceptions of themselves supported a similar

typology of use (Morningstar and Chitwood 1984). Cocaine users

described several traits of IV cocaine use behavior that would

increase the likelihood that IV cocaine users might engage in highrisk injection or sexual behaviors. IV cocaine users often were

reported to have an “addictive predisposition,” to be obsessed with

obtaining cocaine they could not afford, and not to care what they

did to obtain cocaine. Furthermore, many IV cocaine users were

perceived by cocaine users as antisocial persons who would “rip off”

others for drugs (Morningstar and Chitwood 1984.)

These traits indicate that IV cocaine use often becomes uncontrolled

behavior, and, when cocaine is available under high-risk conditions,

many users are likely to engage in those behaviors to obtain cocaine.

This is borne out in self-report data about specific behaviors in

which those IV cocaine users engaged to obtain cocaine. For

example, 46.6 percent reported that they had engaged in either

prostitution or pimping to obtain money for cocaine. A similar

percentage (45.3 percent) reported they traded sexual favors for

cocaine. When differences between cocaine acquisition methods of

men and women were observed, men tended to be more aggressive

and women to be more manipulative (Morningstar and Chitwood 1987).

Several women reported they used sex to get cocaine from men, while

men frequently said they used cocaine to entice women to have sex

with them. Regardless of which perspective is more accurate, it is

clear that high-risk sexual behavior often is bartered for cocaine.

One additional observation is of major consequence. Most men and

women were introduced to cocaine use by male friends or spouses.

Indeed, the cocaine dealing system tends to be male dominated, and a

majority of women often are dependent upon men for their cocaine

source. Consequently, women may be more likely, when sharing

123
works, to shoot after a male partner, a behavior that puts women at

risk for HIV-1 exposure when works remain uncleaned.

In summary, several aspects of IV cocaine use lead to high-risk

behavior for exposure to HIV-1: obsessive behavior, lack of funds to

obtain cocaine, strong craving in the presence of cocaine, never

refusing cocaine regardless of setting, use of cocaine with strangers,

having sex to get cocaine or using cocaine to obtain a casual sexual

partner, and shooting after others upon whom one is dependent for

cocaine.

Most of these traits were present in a plurality, often the majority,

of study participants who were injecting cocaine in the early 1980s

before AIDS had been detected/identified.

Current Risk Behaviors for HIV-1

Current risk behaviors of cocaine users were ascertained by asking

255 persons enrolled in drug treatment programs who had injected

cocaine during the prior year several questions about their injection

and sexual behaviors during the 12 months prior to their interview.

Three general patterns of IV cocaine use were reported by this study

sample:

(1) injection of cocaine only;

(2) injection of cocaine and an opiate simultaneously, as speedball;

and

(3) injection of cocaine and opiates serially.

Two methods used to prepare cocaine for injection increase the risk

of using a dirty needle and thus the risk of exposure to HIV-1. The

first method has been reported by cocaine users who do not inject

opiates. Some persons who inject cocaine reported that they pool

funds with others and together prepare several syringes before they

begin their run. These works may or may not be sterile at this

juncture. Once the run or binge begins, they continue to reuse

works indiscriminately until the cocaine supply is exhausted. A

second high-risk procedure often is used to prepare speedball–a

mixture of an opiate (usually heroin) and cocaine, a combination

which has been used for decades (O’Donnell and Ball 1966). This

method involves drawing the opiate into one syringe and the cocaine

into a second syringe and mixing the contents between the two

124
syringes. The procedure is as follows: in one cooker, an opiate is

placed into solution by heating (“cooking”). In a second cooker,

cocaine is stirred (not cooked) into solution. (A variation is to coldshake cocaine and water in a syringe instead of mixing in a cooker.)

These liquids are drawn into separate syringes and then mixed from

syringe to syringe. This involves removing the needle from one

syringe and injecting the contents of the other syringe into the

needleless syringe. Then the process is reversed. This results in two

syringes filled with speedball. If either syringe is unsterile, both

syringes will become contaminated. The risk of exposure is

heightened when unsterile syringes from shooting galleries are used,

exposing the two users to the contaminants of both syringes.

The percentage of IV cocaine users who engaged in high-risk

behaviors in the year prior to interview is presented in table 1.

Information is presented for persons who inject cocaine only and for

others who inject both cocaine and opiates.

The first portion of table 1 contains information about high-risk

injection behaviors. Note that in most instances persons who inject

cocaine alone are somewhat less likely to have practiced these

behaviors than those who inject cocaine and opiates. The majority

(56.9 percent) of all respondents had injected cocaine on an average

of at least once per day. Eighty percent booted when they were

injecting drugs. Booting involves the aspiration of venous blood into

the syringe to mix the drug solution with the blood. This mixed

solution then is injected into the vein. This process increases the

likelihood that contaminants in the syringe would be injected into the

user.

High-risk sharing of drug paraphernalia also was practiced by most

respondents. Seven out of ten (70.6 percent) had shared cookers and

71.8 percent had shared works (needle/syringe combinations) at some

time during the last year. About one-fourth (25.9 percent) also had

used works of a shooting gallery during that time period.

Data in table 1 also indicate the extent of high-risk sexual behavior

among IV cocaine users. No differences were found between those

who inject only cocaine and other IV cocaine users. Almost all

respondents (91.0 percent) had been sexually active in the past year.

Approximately half (51.4 percent) had one or more sexual partners

who also had a history of IV drug use, while 63.1 percent reported

they had a sexual partner(s) who had not injected drugs.

125
TABLE 1. Propottion engaged in risk behaviors in last 12 months

Cocaine

Only

Users

(n=56)

%

Cocaine

and All

Opiate Between- Cocaine

Users Group Users

(n=199) Difference (n=255)

% p-value %

lniection Behavior

Injected at

least daily

Booted

Shared cooker

Shared works

Shared works

at shooting

gallery

41.1

67.9

51.8

58.9

16.1

Sexual Behavior

Sexually active 91.1

IV sexual

partner(s) 53.6

Other sexual

partner(s) 57.1

Never use condom 76.8

Use condom at

least 50%

of time 10.7

61.3 <.01 58.0

83.4 <.05 80.0

75.9 <.001 70.6

75.4 <.05 71.8

28.6 n.s.

91.0

50.8 n.s.

64.9 n.s.

69.8 n.s.

10.1

n.s.

n.s.

25.9

91 .0

51.4

63.1

71.4

10.2

Condoms seldom were used by any of the study respondents or their

sexual partners. Only 28.6 percent of the participants reported any

condom use during sexual activity in the last year, and only 1 in 10

(10.2 percent) used a condom at least 50 percent of the time they

engaged in sexual activity.

Changes in Risk Behavior

It does appear that lV cocaine users are willing to make behavioral

changes to reduce their risk of AIDS. Of the 255 respondents in

treatment who reported some IV cocaine use in the past year, 179

(70.2 percent) reported that they had changed some high-risk

126
behavior to reduce the risk of AIDS. These changes in risk behavior

were elicited at baseline before respondents had been tested for

antibodies to HIV-1. Table 2 shows the reported changes made by

these IV cocaine users.

TABLE 2. Proportion reporting behavior changes to reduce

risk of AlDS

Cocaine

Cocaine and All

Only Opiate Between- Cocaine

Users Users Group Users

(n=56) (n=199) Difference (n=255)

Behavior Change % % p-value %

Any behavior change

Quit shooting

drugs

Quit sharing

needles

Shared needles

less frequently

Cleaned needles

with bleach

or alcohol

Reduced number of

sexual partners

Reduced number of

casual sexual

encounters

Used condoms more

frequently

67.9 70.9 n.s. 70.2

8.9 4.0 n.s. 5.1

16.1 21.1 n.s. 20.0

12.5 24.1 n.s. 21.6

12.5

25.0

12.5

8.9

13.6

24.6

11.6

11.6

n.s. 13.3

n.s. 24.7

n.s. 11.8

n.s. 11.0

While only 5.1 percent of the respondents reported that they had

ceased all IV drug use, an additional 20 percent said that they had

stopped sharing needles. Another 21.6 percent indicated that they

shared needles less frequently. About 1 out of 10 (13.3 percent)

stated they had begun cleaning works with bleach or alcohol.

127
Some respondents also reported changes in sexual behavior. One

quarter (24.7 percent) had reduced the number of sexual partners

during the preceding year, and 11.8 percent had reduced the number

of casual sexual encounters. More frequent use of condoms was

reported by 11.0 percent of these IV cocaine users.

While these data were self-reported and are not verifiable

independently, they do indicate that IV cocaine users are aware of

the need for behavior changes and are willing to attempt making

them. In addition, none of these changes were initiated as part of

any formal intervention program designed to elicit behavior changes.

It appears that some IV cocaine users are aware of the role of some

high-risk behaviors in the transmission of HIV-1 and are sufficiently

concerned to attempt to change their high-risk needle use and sexual

behaviors. These data are consistent with reports that IVDUs are

willing to make behavior changes to reduce the risk of AIDS

(Chaisson et al. 1987; Friedman et al. 1986).

All respondents also were asked why they changed their works. Most

(71.0 percent) said they did so because the works became dull or

ceased to operate properly. Only three (1.2 percent) changed works

because of fear of AIDS, while an additional 7.1 percent changed

works to avoid hepatitis and other common infections.

DISCUSSION

Three basic observations are evident from these data. First of all,

the IV use of cocaine, because of the compulsive behavior that often

accompanies use, frequently results in injection and/or sexual

behavior that places that person at high risk for exposure to HIV-1.

Because of this, it is essential that risk behavior reduction programs

be developed for cocaine users.

Second, the data suggest that intervention will have to occur on

various levels of prevention. The fact that 7 out of 10 IV cocaine

users (70.2 percent) report some self-initiated efforts to reduce risk

behavior indicates that intervention has the potential to succeed.

In fact, many cocaine users go through periods when they voluntarily

cease cocaine use (Chitwood 1985). However, it would be naive to

develop an intervention that assumed cessation of high-risk behaviors,

e.g., IV cocaine use, would be achievable in all instances. Secondary

prevention goals with specific intervention strategies, e.g., not

sharing drug paraphernalia, cleaning works, using condoms during

128
sexual activity, must be part of risk reduction programs, because a

proportion of users will continue to inject cocaine.

In the absence of effective medical treatment and vaccines, risk

reduction programs must be implemented to restrain the epidemic.

The general objectives of these programs should be to stop or at

least reduce (1) the use of drugs, (2) the IV use of drugs, and (3)

the sharing of needles/syringe (works). In addition, for those who

will not stop sharing works, emphasis must be placed on the proper

method to sterilize used works before sharing. Similarly, efforts must

be targeted to increase the practice of safer sex behaviors, such as

the use of condoms, and to avoid pregnancy if HIV-1 antibody

positive. The specific goals of each program will vary according to

the composition of the population selected for intervention.

Third, the optimal intervention package would be enhanced if it could

incorporate the following six program elements.

(1) Prevention programs must be aimed at specific ethnic groups if

the intervention is to be most effective. Cocaine users are

found among several ethnic groups. Culturally specific

characteristics of the ethnic communities being targeted, e.g., an

emphasis on the role of the family among Hispanic cocaine users

(Marin 1988), must be developed and implemented within the

prevention program.

(2) Issues of gender must be acknowledged and incorporated into

the intervention. Specific intervention programs or program

components must be developed for women, many of whom are

dependent upon men not only for cocaine but for other

economic and security needs as well. Programs for women will

have to grapple with dependency/empowerment needs while

recognizing that empowerment efforts may bring new pressures

upon women who inject cocaine (Treasure and Liao 1982).

(3) Intervention programs must acknowledge the compulsive nature

of cocaine. The ideal solution is to succeed in having the user

cease cocaine use. However, it is essential to realize that, in

those instances where cessation does not occur, there is an

enormous compulsion to inject cocaine regardless of the setting

for use. Many persons who use cocaine intravenously report a

number of personal characteristics that increase the likelihood

that they will engage in high-risk behavior. These include

obsession with acquiring cocaine, frequent inability to afford

129
cocaine, craving cocaine when it is present, never refusing

cocaine regardless of the setting or conditions for the

acquisition of cocaine, shooting after another person with a

dirty needle, exchanging sex for cocaine or funds to purchase

cocaine.

Cocaine use has increased among methadone maintenance clients

over the last 10 years, and IV use is a major route of ingestion

among these clients (Kosten et al. 1987). Although methadone

programs have been successful in reducing IV use (Ball et al.

1988), it is essential that intervention programs be implemented

in methadone maintenance clinics. While the primary goal of

the treatment program is the complete cessation of all drug use,

including cocaine use, education and counseling in HIV

transmission and prevention are necessary to reach clients who

will not stop injecting cocaine.

Many persons who inject cocaine frequently engage in high-risk

drug use behavior, including sharing cookers and works and

using works from a shooting gallery. In these circumstances,

users are likely to use dirty works if new ones or bleach and

water to clean works are not readily available or if they do not

know how to clean those works. Risk reduction programs must

train IV cocaine users to clean works and to develop strategies

for making the cleaning process an integral part of use. Users

must be convinced that they should no longer use shooting

galleries. In a parallel action, individuals who operate shooting

galleries are in a strong position to reduce the risk for exposure

to HIV-1. These individuals, if they learn how to clean works

and become convinced that new or clean works are best for

business, could reduce the potential for exposure by cleaning all

works after each use.

(4) Cocaine users must shift their purpose for cleaning needles from

rinsing in water to prevent the clogging of the needle/syringe

to using bleach and water to destroy HIV-1 before the works

are shared. This requires the development of strategies to

convince the active drug user to integrate the sterilization of

works into the fabric of IV drug use behavior.

(5) Intervention programs also must focus on high-risk sexual

behavior. Many IV cocaine users engage in high-risk sexual

behavior such es having multiple partners and partners who also

inject drugs. These sexually active respondents seldom use

130
condoms. The exchange of sex for money or cocaine is wmmon

and, again, few use protection in the form of condoms. Nearly

two-thirds of the 255 respondents interviewed in 1987 and 1988

had sexual partners who had never injected drugs. Several of

those sexual partners will be exposed to HIV-1 infection from

their partners who do inject drugs. Programs must be prepared

to deal with the difficult issues of how an IV cocaine user who

tests positive for antibodies to HIV-1 can tell his or her sexual

partner. Provision should be made for counseling the IV user

and the sexual partner together. Because the likelihood exists

that such a revelation will disrupt/destroy some relationships,

staff must be prepared to deal with this eventuality.

(6) Followup should be part of a comprehensive intervention. The

risk behavior of many cocaine users will vary considerably over

time. Behavioral changes that are achieved at the time of the

initial intervention need to be reinforced over time.

The need to intervene to stop the spread of HIV-1 is so great that

risk reduction programs must be implemented immediately.

Unfortunately, most risk reduction programs are in their embryonic

phases and definitive effective methods of intervention are only

beginning to emerge. Therefore, it is essential that the effectiveness

of these programs be evaluated simultaneously with the development

of the programs. The results of these evaluations will enable

interventionists to refine programs to improve their effectiveness.

REFERENCES

Ball, J.C.; Lange, W.R.; Myers, C.P.; and Friedman, S.R. Reducing the

risk of AIDS through methadone maintenance treatment. J Health

Soc Behav 29:214-226, 1988.

Chaisson, R.E.; Moss, A.R.; Onishi, R.; Osmond, D.D.; and Carlson,

S.R. Human immunodeficiency virus infection in heterosexual

intravenous drug users in San Francisco. Am J Public Health

77:169-172, 1987.

Chaisson, R.E.; Osmmond, P.; Bacchetti, B.; et al. Cocaine, race and

HIV infection in IV drug users (abstract). Presented at the Fourth

International Conference on AIDS, Stockholm, June 1988.

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Chitwood, D.D. Patterns and consequences of cocaine use. In:

Kozel, N.J., and Adams, E.H., eds. Cocaine Use in America:

Epidemiological and Clinical Perspectives. National Institute on

Drug Abuse Research Monograph 61. DHHS Pub. No. (ADM)85-1414.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off. 1985, pp.

111-129.

Chitwood, D.D., and Morningstar, P.C. Factors which differentiate

cocaine users in treatment from non-treatment users. Int J Addict

20:449-459, 1985.

Des Jarlais, D.C., and Friedman, S.R. HIV infection among

intravenous drug users: Epidemiology and risk reduction. AIDS

Int J 1:67-76, 1987.

Friedman, S.R.; Des Jarlais, DC.; and Sotheran, J.L. AIDS health

education for intravenous drug users. Health Educ Q 13:268-272,

1986.

Ginzburg, H.M. Acquired immune deficiency syndrome (AIDS) and

drug abuse. In: Galea, R.P.; Lewis, B.S.; and Baker, L.A., eds.

AIDS and IV Drug Abusers. Owings Mills, MD: National Health

Publishing, 1988. pp. 61-74.

Ginzburg, H.M.; Weiss, S.H.; MacDonald, M.G.; and Hubbard, R.L.

HTLV-III exposure among drug users. Ca Res 45:4605s-4608s, 1985.

Grabowski, J., ed. Cocaine: Pharmacology, Effects, and Treatment of

Abuse. National Institute on Drug Abuse Research Monograph 50.

DHHS Pub. No. (ADM)84-1326. Washington, DC: Supt. of Docs.,

U.S. Govt. Print. Off., 1984. pp, 1-14.

Kosten, T.R.; Schumann, B.; Wright, D.; Carney, M.K.; and Garvin,

F.H. A preliminary study of desipramine in the treatment of

cocaine abuse in methadone maintenance patients. J Clin

Psychiatry 48:442-444, 1987.

Kozel, N.J., and Adams, E.H., eds. Cocaine Use in America:

Epidemiologic and Clinical Inspections. National Institute on Drug

Abuse Research Monograph 61. DHHS Pub. No. (ADM)85-1414.

Washington DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. 129

pp.

Marin, G. AIDS prevention issues among Hispanics. Paper presented

at the American Psychological Association, Atlanta, Georgia, August

1988.

Morgan, W.M., and Curran, J.W. Acquired immunodeficiency

syndrome: Current and future trends. In: Galea, R.P.; Lewis, B.F.;

and Baker, L.A., eds. AIDS and IV Drug Abusers. Owings Mills,

MD: National Health Publishing, 1988. pp. 267-280.

Morningstar, P.J., and Chitwood, D.D. Cocaine users view of

themselves. Implicit behavior theory in context. Human

Organization 43:307-318, 1984.

132
Momingstar, P.J., and Chitwood, D.D. How women and men get

cocaine: Sex-role stereotypes and acquisition patterns.

J Psychoactive Drugs 19:135-142, 1987.

O’Donnell, J.A., and Ball, J.C., eds. Narcotic Addiction. New York:

Harper & Row, 1988. p. 4.

Treasure, K.G., and Liao, H. Survival skills training for drug

dependent women. In: Reed, B.G.; Beschner, J.M.; and Mondanaro,

J., eds. Treatment Services for Drug Dependent Women. Vol. II.

National Institute on Drug Abuse. DHHS Pub. No. (ADM)BP-1219.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1982. pp.

137-158.

AUTHORS

Dale D. Chitwood, Ph.D.

Associate Professor

Clyde B. McCoy, Ph.D.

Professor

Mary Comerford, M.S.P.H.

Research Associate

Department of Oncology

Division of Cancer Control

University of Miami School of Medicine

Room 309

1550 N.W. 10th Avenue

Miami, FL 33138

133
An Ethnographic Approach to

Understanding HIV High-Risk

Behaviors: Prostitution and

Drug Abuse

Michele G. Shedlin

INTRODUCTlON

Our gaps in knowledge about the acquired immunodeficiency syndrome

(AIDS) epidemic and the role of prostitution in human immunodeficiency virus (HIV) transmission make it unwise to assume that we are

sufficiently informed about “the oldest profession” as it is practiced

in our inner cities today. The high-risk behaviors involved in the

sale of recreational sex, and the use of intravenous (IV) drugs (as

both cause and consequence of prostitution) need to be studied further if we are to develop effective prevention strategies. These

behaviors require research “in the field,” both at the level of the

individual and the “community” as defined by its cultures of drug use

and prostitution.

If we are to achieve behavioral change in these communities and develop mechanisms that will sustain this change, we must attempt to

understand existing behaviors. Quantitative data alone, however important in identifying the outcomes of behavior, do not provide us

with an understanding of how, when, where, or why they occur.

Surveys that rely upon predetermined sets of variables do not permit

discovery and exploration. Moreover, survey research assumes that

“outsiders” as interviewers will be recording truths from one-time

contacts with individuals whose very survival depends upon lies, deception, and the expert manipulation of “outsiders.” Rather, painstaking field research is necessary to provide the data needed for the

microanalysis of high-risk behaviors common to communities implicated in HIV transmission.

As we know, an institutionally based program which reaches out into

the community is not the same as a community-based approach which

134
requires far greater knowledge of the community itself for the design

and implementation of interventions. An emphasis on qualitative

research, combined with the utilization of quantitative data, is important in identifying not only the high-risk behaviors of these communities, but also the information crucial to the design of appropriate

and acceptable programs. This information may include:

perceived community needs;

the cultural (and subcultural) factors that influence the

acceptability and utilization of information and services;

formal and informal communication networks;

existing beliefs and knowledge that determine or influence

behavior;

the identification of potential program resources: and

the identification of existing or potential obstacles in service

delivery and/or the acceptance and utilization of services.

The data presented here represent a part of the qualitative research

carried out with prostitutes in New York Cii and Bridgeport,

Connecticut, and focus upon the beliefs and behaviors that place

them at risk for HIV infection and transmission.

BACKGROUND OF THE RESEARCH

In 1986, I was asked to assist with a program that involved working

with street prostitutes in New York City. Although my objectives

were oriented toward social service rather than research, a colleague

at the Centers for Disease Control (CDC) convinced me to begin an

analytical harvesting of my experience and observations with this

population. In April 1987, I began work in Bridgeport, the largest of

Connecticut’s cities, to develop a model for reaching prostitutes with

AIDS prevention education. The baseline research for developing this

program involved semistructured, in-depth, and informal conversational interviews with street prostitutes and call girls. Interviews

were also carried out with substance abuse treatment professionals,

topless-bar owners, city health officials, politicians, clients of prostitutes, and businessmen who regularly provide prostitutes to their

clients.

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This paper does not attempt to generalize the data presented on perceptions, attitudes, and behaviors to all prostitutes. Nor is it an

exhaustive treatment of the sex-related attitudes and behaviors of

prostitute populations in Bridgeport or New York City. The objective

of this paper is to illustrate the type of qualitative data that can be

useful in developing and directing intervention strategies and educational materials.

It should be noted that all prostitutes interviewed in Bridgeport were

currently, or had been, IV drug abusers, and most were recruited

through a local methadone maintenance program. While many of

those in methadone treatment continue to abuse drugs, they do not

produce the “dirty” urines that would cause them to be dropped from

the program. Thus, the women interviewed were still using some

type of drug and prostituting at the time of the interview.

In addition to a year of informal conversational interviews and observation on the street and in a methadone clinic, over 30 hours of

open-ended, semistructured interviews with 15 prostitutes were

carried out. I stressed the confidentiality of the information, explained the objectives of the data collection (project development),

and made it very clear, for my own protection and theirs, that I did

not want information about the providers of drugs or their locations.

I attempted to obtain descriptive information specific to the practice

of prostitution in the area to assist in the design of the street prostitution project, as well as more in-depth information concerning attitudes, beliefs, and behaviors relating to the sale of recreational sex.

Although everyone in the drug treatment program from which I recruited most of the interviewees had to permit HIV testing as a prerequisite for treatment admission, I never asked questions about test

results. In almost every case, however, results were volunteered,

both positive and negative.

In order to communicate appropriately, one area stressed in the

interview was language. Prostitutes call themselves “working girls,”

and “business girls”; their clients are “dates” or, less frequently,

‘johns.” The terms “hooker” and “trick” are seen as derogatory.

Condoms are most frequently called “rubbers”; however, some girls

call them “condos.” Oral sex is referred to as a “B.J.” (blow job),

and “half and half” means oral and vaginal sex. Anal sex is referred

to as “greeking,” “annual intercourse,” and “up the dirt road.” Their

“old man” is usually a pimp, the other women in his “stable” are

known to each other as “wives-in-law.” “On the stroll” expresses the

136
street girls’ daily (or nightly) activity. Women who do not “work”

are “straight.”

Drug-related vocabulary also pervades their speech. Drug paraphernalia are known as “works”; needles are “spikes”; a “hitter” is someone who is paid to inject; a “cooker” is a bottle cap or anything used

to “melt dope”; and “copping” or “scoring” mean buying drugs. You

don’t use drugs, you “do drugs,” and everyone tries to hide the

“tracks” on their bodies, which testify to IV drug use.

CHARACTERlSTlCS OF THE PROSTlTUTES

“Prostitute” is not a homogeneous category. While Sydney Biddle

Barrows, the “Mayflower Madam,” recruited nursing students, struggling actresses, and divorcing housewives for her call service, most

prostitutes are not the middle-class and upper middle-class women

described by her or the movie “Working Girls“ (produced by Miramax

Films in 1986). These women occupy a high rung in the hierarchy of

prostitution. The better escort or call services recruit the younger,

prettier, better educated women who are less frequently drug addicted

(many agencies forbid drug use) and are more often working for fast

money than to support a habit or a pimp. The New York Police

Department estimates that there are several hundred prostitute locations that can call on between 50 and 150 girls from as far away as

Rhode Island. Bridgeport has numerous call/escort services; however,

most are small-scale operations.

Topless bars and massage parlors occupy the next level of this hierarchy. The girls generally obtain customers through these businesses,

paying a percentage of their earnings to the owners, or being paid

directly by the owners for their sexual services. The dancers tend to

change bars and areas frequently, as their principal draw is a “new

commodity.” Interestingly, many potential johns expect the “exotic

dancer” to maintain the charade that she is only a dancer and not a

prostitute. Even though he may “convince” her to have sex and pay

her for her services, he rationalizes that he has “made it” with a

dancer. This also holds for dancer/strippers at stag parties, who are

raffled off at the end of the evening. They are expected to have

some form of sex with at least one guest for the total fee, but are

not hired as prostitutes. Street prostitutes, call girls, and johns distinguish dancers from others who sell recreational sex.

“Street girls” occupy the bottom rung in the hierarchy; however, the

individuals on the street represent a huge range in age, education,

137
ethnicity, drug involvement, and price. In New York City, a group of

prostitutes with whom I worked in the midtown area were welleducated, well-dressed Canadian and midwestem women who charged

fees usually reserved for call girls. They provided sexual services to

Wall Street executives and wealthy tourists in a nearby hotel, turning

over an average of $100,000 a year to their pimps.

At the bottom of the street scale are the throwaway children, unwanted by parents or family, who are put on the street by their

pimps, usually very late at night, or the drug-addicted mother who

works to support her children and her habit, not necessarily in that

order.

With the exception of the middle-class moonlighter who is short on

money and “getting by” by temporarily prostituting, there are some

common denominators which psychologists and social service professionals have identified. Prostitutes tend to have been sexually abused

or physically abused and/or neglected as children. Many were throwaway children. Another common factor, both cause and effect of

their activities, is an overwhelming lack of ego, sense of self-worth,

and perception of any alternative way of life. This characteristic is

important in understanding their attitudes about sex, professionally

and personally.

It is also important to recognize that many prostitutes are mothers.

Whether wanted and loved, or unwanted and relinquished to the State

or relatives, these women in reproductive age have borne, and are

bearing children. Almost every prostitute interviewed had one or

more children. Often, their only aspirations are for their children.

Even the most strung-out addict, who cared nothing about her body

or her future, expressed guilt and concern about her children. Prostitutes have reported that their greatest fear is that of being investigated by social service agencies and having their children taken

away. This possibility was given as a reason for not utilizing city

health services–the fear of officials learning of their prostitution

and drug abuse and removing the children to foster homes. Some of

the women in Bridgeport limit their prostitution to the daytime, not

only to avoid the dangers of the street at night, but to be home

when the children leave daycare or return from school.

The concern for their children, for the health and well-being of

existing and future children, may be an important element in

promoting behavioral change. A is important to take this into consideration in researching and designing programs.

138
Role of the Pimp

A question that is consistently asked is, “How does the pimp get and

keep women who support him? What does he have?” The caricature

of the tall, black, ostentatious character in a wide-brimmed hat and

fancy car is indeed a reality of the street scene. Many pimps, however, are silent and low-key, black or white. They are, characteristitally, excellent natural psychologists, able to recruit a young runaway

in a bus station in less than 20 minutes. They promise love, security, protection . . . everything denied to the abused or throwaway

child. Their keeping-power is said to be any combination of fear,

drugs, affection, sexual attention, and the fathering and control of a

prostitute’s children.

As Flexner reported in 1914:

The tie is easy to describe, difficult to understand.. . .

One is thrown back for an adequate explanation on the

fundamental fact of the sex relation. The woman has no

attachment whatsoever with her stream of casual

customers, but the pimp belongs to her. (Flexner 1914,

p. 32)

The women who belong to a pimp vie for his attention and sexual

favors, competing to be his “main woman.” He uses this competition,

favoring the one who brings in the most money. I have heard of

prostitutes who have taken years of dreadful abuse; others who have

left pimps to work independently elsewhere; and still others who have

married their pimps–often the fathers of their children. “A girl

likes that control if she’s been an outcast,” said one of my informants. “To you it’s abuse, to us he cares enough to beat her.”

Women who are controlled by pimps are typically difficult to reach.

Some can be contacted only when the pimp is not around and then

with great care, because contact could endanger the prostitute as

well as the health care or social service worker. The Salvation Army

has a mobile canteen that circulates in New York City late at night,

serving coffee to the “girls” and thus contacting many who are

otherwise not reachable, since the pimps are reluctant to interfere

with “the Church” (Major Elizabeth Baker, personal communication).

Many prostitutes will protect the social service street workers by

ignoring or otherwise warning them when the pimp is around. The

young children are the hardest to reach as they are constantly

watched by their pimps.

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Perceived Roles of the Prostitute

The prostitutes interviewed perceived their most important sexual

function as providing what other women, “straight women,” do not

like or refuse to provide. Biddle Barrows states that a call girl is a

woman who “knows how to satisfy certain needs that a man has, and

who, at least professionally, accepts the very kind of behavior that

other women in his life persist in regarding as amoral or a sign of

weakness.” (Biddle Barrows 1988, p. 174) Typically this “behavior” is

oral sex, the most frequent service of the street prostitute and,

usually, at least a part of the services provided by call girls. Clients

interviewed also reported oral sex as their main activity with prostitutes. It is important to note, in considering oral sex as a risk

factor in HIV transmission, that prostitutes are occasionally paid

extra to swallow the ejaculate, and that they frequently have gum

problems and oral lesions. Prostitutes also listed anal sex, bondage,

and a range of fantasy behaviors as the services they provided that

wives and girlfriends would not provide or that clients would not

request of wives and girlfriends.

Prostitutes and their clients acknowledged that many johns need to

degrade, humiliate, and otherwise control the prostitute during their

sexual encounter. “The dirtier you are, the sluttier, the more they

like it.” “You gotta be a pure dog." “They pull hair, slap your face,

talk dirty. ” “They have full control because they have money in

their pocket and you on your knees. ..";" . . . the turn-on is in

control.” For a woman with little or no self-esteem, this role is

simply part of the job.

Biddle Barrows, as well as my informants, report that men use prostitutes because they can be sexually gratified without having to invest

energy in a relationship, maintain an image, or please their partner.

(Biddle Barrows 1986, p. 96) The street prostitutes interviewed saw

their role as providing fast, easy, uncomplicated physical release and

ego reinforcement in exchange for “cash up front.” “I don’t want the

wining and dining routine,” said one john. “Girls get too clingy.”

Call girls, more typically than street prostitutes, provide

companionship.

Many men believe that a call girl is inherently worldly

and that her sexual experience (real or imagined)

somehow endows her with an added measure of wisdom.

After all, she is supposed to be an expert at pleasing

140
men. And if she knows how to please me, the client

reasons, she must therefore understand me. At the

same time, he thinks, she can’t possibly judge me.

(Biddle Barrows 1986, p. 174)

However, even the street girls report “dates” that are exclusively

conversation, usually concerning problems at home or work.

AREAS OF CONCERN

lntimacy vs. Sex

To elicit information concerning intimacy and sex, informants were

asked to explain two quotes. One was taken from the movie

“Working Girls”: “I haven’t cheated on my guy in 5 years,” stated a

call girl waiting for her next client. The second quote was one

recorded during street work with a program in New York City. A

very agitated prostitute was explaining her anger. . . a john had

tried to kiss her. . . “and I said, ‘if you wanna kiss, go home to

your wife’.”

Not cheating was explained in the following ways:

It probably means whatever her guy doesn’t want her to do, she

doesn’t do.

She hasn’t been mentally involved with what she was doing with

the john.

If she feels nothing, she hasn’t betrayed him.

No sexual gratification with the johns.

It was for finance, not romance–that’s not cheating.

It would hurt him if she didn’t get paid for it, if she did it for

nothing and enjoyed it.

She hasn’t given her love to anyone. . . she hasn’t made love.

Emotionally she hasn’t become attached–the only attachment is

financial.

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The distinction between the sale of recreational sex and emotional

involvement was an easy one for my informants.

The second quote was designed to explore behavior and intimacy

further. The significance of kissing elicited some of the most useful

discussion, and questions about kissing usually generated introspection

and thoughtful pauses in the interview. I was told that there were

two cardinal rules that all prostitutes learn: (1) get your money

first, and (2) don’t kiss a john.

You don’t kiss, that’s disgusting.

Johns don’t come out for that . . . R’s not an emotional thing

(sex) . . . strictly business.

More older guys want to kiss . . . they’re missing their wives.

Listen, if you’re a john, I will treat you as a john . . , if you

want something simple like a kiss, go home . . . if you want

something different than what you get at home, I can take care of

that.

She said he should go home because she didn’t want her time

wasted.. . he offended her.

A kiss is different from sex . . . a way of communicating feelings.

I won’t kiss any guy. . . just something in me. . . it turns my

stomach. . . a lot of girls won’t kiss.

You’re faced up front with what you’re doing . . . that’s reality in

the face . . . to a regular girl a blow job is disgusting.

In jail they talk ...what do you do... you kiss’ em?...

Whoever taught you to be a whore?

The most intimate thing you can really have.

My husband says, ‘I’m glad you do something with me that you

won’t do with anyone else. . . don’t let anyone kiss you, it would

destroy me.

He wanted to kiss her maybe because he was getting emotionally

involved.

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Although the prostitutes interviewed differed in what they felt was

the most “intimate” act (e.g., anal sex, vaginal intercourse, talking

about personal things), there was an almost uniform distinction

between kissing and sex. Although some stated that johns do not

want to kiss, most felt it was the prostitute who would not do so.

The exception seems to be the exotic dancer, who frequently deep

kisses men in the audience, men who seem to have little reluctance

to participate in this serial kissing. The dancer, as stated previously,

however, is distinguished from a prostitute and may earn money just

for kissing customers.

Power and Control

The subject of “control“ in the dynamic between the prostitute and

client arose spontaneously in many of the interviews and informal

conversations. As discussed, prostitutes report that some clients need

to debase them and assert control physically, sexually, and economically. A common perception is that the prostitute is controlled by a

john, a pimp, a madam, and frequently a drug habit. While this may

be all or partially true, there is another power dynamic inherent in

the sale of recreational sex. As Biddle Barrows explains:

Most girls assumed that the man would always be in control because he was paying for her company. This was the

critical point, and I tried to make sure each girl understood that she was the one who was actually in control.

‘It all depends on your attitude,’ I explained, ‘if you act

like you’re in control, you will be!’ (Biddle Barrows 1986,

p. 175)

I explored this subject of power and control by asking informants to

explain a quote from “Working Girls”: “You can control any man as

long as you know what his sexual trip is.”

If you pick somebody up, you have to have a street rap in order

to get what you want .. . you can find a way. . . certain things

you can say to that john to get what you want. . . if he likes

you, you use it. . .

I made like I had feelings . . . they need that attention and

affection.

A girl takes control of which character inside him he will be with

you.

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Nine out of ten times you can call what the situation turns out to

be.

When he’s locked in on that (sex), he’s just responding.

In order for you to get paid, to be successful, you have to be in

control.

A man is vulnerable when he wants sex . . . If you are in control,

you can make him do what you want.

The man becomes the weaker sex once you get him in the bedroom . . . in bed she becomes the more powerful one as long as

she knows what he’s into . . .

That’s very true . . . lf this man loves whipped cream, he says

‘how much?’ and your price is there.. . I always ask and they

let me know. . . I’m in complete control as far as being able to

manipulate him . . .

This last statement, interestingly, was made by the same woman who

described the johns’ need to degrade and control the prostitute.

Obviously, the fantasy and reality of power and control in the client/

prostitute relationship is a complex issue, one that is influenced by

many cultural, psychological, and situational factors. The importance

of this issue for education and outreach is in identifying audiences

and messages for the promotion of preventive behaviors. Can the

prostitute insist on her client using a condom? How can she use her

abilities to manipulate and control a situation to ensure her safety?

How can we, as health professionals, utilize this information?

High-Risk “Tools of the Trade”

In discussing a “typical” day/night of drug use and prostitution with

the prostitutes, they themselves mentioned a number of practices as

“risky. ” “It’s not just the needles,” they said, “there’s blood mixed in

with the dope,” “left in the ‘cooker’“, “blood can be in the cotton”

(used to soak up drugs after cooking), “in the water.” The practice

of sharing needles and drugs sometimes signifies more than convenience and cost. Sharing drugs and works can be seen as a form of

trust and street alliance. Sharing with the shooting gallery owner,

his “tip,” is an investment for the rainy day when they may be short

the price of admission.

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Another interesting practice relating to oral sex is the spitting of the

ejaculate into rags or wads of tissues. These rags are then put back

into their handbags for reuse. Meanwhile, the prostitutes take the

money just earned, send a young boy to score their drugs, go to the

shooting gallery, “hit” themselves or “get hit,” and then use the same

rag to wipe up excess blood from their body. The rags then go back

into their handbags as they go back on the street.

The rag, cooker, and cotton are important details in understanding

the risk factors in their behavior. Clearly, as differences in the

prevalence of HIV illustrate, not all “communities” of prostitutes are

doing the same thing the same way. The challenge of prevention

research is to identify the components of their risk behaviors, which

is more complex than simply identifying the use or nonuse of condoms or clean needles.

KNOWLEDGE, ATTlTUDES, AND BEHAVIORS RELATING TO AIDS

The message that AIDS has no cure and that it is fatal has reached

the streets. Prostitutes and their clients know that it is transmitted

by sexual contact; addicts know that it is transmitted through shared

needles. Yet unprotected sex continues to be sold, and “works”

continue to be shared. There are many reasons for this, paramount

among them being the nature of drug addiction. Poverty, addiction,

low educational levels, a lack of self-esteem, hopelessness, and a lack

of appropriate information and supporting services are also to blame.

The prostitutes report that AIDS and “crack” are the two major

factors responsible for changes on the street. They perceive that

older prostitutes are leaving the street because of their fear of AIDS

and violence, and that continually younger women are taking their

places because of addiction to “crack.” “Some are young,” said one

veteran, “what a waste . . . they take a chance, getting arrested,

getting AIDS . . , it’s ‘crack.’”

Many of my informants knew of someone who had died of AIDS; even

more knew of companions with positive HIV test results. One prostitute who also lived by “boosting” (shoplifting), volunteered to work

on an AIDS prevention education project shortly after learning that

one of her friends had died. Most reported that those who died had

“been on dope for years.” One death discussed was that of “The

Vampire.” The name was given to a local shooting gallery owner who

emptied leftover syringes into his veins, blood and all.

145
The association of IV drugs and AIDS is well known. “Everyone is so

AIDS conscious. lf they see tracks, they don’t want you.” “I lie, I

say I’ve never touched a needle. I hide it.” Business has improved

in the underground sale of disposable needles used by diabetics, and

some addicts have begun to check “cookers” and cotton (used for

soaking up the liquified drug) for signs of blood. Prostitutes are now

more careful about covering track marks so as not to scare off

clients, but, I was told, a “girl” in need of a fix will not worry about

dirty needles or using condoms.

One way of dealing with the fear of AIDS is to deny susceptibility to

risk, or even to refuse information. “We don’t want to be constantly

reminded,” I was chastised. “A lot of street girls are not afraid of

AIDS.” “I'm not spending all that money to buy those rubbers.”

They also warned me that prostitutes would not accept materials that

said “AIDS” because someone seeing it would think they were reading

the pamphlet or brochure because they already had AIDS.

Although I was told that AIDS can be transmitted by needles, open

sores, saliva, “the rear if you have hemorrhoids,” and semen, most of

my informants were not really sure how AIDS could be transmitted.

They asked if oral sex was safe. They asked about saliva. They

asked about bleach, and were amazed to hear about Nonoxynol-9

lubricated condoms. lt was my experience that information was

welcome–at the appropriate time, and in an appropriate way.

When I asked what “safe sex” meant, I was told “There isn’t any.”

Some said ‘abstinence”; others said “with rubbers.” Although a few

respondents volunteered that anal sex was probably a risky behavior,

they said that johns asked for anal sex when they were afraid of

herpes. (They are also paid more for anal sex.)

Condoms are more commonly used by call girls than by street girls.

“Guys are very misinformed–they think they can have a thrill and

get hard without a rubber and then only use it when they come.”

Few street girls use them in their main activity–oral sex. I was told

that girls are in such a hurry to “get it over with” or “score” (buy

drugs) that they don’t care. They worry that if they insist on using

a condom, the john will refuse and move up the street to another

girl. The addict earning money for her next fix, or the prostitute

threatened with a beating by her pimp if she does not bring in the

required money, is not likely to risk losing a customer. They are

also afraid that if they insist on the use of a condom, the john will

think they already have AIDS.

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HIV testing was generally seen to be punitive. Testing as a prerequisite for the methadone program was enormously resented and

resulted in a great deal of hostility toward the staff. Other sexually

transmitted disease testing may also be associated with being

arrested, at which time prostitutes are sometimes forced to accept

tests. “When you get busted, the only blood test they give you is

for GC [gonorrhea] not AIDS . . . and if they can’t get a vein they

say ‘too bad, we’re not gonna be involved in that!“’

Some prostitutes report that johns have actually asked to see HIV

test results, and that “some madams want a note on them every 3 to

4 months from the health department!” “I go for tests all the time,”

said one informant, “especially now that I’m pregnant.” One madam

told me, “I don’t want the responsibility for people dying . . . my

girls are tested . . . I run a clean business.”

Discussions with prostitutes who knew that they were HIV positive

were heartrending. One of them seemed relieved to be able to share

her trauma.

I have been exposed to AIDS myself,” she said casually. “I was

in shock.. . it was two things at once, exposed to AIDS and

pregnant at the same time. I associated it with death right

away. . . In the past 6 months I’ve had a series of emotions,

especially about AIDS . . . lt doesn’t affect you until it hits

home.. . like rape.. . it really happens.” She then added,

“They told me over the phone . . . that’s a bad way. They

should have said ‘come in’ . . . if I had suicidal tendencies it

would have had bad results . . . a working girl already feels

bad . . ."

Another confided:

I was giving up my 11⁄2-year-old daughter. . . I felt I had

nothing to offer my daughter because my aunt said “now you

have AIDS, you’re dying.” I talked to a woman who runs

Crossroads; she changed my outlook. Now I’m not signing

papers. . . on my deathbed I will sign.

DESIGNING AN INTERVENTlON MODEL

The objective of the research was to assist in the development of a

model for AIDS prevention education for prostitutes. Thus, in addition to the questions concerning beliefs, knowledge, and behaviors

147
relating to drug use and prostitution discussed here, the “girls” participated in guided discussions about AIDS prevention. The Bridgeport

“girls” were not only willing, but eager to explore the “who,” “when,”

“where,” and “what” of program planning. They felt that they were

the best category of outreach educator because they would have credibility and legitimacy with their peers. In addition, they felt they

would have access to places and people not safe or “open” to

“straight” individuals or health professionals (i.e., shooting galleries

and topless bars). Their perceptions of needs for training, supervision, remuneration, and medical backup were explored over time,

and a project proposal was prepared utilizing this research and an

informal diagnosis of the city’s available human and institutional

resources.

One of the most interesting and productive aspects of this collaboration with the Bridgeport community of prostitutes was the development of a pamphlet on prevention exclusively for prostitutes. A

group of three to five met regularly with me and with a graphic

artist to design a pamphlet in a size that would fit in a handbag,

select the content, decide on appropriate language, fine tune the

graphics, and make decisions on the wording of a title which would

attract, not discourage, its acceptance and consideration–A Safety

Guide for the Working Girl. As the pamphlet became more of a

reality, their sense of ownership and pride became clear, even to the

point of requesting that their names be included on it as authors.

For women whose overriding concern is anonymity, this was especially

significant.

Obviously, the prostitutes themselves were an important resource in

developing a community-based strategy. Their information and suggestions were used in conjunction with the information and advice of

local health officials, politicians, and law enforcement personnel.

Although the program and the educational pamphlet have yet to be

evaluated, a program has begun, our data bank has increased, and the

field research has been shared for others to consider and utilize.

Our challenge in identifying needs and resources, strengths and

obstacles, questions and solutions, is formidable. I believe our best

chance is to work closely with these communities to develop interventions that are subculturally acceptable and that will result in

sustained behavioral change.

148
REFERENCES

Baker, Major Elizabeth, Salvation Army. Personal communication,

1987.

Biddle Barrows, S. Mayflower Madam. Arbor House, NY: Ivy

Books, 1988. 291 pp.

Borden, L., and Kay, S. Working Girls. Miramax Films, 1988.

(Film)

Flexner, A. Prostitution in Europe. 1914. Reprint. Montclair, NJ:

Patterson Smith Publishing Company, 1989. 455 pp.

ACKNOWLEDGMENTS

Research was supported by Family Health International, Research

Triangle Park, NC.

AUTHOR

Michele G. Shedlin, Ph.D.

Sociomedical Resource Associates, Inc.

Westport, CT 06880

149
The Role of Schools in CommunityBased Approaches to Prevention of

AIDS and Intravenous Drug Use

Lewayne D. Gilchrist

INTRODUCTlON

During the last decade and a half, schools have increasingly become

the focus for health promotion and disease prevention efforts aimed

at both children and their families (Iverson and Kolbe 1983). The

purpose of this chapter is to analyze the role that schools might play

in community-based approaches to prevention of acquired immunodeficiency syndrome (AIDS) and intravenous (IV) drug use. The

analysis includes a summary of existing knowledge regarding human

immunodeficiency virus (HIV) infection and AIDS prevention in

school-age populations; consideration of factors that favor and that

hinder effective AIDS prevention efforts in schools; review of documented experiences with health-related, school-based prevention

programming; review of preliminary, anecdotal, and other less formally

documented prevention programming in school settings; and, finally,

suggestions for intervention models and future research initiatives.

HIV INFECTION AND AIDS PREVENTION FOR SCHOOL-AGE

POPULATIONS

Less than 1 percent of total AIDS cases reported to the Federal

Centers for Disease Control have been among youth 13 to 19 years of

age (Centers for Disease Control 1988). However, given the lengthy

latency period between infection and outbreak of classifiable symptoms of AIDS, a heavy proportion of 20-to 29-year-olds with AIDS

(one-fifth of all reported AIDS cases) are presumed to have been

infected with HIV as teenagers. Although adolescents are widely

assumed to be a population at high risk for HIV infection and AIDS,

direct data supporting this assumption are currently sparse. Accepted

facts are these: 50 percent of high school men and 33 percent of

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high school women have engaged in sexual Intercourse at least once

(Hassner 1987). Condom use among adolescents for contraceptive

purposes is known to be sporadic, with less than one-third of adolescents reporting contraception use at last intercourse (Hofferth and

Hayes 1987), and over a quarter in some studies reporting never using

contraceptives at all (Planned Parenthood 1988). Adolescents’ use of

condoms for prophylactic (as opposed to contraceptive) purposes is

not documented, but rates of prophylactic use are widely assumed to

be low. Incidence rates for anal intercourse and other high-risk

sexual activities among teenagers have not been established.

With regard to drug-related risk factors, even the relatively more

complete information available on adolescent drug use does not as yet

shed clear light on incidence of intravenous drug use, needle sharing,

or the culture of such activities among school-age youth. Recent

survey data show that 57 percent of high school seniors in 1988

reported using illicit drugs at least once and that about one-third had

used illicit drugs other than marijuana (Bachman et al. 1987). This is

the highest illicit drug use rate among adolescents in any industrialized country (Johnston, personal communication). Such data are

particularly disquieting given the fact that a large proportion of the

highest-drug-using adolescents drop out of school prior to their

senior year and thus are not counted in this survey report.

The plethora of drug-use questionnaires administered to school-age

youth in recent years most commonly ask about ever-use and frequency of use of certain substances, but only rarely probe for data

on adolescents’ preferred methods for drug administration. Commonly, such drugs as cocaine are available in forms to be snorted,

smoked, injected, or topically applied. Thus, data simply on frequency of use of cocaine or use at any time in the last month do not

contribute a great deal to establishing frequency of needle use in

various adolescent subgroups. Further, a variety of studies outline

the disinhibiting effects of many substances on sexual behavior

(Howard 1982; Room and Collins 1989; Stall et al. 1988). Thus, even

non-IV drug use may play a significant role in precipitating or maintaining an adolescent’s exposure to HIV. Issues related to the interaction of drug use and high-risk sexual behavior among adolescents

are underresearched and currently not of much assistance to program

planners or prevention researchers.

A few recent studies report knowledge levels and understanding of

HIV and AIDS among students in middle and senior high schools.

Data collected in 1984 revealed mass media as the primary source of

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AIDS information for a high school sample of 250 (Price et al. 1985).

Students in this study were both uninformed and misinformed about

the disease. The researchers concluded that provision of accurate

and complete information in the public schools was a desirable and

necessary corrective to frequently superficial coverage of AIDS in the

mass media that led to student misperceptions.

A 1986 study from San Francisco (n=1,326) showed that, even in an

urban setting where AIDS has had high and long-standing visibility,

there was marked variability in high school students’ knowledge of

AIDS and in their understanding of the precautionary measures that

may reduce risk of HIV infection (DiClemente et al. 1986). The

study’s authors emphasize the need to overcome students’ misperceptions by offering school-based instruction on AIDS as part of a comprehensive teaching plan to instruct students about communicable

diseases in general and the role of social values in controlling

sexually transmitted diseases in particular. A second study of San

Francisco high school students (n=628) found substantial ethnic differences in students’ knowledge of AIDS (DiClemente et al. 1988).

The research team concluded that black and Latino students were

approximately twice as likely as white students to have misconceptions about the casual transmission of AIDS and that black and

Latino youth may be at greater risk of HIV infection as a consequence of engaging in unsafe sexual practices attributable to insufficient information.

To date, few if any studies have linked knowledge and attitudes about

AIDS with adolescents’ reports of their own sexual and drug-using

behavior. No evaluations of drug prevention programs for adolescents

containing an AIDS component could be located for this report.

FACTORS COMPLICATING EFFECTIVE AIDS PREVENTlON IN

SCHOOLS

Second only to families, schools are the primary socializing influence

for children and adolescents in our society. Schools allow ready

access to the majority of this Nation’s adolescents through huge,

well-established educational service delivery systems. Schools are

well-respected local institutions, touching all families in a community

regardless of race, ethnicity, or income. There is some evidence that

programs initiated in school settings can reach through students to

engage and alter the health behavior of whole families (Nader et al.

1982; Perry 1986). Through schools, it is possible to present

sequenced curriculum over a span of several years to reinforce and

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expand learning in developmentally appropriate ways. Finally, schools

provide the best system for screening, early detection, and remedial

or ameliorative assistance to children and youth with high potential

for future health and behavior problems (Kirschenbaum 1983). For

these reasons, schools are almost universally seen as principal sites

for primary prevention of a wide variety of social and health prob

lems, including AIDS.

Nonetheless, several realities have limited the effectiveness of schoolbased prevention programs. Adolescents at highest risk for most

problem behaviors are those who are most alienated from this community institution. For example, youth most at risk for AIDS

through drug use–early substance users; children and partners of

substance users; black, Latino, and Native American youth; delinquent

youth; and runaways–are most apt to drop out of school or attend

school too sporadically to be reached by typical classroom-based prevention programs (Pirie et al. 1988; Zabin et al. 1986). Further, as

community institutions, schools and school programs can become

battlefields involving parents and community groups who, on moral or

religious grounds, object to instructional programs for youth that

contain information on sex, contraception, homosexuality, and drugs

(Gilchrist and Schinke 1983B; Lamers 1988). To be effective in

reducing the spread of AIDS, educational materials and programs must

be clear and explicit. But the mechanisms of AIDS transmission raise

moral, religious, and sexual issues that are uncomfortable or outright

threatening for many adults (Lamers 1988) and the explicitness of

some AIDS educational materials have been criticized by some community groups.

Thus, even when mandated by the U.S. Surgeon General, school-based

programs on sensitive and value-laden issues can be difficult to design and launch. Teachers themselves resist involvement in such

programs on the grounds that they are unprepared to address new

politically loaded and complex psychosocial and behavioral topics

(Smith et al. 1984). The complexity of school systems and school

administrative structures in themselves limit the capacity of schools

to make rapid change. Thus, incorporation of new programs is a slow

process. Finally, economic factors play a part in constricting traditional school-based primary and secondary prevention programs. Time

constraints and funding limitations result in the fact that health education programs, including sex education, life skills courses, and early

intervention, are the first to be cut in favor of preserving basic instruction in the three R’s. Even when specially funded research and

demonstration programs produce positive results and enthusiastic local

153
support, such programs are routinely discontinued when the special or

supplementary funding ends.

DOCUMENTED SCHOOL-BASED PREVENTION PROGRAMS FOR

ADOLESCENTS

School-based prevention programs reported in the extensive literature

on health promotion and disease or problem prevention can be

grouped into two categories: self-contained programs offered to adolescents by and in the schools that extend only minimally outside the

school, and school programs that are but one facet of a comprehensive, integrated, multicomponent, communitywide prevention effort.

School-Only Programs

The most sophisticated school-only prevention programs to date

involve smoking prevention. These programs typically involve one of

two related approaches: social inoculation (Flay 1985a; Flay 1985b)

and social skills development (Botvin and Wills 1985; Schinke et al.

1985). The inoculation approach involves anticipating and learning to

refute social pressure and to manage difficult life situations in advance of encountering them. The skills-building approaches emphasize

enhancing positive interpersonal interactions to increase adolescents’

self-esteem and sense of self-efficacy. Descriptions of the social

inoculation and social skills development approaches are available in

other NIDA monographs (Bell and Battjes 1985; Glynn et al. 1983) and

will not be reviewed here. Evaluations of variations on these two

approaches demonstrate positive preventive effects for up to 3 years

postintervention. These smoking prevention studies have been large

and complex. Several thoughtful analyses of methodological weaknesses in the research on these programs mitigate but do not reduce

confidence in their positive findings and provide detailed plans for

improving methodology in future school-based ventures (Biglan and

Ary 1985; Biglan et al. 1987; Flay 1985b; McCaul and Glasgow 1985).

Reports of findings and experiences with school-only programs that

focus on drugs other than smoking have had less clear results

(Goodstadt 1986; Moskowitz 1983; Schaps et al. 1981; Tobler 1986;

Williams et al. 1985). Tobler’s (1986) meta-analysis covering 147

studies provides a useful review of almost two decades of research on

drug prevention research. Her quantitative analysis concludes that,

for the average school-based adolescent population, programs with a

peer-leader focus achieved and maintained the largest positive effects

on participants’ use of cigarettes, alcohol, and soft and hard drugs.

154
On the other hand, for at-risk adolescents (juvenile delinquents, drug

abusers, and students with school problems), the most effective

programs were those that went beyond what school settings usually

provide to give adolescents experience with individualized alternatives

to drug use–e.g., job and academic skills training, physical activities

to increase students’ sense of competence and control over their

environments.

A recent qualitative analysis of school-only drug education programs

notes a general lack of lasting, positive program effects (Goodstadt

1986). The author points to failures to appreciate, at the program

planning stage, that students represent a range of motivation and experience with respect to drug use. Prevention programs proceed as

though classes were comprised exclusively of nonusers, and program

evaluations have failed to examine possible differences in the shortand long-term response of separate student subgroups. Goodstadt

(1986) and others (Biglan and Ary 1985; Gullotta and Adams 1982)

take prevention program developers to task for failing to make the

necessary links between the reality of the classroom and the reality

outside the classroom. These same authors criticize the failure to

take into account the wide array of individual differences in subjects’

beliefs, abilities, aspirations, intentions, and perception of social

norms. These failures sharply reduce many programs’ long-term

effectiveness in reducing drug use and abuse.

Most school programs have focused on increasing adolescents’

information base, interpersonal skills, and motivation to avoid drugs

and other forms of behavior that place them at risk. The majority

of drug prevention programs address the so-called gateway drugs:

cigarettes, alcohol, and marijuana. The rationale used by these

programs is that helping adolescents avoid the first steps in the typical progression from licit to illicit drug use will reduce the number

of students who eventually move to regular and habitual hard drug

use, including intravenous drug administration.

Although the vast majority of school sex-education programs have not

been formally evaluated, two school-based approaches focused on decreasing adolescents’ risk in the area of sexual behavior have had

positive results. One approach involves skills building. A series of

studies testing a cognitive/behavioral skills building program to increase adolescents’ refusal of sexual intercourse and to increase their

negotiation and use of effective contraception during intercourse demonstrated that adolescents can be taught to engage in protected sex

practices (Gilchrist and Schinke 1983a; Gilchrist et al. 1987; Schinke

155
et al. 1981). This cognitive/behavioral skills building approach is

currently receiving further testing in 20 California school districts.

The other approach is what might be called environmental modification. A survey of over 35 school-based programs in several geographic areas showed that, when certain confidentiality measures were

observed, more sexually active adolescents requested and effectively

used contraception. The contraceptives dispensed by a health service

site on school grounds were more effective when compared with request and compliance rates at health service centers located off

school campuses (Kirby 1986).

School Programs Within Larger Communitywide Efforts

Decidedly fewer evaluations are available for prevention programs

that make use of schools as one facet of a larger community-based

approach. In a special issue of the Journal of School Health (November 1986), several researchers articulate excellent rationales for

addressing multiple community institutions at one time to increase

health and reduce problem behavior among adolescents (Perry 1986;

Johnson 1986; Murray 1986; Pentz 1986; Orlandi 1986; Flay 1986;

Griffin 1986). Common to the nascent community-based prevention

approaches described is the analysis of social substructures that constitute and affect given communities. Also important is the planning

of programs most appropriate for each substructure or community unit

so that a collection of multipronged, specially tailored programs are

launched simultaneously to reinforce, augment, and sustain one another (Flay 1986; Griffin 1986; Johnson 1986; Orlandi 1986; Pentz

1988; Perry 1986). Such community analysis for the purpose of designing specific marketing and intervention efforts to reach specific

community segments grows out of work initiated at Stanford to devise

broad-based methods for reducing risk factors for cardiovascular

disease (Solomon and Maccoby 1984). Research evaluating such

community-based health promotion programs is now ongoing in

Minnesota (Blackburn et al. 1984; Murray 1986) Kansas (Pentz et al.

1986) Rhode Island (Lasater et al. 1984) California (Farquhar et al.

1984), and elsewhere.

Several studies on the etiology and treatment of opiate use stress the

need to incorporate social and cultural knowledge about the lives of

groups to whom drug prevention and treatment programs are addressed (Dembo and Shern 1982; Gersick et al. 1981; Kaufman 1978).

Such knowledge seems particularly critical when addressing black and

Latino inner-city adolescents who are at high risk both for adopting

drug-involved lifestyles, for HIV transmission, and for AIDS. In a

156
series of studies, Dembo and his associates demonstrated the power of

sociocultural and environmental factors, as opposed to disturbedpersonality factors, as influences on the drug involvement of lower

class, inner-city youth (Dembo et al. 1979; Dembo et al. 1978; Dembo

et al. 1981; Dembo and Shern 1982). Unfortunately, most of the

well-evaluated, community-based prevention programs to date have

primarily focused on suburban, middle- or working-class communities.

Few community-based prevention studies involving high-risk, lowincome, inner-city groups have yet emerged.

One potential exception is an ongoing series of drug prevention

studies with low-achieving, inner-city elementary school-age children.

These studies focus on reducing a number of precursors or early risk

factors known to be associated with drug experimentation and drug

use in adolescence. Hawkins, Catalano, and associates are studying

methods to ultimately reduce drug use by changing the social context

in which at-risk children develop. This prevention strategy aims at

low-achieving children in elementary schools. The strategy includes a

component to teach teachers to alter classroom climate with reward

and punishment structures. In addition, a component has been developed to help students’ parents increase their monitoring and communication skills, develop appropriate expectations for their child, and

use fair and consistent discipline. This integrated school/home prevention program is designed to decrease family conflict and school

failure and increase students’ bonding to prosocial (i.e., antidrug)

institutions and influences, namely schools and family. Although still

being evaluated, this approach and emphasis on modifying social context and social bonding has produced initial positive effects (Hawkins

and Catalano 1987; Hawkins et al., in press).

ANECDOTAL EXPERIENCES RELATED TO AlDS AND HlV

TRANSMlSSlON

Because alterations in formal school curricula take time to initiate

and implement, those schools that address AIDS education typically do

so with single-shot programs for seniors or, in some cases, for an

entire high school student body. Unpublished data from Washington

State show that high school students’ knowledge can be reliably

increased with as little as 1 hour of instruction specifically about

AIDS and HIV transmission (Miller and Downer, in press). Occasionally, one-shot school programs incorporate a mailing to students’

homes containing information about AIDS and HIV transmission with

encouragement to parents to discuss AIDS with their children. The

effects of such mailed encouragements are not well-documented.

157
Despite this gap in data, the drawbacks of the one-shot health education approach are well known. First, one-shot programs must be

exceptionally well done to hold student attention. For developmental

reasons, a great many students do not see themselves at risk for

AIDS. Sexual identity and sexual functioning are not well established

until late adolescence and early adulthood. For younger adolescents,

feelings and fears surrounding sexual behavior are strong. Homosexuality is a singularly uncomfortable topic for adolescent males.

Adolescents’ difficulties in acknowledging and planning ahead for

their own sexual behavior have long been recognized as a factor contributing to unintended pregnancies (Schinke et al. 1979). For both

sexes, heterosexual encounters are most comfortable when they are

“spontaneous” and unplanned (Gilchrist and Schinke 1983b). With

regard to drugs, active intravenous needle use among adolescents who

attend school regularly is relatively rare, and few youth in school

intend to inject drugs. Thus, messages about anal interwurse,

condom use, and needle sharing, when not rejected outright, seem

remote and irrelevant to many students. Second, even when students

attend to and learn from AIDS education programs, there may be no

application of that knowledge to behavior and no reduction of risk

for HIV transmission. For all age groups, changes in knowledge

alone have not been reliably associated with protective behavior

change (Kelly et al. 1987).

RECOMMENDED INTERVENTION MODELS

Intervention models must be appropriate to the goals that they are

supposed to achieve. Available data (Flay 1985a) suggest that

programs with a social/psychological framework, including both the

social inoculation and social skills-building variations, can positively

affect the behavior of many mainstream, middle-class school students.

These interventions reduce students’ risk of problems associated with

substance use and, less certainly, with sexual behavior. To date, few

if any findings suggest the presence of any unintended negative

effects from these programs that would contraindicate widescale use.

Nonetheless, the primary complaint about programs based on this

model is that they fail to reach or to change the behavior of precisely those students at highest risk–early experimenters with sex

and drugs, and students with school attendance problems. In-school

interventions based on the social/psychological intervention paradigm

thus may be useful for some but clearly not for all adolescents.

Such school-based programs must be supplemented with other kinds of

risk reduction programs aimed at youth not accessible through the

school system.

158
A useful framework for extending thinking about a multipronged

approach to AIDS risk reduction for adolescents may be found in

scholarly work that considers program design on the basis of participants’ risk potential and the probable cost effectiveness of program

components (Gordon 1963; Schinke et al. 1986). This work outlines

three types or measures of prevention/intervention programming.

The most generally applicable type, which we shall call

universal, is [an intervention] measure that is desirable

for everybody. In this category fall all those measures

which can be advocated confidently for the general public

. . . There are many measures, however, in which the

balance of benefits against risk and cost is such that the

procedure can be recommended only when the individual is

a member of a subgroup . . . whose risk of becoming ill is

above average. These measures we shall call selective . . .

The third class of preventive measures, which we propose

to term indicated, encompasses those that are advisable

only for persons who, on examination, are found to manifest a risk factor. (Gordon 1983, p. 108.)

Within this intervention nosology, three types of AIDS- related intervention programs for adolescents appear useful to develop. First is

the universal strategy or approach, using school classrooms in all

schools to disseminate to all students: accurate information about

HIV transmission and AIDS; information about anticipating situations

containing risk; information about decisionmaking regarding personal

behavior in those situations; and some practice with the skills necessary to implement safe decisions. This universal approach is broadest

in scope, least intensive and costly, but also least likely to yield enduring behavior change. Such universal programs, however, may be

sufficient for adolescents at reasonably low risk for infection.

A selective intervention strategy is recommended for reaching students whose risk for AIDS is above average. This strategy dictates

special efforts in particular school districts (or in particular schools

within one district) where drug use, delinquency, and pregnancy or

sexually transmitted disease rates are higher than national averages.

Adolescents in these schools may be assumed to be at greater than

average risk and to require more than information and minimal skills

building. Programs in these schools should incorporate more intensive

programming, involving peer-led stress-management techniques, selfesteem building and communication skills development. Worth investigation is the incorporation of selective in-school intervention efforts

159
as part of a coordinated risk reduction strategy that addresses all

segments of a neighborhood or high-risk geographic community.

Third, special high intensity programs are needed for indicated populations who are already engaging in behavior associated with HIV

transmission. Schools are only peripherally useful sites for such programs, which must address the needs of drug-using and sexually

active dropouts, truants, runaways, young addicts, and other adolescents alienated–probably permanently–from schools. Social service

agencies, detention centers, street shelters, support groups for gay

and lesbian youth, community health centers, and mental health treatment facilities provide more useful access than schools to these highest risk groups. Interventions with these adolescents will probably

need to be highly personalized and supportive over long periods of

time to affect and maintain behavior change that leads to consistent

safety from HIV exposure and transmission.

Complicating all school program planning is the indisputable fact that

student bodies are not homogeneous. Within the same school, different students are at differing levels of risk and thus require different

kinds of intervention strategies. A single school, for example, may

launch a low-intensity universal AIDS intervention program for all

students and, concomitantly, a more intensive selective program for

students enrolled in contract studies or other dropout prevention

classes.

RECOMMENDED RESEARCH INITlATlVES

Epidemiological and ethnographic studies of risk behavior among a

wide variety of adolescent subgroups are needed to determine adolescents’ vulnerability to HIV transmission and to form the basis for

selecting appropriate levels of school-based intervention. Available

studies suggest, but do not definitively show, that a single intervention program can successfully reduce multiple risk behaviors among

adolescents (Botvin 1963). Research might profitably focus on testing

interventions that simultaneously address related risks, for example,

drug use, sexual activity, unintended pregnancy, and sexually transmitted diseases. At the present time, most in-school interventions

address only one risk factor at a time, resulting in fragmentation and

too many competing liens on time within the instructional day.

Research might also profitably move from almost exclusive focus on

intervention content to research on larger organizational and policy

climate issues that support or impede preventive interventions

160
undertaken by schools. Such an expanded focus would include

research on how schools can serve as foci, triggers, or complementary

components in a coordinated communitywide AIDS awareness and

prevention effort.

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AUTHOR

Lewayne D. Gilchrist, Ph.D.

School of Social Work

University of Washington

4101 15th Avenue, N.E., JN-30

Seattle, WA 96195

166
The Role of Drug Abuse Treatment

Programs in AIDS Prevention and

Education Programs for Intravenous

Drug Users: The New Jersey

Experience

Joyce F. Jackson, Leslie G. Rotkiewicz, and

Robert C. Baxter

INTRODUCTION

It is estimated that as many as 150,000 people in New Jersey may

already have been infected with human immunodeficiency virus (HIV),

the virus that causes acquired immunodeficiency syndrome (AIDS)

(New Jersey State Department of Health 1987a). State Health

Commissioner Molly Coye, in her “AIDS Toll Forecast,” has indicated

that approximately 1 in every 75 New Jerseyans may be infected

(Star-Ledger 1987). Many of these exposed individuals unknowingly

carry and transmit HIV to other persons. In New Jersey, HIV transmission is primarily through intravenous (IV) drug use or sexual

intercourse among needle-sharing addicts. Unfortunately, symptoms

of HIV exposure may not appear until 5 or more years after contamination. It is therefore possible for HIV carriers to show no signs or

symptoms of AIDS for extended periods, but still transmit the virus

(New Jersey State Department of Health 1987a). Based upon the

present pattern of this disease, the total number of reported AIDS

cases in New Jersey is likely to reach 20,000 by late 1991 (StarLedger 1987).

This perplexing viral phenomenon has contributed to the seemingly

uncontrollable spread of HIV among primary risk groups, especially

intravenous drug users (IVDUs). The dynamic infectious process, as

well as sexual and drug abuse lifestyles, confound attempts to control

the spread of AIDS in New Jersey. As with any infectious disease,

understanding the complex interaction of “pathogen, host, and

environment” is essential for developing solutions (Selwyn 1986).

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In 1984, Weiss and colleagues (1966) conducted an HIV seroprevalence

study among drug abuse patients enrolled in New Jersey treatment

programs. This study revealed that 29 to 56 percent of the tested

patients in the northeastern part of the State were HIV positive,

with the HIV seropositivity percentage among New Jersey IVDUs in

treatment decreasing as distance from New York City increases.

Today, HIV infection rates are believed to be higher, although this

has not been systematically determined. Preliminary results from a

recent study of “small samples” of drug users from two major northeast cities in New Jersey indicate HIV seroprevalence of 47 percent

and 60 percent (French 1988). According to the State Department of

Health, approximately 76 percent of reported AIDS cases in New

Jersey are found in the northeastern part of the State. This is the

same area where the majority of IVDUs reside. Also, a recent study

by the National Institute on Drug Abuse elsewhere in New Jersey

found seroprevalence rates of 43 percent and 12 percent in two cities

(Battjes, personal communication). The spread of the AIDS virus

among IVDUs appears unabated, with the likelihood of transmission

through shared needles and sexual contact increasing as more active

abusers become infected (Weiss et al. 1986).

New Jersey currently ranks fifth in the Nation in total AIDS cases,

with 3,462 cases reported as of January 31, 1988. Of those, approximately 1,450 are still living and in need of various medical and community support services. The composition of these cases in the State

has been relatively stable since the beginning of the epidemic. As

mentioned, New Jersey’s AIDS population differs from national statistics in that the primary risk group is reported to be IVDUs. Indeed,

Selwyn (1966) has indicated that approximately 60 percent of all

IVDU AIDS-related cases in the Nation were reported from New York

and New Jersey.

AIDS has already spread rapidly in New Jersey, with the number of

reported cases increasing each year since 1981. During the past

5 months alone (July 1, 1987 to December 1, 1987), the rate increased

26 percent, with the reporting of 785 new cases (New Jersey State

Department of Health 1987b). Although some of this is due to a

change in the reporting definition by the Centers for Disease Control

(CDC), effective September 1987, the rate of increase remains

alarming.

Finally, the devastating consequences of AIDS infection among an

increasing number of IVDUs is reflected in a growing number of

pediatric AIDS cases. As of January 31, 1988, 91 percent of the

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110 pediatric cases in New Jersey had a parent at risk for AIDS

(New Jersey State Department of Health 1988), and New Jersey is

second only to New York in total reported pediatric AIDS cases. The

large majority of these cases are the result of maternal transmission

from a mother who is an IVDU or a sexual partner of an abuser.

The preponderance of IVDU AIDS cases in New Jersey has resulted in

a rather different demographic picture compared to the United States,

generally. The following New Jersey statistics will serve to highlight

these differences.

Nineteen percent of our cases are among women, compared to only

7 percent nationally.

Eight percent of cases are attributed to heterosexual transmission,

compared to 4 percent nationally.

Sixty-three percent of all cases are among blacks and Hispanics.

Nationally, the percentage is 38.

Ninety-one percent of children with AIDS are born to a parent

with, or at risk for, AIDS. Nationally, this figure is also high at

76 percent.

A little over 3 percent of our total cases are children with AIDS

(under 13 years), compared to 1.5 percent nationally.

Fifty-six percent of all reported AIDS cases are related to IV drug

use as compared to approximately 25 percent nationally

(New Jersey State Department of Health 1988).

Much has been learned about AIDS in recent years, but there is

unfortunately no cure or anticipated vaccine to curtail this epidemic.

Until a cure or vaccine is discovered, the only means of fighting this

disease is to help individuals reduce their risk through mass media

and specific prevention and education activities aimed at high-risk

groups (New Jersey State Department of Health 1987a). It is hoped

that increasing the AIDS knowledge level of the general public will

result in a reduction in high-risk behavior. Those individuals who

are in high-risk groups must also refrain from behavior that results

in HIV transmission to others. AIDS information or education will

serve no purpose unless it is translated into AIDS avoidance behavior.

169
Nationally, AIDS education and risk-reduction programs have already

effected positive behavioral changes among various high-risk groups,

including IVDUs (Selwyn 1986; Des Jarlais et al. 1968). However,

much high-risk behavior continues among IVDUs. Unless methods to

control the spread of HIV among IVDUs are established, many more

will become ill and die, and this AIDS population will create a severe

burden on the State’s health care and social service systems.

Achieving lasting behavior change among IVDUs is a challenge. They

tend to have more medical and social problems than other risk groups

(Ginzburg 1988). Many IVDUs depend upon public assistance for

financial and medical services. Often unemployed, they also frequently lack medical insurance and other benefits, housing, family

support, and other financial reserves.

In other parts of our country, the predominant AIDS risk group is

composed of homosexual men. The gay community has demonstrated

an ability to organize voluntarily and provide resources and services

to their cohorts across the Nation. IVDUs, on the other hand, generally lack the sophistication, literacy, group morale and resources,

and political clout to mount comparable achievements in education,

prevention, treatment, community support, and advocacy for their

constituency (Jackson 1987). The inability of the drug-using community to organize and advocate for itself has forced the State Department of Health, nonprofit drug treatment programs, and other State

agencies to provide AIDS-related services to IVDUs that are provided

to the gay community by voluntary organizations.

Because the AIDS epidemic is associated with IV drug use and IVDUs’

need for help in changing behavior, the New Jersey State Department

of Health has developed treatment, prevention and education, and

community support projects that are specifically aimed at special

populations of IVDUs and their sexual partners. Efforts that utilize

drug abuse treatment programs in AIDS prevention will be the focus

of this paper.

HEROIN (IV) DRUG ABUSE SERVICES IN NEW JERSEY

The Division of Narcotic and Drug Abuse Control (DNDAC) of the

State Department of Health has estimated that there were 40,000

IVDUs in New Jersey at any time from the seventies to the mideighties (New Jersey State Department of Health 1986), and this same

estimate holds true in 1988. The cost to society of their addiction

alone is estimated to be $750 million or more per year (New Jersey

170
State Department of Health 1965; Schadl, personal communication,

1988). There were 21,344 total drug abuse treatment admissions in

1980. Of those, 8,703 admissions were for outpatient heroin

detoxification.

The Federal Government began reducing revenue designated for State

drug abuse services in 1981. Because of this reduction, treatment

services were decreased and a patient copayment obligation was

introduced, resulting in a dramatic decline in heroin (IV) detoxification admissions. These economic and service barriers resulted in

fewer minorities, especially black males, seeking drug abuse treatment

(New Jersey State Department of Health 1966). Heroin detoxification

admissions among black males declined 79 percent, from 3,643 in 1980

to only 777 in 1985. This is of particular concern, since minority

groups are disproportionately represented in the number of AIDS

cases in the State of New Jersey (New Jersey State Department of

Health 1988). Since the seventies, it has been evident that numerous

heroin addicts in New Jersey were willing to enter detoxification

treatment if it were reasonably accessible.

AIDS Community Educator Program

The earliest outreach directed to the New Jersey IV drug-using community was begun in early 1985. This Community Health Education

Project was established through a grant from the Federal CDC and

involved the use of ex-addicts to reach active IVDUs in the streets.

The goals of the Project were to disseminate information about AIDS

to active IVDUs, stressing risk reduction with respect to sexual and

childbearing behavior, and to develop a mechanism for feedback from

active IVDUs to the drug treatment community on what is happening

on the streets in regard to AIDS and drug abuse activities.

To carry out these project goals, contracts were generated with

community-based drug treatment programs, including those that were

drug-free residential, outpatient drug free, and methadone maintenance. By June 1985, eight former IVDUs (either drug free or

methadone maintained) were hired on a half-time basis. These

exaddict educators were chosen to function within geographic areas

of New Jersey known to have varying numbers of AIDS cases and

HIV seroprevalence ratio among IVDUs. There was a greater number

of educators in northeastern New Jersey, where seroprevalence ratios

in 1984 were known to be between 40 percent and 55 percent among

IVDUs in drug treatment programs (Weiss et al. 1986). Other

171
educators were located in areas of low seroprevalence where it was

considered important to conduct primarily preventive intervention.

Prior to beginning their field work, the ex-addict educators were

trained in concepts such as the definition of AIDS, epidemiology and

etiology of AIDS, modes of HIV transmission, the spectrum of HIV

infection and related diseases, and risks reduction related to IV drug

use and sexual behavior. Later, training was given in ethnography,

and role playing was utilized to simulate situations that might occur

on the streets.

After training, the community health educators were sent out into

their communities to seek active street addicts and inform them about

AIDS, how it is transmitted, and what they could do to decrease

their chances of infection. The educators distributed literature on

AIDS from the New Jersey State Department of Health and the U.S.

Public Health Service, and acted as facilitators in bringing addicts

into local drug treatment programs. The educators met monthly with

the project coordinator to receive training, report on their work, and

exchange information. Monthly reports detailing numbers of contacts,

pieces of literature distributed, and observations were compiled by

each community health educator.

Evaluation of the effect of the Project after the first 6 months came

from direct reports from the ex-addict educators and from the results

of a questionnaire administered to 577 IVDUs entering drug treatment

programs to assess their level of knowledge about AIDS. The findings of the educators were as follows:

(1)

(2)

(3)

(4)

It is difficult to have an educational impact on IVDUs who are

exhibiting compulsive drug-seeking behavior.

Large numbers of street addicts can be reached. Written materials had some importance because they could be read while

users temporarily ceased their drug-seeking behavior.

For many addicts, enrollment in a treatment program is a prerequisite to achieve necessary behavior change on a regular

basis.

More than half of addicts wanted treatment, but saw the cost as

prohibitive.

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The findings of the questionnaire (Ginzburg et al. 1986) administered

between July and December 1985 were as follows:

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

White males and females tend to have better information about

AIDS than either blacks or Hispanics.

Only 30 percent of respondents were aware that soaking needles

and syringes in a bleach solution could reduce the risk of AIDS,

but 62 percent knew that risk of infection could be reduced by

not sharing “sets.”

About half the respondents had correct knowledge of the major

modes of transmission of AIDS. Blacks had the least awareness

that AIDS can be spread by sexual relations.

Fifty-seven percent of the respondents were aware that babies

born to IV users are at risk.

Fifteen percent of the respondents stated that a drug program

field worker (ex-addict educator) was one of their sources of

information on AIDS.

Almost half of the respondents were aware of major risk groups.

Poor knowledge of AIDS symptoms was demonstrated. More

than 33 percent believed that those exposed to the AIDS virus

would be visibly sick, and 66 percent believed that exposure

would almost always result in death.

The most frequent responses for reasons for coming to treatment were “being tired of running” (68 percent) and “fear of

AIDS and other diseases” (47 percent).

The Community Health Education Project has been expanded from the

original 6 half-time educators to 26 full-time personnel. They are

distributed throughout the State, but are concentrated in areas of

high incidence of IV drug use and high HIV seropositivity (e.g., Essex

and Hudson Counties). Over the past 21⁄2 years, their roles and the

messages they deliver have changed. Presently, they attempt to

reach not only IVDUs, but also their sex partners. Although educators continue to warn of the dangers of needle sharing, the delivery

of safer sex messages and warnings of the risk of infection to unborn

children are stressed.

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In many cases, the community health educators have become respected and valuable resources to the drug-using community. They assist

Individuals in enrolling in drug treatment programs, help individuals

apply for entitlements, refer people to the HIV counseling and testing

sites, and advise symptomatic people about medical services available

at various clinics. Many educators are seen as the “AIDS person” by

the drug-using community and as a source of information and help to

this isolated population. Because they are hired directly by a

community-based program, they reflect the cultural and ethnic composition of the surrounding area. As discussed later, health educators

were invaluable in the implementation of New Jersey’s coupon outreach program.

AIDS Coordinator Program

In 1985, the DNDAC began to develop the AIDS Coordinator Program

to address the growing problem of AIDS and the IVDU. The AIDS

Coordinator was used to provide professional expertise to coordinate

AIDS education and support services for IVDUs, drug program staffs,

patients, and community agencies with which they interface.

The 14 community-based drug treatment programs that already had

ex-addicts involved in the Community Health Education Project contracted with the Department of Health to hire individuals who had a

minimum of a bachelor’s degree or were registered nurses. Prior to

beginning their work in March 1966, the AIDS Coordinators received

training that included medical aspects of AIDS, epidemiology and

modes of transmission, HIV antibody testing, social and psychological

issues, entitlements for patients with AIDS or AIDS-related complex

(ARC), and community networking techniques. Meetings and training

sessions were held monthly with program coordinators to discuss

their activities, attend workshops, and receive updates on AIDS

information.

The AIDS Coordinators’ activities involved contact with substance

abusers in treatment, drug treatment program staff, and community

social service agencies, as well as the general community. They were

responsible for:

(1) developing and implementing ongoing AIDS educational programs

for patients and staff;

(2) developing and implementing a program to identify, refer, and

coordinate care of symptomatic patients;

174
(3) assuring that supportive services such as family therapy and

support groups were accessible and appropriate to drug abuse

patients; and

(4) networking with community agencies and serving as an

educational resource.

The AIDS Coordinator Program was expanded from 14 to 28 full-time

coordinators in January 1987. During November 1987 alone, coordinators conducted 948 educational sessions for clients, made 123 presentations in the community, conducted 588 individual AIDS counseling

sessions, and made 307 AIDS-related referrals to medical and social

services. Clearly, the AIDS Coordinator Program has become a vital

and vocal force in New Jersey’s multifaceted effort to confront the

epidemic problem of AIDS and AIDS-related conditions among IVDUs,

their sex partners, and their children.

One of the most important responsibilities of the AIDS Coordinator is

the provision of AIDS education and risk reduction information to

clients. The most obvious time to provide this education is at drug

treatment admission, and many drug treatment programs in

New Jersey have made AIDS education mandatory for new admissions.

Although education at intake is essential, it should not be considered

sufficient, nor is intake necessarily the most opportune time. Clients

coming into treatment are often anxious; some may be feeling sick

from drug withdrawal, and others may be preoccupied with the pressures that drove them into treatment in the first place (e.g., legal,

family, or financial problems).

The AIDS Coordinator assures an ongoing program to support behavioral change. Many methadone programs, for example, have a phase

system in which clients receive increased take-home privileges as

they show progress in the program, and many residential drug-free

programs “promote“ clients based on their demonstration of responsible behavior. AIDS education is a mandatory requirement for

advancement (promotion) in specific treatment programs.

Another significant time when AIDS education is appropriate is when

observation or urinalysis indicates that clients are abusing drugs.

Clients must be alerted to the dangers of continued drug use and

warned that if they persist they may be discharged from the program.

This discharge exposes them to increased AIDS risk. Indeed, this

moment may be critical for AIDS education. Education is extremely

important to the prevention of further HIV infection spread: however,

175
education alone is often not sufficient to create and maintain behavioral change, particularly among IVDUs.

Drug treatment programs, therefore, need to develop systems to encourage and support behavioral change. Joint counseling sessions

with clients and their sex partners and “safer sex” groups are methods that have been tried with varying degrees of success. Programs

have been encouraged to try different approaches to determine what

works for them. For example, one program tried separate safer sex

groups for men and women and found separate groups were not well

received. Few clients attended, and members’ participation was

limited. When the program began groups with men and women together, attendance grew, the groups became much more animated, and

staff felt that the interactions were more positive and the pressure

for behavioral change much stronger.

Coordinators have worked with a wide variety of formal and informal networks. Their efforts have resulted in the formation of

community-based task forces in several communities–an important

element in developing services and advocacy for a population that is

without influential representation. Through the AIDS Coordinator

Program, drug treatment agencies have widened their constituency

and assumed a greater public health role in their communities.

The Coupon Program: Drug Treatment and AIDS Education

Based on statistics related to IV drug use, the transmission of AIDS,

and the reduced percentage of minority males entering treatment

since the imposition of client fees, the New Jersey State Department

of Health determined that a program to entice heroin addicts into the

treatment system was urgently needed. It was theorized that there

were numerous heroin addicts in the inner city who would respond to

free detoxification treatment. By eliminating the cost of treatment

and assuring prompt service, a significant number of addicts who had

been out of the treatment system for some time could be reached.

Furthermore, it was anticipated that a number of these patients

would continue in treatment beyond free detoxification. Finally,

detoxification treatment that included an AIDS education component

could provide opportunities to increase the AIDS knowledge level,

change the behaviors of IVDUs, and thereby lower the probability of

AIDS transmission among IVDUs and their sexual partners and/or

needle-sharing partners.

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A coupon program was developed to address that segment of the

active drug abuse population either unable or unwilling to pay for

heroin detoxification. This program involved the distribution of

serially numbered detoxification coupons in areas where addiction was

prevalent. Coupons valid for a specific program and time period were

distributed through the previously established network of trained exaddict community health educators.

Methadone programs received contracts to provide free heroin detoxification, up to 21 days, for all eligible heroin addicts who presented

a valid coupon at intake. To be eligible, coupon bearers had to be

addicted to the intravenous use of heroin and to have been without

drug abuse treatment for the previous 12-month period. The program

physician had final responsibility to determine eligibility, within State

and Federal criteria.

Participating drug programs were required to provide 1 hour of AIDS

education within the first 3 days of treatment to each person presenting a coupon. Additional program responsibilities included

obtaining a brief sociodemographic history from each addict and

administering pre- and post-AIDS education surveys to each coupon

patient, to determine his or her understanding of the educational

program’s content. Posteducation surveys were conducted immediately after the AIDS education program.

Nine nonprofit methadone programs throughout the State participated

in this pilot coupon project. The field project began in December

1986 and terminated March 31, 1987. Of the 1,000 detoxification coupons made available, 970 were distributed by the end of the program

period. Of the distributed coupons, 64 percent were redeemed for

heroin detoxification services. Thus, a total of 816 coupon questionnaires were evaluated.

Seventy-nine percent of the coupon recipients were males. The

majority of the coupon program patients were black (66 percent),

with white at 18 percent, and Hispanic at 16 percent. The mean age

was 33.03 with a 6.4 standard deviation, and the age range was 18 to

63 years. Forty-five percent of the patients claimed no previous

treatment attempts. The mean for the number of years since last

treatment for those patients who claimed a previous treatment episode was 5.4 or mid-l 981 with a 4.03 standard deviation (Jackson et

al., in press).

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Of the 816 patients who entered treatment via the coupon program,

95 percent received 1 hour of AIDS education. When pre- and postAIDS education surveys were compared, significant improvement was

shown in understanding on almost all AIDS knowledge questions.

Ninety-five percent were initially aware of their IVDU risk-group

status, but were considerably less aware of AIDS transmission to

babies of IVDUs, female sex partners, and male sex partners. Coupon

patients showed marked improvement in recognizing symptoms of

AIDS. Blacks and Hispanics showed lower initial understanding of

AIDS, but all improved at posttesting.

Data were also gathered at each participating program site to identify

those coupon program participants who, as of May 1987, had continued in treatment beyond their coupon detoxification attempt.

“Continuation in treatment” was defined as either acceptance into a

methadone maintenance program or an additional detoxification

attempt. Since the numbers of patients in all programs exceeded

their funded capacity, little effort was made to retain patients beyond

the detoxification period. Yet, 28 percent of the coupon recipients

continued in treatment (Jackson et al., in press).

Subsequently, additional coupons were distributed. The coupon

program was expanded from 9 original programs to 16 participating

programs throughout the State. During 1987, approximately 2,000

IVDUs benefited from the coupon program. State AIDS prevention

and education funding was used to support this project, which is

expected to continue on an annual basis.

Mobile Health Vans

It is difficult for many residents of the inner city to reach health

services and receive health education. This is especially true for

IVDUs. In many cases, hospital emergency rooms are the primary

providers of health care and information to the indigent. Emergency

room interactions are often brief and, in the case of addicts, marked

by mutual antipathy.

The Mobile Van Program of the New Jersey State Department of

Health is designed to ameliorate this situation by providing education,

information, and referral services for a broad range of health concerns to residents of inner-city neighborhoods. This outreach effort

is aimed at drug users, their sexual partners, and significant others,

to provide education, prevention, and early intervention services with

respect to AIDS and substance abuse. Literature about and referral

178
to other health and social welfare concerns are also available from

the van.

Two community-based drug treatment programs, one a methadone

program and the other a therapeutic community, both located in areas

of high seroprevalence for HIV infection and high incidence of IV

drug use (Newark and Jersey City), received State monies for mobile

van units. Funds were provided to purchase, equip, insure, and staff

each van for approximately 3 days of operation a week.

Each van is staffed at all times by a driver, a trained counselor, and

a physician. Upper-body physical examinations are conducted when

indicated, and medical information and referrals provided when appropriate. No drugs are carried on the vans and no prescriptions are

written by the mobile unit physicians. Each van is equipped with a

two-way communication system between van and clinic so that the

system is aware of the van’s location. These services are provided

on an anonymous basis; no identifying information or names are

solicited. Serially numbered contact forms are completed for each

person utilizing the van to facilitate the collection of statistical information and the evaluation of the project.

The van services are publicized through the media and by outreach to

community agencies, tenants’ associations, and church groups. In

addition, the community health educators distribute flyers to drug

users and their associates.

The first van became fully operational in August of 1987 and the

second in December of 1987. Thus far, the vans have visited 44

different sites and served over 600 clients. Analysis of the contact

sheets collected in December from both vans indicates that 74 percent of those using the vans’ services were black, 15 percent were

Hispanic, and 12 percent were white. Clients were almost equally

divided between male and female (52 percent male and 48 percent

female). Significantly, only 11 percent of the clients had any previous exposure to AIDS information or services, despite the fact that

40 percent of them said they themselves had engaged in high-risk

behaviors (26 percent through IV drug use; 74 percent as sex partners

of IVDUs). Almost a third had either a friend or a relative who was

at risk.

Analysis of the data collected by mobile van units will be undertaken

in the future; however, preliminary data indicate that vans are reaching persons at high risk for HIV infection either through IV drug use

179
or as sex partners of IVDUs; they are being reached because service

comes to them in their neighborhood. Almost 50 percent of those

utilizing the vans’ services did so because they saw it on the street,

rather than just having been told about it or through publicity. The

vans have been well received by the communities and community organizations, and tenant groups are requesting that vans visit their

neighborhoods.

SPECIAL SERVICES FOR IVDUS WITH AIDS AND ARC

In addition to the AIDS prevention initiatives described above, drug

abuse treatment programs in New Jersey are beginning to provide

special services for IVDUs who have AIDS or ARC.

Residential Beds

Because there are proportionately more indigent and homeless people

among IVDUs than among any other AIDS risk group, the burden on

New Jersey hospitals treating AIDS and ARC patients has been great.

Long after they no longer require acute medical care, many AIDS/

ARC patients have remained hospitalized at a cost of over $400 per

day (Whitlow 1988) because housing has been unavailable. Others

have been unable to find housing after discharge. Because of their

drug or alcohol abuse, family members are often unwilling or unable

to house them, and they continue their addictive lifestyle until they

return to the hospital.

In mid-1985, the New Jersey State Department of Health began

working on solutions to this problem. The Post-Hospital Residential

Program was developed to provide appropriate, cost-effective,

posthospital placement for drug users who are homeless AIDS/ARC

patients.

Four of New Jersey’s residential drug treatment programs (therapeutic

communities) were initially designated as pilot programs. Each facility was to house three patients at a reimbursement rate of $65.75 per

bed per day, or $24,000 annually. This was significantly less than the

estimated cost of staying in a hospital. The new residential program

reimbursement rate was greater than the normal rate so that higher

levels of medical, nursing, mental health, and social services could be

provided for these patients. All personnel involved in this program

were required to attend training sessions on the medical, psychiatric,

and social service aspects of AIDS and ARC. Additional training is

provided on a regular basis, and site visits are conducted regularly by

180
Department of Health personnel to review records and verify contract

obligations.

To be admitted to this program, a patient must have a diagnosis of

AIDS or ARC; (2) be ambulatory; (3) be independent in all activities

of daily living; (4) be continent; (5) have clear mental status as certified by a psychiatrist; (6) be drug free or on methadone maintenance; and (7) be medically cleared for discharge from the acute care

facility. All placements are coordinated and approved by the AIDS

Community Support Unit office of the DNDAC to ensure that referrals are appropriate and meet requirements.

The Discharge Planner from the referral hospital must provide the

AIDS Community Service Unit with a copy of the medical chart,

along with the following information in the discharge treatment plan:

(1) medication; (2) nutritional assessment with recommended diet plan;

(3) complete psychological and social history; (4) a nursing plan;

(5) all prescriptions; and (6) a medical appointment schedule. In

addition, the referral hospital must include certification from a physician that the patient can be discharged to a residential facility and is

not in need of higher levels of care, as well as documentation showing that application/referral for entitlement has been initiated by the

hospital prior to placement. The hospital must agree to accept the

patient when criteria for admission are no longer met. This information is transferred to the Drug Treatment Program when placement is

made.

The Residential Treatment Facility is required to provide the following services:

(1)

(2)

(3)

(4)

(5)

medical assessment and referral–minimum of 1-hour physician

contact per patient per week;

nursing assessment and liaison with treating hospital–RN daily

contact to include nursing assessment, dietary supervision, and

medication dispensing;

mental health services–M.A.-level therapist to provide individual, group, and family therapy and support services, and psychiatrist to be available for consultation;

transportation to medical and other services;

special medications and supplies;

181
(6) regular drug treatment services modified as medically or psychiatrically indicated; and

(7) continuation of methadone treatment where medically indicated.

The residential programs have different characteristics (e.g.,

Spanish-speaking, geographic location), and attempts are made to

place the patient in the most appropriate program and to maximize

bed utilization. Programs interview potential residents for acceptability but must notify the Department of Health when, and explain

why, an applicant is not approved for admission. All terminations or

discharges must also be reported.

During the treatment process, these AIDS/ARC patients receive therapeutic community-type counseling intervention, so that their own

potentially harmful drug use is curtailed, as is behavior that might

transmit AIDS to others.

As of May 1987, 43 homeless AIDS/ARC drug abuse patients were

housed through the AIDS/ARC residential program for a total of 3,941

bed-days. The average length of stay was 93 days. The program has

been remarkably cost effective: The cost of maintaining these

patients at $65.75 per day was $267,000 vs. $1,576,000 if they had

remained in acute care. Originally, the AIDS/ARC residential program

was composed of 4 participating programs and 12 beds and quickly

expanded to 5 programs and 19 beds by 1987. As of July 1, 1988, the

AIDS/ARC residential program contracts for 35 residential beds.

There have been few reports of other residents showing anxiety or

leaving the program because of the admission of AIDS/ARC patients;

in fact, therapeutic communities report that other patients are for

the most part sympathetic and supportive and serve as family surrogates to these homeless patients. There have been occasional problems

with programs that are unwilling to modify their concepts and practices to accommodate the social, psychological, and pharmacological

needs of the AIDS patients. Referral sources have also caused problems by referring inappropriate patients, particularly those requiring

skilled nursing care, and by not providing necessary records. These

problems are dealt with individually and have decreased as the program continues.

This program is not a panacea for housing problems of AIDS patients,

as many AIDS/ARC patients who are drug abusers refuse to enter a

structured regimen. The AIDS/ARC Residential Program does,

182
however, provide a cost-effective, appropriate alternative to retaining

AIDS/ARC patients who do not require acute care in hospital beds,

and who are willing to accept structured therapeutic community

treatment. The clinical impression is that longevity is enhanced for

these patients; this issue is now under study.

Medical Day Care

In addition to the Post-Hospital Residential Placement Program, the

New Jersey State Department of Health has developed Medical Day

Care Units for drug abusers with AIDS/ARC who can be discharged

from the hospital and reside with their families or “significant

others.” The AIDS/ARC Medical Day Care Program addresses the

needs of recipients of the New Jersey Medicaid Program who could

benefit from a health services alternative to institutionalization.

AIDS Medical Day Care is a program of medically supervised,

health-related services provided in an ambulatory structured drug

treatment program setting to persons who do not require 24-hour

inpatient institutional care. Medical, nursing, social, transportation,

personal care, dietary, recreational, rehabilitative, drug counseling,

and dental care services are included. The program enables IVDU

AIDS patients to remain in the community, in homes where they

would be unattended during the day. The structured drug treatment

setting is designed to help reduce drug use and provide a costeffective, humane mode of health care. It is believed that the

participants’ own health maintenance will be supervised, and their

transmission behavior reduced.

The first AIDS Medical Day Care Unit opened in April 1988. This

program accommodates up to 20 AIDS patients per day, Monday

through Friday.

CONCLUSION

Contrary to the traditional belief that substance abusers are generally

uncooperative and/or unresponsive to their own well-being, no less

society’s welfare, public health AIDS education efforts in various

States have successfully educated this most problematic AIDS risk

group. Once educated, IVDUs have self-reported risk reduction behavioral changes in both unsafe drug use and sexual activities

(Selwyn 1986; Des Jarlais et al. 1988). It is becoming clear to health

care professionals across the Nation that IVDUs are reachable.

183
It is important to devote special attention to IVDUs not only to curtail further AIDS transmission within this population, but also to prevent the sexual and perinatal spread of AIDS. This effort must start

with increased funding for various drug treatment services. The goal

should be to encourage treatment admissions and to provide affordable, accessible care to all who can be persuaded to apply for it.

The AIDS emergency demands that drug treatment programs extend

their efforts to those addicts who do not enter treatment, with a

public-health-oriented message to reduce transmission behaviors.

Outreach efforts must expand to all groups of drug users, especially

minority groups. Our experience indicates that treatment admissions

are enhanced by such an approach, rather than reduced.

Many of the growing numbers of people with AIDS in New Jersey will

depend upon public support for their medical and psychosocial needs.

The care of each person with AIDS is estimated to cost tens of thousands of dollars over the course of the illness (New Jersey State

Department of Health 1987a). To address the escalating demand for

resources, the Federal Government, in collaboration with each State’s

medical and social service providers and their Departments of Health,

must work together to develop innovative service system networks to

care for people with AIDS. It is essential that these services are

humane and cost effective.

The role of community-based drug treatment centers must expand to

meet this public health emergency, as they are the only health care

system with which large numbers of addicts voluntarily interact.

They are in a position to provide consistent educational messages and

support for behavioral change. Treatment programs can furnish the

addicted population with primary medical care where other providers

are scarce, overburdened, or unable to relate well to this population.

They are able to afford symptomatic clients with case management

and support services geared to their special needs. The nature and

mixture of services will vary according to the infection rate and

other characteristics of the addict population.

REFERENCES

Battjes, R.J. Personal communication, 1988.

Des Jarlais, D.C.; Friedman, S.R.; and Hopkins, W. Risk reduction for

the acquired immunodefeciency syndrome among intravenous drug

abusers. In: Galea, R.P.; Lewis, B.F.; and Baker, L.A., eds. AIDS

and IV Drug Abusers: Current Perspectives. Owings Mills, MD:

Rynd Communications, 1988. pp. 97-107.

184
French, J. New Jersey State Department of Health, Trenton.

Personal communications, January 1988.

Ginzburg, H.M. Acquired immune deficiency syndrome and drug

abuse. In: Galea, R.P.; Lewis, B.F.; and Baker, L.A., eds. AIDS

and IV Drug Abusers: Current Perspectives. Owings Mills, MD:

Rynd Communications, 1968. pp. 61-63.

Ginzburg, H.M.; French, J.; Jackson, J.; Hartsock, P.I.; MacDonald,

M.G.; and Weiss, S.H. Health education and knowledge assessment

of HTLV-III disease among intravenous drug users. HeaIth Educ Q

13(4) Winter, 1988. pp. 377-379.

Jackson, J.F. Written Testimony: Presidential Commission on the

HIV Epidemic. Paper presented at Washington, D.C., December 18,

1987.

Jackson, J.F.; Rotkiewicz, L.G.; Quinones, M.A.; and Passannante, M.R.

A coupon program: Drug treatment and AIDS education. Int J

Addict 24, in press.

New Jersey State Department of Health. Statistical Perspectives on

Drug Abuse Treatment in New Jersey, 1984. Trenton, June 1985.

p. 1.

New Jersey State Department of Health. Statistical Perspectives on

Drug Abuse Treatment in New Jersey, 1985. Trenton, November

1986. pp. 4, 10, 12.

New Jersey State Department of Health. AIDS in New Jersey–A

Report from the Department of Health. Trenton, April 1987a. p. 6.

New Jersey State Department of Health. AIDS Cases–State of New

Jersey as of July 1, 1987-December 1, 1987. Trenton, 1987b. 4 pp.

New Jersey State Department of Health. AIDS Cases–State of New

Jersey as of January 31, 1988. Trenton, 1988. 4 pp.

Schadl, R. New Jersey State Department of Health, Trenton.

Personal communication, February 1988.

Selwyn, P.A. AIDS: What Is Now Known. New York: HP Publishing

Company, 1986. pp. 18, 19, 68.

Star-Ledger. AIDS toll forecast doubled. November 5, 1987. p. 1.

Weiss, S.; Ginzburg, H.; and Altman, R. Risk factors for

HTLV-III/LAV infection and the development of AIDS among drug

abusers in New Jersey. Paper presented at the Second

International Conference on AIDS, Paris, June 1986.

Whitlow, J. ‘88 viewed as turning point for health institutions.

Star-Ledger, January 24, 1988. p. 23.

185
AUTHORS

Joyce F. Jackson, M.A.

Director

Leslie G. Rotkiewicz, M.P.A., M.A.

Chief, Administration and Evaluation

Robert C. Baxter, M.P.A., M.Ed.

Clinical Operations Specialist

AIDS Community Support Unit

New Jersey State Department of Health

20 Evergreen Place, 2nd Floor

East Orange, NJ 07018

(201) 414-4404

186
Lost Opportunity to Combat AIDS:

Drug Abusers in the

Criminal Justice System

Eric D. Wish, Joyce O’Neil and Virginia Baldau

INTRODUCTION

In the absence of a cure for acquired immunodeficiency syndrome

(AIDS), societal efforts are aimed toward limiting the spread of the

disease. To accomplish this, information regarding the risk behaviors

for contracting and transmitting the disease is being distributed to

the general population. In addition, outreach programs are being

established in many cities to identify subgroups of the community for

AIDS education and counseling. Most of these programs have been

directed toward drug abusers and homosexuals, persons whose

behavior may place them at high risk for AIDS.

Persons who inject illicit drugs constitute the predominant source of

heterosexual and perinatal transmission of the human immunodeficiency virus (HIV) that leads to AIDS (Des Jarlais and Hunt 1988).

Drug injectors are at high risk of AIDS because their needle-sharing

behavior makes them vulnerable to HIV infection, which, in turn,

they can spread: by exchanging body fluids; by sharing injection

equipment; and, in the case of female drug users, by transmission

from mother to infant.

Because persons do not generally publicize their injection of illicit

drugs, AIDS outreach programs typically locate drug injectors by

approaching persons who have entered publicly funded treatment

programs, or by establishing bases in minority neighborhoods known

to be frequented by drug abusers. This paper suggests that an

important additional avenue exists for reaching drug injectors–by

approaching the thousands of drug abusers among arrestees and

persons supervised by the criminal justice system.

187
Data from the Drug Use Forecasting (DUF) System of the National

Institute of Justice (NIJ) (DUF Statistics 1988) has documented the

high prevalence of recent illicit drug use by arrestees in the largest

U.S. cities. For example, the prevalence of recent cocaine use,

measured by urinalysis, is about 10 times that found in interview

surveys of student and household populations. In addition, the

majority of drug injectors surveyed through DUF indicated that they

had injected cocaine. Since other injectable drugs like methamphetamines and opiates were also detected in various regions of

the country, one might expect that the offender population would

contain substantial numbers of drug injectors at risk for AIDS.

To assess the potential risk of HIV infection in offenders, this report

analyzes new information from DUF interviews about drug injection

and needle-sharing behaviors in male and female arrestees. Because

female arrestees may be at special risk of AIDS–females tend to

have more serious drug abuse problems than females and are likely to

engage in prostitution with numerous partners (Goldstein 1979; Wish

et al. 1985; Des Jarlais et al. 1987), this chapter focuses special

attention on female arrestees.

THE DUF PROGRAM

In 1987, the NIJ established the DUF program, a national data system

for tracking drug use trends in arrestees. Every 3 months, a new

sample of approximately 250 male arrestees in each participating city

is asked to agree to a voluntary and anonymous interview about their

drug abuse and treatment history and to provide a voluntary urine

specimen for analysis. Arrestees are usually interviewed soon after

arrest in the city’s central booking facility. Urine specimens are

tested by Enzyme Multiplied Immune Test (EMlT) technology for 10

drugs: opiates, cocaine, PCP, marijuana, amphetamines (all positives

are confirmed by gas chroma- tography), methadone, Darvon,

barbiturates, methaqualone, and Valium. (The latter five drugs have

rarely been found in the DUF samples.)

DUF interviewers intentionally oversample males charged with serious

nondrug crimes because it is already well established that persons

charged with the sale or possession of drugs are likely to be users

(Wish and Johnson 1986). Because the resulting DUF samples have a

smaller proportion of persons charged with drug offenses than would

be found in a random sample of arrestees, DUF estimates of drug use

should be viewed as minimum estimates of recent drug use in all

arrestees.

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DUF interviewers typically station themselves in each city’s booking

facility for 14 consecutive evenings during the busiest shifts. Over

90 percent of arrestees who are approached agree to be interviewed,

and about 85 percent of the interviewees provide a voluntary urine

specimen. DUF is currently operating in 13 cities: New York;

Washington, DC; Portland, OR; San Diego, CA; Indianapolis, IN;

Houston, TX; Fort Lauderdale, FL; Detroit, Ml; New Orleans, LA;

Phoenix, AZ; Chicago, IL; Los Angeles, CA; and Dallas, TX.

In late 1987, five DUF sites began to collect information from female

arrestees. Because the number of females arrested is typically far

below that of males, DUF interviewers approached all available female

arrestees, regardless of charge, during the 2-week data collection

period. The goal was to interview and obtain urine specimens from

100 females in each city, every 3 months.

METHOD

Sample

The findings in this report come from the five sites that have obtained data from male and female arrestees: Los Angeles, San Diego,

Phoenix, New Orleans, and New York City (Manhattan). The data

were collected between September and December 1987. Response

rates for each site appear in table 1.

Interview response rates for males ranged from 92 percent to 100 percent and from 89 percent to 100 percent for females. Between

81 percent and 95 percent of male interviewees and 70 percent to

96 percent of female interviewees provided a urine specimen for

analysis. The resulting sample of arrestees from the five sites who

were interviewed and provided a urine specimen contained 516 females

and 991 males. (For this presentation, most of the following analyses

aggregate information across the five sites. Some of the more significant findings are presented separately for each site to examine

whether the findings apply to all cities.)

Demographic and Case Characteristics of Male and

Female Arrestees

Table 2 presents descriptive information obtained from the arrest

report and DUF interview for both males and females. Age distributions were quite similar for males and females with the modal age

range being between 21 and 25 years old. Ethnicity was also similar

189
TABLE 1. Percentage of male and female arrestees who agreed to be

interviewed and who gave a urine specimen

in the two groups. The largest group of male and female arrestees

were black. More than one-third (35 percent) of the female arrestees

were white and more than a quarter of the male arrestees were

Hispanic.

While larceny and drug offenses were the most common charges at

arrest for both males and females, there were some differences

between the two groups. Males were more likely to be charged with

burglary (13 percent vs. 6 percent) or robbery (7 percent vs. 1 percent), while females were more likely to be charged with sex

offenses, primarily prostitution (22 percent vs. 3 percent). Male

arrestees’ greater involvement in more serious crimes (seriousness as

defined by legal statute) is evident in the finding that more males

were charged with a felony offense (76 percent vs. 42 percent). This

difference is also attributable to the fact, noted above, that females

charged with felony offenses were not oversampled as males were.

These differences in crime severity should not bias findings with

regard to drug abuse. Moreover, prior studies have documented the

diversity of crimes committed by drug abusers and indicate that the

likelihood of testing positive at arrest is generally unrelated to the

seriousness of the arrest charge (Wish et al. 1981; Wish and Johnson

1986).

190
TABLE 2. Demographic and case characteristics of male and

female arrestees

Percent of Percent of

Males Females

(n=991) (n=516)

Age at Arrest

15-20

21-25

26-30

31-35

36+

Ethnicity

Black

White

Hispanic

Other

Top Charge at Arrest

Larceny

Drug sale/possession

Burglary

Assault

Stolen property

Robbery

Weapons

Sex offense

Homicide/manslaughter

Other

Current Arrest a Felony 76 42

17

29

21

14

19

41 45

29 35

26 16

2 2

15 16

13 17

13 6

10 7

10 4

7 1

4

*

3 22

2

*

23 23

12

30

27

16

15

* = Less than 1 percent.

Limitations

Several limitations should be kept in mind when reviewing these

findings. First, data about drug injection and needle sharing are

based upon voluntary self-reports. Although every effort is made to

191
convince arrestees of their anonymity and that the information cannot be used against them, the jail environment is inherently threatening, and there is considerable underreporting of recent illicit

behaviors. lt should be noted that many more persons test positive

for drugs than admit to recent drug use in the interview. On the

other hand, there is considerable internal consistency in the interview

information from arrestees, and, when persons do report illicit

behaviors, the information appears valid (Wish, in press). Because

some arrestees do conceal their illegal behaviors, findings about

injection and needle sharing should be viewed as minimal estimates of

these behaviors in the arrestee population.

A second limitation involves the generalizability of these findings. In

the pilot phase of DUF, we attempted to determine whether samples

of 200 arrestees yielded estimates of drug use similar to those

obtained by testing several thousand arrestees from the same city.

We found that, in New York and in the District of Columbia, the

estimates from the smaller samples were quite close (within 10 percentage points) to those from larger samples. We are less sure that

our findings from the smaller samples of female arrestees (sometimes

as low as 50 per city) are equally representative of the wider population of female arrestees in that jurisdiction. New data from female

arrestees not included in this paper, however, have replicated the

principal findings in this report. Finally, it should be noted that

these findings apply to persons who have been arrested; they should

not be generalized to the nonoffender population.

FlNDlNGS AND DISCUSSION

Urinalysis Results

Table 3 compares urinalysis results for the male and female arrestees

in each of the five cities. In four of the cities (all except New

Orleans), female arrestees were as likely to test positive for any of

the 10 drugs as male arrestees. However, there were differences in

the specific drugs detected in male and female arrestees. Females

tended to be more likely to test positive for cocaine or heroin

(opiates). The differences in heroin positives were especially large

for arrestees in San Diego and in Phoenix. Marijuana was the one

drug that appeared to be less prevalent in females. In Los Angeles,

San Diego, and New Orleans only about half as many females as

males tested positive for marijuana. Subsequent results from male

and female arrestees tested in January through March 1968 replicated

the above findings regarding the higher prevalence of cocaine and

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TABLE 3. Percentage of male and female arrestees who tested

positive for drug use

DUF City

Percent of Percent of

Males Females

Positive for Los Angeles 89 80

Any Drug San Diego 75 87

Phoenix 53 89

New Orleans 72 48

New York 79 83

Positive for Los Angeles 48 85

Cocaine San Diego 44 58

Phoenix 21 38

New Orleans 45 30

New York 63 70

Positive for Los Angeles 15 18

Opiates San Diego 24 42

Phoenix 5 14

New Orleans 8 4

New York 28 35

Positive for Los Angeles 28 8

Marijuana San Diego 44 24

Phoenix 42 40

New Orleans 48 25

New York 28 25

heroin and lower prevalence of marijuana in female arrestees (DUF

Statistics 1988).

These findings indicate that female arrestees are more involved with

hard drugs such as heroin and cocaine than are male arrestees. They

are consistent with results from a study of jailed arrestees in the

1970s (Wish et al. 1985) and a 1984 study of males and females arrested in Manhattan (Wish et al. 1986a). Because heroin and cocaine

are often injected, these findings suggest that injection might be a

more common behavior in female arrestees.

193
FIGURE 1. Percent of male and female arrestees who

ever injected (n= 1,507)

Drug Injection in Female Arrestees

Figure 1 shows the percentage of male and female arrestees who

reported ever having injected drugs. In all cities except New

Orleans, female arrestees were more likely to admit to injecting

drugs. The largest differences were found in Los Angeles (36 percent

vs. 21 percent) and New York (38 percent vs. 19 percent).

When factors that might be associated with drug injection in the

females were examined (table 4), as expected, age was strongly associated with injection. While about one-fourth of the female arrestees

under age 21 indicated having ever injected drugs, almost one-half

(47 percent) of the women above age 30 had injected. Persons who

had dropped out of school by the 10th grade also had a high rate of

injection (50 percent). lt should be noted that these dropouts are

the very people whom school-based surveys and in-school AIDS prevention efforts would miss. However, there was little variation in

injection by charge at arrest, except that persons charged with assault were least likely (18 percent) to have injected drugs. This is

194
TABLE 4. Correlates of injection of female arrestees

Correlate (n) Percent Ever Injected

Age at Arrest

15-20

21-25

28-30

31+

Years of Education

9 or less

10-11

12

13+

Ethnicity

White

Hispanic

Black

Top Charge at Arrest

Stolen property

Sex offenses

Burglary

Larceny

Drug sale/poss.

Assault

Other

(60) 23

(154) 31

(139) 35

(154) 47

(82) 50

(131) 37

(172) 28

(111) 37

(178) 55

(90) 38

(225) 22

(22) 50

(115) 40

(31) 39

(95) 38

(87) 32

(34) 18

(132) 38

consistent with previous research showing that assaulters are among

those least likely to test positive for hard drugs at arrest (Wish

et al. 1986a). Persons charged with sex offenses were not more

likely to have injected drugs than persons charged with other types

of offenses. However, some females charged with nonsex offenses

may have engaged in prostitution at some time in their lives.

Ethnic Differences in Injection Practices

While it was expected that older females and school dropouts would

be at a higher risk of drug injection, the extent of ethnic differences

195
in drug injection was surprising. White female arrestees were twice

as likely as black females to have injected drugs (55 percent vs.

22 percent, p<.001). Hispanic females were midway between these two

groups (38 percent). However, their small number, n=90, prohibits

further analysis of Hispanic females. lf white females were more

likely to be older or to have dropped out of school, it might explain

why they had higher rates of injection. These factors, however, did

not account for the ethnic differences in injection.

Figure 2 shows that, in each of the five cities, white females were

more likely to have injected drugs. White female arrestees in San

Diego and Phoenix were twice as likely to report injection, and in

Los Angeles there was a threefold difference (72 percent vs.

20 percent).

FIGURE 2. Percent of female arrestees who ever injected,

by ethnicity (n=407)

To investigate these ethnic differences in drug injection, we examined

other information from the DUF interview and test results. As suspected, white females were twice as likely as black females (48 percent vs. 22 percent, p<.001) to report having been dependent on

heroin (table 5). No differences were found with regard to dependence on cocaine, however. In spite of their greater dependence on

heroin, white females were not more likely to report having received

198
TABLE 5. Heroin and cocaine use and dependence in female

arrestees, by ethnicity

Drug Use

Percent Percent

Black White

(n=225) (n=178)

Self Reports

Ever dependent on heroin 22 48

Ever dependent on cocaine 22 23

Ever received drug treatment 23 30

Urine Test at Arrest

Positive for heroin

Positive for cocaine

10 27

60 47

drug abuse treatment (30 percent vs. 23 percent, not a statistically

significant difference).

These differences could have occurred if white arrestees had been

more willing than black arrestees to report illicit behaviors to the

interviewer. Attempts were made to minimize such a bias by ensuring

that the ethnic composition of DUF interviewers was similar to that

of the arrestees in each city. Furthermore, the urine test results

supported the interview findings. White female arrestees were almost

three times as likely to test positive for heroin than were black

females (27 percent vs. 10 percent, p<.001). Black females were more

likely to test positive for cocaine (60 percent vs. 47 percent, p<.05).

However, white female cocaine users were three times more likely to

report a preference for injecting cocaine than were black female

cocaine users (40 percent vs. 13 percent, respectively, p<.001). Black

females who used cocaine said they typically preferred to smoke,

freebase, or snort the drug.

Figure 3 shows the urine test results for heroin for black and white

arrestees. In every city, white female arrestees were more likely to

test positive for heroin. The largest differences were found in Los

Angeles, Phoenix, and New Orleans, where white females were more

than three times as likely to test positive for heroin than were black

females.

197
FIGURE 3. Percent of female arrestees who tested positive

for opiates, by ethnicity

These findings suggest that there is both a greater involvement of

white females in heroin and a reluctance on the part of black females

to inject drugs. Even when black females reported using cocaine,

they tended to take the drug through routes other than injection. A

similar finding of more intravenous heroin use by white females than

by black females has also been reported in a study of females admitted to methadone maintenance programs and therapeutic communities

in five cities (Moise et al. 1982).

Deviance and Drug Abuse Practices

Some authors have suggested a concept of relative deviance that may

explain why white female arrestees may be more serious drug abusers

(Dembo and Shern 1982). According to this theory, persons who

are more deviant from the norms of their social and cultural setting

will exhibit more serious behavior problems and psychopathology

(Kaufman 1978). White females are typically a small proportion of all

arrested females and could be expected to be more deviant than black

females. While this hypothesis cannot be tested directly, the level of

deviance was measured.

Age of initiation of drug use is generally considered to be a strong

correlate of deviance. The younger a person is when she begins to

198
use drugs, the more likely she is to proceed to dysfunctional drug

abuse and other behavior problems. If white female arrestees were

more heavily involved with drugs, we would expect them to have

begun to use and inject drugs earlier. Table 8 shows this to be the

case.

White females were likely to begin the use of alcohol, heroin, and

marijuana about 2 years earlier than black females who were arrested.

They began to use cocaine 3 years earlier than black arrestees. The

median age of first drug injection was about 4 years earlier in white

females than in black females. In addition, the ages of onset for

Hispanic females, not presented here, were virtually identical to those

of the black females.

TABLE 6. Median age of onset of drug use and injection in black

and white female arrestees (arrestees from five

DUF sites)

White Females Black Females

First Tried Marijuana

First Tried Alcohol

First Tried Heroin

First Injected

First Tried Cocaine

13+ 15+

14+ 18+

17+ 19

17+ 21+

18+ 21+

These findings, together with the urinalysis results, offer strong evidence that white female arrestees are among the most serious drug

abusers in the arrestee population. Their drug injection puts them at

high risk for contracting and transmitting HIV.

Needle-Sharing Behaviors and AIDS

If a person reported injecting drugs, additional questions were asked

about needle sharing. Few differences were found between male and

female injectors with regard to sharing needles, although there were

some regional differences (table 7). Almost one-half of male and

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TABLE 7. Needle-sharing behavior in male and female drug injectors

Los Angeles San Diego Phoenix New Orleans New York

M F M F M F M F M F

Injectors

Who

Share 47% 50% 27% 26% 37% 32% 23% 18% 5% 24%

Sharers Who

Changed

Because of

AIDS 78% 68% 47% 59% 63% 76% 90% 78% 95% 50%

female injectors in Los Angeles said that they currently shared their

needles with one or more persons. In the rest of the country, the

percentage was closer to 20 to 25 percent. New York male injectors

were least likely to admit sharing needles (5 percent), although interviewers for this study said that male arrestees were uncomfortable

about this topic and probably underreported needle sharing.

The majority of both male and female arrestees who shared needles

after learning about AIDS stated they had changed their behaviors in

some way because of the AIDS epidemic. Almost all male sharers

interviewed in New Orleans and New York indicated that they had

changed their needle-sharing behaviors This did not necessarily

imply that their altered behaviors were effective in reducing their

vulnerability to AIDS.

The interviewers recorded verbatim each respondent’s explanation for

why and how they had or had not changed their behaviors as a result

of AIDS. Several of these unedited comments appear in table 8.

While male and female arrestees claimed they were taking steps to

avoid AIDS, their answers underscored a number of misconceptions

regarding the disease. For example, a comment frequently made was

that individuals shared needles only with persons who did not look

sick. This is an ineffective strategy for avoiding infection because

HIV has a long incubation period and infected persons may have no

symptoms for several years.

200
TABLE 8. How has AIDS changed your needle-sharing behavior

(Unedited responses from arrestees in five cities)

Males

“Don’t share needles with anyone who partakes in homosexual

activities.” (Los Angeles - Id#3228)

“You can tell if a person is clean and keeps themselves together.

Don’t share with unclean people.” (Los Angeles - Id#3208)

If sharing, cleans with water - usually uses needle first.

(San Diego - ld#850)

Cleans with more care - bleach; shares less - change works more

often. (San Diego - ld#804)

“AIDS has caused me to slow down on needle sharing, but not stop

completely.” (Phoenix - Id#209)

Sharing is “dependent upon specific circumstances. If necessary, will

share.” (Phoenix - ld#102)

“I shared my works because we only had one, and I just take a

chance and hope not to get AIDS. As many as five people share

the same needle. There is no limit to the amount of people that

can use the same needle.” (New Orleans - Id#577)

“I never worry about getting AIDS because of using the same needles

with my friends.” (New Orleans - ld#588)

“Only share with people I know or in case of emergency.”

(New York - Id#3034)

Shares “a little, still shares with friends.” (New York - ld#3043)

Females

“I don’t think I can get it. I don’t think the people I do it with

have it.” (Los Angeles - ld#4049)

‘Don't share as much. Share with just one person.” Cleans with

alcohol. (Los Angeles - ld#4003)

Has found it difficult to get needles. “Use whatever needles I can

find.” Aware of AIDS and still shares. (San Diego - Id#2041)

“Only inject by myself. Before shared with friends. ”

(San Diego - ld#2085)

“Needles are easier to buy so there is no needle sharing at present.”

(Phoenix - ld#262)

“Quit sharing needles due to AIDS scare." (Phoenix - ld#294)

“It doesn’t matter if I share them or not as long as I get my drugs.”

(New Orleans - ld#594)

201
TABLE 8. (Continued)

“Because I only had a few needles so we shared. I didn’t want to sit

there and see everyone else doing it.” (New Orleans - ld#703)

“I only share with one person - my boyfriend, and he is clean.”

(New York - Id#3161)

"I share because there are no works at the gallery.”

(New York - Id#3290)

Responses from male and female arrestees frequently demonstrated a

fear of AIDS and a desire to avoid infection. Arrestees and other

criminal justice system detainees therefore are a receptive audience

for education, prevention, and treatment programs. An invaluable

opportunity exists to correct their misconceptions about AIDS.

SUMMARY AND POLICY IMPLICATIONS

Summary

There is a critical need to identify persons who are likely to inject

drugs, so that they can be taught to limit the spread of AIDS. Results from the DUF program indicate that more than 50 percent of

arrestees in large cities in the United States test positive for illicit

drugs. lf many of these persons also inject drugs, a special opportunity to reach persons at high risk for AIDS may be available.

New information from DUF interviews about drug injection and needle

sharing in male and female arrestees in five cities was analyzed to

examine the characteristics of female drug injectors. The findings

indicated that, while illicit drug use is prevalent in all arrestees,

females are more likely to test positive for injectable drugs like

heroin or cocaine and are more likely to report having injected

drugs. By the time these women passed age 30, about one-half had

injected a drug. About one-half of the females who dropped out of

school had also injected drugs.

Dramatic ethnic differences were found in injection behavior of

females. White females were most likely to have injected drugs.

This difference was partially explained by the fact that white females

were more seriously involved with heroin. Differences in drugs used,

however, could not completely account for the ethnic differences in

injection. Even though black and white female arrestees appeared to

202
be similarly involved with cocaine, white women were far more likely

to inject cocaine.

Other researchers have found similar ethnic differences in injection

practices of female drug abusers. One hypothesis is that white

females who are involved with hard drugs or who are arrested in the

United States tend to be more deviant. As expected, white females

did have an earlier age of onset of drug use and began to inject

drugs about 4 years earlier than black females. This apparent deviance, drug abuse, and involvement in prostitution puts female arrestees, especially white female arrestees, at unusually high risk for

AIDS.

Needle sharing was reported by one-quarter to one-half of both male

and female arrestees interviewed. The majority of male and female

sharers did indicate, however, that they had changed their needlesharing behaviors as a result of the AIDS epidemic. Unfortunately,

misconceptions about AIDS were common. Thus, some of the precautions that they were taking, such as sharing only with someone who

did not look sick, were ineffective and gave a false sense of security.

The sensitivity and responsiveness of the arrestees to the AIDS

problem, along with their apparent ignorance of the best methods to

avoid the disease, suggest that it might be possible to reduce the

spread of AIDS by initiating education, prevention, and treatment

programs for arrestees.

Policy Implications

Although these findings are from arrestees, there is ample evidence

that incarcerated persons and those released on probation or parole

are a subset of the arrestee population with serious drug problems

(Wish and Johnson 1986; Wish et al. 1986b). Thus, all persons

detained or supervised by the criminal justice system should be considered at much greater risk of illicit drug use and AIDS than is the

general population.

Although we did not test any of our samples of arrestees for the

presence of antibodies to HIV, estimates of seropositivity rates in

drug injectors are available from other sources. The rates vary considerably across the country from less than 5 percent of drug injectors in New Orleans and Los Angeles to over 50 percent for injectors

in New York City and northern New Jersey (Des Jarlais and Hunt

1988). Using the estimate of 50 percent seropositive drug injectors

in New York City, and DUF statistics showing that about 25 percent

203
(19 percent of males and 36 percent of females) of all arrestees in

New York have ever injected drugs, we project that at least 12,500

of the 100,000 persons arrested in Manhattan each year (25 percent x

100,000 x 50 percent) would test positive for HIV. This may be an

underestimate, because the DUF program undersampled persons

charged with drug offenses, and an unknown percentage of arrestees

refused to admit to injecting drugs.

Because of the high seropositivity rates in New York City drug

injectors, the estimates above should not be applied directly to

arrestees in other cities. lt is not known whether drug abusers in

other cities will eventually develop rates of seropositivity similar to

drug injectors in New York. Mass screening programs of the general

population of prison inmates across the country have generally

reported rates of seropositivity below 3 percent, but one sample of

“high-risk” inmates, defined as homosexuals or drug injectors, in

Houston found that 33 percent of those tested were seropositive

(Hammett 1988). Consistent with this study, epidemiological surveys

of inmates in Maryland correctional facilities between 1985 and 1987

found that females had twice the seropositivity rate as males (15 percent vs. 7 percent). These seropositivity rates in prison inmates are

somewhat lower than expected from the rates of drug injection found

in this study. As suggested below, however, there are reasons to

believe that inmate populations may contain fewer active street criminal drug abusers who show up repeatedly in the arrestee population.

By definition, criminal justice system detainees are readily accessible

to societal efforts to modify the behaviors that increase their risk

for AIDS. Unfortunately, the enormity of the opportunity for treating these persons contrasts greatly with the paucity of efforts

devoted to this task.

To be sure, all State and Federal prisons and most large city jails

provide AIDS information and training (Hammett 1988). These institutions have been quick to respond to the AIDS epidemic because

they have to house persons for long periods of time and are therefore more vulnerable to problems stemming from infected residents.

Thus, staff or inmate training programs are available in jails or

prisons where persons are detained for some time. In contrast, the

much larger population of arrestees and probationers, who are typically released back in to the community, are less likely to receive

AIDS information. In establishing the DUF program in the largest

booking facilities in the country, interview staff have not seen a

single AIDS education or counseling program for arrestees. Arrestees

204
in the major cities of this country tend to be housed for hours

(before arraignment) in large pens with no attempts to intervene for

drug abuse.

A recent survey of probation and parole departments in all 50

States found that less than half (about 40 percent) have education,

prevention, or information programs for persons being released to the

community (Hunt 1988). Most of the departments with a program

simply hand out public health or Red Cross brochures about AIDS

that are not expressly tailored to the education level and needs of

offenders returning to the community. The majority of these

departments provide this limited information only to persons believed

to have a high risk for AIDS (persons charged with sex offenses,

known drug injectors, and homosexuals). This strategy could miss

many drug abusers (and their sexual partners) because criminal justice

records and arrest or conviction charges are poor indicators of drug

abuse.

The interviewers also found that, although probation and parole

departments included in the study expressed a “desperate” interest in

providing expanded AIDS programs for releasees, they were hampered

by inadequate funds and a lack of available trained personnel. Their

report recommended that mandatory AIDS training be provided for all

staff and for all probationers and parolees (Hunt 1988).

By failing to focus sufficient resources on addressing the drug abuse

and AIDS problem in arrestees and probationers, the country is losing

an important opportunity to reach the largest pool of serious drug

abusers entering the criminal justice system. Because of the extensive overcrowded conditions in the Nation’s jails, there is a deliberate

attempt to detain as few arrestees as possible. Persons charged with

many of the more common petty offenses committed by drug abusers

(larcenies, lesser drug offenses, and prostitution) are routinely

released back to the community soon after arrest (pending trial) or,

if convicted, receive a fine, time served (the time already detained

before disposition satisfies the sentence), or a term of probation

(Johnson et al. 1985). Some of these street criminals may be

detained overnight in jails but rarely are sentenced to prison, where

most of the AIDS programs exist. It is this large group of arrestees

and probationers, who return to their drug-abusing friends and sexual

partners, for whom AIDS education and drug abuse treatment is most

crucial.

205
Unfortunately, with one exception, systematic identification of drug

abusing arrestees and referral to treatment is rare. lt should be

noted that DUF is an anonymous program. Only the District of

Columbia has a fully operational program to test all arrestees for

drug use by urinalysis. Six participating jurisdictions are currently

being funded by the Bureau of Justice Assistance to replicate the

District’s pretrial testing program and are at varying stages of development. Persons who test positive are referred by the judge to urine

monitoring and/or treatment programs as a condition of pretrial

release (Carver 1986). Although probation (and parole) officers have

the authority to order drug tests for persons they supervise, few

departments have the resources to screen all persons for drug use.

Without drug testing, most drug abusers in the criminal justice system

avoid detection (Wish 1988).

Nonanonymous drug testing has the advantage of enabling the identification of persons to be referred to treatment programs or AIDS

counseling, but is costly and takes time to develop. Still, there are a

number of other relatively inexpensive strategies that can be rapidly

adopted. Every person arrested or under the supervision of the

criminal justice system could be presented with educational information about prevention of AIDS. Posters informing persons about the

risk behaviors for AIDS and listing drug abuse treatment referral and

AIDS information sources could be displayed in every police station,

booking facility, probation and parole office, and detention center

across the country. For example, credible AIDS videotapes could be

shown once an hour to the “captive audiences” in urban booking

facilities. lt seems that if only a small subset of the detainees

listened to the information, it would still be beneficial. Clearly, this

information will have to be developed for diverse reading levels and

language problems. lt has also been suggested that some of these

programs be directed toward the spouses and sexual partners of probationers and parolees (Hunt 1988).

In view of their exceptional risk for drug injection and perinatal

transmission of AIDS, female arrestees could receive individual

counseling about how to avoid the disease. If trained justice

personnel are not available, local health departments could be requested to station trained personnel in central booking facilities.

The relatively small number of females who are arrested, even in the

largest cities, makes individual counseling a feasible approach.

Our findings also suggest that outreach and prevention programs both

inside and outside the criminal justice system should not be limited

206
to members of minority groups. These programs should also be provided for deviant white females who have been arrested or who are

likely to be committing crimes or abusing drugs.

Although further research is needed to determine which of the above

strategies will be most effective, the magnitude of the drug abuse

and AIDS problems in persons entering the criminal justice system

presents a compelling case for immediate action.

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Des Jarlais, D., and Hunt, D. AIDS and intravenous drug use.

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DUF Statistics, January 1988. Washington, D.C.: National Institute of

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3rd ed. Washington, D.C.: National Institute of Justice, 1988.

p. 28.

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Washington, D.C.: National Institute of Justice, 1988. p. 107.

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Spunt, B.; and Miller, T. Taking Care of Business: The Economics

of Crime by Heroin Abusers. Lexington, MA: Lexington Books,

1985. 278 pp.

Kaufman, E. The relationship of social class and ethnicity to drug

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207
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black and white women entering drug abuse treatment programs.

Int J Addict 17:3549, 1982.

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J Policy Anal Mgmt 7:551-554, 1988.

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and Tims, F. Compulsory Treatment of Drug Abuse: Research and

Clinical Practice. National Institute on Drug Abuse Research

Monograph 88. DHHS Pub. No. (ADM) 88-1578. Washington, D.C.:

Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 139-159.

Wish, E.D.; Brady, E.; Cuadrado, M.; and Alvarado, L. Female

arrestees: The most serious drug abusers? Presented at the

Annual Meeting of the American Society of Criminology, San Diego,

CA, November 1985.

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Findings from Manhattan. Presented at the National Institute of

Justice-sponsored conference, “Drugs and Crime: Detecting Use and

Reducing Risk.” Washington D.C., June 5, 1986a.

Wish, E.D.; Cuadrado, M.; and Martorana, J. Estimates of drug use in

intensive supervision probationers: Results from a pilot study.

Federal Probation. Vol. 4. December, 1986b.

Wish, E.D., and Johnson, B.D. The impact of substance abuse on

criminal careers. In: Blumstein, A.; Cohen, J.; Roth, J.; and

Visher, C.A., eds. Criminal Careers and Career Criminals. Vol. II.

Washington, D.C.: National Academy Press, 1986. pp. 52-88.

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1981.

ACKNOWLEDGMENT

This work was supported by Visiting Fellow grant 87-IJ-CX-0008 from

the National Institute of Justice, U.S. Department of Justice.

208
AUTHORS

Eric D. Wish, Ph.D.

Joyce O’Neil, M.A.

Virginia Baldau, B.A.

Department of Justice

National Institute of Justice

633 Indiana Avenue, N.W.

Washington, DC 20530

209
The Homeless Intravenous Drug

Abuser and the AIDS Epidemic

Herman Joseph and Hilda Roman-Nay

INTRODUCTION

The topics addressed in this chapter deal with interrelationships

among three of the most pressing contemporary social and public

health issues confronting American society: homelessness, intravenous

(IV) drug abuse, and the acquired immunodeficiency syndrome (AIDS)

epidemic. Homelessness and IV drug abuse affect each other, and

each must be addressed if the AIDS epidemic is to be curtailed and

contained. The uncertainties inherent in a state of homelessness

prevent most homeless IV drug users (IVDUs) from adopting adequate

and sustained risk reduction behavior to avoid transmitting or

contracting AIDS. Furthermore, the state of homelessness makes

delivery of effective medical and social services a tenuous

undertaking at best. This paper will summarize the extent of the

problem, describe a number of surveys and exploratory studies of the

population, and present examples of programs that affect homeless

IVDUs and the AIDS epidemic.

EXTENT OF THE PROBLEM

Extent of the AIDS Epidemic in New York City

Of the 53,069 AIDS cases in the United States reported to the

Centers for Disease Control (CDC) as of February 1988, 13,401

(25 percent) were reported from New York City. Table 1 presents

the number of adult AIDS cases in New York City by risk factor by

race by sex as of February 24, 1988. The data were compiled by the

AIDS surveillance unit of the New York City Department of Health

(1988a).

210
TABLE 1. AIDS risk groups by race by sex

Includes 69 Asians, 8 Native Americans, and persons for whom race/ethnicity is

not known.

Includes persons who died before interview, who refused investigation or whose

doctor refused, and persons still under investigation for risk.

SOURCE: New York City Department of Health (1988a).

211
TABLE 1. (Continued)

Includes 69 Asians, 8 Native Americans, and persons for whom race/ethnicity is

not known.

Includes persons who died before interview, who refused investigation or whose

doctor refused, and persons still under investigation for risk.

SOURCE: New York Cii Department of Health (1988a).

212
These statistics indicate that patterns of risk behavior vary according

to race or gender. For example, homosexual activity is the primary

route of transmission of the AIDS virus for white males. However,

although IV drug abuse is the primary route of transmission for black

and Hispanic males, homosexual activity is an almost equivalent route

of transmission. For black, white, and Hispanic females, IV drug use

is the primary route of transmission and sexual activity with a male

at risk (IVDU or bisexual male) at this time is a secondary transmission route. This pattern of risk may change as the epidemic continues, since more women may become infected with the AIDS virus

through sexual activity with men at risk. Among males, whites

account for 47 percent of the cases, followed by blacks (29 percent)

and Hispanics (24 percent); among females, blacks account for 51

percent of the cases, followed by Hispanics (32 percent) and whites

(16 percent). For adult cases, the ratio of men to women diagnosed

with AIDS is about 7.8 cases to 1. However, the ratio of male

IVDUs, including those who also engaged in homosexual activity, to

female IVDUs diagnosed with AIDS is about 4.6 cases to 1. Also,

IVDUs account for about 37 percent of the adult AIDS cases.

In April 1988, the New York City Department of Health reported that

for the first 3 months of 1988, IVDUs accounted for 386 new AIDS

cases, and homosexual and bisexual men accounted for 385 new cases.

This was the first quarterly period where the number of newly

reported AIDS cases among IVDUs equaled or surpassed the number

reported among homosexual and bisexual men (S. Joseph 1988).

Of the 273 pediatric cases reported to the New York City Department

of Health as of February 1988, approximately 73 percent were known

to have parents, one or both of whom were IVDUS, and 4 percent

(10) had mothers who were former sexual partners of IVDUs. An

analysis of the ethnicity of 257 mothers of the pediatric cases showed

that 60 percent were black, 32 percent were Hispanic, and 8 percent

were white. Of the 9,047 babies born in New York City during a

4-week period in November and December of 1987, 148 (1.64 percent)

tested positive for the presence of human immunodeficiency virus

(HIV) antibodies, indicating that their mothers were infected. This is

an infection rate of 1 out of every 61 women who gave birth during

this period in New York City. Also, about 30 percent to 50 percent

of these babies were probably infected (New York State Department

of Health 1988). The remaining HIV-positive babies had possibly

acquired antibodies from their mothers and were not themselves

infected.

213
On any given day there are 10 children, hospitalized with HIV

infection, who are ready for discharge and subsequent placement.

The Foster Care Division of the New York City Human Resources

Administration has recruited foster parents for children diagnosed

with HIV infection, AIDS, or AIDS-related complex (ARC). Foster

parents are paid an Exceptional Reimbursement Rate ($1,134 per

month) plus money for diapers and clothing. The children’s medical

expenses are paid through Medicaid (Mayberry, personal communication, 1988).

As of February 1988, approximately 56 percent of the adult AIDS

cases and 75 percent of the pediatric cases reported in New York

City were known to have died. in 1986, although AIDS ranked fifth

as a cause of death for all age groups in New York City, it was the

major cause of death for adults between the ages of 25 and 44

(table 2). For the first time, in October of 1987, the number of

deaths among intravenous drug abusers with AIDS surpassed the

number of AIDS deaths among homosexual and bisexual men.

TABLE 2. Number and percent of deaths in 1986 caused by AIDS

in specific age groups by sex

Age Male

Group Deaths

PercentFemale Per- Rank of AIDS as

Deaths cent Cause of Death

All Ages 2,265 5.7 385 1.1 5

1 to14 19 6.9 22 9.6 5

15to24 63 6.2 22 6.6 4

25 to 34 743 27.6 186 18.5 1

35to44 937 27.1 107 8.7 1

45to64 474 5.0 30 0.5 5

SOURCE: New York City Department of Health, Bureau of Health Statistics and

Analysis (1986).

The above cases were classified as AIDS cases using the definition of

the Centers for Disease Control in Atlanta. However, a study released by the New York City Department of Health, the New York

State Division of Substance Abuse Services (DSAS), and Narcotic and

Drug Research, Inc., used an expanded definition of AIDS-related

214
deaths to include conditions associated with the presence of the AIDS

virus: endocarditis, tuberculosis, oral thrush, and unusual pneumonias.

Therefore, an additional 2,520 deaths of IVDUs were reclassified as

AIDS-related for the period 1982 through 1986. Consequently, IVDUs

accounted for 53 percent of the AIDS-related deaths and were considered the primary group at risk for HIV infection. Homosexual and

bisexual men accounted for 38 percent of the deaths; an additional 4

percent were IVDUs who admitted to homosexual activity. About 5

percent of the deaths were in other risk categories, e.g., pediatric

cases, hemophiliacs, and sexual partners of drug abusers (Stoneburner

et al. 1987).

Preliminary reports generated by DSAS indicated that there was a

large increase in the number of first-reported AIDS cases and the

number of reported AIDS deaths in methadone maintenance programs

from 1985 to 1987. Also, preliminary reports from an ongoing study

at Beth Israel Medical Center by Dr. Beverly Richman have shown

that AIDS is the number one cause of death, followed by alcoholism,

in their methadone maintenance program of over 6,000 patients.

Therefore, AIDS has emerged as the most serious growing health

problem with high mortality rates within the methadone program.

Furthermore, studies estimating the HIV-antibody prevalence among

patients entering methadone treatment vary from about 21 percent in

suburban clinics in the Long Island/Queens area to about 60 percent

in clinics located in inner-city neighborhoods of the Bronx, Brooklyn,

and Manhattan (Magura, personal communication, 1987; Brown, personal communication, 1987). Of the estimated 258,000 narcotics

addicts in New York State, approximately 200,000 reside in New York

City. About 36,000 of the estimated number of opiate addicts in New

York State are in methadone treatment, and another 1,900 are in

drug-free programs. Based on the studies of HIV prevalence among

addicts entering methadone programs, it is estimated that perhaps

50 percent to 60 percent of the opiate-addicted population in New

York City (between 100,000 and 120,000 individuals) are HIV

seropositive (Fenlon, personal communication, 1988; Des Jarlais,

personal communication, 1988).

increases in the number of newly reported tuberculosis and syphilis

cases in New York City may be related to poverty, homelessness, and

the presence of underlying HIV infection associated with IV drug

abuse. Since 1979, the number of newly reported cases of tuberculosis has increased, especially among poor 25 to 44-year-old black

males. The rate of newly reported tuberculosis cases has increased

215
from 22.7 cases per 100,000 persons in 1982 to 32.8 cases per 100,000

in 1987 (New York State Department of Health 1988). In 1985 and

1986, the health districts covering Central Harlem and the Lower East

Side reported the highest rates of tuberculosis for health districts in

the city (New York City Department of Health 1988b). Further,

about 5 percent of the AIDS cases were diagnosed with tuberculosis,

and the two diseases were diagnosed closely in time. These factors

suggest that the resurgence of tuberculosis may be caused by the

presence of HIV infection (City Health Information 1988).

The rate of primary and secondary syphilis increased from 29.2 cases

per 100,000 persons in 1986 to 62.4 cases per 100,000 persons in 1987,

while the rate of latent syphilis increased from 27.7 cases per 100,000

persons in 1986 to 48.1 cases per 100,000 persons in 1987 (New York

State Department of Health 1988). Similarities in the geographical

locations and demographics of age and sex of newly reported cases of

AIDS and syphilis among IVDUs, including those who inject heroin

and/or cocaine, and crack users, may suggest a possible relationship

in the transmission of these diseases through the use of shared

needles and sexual promiscuity. Studies completed in 1988 in New

York City and San Francisco showed that cocaine IVDUs may be at

higher risk than heroin IVDUs for transmitting and contracting the

AIDS virus. Cocaine IVDUs inject more frequently than heroin

IVDUs and therefore may share a greater number of contaminated

needles. In New York City a study of 18 addicts who used heroin

exclusively and 32 addicts who used cocaine exclusively showed that

28 percent of heroin users and 66 percent of cocaine users tested

positive for antibodies to the AIDS virus. A group of about 200

addicts who injected cocaine and heroin showed a rate of infection

similar to the cocaine addicts (Friedman, personal communication,

1988).

Extent of Homelessness in New York City

Size of the Population. Over the past two decades, homelessness in

New York City has reached epidemic proportions. It is difficult to

estimate the number of homeless individuals in New York City. Estimates range from 35,000 to 90,000 persons, depending on the formula

used for the calculation. In New York City, about 32,000 persons

currently reside in emergency shelters and temporary housing provided by the Human Resources Administration of New York City and

nonprofit groups including the Partnership for the Homeless, Inc.

The Partnership is a consortium of religious organizations that offer

food and shelter in churches and synagogues to homeless people

216
(Partnership for the Homeless 1988a). A survey of 45 of the Nation’s

largest cities conducted in 1988 by the Partnership revealed an

estimated 5,000 homeless persons with AIDS (PWAs) in New York City

and 20,000 nationwide. In 94 percent of the cities, the number of

homeless PWAs is expected to increase in 1989. These figures do not

include HIV-positive and asymptomatic persons (Partnership for the

Homeless 1988b).

In addition to those assisted by various public, private, and religious

agencies, there are homeless people living in the streets and in

terminals, abandoned buildings, parks, and subways. in 1984, New

York State authorities adopted the formula that the actual number of

homeless may be 150 percent, in addition to those assisted in shelters

and emergency housing, or a total of about 80,000 persons. However,

the Partnership for the Homeless has arrived at a “guesstimate” of

52,000 to 58,000 individuals–men, women, and children–based on the

assumption that the number is in the range of 60 to 80 percent in

addition to those sheltered by various agencies. This more

conservative calculation was used because of the many programs

implemented during the past 4 years. Other groups have calculated

the total number of homeless as 10 percent above the assisted level,

but this has been rejected by the Partnership for the Homeless as too

low an estimate when considering the number of people seeking help

from the streets.

In addition to the “visible homeless,” there are the “hidden homeless”

–families and “couch people” who double or triple up with others in

substandard and overcrowded conditions. it is estimated that there

are about 120,000 to 150,000 families or between 400,000 and 500,000

men, women, and children in these circumstances (Partnership for the

Homeless 1988). If even a small percentage of such people–as little

as 5 percent–should be evicted by primary tenants or landlords of

the apartments, the number of “visible” homeless would be

substantially increased and overwhelm existing services and resources.

Within the past year, however, there has been a leveling off in the

number of known homeless persons in public shelters and other shelter facilities operated by private not-for-profit groups. For example,

12,906 single adults were provided emergency shelter on January 26,

1988. This represents a 4.4 percent increase over the number housed

(12,334) on January 26, 1987. However, in 1986 there was a 20 percent increase over 1985 figures for persons housed in shelters

(Partnership for the Homeless 1988).

217
Description of the Population. Systematic demographic information on

the homeless is not available. Nonetheless, in their study of shelter

residents in the summer of 1987, Struening (1988) and Pittman (1988)

found that in a weighted sample equivalent to 1,000 residents, 85

percent were men and 15 percent were women. About 75.7 percent

were black non-Hispanic, 15.6 percent were Hispanic, 6.8 percent were

white, and 1.9 percent were other. Furthermore, 43.3 percent did not

complete high school, 35.9 percent finished high school, 16.5 percent

attended college, 3.6 percent graduated from college, and 0.8 percent

received graduate degrees. The mean age of the residents was about

35.2 years. Although the range of ages was between 18 and 70 or

more years, about 72.4 percent of the sample were between the ages

of 18 and 39. About 62 percent were never married, 5.2 percent

were currently married, 3.5 percent were widowed, and 29 percent

were separated or divorced.

IVDUs comprise a subset of the homeless population in New York

City. DSAS estimates that 40 percent of the State’s homeless are

substance abusers. Of the 11,394 homeless substance abusers serviced

by the DSAS Homeless Project, about 34 percent had a history of IV

drug abuse.

An ethnographic exploratory study of 70 homeless street addicts was

undertaken by DSAS’ Street Research Unit in the fall of 1985. This

unit monitors drug activity on the streets of New York City and

consists of street workers who, as former drug abusers, are knowledgeable about street life and drug abuse. They are trained in

ethnographic techniques of observation to obtain information.

The homeless addicts interviewed in this study used various accommodations for shelter. During the week preceding the interviews,

homeless addicts may have experienced one or more different types of

homelessness: 58 percent experienced “extreme” homelessness,

sleeping on roofs and in subways, basements, abandoned buildings, and

shelters; 47 percent stayed with relatives or friends. Many of the

addicts used more than one type of housing during the week of the

interview alternating between accommodations with friends or family

and the streets; thus, the percentages add up to more than 100

percent. Since this study was undertaken during warm weather, only

four (6 percent) of the addicts used the public shelter system.

However, about 21 percent stated they intended to stay in public

shelters during the winter, and 34 percent intended to sleep in public

places, such as subways, instead of the shelters. In this study, the

218
public shelter system was used by a minority of the homeless addicts

(Frank et al. 1985).

Of the homeless addicts interviewed, 44 percent were black, 26 percent were Hispanic, and 24 percent were white. The majority, 76

percent, were male, and 82 percent were between the ages of 20 and

39. Most of the subjects used more than one drug within 3 days of

the interview, with heroin, used by 74 percent of the subjects, and

cocaine, used by 57 percent, as the two most popular drugs. The

major reasons given for homelessness by the addicts were use of

drugs, being put out by their families, homeless by choice, unable to

hold on to money, unable to find a place to live, being cut off from

public assistance, and unable to find work (Frank et al. 1985).

About half the homeless addicts in this study would consider entering

residential treatment, while the remainder were not receptive to the

idea. Some of the reasons given for their rejection of residential

treatment included fear of constraints and restrictions in therapeutic

communities, fear of having to reveal personal details of one’s life in

group situations, dislike of red tape, and unwillingness to give up

their way of life (Frank et al. 1985).

An exploratory survey was conducted in February of 1968 among

clients in drug treatment programs known to the Homeless Emergency

Assistance Referral and Treatment (HEART) Project. Subjects were

selected for interviews using the following three criteria: (1) homeless IVDU just prior to admission to the program; (2) resident in a

contracted program for the homeless; and (3) client referred to

treatment through the HEART Project. Thirty-eight clients identified

as meeting the criteria agreed to be interviewed.

To determine the type of housing patterns experienced by the clients,

questions were asked concerning their living accommodations 2 years

prior to their contact with the HEART Project. The following four

findings describe the type of homelessness and instability of housing

accommodations experienced by the clients.

Twenty-two clients lived undomiciled in the streets, terminals,

abandoned buildings, parks, subways, or shelters. Of these 22,

15 alternated between the shelters and the streets.

Seventeen individuals lived in single-room-occupancy hotels or

furnished rooms.

219
Twenty-one persons moved from apartment to apartment with no

permanent address. For the purposes of this study they are

known as the “hidden homeless”or “couch people.”

Twelve people resided with family or friends but were put out of

the apartment because of their drug use.

Of the 38 persons interviewed, 26 had experienced more than one

type of homelessness and were classified in two or more of the

categories.

An exploratory study of 52 addicted inmates in the New York City

Rikers Island jail facility applying for admission to drug treatment in

Key Extended Entry Program (KEEP) was conducted during the summer of 1987. Within the past 5 years, 42 (81 percent) of the inmates

had experienced several episodes of homelessness or unstable housing

conditions in the shelters (31 persons), streets (10 persons), singleroom-occupancy hotels (26 persons), and as couch persons moving

from apartment to apartment with no primary stable tenancy (33

persons). At the time of their arrests in the summer of 1987, only 6

were residing in their own home, and 12 were staying with relatives.

The remainder were living with friends (8), as couch people (9), in

single-room-occupancy hotels (5), in shelters (2), and on the streets

in abandoned buildings, basements, cars, etc. (10). Twenty-nine

(56 percent) indicated that they would need help to obtain housing

upon their release from jail (Joseph et al. 1988).

Urban Decay: A Factor in the Spread of IV Drug Abuse and AIDS

Dr. Roderick Wallace of the Department of Epidemiology and Social

Medicine of the Albert Einstein College of Medicine studied the

consequences of arson and the destruction of low-income housing in

the South Bronx on the spread of IV drug abuse and AIDS in the

Bronx (Wallace, in press). His study (Wallace, in press, 1988) showed

that the population of areas where low-income housing was destroyed

in the 1970s migrated to other neighborhoods. IVDUs were included

in this migration, and, subsequently, new clusters of IV drug abuse

were created. In the Bronx, HIV infection is spread principally

through IV drug use. Therefore, Dr. Wallace contends that the

continued destruction of affordable housing, if it is not replaced, will

result in further population shifts with accompanying homelessness

among the displaced population and new clusters of IV drug abuse

with a high prevalence of HIV infection. Also, old neighborhood

social networks and services were disrupted as a result of the

220
population shifts. Effective future AIDS education and intervention

programs will therefore require the structuring of new community

networks and services.

This process in low-income areas–arson followed by the destruction

of affordable low-income housing, homelessness, and subsequent population migration–is therefore not only an important element in the

continuing spread of IV drug abuse and AIDS, but also hinders the

delivery of effective educational, medical, and social services to

control the AIDS epidemic within the targeted population. As the

process of destruction of housing, homelessness, and migration

continues, efforts to reach IVDUs will be made more difficult by the

ever-increasing geographical areas that require intensive services

(Wallace, personal communication, 1988; Wallace, in press, 1988).

Summary

Three conditions interact and affect the IVDU–the AIDS epidemic,

homelessness, and the destruction of housing in low-income

neighborhoods. The availability of drugs in low-income neighborhoods

places segments of the population at risk for addiction, IV drug use,

and HIV infection. Furthermore, the continued destruction of lowincome affordable housing exacerbates the spread of diseases and

contributes to the general state of homelessness that affects the most

vulnerable segments of the poor black and Hispanic population. The

studies presented in this section indicate that IVDUs in New York

City are becoming the major group at risk for HIV infection and the

group most responsible for its spread to their sexual partners and

offspring. IVDUs are also an integral part of the homeless

population living on the streets. The convergence of the medical and

social problems presented in this section makes the delivery of

services in traditional forms a difficult undertaking at best and

further contributes to the ongoing pathological conditions.

RECENT POPULATION SURVEYS AND STUDIES

Several surveys and studies, some of which are exploratory in nature,

have been done investigating drug-using behavior associated with

AIDS and HIV infection among the homeless. Ethnographic street

studies, surveys in the shelters, single-room-occupancy and low-priced

hotels, interviews with inmates at the Rikers Island jail facility, and

drug treatment programs that serve the homeless IVDUs have collected data. Homeless IVDUs were interviewed and observed under different environmental conditions–such as streets, drug abuse

221
treatment programs, jails, and shelters–by different groups of

workers, including former drug abusers employed as street workers,

survey interviewers, physicians, and professional researchers.

AIDS Risk Behavior Related to Drug Abuse Among

Residents of New York City

The New York State DSAS, in cooperation with the New York State

Division of Alcoholism and Alcohol Abuse, contracted with Louis

Harris and Associates, Inc., to conduct a telephone survey in 1986

(unpublished) on drug and alcohol behavior among New York State

residents. A total of 6,368 respondents across the State 18 years of

age and older participated in the survey. Included in the sample

were a cross-section of 4,010 residents in households with telephones,

with oversamples of residents of Hispanic origin (563), and residents

between the ages of 18 and 24 years (501). There were additional

samples of residents living in households without telephones (399),

college students (483), and “transients” occupying shelters and lowpriced hotels throughout the State (412).

For the purposes of this analysis, the 3,144 respondents who resided

in New York City were classified by two types of living accommodations: (1) shelters and low-priced and single-room-occupancy

hotels, and (2) “other” accommodations (e.g., apartments or houses).

Table 3 presents the proportion of residents in the two types of

living accommodations who admitted engaging in any lifetime needle

use for the injection of nonprescription or illicit drugs. Although no

question was asked about the recency of needle use, a question was

asked about the recency of heroin use. Almost all needle users who

specified what drug they used with a needle mentioned heroin

(although some also used cocaine or amphetamine).

The main trend emerging from table 3 is that the proportion of

persons involved in drug-using risk behaviors associated with AIDS–

use of needles within their lifetime for injection of illegal drugs, use

of heroin within the past 5 years and within the past 2 years–is

about 15 times greater among the homeless and transients in shelters

and low-income hotels than among persons in “other” more stable

accommodations.

For residents in the two types of living accommodations outside of

New York City, similar patterns of needle and heroin use were found

with smaller percentages.

222
TABLE 3. Percentages of New York City residents in different living

accommodations with drug-using risk behaviors

associated with AIDS

Drug-Using Risk

Behaviors

Associated

with AIDS

Living Accommodations

Shelters,

Single-Room- Other

Occupancy, and AccommoLow-Priced Hotels dations

Residents with Any

Lifetime Needle Use 21% 1.5%

Residents with Any

Lifetime Needle Use

and Use of Heroin

With-in Last 5 Years 12% 0.8%

Residents with Any

Lifetime Needle Use

and Use of Heroin

With-in Last 2 Years 10% 0.6%

Base (N) (276) (2,874)

SOURCE: New York State Division of Substance Abuse Services

Statewide Household Survey (1986).

AIDS Risk Behavior Related to Drug Abuse Among the Homeless

The following four findings emerged from the survey of 38 HEART

clients concerning the use of shared unsterilized needles and cookers

in relation to the time they became aware of AIDS and the consequences of sharing needles.

Clients were generally informed about AIDS and received their

information from reliable sources. Only one person claimed he

did not have information from a formal source. The most common

sources of information for this group were treatment programs

(29 percent), magazines or newspapers (25 percent), brochures

issued by agencies about AIDS and risk behavior (24 percent),

223
TV (25 percent), radio (20 percent), family/friends/coworkers

(18 percent), medical personnel (16 percent), or from other drug

users (15 percent).

Notwithstanding the information or the sources, 20 clients

(52 percent) continued to share unsterilized needles and cookers

and some continued to go to shooting galleries (rooms in

abandoned buildings or apartments in tenements where addicts can

rent needles and buy and inject drugs) for an average period of

2.7 years after hearing about AIDS, before they entered the

HEART Program.

Of those interviewed only 5 (13 percent) never shared needles or

cookers or visited shooting galleries. Another 13 (34 percent)

stopped sharing works before they heard about AIDS.

Although all clients were aware of the dangers of sharing needles,

none were aware of the dangers of sharing cookers.

This exploratory survey did not measure the frequency of use of

unsterilized shared needles and cookers or the frequency of visits to

shooting galleries for the period before and after the clients heard

about AIDS. However, while homeless, the majority of the clients did

continue sharing needles and cookers, behavior which could result in

the individual’s transmitting or contracting the virus. After placement in treatment by the HEART Project, however 10 clients (26 percent) voluntarily participated in AIDS education and testing programs

in AIDS outreach centers.

The above findings are similar to those obtained in interviews of

IVDUs and needle sellers by street researchers of the DSAS Street

Research Unit in 1984 and 1987. In 1984, 89 street IVDUs and/or

needle sellers regarded AIDS as a disease confined to homosexuals.

In 1987, 53 percent of 108 IVDUs admitted sharing needles with at

least one other person. Although many addicts preferred using

sterilized needles, they would use any needle available if they were

sick and needed drugs (Hopkins 1988; Hopkins, personal

communication, 1988.).

However, as street IVDUs became aware of the AIDS epidemic, the

demand for clean needles increased. Dealers began to offer “free

needles” as an AIDS prevention measure with $25 purchases of heroin.

Also to meet the demand for clean needles, some dealers would repackage old needles and sell them as “new” to unsuspecting addicts.

224
By 1987, there were indications that some street addicts were trying

to protect themselves, since about 41 percent of the 108 addicts

interviewed in 1987 attempted to clean their needles with boiling

water, alcohol, or bleach. However, interviews in 1987 revealed that

even with the fear of AIDS and knowledge about transmission, street

addicts still used unsterilized needles if they were sick and clean

needles were not available. Furthermore, if money was limited and

the choice was between the purchase of needles or drugs, many of

the street addicts bought the drugs (Des Jarlais and Hopkins 1985;

Des Jarlais et al. 1985; Hopkins 1988).

Narcotic addicts (27 males and 25 females) applying for admittance to

KEEP in the New York City Rikers Island jail facility were interviewed about their addiction, social, and criminal histories. During

the week prior to their arrest, the 52 inmates claimed to have spent

about $7,700 per day on drugs–this expense was mostly for heroin

and cocaine–which were administered by injection; about 85 percent

admitted injecting cocaine within a 2-month period of their arrest.

They averaged about 21 arrests per individual during the course of

their addictions (females, 28 arrests vs. males, 14.4 arrests). Only 8

were employed at the time of their arrests, 10 received public assistance, and 36 had no legal means of support (Joseph et al. 1988).

When 23 males were questioned about their use of shared, unsterilized

needles, 18 indicated they had shared unsterilized needles within 2

years of their current arrests. The inmates were aware that shared,

unsterilized needles are transmission routes for the AIDS virus, and

there were indications that some individuals avoided sharing needles

to avoid contracting AIDS. Three individuals stopped sharing needles

in 1986, two in 1985, and two in 1984 (Joseph et al. 1988).

None of the males interviewed were aware that cookers could be a

transmission route for the AIDS virus. Of the 22 males interviewed

about their use of shared cookers, 20 indicated they had shared

cookers within the last 2 years: 19 in 1987, the year of their

arrests, and 1 in 1986. Although the 25 female narcotic addicts who

applied for admission to KEEP during the summer of 1987 were not

systematically questioned about the use of shared, unsterilized needles

and cookers, those who used heroin and cocaine admitted that IV

injection was the preferred route of administration. Furthermore, the

women interviewed had long histories of IV drug abuse and were of

childbearing age (Joseph et al. 1988).

225
Of the 52 inmates, 38 have a total of 81 children; 23 of the females

have from 1 to 9 children and 15 of the males have from 1 to 7 children. Within this group of IVDUs, a high probability exists that HIV

may be transmitted to the neonates (Joseph et al. 1988).

AIDS Risk Behavior Related to Drug Abuse Among

Shelter Residents

Preliminary findings are available from the following two studies. In

both surveys, a significant proportion of the homeless respondents

admitted injecting heroin within the past 8 years, which places them

at particular risk for contracting or transmitting the AIDS virus.

Notwithstanding the high prevalence of IV narcotics addiction within

the shelter system, onsite methadone programs and detoxification

services are currently not available for a number of administrative

reasons. Because most programs to treat addicts are filled to

capacity in New York City, it is difficult to place many homeless IV

narcotic addicts in treatment immediately.

The first survey was conducted in the summer of 1987 by Dr. Elmer

Struening and John Pittman of the New York State Psychiatric

Institute. A preliminary analysis of the Struening-Pittman survey of

a weighted sample equivalent to 1,000 residents in the 26 New York

City-operated shelters showed that 10.4 percent were hospitalized at

least once for a drug problem, and 10.7 percent had used opiates

within the 6-month period prior to the interview. Also, 18 percent

admitted using heroin more than 50 times during their lives, 36

percent admitted using cocaine more than 60 times, and 18 percent

admitted using crack over 70 times. This group included current

daily abusers of heroin, cocaine, and crack. The three drugs present

a serious risk of transmitting and contracting AIDS because of the

use of shared contaminated needles by heroin and cocaine IVDUs and

possible sexual promiscuity as a result of smoking crack (Struening

and Pittman, 1988; Struening, personal communication, 1988; Pittman,

personal communication, 1988). This group included current daily

abusers of heroin. About 11 percent admitted injecting drugs since

1980.

Preliminary findings of an ongoing survey conducted by Dr. Ernest

Drucker of the Department of Epidemiology and Social Medicine of

the Montefiore Medical Center show that between 35 percent and 40

percent of 115 recent admissions to the Franklin Men’s Shelter in the

Bronx admit to current episodes of IV heroin use. Abuse of cocaine

226
and crack are also major problems within this shelter population

(Drucker, personal communication, 1988).

HIV Infection in the Shelters

The number of homeless AIDS or ARC patients is unknown, since

many of these individuals try to conceal their illness. Although

patients with AIDS or ARC are not officially discharged from hospitals to shelters, PWAs who are evicted from their apartments or

rooms may seek living accommodations within the shelter system.

Also, another group of homeless individuals with AIDS or ARC may

have developed these conditions without episodes of hospitalization

and therefore are part of an unofficial or “hidden” infected

population.

If they are forced to use shelters, people with AIDS, ARC, or HIV

infection conceal their conditions. Many fear they will be intimidated and threatened with physical violence if their condition becomes known to other shelter residents. lf discovered by physicians

or social workers within the shelter system, AIDS patients are referred to proper medical facilities and moved to other quarters

(Drucker, personal communication, 1988; McAdam, personal

communication, 1988).

The majority of the shelter respondents participating in the survey

conducted by Struening (1988) and Pittman (1988) were concerned

about the consequences of the AIDS epidemic. Table 4 summarizes

their responses to specific questions about AIDS. The majority

perceived AIDS as a problem in the shelters. Also, while the

majority (55 percent) were worried about getting AIDS, only about

one-third (31 percent) indicated they had a good or fair chance of

contracting the disease.

The Department of Community Medicine of St. Vincent’s Hospital

administers a medical program servicing the residents of the Keener

Men’s Shelter on Ward’s Island in New York City. Three physicians

and three nurses are assigned to this project, which offers physical

examinations and medical care for acute conditions, trauma, and

chronic conditions (such as tuberculosis) in a medical unit housed

within the shelter. The shelter is run by the Volunteers of America

under contract to the New York City Human Resources Administration. With a capacity of 816 beds, the shelter services about 1,200

men per month (Woods, personal communication, 1988). It is estimated that about 10 percent of the shelter residents request medical

227
TABLE 4. Perception of shelter residents regarding AIDS epidemic

(sample weighted to 1,000 residents)

Question Positive Response

(Percent)

(1)

(2)

(3)

(4)

Is AIDS a big problem

in the shelters?

Do you know anyone who

has AIDS?

Do you worry about

getting AIDS?

What are your chances

of getting AIDS?

good

fair

poor

none

other and

don’t know

59.2

15.3

54.8

8.6

22.8

23.1

33.5

12.0

attention from the St. Vincent’s medical unit (McAdam, personal

communication, 1988).

In August of 1986, Dr. John McAdam, one of the physicians assigned

to the Keener Men’s Shelter, started an informal exploratory study of

possible HIV infection among men who were in known risk groups:

IVDUs, men engaging in homosexual activity, sexual partners at risk,

and men who received blood transfusions. Eventually two other

physicians were enlisted to assist in the project. The physicians

provided pretest and posttest counseling. From August of 1986 to

March of 1988, 35 residents agreed to be tested, with 30 of them

tested between August of 1987 and March of 1988. One individual

who was tested did not belong to a risk group but presented medical

problems suggestive of underlying HIV infection.

The mean age of the residents tested was 33.1 years with an age

range from 21 years to 46 years. About 80 percent of the residents

228
tested were black, 14 percent were Hispanic, and 6 percent were

white. Twenty-eight (80 percent) were found to be seroposltive.

Infection was found across all racial groups. Of the 23 IVDUs, 21

tested positive. Four residents (11 percent) had sufficient symptoms

of ARC to qualify for AZT and were administered the medication

while residing at the shelter. (One AZT patient died from an overdose of narcotics, and another was removed from the drug because of

side effects.) Twenty-five patients (71 percent) reported for the

results of the test. Of the 10 patients who did not report for their

results, 9 were HIV positive (table 5) (McAdam, personal communication, 1988).

TABLE 5. Prevalence of HIV seropositivity and followup status by

risk group of male residents in a New York City shelter

(n = 35)

Number Number

Number Seroposi- Reported

Tested tive (%) for Results

Number

on AZT

(%)

IV Drug Use 20 20 (100) 12 (60) 3 (15)

Homosexual

Activity 9 6 (66) 8 (89) 1 (11)

IV Drug Use and

Homosexual

Activity 3 1 (33) 2 (66) 0

Sex Partner

at Risk 1 1 (100) 1 (100) 0

Blood Products 1 0 1 (100) 0

No-Risk Group 1 0 1 (100) 0

Total 35 28 (80) 25 (71) 4 (12)

The physicians and social worker reported that AIDS patients are not

being discharged from hospitals into the Keener Shelter. Only one

229
AIDS case was reported of a homeless homosexual from another

country; one individual who developed an advanced case of ARC was

referred to Bailey House, a residence for PWAs. The problem in the

Keener Shelter, therefore, is undetected HIV infection and residents

with cases of ARC.

An AIDS prevention program has been developed in this shelter. The

physicians and social worker inform residents about the use of clean

needles to avoid contracting and transmitting HIV. Also, the Keener

Shelter distributes condoms. IVDUs are referred to treatment. However, the lack of adequate treatment facilities in the community,

especially methadone maintenance and detoxification services, has

prevented many addicts from entering programs promptly.

Dr. McAdam and the other two physicians have demonstrated that

voluntary testing and treatment with AZT is possible within a shelter

setting. There has been an unusually high level of compliance by the

35 patients, as the majority reported for the results of the tests,

and, for those eligible, the taking of prescribed AZT. This may be

due to the personalized approach and counseling of the medical staff

and the fact that all services–testing, physical examinations,

counseling, and treatment with AZT–are available on site.

Dr. McAdam estimates that about one-half of his patients in the

Keener shelter have histories of IV drug abuse and that about 75

percent may be involved with crack.

Dr. Paul Perowsky of the Woodhull Hospital in Brooklyn, New York is

the director of medical care for two shelters in Brooklyn: a men’s

shelter with a capacity to serve about 1,000 persons and a women’s

shelter with a capacity to serve about 150 persons. He estimates

that about 300 to 400 residents in these shelters request medical care

every month. Of this number, about 10 percent to 20 percent appear

to be infected with HIV, and about one-half of those infected can be

diagnosed as having AIDS in accordance with the criteria established

by the CDC (Perowsky, personal communication, 1988).

The Franklin Avenue Men’s Shelter in the Bronx was highlighted in

an article in the New York Times on April 4, 1988 (Kolata 1988),

concerning the plight of homeless PWAs living in the city shelters.

Some of these people may not have received an official diagnosis of

AIDS but have symptoms related to HIV infection. Although there

are no surveys to determine the number of current PWAs in this

particular shelter, Dr. Ernest Drucker of Montefiore Hospital

estimates that about 40 percent of the 600 residents are IVDUs and

230
another 5 percent are homosexual. He estimates that about 50 percent of each risk group are infected and about 20 percent show overt

symptoms of AIDS or ARC (Drucker, personal communication, 1988).

In the winter of 1987 to 1988, Dr. Drucker studied the housing

accommodations of 180 PWAs with histories of IV drug use who were

admitted to six voluntary hospitals in New York City. About 10

percent were admitted to hospitals from shelters, another

10 percent were admitted homeless from the streets, and an additional

20 percent were either admitted from single-room-occupancy hotels or

were living as “couch people” moving from apartment to apartment

with no permanent residence. The remaining people had more stable

living conditions (Drucker, personal communication, 1988).

Medical, Management, and Housing Problems of PWAs

The condition of homelessness among PWAs presents serious problems

that affect the delivery of medical and social services, the patients’

welfare, and the public health of the community at large. These

problems were highlighted in a study conducted by Dr. Ramon A.

Torres of the Department of Community Medicine of St. Vincent’s

Hospital in New York City of all 231 AIDS patients hospitalized at

St. Vincent’s Hospital from November 1981 to October 1985. Included

in this sample were 36 AIDS patients (16 percent) identified as

IVDUs. There were 30 patients (13 percent) considered homeless

upon admission to the hospital. IVDUs constituted the majority–21

(70 percent)–of the homeless AIDS patients (Torres et al. 1987).

Management problems of homeless AIDS patients as compared to nonhomeless AIDS patients are more difficult. These problems include

higher rates of signing out of the hospital against medical advice,

refusals to complete diagnostic tests and undergo treatment for

opportunistic infection, broken outpatient appointments, longer hospital stays, lost prescriptions, and patients lost to medical followup.

Medical problems among the homeless AIDS patients include higher

rates of tuberculosis and possibly pneumocystis carinii pneumonia

(PCP) as compared to nonhomeless patients. Confirmation of PCP

was less frequent among homeless patients since they were less

willing to complete the diagnostic procedures (Torres, personal

communication, 1988; Torres et al. 1987). Homeless AIDS patients

may also exhibit the various forms of trauma, infestations, peripheral

vascular disease, mental instability, and other conditions associated

231
with some segments of the general homeless population (Brickner,

personal communication, 1988; Brickner et al. 1986).

In the New York City Beth Israel Methadone Program, AIDS coordinators work with the patient and family as soon as HIV seropositivity

is known or symptoms of infection are recognized. Plans for ads

quate housing are an integral part of counseling. lf the patient does

not have a family or a place to live and is ill, a referral is made to

Bailey House, a residence for PWAs. However, because Bailey House

has a limited capacity of 44 beds, many patients are referred to

single-room-occupancy hotels and YMCAs upon hospital discharge or,

if they are not ambulatory, to Bird S. Coler Hospital (Haig, personal

communication, 1988).

Homeless PWAs released from prison are also referred to single-roomoccupancy hotels or YMCAs. However, if referred to a Y, the patient

must move every 28 days, in accordance with the Y’s regulations

prohibiting persons from establishing long-term residence. These

types of accommodations are inadequate for many discharged from the

hospitals and prisons. The patients usually cannot get nutritious food

and are placed in environments where drugs are readily available.

Patients may relapse to IV drug abuse and are subjected to further

infection in inadequate housing. Unless patients are known to social

workers or other service providers, they may neither receive services

nor be able to comply with prescribed medical procedures (Springer,

personal communication, 1988).

Followup of AIDS or ARC persons known to the Association for Drug

Abuse Prevention and Treatment (ADAPT) has shown that the

majority released from jails die within 3 or 4 months. ADAPT

workers report that PWAs feel isolated in furnished rooms and in

some instances have been found ill and alone in their rooms for

several days. When this occurs, ADAPT workers have had to call for

medical help or escort the patient to a hospital (Serrano, personal

communication, 1988).

Summary

Surveys and exploratory studies focused on drug-related risk behavior

associated with AIDS indicate that as housing accommodations become

more unstable, the proportion of residents admitting to IV heroin use

or any lifetime use of needles for injecting illicit drugs increases

significantly. Homeless addicts interviewed on the streets, in jails, or

in treatment programs were aware of the danger of transmitting or

232
contracting AIDS through use of shared needles. Although attempts

were made, these addicts were unable to translate knowledge into

consistent risk-free behavior. Physicians affiliated with shelters are

now seeing evidence of HIV infection, ARC, and AIDS among the

homeless residents who are IVDUs and/or homosexuals. Also, based

on the cited studies, homeless AIDS patients have greater rates of

tuberculosis than nonhomeless patients, present serious medical

management problems, and may not be able to comply with prescribed

procedures.

EXlSTING AND NEEDED PROGRAMS

Housing for Homeless AIDS Patients

The plight of homeless PWAs has received extensive media coverage.

Attempts over the past 2 years to establish residential and service

centers for PWAs have generated a considerable amount of community

resistance in New Jersey, Queens, and Manhattan. In addition to

community approval and site selection, funding and program issues

have to be resolved. Notwithstanding these obstacles, The AIDS

Resource Center, Inc., a private nonprofit organization in New York

City, currently has succeeded in establishing two model housing

programs for homeless PWAs: the Scatter Site Apartment Program

and the Bailey House Congregate Residence. Because of limited

facilities, the AIDS Resource Center is able to house about one out

of six homeless PWAs who are referred for help. Each program is an

example of support housing with three common features:

(1) a permanent affordable home that can be used until more

intensive medical care is required;

(2) a wide range of social, medical, and recreational services, either

within the residence or in the community (e.g., individual and

group counseling, recreational activities, information about and

referrals to medical facilities, availability of spiritual care); and

(3) home care services (Fisher 1988).

The Scatter Site Apartment Program is currently in operation with 15

units and has a capacity to serve 17 PWAs or 23 persons if other

family members, such as spouses and children, are included. This

program offers independent apartment living in various neighborhoods.

The program protects confidentiality since only the landlord is aware

of the tenant’s condition and the location of the apartment.

233
Therefore, there is no organized community opposition. The apartments have a private kitchen, toilet, and bathing facilities. Residents

can prepare their own meals and, if necessary, apply for and receive

home care services. PWAs from all risk groups are accepted into this

program (Fisher 1988; Fisher, personal communication, 1988).

Bailey House, established in December of 1986, is a converted hotel in

Greenwich Village with a capacity for housing 44 single adults.

Unlike the Scatter Site Apartment Program, confidentiality about the

resident’s AIDS diagnosis is not an issue since residents must have

AIDS to qualify for admission, and the residence is designated as

serving this particular group. The program has been accepted by the

residents of the neighborhood.

All rooms have private toilet and bathing facilities. Three nutritious

meals are served daily in a central dining area. In addition to the

communal dining facility, each floor has areas for socialization. Staff

includes a full-time nurse, personal care assistants to help with room

cleaning, shopping, and other assistance that the resident may

require. In addition, there are social workers who assist patients

with personal problems. Help with substance abuse is available. All

former heroin addicts are served by community methadone programs.

If the patient is too ill to report for medication, the program will

deliver methadone to the patient at Bailey House. Residents can

choose to use a variety of community outpatient or inpatient medical

services. Also, the Visiting Nurse Service provides ongoing care for

persons too ill to go to clinics and may assign personal health aides

to individual residents (Haugh, personal communication, 1988; Fisher

1988).

The program accepts PWAs from all risk groups. At present, about

half are homosexual or bisexual males, and the rest are former IV

heroin addicts. Despite the residents’ varied backgrounds, congregate

living has encouraged positive interaction, with residents helping each

other and visiting those who are hospitalized. The control of

episodes of acute pain, however, is reported to be a major problem

for many AIDS patients in the residence. Prescribed medication for

effective relief of pain and depression is indicated, since some

residents may resort to the use of nonprescribed substances to obtain

relief (Haugh, personal communication, 1988).

Within the past year, hospitals and methadone programs have referred

homeless patients to Bailey House to address the posthospitalization

housing needs of homeless AIDS patients. As a result of increased

234
social services and stable housing conditions, homeless AIDS patients

who entered were better able to comply with medical followup

(Tortes, personal communication, 1988).

Daytop Village, a drug-free therapeutic community, has developed an

extensive AIDS program, which offers education to staff and residents. Drug abusers with AIDS can enter Daytop and are placed in a

special program that has been developed by the staff in consultation

with physicians. Most AIDS patients who participate in this program

are homeless. Residents with AIDS remain in Daytop when asymptomatic or when the illness is stabilized, are hospitalized during periods

of acute illness, and return to Daytop after their discharge from the

hospital. While in Daytop, other residents are assigned to assist

AIDS patients. Physicians knowledgeable about AIDS and drug abuse

treat and monitor the residents with AIDS. Also, AIDS patients

afflicted with pain are prescribed analgesics while living in the

therapeutic community. The program admits only a limited number of

AIDS patients, since many patients might have a detrimental impact

on the program for the other residents. However, the procedures

developed at Daytop can be used as a model for the treatment of

AIDS patients within the setting of a therapeutic community (Sorrel&

personal communication, 1988).

As of February 28, 1988, the Division of AIDS Services of the New

York City Human Resources Administration served about 1,400

(22 percent) of the 6,500 persons diagnosed as having AIDS in the

city by providing counseling, home care, and nursing and family

support services. Also, the agency meets the specific housing needs

of 21 patients in scatter-site housing, 41 patients in Bailey House,

129 patients in single-room-occupancy hotels, and 596 patients in

apartments (Triscari, personal communication, 1988).

In 1982, DSAS established a residence known as the Short Stay

Program as part of the drug treatment services offered by the Lower

East Service Center in Manhattan for marginal methadone patients

with multiple drug abuse problems, who were homeless. This program

is not designed for AIDS patients, but is a model program for homeless patients who may be injecting drugs. Residents are referred

from methadone clinics and are maintained on methadone for their

course of treatment, which usually lasts from 3 to 6 months. During

this period, patients’ problems and housing needs are addressed and,

when ready, the resident is transferred back to the referring

program. Within the next year, homeless addicts eligible for

methadone treatment will be referred to the program.

235
Efforts to Expand Treatment Intake

The Homeless Project. The Homeless Project organized by the New

York State DSAS consists of two components–The HEART Project

and the Shelter Referral Project. The HEART Project was conceived

in May of 1985 by Julio Martinez, the director of DSAS, in response

to Governor Cuomo’s mandate “to develop programs to address the

plight of the homeless.” This program was designed to serve

homeless substance abusers. Mobile vans are used as intake and

referral offices in neighborhoods where addicts congregate. Homeless

addicts are interviewed about their backgrounds: drug, treatment,

and criminal histories; social and demographic data; and medical and

psychiatric histories. Assessments for the type of help that is needed

and appropriate referrals for placement in detoxification and/or

residential facilities are then completed.

The initial steps for the HEART Project were to develop a residential

drug-free treatment modality for homeless drug abusers and to fund

treatment programs to provide appropriate services. Vans staffed

with DSAS personnel experienced in engaging active substance abusers

were located in places where addicts congregate. Input about locations for the vans was obtained from the DSAS Street Research Unit,

community-based organizations, and volunteer groups. Linkages were

developed with offices of New York City’s Borough Presidents, and

additional data were gathered through the Agency’s toll-free information telephone line.

Referrals were obtained from shelters, since DSAS participates in an

interagency effort with the New York State Office of Mental Health

and the New York State Division of Alcoholism and Alcohol Abuse to

provide outreach services to homeless substance abusers in New York

City’s Municipal Shelter System. Teams of workers from the three

agencies are sent to shelters to interview residents. Clients are

interviewed about their drug abuse histories and need for treatment.

Referrals to treatment programs are made from the shelters, and

residents are placed if an opening is available.

By April 15, 1988, 11,394 homeless substance abusers were served by

the Homeless Project. However, 1,814 returned on two or more occasions for services. Therefore, the number of total client contacts

was 13,208. IV substance abusers accounted for 34 percent of those

served.

236
Tables 6, 7, and 8 summarize the interviews for the Homeless Project.

Approximately 43 percent of the total client contacts were referred

to programs; 57 percent were not referred for various reasons. Less

than 1 percent of the contacts refused assistance. There were no

significant differences in the outcomes for those interviewed by the

HEART Project or the Shelter Referral Project. Practically all

clients interviewed in the Homeless Project accepted some type of

help for their drug abuse problems.

TABLE 6. Number of clients interviewed in homeless projects

Category HEART Project Shelter Project Total

New Clients

Seen 6,431 (100%) 4,963 (100%) 11,394 (100%)

Returnees 889 (14%) 925 (19%) 1,814 (16%)

Total

Contacts 7,320 (100%) 5,888 (100%) 13,208 (100%)

Referred

to Rx 3,121 (43%) 2,564 (44%) 5,685 (43%)

Not Referred 4,199 (57%) 3,324 (56%) 7,523 (57%)

Of the 5,685 persons referred to treatment programs, 52 percent were

referred to residential drug-free programs contracted by the HEART

Project, and 17 percent were referred to other residential drug-free

programs. The others were referred to detoxification facilities

(21 percent), social service agencies (9 percent), and other types of

treatment (1 percent). Of the 7,523 not referred to specific programs, 84 percent were placed on waiting lists, with an additional

8 percent being placed on waiting lists and referred to shelters, since

there were no openings in the treatment programs. About 7 percent

received counseling on the van for their drug problems. As of

March 1988,563 homeless clients were in specifically funded drugfree residential programs contracted by the HEART Project. Of this

number, 89 (16 percent) were IVDUs (Fenlon, personal communication,

1988).

237
TABLE 7. Type of referrals made by the homeless projects

Type of

Referral

HEART

Project

Shelter

Project Total

HEART Residential

Drug-Free

Program 1,936 (62%)

Other Residential

Drug-Free

Program 366 (12%)

Detoxification 536 (17%)

Ambulatory

Drug-Free Program

Methadone Program

Alcohol

Other

3 (*)

5 (*)

2 (*)

17 (*)

Social Service

Referrals 256 (8%)

Total 3,121 (100%)

992 (39%)

595 (23%)

672 (26%)

19 (*)

30 (1%)

2 (*)

2 (*)

234 (9%)

2,564 (100%)

2,928 (52%)

961 (17%)

1,208 (21%)

22 (*)

35 (*)

19 (*)

19 (*)

490 (9%)

5,685 (100%)

KEY: (*) = less than 1 percent.

Key Extended Entry Program (KEEP). KEEP was created in 1986 by

Mr. Charles Laporte, Director of the New York State DSAS Bureau of

Chemotherapy Services (BCS) and his staff to help meet the following

objectives:

(1)

(2)

(3)

(4)

to facilitate the entry of untreated heroin addicts into longterm treatment for their drug addiction;

to curtail the AIDS epidemic among IVDUs by offering treatment

for drug abuse and education about AIDS;

to reduce criminal activity related to IV drug abuse; and

to help relieve overcrowded jail conditions.

238
TABLE 8. Status of clients not referred to treatment

Status HEART Shelter Total

Clients Placed

on Waiting

List 3,514 (84%) 2,802 (84%) 6,316 (84%)

Clients Placed

on Waiting List

and Referred

to Shelters 624 (18%) 0 624 (8%)

Clients Who

Received Information and

Counseling 32 (*) 486 (14%) 500 (7%)

Refused Referral 29 (*) 54 (2%) 83 (1%)

Total Not Referred

to Programs 4,199 (100%) 3,324 (100%) 7,523 (100%)

KEY: (*) = less than 1 percent.

The program was developed in the New York City Department of Correctional Services (DOCS) detoxification facilities on Rikers Island

and in community-based methadone programs. Patients are recruited

for KEEP from the following sources: (1) walk-in applicants from the

streets who come to the programs in search of treatment; (2) referrals from AIDS outreach units; (3) methadone maintenance program

waiting lists; and (4) inmates incarcerated at the Rikers Island jail

facility.

Persons who enter KEEP are initially placed on a detoxification

schedule of up to 180 days. During this 6-month period, patients are

maintained on doses of methadone sufficient to curtail heroin abuse

and are evaluated for placement in appropriate long-term treatment.

The decision about placement in long-term treatment is based on the

results of medical examinations, the duration of the patient’s addiction, the patient’s preferences, and an evaluation of the patient’s

behavior, needs, and adjustment during a 1 1⁄2- to 6-month period. The

239
patient may be accepted into methadone maintenance treatment or

referred to an alternative program such as a therapeutic community,

methadone-to-abstinence program, or drug-free counseling. lf a drugfree program is selected, the patient completes the detoxification

process by reducing the dose of methadone to zero in a controlled

series of steps. Twelve community-based methadone programs are

currently participating in this program.

KEEP at the Rikers Island correctional facility was organized from

March through August of 1987 by staff members of DSAS/BCS In

conjunction with the DOCS and the Montefiore-Rikers Island health

facility. The staff of BCS designed the program, planned its implementation, and administered the program for the first 2 months of

operation. Subsequently, appropriate staff were hired by MontefioreRikers Island health services to operate the program in conjunction

with DOCS. However, the staff of BCS continues to provide technical assistance. Inmates voluntarily elect to enter the program from

the detoxification wards operated by the Montefiore Medical Center

on Rikers Island in three facilities: the correctional institution for

women (presentenced and sentenced females), the correctional institution for men (sentenced men) and the Anna M. Kross Center (presentenced men).

KEEP at Rikers Island is a major innovation. For the first time in a

prison system, opiate-addicted inmates eligible to enter communitybased treatment are maintained on 30 mg to 40 mg of methadone a

day until their release. While incarcerated, inmates are educated

about AIDS risk behavior associated with transmitting and contracting

the virus and ways to prevent transmission. Within 24 hours of their

release, they are administered a dose of methadone and referred to a

community KEEP methadone program for continued treatment and

evaluation. The program has proven to be effective in reducing

tensions and discipline problems within the treated population of the

jail.

Of the first 1,146 admissions discharged to the community-based

methadone programs, 786 (69 percent) reported for and were accepted

into treatment. Males had a higher reporting rate than females

(73 percent vs 63 percent). There are indications that female

prostitution may be a factor in the females’ lower reporting rate

(Joseph et al. 1988).

KEEP in the city jails is an example of frontline medicine. The

program provides medical services onsite where potential patients, the

240
majority of whom were homeless or in unstable living accommodations, may be recruited for treatment. By establishing KEEP, the

traditional intake process has been modified to accommodate

populations who are either intimidated by the intake process or who

have been unable to organize their lives to apply for treatment.

AIDS Outreach and Prevention Programs. The AIDS Outreach and

Prevention program (AOP) operates in the boroughs of Manhattan,

Brooklyn, the Bronx, and Queens from various sites in selected neighborhoods where there is a high incidence of IV drug abuse. Outreach

workers who are former drug abusers canvass the neighborhood locating drug abusers to educate them about AIDS, risk reduction behavior, and treatment. Referrals are made to various community services, including drug treatment programs. Drug abusers are also

informed about HIV-antibody testing. lf they agree to be tested,

they are brought to a test site operated by the New York State

Department of Health. The client also receives pre- and posttest

counseling at the Department of Health office.

A mobile van is used to distribute AIDS information to the general

community and to make contact with nonaddicted relatives and

friends of drug addicts. Family members and friends are encouraged

to refer addicted relatives and friends to the program. The program

also distributes an AIDS photonovel about risk behavior and ways to

avoid transmitting or contracting the virus (Mauge, personal

communication, 1988). The photonovel uses still photos to depict a

story about a young substance abuser and his sexual partner and

their concerns about AIDS risk behavior. Actors depict situations.

Dialog about AIDS and risk behavior is presented in comicbook-style

balloons. English and Spanish photonovels are being distributed in

New York City.

AIDS MOBlLE OUTREACH PROJECT

The AIDS Mobile Outreach Project will be in operation in 1989 and

will focus on particular neighborhoods in New York City and Albany

with a high incidence of AIDS, high mortality rates related to AIDS,

and a high incidence of children born with HIV antibodies. The

distinguishing feature of this program will be the use of professional

social workers and substance abuse counselors to establish

comprehensive education, counseling, and referral services in AIDSrelated matters to substance abusers who reside, or who may be

homeless, in the area. Vans will be deployed to the targeted

neighborhoods. Substance abusers will be counseled and educated

241
about AIDS, and the behavior modification techniques necessary to

reduce transmitting and contracting the virus will be discussed.

Videotapes instructing substance abusers about AIDS and riskreduction behavior will be shown. Also, risk-reduction materials will

be distributed including literature (photonovels, pamphlets), condoms,

and bleach. Referrals will be made to appropriate social services,

treatment programs, and HIV testing sites Wender, personal

communication, 1988).

COMMUNITY AIDS PREVENTION OUTREACH

DEMONSTRATlON PROJECT

Additional outreach programs are being implemented that will involve

distributing condoms and bleach for sterilizing needles. Also, formal

self-help groups composed of individuals from different risk groups

(e.g., prostitutes, female IVDUs, male heterosexual IVDUs, and female

sex partners of male IVDUs) will be created to reduce risk behavior.

These groups will be led by experienced professional group leaders.

Street-level self-help groups are organized by trained ex-addict

facilitators. The groups are composed of IVDUs and others who may

be part of their friendship circles and meet where addicts congregate.

Outreach workers attempt to develop impromptu discussions about

AIDS, testing, and risk behavior reduction. The major purpose of

these groups is the development of new behavioral norms, rituals, and

practices by IVDUs to reduce risk behavior, both individually and

within the group. In addition to providing information, the groups

offer a place to express beliefs and fears about AIDS, testing, death,

sexual practices, and rejection. lt is also hoped that the participants

will be empowered to change their behavior, impart their knowledge

to other IVDUs, and promote new norms and practices that would

reduce risk behavior among extended groups of IVDUs. In addition

to discussions, referrals are made to drug treatment programs and

other types of services (Friedman, personal communication, 1988). A

recently funded AIDS outreach and demonstration project will focus

on the Harlem community, engaging both IVDUs and their sexual

partners in counseling efforts to reduce risk behaviors (Deren,

personal communication, 1988). ADAPT participates in these projects,

helping to organize street-level groups, educate addicts, and refer

them to treatment and services.

The Association for Drug Abuse Prevention and Treatment

(ADAPT). ADAPT was originally organized in the late 1970s to merge

the various philosophies and approaches for drug treatment. In

242
response to the AIDS epidemic, the organization was reconstituted in

1986 under the leadership of Yolanda Serrano to educate drug abusers

about AIDS, to advocate programs for drug abusers to curtail the epidemic, to refer NDUs to treatment, and to develop programs to meet

those objectives. The organization consists of former substance

abusers, drug treatment personnel, physicians, patients enrolled in

drug treatment, researchers, and other interested parties.

ADAPT has organized a program to assist hospitalized AIDS and ARC

patients in the New York City jails. Patients are helped with housing and social service referrals upon their release from jail, since

many of the patients have been abandoned by families and friends.

Also, for those who remain in the institution, assistance is provided

for legal and family matters, grievances about conditions, and AIDS

education and treatment opportunities.

Outreach efforts to educate and offer services to street addicts is an

integral part of ADAPT’s program. Teams of ADAPT members have

gone into communities, shooting galleries, shelters, and abandoned

buildings where homeless drug abusers congregate to educate them

about safe sex practices, to instruct addicts how to clean needles

with bleach, and to distribute small packages containing a vial of

bleach, a vial of water, cotton, and a condom. ADAPT currently

backs the establishment of a needle exchange program in New York

City and is participating in research, education, and service outreach

programs aimed at hard-core street addicts who do not avail themselves of services offered by formal institutions (Serrano, personal

communication, 1988).

Homeless Health Initiative. To serve homeless people, including

approximately 4,000 families in shelters and hotels, New York City

established the Homeless Health Initiative. The program is intended

to address unmet needs within this population. Standards and policies

that affect the population positively were developed. Monitoring

relevant health and environmental outcomes and interacting with

other agencies to develop programs are essential project components.

Programs serve families and individuals in shelters and hotels and

focus on alcohol and drug abuse, mental illness, general health

assessment, health education, referrals to community facilities,

adverse environmental conditions in shelters and hotels, services for

pregnant women and neonates, child abuse, and infant mortality.

When applicable, referrals are made to community agencies and programs. Onsite services staffed by health workers and public health

nurses have also been developed.

243
THE NEED FOR TREATMENT

Treatment for the IVDU

The demand for treatment of IVDUs has resulted in a 105 percent

utilization of the treatment capacity of funded methadone programs in

New York State. In March 1988, 84,568 patients were enrolled in

State-funded and private methadone maintenance programs in New

York State, and 1,088 were enrolled in methadone-to-abstinence programs (Management Information System 1988). An additional 975

narcotics addicts were on waiting lists to enter methadone programs

in New York State (Bureau of Chemotherapy Services 1988). To

address the urgent demand for treatment and the problem of AIDS,

Governor Cuomo directed the New York State DSAS to add 5,000

additional methadone treatment slots in 1988.

In the early 1970s, there were waiting periods of up to 24 months to

enter methadone treatment. Clinics known as holding units were

opened to provide immediate treatment to addicts on waiting lists.

These clinics offered minimal services. Their purpose was to expand

treatment intake as quickly as possible for those addicts who applied

and were waiting for admission. When placements opened in regular

methadone clinics, patients were transferred for continued treatment.

A similar model, known as the Interim Clinic, was created in 1986 by

Beth Israel Medical Center as an AIDS prevention measure, to bring

persons on waiting lists into treatment as quickly as possible. The

KEEP community programs affiliated with 12 methadone programs are

also based on the holding clinic model. They accept addicts from

waiting lists for immediate treatment, evaluation, and eventual transfer to programs that offer long-term care and relevant services

(Bureau of Chemotherapy Services 1988).

In March 1988, State-funded, drug-free residential programs throughout New York State were utilized at 107 percent of funded capacity

and were treating about 4,808 clients. Of this number, 17 percent

were IVDUs. Of the 47,000 clients treated in State-funded programs,

72 percent were in treatment in New York City. The need for treatment is underscored by the fact that, in New York City, where the

AIDS epidemic is most prevalent, total treatment for drug abuse–

methadone maintenance, drug-free residential, drug-free day service,

drug-free day outpatient–is utilized at 104 percent of its funded

capacity (Fenlon, personal communication, 1988; Management Information System 1988).

244
Summary

A variety of projects have been developed by New York State and

New York City agencies to meet the needs of homeless IVDUs and

AIDS patients. By developing housing programs, outreach in the community, and expanded intake to allow a greater number of IV drug

abusers to enter treatment, a comprehensive strategy could be created

that would serve homeless AIDS patients and curb the spread of the

epidemic. At present there is such a heavy demand for treatment

and adequate housing for PWAs that drug treatment programs are

over capacity, especially in areas with high levels of drug abuse and

HIV infection.

SUMMARY AND CONCLUSIONS

This chapter summarizes the results of selected ongoing surveys,

exploratory studies, interviews with physicians working with homeless

IVDUs, and programs concerning AIDS and the homeless in New York

City. Current statistical data from the New York City Department of

Health show that IVDUs are now becoming the primary risk group for

HIV infection in New York City. Interviews of homeless IV drug

addicts incarcerated in Rikers Island jail facilities revealed that these

addicts had long histories of involvement with the criminal justice

system and that heroin was the most common drug injected, followed

by cocaine. To curb the spread of HIV infection, the injection of

both drugs must be curtailed.

Preliminary study results undertaken in shelters and hospitals show

that AIDS is a major concern among shelter residents and that HIV

infection has emerged as a major public health issue among homeless

IVDUs. Further, the rates of any lifetime needle use and heroin

addiction are greater among shelter residents and single-roomoccupancy hotels than among residents of other types of accommodations.

Ethnographic and other studies reviewed, however, identify a group of

addicts who avoid shelters or single-room-occupancy hotels and live

primarily on the streets in abandoned buildings, subways, terminals,

and other public places. Programs must be devised to reach these individuals if the AIDS epidemic is to be brought under control.

Outreach units established through National Institute on Drug Abuse

grants in six cities–New York, Philadelphia, Miami, Chicago, Houston,

and San Francisco–are examining different approaches to outreach in

various settings.

245
Preliminary research shows that addicts are aware that AIDS is

transmitted through use of shared unsterilized needles. There are

also indications that street addicts have attempted to reduce risk

behavior by purchasing needles from dealers, attempting to clean

needles, and sharing them less. Among homeless IVDUs, efforts at

risk reduction appear to be difficult to sustain consistently. Outreach therefore must not only offer education but must also refer

addicts to programs and services that will enable them to change

deeply ingrained behavior that facilitates the transmission of the

AIDS virus.

Homeless AIDS patients present serious medical management problems

(e.g., lost to followup, failure to complete medical regimens, or long

hospital stays). In addition, if they are not properly housed, they

are subject to additional infection. Increases in the number of

tuberculosis and syphilis cases reported to the New York City Department of Health during the past 2 years may be related to poverty,

homelessness, and underlying HIV infection among IVDUs. To protect

PWAs from further infection and the public from contagious diseases

such as tuberculosis, proper housing for homeless IVDUs, especially

those infected with the AIDS virus, is essential. The model housing

programs developed for PWAs have limited capacities and cannot

currently address the housing needs of this population.

Services should be established and evaluated near areas where homeless IVDUs congregate or in shelters or single-room-occupancy hotels.

If possible, medical, social, and educational services should be combined into a single program rather than spread out in different locations. The value of onsite services is to help homeless patients

follow through with medical or social service appointments and treatment procedures. For example, a high proportion of homeless men

tested for HIV antibodies in New York City men’s shelter reported

for their test results. This service was offered in the shelter by the

physicians who examined and counseled the patients.

The destruction of low-income housing in areas where drug abuse and

AIDS are concentrated further exacerbates the dual conditions of

poverty and homelessness, resulting in dispersal of the population

most at risk for infection. The delivery of needed services and outreach are made more difficult because of the larger geographic area

that must be served.

Another area of growing concern is the care of children born infected with the AIDS virus and the children of deceased AIDS

246
patients. Based on current surveys, the number of newborns infected

with the AIDS virus and the number of children needing placement

will probably increase as more infected women who are IVDUs or

sexual partners of men at risk become pregnant.

Historically, sharing unsterilized needles has resulted in serious public

health problems. Diseases transmitted by addicts sharing needles

include malaria, endocarditis, hepatitis, and AIDS. Although the

legalization of needles and the establishment of needle exchanges to

provide sterile needles to addicts are volatile issues, the future

direction of the AIDS epidemic will be affected by the way these

issues are resolved. A needle exchange program is currently in

operation in Tacoma, Washington, and another will be created in New

York City in November 1988. Both exchange programs are under the

jurisdictions of the Departments of Health in the two cities. They

will be evaluated over the next 2 years to determine whether they

are effective.

There are an estimated 260,000 opiate addicts in New York State

(New York State Division of Substance Abuse Services 1986). At

present, about 38,000 addicts are in methadone programs (95 percent)

and drug-free programs (5 percent). Since programs reach only

15 percent of the estimated addicts, expanding treatment for IV

heroin addicts in New York State has now become a major public

health effort. Outreach, however, is not sufficient. A sizeable

number of addicts enter treatment only to drop out within a P-year

period, and most relapse. Therefore, long-term or even lifetime

treatment for many homeless addicts would be necessary to curb the

spread of HIV infection. Programs would have to encourage patients

to remain in treatment for an indefinite period.

The programs and surveys presented in this chapter demonstrate that

it is possible to reach out and assist a seemingly intractable population of homeless IVDUs. However, interventions are only a first

step in changing lives and destructive behavior. Intervention without

the backup of treatment, services, and housing can only lead to further despair, HIV infection, and other diseases among the homeless.

At present, it is increasingly difficult to place individuals in programs. The most serious problems are the lack of adequate treatment

facilities, housing for the homeless, and space to locate new programs. Community opposition to the establishment of both drug and

AIDS treatment facilities and funding for services, including renovation and building of the necessary facilities, is common. Commitment,

247
planning, and funds are needed to affect the spread of the AIDS

virus within the homeless population.

Recommendations based on study of the programs and successful

interventions discussed include the following:

(1)

(2)

(3)

(4)

Sufficient program capacity should be developed and funded

to reduce the waiting period for treatment and, if possible,

eventually eliminate waiting lists. Clinic hours should be

extended in existing programs, and medical centers that

currently do not offer methadone treatment should develop

such programs. The delivery, by vans, of methadone,

bleach, condoms, and medication for treating cocaine users

should be evaluated. However, to be effective in reducing

transmission behavior, programs will have to address both

IV heroin and cocaine abuse.

Programs that specifically recruit homeless addicts for

treatment using vans as intake and counseling offices

should be implemented and expanded. Vans recruiting

addicts for treatment in various neighborhoods make intake

into treatment more accessible. The HEART Project, which

aims at the homeless addict, brings knowledgeable workers

to neighborhoods that may be isolated and that lack

resources. This should be expanded.

Frontline medical, social, and educational onsite services

should be combined into a single program and developed at

access points where addicts congregate and live (i.e., shelters, single-room-occupancy hotels, emergency rooms, criminal justice systems, and public health centers). Again, the

delivery of medical and social services by vans to inaccessible populations should be investigated. Treatment and referral systems could be implemented at these access points,

using the resources of several agencies to create new types

of programs. KEEP, a program in the New York City jail

system, is an excellent example of this type of intervention.

Special residences and program components within existing

residences should be developed for homeless substance

abusers with AIDS that address treatment issues and monitor behavior in a humane, flexible manner. The facility

should take into account the episodic nature of the illness

248
and accommodate patients who may require methadone

maintenance, a drug-free approach, or special medication

for pain or depression. The residence should offer a social

support system similar to that in scatter-site housing,

Bailey House, and Daytop Village. These models should be

expanded. Funding should be earmarked for housing

homeless PWAs under the provisions of the McKinney Act.

(5) Programs that combine chemotherapy in a residential setting should be developed for homeless IV drug abusers who

may or may not be infected with the AIDS virus, but who

are at risk for infection. The Short Stay Program, a

residence for marginal methadone patients most of whom

are homeless or on the verge of becoming homeless, is an

example of this type of program.

(6) Outreach units that go into the streets, abandoned buildings, shooting galleries, shelters, jails, and single-roomoccupancy and low-priced hotels to educate addicts about

AIDS-related risk behavior and refer them to treatment

should be expanded. The outreach program developed by

ADAPT is a prime example of this program. Networks

should be developed between outreach units and appropriate

departments within medical centers to expedite referrals of

homeless addicts to treatment programs, health facilities,

and social service agencies.

(7) Medical centers should develop onsite programs for treating

the homeless in shelters and furnished rooming houses. An

example is the program administered by St. Vincent’s

Hospital at the Keener Shelter for Men on Ward’s Island.

(8) Medical and social agencies dealing with this population

must aggressively and cooperatively develop policies and

programs aimed at containing the AIDS epidemic. Again,

the KEEP program demonstrates what can be accomplished

by three agencies with different but overlapping agendas

(i.e., DSAS, Corrections, and Montefiore Hospital).

(9) The relationships between urban decay, the destruction of

affordable low-income housing, and the spread of the AIDS

epidemic should be investigated further.

249
(10) Evaluation of medical, social service, educational, outreach,

and other possible programs should be conducted to determine program strengths and weaknesses.

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252
AUTHORS

Herman Joseph

Research Scientist

Bureau of Research

and Evaluation

Hilda Roman-Nay, J.D.

Director

Bureau of Government

and Community Relations

The Homeless Project

State of New York Division of Substance Abuse Services

55 West 125th Street, 10th Floor

New York, NY 10027

253
HIV-Related Disorders,

Needle Users, and the Social

Services

Lawrence C. Shulman, Joanne E. Mantell,

Charles Eaton, and Stephan Sorrell

INTRODUCTION

With the increasing rates of acquired immunodeficiency syndrome

(AIDS) in the United States among intravenous drug users (IVDUs),

their sex partners, and their children, intensive prevention and

control efforts are needed to curb the spread of the epidemic.

IVDUs comprise the second largest risk group for AIDS in the United

States and, in New York City, account for more than half of all

AIDS-related mortality. They are the major link to spreading the

human immunodeficiency virus (HIV) beyond groups with defined highrisk behaviors. The reported number of women who contracted AIDS

through heterosexual transmission more than doubled since 1982 (from

12 percent to 30 percent) (Guinan and Hardy 1987; Centers for

Disease Control 1988). Since 1981, more than 21,000 IVDUs (27

percent of the cumulative number of AIDS cases nationwide) have

been reported with a diagnosis of AIDS. Recent data in New York

City and San Francisco indicate that rates of HIV infection are

increasing among IVDUs who inject cocaine exclusively (Lambert

1988a). In New York City, the proportion of IVDUs with AIDS is

substantially higher, representing 38.3 percent of all New York City

cumulative adult cases (New York City Department of Health 1989).

A recent review of narcotic-related deaths on New York City death

certificates, which were then matched to the New York City

Department of Health AIDS Surveillance Registry data, indicates that

AIDS has been grossly underreported (Stoneburner et al. 1988).

Narcotics-related deaths increased on the average of 32 percent a

year between 1981 (n=492) and 1986 (n=1996). Although many of

these deaths among IVDUs did not meet the AIDS surveillance case

definition, many were caused by conditions suggestive of HIV

254
infection, such as unspecified pneumonia, endocarditis, and

tuberculosis (TB).

HIV infection rates vary widely across the Nation, with rates as high

as 50 to 60 percent in New York, New Jersey, and Puerto Rico to

less than 5 percent in areas outside the east coast (Centers for

Disease Control 1987). The National Institute on Drug Abuse

estimates that of the 1.1 million IVDUs in the United States, 335,000

are infected with HIV. New York City has 50 percent of the needleusing, opiate-dependent (heroin, street methadone, pharmaceutical)

population in the United States, and IVDUs now surpass homosexual/

bisexual men as the major group with AIDS.

The mounting numbers of AIDS cases due to intravenous (IV),

intramuscular, and subcutaneous drug use are straining the health and

social service delivery systems, especially the drug treatment sector.

Resources for both drug and AIDS-related treatment are drastically

inadequate. In this chapter, we use the term “needle drug user”

(NDU) to indicate more appropriately the range of risk behaviors

implicated in HIV transmission.

CONCEPTUAL FRAMEWORK OF ME SOCIAL SERVICE SYSTEM

Definition and Models of Social Services

Social services may be viewed as efforts to support, supplement, and

substitute for functions traditionally performed by the family or as

efforts to provide supports to compensate for the individual and

family dislocations caused by roller-coaster economic forces (Shulman

1985). Social services are provided within the framework of human

service organizations and are charged with enhancing physical,

economic, and psychosocial well-being. Contemporary social welfare

activity encompasses a wide range of organized services, entitlements

(insurances), and institutions that are “designed to aid individuals and

groups to attain satisfying standards of life and health” (Brager and

Hollaway 1978). While specialization in social services delivery can

lead to efficiency, it also fosters fragmentation of the client or

family unit, lack of coordination, gaps and duplication in service

delivery, and client stigmatization.

Traditionally, social services have been organized along either a

residual or institutional conceptual model (Wilensky and Lebeaux

1965). Throughout history, social policy, planning, and service design

have been directly affected (and expanded or contracted) by the

255
prevailing ethos and the sociopolitical climate. The resulting system

is a patchwork of laws, regulations, and public voluntary and selfhelp agencies and services. The residual model emphasizes

self-reliance, economic individualism, and moralistic judgment

regarding responsibility for one’s actions and the potential consequences of “antisocial” or “deviant” behaviors. The institutional

model sees social welfare services as the required base or “safety

net” to support vulnerable or at-risk persons, families, or groups in a

highly fluid, cyclical modern industrial society (Brager and Hollaway

1978).

Agencies, programs, and services developed with the residual model as

a conceptual or philosophical base tend to erect eligibility barriers

and provide the services in ways perceived to be hostile by the NDU

population. These agencies are not designed to reach out or

accommodate the psychological and social fluctuations that

characterize the lifestyles of the NDU and family. The institutional

model, on the other hand, is generally less judgmental of the

individual, but, by the nature of large-scale entitlement or safety net

programs, agencies organized along this conceptual framework tend to

blend the individual-in-crisis into a standardized category.

All agencies serving the NDU population have struggled for decades

with their level of social responsibility for service delivery to people

with chemical dependency disorders, as well as with shifting concepts

of treatment. The patchwork of public and private programs and

funding has not fostered a coherent, coordinated planning or

treatment approach.

The funding, organization, and delivery of social services to addicts

with AIDS must be examined within the context of episodic hospitalizations, shortened survival, and the interactive effect of multiple

chronic health problems. General problems of surviving as an addict

are heightened immeasurably by the presence of HIV infection.

Underlying lifestyle factors, such as poverty, unstable family

structures, and overall high-risk environment, further compound an

NDU’s access to and use of social services. New York City has been

especially hard hit by the epidemic of HIV infection among drug users

(47 percent of all cases diagnosed since January 1, 1988), many of

whom lack health insurance and other supportive resources (New York

City Department of Health 1989).

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Service Delivery Interface

NDUs may interface with the service provider industry in one or

more of the following categories:

Public assistance (home relief)

Medicaid program

Social Security/Social Security (wage-related) disability

Unemployment program

Child welfare service

Supplemental Security Income program

Law enforcement system (police, court officers, judges, corrections

officers, parole officers, Drug Enforcement Agency personnel,

Legal Aid staff, and Legal Services programs)

Hospital and health department clinics

Psychiatric clinics and outreach programs, psychiatric inpatient

units

Shelters

Meal programs

Drug treatment programs such as drug-free residential and

ambulatory therapeutic communities, and community-based

methadone maintenance treatment programs

Social agencies (especially programs for runaway youth)

A NEW YORK ClTY VOLUNTARY HOSPITAL AND THE SERVICE

DELIVERY INTERFACE

St. Luke's-Roosevelt Hospital Center has had an active Substance

Abuse Program (SAP) funded through patient reimbursement

mechanisms for the past 17 years and has provided methadone

treatment to more than 4,000 patients cumulatively. The clinic

provides treatment 6 days a week. The hospital also has both

257
inpatient alcohol and drug detoxification units. About 12 new

patients are admitted to the SAP each month. Many of the patients

on methadone maintenance are multiple substance abusers; 65 percent

are male; 35 percent of the patients are Hispanic; 32 percent are

white; and another 31 percent are black. Patients range in age from

19 to 74 years. Medicaid recipients make up 46 percent of the

population, and 35 percent of the SAP clientele are employed either

part-time or full-time. Between 1984 and 1986, approximately 36

percent of the patients who requested antibody testing were HIV

seropositive (Grieco 1988), and, as of April 1987, 36.7 percent were

seropositive (Sorrell personal communication, 1988).

Substance abusers (and their children) are seen in all of our

ambulatory and inpatient services, including the emergency

department, obstetrical/gynecological clinics, and pediatric clinics.

Many enter our health care system in crisis, requiring the mobilization of protective social services, entitlement assistance and

advocacy, legal referrals, and housing or income maintenance. The

Hospital Center has a well-trained, professional Department of Social

Work whose social workers and drug counselors provide aggressive

counseling and referral services to this population. In addition, the

Department of Social Work established a Public Entitlements Program

to provide advocacy assistance to patients and staff in overcoming

barriers to accessing services required by all patients of the hospital.

Even with the availability of these expert Entitlement Specialists,

many social and health services cannot be obtained for the substance

abuse population because of constraints and limitations within the

broader service delivery system. Many of the observations and

recommendations in this paper are drawn from our experience at

St. Luke’s-Roosevelt as well as from other service providers in the

field of substance abuse.

More recently, extensive work with IVDUs and their families has

occurred in our AIDS Center Program. The multiple needs and

increasing proportion of cases among this population-at-risk has

caused the hospital, the Department of Social Work, and the SAP to

reexamine the ways in which health and social services are delivered

to the NDU population within the hospital programs. For example,

we considered the establishment of a special inpatient AIDS unit for

NDUs to evaluate the effectiveness of clinical care and social work

services. Two trained drug counselors were hired to provide liaison,

education, and prevention services to the hospitalized NDU

population. Social work staff assigned to AIDS services has tripled

258
since September 1987 (8 master’s level social workers for an average

inpatient census of 85 in 1988).

The hospital has developed an education and prevention outreach

program for street prostitutes and runaway youth in its geographic

area who are at high risk for HIV infection because of drug use and

multiple sex partners. Staff will be assigned to street work in

cooperation with three community-based organizations to link drug

abusers to the social services system, to advocate for needed

entitlements, to encourage prostitutes to seek HIV counseling and

testing, and to encourage and refer clients to enter drug and health

treatment programs. Our goal is to develop a low-barrier, nontraditional primary health care service for women, their children, male

prostitutes, and street youth involved in the dual cycle of sex and

drugs.

BARRIERS TO SERVICE DELIVERY

Barriers to access and utilization of services by NDUs are evident in

the areas of service delivery design, client resistance, public and

staff attitudes and beliefs, and public policy.

An observer will quickly discern that social agency program

procedures and policies are not geared to the needs of NDUs. All

too often, agencies develop and enact regulations and procedures that

result in systems maintenance and that meet staff and administrative

imperatives rather than meeting client needs (Goffman 1967). The

resistant behaviors of drug users and the deficits in the service

delivery system compound the problems of the AIDS epidemic and its

link to needle-associated HIV transmission.

Service providers who perceive that NDUs are socially marginal and

unable to change their behaviors–that is, once an addict, always an

addict–may have antagonistic dealings with clients and their families.

These attitudes reinforce the resistant behaviors of both clients and

the social services system by creating an unwelcome climate that does

not provide “user friendly” services.

Public policy has treated drug abuse historically as a criminal rather

than a health or social problem. Drug control and drug interdiction

have received greater public and governmental support than drug

treatment approaches or social problem solutions. With the

intertwining of AIDS, drug abuse, and crime, however, pressure to

259
expand drug treatment programs is accelerating (Kerr 1988; Lambert

1988b).

The NDU is the uncontrolled link to widespread drug-related HIV

transmission, as well as sexual and perinatal HIV transmission, and

thus represents the explosive potential for spread of the disease.

Since AIDS is disproportionally represented by two stigmatized risk

groups (gay men and IVDUs), the “victims” are blamed and the need

for social services basically ignored. Only when sensational claims of

“dire threat to the heterosexual population” or the irrational fear of

casual contagion receive high media visibility does the need for public

spending and resource allocation become recognized (Check 1987).

St. Luke’s-Roosevelt Hospital staff and other drug treatment program

staff report that, historically, NDUs have been cut off in a real sense

from formal health and social service organizations. Their

longstanding, inherent characterological problems in living and

manipulation of “the system” mirrors their difficulty in dealing

appropriately with all aspects of their lives. Needle users with HIVrelated disease enter the mainstream health care and social service

systems in a more advanced stage of disease than do gay men or

people with transfusion-associated disease (Maayan et al. 1985;

Belmont et al. 1985). Moreover, as reflected by New York City AIDSrelated mortality data, IVDUs (especially black females), have the

poorest survival from diagnosis to death compared to people with

other risk-associated behaviors (Rothenberg et al. 1987).

Unlike the “junkiebonden,” the junkie unions in The Netherlands,

which are collective self-help organizations set up by drug users,

needle users in the United States generally lack the natural or shared

community evident in organized self-identified gay populations where

there is active political and social advocacy for their constituents.

Needle users are frequently economically and socially disadvantaged.

Based on our experience at St. Luke’s-Roosevelt Hospital Center, we

suggest that for nondrug-using female partners of NDUs, the

additional barrier of economic dependence on the NDU male partner

may limit access to formal services, because of the NDUs’ suspiciousness and distrust of authority. Concrete problems of day-to-day

survival in families where one or both partners use drugs are

intensified and complicated by AIDS.

Psychological factors can be a barrier to service delivery. Empirical

and anecdotal data from drug treatment centers revealed temporary

drug bingeing following notification to the addict of positive HIV

antibody status (Marlink et al. 1987). Real and/or perceived social

260
stigmatization about being a “two-time loser” (a drug addict and an

infected HIV carrier) may also act as a barrier to service use.

Few social service programs have been established to serve NDUs on

a priority basis. Funding has supported methadone and drug-free

treatment centers to the exclusion of other social services that are

crucial to the rehabilitation of the drug addict. Even the availability

of drug treatment “slots” has been far below the acknowledged need

level. About 100,000 treatment slots are available nationwide, or

spaces for about 1 out of 12 addicts (New York Times 1988a). In

New York City, for example, residential drug treatment programs

offer fewer than 6,000 spaces, methadone maintenance treatment

programs (MMTPs) have 29,000 addicts enrolled, and another 10,000

addicts are in community-based drug-free programs. New York has

an estimated 200,000 drug addicts. Many desire treatment and are

turned away and placed on waiting lists.

Until recently, there was major opposition to permitting distribution

of free needles and syringes to addicts in New York City. Societal

resistance to this revolutionary proposal stems, in part, from the

unwillingness to challenge public drug and law enforcement officials’

beliefs that provision of clean needles condones and legitimizes drug

use and abets an illegal activity. A free needle distribution campaign

is contrary to the ideology of therapeutic drug-free communities,

which view sobriety as the primary value. Data from The Netherlands, France, England, Scotland, and Tacoma, WA, show that, with

governmental distribution of free needles and syringes, significant

numbers of NDUs are exchanging their syringes and needle-sharing

practices have decreased (Balian et al. 1988; Mulleady et al. 1988;

Gross 1989).

The unavailability of appropriate and adequate housing is a problem

for many people with HIV-related disorders, but for addicts who are

diagnosed late, the problems are exacerbated. As many NDUs do not

have intact social support systems, they do not have family and

friends to assume caregiving responsibilities in the home. Caring for

addicts with symptomatic HIV infection is almost impossible in a

context of homelessness. An ineffective support system is further

compromised by their poor health status. If an NDU is unable to

maintain self-care, home care options are limited, and residentialbased models of health and social service delivery become essential.

Public shelters in New York City do not knowingly accept persons

with AIDS. When families of the NDUs with HIV-related disorders

are also homeless, the housing crisis is worsened.

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Substance abuse treatment is generally unresponsive to the needs of

women. Women do not have adequate network support to motivate

them to enter treatment. Treatment models tend to be maleoriented, and case-finding systems are not gender-sensitive

(Mondanaro 1989). Few agencies have programs for pregnant addicts

or deal with issues of child care, foster care, parenting education,

job retraining, and limited ability to pay for treatment (Cohen et al.,

in press). In New York City, 1 in 61 babies are born HIV seropositive, and in the Bronx, 1 in 43, statistics that coincide with endemic

areas of high drug use in the city (Novick et al. 1988). Over 100

“boarder babies” were reportedly abandoned in New York City hospitals in 1987, because they were infected or their families were too

sick to care for them. While availability of foster care placement for

such infants has increased in New York City, there are few other

alternatives when a mother or family members are unable to provide

at-home care.

Two recent studies attribute social factors as the cause of children’s

unnecessary medical hospitalizations. At Yale-New Haven Hospital in

Connecticut, 54 percent (n=18) of 34 children with symptoms of HIV

infection remained in the hospital beyond medical need (Kemper and

Forsyth 1988). Difficulty in placement was associated with a disorganized home environment due to parental IV drug use, hospitalization or jail placement, or death. Similarly, a Harlem Hospital Study

in New York City found that 86 percent of the parents of the 37

children with AIDS-related complex (ARC) or AIDS were NDUs.

Many of the unnecessary hospitalizations were attributed to unstable

family life; children with less serious health problems had the same

amount of hospital medical costs as those who were seriously ill or

had died (Heagarty et al. 1988).

FRAMEWORK FOR SOCIAL SERVICE SYSTEMS PLANNING AND

POLICY DEVELOPMENT

Strategic planning, with a needs-assessment component, provides a

useful framework for the design and delivery of comprehensive social

services for people with HIV-spectrum disorders. First, there must

be recognition of the diversity of NDUs. The needs of the homeless

NDU, the adolescent addict, street prostitutes who support their habit

as sex industry workers, heroin addicts, skin-popping addicts, those

on methadone maintenance, and those in drug-free treatment programs must be distinguished. These differences suggest that multiple

points of access, different social service models, and various channels

262
of service delivery will be required to reach subsets of the

population.

Second, the fit between service providers’ characteristics and those

of the NDU group needs to be examined. What cultural, language,

ethnic, and socioeconomic barriers might interfere with service

provision and utilization?

Third, family influence on the use of social and health services must

be addressed. How does the codependency of some family members

impede service use? Social service delivery systems need to develop

ways to build upon the strengths of the family to support and

reinforce the addict’s psychosocial and medical “treatment” plan.

Finally, the pathways and procedures surrounding the matrix of public

and private sector services and entitlements and the messages that

they convey to potential service recipients require critical

examination.

CONSIDERATIONS FOR DESIGNING AND DELIVERING SOCIAL

SERVICES

The heterogeneity and complexity of social, medical, psychological,

and economic needs of the NDU population, coupled with the rapid

spread of HIV infection among NDUs and their sex partners, suggest

that we can no longer be rigidly wedded to existing service delivery

structures. Provision of social services between 9 a.m. and 5 p.m.

may be convenient to staff, but not necessarily responsive to clients’

lifestyles and variable health conditions.

Integration of Health Services and Social Services for the NDU

Population

Models for service delivery to the NDU population require effective

integration of those complex components of care: health, drug

treatment services, social services, including housing, income supports,

maternal and child health and nutrition services, disability supports,

job programs, and legal and advocacy services. Community planning

and coordinating efforts are a first step in the development of such

models. Organizing and nurturing community coalitions, such as the

New York AIDS Coalition and the Worcester AIDS Consortium

(Massachusetts), is needed to develop a consensus and support base

for addressing the broad range of problems facing NDUs.

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The fragmented organization and lack of continuity of health and

social services existed prior to the epidemic of HIV infection. With

the burgeoning numbers of infected drug users, the epidemic has

exacerbated these gaps by placing excessive strains on service

systems and creating a shortage of personnel resources. The

coalition of agencies in Worcester monitors HIV surveillance,

facilitates priority entry of clients into drug treatment, and provides

risk-reduction services (distributing bleach and condoms) (Lewis et al.

1988).

Low-Barrier Models

Developing low-barrier access to social service systems to increase

service use must be considered. Social services should be designed

and provided in a way that increases the trust of HIV-infected addicts and their families. In addition, entitlement system requirements

that erect barriers to service accessibility must be reexamined. Similarly, Federal regulations that require methadone clinics to provide

addicts with counseling (as part of treatment) place another barrier

in the pathway of those desiring treatment and drive addicts away

from mainstream service facilities.

Four low-barrier social services models suggested for evaluation are:

(1)

(2)

(3)

(4)

Mobile (van) services with a multidisciplinary team of medical,

case management, and prevention staff would provide more

direct access to NDUs. Mobile services would be concentrated

in communities with high HIV-related mortality rates and would

be satellites of acute health care facilities.

Storefront multipurpose service centers, like those developed by

the Office of Economic Opportunity in the 1960s, could be set

up to bring services closer to addicts. Storefront facilities,

coupled with effective case management, may help break down

barriers between addicts and the system.

Low-barrier drop-in service centers where NDUs could receive

services with minimal or no requirements could try to reach the

difficult-to-access addict who shuns the formal treatment and

service systems.

Outreach workers/teams that go “where the action is”–on the

street, in neighborhood hangouts, and shooting galleries. This

approach is similar to that used by the New York City Youth

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Board in the late 1950s and early 1960s to work with youth

gangs and has been used by the Association for Drug Abuse

Prevention and Treatment, Inc., in New York Cii and by

ethnographic field workers in San Francisco, CA, Chicago, IL;

Baltimore, MD; New York Cii; Washington, DC; El Paso, TX,

and others.

The underlying thrust of each of these four models is to bring social

services to the community-to remove barriers to service accessibility

and availability. These recommended service models are based on

experiential understanding that NDUs and their families (1) tend to

be suspicious of and avoid “official” public social agencies (unless

absolutely necessary for survival), and (2) are resistant to using

highly bureaucratic service agencies that present eligibility and

utilization barriers.

Case Management Strategies

Effective and realistic case management strategies for NDUs with

HIV-related disorders must be developed. Continuity of care is

essential for AIDS-diagnosed addicts and their families, who move

rapidly between hospitalization, drug treatment, social service

agencies, their homes, and, in some cases, the streets. While providing a single case manager for these clients may be unrealistic, the

multiple case management systems these clients encounter must be

coordinated, with all (including the NDU) agreeing upon who should

be the primary case manager. Linkage and coordination with formal

and informal community-based institutions are necessary. Intensive

efforts must also be directed toward strengthening links with public

entitlement systems and perhaps broadening their scope of responsibilities as well. For example, in New York City, the Health

Resources Administration formed an AIDS Case Management Unit to

deal with public assistance and Medicaid needs of persons with AIDS

and funds a residential facility for homeless persons with AIDS

(Campbell, personal communication, 1987). Links with communitybased institutions, such as schools, churches, welfare, vocational

rehabilitation, day care, foster care, prisons, and juvenile justice

systems, must be forged.

Provision of Concrete and Clinical Services

Direct provision of concrete social services might attract NDUs to an

AIDS education and counseling program. Services might include HIV

antibody counseling and testing, screening for sexually transmitted

265
diseases (STDs) and TB, and service advocacy, especially legal, housing, and public assistance. The provision of these services might

increase NDUs’ tolerance and tentative trust of the professional

health care providers. For example, the AWARE program for sex

industry workers in San Francisco has found the provision of a

health and physical evaluation, and HIV counseling and antibody

testing, are effective means of engaging and maintaining women in

the program (Cohen, personal communication, 1987).

Provision of mental health services for NDUs with HIV-spectrum

disorders and their collaterals is essential. Currently, there are few

psychosocial support services available for the asymptomatic seropositive; day treatment services for those suffering from impaired

mental functioning as a result of AIDS dementia are virtually

nonexistent. Treatment services for children whose parents or

siblings have AIDS are only just being developed in some

communities.

Greater creativity and innovation in the use of volunteers and

indigenous staff to support the NDU with AIDS are essential. A

corps of indigenous public health and social service workers who are

recovering addicts must be recruited and trained to work in the highrisk, high-drug-activity areas. These “natural” helpers serve as

gatekeepers of the community and can help bridge the gap between

the NDUs and the formal health and social service institutions.

Intensive community outreach with “shooting gallery” and “crackhouse” owners or managers should be attempted and evaluated to

examine the potential for reaching untreated addicts. Owners may be

trained to urge addicts to take advantage of the new social services

being provided. In addition, if needle exchange programs were to

move beyond the pilot demonstration phase, they could serve as the

gatekeepers for needles and “works” exchanges.

Increased Drug Treatment Resources

The availability, accessibility, and adequacy of drug treatment are

core ingredients of a comprehensive social service system for NDUs.

While funding for 5,000 more methadone treatment slots has been

approved in New York City, the numbers will still be inadequate to

handle the 50,000 spaces needed to accommodate the influx of addicts

desiring treatment (Schmalz 1988). Some expansion could be handled

266
by extending the hours of treatment programs and converting cityowned buildings into drug treatment facilities to serve an additional

3,000 addicts (New York Times 1988b).

Residential programs that provide treatment for substance abuse

disorders and AIDS and case management for NDUs with AIDS are

essential. Not all NDUs with HIV-related disease can function

independently and be managed on an outpatient service basis for

sociomedical care. A variety of institutional arrangements will be

required. Several drug treatment programs are moving beyond their

traditional roles and attempting to establish innovative residential

services for addicts with ARC or AIDS. For example, San Francisco’s

Baker Places has opened a daytime six-bed cooperative care unit for

people with triple diagnoses–ARC/AIDS, substance abuse, and a DSM

Axis 1 or 2 psychiatric disorder–and plans to open a 21-bed residential treatment unit for those capable of independent living in the

near future (Vernick, personal communication, 1987). Samaritan

Village and Project Return, large, drug-free therapeutic communities

(TCs) in New York City, have embarked upon a joint project to set

up an extended substance abuse treatment program within a TC

environment for HIV-symptomatic recovering addicts (Barton, personal

communication, 1988). These facilities might function like a flexible

health-related facility or an intermediate care facility, but provisions

would have to be made for maintaining a fixed number of skilled

nursing-level beds.

Combining Models in a Multiservice “Bridging” Project

The recently begun Pilot Needle Exchange Study of the New York

City Department of Health provides an example of integration of

health services and social services for the NDU population. NDUs

who want drug abuse treatment, but who cannot be immediately

admitted, can obtain services from the Department of Health through

the efforts of outreach workers or the treatment programs themselves. The staff of the Needle Exchange Study develop individualized case management strategies as a “bridge to treatment.” These

strategies induce health services, STD tests and HIV antibody testing,

counseling on risk reduction for both sexual and needle-sharing

routes of transmission, and advocacy to obtain the earliest possible

entry into treatment.

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Housing Alternatives

The lack of viable community-based alternatives to acute care has

resulted in excessive overstay of patients in acute care facilities, as

well as an inadequate number of appropriate housing facilities across

the spectrum of need. In New York City, these patients are likely to

be NDUs. While there is a serious lack of nursing homes and hospice

care, there are also inadequate services for persons with AIDS

(PWAs) who need a lower level of housing/supportive care. Many

residential care facilities do not want to accept the PWA with a

history of NDU because of management problems, e.g., how to handle

patients who have not kicked the habit and “shoot up” on the

premises. Discrimination and fear, the NIMBY (not in my backyard)

syndrome in the community, also play a major part in restricting the

development of housing resources. The lack of health insurance,

difficulty in securing public entitlements, and lack of documentation

to prove public assistance/Medicaid eligibility are major barriers to

the NDU obtaining supportive housing. To date, there have been few

successful housing initiatives for persons with HIV-related illness.

Homelessness has increasingly become a problem among persons with

HIV-related disorders. NDUs with HIV infection may lose their

housing because of difficulty in accessing the social services system,

money mismanagement, disorganized lifestyles, health complications or

activities of daily living problems, and discrimination (Norman 1988).

In many urban areas, especially where there is a large low-income

population, adequate, affordable housing is most difficult to obtain

and is a major cause of homelessness. For the NDUs, especially

those infected with HIV, the problem of housing accessibility is

compounded.

While there are many unresolved questions pertaining to the most

effective and appropriate housing alternatives for NDUs, we

recommend that experimental, innovative solutions be tested for

housing addicts and their families. This might include emergency

housing vouchers (Froner 1988) the provision of onsite methadone

with counseling and job-related services as well as a minimal service

program that provides methadone to those waiting for acceptance into

treatment programs (such as the outpatient program of New York’s

Beth Israel Medical Center recently approved by the Food and Drug

Administration). Since private real estate interests have been slow to

participate in developing housing resources for NDUs and the

homeless, it will become the responsibility of public social services

and the not-for-profit social agency sector to mobilize the resources

268
and serve as catalysts in establishing these programs. One such

program that could serve as a model for public/voluntary partnership

is the San Francisco Department of Health’s AIDS/ARC residential

program for the homeless population (many of whom have substance

abuse and/or mental health problems), which provides housing, social

services, nursing care, and family counseling (Carpi 1988; San

Francisco Department of Health 1988).

The specialized needs of women with AIDS and the increasing

population of HIV-infected babies of parents who are NDUs must be

addressed. Respite care for the mother or regular caregiver is one

arrangement that might increase a family’s ability to remain intact.

Housing and cooperative care for mothers who may be sick with HIV,

but want to keep their babies, is critical. For families unable to

care for their children, hospice programs (home based, hospital based

or freestanding) should be considered. Health services, income

supports or supplementation, and psychosocial support services may

also be required.

Reaching Youth At Risk

While less than 1 percent (n=325) of all reported AIDS cases have

occurred among adolescents as of December 12, 1988 (Centers for

Disease Control 1988), 21 percent (n=16,662) are among persons

between the ages of 20 and 29 years. Many of the latter were

probably infected during their teens as it may take up to 8 years

between the time of infection and the onset of HIV illness. Adolescents who lead dysfunctional or disorganized lives are at higher risk

for HIV infection than is currently evident in epidemiological data.

They reflect a spectrum of youth including: (1) the growing number

of runaways who show up in major cities and get involved in drugs,

crime, and prostitution; (2) homeless youth who are part of homeless

families; (3) hard-core unemployed youth; (4) adolescents who are

heavily into polydrug abuse or hustling activities; and sexually abused

teens (Daley 1988; Axthelm 1988). Of the approximately 1 million

teenagers who run away each year, 187,500 are estimated to be

involved in drug use, drug trafficking, prostitution, or solicitation

(U.S. Department of Health and Human Services 1986). In addition,

many adolescents who are still functional at home and in school are

experimenting with drugs and sex. These adolescents are difficult to

engage, because they are alienated from the mainstream service

delivery system. Therefore, strategies must be developed to reach

them within the context of their “natural” communities–in schools, at

“hang-outs,” on the streets, bus terminals, rock concerts, and
record/video stores. Offers of food, shelter, clothing, and pocket

money may be necessary to approach adolescents and “break the ice.”

While adolescence is a turbulent, distrustful developmental stage

under the best of circumstances, when compounded by drug abuse, the

prospects for effective service engagement are diminished. Therefore,

innovative “offbeat” ways must be devised to make services available

and inviting to kids who “hang tough.” Outreach services sponsored

by community organizations should be linked with discrete, creatively

designed school, hospital, clinic-based, or mobile health services to

make care more accessible.

The social and health services systems need to recognize and deal

with the conflict between adolescent resistance to parent-guided

utilization of services and the lack of emancipated minor status of

many youth. Issues of insurance and reimbursement for services

under public or private systems must be resolved to improve delivery

of services to this population (Hein 1988).

RESEARCH RECOMMENDATIONS

All the social service initiatives discussed in the previous section

must be supported by planned, systematic process, outcome, and

impact evaluation to determine program effectiveness and outcomes.

All-too-many programs have been designed and implemented based on

professional intuition or common wisdom and have lacked an effective

evaluation component. Program and education/prevention strategies

that show promise in reducing HIV infection rates and/or slowing the

spread of AIDS, increasing addicts’ entry into drug treatment, and

their use of health and social services, must be explored.

Needs assessment

Needs assessment is a formative type of evaluation used to help

shape population-sensitive and service-effective social service and

health programs.

The design of innovative and nontraditional programs must be

supported by a documentation of the needs of the various subsets

of the NDU populations. For example, the health and social

service needs of drug-using street prostitutes may not be the same

as those of a hard-core crackhouse population. A needs

assessment may inform us that these employed women require

ongoing monitoring of health status and STDs, child care

270
assistance, and psychosocially supportive services. Such

assessment might lead us to the development of a low-barrier

primary care health and social services center (like a storefront).

In contrast, the single male homeless addict might be shown to

require residential drug treatment as a means to extricate himself

from the destructive and seductive street environment.

Program evaluation

Evaluation of traditional and low-barrier services to the NDU

population is essential. Dedicated resources for outreach services

to NDUs are both labor and resource intensive. For example, the

use of a mobile van to provide multipurpose HIV prevention

services and case management must be evaluated to determine

whether the delivery of services in this fashion is more effective

than providing them in a traditional institutional setting. Evaluation would assess the numbers of people served, staff/client ratio,

number of counseling sessions required to engage a client, number

of referrals made to social service and drug treatment agencies,

number of entitlement Fair Hearings held, etc. Program impact

evaluation would entail assessment of changes in NDU clients’

HIV-related knowledge, attitudes, and behaviors, The success of

program outcome might be measured by a reduction of HIV seroprevalence and STD rates among NDUs in the broader community.

Another example of needed evaluation research relates to the

current controversy over the relative effectiveness of providing

methadone alone on demand to NDUs awaiting entry into

treatment programs versus methadone provided as part of a

comprehensive chemical dependency program that involves

psychotherapy, residential milieu treatment, vocational counseling,

and job-finding services.

Assessment of the effectiveness of community outreach workers as

“natural helpers” for HIV risk-reduction education and linkage to

social service and drug treatment agencies has received little

attention. This is an important avenue of research.

Investigators must evaluate the capacity for programs that have relied

on chemotherapeutic interventions alone (MMTP) to deal with both

the medical-social problems of HIV/NDU, and drug problems (cocaine/

crack) not currently amenable to chemotherapeutic intervention. We

271
must learn how the switch to cocaine and “crack” as the drugs of

choice has affected treatment potential for the NDU.

CONCLUSION

Clearly, community-based social services (linked closely with health

services) for the NDU with symptomatic HIV disease present a

challenge to policymakers and service providers. While NDUs are

dying sicker and quicker from AIDS than people infected by other

means, this trend may not continue. Through participation in experimental drug trials, such as those for AZT, and creation of a strong

supportive care network, the lives of NDUs with AIDS may be prolonged. The increased prevalence of the disease underscores the need

for augmentation of resources and new care and service arrangements.

Without systematic planning, thousands of NDUs will remain outside

the health and social service systems. With creativity, however,

perhaps another 20 percent or more of the currently untreated

addicts can be successfully engaged and treated.

The Nation’s consciousness and sense of humanity relative to the

AIDS epidemic will be the driving force behind our willingness to

allocate adequate financial resources and encourage the development

of alternative structures and new modes of service delivery. History

tells us that change is often precipitated by socioeconomic crises

(resulting from war and disease) and people’s reactive values and

attitudes rather than incremental planning. With AIDS, the pendulum

is still swinging. Will people be more compassionate and strongly

voice their support for increased resource allocation and service

system restructuring? Or will Puritanism and condemnatory social

and health policies prevail?

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pp. 64-68.

Balian, P.; Lebouc, V.; Roustang, I.; Bouchard, I.; Polo de Voto, J.;

and Espinoza, P. Has the open sale of syringes modified the

syringe exchanging habits of I.V.D.A. Poster session presented at

the Fourth International Conference on AIDS, Stockholm, Sweden,

June 1988.

Barton, E. Vice President for Administration, Samaritan Village, New

York, NY. Personal communication, 1988.

272
Belmont, M.; Mantell, J.; and Spivak, H. Resource Utilization by

AIDS Patients in the Acute Care Hospital. Final report to the

Health Services Improvement Fund, Inc., Empire Blue Cross/Blue

Shield, New York, NY, December 1985.197 pp.

Brager, G., and Hollaway, S. Changing Human Service Organizations:

Politics and Practice. New York: The Free Press, 1978. 244 pp.

Campbell, G. Director, Division of AIDS Services, Office of Home

Care Services, New York City Human Resources Administration.

Personal communication, 1987.

Carpi, J. Housing IV drug users who have not kicked the habit.

AIDS Patient Care, April 1988.

Centers for Disease Control, AIDS Program, Center for Infectious

Diseases. AIDS Weekly Surveillance Report-United States,

November 28, 1988.

Centers for Disease Control. Human immunodeficiency virus infection

in the United States: A review of current knowledge. MMWR 36

(suppl. no. S-6):1-48, December 18, 1987.

Check, W. Beyond the political modeling of reporting: Nonspecific

symptoms in media communication about AIDS. Rev Infect Dis

9:987-1000, 1987.

Cohen, J. Director, AWARE Program, University of California at San

Francisco. Personal communication, 1987.

Cohen, J.; Hauer, L.; and Wofsey, C. Women and IV drugs:

Parenteral and heterosexual transmission of human immunodeficiency

virus. J Drug Issues, in press.

Daley, S. Runaways of 42nd street: AIDS begins its scourge. New

York Times, May 30, 1988. p. 25.

Froner, G. AIDS and homelessness. J Psychoactive Drugs 20:197-202,

April-June 1988.

Goffman, E. Asylums. Garden City: Doubleday/Anchor Books, 1967.

Grieco, M.H. Director, Infectious Diseases and Epidemiology,

St. Luke's-Roosevelt Hospital Center, New York, NY. Personal

communication, 1988.

Gross, J. Needle exchange for addicts wins foothold against AIDS in

Tacoma. New York Times, January 23, 1989. p. A12.

Guinan, M., and Hardy, A. Epidemiology of AIDS in women in the

United States. JAMA 257:2039-2042, 1987.

Hegarty, J.D.; Abrams, E.J.; Hutchinson, V.E.; Nicholas, S.W.; Suarez,

M.S.; and Heagarty, M.C. The medical care costs of human

immunodeficiency virus-infected children in Harlem. JAMA

260:1901-1905, 1984.

Hein, K. AIDS in adolescence: a rationale for concern. Paper

prepared for the Council on Adolescent Development of the

Carnegie Corporation, April 1988. 68 pp.

273
Kemper, K, and Forsyth, B. Medically unnecessary hospital use in

children seropositive for human immunodeficiency virus. JAMA

260:1906-1909, October 7, 1988.

Kerr, P. Concerns about AIDS and crime spurring push to expand

drug treatment programs. New York Times, September 7.1988.

p. A18.

Lambert, B. AIDS danger rises for cocaine users. New York Times,

November 28, 1988a. p. A2.

Lambert, B. Panel asks for major expansion of drug clinics to

combat AIDS. New York Times, September 16, 1988b. pp. B1, B7.

Lewis, B.; Sullivan, J.; McCusker, J.; Birch, F.; Koblin, B.; and Hagan,

H. Comprehensive surveillance of HIV among NDUs in Worcester,

Massachusetts. Poster presented at the Fourth International

Conference on AIDS, Stockholm, Sweden, June 1988.

Maayan, F.; Wormser, G.; Hewlett, D.; Miller, S.; Duncanson, F.;

Rodriguez, A.; Perla, E.N.; Koppel, B.; and Rieber, E.E. Acquired

immunodeficiency syndrome (AIDS) in an economically disadvantaged

population. Arch Intern Med 145:1607-1612, 1985.

Marlink, R.; Foss, B.; Swift, R.; Davis, W.; and Essex, M. High rate

of HTLV-III/HIV exposure in IVDAs from a small-sized city and the

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Paper presented at the Third International Conference on AIDS,

Washington, D.C., June 1987.

Mondanaro, J. Chemically Dependent Women–Assessment and

Treatment. Lexington, MA: Lexington Books, 1989. 170 pp.

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Clarke, H.; and McAught, A. HIV and drug abuse: Essential

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Surveillance Update, January 25, 1989.

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January 31, 1988a. p. 26.

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February 11, 1988b. p. A34.

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October 14, 1988.

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Rothenberg, R.; Woelfel, M.; Stoneburner, R.; Milberg, J.; Parker, R.;

and Truman, B. Survival with the acquired immunodeficiency

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San Francisco Department of Public Health. AIDS in San Francisco:

Status Report for Fiscal Year 1987-88 and Projections of Service

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Health, San Francisco, CA, April 22, 1988. 283 pp.

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New Orleans, L.A, May 24, 1985.

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1988.

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Sotheran, J.L; Friedman, S.R.; Schultz, S.; Marmor, M.; Mildvan, D.;

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Personal communication, April 1987.

Wilensky, H., and Lebeaux, C. Industrial Society and Social Welfare.

New York: The Free Press, 1965. 397 pp.

AUTHORS

Lawrence C. Shulman, M.S.W., A.C.S.W.

Vice President for Social Work

St. Luke's-Roosevelt Hospital Center

428 West 59th Street

New York, NY 10019

and

Adjunct Associate Professor

Columbia University School of Social Work

622 West 113th Street

New York, NY 10025

275
Joanne E. Mantell, Ph.D., M.S.P.H.

Senior Research Scientist

New York City Department of Health

Director and Principal Investigator, Prevention

of Perinatal HIV Infection and AIDS Community

Demonstration Project

AIDS Research Unit, Box A/l

125 Worth Street

New York, NY 10013

and

Principal Investigator, AIDS Behavioral Research Program

Gay Men’s Health Crisis

Education Department

129 West 20th Street

New York, NY 10011

Charles Eaton, M.S.

Coordinator

Needle Exchange Program

New York City Department of Health

AIDS Research Unit

125 Worth Street

New York, NY 10013

Stephan Sorrell, M.D.

Medical Director, Substance Abuse Program

St. Luke's-Roosevelt Hospital Center

428 West 59th Street

New York, NY 10019

278
Accessing Intravenous Drug

Users via the Health Care

System

Patricia E. Evans

INTRODUCTION

The acquired immunodeficiency syndrome (AIDS) epidemic in

San Francisco has been an enigma since the first cases were

described in 1981. This enigma has continued into 1988 and must

be clearly understood to understand the unique differences that exist

between San Francisco and other areas of the country. For example,

the epidemic in San Francisco is largely a disease affecting gay and

bisexual men and has continued as such since the beginning of the

epidemic in 1981. Of the 4,371 total AIDS cases reported in San

Francisco as of 31 January 1988, 4,212 cases, or 97 percent, are

gay/bisexual men, of whom 520, or 11.9 percent, are also intravenous

drug users (IVDUs), while 3,681 cases, or 84 percent, are white

(San Francisco Department of Public Health 1988a). Nationally,

52,256 cases were reported to the Centers for Disease Control (CDC)

as of 1 February 1988, of whom 37,227, or 72 percent, were gay/

bisexual males. Of these, 3,858, or 8 percent, were IVDUs. In

contrast to the local statistics, 31,283, or only 61 percent nationally,

were white (Centers for Disease Control 1988).

In San Francisco, the number of heterosexual IVDUs is 62, or

1.4 percent of the total caseload. In contrast, the number of

heterosexual IVDUs nationally is 8,877, or 17 percent.

MINORITIES AND AIDS

A closer review of minorities with AIDS in the United States

illustrates the stark realities of the disproportionate number of cases

among blacks and Hispanics, as depicted in tables 1 through 6.

277
TABLE 1. AIDS in blacks and Hispanics (n=44,787)

Blacks and

Hispanics

Percent of

AIDS Cases

Total

Women

Heterosexuals

Children

39

70

71

77

NOTE: Cases reported to CDC by 2 November 1987.

Tables 2 and 3 provide a closer review of AIDS cases by transmission

category for ethnic groups.

TABLE 2. AIDS cases by transmission category and ethnic

group (percent)

White Black Hispanic

(n=22,299) (n=7,729) (n=4,373)

Gay/BisexualNon-IVDU 82.8 47.5 54.5

IVDU or Sex

Partner of IVDU 12.3 40.1 40.4

Other 4.9 12.4 5.1

A look at the IV-drug-using population in the United States and

San Francisco is depicted in table 5.

As can be seen, the percentage of AIDS cases associated with IV

drug use in San Francisco is lower in all categories with the

exception of gay/bisexual males, who have used IV drugs (8 percent

vs. 12 percent) (Centers for Disease Control 1988; San Francisco

Department of Public Health 1988a).

278
TABLE 3. AIDS cases by transmission category comparing

ethnic groups (percent)

White Black Hispanic

(n=739) (n=1,314) (n=446)

IVDU or Sex

Partners of IVDUs 47.8 89.9 82.5

Sex Partner of

Bisexual Men 6.9 2.8 2.7

Other Women with

AIDS 45.3 27.3 14.8

TABLE 4. AIDS cases in children by transmission category

comparing ethnic groups (percent)

White Black Hispanic

(n=117) (n=283) (n=107)

Mother or Mother’s

Sex Partner was

IVDU 39.8 60.8 5.7

Other Children

with AIDS 60.2 39.2 24.3

SOURCE: Centers for Disease Control 1997.

CHARACTERlSTICS OF lVDUs IN SAN FRANCISCO

There are an estimated 10,000 to 12,000 IVDUs in San Francisco

(Newmeyer 1987). The racial composition of IVDUs in drug abuse

treatment in 1985 to 1986 and 1986 to 1987 is presented in table 6.

In the period 1986 to 1987, 38 percent of the IVDUs in San Francisco

were female and 62 percent were male. Sixty-eight percent, or 5,651

IVDUs were admitted for heroin use, 6 percent, or 460 for

279
TABLE 5. Comparison of AIDS case distribution for selected risk

groups, United States vs. San Francisco (percent)

Risk Group United States San Francisco

(n=51,487) (n=4,371)

Heterosexual IVDUs

as Percent of All

Adult AIDS Cases 17 8.5

Gay/Bisexual Male

IVDUs as Percent of

All Adult AIDS Cases 8 12

Female Sex Partners

of IVDUs as Percent

of All Female Heterosexual Cases 80 46

Children Born to IVDUs

or Their Sex Partners

as Percent of All

Perinatal AIDS Cases 75 54

TABLE 6. Racial composition of IVDUs in treatment in San Francisco,

1985 to 1986 and 1986 to 1987 (percent)

Race 1985-86 1986-87

(n=5,800) (n=8,232)

White 58 52

Black 23 28

Latino 15 14

Asian 3 5

Native American 1 1

SOURCE: San Francisco Department of Public Health 1988b.

280
amphetamine use, and 13 percent, or 1,045 for cocaine use (San

Francisco Department of Public Health 1987).

There are indications that the IV-drug-using populations in

San Francisco are at increasing risk of developing AIDS, especially

when seropositivity data are analyzed. These data indicate that, over

time, there has been a slow but steady increase In human immunodeficiency virus (HIV) seropositivity, especially among the ethnic

minority IV-drug-using populations. Chaisson and colleagues have

followed IVDUs in treatment since 1984, and their data, presented in

table 7, demonstrate these increases (Chaisson et al. 1988).

TABLE 7. HIV seropositivity rates in heterosexual IVDUs

Treatment Programs Hospitalized Users

HIV HIV

Sero- SeroYear positive IVDUs Percent positive IVDUs Percent

1983-84 3 77 4 3 21 14

1985 22 234 12 N/A

1986-87 98 784 13 8 44 18

Watters, of the Urban Health Project, has provided information

regarding the IVDUs not in treatment. His figures for 1988 range

from 7 percent for IVDUs participating in a 21 day detoxification

program to 16 percent for IVDUs not in treatment (Watters 1987).

Chaisson’s data, broken down by ethnic group, are presented in

table 8.

HEALTH CARE SYSTEMS

There has been a greater increase for the black IV-drug-using

community than for other groups. Consequently, the door is open for

a significant increase in HIV infection and AIDS among heterosexual

IVDUs to emerge in San Francisco unless effective strategies to

prevent further spread among IVDUs are in place and working

effectively.

281
TABLE 8. HIV seropositivity rates by ethnic group for heterosexual

IVDUs in treatment (percent)

Ethnic Group 1985 1986-87

White 143 (6%) 328 (7%)

Black 80 (15%) 188 (26%)

Hispanic 78 (14%) 94 (10%)

First, we must ask ourselves if we intend to solve this epidemic using

known public health methods, which are global in nature, or if we

will use the political, or band-aid, approach.

Since I have been asked to focus on the health care delivery system

and how to reach the IV-drug-using population, let me provide some

background information. In general, the health care system can be

described as a huge and complex system within systems, which can be

divided into the public and the private sectors.

The private sector consists of health care providers in private

practice, members of health maintenance organizations (HMOs),

preferred provider organizations (PPOs), Independent Practice

Associations (IPAs), and other alphabetical abbreviations, so

commonplace today. Various hospital systems, for profit or not for

profit, are also included in the private sector share of the health

care system. Although there are IVDUs who use the private system,

the vast majority of highest risk IVDUs do not generally receive

services from this part of the health care system.

The public sector includes public hospitals, public clinics, and other

public health care facilities and services, such as laboratories,

immunizations, or environmental health.

For our purposes, health care services incorporate all health services

including public health. “Public health services exist primarily to

prevent disease, promote health, and to measure and evaluate the

health status of populations” (Last 1980, p. 3). By taking a global

approach to the AIDS epidemic, good public health measures can

certainly assist in the war against this deadly disease.

282
Prevention Via the Public Health System

Preventive services, which form a large part of public health, can be

broken down as follows:

Community services–those aimed at the community (e.g., clean

water);

Personal services–those aimed at the individual (e.g., health

education and risk reduction for smoking cessation); and

Combined community and personal services–those aimed at both

the community and the individual (e.g., screening or immunizations) (Jonas 1980).

Prevention can be further categorized as primary, secondary, or

tertiary (Last 1980). Primary prevention deals with preventing the

occurrence of disease or injury (e.g., by immunization). Since there

is no vaccine currently available for AIDS, primary prevention does

not seem likely in the very near future.

Secondary prevention deals with early detection and intervention

(e.g., HIV antibody screening, health education, and counseling of

seropositive individuals.)

Tertiary prevention deals with minimizing the effects of disease and

disability by surveillance and maintenance aimed at preventing

complications and deterioration (e.g., use of AZT in asymptomatic

HIV-positive individuals).

A major question to ask is: How can the IVDU be reached through

the current health care system from a public health, preventive

perspective?

Figure 1 is a very complicated diagram of perinatal services in

San Francisco. Although complex, it can be viewed as an excellent

example of reaching IVDUs. As can be noted, many of the programs

listed are actually prevention programs. Many public health

departments have moved away from the prevention-only model to

providing primary care in public health clinics. The hospital system

is a prime example of a model that combines primary, secondary, and

tertiary care required for medically indigent adults as well as those

individuals requiring care through the public health system. Many

contacts with IVDUs may be secondary or peripheral to the IVDU,

283
because the primary contact is with the sexual partner of the IVDU

or other family members. These opportunities must be seized and

utilized to the greatest advantage. Thus, unique opportunities for

providing education and prevention do exist.

FIGURE 1. Perinatal program links

SOURCE: San Fmndsco Department of Health 1987.

284
Utilizing Prevention/Education Opportunities

Public health nursing is often called upon to assist in a clearer

understanding of family dynamics related to certain circumstances

(e.g., child abuse, family dysfunction, or inappropriate use of the

health care system.) During these family or home visits, the public

health nurse is instrumental in obtaining significant information that

may assist providers in understanding the family situation and the

reason behind certain types of behavior. These encounters can assist

in identifying high-risk individuals and can also provide opportunities

for education and referral of high-risk persons.

District health centers provide primary care as well as preventive

care to families and individuals seeking services from the public

health care system. Thus, there is opportunity for direct contact

with the IVDU or with family members within these centers.

Preventive programs such as WIC (Women, Infant, and Children

Feeding Program), CHDP (Child Health and Disability Prevention

Program), and immunizations allow for repeated contacts with family

members, during which brief educational messages can be imparted.

The Forensic Program allows direct access to jail inmates, male and

female, and again provides opportunities for individual and group

educational interventions with IVDUs and their sex partners.

The hospital system provides for a variety of needs for the clients

seeking care through this system. Although usually overburdened and

overworked, it can provide a setting to reach IVDUs at many levels

(San Francisco Department of Public Health 1987).

STRATEGIES FOR DEVELOPING HEALTH CARE SYSTEMS

Although these are only a few examples of how to reach the at-risk

populations, this model can be developed for most public health

programs. There are a number of steps that must be taken to make

this type of system effective, however, if behavior change of the atrisk population is the ultimate goal.

Full education of health care providers working in the system is

needed to enlighten providers regarding AIDS, its prevention,

transmission, etc. Too often, it is assumed that knowledge about a

new development or disease will be acquired automatically by those

caring for the ill. This assumption is a fallacy: education must be

285
afforded health care providers to assist them in gaining the

knowledge to become more comfortable with a disease process.

Since AIDS touches upon subjects often taboo in society (sexuality

and IV drug use), providers’ prejudices regarding these subjects must

be dealt with in an open and forthright manner.

Because IVDUs and minorities are so closely linked with AIDS,

providers’ prejudices relating to social deviance, sexism, and racism

must be dealt with openly, and opportunities for understanding one’s

feeling in relationship to this disease must be given.

There must be better education of students of health care and health

care professionals, so that they clearly understand drug abuse,

treatment modalities, and the whys and wherefores of intervention

programs.

Providers must become comfortable with taking sexual and drug

histories in a nonjudgmental fashion with all clients entering and

participating in the health care system, not just those considered to

be at risk. Assumptions about one’s probability of being infected

should not enter into history taking. But a good history will assist

in identifying additional patients who could be at risk.

There must be a clear understanding of the entire health care system

and where, throughout the system, efforts can be made effectively to

change a client’s behavior and allow positive reinforcement of

behavior change.

Informal or formal links must be developed between programs to

allow for ease of referral.

Last, additional monies must be added to an already overburdened and

overwhelmed system. AIDS has pushed the system to the limits and

will continue to do so. Therefore, additional funding must be added

to the system to prevent total collapse. Other prevention programs

cannot be allowed to fall by the wayside at the expense of those who

are already infected, ill, and dying.

REFERENCES

Centers for Disease Control. Minority Slides (1-238). Center for

Infectious Diseases, Centers for Disease Control, November 2, 1987.

286
Centers for Disease Control. AIDS Surveillance Report - United

States AIDS Program. Center for Infectious Diseases, Centers for

Disease Control, February 1998.

Chaisson, R.; Bacchetti, P.; Osmond, D.; Brodi, B.; Sande, M.; and

Moss, A. HIV infection in intravenous drug users in San Francisco.

Presented by Andrew Moss, M.D., at the Center for AIDS

Prevention Studies Community Forum on AIDS Education

Interventions for IVDUs, February 1988.

Jonas, J. Provision of public health services. In: Last, J.M., ed.

Public Health and Preventive Medicine. New York: Appleton,

Century-Crofts, 1980. pp. 1614-1633.

Last, J.M. Scope and methods of prevention. In: Last, J.M., ed.

Public Health and Preventive Medicine. New York: Appleton,

Century-Crofts, 1980. pp. 3-8.

Newmeyer, J. Personal communication, 1987.

San Francisco Department of Public Health. Perinatal Plan,

FY 1987-88. Report to Health Commission, City and County of San

Francisco, January 1987.

San Francisco Department of Public Health. Acquired

lmmunodeficiency Syndrome (AIDS) Monthly Surveillance Report:

Summary of Cases Meeting the CDC Surveillance Definition

in San Francisco Cases Reported through 1/31/88. 1988a.

San Francisco Department of Public Health, Division of Mental

Health, Substance Abuse and Forensic Services. Community

Substance Abuse Services Updated Plan for Fiscal Year 1988-89.

Draft, 1988b.

Watters, J.K. Preventing human immunodeficiency virus contagion

among intravenous drug users: The impact of street-based

education on risk behavior. Presented at the Third International

Conference on AIDS, Washington, D.C., June 1-5, 1987.

AUTHOR

Patricia E. Evans, M.D., M.P.H.

Associate Medical Director

AIDS Office, San Francisco

1111 Market Street, 3rd Floor

San Francisco, CA 94103

287
Community Prevention Efforts to

Reduce the Spread of AIDS

Associated With Intravenous

Drug Abuse

Robert J. Battjes, Carl G. Leukefeld, and Zili Amsel

Developing an effective vaccine to prevent the spread of the acquired

immunodeficiency syndrome (AIDS) is expected to take a long time,

and, until a vaccine is developed, the only means to prevent the

spread of AIDS is through behavior change. Therefore, persons at

risk for human immunodeflciency virus (HIV) infection must be

informed of their risk for AIDS and helped to modify behaviors that

place them at risk.

This monograph has focused on the prevention of HIV transmission

among intravenous (IV) drug abusers, from drug abusers to their

sexual partners, and perinatally to their children. IV drug abuse has

played a major role in the spread of the AIDS epidemic. IV drug

abusers constitute 30 percent of recently reported adult AIDS cases

in the United States (Centers for Disease Control 1988). Also, the

heterosexual and perinatal spread of AIDS is largely associated with

IV drug abuse (Chamberland et al. 1987; Oxtoby, personal communication, 1987), and IV drug abusers have been identified as major

vectors for the spread of AIDS to the general population (U.S. Public

Health Service 1986).

The potential for rapid spread of HIV among IV drug abusers exists

because such drug abusers commonly share drug injection equipm

This rapid spread has been demonstrated in New York City. While

the first cases of HIV infection among IV drug abusers appeared

there in 1978, 25 percent of a sample of such abusers were infected

by 1979, and infection rates approximated 60 percent by late 1986

(Des Jarlais, personal communication, 1967). While high levels of H

infection are found among IV drug abusers in New York City and

several other major metropolitan areas, infection rates are still low in

288
many parts of the United States (Hahn et al. 1988). lt is crucial

that effective AIDS prevention programs be initiated throughout the

country to prevent further spread of HIV in high-prevalence areas

and to prevent initial spread in low-prevalence areas. IV drug

abusers and their sexual partners must be helped to change those

behaviors that place them, others, and their unborn children at risk.

Behavior change is often difficult, especially when targeted behaviors

are valued and/or reinforced. Yet, many Americans are changing

their behaviors to improve their own health–fewer people are

smoking; more people are exercising; and many people have reduced

fat consumption. These behavior changes within the general U.S.

population have been achieved slowly and incrementally over the past

few decades, and many Americans continue to smoke, lead sedentary

lives, and consume excess fats.

Drug-abusing behaviors–most specifically, needle use–are among

those behaviors that have proven difficult to modify. Drug dependence is a chronic medical disorder, not a temporary condition.

Overcoming dependence requires extensive lifestyle change, and longterm abstinence is difficult to achieve without help. Even with

intensive drug abuse treatment, most IV drug abusers require repeated

and prolonged treatment to overcome drug dependence. Short of

abstinence from drugs, behavior change to reduce risk of HIV

transmission is also difficult to achieve. However, IV drug abusers

are generally concerned about their risk for AIDS, and many are

taking steps to reduce their risks (Des Jarlais et al. 1988; Newmeyer

1988). Yet, it appears that risk-reduction efforts by drug abusers are

often incomplete and inconsistently applied, and many IV drug abusers

continue to regularly engage in high-risk behaviors. Sexual behaviors

are also difficult to modify and may be even more resistant to change

than drug-using behaviors (Newmeyer 1988).

Thus, using behavior change approaches to prevent AIDS associated

with IV drug abuse presents a challenge. Providing information alone

is not sufficient. lt is apparent that IV drug abusers and their

sexual partners will need considerable help to consistently and

effectively reduce their risks for contracting and transmitting HIV.

Considering the urgency of this need, it is essential that AIDS

prevention initiatives be designed for maximum effectiveness.

Experiences with other behaviors, such as dietary modification,

smoking cessation, and performance of a regular exercise regimen,

289
have shown that both the initiation and the maintenance of

behavioral change can be successfully achieved within the context of

the target group’s environment or community (Fortmann et al. 1986;

Pushka et al. 1988). Community prevention approaches are designed

for specific target groups, are delivered by individuals and

organizations that have credibility and are trusted within the target

groups, and incorporate social support within the community to

reinforce behavioral change (Nelkin 1987). Thus, rather than relying

on a single intervention strategy, community prevention approaches

use multiple sources to encourage, support, and reinforce change.

Based on the success of community prevention in changing selected

health behaviors, this approach provides possible models for designing

programs to prevent the spread of AIDS.

Like the general population, IV drug abusers and their sexual partners

are members of various well-defined communities. By consolidating

knowledge about these communities, their structure, how IV drug

abusers and their sexual partners interact with their communities, and

how these communities affect behavior, strategies can be developed to

reach IV drug abusers and their sexual partners and to help these

target groups reduce their risks for contracting and transmitting HIV.

The technical review that served as the basis of this monograph was

designed to explore “communities” and their potential as vehicles for

the implementation of AIDS prevention strategies aimed at IV drug

abusers, their sexual partners, and their children. In the prior

chapters, the authors have discussed AIDS prevention issues relevant

to various target communities. Some of the communities are

distinguished by the demographic characteristics of their memberships.

Chapters address specific racial/ethnic groups, women, white males,

gay IV drug abusers, nonopiate IV drug abusers, and prostitutes who

are IV drug abusers. The monograph also includes communities that

are defined by institutional setting. Chapters address schools, drug

abuse treatment programs, the criminal justice system, shelters for

the homeless, the social service system, and the health care system.

FRAMEWORKS FOR COMMUNITY PREVENTlON

Two of the authors, Maccoby and Gilchrist, present frameworks that

are useful guides for community AIDS prevention, regardless of the

“community” that is being considered. These frameworks will be

reviewed briefly before considering the recommendations for

community prevention and research that emanated from the technical

review.

290
Maccoby has summarized the experiences of one research team that

implemented a series of coordinated community health promotion

programs combining the use of media and face-to-face interventions.

Several points made by Maccoby in his chapter warrant emphasis

here.

First, their research and interventions moved beyond many prevention

approaches that focus simply on providing information, modifying

attitudes, and motivating behavior change to include teaching target

audiences specific behavioral skills in self-regulation (i.e., control

over ones own behavior).

Second, they used a sequential strategy that proceeded through

specific stages, including the presentation of information, stimulating

the development of personal analyses of risk behaviors, and

demonstrating desired skills.

Third, knowledge, beliefs, attitudes, risk-related behaviors, and media

exposure of their target audience were continuously monitored and

their intervention(s) were modified, based on this feedback

information.

Fourth, program design proceeded through specific steps and was

guided by a formative evaluation that began with a needs analysis of

the target audience and proceeded to segment the audience into

subsections for program development.

Fifth, local communities were involved in program design from the

outset to assure their ownership and control of the program, to take

advantage of interpersonal leadership of key individuals, and, thereby,

to enhance the likelihood of initial success and program durability.

Another broad framework that is useful in developing community

AIDS prevention initiatives was presented by Gilchrist, drawing on

the work of R.S. Gordon (1983). This typology for adolescent

prevention programming, which is applicable to prevention efforts

with other “communities” as well, identifies three levels of program

intensity, based on the target groups’ risk potential. The first level

of programming, “universal,” is aimed at the general public.

Universal programming, the least intensive level, provides information

and opportunity to practice those skills that are needed to maintain

safe behavior. The second level of programming, “selective,” focuses

on geographic areas where the AIDS risk is above average, i.e., areas

where drug use, delinquency, and sexually transmitted disease rates

291
are high. Selective programming is more intensive, including

additional program elements such as stress management, building selfesteem, and developing communications skills. The third level of

programming, “indicated,” concentrates on individuals who are already

engaging in behavior associated with HIV transmission. Indicated

programming must be highly personalized and provide support over an

extended time period. Thus, in planning community AIDS prevention

programs, it is important to first analyze the degree of risk potential

of the community and various segments of the community.

RECOMMENDATIONS

The following recommendations are presented with the general goal of

furthering and expanding the current state-of-the-art of community

interventions focused on preventing the spread of HIV among IV drug

abusers, their sexual partners, and their children. In keeping with

the comprehensive purpose of the technical review, to describe

innovative community prevention efforts for IV drug abusers, and to

specify research initiatives, the recommendations are grouped under

two areas: community intervention recommendations and research

recommendations. lt should be noted that these recommendations do

not represent the consensus of those participants who attended the

technical review, but they do present general agreement.

Community Intervention Recommendations

Guiding principles recommended for community intervention

programs are as follows: (1) interventions should incorporate

multiple and repeated components to increase the likelihood of

reaching and having a lasting effect on the target group;

(2) interventions cannot be viewed in isolation, but must draw

upon other community resources; (3) case management staff are

needed to aggressively seek out the target groups (IV drug

abusers, their spouses, and other sexual partners) and to link them

with relevant community resources; (4) interventions must be

intended to reach people where they are–to build on their own

motivation, rather than demanding that they behave as society

believes they should; and (5) activities related to AIDS

transmission cannot be considered in isolation, but must be

considered in the context of major social problems, including

homelessness, poverty, joblessness, and racism.

From the public health point of view, and to contain the spread

of HIV, it is essential that the goal of drug abuse abstinence and

292
the goal of HIV prevention be recognized as separate issues.

Abstinence is the most effective means of HIV prevention, and it

is desirable to help IV drug abusers stop uslng drugs. However, it

must be recognized that many IV drug abusers will be unwilling or

unable to stop. Thus, interventions with IV drug abusers who are

not in treatment should have a dual focus–encouraging riskreduction efforts and entry into treatment.

Drug abuse treatment is an important element in community AIDS

prevention. A major limitation has been the lack of sufficient

treatment availability. In major metropolitan areas where drug

abuse is endemic, drug abuse treatment programs are filled to

capacity, and addicts seeking treatment are placed on waiting lists

or simply turned away. If the potential of drug abuse treatment

as an AIDS prevention strategy is to be realized, treatment

capacity must be expanded, and additional treatment personnel

must be trained to provide these services.

If the contribution of drug abuse treatment to AIDS prevention is

to be maximized, treatment must not only be expanded, but must

also be made more flexible and accessible. Same-day intake

services should be available to those seeking help, and treatment

should be available 24 hours per day. In addition, treatment

programs need to reach out into the community. Services must be

culturally specific and linguistically appropriate for various target

communities.

Outreach efforts should encourage and facilitate entry into drug

abuse treatment for those who are willing, and should encourage

other risk-reduction behaviors for those who are not. The

expansion of treatment must be accompanied by an expansion of

outreach efforts into all areas where IV drug abuse is endemic.

Outreach services, using indigenous workers who have credibility

and can penetrate drug-abusing subcultures, are an important part

of community prevention efforts with drug abusers not in

treatment. However, outreach efforts should not rely entirely on

indigenous workers–workers with a range of expertise and

background experiences are needed. In addition to street

outreach, outreach should also occur using other approaches, such

as the use of mobile vans in areas where drug abuse is endemic

and through various community agencies such as public housing

programs, the criminal justice system, hospital emergency rooms,

public health centers, sexually transmitted disease clinics, homeless

293
shelters, and single-room-occupancy hotels. Staffs of such

agencies should be trained regarding both IV drug abuse and AIDS,

and AIDS education should be available to IV drug abusers within

these facilities.

Given the large numbers of IV drug abusers who are involved with

the criminal justice system, lockups, jails, prisons, and probation

and parole offices can provide important access points for AIDS

education to encourage behavior change and to facilitate referral

to drug abuse treatment. Linkages between the criminal justice

system and drug abuse treatment should facilitate initiation of

treatment prior to institutional discharge and provide for the

ongoing involvement of probation and parole officials in support of

the treatment process.

Specific outreach programs are needed for the various special

target communities addressed earlier in this monograph, such as

blacks, Hispanics, women, gays, and the homeless. And there is a

need to target subsegments of these communities, such as pregnant

women. Homeless drug abusers provide an example of a target

community that will need an array of supportive social services if

AIDS prevention services are to be effective. AIDS risk behaviors

and housing problems are intertwined–the needs of homeless IV

drug abusers for adequate housing must be addressed if AIDS risk

reduction is to be achieved and maintained. Similarly, for many

target groups, health care services play an important role in

community AIDS prevention by providing a locus for interventions

and supporting behavior change efforts. Community-based, multiservice centers are necessary to provide adequate health care to

supplement drug abuse treatment programs in order to meet the

health care needs of IV drug abusers.

Prevention efforts cannot focus on IV drug abusers only, but must

also reach their sexual partners. As with IV drug abusers

themselves, prevention efforts aimed at sexual partners must

utilize indigenous workers and community agencies that currently

are in contact with this group. It is especially important that

supportive services for women offer alternatives to unprotected,

unsafe sex. Prevention efforts should also target families of IV

drug abusers, so that family members encourage and support

behavior change.

Community AIDS prevention efforts must focus not simply on

those who are not yet infected, but also on those who are already

294
infected, in order to reduce thelr likelihood of transmitting HlV to

others. Messages for those infected need to communicate–“Living

with HIV infection, not dying from AIDS.”

Finally, major barriers to community interventions were identified.

These included the lack of adequate funding for drug abuse

treatment and AIDS outreach, community opposition to the

expansion of drug abuse services, fragmentation of services, fees

for treatment that deter treatment entry, lack of appropriately

trained personnel to provide treatment and outreach, lack of

leadership at all levels, and existence of paraphernalia laws that

prevent exploration of needle distribution approaches.

Research Recommendations

Community research in the drug abuse field is in its infancy. Success

with community interventions focused on selected health behaviors

are encouraging, yet the promise of community approaches in

preventing the spread of HIV infection among IV drug abusers, their

sexual partners, and children is as yet untested. Thus, a rigorous

program of research is needed to develop effective interventions.

The review group made a number of recommendations relevant to

community interventions. These recommendations touched on the

need for data to guide interventions as well as outcome research to

determine program efficacy.

Research is needed on the incidence and prevalence of HIV

infection among IV drug abusers and their sexual partners to

better define the target populations. Changes in prevalence over

time must also be determined to understand the spread of the

epidemic.

Research should focus on risk behaviors. What are these

behaviors? What is the prevalence and incidence of these

behaviors? What is their meaning? What factors support the

maintenance of risk behaviors? How are behaviors changing in

response to the AIDS epidemic?

295
Research should focus on community or population traits that

support or impede behavior change. What are community

attitudes, norms, values, or other cultural characteristics that

affect risk behaviors and efforts to change behaviors? What

community support systems and communication patterns affect

efforts to change risk behaviors?

Research should focus on community information channels. What

networks, resources, and services have credibility?

At the community level, evaluative research needs to determine

baseline measures of risk behaviors, HIV infection, and AIDS and

determine the changes in these measures over time. Community

interventions need to be theory-based and adapted to the needs of

the specific community through developmental research. Project

implementation should be designed to permit evaluation of program

models, including process evaluation (e.g., availability, acceptability, satisfaction) and outcome evaluation (e.g., changes in

knowledge and attitudes, risk behaviors, and incidence of HIV

infection).

A number of methodological issues affect the ability to evaluate

community interventions. These issues are not unique to AIDS

prevention initiatives, but are common to all community prevention

research efforts. A major drawback to efforts to “prove” that

community prevention approaches are effective may be a lack of

appropriate research methods to demonstrate a program effect.

Specific methodological issues identified include the following:

One issue is the difficulty in measuring effect. HIV infection, the

ultimate measure of program effect, may not be a sensitive

indicator, especially in areas where infection rates are initially

very low. Measurement of highly personal and illegal risk

behaviors such as sexual intercourse and IV drug abuse must

generally rely on subject self-report, which raises issues of the

validity of the outcome data.

Other issues relate to the use of appropriate control or

comparison groups in community research. Randomization of

subjects to treatment conditions is seldom possible. Random

assignment of communities to treatment conditions does not assure

comparability across conditions except in very large studies where

a large number of communities are involved. Comparison communities may be used, but comparability between experimental and

296
comparison communities cannot be assured. Change within a

community over time might be assessed, but such a historical

control is particularly questionable in the rapidly changing AIDS

field.

Another issue is the independence of the evaluation. Is the

evaluation internal (i.e., conducted by the organization

implementing the intervention) or is it external (i.e., conducted by

an independent group)? If the evaluation is internal, is there an

independent advisory group or some other mechanism to assure the

objectivity of the evaluation?

A final issue concerns generalizability of research findings.

Interventions may not generalize between high- and low-risk

communities or across subgroups of a community. Thus, multisite

studies and studies focusing on multiple subgroups may be

necessary.

A common problem facing both program implementation and research

is the definition of the community. To develop effective interventions and to demonstrate their effectiveness require clarity regarding

the target community. Too often, community interventions have a

vague sense of community–often defined as residents of a certain

geographical area. In this review of community AIDS prevention, a

number of distinct communities have been identified and considered.

While a community intervention may cover multiple communities, the

intervention strategies employed must be tailored to the unique needs

and resources of the component communities, and research must

address program effect on each of these communities.

REFERENCES

Battjes, R.J., and Pickens, R.W., eds. Needle Sharing Among

Intravenous Drug Abusers: National and International Perspectives.

National Institute on Drug Abuse Research Monograph 80. DHHS

Pub. No. (ADM)88-1567. Washington, D.C.: Supt. of Docs., U.S.

Govt. Print. Off., 1988.189 pp.

Centers for Disease Control. AIDS Weekly Surveillance Report -

United States. Atlanta, GA, October 3, 1988.

Chamberland, M.; White, C.; Lifson, A.; and Dondero, T.J. AIDS in

heterosexual contacts: A small but interesting group of cases.

Paper presented at Third International Conference on AIDS,

Washington, D.C., 1987.

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Des Jarlais, D.C. New York State Division of Substance Abuse

Services, personal communication, 1987.

Des Jarlais, D.C.; Friedman, S.R.; Sotheran, J.L; and Stoneburner, R.

The sharing of drug injection equipment and the AIDS epidemic in

New York City: The first decade. In: Battjes, R.J., and Pickens,

R.W., eds. Needle Sharing Among Intravenous Drug Abusers:

National and International Perspectives. National Institute on Drug

Abuse Research Monograph 80. DHHS Pub. No. (ADM)88-1567.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp.

180-175.

Fortmann, S.P.; Haskell, W.L; Williams, P.T.; Varady, A.N.; Hulley,

A.B.; and Farquhar, J.W. Community surveillance of cardiovascular

disease in the Stanford Five-City Project: Methods and initial

experience. Am J Epidemiol 123(4):856-669, 1986.

Gordon, R.S., Jr. An operational classification of disease prevention.

Public Health Rep 98:107-109, 1983.

Hahn, R.A.; Onorato, I.M.; Jones, T.S.; and Dougherty, J. Infection

with human immunodeficiency virus (HIV) among intravenous drug

users. Paper presented at Fourth International Conference on

AIDS, Stockholm, Sweden, June 1988.

Nelkin, D. AIDS and the social sciences: Review of useful

knowledge and research needs. Rev lnfec Dis 9(5):980-986, 1987.

Newmeyer, J.A. Why bleach? Development of a strategy to combat

HIV contagion among San Francisco intravenous drug users. In:

Battjes, R.J., and Pickens, R.W., eds. Needle Sharing Among

Intravenous Drug Abusers: National and lntemational Perspectives.

National Institute on Drug Abuse Research Monograph 80. DHHS

Pub. No. (ADM)88-1567. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1988. pp. 151-159, 1988.

Oxtoby, M. Centers for Disease Control, personal communication,

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Pushka, P.; Salonen, J.A.; Nissinen, A.; Tuomilehto, J.; Vartiainen, E.;

Korhene, H.; Tanskanen, A.; Rönnqvist, P.; Koskela, K.; and

Huttunen, J. Change in risk factors for coronary heart disease

during 10 years of a community intervention programme. (North

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298
AUTHORS

Robert J. Battjes, D.S.W.

Associate Director for Planning

Carl G. Leukefeld, D.S.W.

Deputy Director

Zili Amsel, Sc.D.

Research Epidemiologist

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Rooms 10A38 and 10A16

5600 Fishers Lane

Rockville, MD 20857

299
monograph series

While limited supplies last, single copies of the monographs may be

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and Drug Information (NCADI). Please contact NCADI also for

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publications of the National Institute on Drug Abuse relevant to

drug abuse research.

Additional copies may be purchased from the U.S. Government Printing

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(NTIS) as indicated. NTIS prices are for paper copy. Microfiche

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Addresses are:

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P.O. Box 2345

Rockville, Maryland 20852

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25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman A.

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26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor. Ph.D.,

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30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES. Dan

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31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D., ed.

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32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

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38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan J. Lettieri, Ph.D.,

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40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

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42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

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45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

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47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

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48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING BEHAVIOR.

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50 COCAINE: PHARMACOLOGY, EFFECTS, AND TREATMENT OF ABUSE. John

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51 DRUG ABUSE TREATMENT EVALUATION: STRATEGIES, PROGRESS, AND

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52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND ABUSE

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53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John Grabowski.

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54 MECHANISMS OF TOLERANCE AND DEPENDENCE. Charles Wm. Sharp,

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56 ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION. Coryl LaRue

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57 SELF-REPORT METHODS OF ESTIMATING DRUG USE: MEETING CURRENT

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58 PROGRESS IN THE DEVELOPMENT OF COST-EFFECTIVE TREATMENT FOR DRUG

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59 CURRENT RESEARCH ON THE CONSEQUENCES OF MATERNAL DRUG ABUSE.

Theodore M. Pinkert, M.D., J.D., ed.

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60 PRENATAL DRUG EXPOSURE: KINETICS AND DYNAMICS. C. Nora Chiang,

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63 PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG CHILDREN AND

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D.S.W., eds.

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64 PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.

GPO Stock #017-024-01281-5 $6.50

65 WOMEN AND DRUGS: A NEW ERA FOR RESEARCH. Barbara A. Ray, Ph.D.,

and Monique C. Braude, Ph.D., eds.

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66 GENETIC AND BIOLOGICAL MARKERS IN DRUG ABUSE AND ALCOHOLISM.

Monique C. Braude, Ph.D., and Helen M. Chao, Ph.D. eds.

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68 STRATEGIES FOR RESEARCH ON THE INTERACTIONS OF DRUGS OF ABUSE.

Monique C. Braude. Ph.D., and Harold M. Ginzburg, M.D.,J.D.,M.P.H.,

eds.

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69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S. Rapaka, Ph.D.;

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70 OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY, BIOSYNTHESIS, AND

ANALYSIS. Rao S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.

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71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M. Brown,

Ph.D.; Doris H. Clouet, Ph.D.; and David P. Friedman, Ph.D., eds.

GPO Stock #017-024-01303-0 $6 PB #89-151955/AS $28.95

72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims. Ph.D.. and

Carl G. Leukefeld, D.S.W.. eds.

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73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D.,

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74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE. Stephen I

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and

75 PROGRESS IN OPIOID RESEARCH. PROCEEDINGS OF THE 1986 INTERNATIONAL NARCOTICS RESEARCH CONFERENCE. John W. Holaday, Ph.D.;

Ping-Yee Law, Ph.D .; and Albert Herz, M.D., eds.

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76 PROBLEMS OF DRUG DEPENDENCE, 1986. PROCEEDINGS OF THE 48TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE. INC. Louis S. Harris, Ph.D., ed.

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77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT RESEARCH.

Elizabeth R. Rahdert, Ph.D., and John Grabowski, Ph.D., eds.

GPO Stock #017-024-01348-0 $4 NTIS PB #89-125488/AS

78 THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO DRUGS

David P. Friedman, Ph.D., and Doris H. Clouet. Ph.D., eds.

GPO Stock #017-024-01330-7 $6

79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS

Rao S. Rapaka, Ph.D., and Alexandros Makriyannis. Ph.D., eds

GPO Stock #017-024-01331-5 $6

80 NEEDLE-SHARING AMONG INTRAVENOUS DRUG ABUSERS: NATIONAL AND

INTERNATIONAL PERSPECTIVES. Robert J. Battjes, D.S.W., and Roy W.

Pickens. Ph.D., eds.

GPO Stock #017-024-01345-5 $5.50

81 PROBLEMS OF DRUG DEPENDENCE, 1987. PROCEEDINGS OF THE 49TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01354-4 $17

82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D., and

David P. Friedman, Ph.D. eds.

GPO Stock #017-024-01344-7 $4.25

83 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos, M.D. and

John A. Dougherty, Ph.D., eds.

GPO Stock #017-024-01351-0 $3.25 NTIS PB #89-125496/AS

84 LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A. Ray, Ph.D., ed.

GPO Stock #017-024-01353-6 NTIS PB #89-125504/AS

85 EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE. Raquel A Crider, Ph.D.,

and Beatrice A. Rouse, Ph.D., eds.

GPO Stock #017-024-01360-9 $5.50 NTIS PB #89-123178/AS

86 COMPULSORY TREATMENT OF DRUG ABUSE: RESEARCH AND CLINICAL

PRACTICE. Carl G. Leukefeld, D.S.W., and Frank M. Tims, Ph.D., eds

GPO Stock #017-024-01352-8 $7.50 NTIS PB #89-151977/AS $28.95

87 OPIOD PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and Bhola N.

Dhawan, M.D., eds.

GPO Stock #017-024-01366-8 $7

88 MECHANISMS OF COCAINE ABUSE AND TOXICITY. Doris H. Clouet, Ph.D.,

Khursheed Ashar. Ph.D., Roger M. Brown, Ph.D., eds.

GPO Stock #017-024-01359-5 $11 NTIS PB #89-125512/AS

304
89 BIOLOGICAL VULNERABILITY TO DRUG ABUSE. Roy W. Pickens, Ph.D.,

and Dace S. Svikis, B.A., eds.

GPO Stock #017-022-01054-2 $5 NTIS PB #89-125520/AS

90 PROBLEMS OF DRUG DEPENDENCE, 1988. PROCEEDINGS OF THE 50TH ANNUAL

SCIENTIFIC MEETING. THE COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE,

INC., Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01362-5 $17

91 DRUGS IN THE WORKPLACE: RESEARCH ND EVALUATION DATA

92 TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS. Marian W.

Fishman, Ph.D., and Nancy K. Mello, Ph.D., eds.

U.S. GOVERNMENT PRINTING OFFICE: 1994 300-973/00009

305
National Institute on Drug Abuse

NIH Publication No. 94-3714

Formerly DHHS Publication No. (ADM) 89-1627

Printed 1990

Reprinted 1994