Overview
In 2004 the California Department of Health Services, Office of AIDS (CDHS/OA) solicited applications from qualified local health jurisdictions (LHJs) that were interested in developing, implementing, and evaluating targeted HIV prevention interventions among injection drug users (IDUs) and satellite syringe exchangers (SSEs) through peer-based prevention efforts. LHJs were encouraged to collaborate with community-based organizations that had a track record of effectively working with IDUs. Five programs were funded in California and awards were approximately $100,000 per site, per year for three years beginning July 1, 2004. The LHJs which were funded, and their community partners are listed below. Click on the program name to link to the programs website.
Participating Sites
Technical assistance (TA) is provided to all funded programs by OA staff with expertise in working with IDUs and SSEs. Early in the implementation phase, contractors attended a mandatory orientation meeting to discuss program goals and implementation guidelines. Periodic TA meetings and site visits are organized and facilitated by OA thereafter in order to coordinate intervention implementation and evaluation efforts across all sites.
Background
HIV and Hepatitis Risk Among Injection Drug Users (IDUs)
Injection drug users continue to be at high risk of HIV/AIDS and hepatitis infection in California. Sharing of contaminated syringes and other injection equipment is linked to 20 percent of all reported AIDS cases in the state. Through March 31, 2006, 140,425 AIDS cases have been reported in California with 14,479 (10%) reported among injection drug users (IDUs) and 13,055 (9%) reported among men who have sex with men and inject drugs (CDHS/OA, 2006). State data suggests that over 1,500 new syringe-sharing infections occur annually (CDHS/OA, 2001).
The link between injection drug use and HIV in California is particularly strong for women and people of color. Among adult/adolescent women in California, IDU-related risk factors account for 36 percent of cumulative AIDS cases (CDHS/OA, 2006). Forty-six percent of AIDS cases among African American women and 55 percent of AIDS cases among Native American women are associated with injection drug use compared to 40 percent of AIDS cases among white women (CDHS/OA 2002). As the average lifetime cost for treating a person with AIDS is estimated to be $195,000, it is clear that reducing the number of IDU-related AIDS cases would also reduce the fiscal burden on publicly-funded AIDS care and treatment programs across the state. This requires outreach that focuses on both injection and sexually-related risk behaviors.
There are an estimated 500,000 to 600,000 Californians currently infected with hepatitis C virus (HCV) with an additional 5,000 new infections annually. It is estimated that 60% of these infections are related to injection drug use. Up to 90% of IDUs are estimated to be infected with HCV (CDHS, 2001; Williams, 1999). A reduction of the number of IDU-related HCV cases would reduce the associated public costs of care and treatment that reach approximately $20,000 per person per year for medications and approximately $300,000 for a liver transplant.
The U.S. Public Health Service and the Centers for Disease Control and Prevention (CDC) have recommended that sterile syringes be used on a one-time-only basis in order to reduce the spread of deadly bloodborne viruses and diseases (CDC, 1997). Syringe exchange programs (SEPs) are one source of sterile syringes that can assist IDUs in trying to carry out this recommendation.
Syringe Exchange Programs (SEPs)
Public health science has demonstrated that SEPs, first developed and implemented in the U.S. during the 1980s, are among the most effective HIV prevention interventions that target IDUs. SEPs facilitate the exchange of used and potentially contaminated syringes for new, sterile syringes among IDUs who might not otherwise have access to syringes. Since they typically require that used syringes be exchanged for new ones, they also foster safe syringe disposal, decreasing the chance that other community members will come into contact with used syringes. SEPs also provide IDUs with regular access to other injection equipment (e.g., cookers, cottons, water, alcohol pads, antibiotic ointment) and condoms that decrease risky sexual behavior (potentially an even greater risk for HIV infection among IDUs in California). Further, SEPs offer a number of ancillary services to IDUs who are not often served in traditional health care settings. Such services frequently include HIV and hepatitis counseling and testing, hepatitis vaccination, abscess/wound care, health education, peer education and health assessments, for example. Finally, SEPs also provide IDUs with referrals to drug treatment programs, housing shelters and food banks as well as additional medical and social services.
Numerous studies concur that improved syringe access reduces the rate of HIV transmission, without increasing rates of drug use, drug injection, or crime. A recent study of syringe exchange found more than a twofold decreased odds of HIV risk behavior associated with SEP use and a sixfold decrease in the odds of HIV risk behaviors in IDUs who do not have access to other sources of syringes (Gibson, 2002). In cost-benefit analyses, SEPs have been shown to be extremely cost-effective typically costing between $4,000 and $40,000 in primary prevention funds per HIV infection averted (Kahn,1998) significantly less than the average lifetime cost for treating a person with AIDS.
Presently, 37 SEPs operate in California in 20 Counties, providing important HIV and hepatitis prevention services, as well as other health services, to IDUs throughout the state.
Satellite Syringe Exchange
While scientific evidence suggests that SEPs play a crucial role in preventing injection-related viral transmission, research suggests that SEPs cannot do this alone and need to be supplemented by additional services (Sears et al., 2001; Snead et al., 2003; Strathdee et al., 1997). Limited funding and service schedules make it difficult for SEPs to reach all IDUs (Stopka et al., 2003, Lurie et al., 1993) and may be less effective at reaching young IDU populations (Snead et al., 2003). The California Syringe Exchange Program (CALSEP) study found that legally sanctioned SEPs are open an average of 18 hours per week. Consequently, when looking at location and hours of operation of California SEPs, the studys researchers found that only 9% of the states SEPs were found to provide sufficient access to syringes to maximize disease prevention (Bluthenthal et al., 2003). Even if traditional SEPs could be open and staffed for longer periods of time on a daily basis, it is widely understood that some IDUs do not feel comfortable attending SEPs for fear of being identified and stigmatized as drug users and for fear of harassment or arrest by local police.
Scientific research indicates that IDUs who do not visit SEP sites may nonetheless be receiving their services through networks of satellite syringe exchangers (SSEs), that is, IDUs who collect used syringes from their peers, exchange them for clean syringes at SEP sites, and deliver clean syringes back to their peers (Valente et al., 1998; Tyndall et al., 2002, Snead et al., 2003; Sears et al., 2001; Anderson et al., 2003; Voytek et al., 2003). To date, limited research has been conducted on the extent of effectiveness of satellite exchange networks in reducing HIV and hepatitis transmission risk (Sears et al., 2001), but it appears that SSEs are able to extend HIV prevention materials and messages to large numbers of injecting peers and are able to reach pockets of transmission risk that might not otherwise be reached. Recent research suggests that, while SSEs may be able to reach large numbers of IDUs with harm reduction materials, they appear to be at higher risk for accidental needle sticks due to the high volume of syringes that they handle and they may practice higher risk behaviors than IDUs who are not SSEs (Lorvick et al., 2006). Thus, it appears that SSEs are important people to integrate into existing HIV prevention programs in California for two primary reasons: 1) to extend the viral prevention services of existing SEPs to a broader community of IDUs, and; 2) to decrease potentially risky behaviors among SSEs while they reach out to IDUs during prevention efforts.
Peer Education Within Drug Using Populations
Peer-based prevention has been a widely used strategy for HIV prevention with drug users that capitalizes on peer influence processes. Peer educators may have access to and influence of drug users at highest HIV risk and may be able to alter group norms and risk behaviors. Through social diffusion, a process by which an innovation is adopted and gains acceptance by members of a certain community, indigenous peer-based prevention may potentially impact risk behaviors of large segments of communities at risk (Friedman, et al., 1999). Outreach by peers may also be a means of self- and community empowerment and serve as an important step in organizing drug users and other disenfranchised groups (Friedman et al., 1987). Peer outreach appears to be effective in reducing injection-related risk behavior among IDUs who are contacted by peer educators who are much like themselves (Coyle et al., 1998).
Peer outreach can also affect behavioral risk reduction of the peer educators. Social identity theory (Tajfel, 1981; Turner, 1978) holds that when individuals identify with a group, the collective group concept becomes part of their self-concepts. In this process, a redefinition of self emerges and the individuals behaviors tend to become congruent with the groups goals and actions. Researchers in one study found that low-income, primarily African American women who discussed risk reduction with friends and neighbors as part of an intervention reported long-term sexual behavior change (Sikkema et al., 1996). Participants in a peer-based intervention who were encouraged to provide peer outreach and education to drug users were more than 3 times as likely to report cessation of drug injection, almost 3 times as likely to report reduction in needle sharing, and over 7 times more likely to report increased condom use with casual partners than IDUs who did not participate in the peer-based intervention (Latkin et al., 2003). The intervention was equally effective for HIV seropositive and seronegative participants. The study results support the premise that public advocacy of risk reduction leads to behavior change. Some participants reported that to be respected as peer educators they could not be hypocritical, which may have helped promote and sustain their own behavioral risk reduction (Latkin et al., 2003). All of the five programs which were awarded contracts chose to develop interventions which position IDUs to provide peer support, guidance and education to others. Prior research indicates that if SSEs are trained as peer educators, they may feel obliged to reduce their own injection and sexual risks so as to avoid feeling hypocritical and to lead by example when it comes to prevention.
In summary, HIV and hepatitis infection risks are high within the IDU community. SEPs are effective in decreasing syringe sharing as well as other injection-mediated and sexual risk factors. SSEs serve as well positioned extensions of established SEPs and possess tremendous potential as popular opinion leaders and peer-based prevention educators in California.
Program Description and Scope of Work
Comprehensive Services
Funded programs contracted to implement a comprehensive prevention model that integrates a peer-based intervention with IDUs and SSEs and includes both mandated and optional services. Optional services address a broad spectrum of needs that contribute to increased risk of HIV exposure and other health problems. These services include counseling and workshops on such topics as substance use, overdose prevention, safer sex negotiations, resources for homeless individuals, hepatitis prevention, and vaccination. All sites opted to include one or more optional services. Mandated services include those listed below.
Health Education and Prevention
Individual and/or group education services on HIV/AIDS prevention are provided to the target population where the client can discuss behaviors that present a risk for acquiring and transmitting HIV infection. Interventions include provision of activities that encourage safe behaviors among SSEs and IDUs (e.g., safer injection practices, safer sex strategies, harm reduction approaches, etc.) as well as peer educator training for SSEs that facilitates their health education and prevention efforts with the injecting community. This may take the shape of formalized workshops or be incorporated into less structured ongoing discussions/follow-up with SSEs. Activities may include support group sessions, drop-in discussions, group outreach-oriented prevention and education, materials development (e.g., ‘zine, SEP brochures, satellite syringe exchange guide, safe injection guides) and the like.
HIV and HCV Counseling and Testing (C&T)
HIV counseling and testing are encouraged as a core component in the work with the target population. The provision of HIV testing in each community allows participants to identify testing as a regular and normalized means of participating in risk reduction.
Staff working on each intervention refer SSEs and IDUs to HIV testing sites. If outreach staff involved in the project are HIV counselors, they themselves can conduct the HIV C&T. If not, they build rapport with local HIV C&T coordinators and staff in order to facilitate regular referrals and testing of IDUs throughout their LHJ. Staff also refer participants to HCV counseling and testing locales. Additionally, program staff are required to provide IDUs and SSEs with referrals to medical and social services as needed. Potential referral locales include, but are not limited to, drug treatment programs, mental health programs, health clinics, shelters, and food banks.
Staffing
Staffing needed to offer effective peer-based HIV prevention and education as well other essential services to IDUs and SSEs may include but are not limited to the following examples:
Peer-based Prevention Coordinator: designs and implements activities that will include recruitment, outreach, health education, referrals, etc.; trains and supervises outreach staff, provides regular guidance and support; communicates regularly with OA to provide updates and to seek support; writes quarterly reports that highlight program challenges and successes for submission to OA; establishes relationships with other organizations in the community to facilitate smooth referral processes for outreach staff and clients; assists with outreach efforts as needed; attends trainings as needed (estimated 10%-25% FTE).
Community Health Outreach Worker/Peer Educator: recruits project participants and peer educators and maintains contact with them throughout project; implements and evaluates outreach services that include health education, provision of harm reduction materials, provision of appropriate referrals; establishes rapport with other community agencies to which client referrals can take place; documents client (i.e., IDUs and SSEs) interactions; maintains supplies and access to outreach supplies; assists with quarterly reports; attends trainings as needed (estimated 50%-100% FTE).
Evaluator: aggregates data that is required for thorough evaluation of the project; communicates with OA staff regularly about project findings and lessons learned; documents extent to which program is effective in decreasing HIV risk behaviors among IDUs and SSEs impacted by the project; transfers project data to the OA regularly; attends trainings as needed (estimated 10%-25% FTE).
References
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Bluthenthal, R. (2003). Syringe Exchange Program Diversity and Correlates of HIV Risk: Preliminary results from the California Syringe Exchange Program Study. Presentation to the CA State Office of AIDS, Aprill 22, 2003. Sacramento, CA.
Centers for Disease Control and Prevention, “HIV Prevention Bulletin: Medical Advice for Persons Who Inject Illicit Drugs”, May 9, 1997
Department of Health Services. California & the HIV/AIDS Epidemic: The State of the State Report 2001. Released December 2002.
Department of Health Services. Hepatitis C Strategic Plan. Recommendations for the Prevention and Control of Hepatitis C in California. 2001
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