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HIV/STD Prevention in Rural America

 
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Programs to Decrease Risk from Injection Drug Use
 

Alcohol and illegal drug use can lead to behaviors that put people at heightened risk for HIV infection. Nearly 12% of rural male adolescents and adults diagnosed with HIV in 2008 were exposed to the virus by injecting drugs. Approximately 5% of rural men were exposed by both injecting drugs and having male to male sex. In comparison, over 15% of female adolescents and adults diagnosed with HIV in 2008 in rural areas (with fewer than 50,000 residents) attribute their infection to exposure from injecting drugs. [1] This means that interventions need to target sexual risk behaviors as well as behaviors that involve sharing drugs, syringes and injection works, or rinse water. The programs that follow are tailored to those who inject drugs. Programs specific to women who have sex with drug users are included in the subsequent section on women. Adaptations of published effective interventions are described first, followed by locally developed programs.

Healthy Communities / Safety Counts

Target Behaviors and Behavioral Determinants
Sharing unclean syringes, rinse water, other injection works; engaging in unprotected sex; unknown HIV serostatus; lack of motivation to change drug use or sexual risk behaviors; lack of social support for safer sex and drug use practices.

Description
Adaptation of Safety Counts (DEBI)
Healthy Communities is an individual-level outreach HIV prevention intervention based on the Safety Counts DEBI that targets out-of-treatment injection and non-injection drug users in rural Connecticut. The program aims to reduce high-risk drug use and sexual behaviors. The behaviorally focused, seven-session intervention includes both structured and unstructured –educational, social, and counseling activities in group and individual settings. It helps clients identify the stage of their readiness to change, create a plan for behavior change, and access substance use counseling and medical services including HIV testing.

Adaptation
The core elements that dictate the content of the seven sessions remain unchanged. Recruitment is done at local single room occupancy living facilities, soup kitchens, shelters, and locations where drug users gather. The groups are held in a neutral appearing, but agency owned space. Recruiting from outlying rural areas has proven very difficult in arranging transportation to get people to a central location for the intervention.

Evidence
The original research showed that Safety Counts participants were more likely than a control group to decrease injection frequency, increase condom use, and decrease drug use and sexual risk behaviors. Process and outcomes measures are being collected by Healthy Communities but are not available at this time.

Recommendations
This model may not work in all rural communities. We have been successful because recruitment was done in a rural town with a large addict/recovering addict community and a long history of relationships between public health and gatekeepers. Small communities with fewer spaces for drug users to gather may require more creative recruitment strategies. Providing transportation assistance is important for retention.

Where Implemented
Willimantic, Connecticut (town of about 16,000)

Contact Information
Connecticut Department of Health
860-509-7806

 

Taking it to the Population

Target Behaviors and Behavioral Determinants
Sharing unclean syringes, rinse water, other injection works; engaging in unprotected sex; unknown HIV and hepatitis C serostatus; lack of access to clean syringes; lack of motivation to adopt safer sex and drug use practices.

Description
Taking it to the Population is a locally developed one-hour group-level HIV education outreach program facilitated by an outreach worker who preferably is a recovered addict or alternatively a service provider with a strong ability to relate to active drug users. The program includes information about HIV transmission, prevention, and testing resources; strategies to increase motivation to engage in HIV prevention behaviors; and skills needed to practice HIV prevention behaviors. The program is based on the Information-Motivation-Behavioral Skills HIV Prevention Model.

Evidence
The intervention group showed a significant gain in knowledge, motivation, and intention to engage in prevention behaviors from pre-test to post-test as compared to a control group. Of those followed for 18 months, 93% reported an ongoing positive effect from the training including: abstaining from drug use, not hanging out with people who use drugs, getting tested for HIV and HCV, and seeking positive social support from a variety of sources.

Recommendations
Implementing Taking it to the Community at the same time to target community providers who interact with drug users. For instance, working with pharmacies to support needle exchange and distribute prevention messages. Working on multiple levels enhances the impact. Using a former user to recruit and facilitate the group can open the door to the drug using community. This requires sensitive support and supervision of the facilitator.

Where Implemented
Rural Montana and Rural Colorado

Contact Information
Casey Rudd 406-556-1139

 

 

Taking it to the Community (Westcap) and Reaching Rural Drug Users (NCAP)

Target Behaviors and Behavioral Determinants
Increased perception of HIV and HCV risk; increased knowledge of HIV and HCV status; increased and correct use of condoms; decreased number of sexual partners; decreased sharing of used syringes, spoons, water, other drug works; and increase capacity to seek and use community services.

 

Description  
Locally developed intervention aimed at individuals with a history of          substance use and/or addiction.  Developed to replace an EBI (effective       behavioral intervention), Community PROMISE, that was not effective in    this rural community.  The tailored intervention is based on Taking it to the Population, an intervention developed and used in Montana, as well as information from key informant interviews, focus groups and provider input. The 2-hour small group education session includes skills-building exercises to increase adoption of safer sex and drug use practices, and to increase use of basic needs services.  One-on-one risk reduction counseling and HIV and hepatitis testing offered individually.

 

Evidence           
Pilot programs in two areas of Colorado have served a total of 454 clients at WestCAP and provided more than 1,000 counseling sessions at NCAP. Although about 50% of participants have been tested for HIV, allwith negative results, the hepatitis C positivity rates at the two sites have been 17% and 24%. The intervention has resulted in an increase in knowledge of both HIV/HCV risk reduction and personal viral status and increased access to mental health services.

 

Recommendations          
Focus groups are needed to tailor and adapt an intervention for the local audience. For instance, focus groups indicated that rural Colorado drug users needed to have basic needs (food , hygiene, transportation) met before they were able to “hear” prevention messages. Therefore, monetary incentives such as supermarket gift cards and local transit passes are provided to program participants along with basic hygiene kits and safer injection and safer sex kits.

Where Implemented

     Western Colorado AIDS Project (WestCAP)

     Northern Colorado AIDS Project (NCAP)

    Contact Information

Rabeeha Ghaffar
Resource and Prevention Director, Western Colorado AIDS Project
rabeeha@westcap.info
(970) 243-2437

Christopher Grano
Prevention Director, Northern Colorado AIDS Project
chris@ncaids.org
(970) 484-4469 x 20                 

 

 

Risk Reduction Education (Westcap)

Target Behaviors and Behavioral Determinants

Increased perception of HIV and HCV risk; increased knowledge of HIV and HCV status; increased and correct use of condoms; decreased number of sexual partners.

 

Description  
Locally developed intervention aimed at individuals with a history of  substance use and/or addiction that provides HIV and HCV education combined with testing in correctional and substance use treatment facilities. Since 80% of WestCAP’s HIV-positive clients indicate they were under the influence of alcohol or other substances at the time of infection, this is a priority population for intervention. The tailored intervention is based on the Health Belief and Transtheoretical models of behavior change plus information from key informant interviews, focus     groups and provider input.

 

Evidence           
Since its inception in 2007, 2,178 individuals have received HIV/HCV education through RRE, 1,140 have been tested for HIV, and 616 screened for HCV.   Over 80% of clients served indicated an increase in HIV/HCV knowledge.  Additionally, over 50% of clients tested for HIV and 85% for HCV were previously unaware of their status. 

 

Recommendations          

Focus groups and interviews with the target audience and providers indicated two distinct needs: one for an education-based prevention program with HIV and HCV testing provided on site at locations like substance addiction programs; and second, a need for a separate intervention for substance users other than those with a history of injection drug use.

Where Implemented

     Western Colorado AIDS Project (WestCAP)

   

    Contact Information

Rabeeha Ghaffar
Resource and Prevention Director, Western Colorado AIDS Project
rabeeha@westcap.info
(970) 243-2437

 

 

Peer Delivered Syringe Exchange

Target Behaviors and Behavioral Determinants
Reduced sharing of HIV or Hepatitis C contaminated syringes;  reduced unprotected male to male sex; increased perception of HIV risk.

 

Description 
Locally-developed Peer Delivered Syringe Exchange (PDSE) allows for syringe exchange without geographic boundaries or scheduling constraints. The program based on social network theory builds on established relationships between PDSE Peers and drug using participants with whom they conduct exchange. Additionally, Peers are trained to provide harm reduction education and referrals for other related services such as HIV and hepatitis C testing.

Evidence           

Early data document that the volume of exchanges Peers perform in any given month far surpass the number of transactions completed in storefronts. Without the PDSE program, entire at-risk populations of injection drug users would have little or no access to clean syringes.

 

Recommendations          
Rural storefront syringe access can be challenging due to participants having to travel long distances with limited or no public transportation options or the inability to get to a Syringe Exchange Program (SEP) during open hours. Peer Delivered Syringe Exchange (PDSE) allows for syringe exchange to occur without geographic boundaries or scheduling
  restrictions.

Where Implemented

Southern Tier AIDS Program

2 rural sites in upstate New York

Contact Information
Jeffrey Wynnyk

Director Prevention Services, Southern Tier AIDS Program

(607) 798-1706

 

Target Behaviors and Behavioral Determinants
Sharing unclean syringes, rinse water, other injection works; engaging in unprotected sex; unknown HIV and hepatitis C serostatus; lack of access to clean syringes; lack of motivation to adopt safer sex and drug use practices.

Description
Montana Targeted AIDS Prevention (MTAP) is a collaborative project between local community-based organizations and the Missoula AIDS council to provide individual-level street outreach to reduce injection and sexual behaviors that increase risk of HIV transmission. Target populations are rural injection drug users (IDU), MSM and MSM who also inject drugs (MSM/IDU). MTAP services include HIV prevention education, rapid HIV testing and counseling, distribution of risk reduction materials (condoms, lubricant, fit packs of clean syringes, bleach kits, cottons), and referrals for health and mental health care. Recent emphasis is on increasing HIV and hepatitis C testing and counseling. Small gift cards and at-home hepatitis C test kits are being assessed for their impact as incentives for getting HIV tested.

Evidence
Since its inception in 2000, MTAP has reached over 20,000 contacts. In the most recently evaluated twelve month period, 3,444 contacts were made with individuals who identify as MSM, IDU, or MSM/IDU and 223 HIV tests were conducted. There were no positive results in that period. Testing was also targeted to heterosexual American Indians who are alcohol dependent and reported sexual risks. Changes in risk behaviors have not been measured at this point in the project due to budget limitations.
Recommendations: Be careful conducting IDU street outreach. Most rural communities do not have a “visible” street culture which makes direct contact outreach to active users risky from the user’s perspective and law enforcement’s. Make sure to have community buy-in. Outreach workers are the key to success for the program. Making sure that those tested are in the risk categories targeted is an ongoing challenge.

Where Implemented
Montana statewide through collaborations

Contact Information
Missoula AIDS Council
500 North Higgins Avenue, Suite 100
Missoula, Montana 59802
Phone: 406.543.4770
Fax: 406.728.4172
Web: Missoula AIDS Council

 

 

Target Behaviors and Behavioral Determinants
Sharing unclean syringes, rinse water, other injection works; having unprotected sex; lack of access to HIV/STD testing and hepatitis vaccination; lack of access to clean syringes; lack of transportation and access to counseling and medical services.

Description
LifeGuard was formed to respectfully collaborate with persons who choose to make positive change in their life. To work with intention toward this point, LifeGuard will: Strive with intention to carry no bias, judgement or condemnation into relationships. Meet with people where they are - physically, emotionally, spiritually, and geographically (as possibl.) Provide harm/risk reduction counseling as indicated and rquested. Provide easy access to syringe exchange through the I-74X-Change, a privately-supported research project. Provide access to outreach HIV Counseling, Testing, and Referral. Provide capacity building for service providers upon request. Provide accesss to confidential Hepatitis C testing for individuals meeting program criteria. Provide acces to confidential Hepatitis A & B immunization for individuals meeting program criteria. Provide overdose prevention education including access to Naloxone

Evidence
Based on Social Network Theory and Diffusion of Innovation theory as well as evidence of efficacy of harm reduction activities in other settings. Budget constraints have prevented this small program from collecting evaluation data.

Recommendations
The LifeGuard program works because it is small, flexible and low-threshold. "We don’t try to be all things to all people. We grow contacts through word-of-mouth, collaborate with other organizations, and deliver services that meet the needs of the user." Requires thinking and working outside the box.

Where Implemented
Chicago Community Area: Outside Chicago
Chicago Neighborhood: Outside Chicago / Not Listed
Chicago Area: Outside Chicago

IL County: Rock Island
County Area: Central

Contact Information
Phone: (888) 528-1173
Contact Name: Beth Wehrman
Email: lifeguard@mindspring.com
Website: www.lifeguardonline.org

 

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