Running Head: HIV PREVENTION PROGRAM IUDs 1

HIV Prevention Program for High Risk Injection Drug Users

Kayla Martinez

California State University Long Beach

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Background
It is estimated that over 1.1 million adults and adolescents were living with HIV at the

end of 2015 in the U.S. (CDC, 2017). HIV or Human Immunodeficiency Virus is a virus that

attacks the body’s immune system, depleting our body’s natural defense system or ability to

ward and fight off disease (AVERT, 2017). The virus accomplishes this by destroying T-helper

cells, a type of white blood cell, and then creates copies of itself (AVERT, 2017). As, HIV

creates copies of itself inside the host cells, it gradually breaks down a person’s immune system

leaving them weak and ill (AVERT, 2017). If left untreated, HIV eventually advances to AIDS

or Auto Immune Deficiency Syndrome, which can be a death sentence for those who do not get

proper treatment (AVERT, 2017). Due to advances in health promotion programs, the number of

HIV diagnoses here in the U.S. have declined. The annual number of HIV cases fell 10% from

2010 to 2014 (CDC, 2017). However, those that use injection drugs are at increased risk for

obtaining the disease, accounting for more than one third of new AIDS cases, which is double

the proportion of 5 years ago (Gibson, 1998). The Center for Disease Control estimates that

Injection Drug Users or IUD’s account for nearly half of the 40,000 new HIV cases per year

(CDC, 2017). Additionally, IUD’s are 28 times more at risk for HIV compared to that of the

general population (AVERT, 2017). The growing opioid epidemic is also cause for concern in

relation to HIV rates, since it is creating new injection drug users who may be unaware of the

risk involved with needle usage (CDC, 2017). Furthermore, since drug use is highly stigmatized

behavior, injection drug users often fall through the cracks of our health system. Meaning there

is strong public health need for HIV prevention programs aimed at rehabilitating those who use

injection drugs.

Literature Review
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For the purpose of this paper, 5 HIV prevention programs were chosen as a basis for

review. The first program, Safety Counts, is an HIV prevention intervention aimed at reducing

both high risk drug use and sexual behaviors (CDC, 2015). It utilizes the health belief model,

theory of protection motivation, and the transtheoretical stages of change model as a basis for

understanding HIV behavior in IUD’s (CDC, 2015). Safety first involves 9 sessions over the

course of a 4-6 month period which focus on developing and implementing a personalized risk

reduction plan (CDC, 2015). The first two sessions of the program involve individual standard

pretest counseling meetings, which focus on drug prevention education, mostly illicit injection

drugs such as morphine, heroine, and amphetamine (CDC, 2015). The education element in the

first two sessions incorporates basic HIV/AIDS information and provides supplement HIV

testing and counseling if participants so desire (CDC, 2015). The following 2 sessions involve an

interactive workshop that implements a stage of change model with peer to peer involvement

(roughly 3-7 participants), where participants create a risk reduction plan, identify sources of

support, watch videos that feature “role models”, and determine their own HIV risks (CDC,

2015). The fourth session involves a one on one counseling session where counselors help

participants to strengthen their commitment to personal goals, establish a social support network,

and given referral to support services if needed (CDC, 2015). After one month, participants are

required to perform 2, 15-20 minute field-based outreach to reinforce progress (CDC, 2015).

Lastly, the program features 2 monthly social events, where clients and their peers provided

support to one another (CDC, 2015). Evaluation of the program found that those who completed

the program were significantly less likely to report injecting drugs at 1 to 5 months after

completion of the program (CDC, 2015). Additionally, of those participants who completed 7 out
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of the 9 sessions, were significantly more likely to report an increase in condom use from

baseline to follow up as well report a decrease in high-risk drug behavior (CDC, 2015).

The next program analyzed is called Project Start and focuses on HIV/Hepatitis risk

reduction for people returning to the community after incarceration (CDC, 2010). Although the

population is different, those who are incarcerated are more likely to involve themselves in drug

use behavior, so I thought the program could be generalized to IUD’s. Project Start is an

individual level intervention based of conceptual framework of incremental risk reduction, and

focuses mainly on increasing participants awareness of HIV/Hepatitis risk (CDC, 2010). Four

program sessions start before participants are released from incarceration and three more take

place after incarceration, spanning a three month period with each session lasting between 60-

120 minutes (CDC, 2010). Activities before release include one on one sessions with program

staff, where they assess their client’s knowledge of HIV and create a personal risk-reduction plan

(CDC, 2010). Clients are provided information, skills, and referrals aimed to help them identify

steps toward reducing HIV risk (CDC, 2010). The sessions following release involve a review of

client needs and goals (housing, food, mental health services etc.) additionally, staff and client

make updates to the created risk reduction plan. Each session post release also involves condom

distribution to the clients for added risk reduction (CDC, 2010). Results from the program

showed a decrease in reporting of unprotected anal or vaginal sex in participants at six months

after release (CDC, 2010).

Peers Reaching Out and Modeling Intervention Strategies or PROMISE for HIP, is a

community-level intervention program that relies on role model stories and peer advocates to

help reduce HIV risk behavior (CDC, 2017). This intervention program has been tested on a span

of high risk HIV individuals including: African Americans, White, and Latino communities,
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including high risk drug users, female sex workers, and men who have sex with men (CDC,

2017). PROMISE for HIP activities include: community identification process to collect info

about the network, creating role model stories from individuals living in the target population

and recruiting and training peer advocates that pass out HIV prevention material (education) and

role model stories (CDC, 2017). Additionally, they conduct formative evaluations within their

target population to measure change (CDC, 2017). Evaluation of the program showed that those

who were exposed to the outreach started using condoms more consistently and showed positive

progression in the stages-of-behavior change for condom and bleach use (for the sterilization of

needles)(CDC, 2017).

ConnectHIP is a three session, partner-based intervention aimed at teaching couple’s

techniques and skills to enhance communication as well as their shared commitment to safety

and health (CDC, 2016). It uses the AIDS Risk Reduction Model, organizing behaviors into

three phases, recognize risk, commit to change, and act on strategies. ConnectHIP also uses the

Social Ecological model that stresses the impact that relationships and societal influences have

on behavioral outcomes (CDC, 2016). The program also focuses on target populations including:

Heterosexuals, MSM, and transgender couples with their main sex and/or drug using partners

(CDC, 2016). Activities for ConnectHIP include: creating prevention and/or risk reduction plans,

education on how gendered expectations, stigmas, and power balances influence behavioral and

biomedical prevention, using modeling practices, goal setting, problem-solving and social

support to reduce HIV risk and development of skills to navigate barriers (family, community,

structural level) (CDC, 2016). Additionally, program staff provide participants with linkage to

care for needed services (testing, health care services, housing, food, etc.) (CDC, 2016).

Evaluation to determine the effectiveness of Connect HIP found that among participating couples
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at 3 and 12 months after the intervention there were significant increase in the proportion of safe

sex acts and an increase in the rates of 100% condom use (CDC, 2016).

The last program analyzed is the Self-Help in Eliminating Life-threatening Disease or

SHIELD intervention, which focus on strategies to reduce HIV risk associated with drug use and

sex behavior (CDC, 2013). The target population for SHIELD are male or female adults who are

current or former drug users and interact with peer drug users (CDC, 2013). It implements

several health theories including: Social Cognitive Theory, Social Identity theory, Cognitive

Dissonance, and Social Influence theory (CDC, 2013). The main component of SHIELD uses

peer education by training current or former drug users to spread information about HIV risk to

their social support network (CDC, 2013). SHIELD involves 6 small group sessions of 4-12

participants, including a pre-program session to obtain pre testing data needed for evaluation

(CDC, 2013). Each of the intervention sessions include 5 different components, homework check

in, presentation of new information, peer educator training activities, homework assignment, and

summaries (CDC, 2013). Additionally, each session includes interactive peer education training

activities aimed to build peer outreach skills and increased their self-efficacy as a peer educator,

these activities may include things such as role playing, group problem solving, and facilitator

role-models (CDC, 2013). Evaluation of SHIELDs effectiveness showed increase in condom

usage during vaginal sex with casual partners (16% peer educators vs 4% control) (CDC, 2013);

reduced needle sharing (69% of peer educators vs. 30% of control group)(CDC, 2013);

decreased injection drug use (48% of peer educators vs. 25% of control group)(CDC, 2013); and

stopped participants from using injection drugs (44% of peer educators vs. 22% of control group)

(CDC, 2013).

Health Promotion Methods

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The purpose of my program is to reduce HIV rates in high risk injection drug users and is

based off the effectiveness of the evidence based interventions analyzed in this paper. Firstly,

this program will be a behavioral intervention with the following components: peer outreach

education, condom distribution, skills training, testing and treatment for HIV, and referrals for

drug treatment and other services. Similar to both the SHIELD and ConnectHIP programs, my

program will implement the use of peer outreach as the main avenue for health promotion and

HIV risk reduction. Due to the stigmatization of drug abuse, many users are unwilling to find or

accept help. By using former drug users as peer educators, I hope to eliminate the perceived

barrier of access to care services.

Firstly, before implementation of the program, data analysis should be conducted to find

which geographical locations contain the highest amount of high risk drug injection users. Next

involves the recruitment and training of former drug users to be peer educators, ideally those

who live in the chosen geographically location. Extensive training on HIV and drug use

information, risk reduction, and peer to peer communication should be provided to the outreach

educators. These training sessions should span 6 different 1-hour sessions and involve other peer

educators. After that, pamphlets with HIV, drug use, and linkage to services information, small

vials of bleach, and condoms should be provided to the peer educator for distribution. The actual

program should consist of 2 weekly, 1-hour community-outreach sessions where peer educators

distribute pamphlets, condoms, and bleach to injection drug users. Additionally, educators

should encourage dialogue between IUDs in order to form relationships and encourage safe sex

and drug use behaviors (needle cleaning).

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Health Theory

My program utilizes the Social Cognitive Theory as a basis for understanding behavioral

outcomes. Since SCT involves knowledge acquisition through observing others within social

interactions, experiences, and outside media influences it seemed appropriate for the usage of my

program. Two main constructs can be seen in my program utilization; Facilitation, which refers

to providing tools or resources that make performing new behaviors easier is applied in the

distribution of HIV and drug information pamphlets to my target population. Secondly,

observational learning, which outlines that individuals are more likely to learn form like minded

individuals or role models can be seen through the use of former drug users as peer educators.

Evaluation Plan

To evaluate the effectiveness of my program, extensive evaluation procedures will be

utilized. Firstly, data should be collected from the IUD participants before implementation,

through the use of surveys. That means have the peer educators walk around and collect the data

from the target population personally. The questionnaire should examine variables such as drug

use, condom use, sexual orientation, relationship status, and any indication of previous HIV tests.

Additionally, it should measure knowledge based variables understanding if participants know

about HIV risks and transmission modes. Descriptive statistics on sociodemographic variables

should be generated as well as outcome measures. The type of evaluation performed will be

summative as data will be collected by participants in the form of surveys at the end of the

program. Additionally, the type of evaluation design utilized will be the Pre-experimental design,

as no control group will be measured for comparison.

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Barriers and Limitations

Like mentioned earlier, injection drug users are a stigmatized population that come with

their own unique set of challenges. For one, drug users are less likely to talk about their drug

abuse in fear of persecution or arrest (Copenhaver, Johnson, Lee, Harman, & Carey, 2006).

Second, some are unwilling to accept services being offered to them. Another limitation to my

program is the utilization of self-reports for data collection. Since it is self-reported, the data can

end up being bias affecting the true results of the program, which can have a huge impact on

public health outcomes. Lastly, the target population “injection drug users” is a little too general,

and programs targeting specific populations like women who are injection drug users might see

better results.
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References

AVERT. (2017). What are HIV and AIDS? Retrieved from https://www.avert.org/about-hiv-

aids/what-hiv-aids

CDC. (2017). HIV in the United States: At a glance. Retrieved from

https://www.cdc.gov/hiv/statistics/overview/ataglance.html

CDC. (2017). HIV and injection drug use. Retrieved from https://www.cdc.gov/hiv/risk/idu.html

CDC. (2015). Safety counts HIV prevention program. Retrieved from

https://www.cdc.gov/hiv/research/interventionresearch/compendium/rr/safetycounts.html

CDC. (2013). Self-Help in Eliminating Life-threatening Diseases (SHIELD): Training Peer

Educators to conduct HIV Prevention . Retrieved from

https://effectiveinterventions.cdc.gov/docs/default-source/shield-

docs/SHIELD_Factsheet_Jan_2011.pdf?sfvrsn=0

CDC. (2017). PROMISE for HIP. Retrieved from

https://effectiveinterventions.cdc.gov/docs/default-source/promise-docs/promise-for-hip-

fact-sheet.pdf?sfvrsn=0

CDC. (2010). Project start monitoring and evaluation field guide. Retrieved from

https://effectiveinterventions.cdc.gov/docs/default-source/project-

start/Project_START_M_E_Field_Guide_10-1108.pdf?sfvrsn=0

CDC. (2016). ConnectHIP: A couples-level intervention for relationships living with or at risk

for HIV/STIs. Retrieved from https://effectiveinterventions.cdc.gov/docs/default-

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source/connect-docs/connecthip/16-1220_connect-hip_fact-sheet_final(508-

compliant).pdf?sfvrsn=2

Copenhaver, M. M., Johnson, B. T., Lee, I., Harman, J. J., & Carey, M. P. (2006). Behavioral

HIV risk reduction among people who inject drugs: Meta-analytic evidence of

efficacy. Journal of Substance Abuse Treatment,31(2), 163-171.

doi:10.1016/j.jsat.2006.04.002

Gibson, D., PhD. (1998). Comprehensive, up-to-date information on HIV/AIDS treatment and

prevention from the University of California San Francisco. Retrieved from

http://hivinsite.ucsf.edu/InSite?page=kb-07-04-01-01