Drug users are at high risk for HIV infection because the virus can be spread through needle-sharing or the high-risk sex that some users exchange for drugs. Researchers from Washington University School of Medicine in St. Louis have been studying ways to help lower the risk. In the journal Public Health Reports, they report that a peer-led intervention program is having success for some behaviors, but getting users to engage in safer sex remains a problem. Linda Cottler, Ph.D., a professor of psychiatric epidemiology, and colleagues are targeting high-risk groups with programs to modify high-risk behaviors. She says such research to slow the spread of AIDS is essential because an effective vaccine is still years away.
"We know how AIDS is spread, and we know several ways to help lower individual risk, but still seven Americans become infected every hour. We need to develop more and better interventions to change those numbers," says Cottler.
Cottler and colleagues focused on a program they developed called EachOne TeachOne, funded by a grant from the National Institute on Drug Abuse (NIDA). In 1990, NIDA launched a multisite outreach program to reduce the spread of HIV among drug users, and each of the 23 sites has developed its own enhanced interventions to address the spread of AIDS in their communities.
The EachOne TeachOne program is a collaboration between Washington University and the St. Louis Health Department. The program recruits subjects from an area with an AIDS rate of almost 19 per 100,000 and a syphilis rate twice the national average and 60 times the national average among African Americans. It involves peer counselors in recovery from drug use, and the sessions cover drug awareness, stress management, AIDS and reducing high risk sexual behaviors such as having sex with multiple partners or failing to use a condom.
The investigators surveyed high-risk drug users at the beginning of the study and again, three months later, comparing results of those randomized to an enhanced intervention to results of those assigned to a standard intervention. The primary risk factors were drug use, number of sex partners and failure to use condoms both before and after the intervention.
Participants who engaged in high-risk behaviors less frequently than their peers, after three months, were considered improved. If, for instance, a crack cocaine user was still using but had cut back from several times a day to less than once a day, that person was classified as improved. Smoking crack about twice daily changed the user's classification to moderate risk. More than twice a day was considered highest risk.
The same system was used to measure the risk from multiple sex partners. One partner in the last 30 days equated with lower risk. A person who had two sex partners during the previous month was classified as moderate. Those with three or more sex partners were considered high risk.
"This study looks at this matrix of people, and it allows us to say who improved by comparing follow-up with baseline status," Cottler explains. "Crack cocaine users really do reduce their HIV risk by cutting back."
Cottler's team found that 80 percent of the participants either cut back on their drug use or maintained a low level of risk while taking part in the EachOne TeachOne program. In the area of sex partners, 75 percent had fewer or maintained a lower risk and were considered improved. But not all of the news was good.
"Condom use was the one area where we did not see relative improvements. To classify a participant as improved, they either had to abstain from sex or use condoms 100 percent of the time. Those who reported they didn't use condoms at all or used them only some of the time were classified as high risk. Using this definition, our overall sample worsened more than it improved in terms of condom use," Cottler explains.
Like investigators in other studies, Cottler and colleagues found it was easier for drug users to reduce their number of sexual partners than increase their frequency of condom use. For some reason, it is especially difficult to get people to change their sexual behaviors, but Cottler compares the problem to a diabetic managing blood glucose. Taking insulin shots, while important, does not entirely solve the problem. Patients also need to make dietary adjustments and monitor their glucose levels to maintain the proper balance. She says the EachOne TeachOne program also may need better balance.
Focus on drug use
Perhaps the intervention focuses on drugs in such a way that the participants think of sexual behaviors as secondary risk factors. On the other hand, Cottler believes it would be unwise to take the focus off drug use.
"Many of these people have used their sexual behaviors to get their drug. Even though we're currently doing a better job with drug use than with sex behaviors, we can't let up on the drugs. We just have to fight harder in the area of sexual behaviors," she argues.
Cottler remains convinced that even members of very high-risk groups can lower their risk of contracting AIDS. Therefore, the researchers are constantly reevaluating and measuring the effects of various interventions to learn which people they are reaching and which ones still are engaging in high-risk activities. Because their study measured not only outcomes but also the direction in which subjects were moving, Cottler says it may be possible to tweak the intervention to emphasize different messages for different risk groups.
"Behavior is the most important factor in preventing AIDS, and we know that changing behaviors is very difficult -- whether it's getting kids to clean their rooms or getting drug users to use condoms -- but changing behavior is essential if we hope to slow the spread of AIDS and other sexually transmitted diseases," she says.
Note: For more information, refer to: Cottler, LB., et. al, "Peer-Delivered Interventions Reduce HIV Risk Behaviors Among Out-of-Treatment Drug Abusers," Public Health Reports, vol. 113, Supplement 1, pp. 1-11, June 1998.