Strategies to Improve the Replicability, Sustainability, and Durability of HIV Prevention Interventions for Drug Users

May 6-7, 2002

Sponsored by:
Center on AIDS and Other Medical Consequences of Drug Abuse, NIDA

Purpose

On May 6-7, 2002, NIDA's Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA) sponsored a Working Meeting on "Strategies to Improve the Replicability, Sustainability, and Durability of HIV Prevention Interventions for Drug Users" in Chevy Chase, Maryland. Dr. Wendee Wechsberg, of the Research Triangle Institute in North Carolina, served as Chair of the meeting.

The immediate purpose of the meeting was to bring together multi-disciplinary experts in the study of HIV prevention and drug abuse to present their research findings, discuss and exchange emerging scientific data, and identify gaps and future directions in research to improve behavioral prevention interventions that target HIV/AIDS and other blood-borne diseases among drug users and their sexual partners. In-depth discussion sessions were interspersed throughout the 2-day meeting to focus on individual studies, to highlight emerging, new, and common themes, and to identify key features and approaches for improving the replicability, sustainability, and durability of behavioral interventions to prevent HIV/AIDS and other infectious diseases in drug users

The Director of CAMCODA, Henry Francis, M.D., set the stage for the meeting by underscoring the importance NIDA gives to prevention, and the need for new, innovative approaches to improve long-lasting behavioral changes among drug users to prevent HIV and other infections. Since no single intervention strategy will work equally well for every drug user, it is important that multiple, complementary, and coordinated behavioral interventions are available to reach diverse populations of drug users, across different time periods and social contexts.

Dr. Wechsberg reviewed the objectives of the working meeting, namely to review the current science of HIV prevention in drug-using populations, and to identify innovative approaches for enhancing HIV interventions so that their outcomes - positive behavioral change, HIV risk reduction, and the development and maintenance of protective behaviors - become the norm. She also discussed the concepts of replicability, sustainability, and durability, and their roles in the characterization of effective HIV interventions, and added other important concepts for discussion, including adaptability, maintainability, and "translatability."

A number of themes emerged during the meeting presentations and discussions, of which five of the more salient ones are mentioned here. One was that, while the medical model may be relevant for the development of HIV prevention interventions among drug users in some situations, it is not relevant in others. Social, behavioral, and biological experts must work together to distinguish appropriate intervention models for given circumstances and populations, since HIV risks and drug use are multidisciplinary problems.

A second theme concerned the questions that arise from the complexities of drug abuse and addiction. HIV risk reduction interventions for drug users have beneficial effects, but the effects may vary with, among other factors, the intervention dose and its timing, and the type of drug user. Since drug addiction is a chronically relapsing disease, there will never be complete elimination of risk. For this reason, it is important to ask such questions as, what are reasonable expectations to achieve risk elimination, or to sustain risk reduction? What is the most effective way to allocate limited resources to maximize risk reduction? Is it more cost-effective to avert risk in a high-risk population, in a young population, or in other special populations?

Still another theme highlighted what research has shown about HIV interventions that work at the individual level, including a cognitive approach and changing norms. Less clear is what interventions work, for whom, and how long at the level of couples and networks. Research is also needed to develop cost-effective approaches for adapting and tailoring proven behavioral interventions to fit the needs and characteristics of heterogeneous populations and situations, rather than to create and test new interventions for each context.

A fourth theme spanned the discussions throughout the meeting: While research on HIV prevention interventions for drug users is critically important, so also is research to address the variety of co-occurring diseases and co-morbidity that drug users often experience, including hepatitis B and hepatitis C, other sexually transmitted infections, violence victimization, psychological stress and mental illness, and alcoholism. Recognition of the need for linkages and collaborations among multi-disciplinary experts who can address HIV as well as a range of potential co-morbid conditions among drug users is important for developing durable, sustainable, and replicable behavioral interventions.

A fifth theme concerned the need to develop and promote protective behaviors - what drug users can do to protect themselves from HIV and other infections in a positive, empowered way - in addition to reducing risk behaviors. Often, HIV prevention interventions for drug users focus on behavioral risk reduction and "don'ts" rather than on positive behavioral changes or "do's." HIV interventions that promote pro-social, positive behavioral change among drug users can also be empowering, and can thereby facilitate the diffusion of social norms that are both reinforcing and self-sustaining.

Current data on the etiology and underlying pathophysiology of cardiovascular complications of HIV/AIDS, substance abuse (cocaine, alcohol), and HIV infection,

Next Steps:

As a result of the Working Meeting, plans are now underway to publish a special issue of a journal or other publication on strategies for improving the replicability, sustainability, and durability of HIV prevention interventions for drug users. Meeting participants will work with CAMCODA staff in the development of manuscripts for such a publication. Future forums and science meetings on strategies to improve HIV behavioral prevention interventions are also likely to build on the results of this meeting, to promote new research and cross-disciplinary collaborations, and to disseminate widely information on emerging research findings and applications.

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