Introduction

Injection drug use is a major risk factor for HIV infection in the Iran and numerous other countries. Specific behaviors associated with drug use that are risk factors for HIV transmission include shared use of drug injection equipment and unprotected vaginal or anal sex with multiple sexual partners.For this reason, interventions that can reduce the prevalence of these practices are critical components of a comprehensive AIDS prevention policy.

Drug Treatment

Increasing access to drug treatment is a frequently recommended approach to slowing the spread of HIV in IDU.

Needle Exchange

The first needle exchange was formed by the Amsterdam junkiebond in 1984 in an effort to slow the spread of hepatitis B among IDU.(16) As the number of European AIDS cases increased sharply, needle exchange programs were soon adopted in other European cities. By the early 1990s, programs had been implemented in more than 20 countries, including the United States, Canada, Australia, and most member nations of the European Union.

Street Outreach


Counseling and Testing

Little conclusive evidence exists that counseling and testing is an effective approach to reducing high-risk behavior in IDU. Few studies that have examined outcomes of HIV testing with IDU have reported reductions in risk behavior (for a review, see Higgins and colleagues. In two studies, greater needle hygiene was noted among tested users than among users who had never tested or received their test results. Results of three studies, however, showed no differences in injection or sexual practices between tested and untested drug users, and results of four other studies demonstrated a mixed pattern of relationships between testing and behavior. Only two studies assessed outcomes with a randomized design that followed subjects after they had been tested. In both studies, IDU assigned to group/individual counseling reduced high-risk behaviors, but comparison group subjects reported similar reductions.
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Other Interventions
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The pattern of results of these two studies has been mirrored in other controlled evaluations of interventions to prevent HIV in drug users. A review of 17 such evaluations identified only three without design limitations in which the experimental intervention was more effective than a comparison condition in reducing the prevalence of high-risk practices. In the largest of three evaluations (n = 567), which involved following subjects for 12 months, a six-session skills building group intervention proved more effective in reducing high-risk injection practices than a two-session informational intervention; this was true, however, only for subjects initially at lower risk.

In a second, smaller (n = 93) study, IDU assigned to 6 hours of counseling designed to prevent relapse to high-risk behaviors reported less high-risk injection behavior during the heaviest risk-taking month following a baseline assessment; however, they did not differ from no-treatment controls for the most recent month, and there were no differences between the experimental and comparison groups in self-reported sexual practice.

In a third study, a small (n = 84) sample of female methadone patients assigned to five 2-hour skills building intervention sessions reported greater condom use 15 months following intervention than subjects assigned to an information-only control group.

Comparing these outcomes with those of the other evaluations, the authors of the review concluded that the success of the experimental interventions appeared to be due to their greater length as well as to having been conducted with stable and well-motivated (drug treatment) populations. Their more surprising finding, however, concerned 10 of the 17 studies in which no differences in outcomes were noted between the experimental and comparison group(s).

In these 10 studies, there was evidence of marked behavioral changes in both the experimental and comparison conditions, with the changes in several cases being sustained for as long as to 12 months. A close examination of the evidence for completing hypotheses for this pattern of results suggested that participation in research may have had contributed to this patterns of findings. In one study, subjects assigned to a wait-list control group had, by the time of a 4-month follow-up interview, reduced high-risk practices as much as subjects assigned to two experimental interventions. It is worth noting that all of the studies involved lengthy behavioral assessments prior to randomizing subjects.

That relatively brief assessments can have a marked impact on behavior should not surprise practitioners in the fields of public health and preventive medicine. In the last 20 years, health risk assessments have become commonplace in the workplace and other settings. The aim of such assessments is to influence individual health behavior in a "health ward" direction. A health risk assessment typically consists of the following elements:
 

• An assessment of a person's health habits and risk factors based on responses to questionnaire items, sometimes supplemented by biomedical measurements such as blood pressure and laboratory tests

• A quantitative estimation or qualitative assessment of the individual's future risk of death and/or other adverse health outcomes

• The provision of educational messages and/or counseling about how changing one or more personal risk factors would alter a person's risk of disease or death

There is evidence that health risk assessments can be a powerful tool for changing behavior. For example, a large randomized trial of a health risk assessment involving administration of health habit questionnaires, individualized health recommendation letters, newsletters, and other program materials found a sizeable impact on a variety of health behaviors over a 12-month period, including smoking, dietary intake of salt and fat, alcohol consumption, and exercise.

Both similarities and differences exist between health risk appraisals and assessments employed in evaluating interventions to prevent HIV in drug users. The differences include the fact that health risk appraisals cover a wide variety of health-related risks, whereas assessments of drug users in intravenous behavioral research involve reviewing a relatively limited range of behaviors having to do with drug use and sex. Another difference is that behavioral assessments of drug users do not involve an evaluation of subjects' future risk of death per se, although given the life-threatening nature of AIDS and widespread knowledge about links between certain practices and infection with HIV, such an evaluation may not have been needed.

Health risk appraisals and assessments of drug users high-risk behaviors nevertheless are similar in that they involve a microscopic examination of participants'/subjects' behavior as it relates to the probability of disease and death. Behavioral assessments with drug users, however, frequently elicit information not only about behavior but also about an array of knowledge, attitudes, and beliefs that may support such behavior.

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