HIV outreach for hard-to-reach populations: a cross-site perspective

doi:10.1016/S0149-7189(99)00015-4

Evaluation and Program Planning

Volume 22, Issue 3, August 1999, Pages 251-258

https://doi.org/10.1016/S0149-7189(99)00015-4 Get rights and content

Abstract

This article examines the effectiveness of outreach as a vehicle for moving hard-to-reach substance abusing clients into substance abuse treatment. These clients were recruited by and participated in one of twelve HIV Outreach Demonstration Projects funded by the Center for Substance Abuse Treatment (CSAT). The analysis combines data across projects to provide a cross-site perspective. Data from 1675 clients were analyzed in this study. In addition, a comparison group of 3704 subjects was generated from the National Treatment Improvement Evaluation Study (NTIES) data. The results supported the hypothesis that clients representing traditional hard-to-reach populations would be more likely to enter treatment for substance abuse through participation in HIV Outreach programs than would clients exposed to treatment-specific recruiting methods (e.g. NTIES). The findings from this cross-site study support the view that HIV Outreach, as an integrated approach to several behavioral constellations, is more effective in recruiting clients to substance abuse treatment than are approaches that focus exclusively on substance abusing behavior. The HIV Outreach model is especially effective in reaching substance abusers earlier in the cycle of abuse. This has importance clinically for developing and focusing more effective methods for treatment for younger substance abusers with shorter histories of abuse. It also has implications for policy to guide the effective use of scarce treatment resources. Targeting specific populations and affiliation with substance abuse treatment providers were also influential in facilitating access to substance abuse treatment for groups at increased risk for HIV.

Introduction

In 1995, the Center for Substance Abuse Treatment (CSAT) awarded 12 grants to provide outreach services to injection drug users (IDUs), other chronic, hard-to-reach substance abusers, and their sex and/or needle-sharing partners.

The HIV Outreach program targets hard-to-reach drug-abusing populations for outreach services, with the goals of reducing HIV transmission among these high-risk populations and providing greater access to substance abuse treatment. Projects funded in this program provide four core services:

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Community-based outreach services to encourage entry and facilitate access to substance abuse treatment;
•
HIV/AIDS risk reduction interventions;
•
Medical diagnostic testing and screening for HIV, sexually transmitted diseases (STDs), tuberculosis (TB), and pregnancy; and
•
Linkages to primary medical care, mental health care, social services, and other ‘prophylactic means’ to effect behavioral changes most likely to reduce the risk of acquiring or transmitting HIV, STDs, TB, and related diseases.

This paper presents a preliminary look at the clients who were brought into substance abuse treatment by the projects in this ongoing demonstration program. It also looks at some structural factors that may influence project differences in the extent to which they are able to bring eligible clients into treatment. The analysis combines data across projects to provide a cross-site perspective.

Section snippets

Background

The effectiveness of outreach in reducing risk-taking behaviors of injection drug users (IDUs) has been well-documented (Coyle & Needle, 1997). Outreach interventions have been shown to help IDUs reduce their risk-taking behavior, particularly drug and needle using practices, and to a lesser extent, sex risk behaviors. The outreach interventions used by earlier Federal programs such as the National AIDS Demonstration Research (NADR) program and the Cooperative Agreement for AIDS Community-Based

Outreach sample

All of the HIV Outreach projects have a programmatic focus on ‘hard-to-reach’ populations who are at risk from HIV exposure and transmission. Among the at-risk populations targeted by the projects are substance abusers—especially Intravenous Drug Users (IDUs)—partners of substance abusers, and others at risk to HIV exposure because of close association with substance abusers (e.g. sex workers). Three of the twelve demonstration projects specifically target women, two focus on Hispanic/Latino

Results

Three evaluation questions guided the analyses. They are addressed separately in the following sections.

Discussion

Although all but one of our comparisons were statistically significant, statistical significance does not necessarily translate to clinical relevance. The attainment of statistical significance is in part influenced by sample size. Our sample sizes were quite large. Therefore, the proportional difference required to obtain significance is considerably less than would be the case if the sample sizes were smaller. For example, consider heroin use in the last 30 days. Remember that all of these

Summary and conclusions

The HIV Outreach program targets hard-to-reach drug-abusing populations for outreach services with the goals of reducing the HIV transmission among these high-risk populations and providing greater access to substance abuse treatment. In 1995, the Center for Substance Abuse Treatment implemented a cross-site evaluation of the HIV Outreach program to evaluate the overall effectiveness of the grant program in achieving CSAT program goals. Two primary indicators of program success were referral to

Acknowledgements

This article was provided under a contract funded by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services.

The authors wish to thank Kenneth Burgdorf and Marc Rogers for their valuable contribution in reviewing and editing drafts of this article.

References (11)

M. Barnard et al.
Combining quantitative and qualitative approaches: Researching HIV-related risk behaviours among drug injectors
Addition Research
(1995)
Centers for Disease Control and Prevention (1998). Dangerous intersection of drug use and sexual HIV transmission...
S.L. Coyle et al.
Community-based outreach as an HIV risk reduction strategy for out-of-treatment injection drug users (IDUs)
Gordon, J. (1994). African American perspective. In: J. U. Gordon (Ed.), Managing Multi-Culturalism in Substance Abuse...
C.E. Grella et al.
HIV risk behaviors among women in methadone maintenance treatment
Substance Use and Misuse
(1996)

There are more references available in the full text version of this article.

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View full text

HIV outreach for hard-to-reach populations: a cross-site perspective

Abstract

Introduction

Section snippets

Background

Outreach sample

Results

Discussion

Summary and conclusions

Acknowledgements

Combining quantitative and qualitative approaches: Researching HIV-related risk behaviours among drug injectors

Addition Research

Community-based outreach as an HIV risk reduction strategy for out-of-treatment injection drug users (IDUs)

HIV risk behaviors among women in methadone maintenance treatment

Substance Use and Misuse