Street Outreach Research Articles

A model for adolescent-targeted HIV/AIDS services: Conclusions from 10 adolescent-targeted projects funded by the Special Projects of National Significance Program of the Health Resources and Services Administration

This article describes a model of service for youth living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and youth at high risk for HIV, based on the lessons learned from a set of innovative service projects funded by the Health Resources and Services Administration Special Projects of National Significance (SPNS) Program. Although each project has a unique focus, all collectively seek to enroll youth with HIV into care through new or existing HIV service networks, and direct recruitment via street outreach and other similar methods. The use of various outreach methods tends to yield different patterns of engagement of youth in services. An ideal approach may use a combination of complementary outreach methods. Data at both the national and local levels point to five major elements that capture the innovations of the collective service model: (a) peer-youth information and dissemination; (b) peer-youth advisory groups; (c) peer-youth outreach and support; (d) professional, tightly linked medical social support networks; and (e) active case management and advocacy, for individual clients as well as the programs themselves, to link the various components together. One of the most important factors in the model’s success is that youth and professionals share an equal partnership in all stages of program design, planning, and implementation. Youth and professionals each share their expertise in a dynamic process. In addition, active case management is crucial, not only to ensure that clients receive needed services, but also to ensure that the programs themselves run in a coordinated, tightly linked way. Given needs of adolescent clients and existing adult-oriented service networks, the use of active case management and the active participation of youth in the services system are critical.

Boston HAPPENS Program: A model of health care for HIV-positive, homeless, and at-risk youth

The Boston HAPPENS [Human immunodeficiency virus (HIV) Adolescent Provider and Peer Education Network for Services] Program is a project supported by Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration, which provides a network of care for homeless, at-risk, and HIV-positive youth (ages 12–24 years), involving eight agencies. The program has provided services to 1301 youth, including 46 who are HIV- positive. Boston HAPPENS provides a citywide network of culturally and developmentally appropriate adolescent-specific care, including: (a) outreach and risk-reduction counseling through professional and adult-supervised peer staff, (b) access to appropriate HIV counseling and testing support services, (c) life management counseling (mental health intake and visits as part of health care and at times of crisis), (d) health status screening and services needs assessment, (e) client-focused, comprehensive, multidisciplinary care and support, (f) follow-up and outreach to ensure continuing care, and (g) integrated care and communication among providers in the metropolitan Boston area. This innovative network of youth-specific care offers a continuum from street outreach to referral and HIV specialty care that crosses institutional barriers.

Drug Use Patterns of Substance Abusing Women: Gender and Ethnic Differences in an AIDS Prevention Program

SUMMARY The social context of drug use defines women's experiences of addiction and their patterns of use. Gender relations and roles, ethnic identity, poverty, and local circumstances, including drug-related epidemics such as the human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs), constitute powerful social forces that create a unique set of risky conditions for women drug users. This paper presents findings from a community-based AIDS prevention research project for 1,022 out-of-treatment drug users recruited through street outreach and targeted sampling. Data from a baseline risk behavior assessment and in-depth interviews on contexts of women's drug use show different patterns of use when comparing women to men, and among women comparing African Americans, Puerto Ricans, and Whites. Related differences in prevalence of HIV, STDs, and other consequences of drug use and addiction also are presented. Implications of these findings are discussed in terms of the development of drug...

Ethnic and Cultural Differences in Drug-Using Women Who Are In and Out of Treatment

SUMMARY In recent years, increasing emphasis has been placed on race, ethnicity and culture as they relate to recruitment into and retention in substance abuse treatment as well as treatment effectiveness. Racial/ethnic and cultural differences were studied among women participating in two programs located within a large southwestern city. One of these programs was residential treatment for drug-using women and the other program provided street outreach for HIV prevention/education to drug-using women. Significant differences were found among racial/ethnic groups within each program and between the two programs. Differences were explored for the following factors: marital status; education; age at entry into the program; drug use history; drug treatment history; current use patterns; injection rates; history of arrests and exchange of sex for drugs. The authors conclude with a discussion of these differences and their potential ramifications for conducting future research and in developing/implementing ef...

Effectiveness of psychosocial interventions in preventing HIV risk behaviour in injecting drug users.

To consider evidence for the effectiveness of psychosocial interventions in reducing the risk of infection with HIV of injecting drug users. We reviewed 19 published studies of the effectiveness of individual counselling, HIV testing, group interventions, street outreach, and a 'social' intervention designed to change norms for safer behaviours. Eight of 15 studies that examined behavioural outcomes provided evidence of the effectiveness of an experimental intervention, compared with a control or comparison group. In four of these studies, however, serious design limitations made results difficult to interpret. In the other four studies without design limitations, the success of the experimental interventions may have been due to their greater length and intensity as well as to having been conducted with stable and well-motivated populations. Nine of the 15 studies showed evidence of marked behaviorial changes in both experimental and comparison group(s), with the changes in many cases being sustained for upwards of 12 months. A close examination of the evidence and competing hypotheses for the pattern of results suggests that participating in evaluation research may itself be a valuable intervention. Implications for the development of interventions include the potential efficacy of health risk assessment. Implications for evaluation of interventions include the need for developing unobtrusive measures and for assessing the impact of behavioural assessments. Despite the large behavioural changes reported in most of the studies, a substantial proportion of subjects receiving interventions reported unacceptably high levels of risk behaviours. New, more potent interventions are needed, such as those designed to change the norms of entire communities of drug users concerning safer injection and safer sex.

Tuberculosis screening and compliance with return for skin test reading among active drug users.

This study assessed the independent and combined effects of different levels of monetary incentives and a theory-based educational intervention on return for tuberculosis (TB) skin test reading in a sample of active injection drug and crack cocaine users. Prevalence of TB infection in this sample was also determined. Active or recent drug users (n = 1004), recruited via street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 2 levels of monetary incentive ($5 and $10) provided at return for skin test reading, alone or in combination with a brief motivational education session. More than 90% of those who received $10 returned for skin test reading, in comparison with 85% of those who received $5 and 33% of those who received no monetary incentive. The education session had no impact on return for skin test reading. The prevalence of a positive tuberculin test was 18.3%. Monetary incentives dramatically increase the return rate for TB skin test reading among drug users who are at high risk of TB infection.

Houston Homeless Street Outreach

Several cities in the nation have developed innovative programs to assist the homeless who are “living on their streets.” This paper describes one such program developed in Houston, Texas. The Homeless Street Outreach was a collaborative project of several service agencies in the greater Houston area. The outcome of this outreach project indicates that a coordinated effort can bring about delivery of more comprehensive services to the homeless population. The principles that emerge from the outreach include involvement of the homeless in planning and development, service agencies taking “ownership” of the project, and agency flexibility in delivering services to the homeless.

Child Sexual Abuse, HIV Sexual Risk, and Gender Relations of African-American Women

A cross-sectional study was conducted to examine the association between childhood abuse, HIV-related sexual risks, and gender relations among African-American women. The sample 165 African-American women, 18-29 years of age, were recruited by street outreach from a lower socioeconomic community in San Francisco, CA. A face-to-face interview was administered to assess HIV/STD-sexual risk practices, alcohol use, physical abuse, affective health, and relationship commitment. Childhood sexual abuse was defined as experiencing forced sex prior to age 16. The prevalence of childhood sexual abuse in this sample was 13.3%. Compared to women who were not abused during childhood, women who reported a history of childhood sexual abuse were 1.5 times more likely to have had an abortion, 1.4 times more likely to report having an STD, 2.4 times as likely to report having greater than two lifetime STDs, 3.8 times as likely to have a history of anal sex, 2.6 times as likely to worry about acquiring HIV, 3.9 times more likely to believe their partner did not care for them, twice as likely to doubt the longevity of their relationship, 5.1 times as likely to have a partner who had been physically abusive within the previous 3 months, 2.6 times as likely to have a partner who was physically abusive when asked to use condoms, and 1.5 times as likely to consume three or more glasses of alcohol at one time. Awareness of a women's history of child sexual abuse can assist in making appropriate medical and social referrals and can lead to the development of more tailored HIV prevention programs for African-American women.

Needle exchange is not enough: lessons from the Vancouver injecting drug use study.

To describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drugs users (IDU). Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year. IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi-annually, subjects underwent serology for HIV-1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence. Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV-positive and HIV-negative IDU reported lending used syringes (40%). Of HIV-negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV-negative IDU, HIV-positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV-positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence was 18.6 per 100 person-years (95% confidence interval, 11.1-26.0). Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.

A study of HIV seroprevalence in a group of homeless youth in Hollywood, California

The objective of this descriptive-exploratory study was to examine the HIV seroprevalence rate among a sample of homeless youth in Hollywood, California. A total of 96 respondents (age 14-24) were administered a questionnaire and had their blood drawn to test for the presence of HIV antibodies, during nightly street outreach activities conducted by Covenant House California. The HIV seroprevalence rate was 11.5% for the sample. Chi-square analysis showed strong correlation between HIV status and sexual risk behavior but not for HIV status and drug-related risk behavior.

The impact of intensive outreach on HIV prevention activities of homeless runaway and street youth in San Francisco: the AIDS Evaluation of Street Outreach Project (AESOP).

We evaluated the impact of an HIV prevention intervention combining street outreach, storefront prevention services, and subculture-specific activities for homeless, runaway, and street youth. Using systematic, street-based sampling techniques, we conducted 1,146 interviews in cross-sectional surveys at intervention and comparison sites prior to and during intervention implementation. Youth in both sites reported high rates of risky sexual and injection drug use behaviors. In logistic regression the intervention did not impact HIV risk behaviors, but was independently associated with increased outreach worker (OW) contact and referrals for services. Higher levels of OW contact were associated with following through with HIV-related referrals and using new syringes. Youth-oriented needle exchange increased use of new syringes. While our study did not demonstrate an intervention effect on HIV risk behaviors, intensive, subculture-specific outreach, including needle exchange, may improve the lives of street youth.

The Margins of Underdog Sociology: Implications for the "West Coast AIDS Project"

Based upon participant-observation in a research project that conducted AIDS prevention among street-based drug injectors, this paper analyzes the challenges presented in the application of an underdog sociological perspective in a quasi-human service agency. The directors of the AIDS Project incorporated the principles of Becker's labeling theory (1963) and the epistemological foundations of naturalist ethnography into the agency's outreach and research design. As such, this paper explores the bounds of the promoted “underdog sympathy.” In addition, since the agency hired mostly former “underdogs” to conduct street outreach, the author examines conflicts in theoretical knowledge claims between the administration and staff. Whereas the outreach staff members embraced more lay-oriented psychological and therapeutic concepts, their experiential authority was dismissed by the sociologist administrators, belying formal claims to privileging underdog perspectives. Inasmuch as the directors dismissed the outreach workers' experiential knowledge, the directors were engaged in “ontological gerrymandering” (Woolgar and Pawluch 1985): selectively distinguishing objective reality from subjective claims. This paper focuses on two issues that represent the difficulty in applying an underdog sociology: 1) the dynamic construction of drugs, addiction, and recovery; and 2) collective representations of drug using clients. Employing Gouldner's (1967) critique of labeling theory, this paper deconstructs empirically the role of interests in the production of knowledge and contradictory sociological sentiments toward “deviants” in an applied setting.

African-American Adolescents Residing in High-risk Urban Environments Do Use Condoms: Correlates and Predictors of Condom Use Among Adolescents in Public Housing Developments

African-American adolescents living in high-risk inner-city environments have been disproportionately affected by the epidemics of human immunodeficiency virus (HIV) and other sexually transmitted diseases. Understanding the factors that influence the use of condoms by adolescents is critical for developing effective behavioral interventions. The present study examined the demographic, psychosocial, and behavioral correlates of condom use among African-American adolescents residing in public housing developments in an HIV epicenter (San Francisco) and prospectively evaluated the stability of these significant cross-sectional variables to predict consistent condom use. A prospective study. Two public housing developments in San Francisco. African-American adolescents and young adults between 12 and 21 years of age were recruited though street outreach and completed a theoretically derived research interview assessing HIV-related knowledge, attitudes, and behaviors. After a 6-month period, adolescents completed a follow-up interview similar to the baseline measure. Among adolescents reporting sexual activity in the 6 months before completing the baseline interview (n = 116), logistic regression analysis evaluated the influence of demographic, psychosocial, and behavioral factors on consistent condom use. Adolescents who had high assertive self-efficacy to demand condom use (adjusted odds ratio [OR], 11), perceived peer norms as supporting condom use (OR, 4.2), had greater impulse control (OR, 3.7), were male (OR, 4.7), and were younger (OR, 2.9) were more likely to report consistent condom use. Frequency of sexual intercourse was inversely related to condom use; adolescents with higher numbers of sexual episodes were less likely to use condoms consistently. Prospective analyses identified the baseline level of condom use as the best predictor of condom use at the 6-month follow-up. Adolescents who were consistent condom users at baseline were 7.4 times as likely to be consistent condom users during the follow-up period. Of those adolescents changing their frequency of condom use during the follow-up interval, significantly more engaged in risky behavior; 33.3% changed from consistent to inconsistent condom use, whereas 20.6% changed from inconsistent to consistent use (OR, 1.6). The findings suggest that HIV prevention programs need to be implemented early, before high-risk behaviors are established and may be more difficult to modify.

Are We Reaching and Enrolling at-Risk Drug Users for Prevention Studies?

The St. Louis EachOneTeachOne (EOTO) project is a National Institute on Drug Abuse (NIDA)-funded cooperative agreement aimed at examining rates of HIV risk behaviors and studying HIV risk reduction interventions among out-of-treatment injection and crack cocaine drug users. This paper uses data collected during the first year of recruitment and enrollment to document the effect of street outreach on HIV risk behavior involvement. The major findings are that: (1) men reported more HIV risk behaviors than did women, but the results failed to show striking racial or ethnic differences; (2) we successfully enrolled women in spite of the fact that our women street contacts were largely ineligible to enroll in EOTO; and (3) actual EOTO enrollees, compared with all street contacts and eligible street contacts, engaged in fewer HIV risk behaviors. These results imply that strategies in addition to street outreach may be needed to enlist more individuals, particularly whites and women who are engaging in the highest risk drug and sexual behaviors.

Stages of Change for HIV Risk Behavior: Injecting Drug Users in Five Cities

SUMMARY Objectives: To examine risk behavior and stages of behavior change for condom and needle behavior measured in surveys of drug using populations; To determine factors associated with stages of change. Data: Two rounds of baseline surveys of injecting drug users in 5 cities conducted as part of the AIDS Evaluation of Street Outreach Projects. Methods: Representative samples of injecting drug users were conducted in 5 cities. Questionnaires obtained information on risk behaviors, exposure to street outreach and stages of change for risk behaviors. Ordinal logistic regression analysis was conducted to determine factors associated with stage of change variables. Results: Respondents interviewed in the street-based samples in the 5 AESOP IDU sites had a very high level of risk for HIV, in terms of sexual and drug risk behavior. Stages of change for condom use was higher for non-steady partners compared to steady or main partners. Having a condom at interview was the most consistent predictor of responde...

Using Stages of Change to Assess Intervention Readiness and Outcome in Modifying Drug-Related and Sexual HIV Risk Behaviors of IDUs and Crack Users

SUMMARY This paper examines the utility of the stages-of-change model in assessing intervention readiness and measuring the outcome of targeted interventions in modifying eight drug-related and sexual risk behaviors of active drug users. Injection drug and crack cocaine users (N = 560) recruited through street outreach were administered questionnaires measuring intentions, behaviors, and beliefs pertaining to eight drug-related and sexual strategies for reducing personal HIV risk at the time of their enrollment in an HIV risk intervention program. Six-month follow-up data were available for 205 of the 325 individuals who were eligible for follow-up. At baseline, a large percentage of injectors were in the action or maintenance stage with regard to safe injection practices. Men were significantly higher than women in stage of change for not sharing needles. Very few individuals were using condoms with their main partner, but the percentage was much higher with casual partners, especially among sex workers. Follow-up data indicated a general shift toward higher stages for all behaviors, with changes in both intentional and behavioral stages. Differences between initial and final stage of change were statistically significant for all target behaviors except condom use with main partner.

Service delivery using consumer staff in a mobile crisis assessment program.

Interest has developed in the use of mental health consumers as staff members in community programs for persons with serious mental illness. The present study investigates consumer service delivery in a mobile assessment program designed to assist homeless people with severe psychiatric disorders. Consumer and non-consumer staff were generally comparable. Results suggest that consumer staff engaged in more street outreach and were less often dispatched for emergencies. There was a trend for consumer staff to be more likely to certify their clients for psychiatric hospitalization. In sum, consumer staff appear to provide a valuable contribution to this form of service delivery.

Early evaluation results of a collaborative partnership.

Early evaluation results of a collaborative partnership.

HIV seroprevalence among Atlanta's homeless.

Brief communication 83 HIV SEROPREVALENCE AMONG ATLANTAS HOMELESS During the 1980s, America was hard hit by two epidemics: HIV/AIDS and homelessness. By 1990, the Centers for Disease Control and Prevention (CDC) reported more than 115,000 cumulative cases of AIDS and an estimated 1 million infected persons.1,2 The connection between poverty and poor health, including HIV infection, is a result of many interrelated factors including lack of access to health care, poor nutrition, lack of adequate housing, and increased incidence of substance dependence.3 Homelessness is one of the most dramatic indicators of poverty. Of the 185 million adults identified by the census in 1990, about 13.5 million have been literally homeless at some time during their lives with 5.7 million homeless during the past five years. The conditions of homelessness pose severe problems for the control of infectious diseases and put homeless people at risk of serious debility and disability.4 The combined effects of HTV/AIDS and homelessness make these among the most challenging and pressing of public health problems. Atlanta, Georgia has been dramatically affected by both AIDS and homelessness . The city's economic prosperity has often masked the public health challenges created by a lack of affordable housing and creation of service sector jobs with little stability and no health benefits. According to the city's Task Force for the Homeless, more than 20,000 people call Atlanta's streets "home. "5 In 1993, Atlanta ranked eighth among all U.S. cities in the cumulative number of AIDS cases.6 HIV/AIDS is not the only epidemic facing metropolitan Atlanta. In 1991 and 1992, Atlanta had the highest rate of tuberculosis of all U.S. cities7; in 1992, it also had the highest rate of syphilis infection. Both tuberculosis and syphilis are strongly associated with HTV/AIDS. Addressing the health care needs of the homeless led Mercy Mobile Health Care (MMHC) into a partnership with the Georgia Department of Human Resources (DHR). One result was a seroprevalence study designed to quantify the level of HIV infection among the homeless. The blinded study targeted the approximately 7,500 homeless persons in inner-city Atlanta who received primary care from MMHC. During seven months of 1990 (March to September), 676 clients were tested (9 percent of the estimated target population ). Clients were served in parks, shelters, soup kitchens, and labor pools by outreach workers, health advocates, nurses, and doctors. The initial result of the survey pointed to the immediate need for HIV counseling/testing and early intervention programs for the homeless, both of Journal of Health Care for the Poor and Underserved · Vol. 7, No. 2 · 1996 84 HIV Seroprevalence Among Homeless which have been initiated. Further analysis of data obtained from two and a half years of the nonblinded seroprevalence study provided information that is being used to enhance risk reduction and prevention efforts. Background MMHC was created during the mid-1980s to provide primary care, social services, and health education to Atlanta's homeless as a part of Saint Joseph Health System's outreach to the poor in the inner city. The mission of MMHC is to improve the health status of the medically underserved. This is accomplished by using an interdisciplinary multicultural staff; a fleet of vans and mobile clinics; and a network of donated community sites and numerous collaborative relationships to deliver health care, education, and social services. As information about HIV began to be collected during the late 1980s, MMHCs staff and volunteers realized that homeless clients were at significant risk of acquiring and transmitting the virus. Clients reported unprotected sex with multiple partners, exchanging sex for drugs, and substantive alcohol and drug use, and were regularly diagnosed with sexually transmitted infections. However, homeless clients did not recognize that these behaviors were associated with HIV transmission. After diagnosing with AIDS several homeless individuals who had no knowledge of the disease and were unaware of their risk for infection, the MMHC staff set out to develop a comprehensive HIV services program. The first grant was obtained in 1988 from the CDC for street outreach and risk reduction education. That same year, the DHR was selected by the CDC to...

A Randomized Controlled Trial of an HIV Sexual Risk—Reduction Intervention for Young African-American Women

To evaluate the efficacy of a community-based social skills human immunodeficiency virus (HIV) prevention intervention to enhance consistent condom use. A randomized, single-blind controlled trial. Bayview-Hunter's Point neighborhood of San Francisco, Calif, a predominantly African-American community that is economically disadvantaged. A sample of 128 sexually active, heterosexual, African-American women 18 through 29 years of age was recruited using street outreach techniques. Participants completed a structured baseline interview; 100 women (78.1%) completed 3-month follow-up interviews. Women randomized to the social skills intervention completed five sessions that emphasized ethnic and gender pride, HIV risk-reduction information, sexual self-control, sexual assertiveness and communication skills, proper condom use skills, and developing partner norms supportive of consistent condom use. Women randomized to the HIV education condition participated in a single session that provided HIV risk-reduction information. Women randomized to the delayed HIV education control condition received no HIV risk-reduction information until all follow-up interviews were completed. Consistent condom use, HIV risk-reduction knowledge, sexual self-control, sexual assertiveness, sexual communication, and partner norms supportive of consistent condom use. Compared with the delayed HIV education control condition, women in the social skills intervention demonstrated increased consistent condom use (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.03 to 4.15; P = .04), greater sexual self-control (adjusted OR, 1.9; 95% CI, 1.00 to 3.60; P = .05), greater sexual communication (adjusted OR, 4.1; 95% CI, 1.67 to 10.01; P = .002), greater sexual assertiveness (adjusted OR, 1.8; 95% CI, 1.01 to 3.27; P = .05), and increased partners' adoption of norms supporting consistent condom use (adjusted OR, 2.1; 95% CI, 1.08 to 3.87; P = .03). No statistically significant differences in outcome variables were observed between the HIV education condition relative to the delayed HIV education control condition. Community-based HIV risk-reduction programs that are gender relevant and culturally sensitive and provide social skills training can effectively enhance consistent condom use.