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Overcoming Social Barriers
Pages 97-136

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From page 97...
... The Committee believes that while these entrenched barriers cannot be easily overcome, they must nevertheless be explicitly acknowledged in HIV prevention efforts. The Committee also believes that specific policies and laws emanating from these social and political conditions and attitudes can and must be changed.
From page 98...
... that have demonstrated associations with morbidity and mortality (Geronimus, 2000~. Further, inadequate access to health care and lack of supportive, culturally appropriate social services allow co-occurring conditions such as substance abuse, mental illness, tuberculosis, sexually transmitted diseases (STDs)
From page 99...
... For example, a recent survey found that 27 percent of AfricanAmerican respondents believed that HIV/AIDS is a government conspiracy against their racial group (Klonoff and Landrine, 1999~. The distrust and fear derived from racist experiences and historical traumas have serious implications for carrying out effective HIV prevention and treatment activities in minority communities.
From page 100...
... Further, because many adolescents are not receiving accurate information regarding drugs, STDs, and healthy sexual behavior from their parents or other trusted adult sources, they often rely on the media as a primary source of information (STD Communication Roundtable, 1996~. Given the impact of media on young people's attitudes, as well as on consumer behavior, messages that consistently promote risk reduction could facilitate much-needed changes in social norms regarding sexual behaviors and drug-use practices.
From page 101...
... This campaign would make extensive use of the media to promote comprehensive public health messages regarding STDs, HIV infection, sexual abuse, and unintended pregnancy (Text Box 7.1~. The strategies set forth in The Hidden Epidemic recommendations, if they were implemented, would constitute significant steps toward changing social and cultural norms and beliefs about sex.
From page 102...
... Similarly, AIDS-related stigma has combined with stigma of drug use to affect public policy about HIV prevention programs that target injection drug users (IDUs)
From page 103...
... Thus, while some progress has been made in reducing AIDS stigma, and while public support for discriminatory policies has diminished, AIDS stigma still persists and continues to undermine HIV prevention efforts. As a result, the Committee believes that the protection of human rights, privacy, and equity continues to be a significant concern, and that concurrent efforts at the federal, state, and local level to remove or at least lessen the impact of stigma and discrimination are necessary.
From page 104...
... , particularly among men who have sex with men. Lack of Leadership Concerted efforts by politicians and national leaders to openly discuss HIV and engage the public in HIV prevention efforts can set the stage for a national-level mobilization against the epidemic.
From page 105...
... Among industrialized countries, government leaders in Australia and the Netherlands have worked with communities to develop policies that minimize the harm incurred by drug abuse and reduce stigmatization of drug users. These countries offer drug abuse treatment on demand; they also have rapidly expanded the availability of methadone maintenance, and they have successfully developed innovative methods for targeting drug users and slowing the HIV/AIDS epidemic among IDUs (Drucker et al., 1998~.
From page 106...
... . Two of the most effective strategies for preventing HIV infection among IDUs include eliminating or reducing the frequency of drug use and associated risk behaviors through drug abuse treatment, and reducing the frequency of sharing injection equipment through expanded access to sterile injection equipment.
From page 107...
... In recent years, a number of studies have found that drug abuse treatment also reduces risk behaviors associated with HIV/AIDS. Methadone maintenance, which reduces injection and needle-related behaviors that place individuals at risk for HIV have shown particular success (Broome et al., 1999; Magura et al., 1998; Camacho et al., 1996; Longshore et al., 1993; Ball et al., 1988~.
From page 108...
... block grant to support substance abuse prevention and treatment services. States have broad discretion in how the SAPT block grant funds are distributed (to cities, counties, and service providers)
From page 109...
... of total drug abuse treatment spending (McKusick et al., 1998~. Recent changes in public and private insurance coverage may have affected access to drug abuse treatment.
From page 110...
... While the public treatment system remained neglected throughout most of the 1980s, federal investments in the criminal justice system experienced a period of unprecedented growth. Although federal funding for drug abuse treatment has increased over the past decade, the growth rate for drug abuse treatment spending remains much flatter than the growth rate for criminal justice spending (ONDCP, 2000b)
From page 111...
... _ . _ ~5 Q En o Is o In IL 7,000 6,000 5,000 4,000 3,000 2,000 1 ,000 O111 -- Criminal justice Drug abuse treatment Drug abuse prevention _ _ _ , _ ,_ _ _ — — _ __ _ ~ — _ — ._ · — — _ __ _ _ _ _— _ __ _ .
From page 112...
... have consequently recommended that current regulations be modified to give greater weight to clinical judgment and to allow for improved access to methadone treatment.l2 Many of the factors limiting access to or availability of drug abuse treatment are related to several common misperceptions. For example, a recent IOM study noted that one of the most enduring myths related to addiction is that treatment for these disorders is ineffective (IOM, 1997a)
From page 113...
... The Committee believes that drug abuse treatment is an effective, but highly underutilized HIV prevention strategy. However, there is increasing support on the federal level for closing the public drug abuse treatment gap (ONDCP, 2000c; ONDCP, 1999~.
From page 114...
... Therefore, the Committee recommends that: Federal agencies (including the Substance Abuse and Mental Health Services Administration, the Health Care Financing Administration, the Office of National Drug Control Policy, the Department of Veterans Affairs, and the National Institute on Drug Abuse) , state and local agencies, and private insurers that fund, administer, or conduct research on drug abuse treatment programs should collaborate to develop mechanisms to: (1)
From page 115...
... In addition, the federal Mail Order Drug Paraphernalia Act prohibits sale and transportation of syringes and other drug paraphernalia in interstate commerce (Gostin, 1998~. In addition, a series of statutes enacted by Congress since 1988 specifically prohibit the use of federal funds to support needle exchange programs, regardless of whether or not programs are legally authorized by the individual state.
From page 116...
... . The Committee believes that improving access to sterile injection equipment is a critical component of HIV prevention.
From page 117...
... . Studies reviewing the scientific literature, as well as expert panels that have studied this issue, have concluded that comprehensive sex and HIV/AIDS education programsl4 and condom availability programs can be effective in reducing high-risk sexual behaviors among adolescents 14In a comprehensive review of school-based sex education programs, Kirby (2000)
From page 118...
... National surveys show strong public support for comprehensive sex education policies and condom availability programs. A 1998 poll found that 81 percent of adults supported schools teaching information about abstinence as well as about contraception and prevention of STDs (Kaiser Family Foundation, 1998~.
From page 119...
... : that legislative restrictions discouraging efteach: lathe law defines an abstinence education program as having eight components that · abstinence has social, psychological, and health benefits; · unmarried, school-aged children are expected to abstain from sex; · abstinence is the only certain way to prevent out-of-wedlock pregnancy and STDs; · a mutually faithful monogamous married relationship is the standard for sexual activity; · sexual activity outside marriage is likely to have harmful psychological and physical effects; · out-of-wedlock childbearing is likely to harm the child, the parents, and society; how to reject sexual advances and how alcohol and drug use increases vulnerability to them; and · the importance of attaining self-sufficiency before engaging in sex. SOURCE: Kaiser Family Foundation, l999b.
From page 120...
... The benefits of such efforts will extend beyond the correctional system as well, since the circulation of infected or high risk individuals between correctional facilities and communities is a dynamic that now helps maintain the epidemic and contributes to new cases each year in many urban areas (Braithewaite et al., 1996~. The primary barrier to implementing HIV prevention programs and strategies in correctional settings is the difference in priorities between public health officials and correctional system officials.
From page 121...
... However, failure to address HIV prevention needs in prisons and jails is a shortsighted strategy that will lead to unnecessary new infections and wasted expenditures. There are four primary routes for addressing this issue: helping inmates when they are released, providing HIV/AIDS education to inmates, providing drug abuse treatment in correctional settings, and implementing harm reduction programs.
From page 122...
... Percentage of City/ County Jail Systems Providing (N= 41) Discharge planning services for HIV+ inmates 92 76 Referral Appointment Referral Appointment Made Made Made Made Medicaid/related benefits CD4 monitoring Viral load monitoring 61 HIV medications 82 Substance abuse treatment 75 HIV counseling 73 Psychosocial support 73 STD prevention and treatment 78 71 65 35 24 22 31 22 27 24 22 56 54 46 66 63 61 54 46 29 17 20 27 24 32 27 17 *
From page 123...
... HIV Prevention Education While all state and federal prison systems offer basic HIV information and instruction on the meaning of an HIV test result, only two-thirds of the systems provide information on safer sex practices, and less than half teach safer sex negotiation skills or provide information about safer drug injection practices (see Table 7.1~. Only 10 percent of prisons and 5 percent of jails currently offer comprehensive programs of instructor- and peer-led education, pre- and pastiest counseling, and multisession prevention counseling (Hammett et al., 1999~.
From page 124...
... Many of these individuals are poorly supervised, lack employment or health insurance coverage, and often relapse into substance use or other risk behaviors (Pollack et al., 1999~.17 However it has been estimated that only 18 to 25 percent of inmates in need of treatment are actually receiving it (Mumola, 1999; National Center on Addiction and Substance Abuse, 1998~. A recent study of women's prisons also found long waiting lists for residential drug abuse treatment programs (GAO, 1999~.
From page 125...
... Thus, it is important to address the multiple needs that substance abusers may have if treatment is to be accepted and effective. Not all correctional facilities can realistically offer drug treatment services to inmates.
From page 126...
... correctional facilities provide information about safer drug injection practices, no facilities distribute needles or injection equipment (Hammett et al., 1999; NIT et al., 1999~. Indeed, possession of needles and syringes is illegal in correctional settings (NIT et al., 1999~.
From page 127...
... are linked with appropriate community-based prevention and treatment services; comprehensive HIV prevention education programs for incarcerated individuals and staff are implemented in all correctional settings; and · drug treatment is available for inmates with drug abuse problems. While there is not yet definitive evidence that condom distribution in correctional facilities would reduce HIV transmission, in light of the absence of problems reported by facilities that have implemented such programs, the Committee recommends that condoms be made readily available to incarcerated individuals.
From page 128...
... However, in the absence of these measures, the Committee believes that HIV educational programs in correctional facilities should include information about safe injection practices and all inmates needing substance abuse treatment should receive such services upon request. REFERENCES Abdool Karim Q
From page 129...
... 1999. An institutional analysis of HIV prevention efforts by the nation's outpatient drug abuse treatment units.
From page 130...
... 2000. Medical and psychosocial services in drug abuse treatment: Do stronger linkages promote client utilization?
From page 131...
... 1997. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS)
From page 132...
... 1997. AIDS epidemic in San Francisco among men who report sex with men: Successes and challenges of HIV prevention.
From page 133...
... 1999. Substance abuse and treatment, state and federal prisoners, 1997.
From page 134...
... 1990. The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection.
From page 135...
... Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 10~1~:73-81. Walker EA, Katon WJ, Hansom J
From page 136...
... SPECIFIC REFERENCES USED IN DEVELOPING MODEL SCENARIOS FOR HIV PREVENTION Belcher A, Kalichman S Topping M, Smith S


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