INTRODUCTION
By the mid 1980s, it was apparent that injecting drug users (IDU) were a significant source for the spread of HIV/AIDS. Harm reduction efforts such as street outreach focused on safer injecting (and sexual) practices, and for amenable outreach clients, referrals to substance abuse treatment. The full efficacy of treatment for preventing HIV/AIDS could be realized, however, only if motivated IDUs could readily enroll in treatment. Outreach workers and IDUs report anecdotally, however, that enrolling in treatment is fraught with obstacles. This study was done to identify the obstacles systematically and to specify remedies with aim of reducing HIV/AIDS morbidity and mortality.
BACKGROUND
In 1989-1990, the Office of Alcoholism and Substance Abuse Services (OASAS), New York's single state agency for substance abuse treatment and prevention, set up a network of street outreach programs to provide HIV/AIDS prevention services. Focused on injecting drug users (IDUs), the street-based interventions evolved from HIV/AIDS education and securing HIV testing and counseling services to a wider variety of services but with a continued emphasis on harm reduction.
The harm reduction approach involves providing a broad range of risk reduction, health, social, and related services aimed colloquially at "meeting the client where they're at." Referring interested clients to alcohol and other drug (AOD) treatment is integral to outreach workers' street contacts with IDUs, which clearly imply offering them help to get these services. However, the impetus for addressing an abuse or dependency problem and initiating the process of enrollment depends on explicit direction from the client. Rates of referral and admission of OASAS outreach clients to AOD services have been around 5% of all IDUs contacted and while low, these results are consistent with results achieved elsewhere (R.E. Booth, Field Consensus Regarding AOD Treatment Enrollment Rates for Street Outreach Clients. Personal Communication, 1999).
The stimulus for this study arose from reports of IDUs and street outreach workers that there are a variety of obstacles to enrollment in AOD programs apart from the low expected rate associated with the harm reduction approach to risk reduction. The concern is that since IDUs continue to be a major source of HIV/AIDS and other infectious disease transmission (1), a comprehensive prevention strategy must use the prophylactic effects of AOD treatment [recognized early in the HIV/AIDS epidemic (2)]. Thus, there is particular urgency in identifying and reducing obstacles to enrollment in AOD services for injecting drug users.
Barriers and remedies were specified analytically by examining the actors and institutions involved in treatment referrals and admission, and what could obstruct these activities. For convenience, these activities are called "treatment enrollment." Nominations were obtained from OASAS, outreach, and treatment program staff with firsthand knowledge of treatment enrollment issues for IDUs. Nominees included IDUs themselves and the practices, policies, and attitudes of staff of street outreach programs, treatment programs, and directly involved government agencies including OASAS, the AIDS Institute of the New York State Department of Health (the agency that coordinates New York's response to the HIV/AIDS epidemic), the Human Resources Administration (the local social services agency in New York City), and the New York City Police Department.
Literature
While some work has been done on client and admissions process factors (3) affecting enrollment in treatment, there has been little on organizational, policy, or systemic factors that impede the process. Bux et al. (4), for example, found, in a study done in New Jersey, that the majority of coupons for free 21- or 90-day methadone detoxification were redeemed (58.5%), many by first-time treatment participants. The relevance of Bux et al.'s coupon initiative is that New Jersey eliminated most "free" (publicly-funded) AOD services in 1981, a policy change with obvious impact on HIV/AIDS prevention and treatment enrollment for that state's IDUs.
Fifteen percent is an oft-cited figure for the number of drug abusers in treatment relative to the total in need (5). Limited though it may be, the effectiveness of AOD services for HIV/AIDS prevention is unequivocal (6). Nevertheless, the rate of enrollment from street outreach and other harm reduction efforts remains low aside from exceptional gains resulting from specialized research interventions (7). The present study was designed to assess the obstacles to AOD enrollment inherent in the policies, practices, and attitudes of various institutions that affect IDUs who are potential recipients of care as well as obstacles associated with the IDUs themselves. Secondly, the study aimed to identify suggestions for remedial measures to address the various barriers. Information on obstacles and suggestions was obtained from interviews of IDUs and from staff of the organizations and institutions nominated as presenting barriers to treatment enrollment.
METHOD
Separate, semi-structured questionnaires were used to interview: 1) IDUs contacted by street outreach workers, 2) staff of street outreach programs, 3) staff of treatment programs, and 4) staff of OASAS, the AIDS Institute, and the Human Resources Administration (HRA). (Persistent efforts to access Police Department policy managers were to no avail).
Injecting Street Outreach Clients
The six OASAS street outreach providers all agreed to facilitate recruitment of IDUs for interviews. Four operated in New York City proper, one served Westchester County just north of New York City, and one served the mid-Hudson area about 100 miles north of the city.
Sample
Street outreach clients could be known or likely injecting drug users engaged by an outreach worker for the first time as part of the study. To be eligible, an outreach client had to be screened in as an IDU by the outreach worker and the research interviewer. The latter screened candidates by observing track marks, asking to see them if not evident, and by probing the candidate's use pattern for additional verification. Subjects had to be 18 or older, to have injected heroin or cocaine at least once in the past week, and not have been in drug detoxification or treatment in the past 30 days.
Instrument
The questionnaire took 20-30 minutes and covered: demographics, living arrangements, employment, criminal justice status, medical and psychiatric history, illicit drug use and modes of consumption, HIV/AIDS injection risk behaviors, perceived risk of contracting HIV, current HIV/ AIDS status, precautions taken, number and type of previous AOD treatment episodes longer than 2 weeks, main things/reasons in the way of enrolling in drug treatment now, personal relevance of 21 specific obstacles to treatment enrollment, and suggestions for making it easier to enroll.
Design
The initial quota sampling plan of N = 20 per outreach provider was modified because of variations in yield and geographical coverage. The final N = 144 was distributed geographically as follows: Manhattan = 40, Bronx = 40, Brooklyn = 10, Queens = 10, Westchester County = 30, and Ulster County = 14.
Procedure
Interviewers accompanied workers as they did outreach during the day and on occasional evening stretches. As a worker completed their primary service with a client, they would indicate that the person(s) (interviewer) standing nearby wanted to do a private, paid interview with them about things standing in the way of them going into treatment and about suggestions for making it easier to enroll. Interested candidates were screened for eligibility and arrangements were made for an interview.
The client was told the purpose of the project, that their responses were confidential and anonymous, and that they would be paid $15 after completing the interview. After signing an informed consent using a pseudonym, the subject was interviewed, paid, and thanked for their assistance. All subject recruitment and data collection procedures for the outreach clients and agency staff participants were approved by the OASAS Institutional Review Board (IRB) at the University of Buffalo.
Interviews were done in a variety of settings with a focus on the privacy of the interview and the security of the interviewer. The settings ranged from the field or central offices of the outreach program to various street or public settings (see Table 1).
Street Outreach Program Staff
