Knowledge about and behaviors affecting the spread of AIDS: a street survey of intravenous drug users and their associates in New York City.

An informal survey of knowledge about and behaviors relevant to the spread of AIDS was conducted on the street in New York City during October 1986. The sample (n = 204) includes IV drug users (60%) and others (40%). The informal nature of the interview suggests that respondents gave "salient" answers rather than the complete answers that would be expected in a formal interview situation. A smaller proportion of respondents reported salient knowledge about drug-related transmission of AIDS than had been found in other populations, using formal interview methods. A close association was found between any accurate knowledge about spread of AIDS and likelihood of practicing one or more risk reduction behaviors. New users (persons who had been using drugs for only 1 or 2 years) were significantly less likely than others to have salient knowledge about AIDS transmission and also less likely to practice risk reduction measures.

Effects of outreach intervention on risk reduction among intravenous drug users.

Considerable voluntary risk reduction has occurred among IVDUs in New York City. The purpose of the AIDS Outreach Project was to improve upon the existing level of risk reduction by providing information and anonymous HIV testing to street-recruited IVDUs. Intake and follow-up interviews were conducted with 121 subjects (44% of 276 at intake), with a mean of 4.5 months between interviews. Significant risk reduction occurred in many drug and sexual risk behaviors, although not in bleach use, and more than half of the subjects continued to engage in high-risk sexual behavior. An analysis of differences in risk reduction between early and later intake groups indicated that external trends were not sufficient to account for observed risk reduction. Among subjects engaged in high-risk behavior at intake, those who injected less or were enrolled in drug abuse treatment were more likely to stop high-risk drug injecting. Subjects who (at intake) engaged in less frequent unprotected sex, or who had had sex with someone with AIDS, were more likely to stop high-risk sexual behavior. The majority of subjects at low risk at intake maintained low-risk behavior. Informational interventions appear to be most successful among those IVDUs already engaging in lower levels of risk behavior. More effective methods are needed for those whose level of risk behavior is greater. These might include peer pressure and distributing bleach (as opposed to only providing information about bleach).

Patient-staff governance in methadone maintenance treatment: a study in participative decision making.

To help counteract some methadone patients' unfavorable attitudes to treatment and consequent antitherapeutic behaviors, a participative decision-making model was implemented in two methadone maintenance programs. Team building was used to initiate collaboration between patients and staff, resulting in the establishment of joint patient-staff governance committees. Outcomes as measured by the Client Attitudes Toward Methadone Programs (CAMP) Scale (a new instrument developed for the study) and by patients' supplementary drug use showed no statistically significant changes. The process evaluation, however, indicated that the committees had positive results in increasing communication and understanding between patients and staff, and in improving the efficiency of certain clinic procedures. The study analyzes the organizational dilemmas encountered in implementing participative decision making in drug treatment programs and gives recommendations for promoting future work in this area.

Contingency contracting with polydrug-abusing methadone patients.

The study assessed the effects of contingency contracting for medication take-home privileges on the polydrug use of methadone patients. Comparisons were made among 20 patients using cocaine, 13 using other illicit drugs, and seven exhibiting other noncompliant behavior. A within-subjects reversal design showed that there was no overall difference in the percentage of positive urines between the pre-contingency and contingency periods, nor between the pre- and post-contingency periods. During the first contingency month, however, one group of patients eliminated drug use, while the remaining had an increased percentage of positive urines. This increase may have been due to the heightened urinalysis regimen during the contingency period rather than to more actual drug use. During the first month, drug-related contracts not involving cocaine were more successful than those targeting cocaine, and non-drug-related contracts were more successful than drug-related ones. The study concluded that contracting had a favorable, though transient, effect primarily on non-cocaine-abusing methadone patients. Further research using stronger or multiple reinforcers is indicated.

The AIDS epidemic among blacks and Hispanics.

Social researchers and epidemiologists, as well as their major institutions and the general public, have been slow to address the racial and ethnic aspects of the AIDS epidemic. Whether measured by categories associated with major routes of infection, age level, gender, or by diminished length of survival, blacks and Hispanics are disproportionately affected by AIDS. Education, care, and outreach efforts based upon stereotypes of gay white males will have to yield to greater attention to cultural differences--and potential strengths--within each of the special "communities at risk." Evidence indicates areas of social resistance along with unique possibilities for change.

Alcohol use and abuse: heavy drinking among methadone clients.

This paper discusses alcohol use among methadone maintenance clients and narcotics users not in treatment. The data are derived from the Tri-State Ethnographic Project, a study of four methadone maintenance clinics in three states. Data indicate that methadone clients consume more alcohol than comparable age groups in the general population, but not more alcohol than narcotics users not in treatment. For a portion of the treatment population, however, heavy drinking presents significant problems. Sixteen percent of the treatment sample were found to be abusive pattern drinkers; that is, persons who report not only drinking heavily but also spending a great deal of time hanging out on the street, getting high, and consuming many other additional drugs. These abusive pattern drinkers reflect a pattern of polydrug use which began in their early teens and report multiple unsuccessful treatment attempts.

"It takes your heart": the image of methadone maintenance in the addict world and its effect on recruitment into treatment.

Using data gathered on 368 current methadone clients and 142 narcotics users not in treatment in structured interviews and through ethnographic fieldwork, the study examines the image of methadone maintenance treatment in the drug-using community and discusses the effect of that image on recruitment of addicts into methadone treatment. The results indicate that the image of the methadone client as a "loser," fear of the long-term effects of methadone, and the perception of treatment as an intrusion in the user's daily life make addicts often difficult to recruit and, once in treatment, ambivalent about their participation. The image of methadone is based on both misinformation about treatment and the user's contrasting of a treatment status with the stereotypic ideal of the "righteous dope fiend." Policy implications and suggestions derived from the data are discussed.

Patterns of cocaine use among methadone clients.

This paper presents data on cocaine use and its consequences among 368 methadone-maintained clients. Data come from the Tristate Ethnographic Project (TRISEP), a study of methadone maintenance at four treatment programs in three states. Cocaine is a part of the drug use and social life of clients in methadone treatment; it is found not only among a handful of deviant clients but also among one-fifth of clients otherwise compliant with program rules. Cocaine is reported to be a high-status drug among clients, but one with potentially dangerous consequences. Cocaine is associated with increased criminal activity and exposure to violence and the addict life-style. It is reported to be a substitute high, an economic drain on the client user, and a possible route back into the life-style of addiction. Cocaine use, and the consequences stemming from that use, may affect the success or failure of treatment and, therefore, is of critical importance to the treatment community.