Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 18, 2008

Managing HIV Risk Among Injecting Drug Users: A Critical Review of United States Substance Abuse Policy – Mikey Hager


Injection Drug Use (IDU) is a major risk factor for HIV exposure, but the United States has failed to adopt the full spectrum of substance abuse intervention models to manage HIV exposure risk in the drug injecting population. The Moral Model, the Disease Model, and the Harm Reduction Model are the three predominant models for substance abuse interventions (1). The United States is the only developed country where Harm Reduction interventions remain controversial and public policy forces a public health focus on the other two models (2). Both of these models are variations on Risk Elimination strategies for managing IDU risk and are loosely based in the Health Belief Model and the Theory of Reasoned Action. Both of these models believe that an individual’s true intention will translate directly into behavior (or behavior change). In the Health Belief Model, one formulates intention by weighing one’s perceived benefits of a behavior against one’s perceived severity and perceived susceptibility associated with that behavior. In the Theory of Reasoned Action, one formulates intention by weighing one’s personal attitudes regarding a behavior with perceived social norms regarding the behavior. These models are relatively ineffective at reducing high risk behavior for HIV exposure for IDU due to their emphasis on abstinence, leading to slow progress in achieving behavior change (3). Harm Reduction, on the other hand, is based on health promotion and is rooted in the Stages of Change Theory and is designed to meet clients where they are in terms of their addiction and ability to seek help (4). Stages of Change Theory assesses an individual’s readiness to engage in behavior change through a step-wise process that typically involves substance abuse abstinence as an end goal, but does not require abstinence to begin treatment. Considering the move away from the focus on Risk Elimination strategies world-wide (1), why is the United States resistant to adopting more of a Harm Reduction approach to address the problem of IDU HIV risk? There are three main reasons: (a) the United States systematically plans interventions that target individualized and not social group factors; (b) the social norms of the United States err on the conservative side making Harm Reduction unappealing at first and; (c) United States institutions are resistant to change that involves Harm Reduction programming.

Injecting Drug Use Culture and Substance Abuse Interventions

One way to examine this problem is to assess the United States substance abuse interventions in terms of an individual’s social factors. IDU are most often portrayed as criminal, isolated, and damaged persons, but things were not always that way. IDU worldwide can be traced back to the late 19th Century and was so concentrated in the United States that it was considered ‘The American Disease’ (5). Even so, psychoactive substances were not regulated by the United States until the Harrison Act of 1914 (6). Up until that point, psychoactive substances could be purchased by the public in a range of settings from pharmacies to grocers to traveling salesmen. The Harrison Act effectively removed IDU and other substance users from normalized society and pushed them underground (6). Social emphasis was placed on helping steer people away from substance abuse, but also on stopping any active use. This Risk Elimination approach later diverged into the two main substance abuse intervention models practiced in the United States (7).

While blood-borne infections have always been a concern among IDU, HIV was the first infection that had the potential to broadly infect and destroy the IDU population. In fact, some clusters of IDU have witnessed a very fast transition from 1% HIV prevalence to over 40% in less than a year. Furthermore, up to 40% of IDU in some places are romantically involved with non-IDU providing an opportunity for HIV to enter the general population from high-risk groups (3). Other nations noticed the connection between HIV, IDU and non-IDU involved in relationships with IDU and developed a new model for substance abuse interventions (8). The new model viewed abstinence and risk elimination as an ideal goal, but appreciated the urgency of reducing the highest risk behaviors among IDU as a means to prevent a large scale transition of HIV into the general population. United States substance abuse policy has not kept pace with these interventions, however, and continues to overlook the importance of reducing HIV risk among this critical group of people; the emphasis in the United States continues to be on abstinence first, treatment later (2). This application of the Health Belief Model focuses too much on individuals proving intent to ‘get and stay clean,’ which is putting the cart ahead of the horse in terms of usual treatment practices. Insistence on following this model is the failure to acknowledge a real and present danger to the IDU population and places the general public in danger in terms of long term HIV prevalence and incidence rates. More importantly, stigmas associated with IDU are heightened by policies that view this group as either criminal or mentally diseased (1). These stigmas make it difficult for outreach workers to develop a rapport for IDU for the purpose of secondary prevention that is so necessary (2).

United States Popular Culture and Substance Abuse Interventions

There have been laws on abstinence of psychoactive drugs for nearly 100 years in the United States. As a result, popular culture has been imprinted with the concepts of the medical and disease models for substance abuse interventions and their foundations in the Health Belief Model and the Theory of Reasoned Action (7). Two other important concepts to mention are stigma and the labels related to stigma. Labeling Theory and Stigma Theory fill in much of the background left unaddressed in the previous section. It is human nature to place labels on people, behaviors and concepts, and wherever there are labels, stigma is not far behind. It should be noted that the Harrison Act of 1914 came just eight years before prohibition and the 18th Amendment to the United States Constitution reflecting the prevailing socio-spiritual climate of wholesomeness. Before Harrison, substance abusers were not dragged down by these concepts because they could access drugs through ordinary channels. After the Harrison Act came to force, substance abusers were fiercely reminded of the way they were viewed by broader society. The sharpest stigmas are wrought by newness of an individual’s exposure to them and the degree to which the concepts behind them are espoused by the surrounding public (2). The Harrison Act embodied a movement of enormous social pressure and turned average citizens into criminals overnight. It is arguable that this increased individual’s dependency on drugs right at the very beginning to compensate for new feelings of social isolation (7). Many writers on this topic have discussed how policies that are supposedly intended to help IDU have actually backfired, encouraging IDU to withdraw further underground (1-4,6-9). This greatly increases risk of HIV exposure, because people are less likely to ask about or enter treatment and there is a great distrust of the medical care and social services system.

Institutional Culture and Substance Abuse Interventions

The second way to approach this problem is to examine social factors of the IDU community. While the criminal justice system and medical profession were responsible for the development of the criminal and medical models of substance abuse interventions, IDU themselves are most often credited with the creation of Harm Reduction methods (9). The world’s first Needle Exchange Program (NEP) was opened in Amsterdam, Netherlands in 1984, but many cities, including New York City and other American cities witnessed the banding together of their IDU populations in the face of HIV through the 1980’s (9). The new IDU advocacy groups were more successful in other developed countries, presumably because the United States is large and subject to a more intense and wider range of political ideology . While cities and states in the United States can operate NEP and other Harm Reduction interventions for HIV exposure risk among IDU, federal law prohibits the use of federal dollars for these purposes, because there is a fear of being seen as ‘soft of drugs’ (4). In fact, language from a 1994 policy states that NEP are ineligible for funding in the United States until such time that they have proven to be safe and effective (3,10). This is the reverse of the normal policymaking process and there is no other HIV policy in the United States or any other country that requires that a project prove its efficacy before funding is made available for a demonstration project proving its efficacy (3). It seems unlikely that any evidence in support of Harm Reduction interventions would be acknowledged by policymakers who enacted such backward regulations.

There is no doubt that there has been an overwhelming amount of research done on this topic (11-14). NEP and other Harm Reduction interventions designed to manage HIV exposure risk among IDU have been proven to be effective at reducing this risk and do not increase risk of new IDU among former non-users. Another analysis of this issue found that of 15 studies conducted in the United States and abroad all 15 showed a statistically significant reduction in HIV incidence among IDU who frequent NEP (3). Even so, federal officials with Centers for Disease Control and especially Substance Abuse and Mental Health Services Administration remain skeptical of the Harm Reduction model (15). A review of Centers for Disease Control priorities and projects shows that there is an increasing emphasis placed on Harm Reduction interventions for substance abusers, but that only among interventions aimed specifically at reducing HIV incidence (15). Very interestingly, Centers for Disease Control officials prefer to call Harm Reduction by a different name: Holistic Health Recovery (16). A similar review of the United States criminal justice system revealed a similar theme: Harm Reduction practices operating under a different name (6). Substance Abuse and Mental Health Services Administration priorities and projects shows a complete lack of harm reduction interventions. Minutes from a Center for Substance Abuse Treatment National Advisory Council meeting attest to the active forces still at work within Substance Abuse and Mental Health Services Administration to push for the continuation of either the medical or criminal models for substance abuse interventions (17). How bizarre that federal bureaucracy would feel the stigma of certain policy options and either call them by a different name in the case of the Centers for Disease Control or pretend that they do not exist at all in the case of Substance Abuse and Mental Health Services Administration. This irony is lost on United States public health policymakers.


Riley and O’Hare define the four basic assumptions central to Harm Reduction: “(a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addition; (b) it recognizes abstinence as an ideal outcome, but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “top-down” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches” (4). As compared to the current United States policy based on Risk Elimination, this Harm Reduction approach addresses the urgency of high-risk activity in terms of HIV exposure. It is essential that such high risk is addressed for the safety and protection of the entire population since there is sexual networking between IDU and non-IDU. Chesney and Antoni contrast what they call use-reduction and harm reduction very effectively: “based on experience since 1985, the rhetorical and policy-oriented emphasis on making drug use less acceptable and drugs less available, as well as the focus on drug prevalence as the dominant indicator of program success, has probably outlived its usefulness” (3). The arguments made by Riley and O’Hare and by Chesney and Antoni reverberate with the three points of this critique: the United States has not adopted broad-based Harm Reduction techniques for reducing HIV risk among IDU due to a systematic failure to examine cultural instead of individual risk factors, the social norms of the United States and an institutional resistance to institutionalizing Harm Reduction. On the other hand, Riley and O’Hare also point out that once NEP and other Harm Reduction interventions move into an area, public opinion reverses and Harm Reduction is accepted into the community (4).


1. Marlatt G. Harm Reduction: Come As You Are. Addictive Behaviors; 1996; 21:779-788.

2. MacMaster S. Harm Reduction: New Perspective on Substance Abuse Services. Social Work 2004; 49:356-363.

3. Jarlai D and Friedman S. Strategies for Working with Injecting Drug Users: The Role of Health Psychologists in Harm Reduction. In: Chesney M and Antoni M, ed. Innovative Approaches to Health Psychology: Prevention and Treatment Lessons from AIDS. Washington, DC. American Psychological Association, 2002.

4. Riley D and O’Hare P. Harm Reduction: History, Definition and Practice (pp. 1-26). In: Inciardi J and Harrison L, ed. Harm Reduction: National and International Perspectives. London, UK. Sage Publications, Inc. 2000.

5. Musto D. The American Disease: origins of narcotic control. Oxford, UK; Oxford University Press; 1998.

6. Inciardi, J. The Harm Reduction Roles of the American Justice System (pp. 193-206). In: Inciardi J and Harrison L, ed. Harm Reduction: National and International Perspectives. London, UK. Sage Publications, Inc, 2000.

7. Denning P. Practicing Harm Reduction Psychotherapy. New York, NY USA; The Guilford Press; 2000.

8. Blume and Marlatt. Harm Reduction (pp. 196-201). In: O’Donohue, Fisher, and Hayes, ed. Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice. Hoboken, NJ. John Wiley & Sons, Inc. 2003.

9. Lane S, Lurie P, Bowser B et al. The Coming of Age of Needle Exchance: A History Through 1993 (pp. 47-68). In: Inciardi J and Harrison L, ed. Harm Reduction: National and International Perspectives. London, UK. Sage Publications, Inc, 2000.

10. Hearing Before the Subcommittee on Criminal Justice, Drug Policy, and Human Resources of the Committee on Government Reform. Pros and Cons of Drug Legalization, Decriminalization, and Harm Reduction.
House of Representatives, 106th Congress. June 16, 1999.

11. Islam M and Conigrave K. Assessing the role of Syringe Dispensing Machines and Mobile Van Outlets in Reaching Hard-to-Reach and High-Risk Groups of Injecting Drug Users: a review. Harm Reduction Journal 2007; 4:14.

12. Tyndall M, Wood E, Lai C et al. HIV Seroprevalence Among Participants at a Supervised Injection Drug Facility in Vancouver, Canada: implications for prevention, care and treatment. Harm Reduction Journal 2007; 3:36.

13. Stimson G. Harm Reduction Coming of Age: a local movement with a global impact. International Journal of Drug Policy 2007; 18:67-69.

14. Van Den Berg C, Smit C Van Brussel G et al. Research Report: full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis c virus- evidence from the Amsterdam Cohort Studies among drug users. Addiction 2007; 102:1454-1462.

15. Centers for Disease Control and Prevention. Goals and Objectives of the CDC HIV Prevention Plan: Extended Through 2010.
Updated December 28, 2007.

16. Centers for Disease Control and Prevention. Holistic Health Recovery Program (HHRP) Program Description.

17. Substance and Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment National Advisory Council Official Minutes.
May 19-20, 2005.

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