228 AIDS/HIV
- and to women living in 18 low-income housing devel-
opments (Sikkema et al., 2000) have been reported. This
model has proven to be so successful that it serves as the
conceptual basis for an ongoing, NIMH-sponsored multisite
international study.
Two approaches to HIV risk-reduction strategies for
drug-using populationscan be considered midstream ap-
proaches: community-based outreach and network approaches.
Community-based outreach typically targets out-of-
treatment injection drug users (IDUs), and provides risk re-
duction messages, condoms, bleach and needle disinfecting
supplies, encouragement to seek HIV C&T, and referrals to
drug abuse treatment. A recent review of 36 single group and
quasi-experimental studies indicated that two-thirds of the
outreach efforts resulted in subsequent HIV C&T and IDUs
reduced baseline levels of drug-related and sex-related risk
behaviors following their participation in a outreach inter-
vention (S. Coyle, Needle, & Normand, 1998). This review
also concluded that, following involvement in outreach pro-
grams, IDUs reduce drug injection behavior and are less
likely to reuse syringes, needles, and other injection equip-
ment (e.g., cookers, cotton). Outreach interventions have re-
sulted in greater use of needle disinfection and an increased
likelihood of entry into drug treatment (S. Coyle et al., 1998).
One quasi-experimental study found reduced HIV seroinci-
dence among outreach participants (Wiebel et al., 1996). The
effects of outreach efforts on sex-related risks are less im-
pressive; there has been increased condom use but the major-
ity still practice unsafe sex.
Network approaches targeted toward drug users seek to
change community based norms and patterns of risk among
network members and to enhance readiness to enter drug abuse
treatment. These approaches represent a shift in focus from the
individual to transactions among individuals and to the context
in which drugs are procured and used (Needle et al., 1998).
Latkin (1998) compared a network with a standard interven-
tion; the network approach was similar to the POL imple-
mented in Kelly et al. (1992) in that peer leaders were identi“ed
and they participated in a 10-session training program. They
were then encouraged to contact their drug using peers and pro-
vide outreach. Pretest and posttest surveys found that IDU
opinion leaders were able to reach 78% of their peers. Contact
with opinion leaders was associated with increased condom
use, and increased use of bleach to clean needles; peers in the
network were less likely to use unbleached needles.
MediaApproaches. Many preventionists recognize that
intensive, individual and small group approaches work well,
but they reach a relatively small segment of the community.
Mass media, such as television, radio, and print publications,
afford the potential for greater •reach.Ž Use of the media as a
primary prevention strategy in the United States has not been
widely implemented. One notable exception is the •Condom
Campaign,Ž which occurred in three urban Washington com-
munities (Alstead et al., 1999). This quasi-experimental pro-
gram targeted urban adolescents in areas known for high rates
of adolescent STDs, and sought to overcome two widely cited
obstacles to condom use among adolescents: negative attitudes
and dif“cult access. Campaign leaders “rst formed an advisory
board; next, they secured pro bono services from a local adver-
tising agency to donate advertising expertise. Then, working
with the advisory board and ad agency, they developed a three-
pronged approach to improve condom attitudes and use: (a) se-
cure support through outreach efforts to community-based
leaders and organizations, (b) develop and distribute procon-
dom messages through the media (e.g., radio, billboards, bus
signs, and brochures); and (c) make condoms available
through free or low-cost distribution in easily accessed public
settings (e.g., condom bins and vending machines in dressing
rooms, restrooms and other private settings accessible to
teens). Pilot evaluation indicated that 73% of the target youth
reported exposure to the campaign and radio in”uenced the
largest number of adolescents. Unfortunately, evaluation of
the risk reduction effects of the campaign was meager, and did
not reveal risk reduction over the study interval.
Although media programs have a larger reach, we would
expect individual and small group approaches to result in
larger effects. As suggested earlier in this chapter (Fig-
ure 10.1), complementary prevention initiatives across multi-
ple target points are needed over a sustained period of time.
Such approaches require a large commitment of resources to
implement, and would be very challenging to evaluate. From
a theoretical perspective, however, such an approach would
appear to be the most effective. A recent study illustrates how
we might begin such a challenging task.
Celentano et al. (2000) report the results of a study that
sought to evaluate the effectiveness of both a small group and
social diffusion intervention. Their small group intervention
was designed to encourage condom use, reduce alcohol con-
sumption and brothel use, and enhance sexual negotiation
and condom skills. Three group were formed for the study.
Group 1 (n450) received the small group intervention.
Group 2 (n681) lived in near-by barracks at the same mil-
itary base but did not receive the intervention; this was the
diffusion group. Group 3 (n414) were in distant camps
(controls). Outcome measures included testing for HIV in-
fection as well as behavioral measures. The intervention was
applied for 15 months, and men were followed up at 6-month
intervals (with repeated HIV and STD testing). The results
were rather stunning. The intervention decreased incident