Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin over-dose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants' knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.

Injection drug use plays a critical role in the spread of HIV/AIDS, with an estimated 19,000 drug users infected each year. Counselling and testing services can be an important gateway for engaging HIV-infected individuals into medical care and can positively influence the preventive behaviours of IDUs. This study seeks to document and understand the complexity and range of motivations and deterrents to HIV testing among IDUs. Participants were recruited using a convenience sampling method. Interviews consisted of a qualitative guide and a quantitative survey to collect HIV testing histories, sex and drug risk behaviours, and demographic information. Interview data was coded and content analyzed to identify emerging themes and clarify the processes that drug users employ in deciding whether or not to test. Sixty-six drug users were interviewed. The sample reported a median of four lifetime HIV tests. Participants described a range of motivating and deterring factors to HIV testing across personal, interpersonal and structural categories. Drug users' decision to test is influenced by a complex network of factors. Better understanding of these motivators and deterrents can help providers develop a more holistic approach to targeting this high-risk population for HIV prevention efforts.

Syringe-exchange programs (SEPs) have proven to prevent the spread of bloodborne pathogens, primarily human immunodeficiency virus (HIV), among injection drug users (IDUs). In the United States, only about 7% of IDUs have access to and use SEPs. Some IDUs engage in secondary syringe exchange (SSE), meaning that one IDU (a "provider") obtains syringes at an SEP to distribute to other IDUs ("recipients"). This formative qualitative research was conducted to understand why and how IDUs engage in SSE to aid in the development of a large-scale peer HIV prevention intervention. Interviews with 47 IDUs in Oakland and Richmond, California, indicated that SSE was embedded in existing social networks, which provided natural opportunities for peer education. SSE providers reported a desire to help other IDUs as their primary motivation, while recipients reported convenience as their primary reason for using SSE. Building SSE into SEP structures can facilitate an effective provision of risk reduction supplies and information to IDUs who do not access SEPs directly.

Syringe exchange programs (SEPs) have been shown to be highly effective in reducing HIV transmission among injection drug users (IDUs). Despite this evidence, SEPs have not been implemented in many communities experiencing HIV epidemics among IDUs. We interviewed 17 key informants in nine U.S. cities to identify factors and conditions that facilitated or deterred the adoption of SEPs. Cities were selected to represent diversity in size, geographic location, AIDS incidence rates, and SEP implementation. Key informants included HIV prevention providers, political leaders, community activists, substance use and AIDS researchers, and health department directors. SEPs were established by one or more of three types of implementation models: (a) broad community coalition support, (b) community activist initiative, and (c) top-down decision making by government authorities. In each model, coalition building and community consultation were critical steps for the acceptance and sustainability of SEPs. When others were not prepared to act, community activists spearheaded SEP development, taking risks in the face of opposition, but often lacked the resources to sustain their efforts. Leadership from politicians and public health officials provided needed authority, clout, and access to resources. Researchers and scientific findings lent force and legitimacy to the effort. Rather than adopting adversarial positions, successful SEP implementers worked with or avoided the opposition. Fear of repercussions and lack of leadership were the greatest barriers to implementing SEPs. Communities that successfully implemented SEPs were those with activists willing to push the agenda, public officials willing to exercise leadership, Correspondence to: Moher Downing.Address correspondence to Moher Downing, M.A.,

Conducted a study of behavior change associated with a street-based AIDS education project targeted to intravenous (IV) drug users in San Francisco. Two cross-sections were sampled from drug detoxification clinics and street locations in 1986 (n = 438) and 1987 (n = 623). Significant increases were reported in the percentage of IV drug users who used bleach to decontaminate syringes, who did not share needles in past year, and in condom use. A significant reduction in an index of the number of needle-sharing partners was reported. Respondents ranked treatment program as most important source of AIDS information prior to implementation of the program, and ranked outreach workers as most important after implementation. Findings suggest that this community-based outreach program had at least some impact on knowledge about AIDS and may have led to reductions in behaviors known to transmit HIV.

We employed capture-recapture methods as a strategy for evaluating needle exchange. Needles distributed by the exchange at two time periods were marked with color coded bands indicating the date and site of distribution. Half of the marked needles (2,068/4,239) returned within two weeks of distribution, and 61 percent (2,593/4,239) returned during the study period. The rate of return for stationary exchange sites (63 percent) was greater than that for roving/mobile sites (51 percent; chi 2 = 28.6, p less than .001). Of all needles returned, 87 percent (2,248/2,593) returned to the site of original distribution.

This article examines gender differences related to why 66 injection and noninjection drug users tested for HIV. Study participants from three northern California counties underwent an open-ended qualitative interview covering: access to HIV testing, the meaning of HIV testing and test results, drug and sexual risk behaviors, and behavior changes associated with HIV testing, as well as a brief quantitative survey. The responses were analyzed using the following categories: (a) financial incentives for testing, (b) concerns related to family members and significant others, and (c) personal anxieties due to lack of knowledge of HIV status. Analyses showed that gender differences exist regarding reasons for HIV testing. The most significant finding was that women were motivated to test with regard to concerns related to family and significant others in their life more so than men, particularly during pregnancy. The impetus to test for many individuals was dependent on a social setting, such as jail, hospital, or drug rehabilitation program. Further research examining the motivational factors why drug users test for HIV can provide valuable information for outreach and marketing of HIV counseling-and-testing services.

This article presents a unique approach to HIV/AIDS training in resource-poor settings that incorporates the use of standardized patients (SPs). Integrated Management of Adolescent and Adult Illness (IMAI) is a World Health Organization health systems strengthening initiative with a strong emphasis on training health workers in the management of common diseases and conditions. In IMAI, SPs are called Expert Patient-Trainers (EPTs) to emphasize their role in the training of health workers. EPTs were first used in IMAI training in Uganda in 2004. Since then, the method has been adopted by a number of other countries in Africa, Latin America, and Asia. EPTs are usually recruited from groups of people living with HIV/AIDS. In the classroom, EPTs discuss living with HIV and help participants understand HIV as it affects patients. Course participants spend approximately two hours per day in "skill stations," multiple-station assessments consisting of one-on-one encounters with EPTs. In each encounter, the health worker interacts with an EPT portraying a standardized case. Instructions on how to portray each case provide only broad outlines of the major clinical and counseling points; the EPT is expected to use his or her own life experiences to fill in emotional details. Course facilitators noted that health workers were often initially skeptical about EPTs, but this generally turned to enthusiasm after participating in the skill stations. EPTs benefited from the sense of being part of the training team, the satisfaction of improving the skills of health workers, and learning more about their illness.