Assessment of Street Outreach for HIV Prevention -- Selected Sites, 1991-1993

Street outreach programs for human immunodeficiency virus (HIV) prevention are designed to deliver HIV prevention messages, materials, and referral services to high-risk persons outside of traditional health-care and drug-treatment clinics. The Acquired Immunodeficiency Syndrome (AIDS) Evaluation of Street Outreach Projects (AESOP) is an eight-site * study designed by CDC in collaboration with researchers in each of the sites to better understand client characteristics, service delivery, and the impact of street outreach programs on the risk behaviors of high-risk populations. The populations studied are injecting-drug users (IDUs) in five of the eight sites and youth in high-risk situations (YHRS) (i.e., youths aged 12-23 years who are homeless or runaway or who support themselves through the "street economy" of drugs, prostitution, panhandling, and crime) in three sites. This report summarizes information collected during the first 2 years of the project.

During the first year of AESOP, from September 1991 through October 1992, each site conducted a community assessment process (CAP), a qualitative, ethnographically based series of individual interviews with IDUs, YHRS, and others involved with the community (e.g., outreach workers, social workers, agency directors, law enforcement personnel, drug-treatment workers, and neighborhood shopkeepers). A total of 618 of these open-ended interviews were conducted in the eight sites; 350 (57%) of the interviews were with IDUs and YHRS.

During CAP, three common components of outreach programs were determined: 1) distribution of condoms, bleach kits, and HIV risk-reduction materials and messages; 2) delivery of these HIV-prevention services in outdoor "street" locations or at fixed sites (e.g., homeless shelters, drop-in centers, and soup kitchens); and 3) the provision of other services or activities (e.g., referral for treatment, case management, and mobile health vans). Estimates obtained by AESOP investigators of the size of the high-risk populations ranged from 1000-2000 YHRS in San Francisco to 240,000-250,000 IDUs in New York City. However, outreach programs were not equipped to reach all members of these populations.

During the second year of AESOP, from January through August 1993, a baseline quantitative survey was conducted at each of the eight sites. In these surveys, IDUs and YHRS were sampled systematically to be as representative as possible of the high-risk populations. Interviews were conducted at locations such as drop-in centers, food lines, meal programs, outdoor congregating areas, drug buying areas, and shooting galleries.

Results from the initial round of closed-ended interviews indicated that 17%-65% of IDUs and 23%-46% of YHRS reported that they had talked with an outreach worker (Table_1). In addition, 14%-58% of IDUs and 11%-26% of YHRS had received HIV- prevention literature; 16%-58% of IDUs and 22%-39% of YHRS had received free supplies of condoms; and 13%-55% of IDUs and 7%-10% of YHRS had received bleach kits from outreach workers. Among IDUs who reported contact with outreach workers, 15%-43% reported that they had never received any form of drug treatment. Reported by: Y Serrano, S Faruque, MD, Association for Drug Abuse Prevention and Treatment; H Lauffer, M Clatts, PhD, Victims Svcs, New York City. M Kipke, PhD, S LaFrance, SD O'Connor, MPH, Div of Adolescent Medicine, Childrens Hospital of Los Angeles; A Long, PhD, AIDS Program, Los Angeles County; S Mills, MPH, AIDS Office, San Francisco Dept of Public Health. J Wilber, MD, J Geoffrey, MSW, Georgia Dept of Human Resources. R Cheney, PhD, Philadelphia Health Management Corporation. W Wiebel, PhD, Univ of Illinois, Chicago. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that IDUs and YHRS can be identified and reached through outreach programs; will talk with outreach workers about HIV prevention; and will accept HIV-prevention literature, materials, and referral services from outreach workers. In addition, survey findings indicated that a substantial proportion of IDUs and YHRS had been in contact with outreach workers.

Street outreach programs may be an effective means for delivering HIV-prevention services to persons at risk for HIV who do not receive such services from more conventional sources. However, to be most effective, public health workers must foster trust and have a basic understanding of the daily lives and needs of their clients. Formative research, such as that conducted during CAP, assisted in identifying the groups, the locations where they could be reached, and their particular needs for services.

Outreach efforts are conducted outside of institutional or clinical settings and involve personal interactions between an outreach worker and a client. These critical aspects of outreach present specific challenges both in the delivery of services and in the assessment of the impact of such services. Assessment is particularly difficult because persons engaging in high-risk behaviors targeted by outreach programs cannot be surveyed by the household or telephone-based sampling methods conventionally used to develop representative samples of populations. Although outreach workers may have easier access to persons with high-risk behaviors, other persons may be difficult to reach because of timing and movement into public places. In addition, outreach efforts are often conducted in public places where highly sensitive subjects might be discussed, further constraining the collection of information.

Outreach programs designed to serve high-risk populations are an important component of CDC's HIV-prevention strategy (1-4). CDC supports, directly or indirectly, more than 700 community-based organizations that provide information, materials, and referrals to those at risk for HIV infection. The programs included in the AESOP evaluation are typical of those attempting to reach and influence persons engaging in high-risk behaviors through a variety of outreach strategies. Further work on the AESOP project involves thoroughly assessing the impact of different types of street outreach interventions on risk behavior.

Each AESOP site has developed enhancements to its existing street outreach program. The impact of these enhancements on the risk behaviors of IDUs and YHRS is being evaluated through preenhancement and postenhancement population-based surveys that measure outreach interactions and extent of behavior change in an enhancement area and in a comparison area. Results from this quasi-experimental study should suggest specific recommendations for improving street outreach programs.

References

1. Roper WL. Current approaches to prevention of HIV infections. Public Health Rep 1991;106: 111-5.

2. Hinman AR. Strategies to prevent HIV infection in the United States. Am J Public Health 1991;81:1557-9.

3. CDC. Street outreach for STD/HIV prevention -- Colorado Springs, Colorado, 1987-1991. MMWR 1992;41:94-5,101.

4. CDC. Cooperative agreements for human immunodeficiency virus (HIV): prevention projects program announcement and availability of funds for fiscal year 1993. Federal Register 1992;57:40675-83.

* The eight projects are located in six cities: Atlanta, Chicago, Los Angeles, New York, Philadelphia, and San Francisco.
Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Percentage of respondents who have talked with or received literature,
condoms, or bleach from street outreach workers -- selected sites, AIDS Evaluation
of Street Outreach Projects, 1991-1993 *
=============================================================================================================
                                 Talked with          Received            Received
                               outreach worker       literature            condoms         Received bleach
                              -----------------   -----------------   -----------------   -----------------
Site                     No.   %    (95% CI +)     %     (95% CI)      %     (95% CI)      %     (95% CI)
-----------------------------------------------------------------------------------------------------------
Injecting-drug
 user sites
  Chicago                417  17.3  (13.6-20.9)   14.3  (10.9-17.6)   16.3  (12.7-19.9)   13.5  (10.2-16.8)
  Atlanta                428  63.3  (58.7-67.9)   58.2  (53.4-63.0)   57.9  (53.2-62.7)   28.6  (24.2-33.0)
  Los Angeles
    County               403  44.9  (40.1-49.8)   36.3  (31.5-41.1)   39.8  (34.9-44.7)   39.4  (34.5-44.3)
  Philadelphia           270  65.2  (59.5-70.9)   54.0  (47.6-60.4)   55.7  (49.4-62.1)   50.0  (43.6-56.4)
  New York
    ADAPT &              396  59.6  (54.8-64.5)   51.8  (46.8-56.8)   57.4  (52.4-62.3)   54.7  (49.7-59.6)

Youth sites
  Los Angeles
    Childrens Hospital   400  41.0  (36.2-45.8)   25.9  (21.6-30.1)   31.8  (27.2-36.3)   10.3  ( 7.4-13.3)
  San Francisco          215  23.3  (17.6-28.9)   10.8  ( 6.7-14.8)   22.0  (16.5-27.4)    7.2  ( 3.8-10.6)
  New York Victims
    Services             195  46.2  (39.2-53.2)   21.7  (15.6-27.8)   38.5  (31.6-45.3)    6.7  ( 3.2-10.2)
-----------------------------------------------------------------------------------------------------------
* Baseline surveys.
+ Confidence interval.
& New York Association for Drug Abuse Prevention and Treatment.
=============================================================================================================

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