Feb 6, 2008 - and hepatitis programs can employ to increase or enhance prevention .... Does mean young people as legitim
HIV and Viral Hepatitis Prevention: Addressing the Needs of Young People Who Inject Drugs Prevention Networking Group Viral Hepatitis Work Group Youth Program February 6, 2008
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Close to 100 Participants
Overview • • • • •
Focus on Young People who Inject Drugs HIV, Hepatitis and Youth Development and Programs Opportunity to interrupt disease transmission Invisible population Venue to Talk with Our Peers
Webinar Objectives • Provide information to health department HIV and viral hepatitis programs on working with marginalized youth, particularly young people who inject drugs. • Discuss interventions that address the complex and unique HIV and viral hepatitis prevention needs of young people who inject drugs. • Identify specific strategies that health department HIV and hepatitis programs can employ to increase or enhance prevention services for young people who inject drugs.
Webinar Agenda •
Welcome & Overview – Ann Shindo • Adult Viral Hepatitis Prevention Coordinator, Oregon
•
Engaging Marginalized Youth – Jerry Fest • JTFest Consulting: Training & Development, Oregon
•
Making Space for Young Injection Drug Users – Eliza Wheeler • Program Manager, Cambridge Cares About AIDS, Massachusetts
– Ed Debortoli • Massachusetts Department of Public Health
•
UFO Study – University of California San Francisco – Kim Page-Shafer • Principal Investigator
•
Facilitated Discussion
Overview of Issues Facing Youth Adolescence ~ highly pathologized Adolescence ~ characterized by More abstract cognitive functions Self-growth and identification through peerbased relationships
Adolescence ~ highly volatile period for youth who have experienced trauma
High-Risk Youth Youth who experience trauma (including homelessness) are at susceptible to high-risk sex and drug behaviors that put them in the public health intervention realm – why we’re here today!
Specific Issues Drug & Sex behavior of concern: 60% ~ some substance use 6% ~ injectable substances use 85% ~ sexually active (Baron, 1999; Forst & Crim, 1994; Greene, Ennett, & Ringwalt, 1997; Pires & Silber, 1996; Solorio, et. al., 2008)
Specific Issues Bottom Line: Homeless, marginally housed high-risk youth are at greater risk of HIV, viral hepatitis, and STDs in comparison to housed youth. Higher incidents of hunger, rape, survival sex and drug use ~ increases the likelihood of BBP transmission. (Kipke et al., 1992 & 1997)
Specific Issues Public Health Focus: Safe syringe access and disposal programs NEX, pharmacy sales, syringe drop kiosks Many jurisdictions have age limits – OR = no prescription required for persons age 18 years and older Oregon Revised Statutes (§§ 475.525, 1987)
Where Does PH Begin? Greater understanding of the target population Identification of evidence-based programs that work to address youths’ needs in culturally competent, ageappropriate fashion
Where Do We Need To Go Development of appropriate youth services; Acquisition of funding for primary prevention activities targeting youth (instead of serostatus-based funding algorithms); Evaluation criteria that consider appropriate developmental benchmarks not just head counts; Others?
Youth Risk Behavior Surveillance System Housed or In-School Youth Report 71% of all deaths among youth 10 – 24 years old due to: Motor-vehicle crashes Unintended accidents Homicide Suicide
(MMWR, 2006)
Youth Risk Behavior Surveillance System Drug, including alcohol, behavior of concern: Within 30 days YBRS youth report: 9.9% driven while intoxicated 43.3% consumed alcohol 20.2% consumed marijuana/pot 2.1% ever used a needle for drug-use (MMWR, 2006)
Youth Risk Behavior Surveillance System Sexual behavior of concern: 46.8% ~ had engaged in sexual intercourse 37.2% ~ had not used condoms @ last sexual intercourse 7.5% ~ have been forced to have sex when didn’t want to (MMWR, 2006)
Engaging Marginalized Youth A brief overview of issues and strategies to consider when intervening in the lives of difficult-to-serve young people Presented by Jerry Fest
Introduction
Background: Homeless, Street-dependent youth Training/Consultation: Positive Youth Development
Agenda
Discuss some of the general issues related to working with marginalized youth Provide an overview of the Positive Youth Development (PYD) approach Relate PYD to Harm Reduction principles
General Issues: #1
Marginalization is external and internal “I may be nothin’ more than a sleazy little street walking whore, but by God at least I’m honest about it.” - Street Culture: an epistemology of street-dependent youth
General Issues: #2
The impact of concepts of time “I like living hour to hour. I just don’t get this week to week shit.” - Street Culture: an epistemology of street-dependent youth
General Issues: #3
Relevance of prevention rationale
“The streets aren’t under your feet, they’re under your scalp.” - Street Culture: an epistemology of street-dependent youth
PYD: The Beginning …
“The starting point is the belief that all youth have innate resilience” - Bonnie Benard
Werner, E. and Smith, R. (1982, 1989). Vulnerable but Invincible: A Longitudinal Study of Resilient Children and Youth. New York: Adams, Bannister, and Cox.
Werner, E. and Smith, R. (1992). Overcoming the Odds: High-Risk Children from Birth to Adulthood. New York: Cornell University Press.
Benard, B. (2002). "The Foundations of the Resiliency Framework: From Research to Practice". In Resiliency in Action: Practical Ideas for Overcoming Risks and Building Strengths in Youth, Families, and Communities. San Diego, Calif.: Resiliency in Action. Also available at c
The other 30-50%
Why do some young people demonstrate resilient behavior, while others do not? An individual’s capacity for resilience is affected by internal and external factors Environmental factors can foster or inhibit a young person’s capacity for resilience.
Risk Factors Abuse/neglect, Family conflict, Poor family support, Substance use/abuse, Poor or unstable housing or homelessness, Extreme economic or social deprivation, Community deterioration or disorganization, Community violence and/or gangs, Inadequate education and recreational opportunities, Mental or physical health issues, Learning disabilities, Early unplanned pregnancy, Cultural and/or linguistic isolation … to name a few …
Risk Factors inhibit resilience
Protective Factors
Protective Factors foster resilience
Caring/Supportive Relationships High Expectations Meaningful Participation
Caring/Supportive Relationships
Caring
Supportive
Someone is interested in the fact that I exist I can count on someone as a resource
Relationship(S) Multiple Defined Appropriate
High Expectations
What “High Expectations” is not:
Positive Thinking Goals, Measurements, Benchmarks, etc.
High Expectations are beliefs
Messages from people and environments about who a young person is and what they are capable of doing High Expectations reflect what you really believe about a young person
Meaningful Participation
Anything that directly affects them
Choices, decisions, actions, environments, etc.
Must be legitimate
Does not mean that youth have all the power and can do anything they want Does mean young people as legitimate stakeholders; participation is real and valued
Research base of PYD
All people are innately resilient
The human capacity to face, overcome, and even be strengthened by adversity
External factors affect resilience
Risk Factors inhibit resilience Protective Factors foster resilience Caring/Supportive Relationships High Expectations Meaningful Participation
PYD Defined
Youth Development as a concept:
A process by which all people seek ways to meet their basic physical and social needs and build competencies
Youth Development as a practice:
An approach to working with young people that fosters their innate resilience and supports their developmental process
A Framework for PYD …
PYD is implemented, that is, Protective Factors are created, through an approach best remembered with the acronym (s)OS
(services) Opportunities & Supports
(s): (services)
Services are not PYD
They are sometimes a necessary foundation for PYD
To or For
Anything that can be defined as being done to or for another is by definition a service
Opportunities & Supports
Opportunities without supports
Supports without Opportunities
A setup for negative youth experiences
Staff directed activity
Opportunities AND related Supports
Create a framework for Protective Factors
Opportunities
By
Things that are done by young people Requires voluntary participation and internal motivation Requires honesty on the part of adults
Supports
With
Things that are done with young people in support of their opportunities People, resources, information, guidance
How do you teach someone to drive?
The Essence of PYD
An approach to working with young people designed to foster their innate resilience by exposing them to Protective Factors.
Protective Factors are created by minimizing the things you do to or for young people (services) and maximizing the things they do with your support (opportunities & supports).
PYD and Harm Reduction
PYD is an approach, not a model
PYD is not what you do, it is the way you do it
As an approach, PYD is compatible with many strengths-based models
Motivational interviewing Stages of Change &, particularly with drug-affected populations, Harm Reduction
Principles of Harm Reduction
Be nonjudgmental, avoid labeling Avoid being parental/authoritarian, meet the client where they are Value the client's information, emphasize client's strengths Avoid having preconceived goals, provide guidance and consultation Provide support, build rapport/trust See small changes as success, emphasize personal responsibility for outcomes
In other words, Harm Reduction:
Works through relationship, demonstrates high expectations, and allows for meaningful participation Is present focused and relevant to a young person’s current needs, reality, and environment
THANK YOU! “If we take people as we find them, we may make them worse, but if we treat them as though they are what they should be, we help them to become what they are capable of becoming.” - Johann Wolfgang von Goethe
Making Space for Young Injection Drug Users: Identifying Opportunities and Challenges Presented by Eliza Wheeler Cambridge Cares about AIDS
Data from the YIDU Study, designed and implemented by CCA and the Institute for Community Health Participant statements taken from video documentary of YIDUs who access the Cambridge NEP
HIV/AIDS and IDUs
As of 2005, 30% (N=4,773) of PLWHA in Massachusetts had a history of IDU 6% (N=899) were exposed to HIV through heterosexual sex with an IDU partner From 1996 to 2005, the proportion of deaths among people diagnosed with AIDS represented by those who had a history of IDU rose from 42% to 55%.
*Massachusetts HIV/AIDS Surveillance Program
HIV and young people, MA
From 2003 to 2005, 7% (N=201) of HIV diagnoses in Massachusetts were among 13 and 24 year olds. Of all HIV infections among 13-24 year olds (2003-2005), 9% identified IDU as mode of exposure.
*Massachusetts HIV/AIDS Surveillance Program
HCV and young people, MA
From 2002 to 2006, rates of newly diagnosed reported HCV infection in 15 to 25 year-olds in Massachusetts rose from 16 to 44 per 100,000 population. 1,054 (14%) of cases in 2006 were 15 to 25 years of age.
*Massachusetts Hepatitis Surveillance Program
Onofrey SL, Church DR, Heisey-Grove DM, Briggs P, Bertrand TE, DeMaria A Jr.
Opioid-related data: 2005
43,450 treatment admissions for heroin** 71% of these individuals reported IDU** 544 opioid-related deaths** 11,750 opioid-related ED visits* 17,104 opioid-related acute care inpatient hospital discharges* According to 2004-2005 data, 150,000 MA residents reported needing, but not receiving treatment for illicit drug use within the year***
*MDPH Bureau of Substance Abuse Services **MDPH Center for Health Information, Statistics, Research and Evaluation ***SAMHSA State Estimates of Substance Use from the 2004-2005 National Surveys on Drug Use and Health, February 2007
18-25 year olds who enrolled in the NEP in FY05/FY06: There is low rate of seropositivity at the time of enrollment, but many do not know their status.
Less than 1% HIV positive, but over 20% didn’t know their status Only 9% HCV positive, but nearly 30% didn’t know their status
Approximately half report sharing injection equipment, either sometimes or always.
Approximately 50% report NEVER sharing syringes, over 40% report NEVER sharing cookers/cotton
Continued… Many already have a history of accessing drug treatment programs.
67% have already been in treatment of some kind.
Nearly two-thirds report never or sometimes using condoms.
Over 30% NEVER, approximately 30% SOMETIMES.
Many have experienced overdose, or witnessed another person overdose.
22% their own experience, approximately 50% had witnessed another person.
Why did we do the YIDU study?
Beginning in 2003, needle exchange staff noticed a significant increase in the number of young people (18-25) that were enrolling in the program. This trend mirrored media reports and drug treatment data showing an increase in heroin and OxyContin use among young people in the state. Between 2005-2006, 18-25 year olds accounted for over HALF of new enrollees into the program.
Who was interviewed?
150 Young Injection Drug Users (18-25 years old) who were enrolled in the needle exchange program, between September 2005 and July 2006. 51% males and 48% females 96% White 75% completed 12th grade or higher 38% employed in a part or full-time job 38% had no health insurance 80% were housed (NOT homeless) Residents of 46 different Massachusetts towns responded to the survey.
Average ages of first use: Vicodin Benzos (Valium, Klonopin, Xanax) Oxycodone (OxyContin, Percocet) Heroin Age of First Injection
16 16 17 18 19
IDU-related risks and issues
HIV, Viral Hepatitis, STIs Overdose Abscesses, Endocarditis, other injectionrelated infections Criminal justice system involvement Homelessness or unstable housing Undiagnosed/untreated mental health issues Lack of consistent/competent medical care Undernourishment and malnutrition Relationship issues Many more…
Harm Reduction Current Practice
Basic needs (food, clothes, hygiene supplies, safe space while under influence) Needle Exchange Programs Syringe Access interventions Safer injection materials distribution OD Prevention, Naloxone distribution Access to services (internal/external referrals) Groups and 1:1 Education/Risk Reduction Low-threshold case management Drug User advocacy opportunities (CABs)
Comments from Young IDU video:
10 young participants of the Cambridge NEP took part in a 30 minute video project taped at the exchange last year. The video documented the participants discussion of their drug use histories, their thoughts about risk, their support systems, and their suggestions for better services.
Drug Use History
Drug transition (oxy to heroin) (D.) Boredom, hopelessness, risk-taking--“If I hadn’t found drugs, I would have killed myself.” (D.) Peer pressure, family pressure (S.) Experimentation, pain, both emotional and physical (C.) Family Drug use (S.) Trauma/abuse, unhappiness (A., J.)
Perception of Risk
“Everyone I know has Hep,” “I know it will affect me later” (D.) Major concerns are police, not enough money/drugs—not other risks (J.) Practicing safe behaviors within unsafe social networks (C., A.) Worrying about risk after the fact (J., C.)
Support Systems
Other friends who are using (D., S.) Isolation, no support (M., S.) Family, friends (C.) Drugs/drug dealers, other users (J.) Service providers (C., A., J.)
Services that YIDUs want:
Youth-only spaces (A.) All-inclusive spaces (J.) Safer Injection rooms (C., D., J.) Harm Redux housing/shelter (D., C.) Low-threshold, non judgmental spaces (J.)
Trauma-informed services Many young drug users have experienced trauma in their lives. It is important to remember this when developing programming. For example, among members of Youth on Fire, a program of CCA that serves homeless and street involved youth:
52% have lived in an abusive household 36% have been involved with DSS 58% have mental health dx 42% have been hospitalized for psychiatric reasons 11% have been forced to have sex in the previous year 13% have attempted suicide
What is trauma? An extremely stressful and unexpected physical or emotional experience that is felt to be threatening to a person’s life or sanity and overpowers a person’s ability to use normal coping mechanisms to adapt to a situation.
How does trauma affect people?
Physical Reactions
Aches, pains, easily startled,changes in sleep patterns, appetite, getting sick, substance use
Emotional Reactions
Shock, fear, grief, emotional swings, nightmares, flashbacks, increased need to control everyday experiences, isolation, anger, difficulty trusting people, shame, hyper-vigilance
What are “trauma-informed” services?
Assume that everyone has experienced trauma See trauma as a defining organizing experience that forms the core of a person’s identity rather than a single event Protect client from physical harm and re-traumatization
What are “trauma-informed” services?
See symptoms & behaviors as attempts to cope Emphasize skill building rather than symptom management Encourage open and genuine collaborations between provider and consumer Give control and decision-making to the client
How can we support programs to create trauma-informed services?
Encourage programs to conduct traumainformed assessments Incorporate services that are sensitive to trauma-related issues present in survivors Provide trainings and information about trauma-informed services to service providers working with young people
Opportunities
Family contact is still intact in some instances— development of interventions to target families, teaching harm reduction techniques with loved ones. Low-threshold interventions—pharmacy access is a desirable option for young people who want little contact with providers. Willingness to engage with certain kinds of services and rely on them for support. Social networks are important—assess level of risk in the network in order to develop risk reduction plan for individual.
Opportunities
Keep contact with YIDUs through venues that they frequent (NEPs, drop-in centers, jails, detoxes, youth-oriented programs, etc.), keep them engaged. Educate about drug-related risks like HCV, HIV and overdose early—we saw how early drug use started—start before then. Adapt to the unique challenges and opportunities that YIDUs present—cultural competency!
Recommendations
Enhance HCV surveillance—we need more/better information to make a good case for more services Work collaboratively with programs to design realistic and culturally competent outcome measures:
According to Ruefli & Rogers, in designing outcome measures for our programs, we must “involve program clients in a process that would generate valid measures that are 1) culturally relevant to the way they see the world and live their lives; 2) incremental—i.e., capable of measuring small changes and 3) hierarchical—i.e., capable of showing how clients improve over time”
Recommendations, cont.
Allow for innovation, creativity in programming: participant designed drop-in spaces, groups and activities instead of just prepackaged interventions Visit programs, meet program participants, ask them what they need! Advocate for policy change around syringe access, overdose prevention interventions and safe spaces for active users Provide access to ongoing harm reduction trainings and skills building sessions to build staff and program capacity
Conclusion
Thank you! Any questions?
HIV, HBV, and HCV in Young Injection Drug Users in San Francisco Kimberly Page-Shafer, Ph.D. MPH; Peter Davidson, Ph.D. candidate. University of California San Francisco NASTAD WEBINAR FEB. 2008
The UFO Studies: community-based studies of HIV, HBV and HCV infections, health consequences of drug use, vaccine feasibility and adherence in young injectors in San Francisco
HIV Hepatitis C virus (HCV) Hepatitis B virus (HBV) HBV immunizations Sexually transmitted infections Heroin-related overdose Methamphetamine Intergenerational drug use Gender and injection risk Incarceration MSM-IDU HCV superinfection Serosilent HCV Immunology of HCV clearance Traveling IDU and risk behavior Community collaborations
Young injection drug users • San Francisco ~18,700 IDU; 1/3 < age 30 • Large number of homeless runaways • Many with history of negative & traumatic events
• Illicit drug use and illegal street economy • prostitution, drug sales, theft, panhandling, or selling stolen property.
• Disenfranchised, marginalized, mistrustful • “threatening, offensive, obnoxious, or generally disagreeable”
• Outside the public health system • Susceptible to blood-borne and sexually
BACKGROUND •
Most young injectors began injecting after the advent of needle exchange – many needles available in SF
•
Young IDUs are more likely to borrow needles than older IDUs
•
HCV risk is highest among young and new IDU
•
HIV risk is highest among IDU MSM
•
HBV vaccine still needed among young IDU .
HIV - Key points • HIV prevalence and incidence has stabilized among IDU in San Francisco: –
–
Prevalence: 3% to 12% over past 10 years (depending on age and risk group) HIV incidence in 5 IDU groups 1990-2000: 0.87% (0.54, 1.36) (*Kral et al, 2004).
• Young IDU –
–
HIV prevalence: 5.3% overall • Self-identified homo/bi-sexual: 15.6% • Heterosexuals: 3.1% HIV incidence in young IDU 1990-2000: 0.45% (0.03-2.16). (*Kral et al, 2004).
HCV - Key points • HCV infection is most common among IDU – up to 90% infected overall. • In San Francisco in 2000, 44% prevalence among young IDU and 50% infected after 5 years of injecting (Hahn 2002), –
•
compared to 65% after 1 year in Baltimore in early 90’s
Moderate declines in HCV coincide with implementation of HIV prevention programs, especially clean needles and education
HBV – Key points • Infection common in IDU (44-80%) • Incidence higher in young IDU than older IDU • Effective preventive vaccine available since 1982 • Populations at highest risk of infection are least likely to be immunized
METHODS: UFO-3 Study cohort •
Prospective study of young active IDU
•
Outreach-based street recruiting
•
Eligibility: Age =10
Characteristics of young IDU with incident HCV infection compared to HCV negative Incident HCV (n=132)* N (%) or median (IQR)
HCV negative (n=220) N (%) or median (IQR)
Age
22 (20-25)
22 (20-26)
Male
85 (64.9)
149 (67.7)
Years injecting
3.5 (1.2-6.2)
3.6 (1.1, 6.0)
No. of daily injections
3.0 (2.0-4.0)*
2.0 (1.5-3.5)*
Used dirty needle with cooker (last 3 mo.)
48 (37.5)*
53 (25.0)*
Incarcerated last 3 mo.
51 (39.2) #
52 (24.1) #
* 0.05; # 0.01
Factors independently associated with incident HCV AOR
95% CI
Age (per year)
1.2
1.1-1.3
Duration injecting (per year)
1.2
1.1-1.3
Duration in SF (per year)
1.1
1.0-1.1
Initiation into injecting by a sex partner
4.1
1.7-9.5
Injected daily (prior month)
3.9
2.1-7.2
Ever borrowed a needle
2.6
1.2-5.5
Bleached last time borrowed a needle
0.5
0.2-1.0
Snorted or smoked drugs (prior year)
0.5
0.3-0.9
Injected by someone else (prior month) 0.5
0.3-1.0
Factors associated with prevalent HIV
OR 95% CI Sexual orientation: homo/bi-sexual vs. heterosexual 7.5 1.5-36.6 Duration in SF (per year) 1.4-95.8
11.7
Recruitment area: Polk street vs. other neighborhood 4.8 1.4-17.6
HBV serology results 60% 58%
40% 19%
20%
6% 3% 14%
0% Anti-HBc Anti-HBc alone with antiHBs
HBsAg
Anti-HBs alone
Naïve
Vaccine completion 75% (128/170) received second dose Median 5 wks (IQR 4-8 wks) between first two doses
47% (80/170) completed vaccine series Median 21 wks (IQR 17-26 wks) between first and third doses
HBV vaccine in young IDU (UFO-2) 1. Vaccine completer may be more geographically stable and engage in other prevention activities. 2. Outreach worker support with modest cash incentives may improve vaccine adherence. 3. Young IDU demonstrate suboptimal immune response to HBV vaccines. 4. Repeat or higher vaccine doses may be indicated. Lum, et al. AJPH 2003; 93(6):919-923
Prevalence of anti-HBV, anti-HCV and HIV by incarceration history among Young IDU in SF *p-value
