Impact of HIV risk and infection on delivery of psychosocial treatment services in outpatient programs

Journalof SubstanceAbuseTreatment.Vol. 13, No 5, pp 387-395, 1996 Copyright© 1996Elsewer Soencelnc Printedm the USA.Allrightsreserved 0740-5472/96$15 00 + (X) PII S0740-5472(96)00113-4

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Impact of HIV Risk and Infection on Delivery of Psychosocial Treatment Services in Outpatient Programs JAMES L.

SORENSEN AND MEREDITH S. M I L L E R Umversityof Califorma, San Franosco

Abstract- HIV risk and HIV infection have profoundly affected the delivery, of psychosoclal treatment services in outpatient drug treatment settings. First, HIV has changed the programmatic emphasis of outpatient treatment, from the intake process through tile goals of care, and treatment program staff are being altered significantly. Second, HIV brings with it a pull to extend the reach of drug abuse treatment to the sexual partners and families of patients. Finally, for communi~., and statewide planners, a debate is emerging between the idea that programs should provide high-quality services to a few targeted "high risk" or "vital categoo'" patients versus providing minimal services to as many drug abusers as possible. There is a vital need for research studies that will add data to the decision-making process, at both the policy and programmatic levels. © 1996 Elsevier Science hw. Keywords-HIV risk; HIV infection: psychosocial treatment: outpatxent programs: drug abuse.

INTRODUCTION

of the cases reported in 1981, the inaugural year of the epidemic, to 31% ( 138,914) of the total cases reported by the end of 1994 (Centers for Disease Control & Prevention, 1994). AIDS is having a dramatic impact on the delivery of outpatient and residential drug treatment, medical services, treatment in the criminal justice system, outreach, and the planning of state and community services. AIDS has also changed practices in the delivery of outpatient psychosocial services in the context of drug abuse treatment. In short, because of AIDS the nature of substance abuse treatment has changed. This article discusses the impact of HIV risk and HIV infection on the delivery of psychosocial treatment services in outpatient drug treatment settings. "Outpatient" settings refers to programs where patients receive drug treatment but do not reside, ranging from traditional counseling in "outpatient drug free" programs, to outpatient detoxification, day treatment, and medication-assisted programs such as methadone or naitrexone maintenance. Other authors in this volume are discussing residential programs,

As HIV INFECTION continues to spread among injecting drug users it has become imperative to deliver AIDS prevention messages to them and, if prevention fails, to deliver AIDS treatment. In the United States the proportion of the people diagnosed with AIDS who are drug injectors has risen consistently through the years, from 18%

An earlier versionof this paper was presentedat a conferenceon AIDS/ HIV Infection and Drug Abuse Treatment. March 1995, Baltimore, MD. Supported in part by Grants RI8DA06097, R01DA08753, and P5009235 from the NationalInstituteon Drug Abuse. The authors appreciate the staff and patients of Substance Abuse Services of San FranciscoGeneralHospital, San Francisco,CA for the inspirationto undertake this paper and the helpful editorialsuggestions of Drs. Barry Brown, Harvey A. Slegal, and Laurie Wermuth. Requests for reprints should be addressed to James L. Sorensen, PhD, Substance Abuse Services-Building90, Ward 93, UCSF at San Francisco General Hospital, 1001 Potrero Avenue,San Franosco. CA 941 I0

Received March 12, 1996; Accepted August 8. 1996. 387

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medical services, and outreach to drug users who are not in treatment.

HOW DOES HIV CHANGE PROGRAMMATIC EMPHASIS? The Intake Process The existence of HIV disease has added another convincing reason to admit drug users into treatment programs. Research has provided clear evidence that drug treatment prevents HIV infection. A dramatic example comes from an 18-month follow-up of drug injectors in Philadelphia. At intake into the study 10% of those in methadone maintenance had HIV infection, compared with 16% for those not in methadone (Metzger et al., 1993). After 18 months of following the subjects, HIV seroconversion was 3.5% for those who remained in methadone maintenance but 22% for those who remained out of treatment, a six-fold difference. Numerous research projects have found that longer times in methadone treatment are associated with lower rates of seropositivity (Abdul-Quader et al., 1987; B liz & Grondbladh, 1988; Grimm, Wolf, Bornemann, & Bschor, 1989; Hartel, Selwyn, Schoenbaum, Klein, & Friedland, 1988; Tidone, Sileo, Goglio, & Borra, 1987; Truman et al., 1989; Williams et al., 1990). Other studies have found that patients who have been in methadone maintenance a long time have lower rates of HIV infection (Barthwell, Senay, Marks, & White, 1989; Novick et al., 1989). Indeed, many drug users may be waiting out the HIV epidemic in the protective atmosphere of a drug treatment program. This research has provided strong evidence that methadone treatment, by itself, can lower the risk of a patient acquiring HIV infection. The information about the relationship between cocaine treatment and HIV risk behaviors is less sanguine. Smoking crack cocaine has been closely associated with high-risk sexual behaviors (Siegal et al., 1992), and the treatment of cocaine addiction remains one of the most crucial issues in substance abuse. The prevalence of cocaine use across most areas of the United States and the dramatic increase in the number of cocaine users seeking treatment have placed new and unanticipated demands on the existing treatment system. In response to this crisis, researchers and clinicians continue to test various treatments that will aid the addicted patient in achieving and maintaining abstinence. A variety of pharmacotherapies and behavioral interventions have been attempted (Sorensen & DePhilippis, in press), but they have not been demonstrated to reduce HIV risk or to be associated with lower seroprevalence of HIV. Information and education can be helpful in the beginning stages of treatment. As early as 1986 policy groups were calling for the provision of information about transmission of HIV in all treatment programs (Inciardi, 1990). Some states now require that the intake process include

HIV information and education. There are questions about "how far to go" to provide HIV education. For example, one study found that monetary incentives were more effective in encouraging attendance at educational sessions than were incentives like providing food coupons or gift certificates (Stephens, Davis, Feucht, & Tortu, 1994); however, providing money to drug injectors is controversial if not impractical in most programs. Moreover, there have been mixed results in controlled clinical trials of formal education such as providing information, skills training, and HIV counseling and testing (Auerbach, Wypijewska, & Brodie, 1994). In general, information about HIV may be a necessary condition for a drug user to avoid acquiring or transmitting the virus, but educational programs alone are not enough to significantly lessen the risk of HIV transmission. The HIV epidemic has also made it more important to get drug users into treatment quickly. In one experiment an "interim" methadone clinic was created to provide temporary methadone maintenance without counseling, and patients in this program showed significant reductions in drug use compared with patients left on a waiting list (Yancovitz et al., 1991). This research influenced a federal proposal to make interim methadone treatment available. Other programs have relaxed their criteria for entering treatment, making it less difficult to cross the threshold for getting into a clinic (Ward, Darke, Hall, & Mattick, 1992). A "fast track" into treatment may be beneficial: one study found that those admitted rapidly to a maintenance program were less likely to drop out of treatment in the first 6 months (Bell, Caplehorn, & McNeil, 1994). HIV has begun to change admission priorities. Brown (1991) contends that it has become the responsibility of drug treatment "not simply to provide opportunity to the motivated, but to motivate and engage" drug users to get into treatment programs. Categorical funds have even been allocated for special patient groups. For example, in the program with which the authors are associated, the San Francisco General Hospital Substance Abuse Services (hereafter SFGH-SAS), several treatment "slots" are supported by Ryan White CARE funds, and these are designated for people with HIV disease.

Relapse Prevention In conjunction with the AIDS epidemic the term "relapse prevention" has acquired new meaning. First, relapse to drug abuse has always carried with it a danger of health problems, violence, and criminality. Consequently, avoiding relapse to drug abuse has traditionally been a theme of substance abuse treatment programs. Substance abuse problems generally carry with them high rates of relapse once treatment has been discontinued (cf. Havassy, Hall, & Wasserman, 1991). One estimate is that 35% of drug treatment patients will relapse to heroin use within a year after discontinuing treatment (Joe, Chastain, Marsh, & Simpson, 1990).

Psychosocial Treatment

With the AIDS epidemic has come greater willingness to experiment with the length of detoxification treatment. For some time the 3-week limit has been thought to interfere with achieving success in detoxification, even though it was the federal detoxification policy (Mann & Feit, 1982). A longer detoxification of 6 weeks has been shown to improve the likelihood that drug users will abstain from opiates during treatment, but relapse rates appear to be just as high with 6-week as with 3-week detoxification (Sorensen, Hargreaves, & Weinberg, 1982). Others have experimented with 90-day detoxification, showing dramatic decreases in opiate drug use during treatment, but not demonstrating beneficial effects in avoiding relapse (Iguchi & Stitzer, 1991: Stitzer, McCaul, Bigelow, & Liebson, 1984). Recent changes in law have allowed longer detoxification as an option. In 1989 the federal regulations changed to allow detoxification to occur over a period as long as 180 days (Department of Health and Human Services, 1989). In San Francisco research has begun to investigate the efficacy of the 6-month length of methadone treatment (cf. Reilly et al., 1995). One study indicated the superiority of an 80 mg dose of methadone over 40 mg (Banys, Tusel, Sees, Reilly, & Delucchi, 1994). Another study indicated no difference between providing higher- or lower-intensity treatment in the 6-month period (Sees et al., 1994). A follow-up study indicated that 71% of participants had entered into some form of substance abuse treatment within six months after finishing the program (Tusel, Reilly, Banys, Sees, & Delucchi, 1993). The new meaning of "relapse," which attends the HIV epidemic, is returning to unsafe needle use or unsafe sex. This relapse to behaviors that risk HIV infection has received much attention in other "at risk" communities (cf. Stall, Ekstrand, Pollack, & Coates, 1990). The idea of maintaining AIDS risk reduction practices may be the next major problem for policy planners working with drug abuse as well (Des Jarlais, Abdul-Quader, & Tross, 1991 ). In fact, substance abuse professionals have much to offer these other communities when it comes to understanding how to prevent relapse to risky behaviors, because this group has been working with the problem in substance abuse for a long time. The relapse prevention techniques used by substance abuse professionals involve identifying situations that are high risk for returning to drug abuse, then working with patients to either avoid or cope with these high-risk situations (see Marlatt & Gordon, 1985; McAuliffe, Albert, Cordill-London, & McGarraghy, 1990-91 ; Wells, Peterson, Gainey, Hawkins, & Catalano, 1994). Staff Issues HIV disease has affected the staff in drug treatment programs in several ways. There have been changes in recruitment of staff, their training, and the factors that influence their retention in programs.

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Recruitment of qualified staff has always been a problem in drug abuse treatment, but this task has become even more difficult with the coming of HIV disease. In a survey of drug treatment staff at 67 public contract drug treatment centers in San Francisco and San Jose, CA, counselors who personally did not know someone infected with HIV were more likely to avoid HIV+ clients than counselors who knew someone with HIV (Lodico, Evans, Clark, Hughes, & Robinson, 1995). Administrators at drug treatment programs need to incorporate potential employees' attitudes and beliefs related to HIV into the hiring decisions. Staff who are otherwise wellqualified may want to distance themselves from the HIV epidemic. Regarding training of staff, information about HIV disease has become a mandatory part of counselor training. Although there were delays in the development of appropriate training materials, several training or orientation manuals have been recently published. Through its Community and Professional Education Branch (David, 1991), the National Institute on Drug Abuse has published an excellent series of videotapes that cover such wide-ranging topics as relapse prevention, methadone treatment, and treatment of women. In addition, the Center for Substance Abuse Treatment has published a Treatment Improvement Protocol series that includes such topics as screening for infectious diseases among substance abusers (Barthwell & Gibert, 1993) and guidelines for methadone treatment (Parrino, 1993). These training materials will need to be revised to keep up to date with the rapidly changing information about HIV. However, the greater problem is making use of excellent training materials. There is little information about the type and amount of training that drug treatment staff receive, but it is the authors' impression that there is vastly insufficient time allotted to training of new staff or ongoing staff development activities. Some training issues are controversial. For example, Conviser & Rutledge (1989) relate that when staff were asked to give patients information about how to sterilize needles, counselors in many programs objected because the "clean your needles" approach was in opposition to the programs' drug-free philosophy. The needle hygiene issues have become even more confusing for counselors recently. Research has called into question the effectiveness of the information that has been disseminated on methods to clean needles. This leaves counselors in the unenviable position of being grilled by their clients on the accuracy of their information about needle cleaning (cf. Sorensen & Mills, 1995). Because there are numerous and controversial issues related to treating substance users with HIV, outpatient treatment programs may benefit from instituting policies regarding working with terminally ill patients, their sex partners, and their families. Wermuth (1995) argues that clear policies focusing on educating and reaching out to sexual partners is necessary to guide staff practices. For

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example, a counselor who is well informed of her program's policy on providing patients' sex partners with educational materials is better able to provide counseling confidently and expediently. Retention issues are also complicated as programs treat more patients with HIV disease. Staff morale is understandably eroded by the steady decline and death of HIV-infected patients. Staff who care for people with AIDS need support systems to help them overcome the complicated problems raised by the illness, such as defining boundaries (how close or distant to be) with patients who are dying (Baginski, 1993). Staff support groups are emerging as one way to cope with the difficulties of seeing an increasing number of medically ill patients (Frost et al., 1991). Drug treatment programs also derive some benefits by offering treatment to HIV-infected patients. Staff morale can be greatly buoyed by the knowledge that patients are receiving appropriate, compassionate care. As HIV disease spreads into high-risk communities it creates occupational stresses for caregivers. For example, Coyle and Soodin (1992) noted that counselors experienced increased stress while counseling HIV-infected patients. Those with minimal HIV-related training were more likely to experience stress. There has been some excellent research on caregiver stress and the impact of multiple losses, but few studies have addressed these issues in the drug-abuser population. Drug abuse treatment staff may be poorly prepared to cope with the stresses of AIDS among their patients. Many of the staff in drug abuse treatment programs are paraprofessionals, nondegreed former drug abusers working in a clinical capacity. Paraprofessionals can be key staff members because, as individuals who have "been there" and escaped to a new life-style, they have a personal credibility with active drug users that professional staff can never obtain. Paraprofessionals carry a burden because they are working with patients from a life-style they experienced. Early family experiences with loss may have been involved in the genesis of the caregiver's addiction (Coleman, Kaplan, & Downing, 1986). Paraprofessional caregivers are at greater risk for burnout than degreed professionals (Broadhead & Fox, 1993; Niehoff, 1984; Rubington, 1984) and more vulnerable to occupational stress because of their limited training (Coyle & Soodin, 1992). Because paraprofessionals are susceptible to the occupational stress of losses, it is important to understand their specific workrelated difficulties and coping styles in confronting patient illness and death. The SFGH-SAS program began to specialize in patients with HIV disease early in the epidemic. The program identified several problems for staff (see Sorensen, Costantini, & London, 1989), which have continued as important themes in the treatment program. First is fear of infection. To lessen the fears of infection, programs can exercise clear body substance precautions, conduct frequent in-service training, and hold periodic updates

J.L. Sorensen and M.S. Miller

for staff. Protection of patients' confidentiality has been a second and continuing, problem for staff. The solution to these problems has been for the program to keep updates regarding confidentiality laws and guidelines. AIDS has significantly altered the goals that staff hold for patients. As more patients with AIDS came into treatment the program gradually moved toward a public health model, which held that it was worse for a drug injector with HIV disease to be untreated than it was for that person to be using drugs occasionally but in the treatment program. Several activities helped staff to alter treatment goals due to the presence of AIDS, including an informal AIDS task force of concerned staff, developing extensive referral networks with other programs that worked with HIV, and lowering the patient--counselor ratio for counselors with HIV patients. Recently, many staff have supported the ideas of harm reduction (cf. Des Jarlais, Friedman, & Ward, 1993; Marlatt & Tapert, 1993), and training in the harm reduction approach has reinforced the public health goals of the program as an alternative to more abstinence oriented treatment. I N C L U S I O N OF SEXUAL PARTNERS AND FAMILIES Before the AIDS epidemic the delivery of psychosocial treatment in outpatient substance abuse programs focused solely on the needs of the clients. However, HIV disease has challenged this mode of treatment, forcing programs to evaluate their responsibilities to the public. More specifically, how and to what extent do outpatient drug programs play a role in counseling and educating clients' sex partners and families? Much of the literature suggests that substance abuse counselors aim to educate and counsel clients not only to change risk behaviors of clients, but indirectly to affect their social contacts' behaviors as well. The hope is that clients will take the information from the program and provide it to their sex partners, family members, and other drug users. Outpatient drug treatment programs educate and counsel drug users in a variety of ways. The distribution of supplies like condoms can help slow the spread of HIV: however, providing educational materials in an individual or group counseling setting can be even more useful. For example, although it is necessary for programs to make condoms available to drug users, providing pamphlets on how to properly use them and having a discussion about how to talk with sexual partners about using condoms is also needed (Friedman et al., 1993). If clients are encouraged to take this information outside of the program, ultimately both the client and his/her sex partner will benefit from the information and supplies provided. Skills such as discussing sexual practices with one's partner can be taught through various modes of psychoeducational interventions, including individual and/or group counseling. Overall, the research on the effectiveness of

Psychosocial Treatment

group counseling has not shown a dramatic difference in participants' behaviors; however, some random assignment studies have shown an increase in risk reduction practices. For example, women in methadone maintenance were more likely to discuss sexual issues with their partners and to use and carry condoms more often after having received a small-group intervention (Schilling, E1Bassel, Schinke, Gordon, & Nichols, 1991). Other random assignment studies conducted at the SFGH-SAS outpatient methadone maintenance and detoxification clinics demonstrated, at the 3-month follow-up, that participants assigned to a 6-hour AIDS prevention workshop benefitted more from the information provided than controls who received informational brochures (Sorensen et al., 1994). Workshops were organized to increase the participants" knowledge of AIDS transmission and prevention, build skills to help the drug users decrease their risk of getting or transmitting AIDS, and help clients make the necessary changes in their lives to reduce risk to themselves and others. This group approach is an example of how outpatient programs can focus primarily on educating and reducing the risk to clients while maintaining a secondary emphasis on protecting and educating sex partners and others in the community regarding HIV. Although insufficient research has been conducted to assess the outcomes of outpatient programs' more direct attempts to educate clients' sex partners, it has been demonstrated that sex partners of drug injectors significantly reduce their risky sex behaviors following an AIDS education intervention. The National AIDS Demonstration Research (NADR) Project incorporated a quasiexperimental design to assess the efficacy of its outreach program. NADR collected data on injecting drug users not in treatment and their sex partners in 28 grants-funded sites across the United States and compared the efficacy of a standard versus an enhanced intervention. At the 6-month follow-up, the 1,637 sex partners from both interventions showed a substantial decrease in their sex risk behavior based on condom use and number of sex partners. For example, among the 1,127 females, 20% reported always using condoms at follow-up, compared to 5% at baseline; of the 510 males, consistent condom use increased from 9 to 24% (National Institute on Drug Abuse, 1994). Treatment philosophies, combined with economic constraints, often dictate how much a program can reach beyond drug-abusing clients to their sex partners and families. However, perhaps all involved, including the treatment program, could benefit from more vigorous attempts to directly educate clients' sex partners and their families. For example, a drug user's sex partner may learn more about how to correctly put on a condom if taught directly by the counselor; learning first-hand eliminates the potential for receiving misinformation. Moreover, the opportunity for the sex partner to reeducate the drug user in the future with this first-hand information--and for the partner to accurately practice low-risk behaviors-can be beneficial for the client as well. Although the

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costs to the treatment program would increase due to more group participants and/or individual counseling sessions, long-term costs might decrease due to the decreased risk behaviors of both clients and their sex partners, lessening the need for future treatment admissions. Women's sexual risk is confounded by a variety of factors. Women sexual partners of drug users in many cases are Black or Hispanic, live in urban areas, and are of childbearing age (Cohen, Hauer, & Wofsy, 1989). Furthermore, women sexual partners of drug injectors who do not themselves use drugs intravenously, often use noninjecting drugs like crack and amphetamines. Tortu, Beardsley, Deren, and Davis (1994) compared women who either (1) had single partners, (2) had multiple partners and did not exchange sex for drugs and/or money, or (3) had multiple partners and did exchange sex for drugs and/or money. They found that women in the latter group were at higher risk for HIV than women in the other two groups. The study also found that women who traded sex for drugs and/or money "lead fives that are the most chaotic, the least healthy, and the most risky" (Tortu et al., 1994). Similar results appeared in a study by Cohen, Navaline, and Metzger (1994). They compared high-risk behaviors for HIV between crack-abusing and opioid-abusing African-American women. In addition, they were able to detect a small subgroup of injecting crack-using women who were at "highest" risk for contracting and spreading HIV based on their increased rate of prostitution, lack of condom use, and sharing of needles. Given these conceres, numerous ways of counseling and educating female sex partners are critically necessary. Drug treatment programs must be adequately funded to incorporate education, counseling, and referrals for sexual partners of patients enrolled in drug treatment programs. Individual counseling, another venue for psychoeducational intervention in an outpatient drug program, can be particularly effective for women sexual partners of druginjecting men. One-on-one counseling allows a woman to ask questions specific to her own situation, particularly those that she may be inhibited to ask in a group setting due to feelings of embarrassment (Wermuth, Robbins, Choi, & Eversley, 1991 ). The Partners Outreach Project, a random assignment study conducted in the San Francisco Bay Area, compared the effectiveness of one informational session of AIDS prevention counseling to an experimental condition of three one-hour sessions focusing on problem solving (Wermuth, Ham, & Robbins, 1992). The counseling model developed tbr the project focused on assessing a woman's concerns and individual circumstances, informing her about HIV prevention and transmission, problem solving about situations of risk, and evaluating her support system. Like many random assignment studies in AIDS prevention, this one found few differences between the women who received information versus more intensive counseling. The researchers concluded that programs might be more effective if, rather than at-

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tempting to change the relationship by working with just one member of the dyad, they worked with the woman and the male drug injector together.

T H E QUALITY/QUANTITY ISSUE In response to the AIDS epidemic a debate has emerged concerning the level of service delivery necessary to achieve the complementary goals of drug abuse treatment and preventing HIV infection. These have been characterized as the "minimalist" versus the "comprehensive" models of drug abuse treatment. On one side the argument is that providing minimal treatment (e.g., medically supervised methadone but few support services) to patients awaiting treatment entry is effective in reducing injection drug use and HIV transmission (Dole, 1991). By offering this restricted treatment package, programs can use their limited resources to treat a greater number of patients. The idea is minimal intensity but maximum spread. The approaches of interim methadone (Yancovitz et al., 1991 ) and "low-threshold" methadone treatment in the Netherlands (Hartgers, van den Hoek, Krijnen, & Coutinho, 1992) illustrate this philosophy of care. The alternative strategy targets a specific population for intensive treatment. Proponents of this strategy use their limited resources to treat fewer patients (e.g., substance abusers with HIV disease) with intensive treatment. The rationale is that substance-abusing patients with HIV disease should receive services preferentially because they are more in need and also can be the vector for HIV transmission beyond the substance abuse patient population. Programs that offer primary medical care in the context of drug abuse treatment (O'Connor, Molde, Henry, Shockcor, & Schottenfeld, 1992; Selwyn, Budner, Wasserman, & Arno, 1993; Selwyn et al., 1989; Umbricht-Schneiter, Ginn, Pabst, & Bigelow, 1994) illustrate this approach. The minimalist and comprehensive treatment strategies each have drawbacks. The minimalist approach to service delivery risks treatment attrition by patients with unmet service needs. For example, a study examining the differential effects of psychosocial services revealed that patients offered methadone alone fared worse (in returning to drug abuse) than those receiving methadone and drug abuse counseling (McLellan, Arndt, Metzger, Woody, & O'Brien, 1993). The comprehensive approach, however, can set up treatment barriers that thwart the goals of the program. For example, some patients may not be prepared to engage in high-intensity treatment (Guydish, Temoshok, Dilley, & Rinaldi, 1990). In work with substance abusers recruited in the emergency room the authors find that the problems they self-identify are more related to wanting shelter and food than they are associated with recovery to a drug-free life-style (London et al., 1996). With either strategy, some patients are likely to drop out of treatment, relapse, and continue the spread of HIV.

There is a middle ground between the minimalist and comprehensive approaches. Each strategy has its indications and contraindications. One challenge for treatment providers is to personalize treatment, for example by developing a treatment matching process in which patients are monitored and services delivered or discontinued as a function of patient changes and needs during treatment. An additional challenge is to accept the legitimacy of a range of treatment options, including a minimalist intervention in lieu of none at all. CONCLUSIONS AND RECOMMENDATIONS This article has detailed the ways that the emergence of the epidemic of HIV disease has affected the delivery of psychosocial services in outpatient drug abuse treatment programs. An examination of each area of impact reveals clear needs for more information (i.e., more education and more research). In some areas the research is already sufficient to make recommendations. Although more information would be helpful, the greater need is for action that will change policies, or the way that policies are interpreted and delivered. Regarding the programmatic emphasis of outpatient treatment, it is clear that methadone treatment for opiate abusers reduces the likelihood that a patient will become infected with HIV. The research is "in" on this issue. The policy issue remaining is what action to take. Should society expand the availability of methadone treatment and, if so, how? There is a need for more research on the impact of other treatment modalities on HIV risk. The expansion of drug treatment has been long-recommended by such bodies as the Institute of Medicine and National Academy of Sciences (Institute of Medicine, 1988; Jonsen & Stryker, 1993; Miller, Turner, & Moses, 1990; National Academy of Sciences, 1986: Turner, Miller, & Moses, 1989). The nation's drug abuse treatment capacity has not, however, been significantly expanded. Why not? This is one area where significant further action is imperative. What about information and education, provided at intake or during treatment? The research indicates that education is moderately helpful, but education alone does not appear to change people's behavior significantly. This raises policy issues. Specifically, should policy-making bodies mandate that programs provide HIV education, when most educational interventions have not been shown to change behavior? If so, what educational interventions should be implemented? Should programs give out information about how to clean needles with bleach? What information should they give? Should programs, instead of educating about needle hygiene, actually provide disinfectants? Should they provide clean needles? This is fertile ground for both research and careful policy analyses that weigh the pros and cons of various options. Further, should treatment slots be targeted to special groups, or should minimal treatment be available to everyone without regard to their disease status, addiction

Psychosocial Treatment

severity, or p a y m e n t source? This is an area w h e r e there has b e e n very little research, and more information will help to shape policies. R e g a r d i n g staff m e m b e r s , the e m e r g e n c e o f the A I D S e p i d e m i c has stretched the resources o f counselors working in drug treatment programs. N o t only are they dealing with drug abuse, they are dealing with the p r e v e n t i o n o f disease and, w h e n seeing patients with H I V disease, they are dealing with a sick and rapidly dying clientele. Issues arise regarding h o w active to be in attempting to forestall the H I V infection o f sexual or needle-sharing partners, boundary conflicts, and h o w to cope with patients' illness and death. The research in this area is just e m e r g i n g , and it will no doubt have rich benefits to the field by addressing such issues as the stresses on staff, the needs staff have in coping with the e p i d e m i c o f H I V disease, and the staff d e v e l o p m e n t activities required to help counselors c o p e with A I D S . R e g a r d i n g reaching the sexual partners and families of drug abusers, m u c h more research is needed to assess the impact o f w o r k i n g with sexual partners and families. R e s e a r c h needs to develop, assess, and disseminate techn o l o g i e s that are effective. Studies should c o m p a r e different counseling or educational approaches that w o r k with w o m e n or family m e m b e r s individually and in c o m bination with drug-users in treatment programs. R e g a r d i n g the m i n i m a l i s t versus c o m p r e h e n s i v e services debate, there is a need for serious efforts at services research. It will be e x t r e m e l y helpful to analyze the impacts of policies that increase or decrease the availability of treatment o f various intensities, and c o m p a r e the costs and benefits of these options. H I V infection will continue to spread a m o n g injecting drug users. It will b e c o m e increasingly urgent to base A I D S p r e v e n t i o n and treatment activities on a solid foundation of research.

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