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The HIV epidemic in China and Vietnam is on the increase among injection drug users (IDUs). We report on the results of a pilot outreach study in northern Vietnam and southern China to test the feasibility of a peer-driven intervention (PDI) to prevent HIV among IDUs. In the PDL recruitment relies on a 'chain-referral' model in which IDUs carry-out the core outreach activities that salaried outreach-workers/ peer-educators traditionally provide. A 6-month follow-up was built into the study design to measure possible changes in IDUs' risk behaviors. The impact results of the pilot study are reported bearing on several different measures, such as changes in IDUs' rates of lending or borrowing used syringes, willingness to enter into drug treatment, baseline and follow-up recruitment success, and effectiveness of serving as peer-educators in the community. The evidence suggests the PDI is highly feasible and deserving of greater research in both China and Vietnam.

This article examines health care utilization among injection drug users. Based on previous health care models, we identify various attitudes and personal characteristics that have been found to affect health care utilization in the general population, and we examine their effect with this at-risk group. They include trust in physicians, self-esteem, self-efficacy, social isolation, and depression. We examined survey data collected from 374 injection drug users in New Haven, Connecticut. Our findings indicated that trust in physicians significantly increased health care utilization, and depression decreased it. We also found that HIV+ respondents as well as those with health insurance utilized health care more often. These findings broaden the generalizability of existing health care utilization models, and they inform efforts to increase health care among vulnerable populations such as injection drug users.

HIV, hepatitis B & C, drug overdose, and other drug-related health problems still pose significant health risks to injection drug users (IDUs) and their sexual partners, indicating the need for further development of innovative public health interventions. A relatively new intervention implemented in many municipalities throughout the world is the 'safer injection site' (SIS). An SIS is a legal facility that allows people to prepare and inject pre-obtained drugs in a hygienic, anxiety-free atmosphere under the supervision of health personnel. This paper examines the responses of a sample of IDUs in New York City to whether they would use an SIS should one be implemented in mid-town Manhattan. The SIS would be part of a comprehensive harm reduction project that already offers needle-exchange, street outreach, testing and counseling, support groups, referral services including drug treatment, and on-site primary medical and dental services. The results of our study indicate that a large majority of the IDUs sampled would utilize an SIS should one be implemented, and that those most likely to use it are IDUs at the highest risk for contracting or spreading blood-borne diseases such as HIV and hepatitis, and for experiencing a drug overdose.

Active drug users with HIV infection suffer from both low utilization of, and adherence to, primary care. Combining drug treatment and primary care on-site reduces these problems significantly because it creates a social support structure; treatment program staffs can monitor patients' adherence and provide ongoing encouragement. But in the United States, only a very small minority of HIV + drug users receive this demonstrably effective form of care. We report the results from a feasibility study of an alternative support structure, termed a 'peer-driven intervention', that serves as a functional equivalent to drug treatment for increasing drug users' adherence to HIV therapeutics. The six-month study included 14 adult active drug users receiving medical care for HIV disease in New Haven, Connecticut. As a health advocate, each subject was assigned and asked to meet with another subject once a week at the project's storefront to provide peer support and counseling. As a peer, each subject was assigned and asked to meet with another health advocate once a week to receive support in keeping up his or her medical care. No two subjects played both roles for one another. Advocates earned nominal monetary rewards for eliciting positive responses from their peers in keeping clinical appointments, responding to physicians' referrals, picking up prescriptions on time and attending weekly meetings with the advocate. The results of the study suggest that an alternative social support structure to drug treatment is feasible for increasing active drug users' adherence to medical care. Innovative mechanisms that harness drug users' peer pressure to promote positive behavioral changes deserve greater study. Keywords: HIV/AIDS; Adherence; Health care utilization; Injecting drug users; Substance abuse; Intervention; Antiretroviral therapy; Social supports; USA

In 1985, the National Institute on Drug Abuse (NIDA) funded an ethnographic research project in San Francisco to study the needle sharing behavior of injection drug users (IDUs). The goal of the research was to develop a strategy to slow the spread of HIV among this hidden and hard to reach population of drug users and their sexual partners. This small-scale project grew into a model intervention in which bleach, condoms, and street-based education by outreach workers were employed to inform IDUs of the risk of AIDS and of methods for protecting themselves. The 'reach and teach bleach' model was adopted by NIDA and implemented in a number of American cities. This study describes the development of the model intervention, the adoption of the model by NIDA as part of its National AIDS Demonstration Research (NADR) project, and the political circumstances under which the city of San Francisco applied for the NADR grant. Drawing on Social Worlds/Arena theory, and based on extensive interviews and participant observation, a sociohistorical analysis examines the initial development, implementation, and disintegration of the model outreach project and the impact of the program on drug policy in the city of San Francisco.

Following decades of corporate strategy promoting common household bleach as essential for peoples' health and happiness, a use for bleach was finally discovered in 1986 that actually achieved life-saving proportions for a certain population: injection drug users in preventing the spread of AIDS. Since then, substantial promotional efforts have surfaced -- corporate, governmental, and community-based -- to downplay or obstruct the public definition of bleach as a major AIDS prevention weapon. An analysis is offered of four competing social constructions of bleach that have emerged since 1986: bleach as a apublic health breakthrough; bleach as a liability; bleach as an endorsement for drug abuse; and bleach as a social policy copout.

An ethnographic analysis is offered which examines four methodological problem areas that community health outreach workers manage in attempting to stop the spread of AIDS. Outreach workers' client populations include drug injectors and their sexual partners, prostitutes, and homeless/runaway youths. The analysis notes that outreach workers confront several problems of work that are strikingly similar to some of the central methodological problems of conducting ethnography. These are (a) establishing a very unusual but credible identity in communities whose members harbor substantial distrust; (b) discovering a community from members' points of view; (c) forming relationships, but controlling one's level of involvement and impact; and (d) cultivating viable roles in the field.

A dilemma arises for researchers who sample hidden populations, such as injection drug users (IDUs), and use financial incentives to recruit respondents. To prevent respondent duplication (a subject participates in a study multiple times by using different identities) and respondent impersonation (a subject assumes the identity of other respondents), researchers must confirm their subjects' identities. Documentation, however, introduces sampling bias against those who lack such identification, or who wish to remain anonymous. Definitive forms of identification like photography and fingerprints introduce a bias against the more distrustful members of the population, and scanner-based biometrics can be expensive. Most research projects therefore rely on staff to recognize former respondents, but staff turnover and a large number of respondents compromise accuracy. We describe and assess quantitatively the accuracy of a method for subject identification based on a statistical principle, the interchangeability of indicators, in which multiple weak indicators combine to form a stronger aggregate measure. The analysis shows that observable indicators of identity (scars, birthmarks, tattoos, eye color, ethnicity, and gender) and five biometric measures (height, forearm lengths, and wrist widths) provide the basis for a reliable and easily administered method for subject identification.

Results are presented of enrolling HIV+ active-injection drug users (IDUs) into a peer-driven intervention (PDI) to improve their adherence to medical care. Using respondent-driven sampling (RDS), which evolved out of the PDI model, the authors recruited and tested 1,097 IDUs, of whom 145 were confirmed to be HIV+. Despite promises of confidentiality, increased social supports, and direct cash rewards for participating, only 78 (54%) of the HIV+ IDUs enrolled in the subsequent adherence study. Correlates of participation as well as interviews with respondents who declined participating are presented. The seemingly negative findings have important implications for future adherence studies. RDS provided a powerful mechanism for recruiting HIV+ IDUs. But selection biases were revealed to favor sicker yet more socially connected respondents, which resulted in more conservative outcomes with regard to social supports and positive health-seeking behaviors. The analysis may help streamline future efforts using the PDI, which harnesses IDUs' abilities to help one another, by underscoring some of the mechanism's limitations. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue including the one by Ian Malkin, Richard Elliott and Rowan McRae on international laws governing supervised injection facilities and another by Thomas Kerr and colleagues on safe injecting facilities and its relation to HIV epidemic.

The research literature is replete with discussions of ethnography as a methodology involving deception, especially in the conduct of participant observation. When such research involves forging trusting relationships with active drug users -- who develop many skills in deception during their 'careers in dope' -- deception may be used as much by, subjects in dealing with researchers as it is used by researchers in dealing with subjects. The element of deception increases further in ethnographic studies of AIDS prevention efforts for injection drug users (IDUs). Here ethnographers work to forge trusting relationships with outreach workers, who have been hired by prevention projects to forge trusting relationships with IDUs in the community to help protect themselves from HIV. In this paper, I discuss some deceptions basic to participant observation in virtually all social settings, with examples taken from my research of outreach workers and their dealings with IDUs in working to combat HIV. I then discuss some common deceptions run by outreach workers against the projects in which they work, and in their dealings with ethnographers. [ABSTRACT FROM AUTHOR]

This article presents a reply by social theorists Douglas D. Heckathorn and Robert S. Broadhead on comments made by several social scientists on their article titled "Rational Choice, Sociology and AIDS." According to Heckathorn and Broadhead, comments on the article "Rational Choice, Public Policy and AIDS" are thoughtful and constructive and illustrate well the diversity of perspectives in the social sciences and raise important issues regarding both the nature of rational choice sociology and AIDS prevention. If authors' comments dwell on points of disagreement with commentators, rather than on the many points on which the author's agree, it is because disagreement requires discussion but agreement requires merely assent. A second possibility is for rational choice sociology to develop a body of theory which is distinct from economic theory. Much support can also be found for this possibility. With the exception of the project's experimental intervention, virtually all AIDS prevention interventions that target drug injectors, including most needle-exchange programs, use the traditional provider-client model. This includes reliance on former users and other street-wise persons as salaried workers. When the article "Rational Choice, Sociology and AIDS" was written, results were available from only this single peer driven intervention.

The aim of this article is to assess rational choice as a basis for policy analysis and institutional design, and to do so in a manner that is grounded in empirical research and actual practice. If the problems which are supposedly universal to rational choice are not found, the criticisms are refuted. Alternatively, if the alleged problems are found, then assessment is more complex, because a determination must be made as to whether the problem is inherent in the approach or the approach is merely being misapplied. The authors first proceed by examining one case of rational-choice-based institutional design. They look at a social intervention intended to reduce the transmission of HIV, the virus that causes AIDS, among active injection drug users (IDUs). In part I, the authors summarize the theory of group-mediated social control, which underlies and organizes the AIDS prevention intervention. In part II, they discuss the operation of the project and provide data on the project's impact in reducing IDUs' risk behaviors.

New guidelines implemented by the U.S. Department of Health and Human Services exempt broad categories of social science research from regulation by university review boards. The analysis examines how exemption from regulation will change the way researchers manage ethical matters in the future. Social scientists will wish to protect the rights of research subjects and, at the same time, study sensitive social issues by scientific designs. As in the past, these goals will be incompatible in various ways. The analysis examines the parameters within which researchers will deal with several ethical and methodological dilemmas. [ABSTRACT FROM AUTHOR]

This article presents information regarding the concept of oversocialization of man in modern sociology. But functionalism is on the demise, its inadequacies are now calmly admitted, negative criticism toward it is losing wind, and further critical analysis will probably be redundant. Functionalism implies an oversocialized conception of man, the sociology of the Absurd implies an undersocialized conception. An undersocialized conception is one that first, sees action to be primarily the result of intention and subjective meaning: and underplays, if not negates, the contributory influence of social norms, values, habits, routines, customs, contracts, or rituals in determining social behavior. Because the Absurd argues that the social world is continually created and recreated by man, it eschews and denies the existence of any social world that influences or channels the behavior of people. The Sociology of the Absurd implies an wider-socialized conception of man in that it depicts human behavior as being in a constant state of conflict and alienation with other men, as opposed to having a multidimensional relationship consisting of consensus, cooperation, loyalty, and competition.

This paper focuses on outreach workers' own perceptions of the health risks they face, and how they have devised innovative methods of managing them. The analysis examines four risk categories, physical assault, psychological and emotional assault, work-related drug use and addiction relapse, and demoralization and burnout. Although outreach workers have played a pivotal role throughout the United States since 1987 in combating the spread of HIV among injection drug users, there are no analyses of the occupational health risks which they must manage. The authors were trained as outreach workers and deployed with several outreach teams for a year and a half in various targeted areas within San Francisco, California. Data suggests that outreach workers exercise substantial influence over determining the conditions of their work and what they experience on the job. Thus, in even the most beleaguered of circumstances, the analysis revealed that workers frequently find themselves inspired by their many troubled clients, and that much of the emotional and psychological stress they ostensibly face on the job is mitigated by workers suspending their own moral judgments about their clients.

The paper, based on empirical research focused on the professional and private lives of medical students, presents a theoretical perspective on the problem of multiple identities and the process of their articulation. The primary theoretical issue addressed here is how individuals articulate multiple identities, whether those identities are in the process of emerging, or are already established. Individuals are continuously presenting, announcing, revealing and projecting multiple identifies. However, to the extent that individuals embrace and present many different identities simultaneously, it is imperative for them to engage in a continuous process of identity articulation, emphasizing some and effectively deemphasizing other identities and aligning and realigning them into differing configurations. This is because, due to the exigencies of social interaction and social organization, failure to articulate identifies in ways that are appropriate to situations can create many different kinds of interactional problems.

In analyzing the process of facework engaged in by medical students in applying or medical school admission, data were collected on a number of theoretical problems which are in need of greater research and empirically based theorizing. In terms of theory on facework, it was found that future research is needed into the stages of individuation and normalization. In terms of theory on professional socialization, analyses are required which reveal (1) the interpenetration of multiple socialization processes which individuals participate in simultaneously and (2) how individuals may use specific socialization processes to prepare them for multiple identities and roles. [ABSTRACT FROM AUTHOR]

Since the relatively recent advent of evaluation research, researchers have overwhelmingly advocated the use of experimental designs over other methodological approaches. However, implementing such designs produces an interaction effect which greatly alters the nature of programs being evaluated. As an alternative to experimental designs, an interactionist approach to evaluation research is introduced and developed, both conceptually and procedurally. The advantages of a phenomenological skepticism, which is epistemologically integral to an interactionist approach, over an experimentalist's naive or common sense skepticism, is discussed. Stages and methodological problems of carrying out an interactionist approach are explicated. It is argued that the implementation of an interactionist approach would be "nonreactive" with either the structure or functioning of a program under analysis. And it would simultaneously bring into relief much of the anxiety and distrust between researchers and those being evaluated that characteristically accompanies the application of experimental designs. [ABSTRACT FROM AUTHOR]

The article presents a historical analysis focusing on the arrival of acute poisoning as a fully institutionalized social problem in the U.S. It examines reasons why hospitals rushed into poison control as well as why, despite a high incidence of poisonings and over two million hotline calls annually, hospitals are now abandoning poison control. Efforts to plan and consolidate health services have always been hotly contested and resisted, particularly by the American Medical Association and other health provider associations. Critics have even argued that distortions in services were caused by the disorganized and redundant efforts of planning agencies themselves. As a component of the health care "system," poison control services exhibited the same erratic development and disorganization as the larger health industry. However, in contrast to the larger world of health care, poison control centers since the late 1970s have been in a widespread process of consolidation and regionalization.

This article discusses various reports published within the issue, including one by Judith Levy on support groups and another by Lisa Moore on the role of drug users in establishing effective needle exchange programs.

We report on the first two years of operation of the Yaroslavl, Russia harm reduction project for injection drug users (IDUs). From October 1996 to September 1998, the project was one of 13 projects in central and eastern Europe that comprised the International Harm Reduction Development Program, funded by the Open Society Institute in New York City and the city and province of Yaroslavl. The project is modeled after and received technical support from the Eastern Connecticut Health Outreach project of the University of Connecticut, which was funded by the National Institute on Drug Abuse. The Yaroslavl project consists of two interrelated programs: a peer-driven outreach intervention that offers active drug users modest rewards for educating their peers in the community and recruiting them to a storefront for further education, interviews, free HIV, STD, and hepatitis B and C test counseling; and a needle exchange where IDUs can return used syringes for new ones and also receive other harm reduction materials such as condoms. We report on the development and implementation of the project and on in-depth interviews with 484 IDUs recruited to the project, 161 first follow-up interviews, 86-second follow-up interviews, and 35 third follow-up interviews. These interviews are based on clients' drug use and sexual risk behaviors, knowledge of HIV and other drug-related harms, and the Yaroslavl drug scene. We conclude with a discussion of the operational and political obstacles that the Yaroslavl project faces as those factors bear on the future of harm reduction programs in Russia. [ABSTRACT FROM AUTHOR]