Samuel R. Friedman National Development and Research Institutes, Inc. New York, NY

1. Case study of NDRI contributions to social understandings and interventions of the HIV epidemic in drug users and their communities--and how to fight it Samuel R. Friedman National Development and Research Institutes, Inc. New York, NY

2. I would like to acknowledge • P30 DA11041 (Center for Drug Use and HIV Research) • R01 DA19383 (Staying Safe: Long-term IDUs who have avoided HIV & HCV) • R01 DA13336 (Community Vulnerability and Response to IDU-Related HIV) • R01 DA13128 (Networks, norms & HIV risk among youth) • R01 DA03574 (Risk Factors for AIDS among Intravenous Drug Users ; DC Des Jarlais, PI) • R01 MH62280 (Local context, social-control action, and HIV risk) • Thousands of participants in these studies • Many collaborators and co-authors • Users’ group activists who have given me insightful ideas

3. NDRI • NDRI is a non-profit organization with a staff of 200+ people. • Center for Drug Use and HIV Research about 60+ people. See newsletter on back table. • It has many research, action and training projects about public health and drug users. • This talk focuses on some areas of work that I have been involved with that have affected either policies or programs: • International Working Group • SEP research • Users’ groups • Argentine crisis assessment • (If time) Risk networks research

4. A. International Working Groupon Drug Users and HIV • In the mid-1980s, Don Des Jarlais coordinated an international coalition of researchers and others concerned about HIV among users to encourage and advocate for epidemiologic and prevention research and the establishing of HIV prevention and care programs. • The International Working Group pressures International AIDS Conferences and others to pay attention to drug users. • We collated and sent out information about new programs that were set up, new research findings, and new ideas. • This helped spark many actions by governments, researchers, users’ groups and other people who became involved in these efforts. • Schools of Public Health can take similar leadership roles on issues that are being ignored in teir countries, regions or the world.

5. B. SEP Research and Advocacy (1) • We have shown that: • Portland, OR: • “Do no harm”: The opening of the SEP DECREASED the numbers of syringes in the streets (Oliver et al) and reduced risk behaviors by participants (Oliver et al) • Brooklyn: youth in SEP neighborhood don’t even know it exists • NDRI staff on my projects were part of the activist groups who formed underground SEPs in NYC and helped create the conditions that led to the large SEPs in the city in the early 1990s.

6. SEP Research and advocacy (2) • NYC research: Much of this was led by Don Des Jarlais • Following the introduction of large-scale SEP in early 1990s, decreases took place in many NYC samples of IDUs recruited in different ways and localities (and, thus, we think in the community as a whole) in: • Risk behaviors • HIV prevalence • HIV incidence • We also showed that, at an individual level, those IDUs who used syringe exchanges were more likely to reduce risk behavior, were less likely to be infected, and were less likely to become infected.

7. SEP Research and advocacy (3) • We communicated these findings to: • Mass media • Federal panels and officials • State and local officials and panels • Professional meetings • NGOs • Students • Drug treatment programs • Users • Our efforts, together with those of many others (such as Drs. Heimer and Sherman, for example), have helped spread SEPs in the USA

8. C. Users’ groups (1) • In 1984, looking at data that showed that IDUs were already reducing HIV risk on their own, and that it seemed to be due to group communication and pressure, I hypothesized that drug users, like gay men, could form organizations to fight the spread of HIV and to help those who were sick. • In 1985, I learned that Dutch users’ groups already existed and were doing this. • Starting in 1986, I visited Dutch and other users’ groups to see what they were doing and what, if anything, my knowledge of epidemiology and of social movements could contribute to their efforts.

9. Users’ groups (2) • My descriptions of kinds of users’ groups and of their histories helped them in thinking about their roles and strategies. • My analyses of the reasons why drug users are treated so badly helped provide ideas for users’ groups. For example, “The Political Economy of Scapegoating” provided the ideology for the coming together of local groups in the British Isles into a national users’ group federation that lasted for several years.

10. Users’ groups (3) • My presentations of my observations and of the results of a partially-successful effort to organize NYC users helped to legitimate users’ groups to government funders in Australia, Canada and other countries, and to private funders as well. • I co-authored many articles over the years with users’ group members and leaders. This also helped boost the standing of users’ groups. The intellectual contributions of the users were important to the direction and accuracy of these papers.

11. Users’ groups (4) • In all of this, my ability to work with users in users’ group was based on my treating them as colleagues and equals—indeed, as friends who in many ways knew much more than I do. • I recommend this last point as a model for Schools of Public Health—work with “the people” as equals who may know more than you do. • And always get to know those who are the targets of any intervention before you do it. Get their ideas, get their aspirations, learn what they are already doing, and then work with them to figure out how you can help.

12. D. Argentina crisis assessment • Argentina went through political revolution and economic crisis; in some ways, a “transition.” • Question: What impact on HIV risk? • Joint project of NDRI and Intercambios (Diana Rossi) found no increased risk in a very impoverished, high-drug use part of Buenos Aires where Intercambios had been working. • Ethnography important • Second question: Did the crisis have impacts on working class neighborhoods that had had something to lose, or on middle class neighborhoods? • Current assessment: The School of Social Work has many graduates. Intercambios is surveying them and public health contacts about whether they have observed increases in drug use, sex work, or sexually transmitted diseases in the areas where they work. • Schools of Public Health can create networks of their graduates to report similar information.

13. E. (If time) Risk networks research • Finally, I want to mention our research on the networks of drug users. Alan Neaigus of NDRI and I have helped to develop this field. • It shows that “behaviors” are only one component in the spread of HIV, hepatitis, and STIs; networks also count. • Furthermore, the actions and norms and health communications of network members shape an individual’s actions and norms.

14. Risk is a conditional probability that is shaped by networks and much else +, on HAART - Negative Unknown, but GC+ and HSV-2+ The probability is socially structured

15. SOCIAL network ties can carry influence that can shape behaviors: Within relationships To or from an individual Throughout a community or small group

16. HIV Positive by Gender/Sexuality (MSM=up triangle, WSW=down triangle, other female=circle, other male=square) by Hardest Drug Use Ever (from dark red to light pink: IDU, Crack, NI Heroin or Cocaine; blue=other)

17. HSV2 Positive: We need to deal with STIs among drug users

18. Sex at Group Sex Party

19. Star Urgers: Community members are intraventionist health actors

20. SOCIAL networks and prevention issues Network concepts let us develop ideas that focus on: • The individual client • The relationship • The client’s friends and partners • The risk community as a whole • The peer structure of communities that are trying to organize prevention and care This helps us get “outside of the box” of thinking only about the individual, but also keeps us from forgetting about her or him