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Meaning Of Drug Addiction

A study of drug use locations in Hartford, CT, is designed to understand the environmental and social conditions within "high risk sites" where drug users inject drugs or smoke crack, in order to develop AIDS prevention models that build upon the physical and social organization of these locations. The study assesses high-risk sites characterized on the basis of type of location or structure, presence and strength of gatekeepers, and presence and strength of HIV prevention opportunities and pressures. A combination of ethnographic, epidemiological, and social network methods are used to document the characteristics, social organization, natural history, and dynamics of these sites, the network relations of site users, and the various opportunities for, or barriers to, on-site social-level HIV prevention intervention. This paper provides an overview of the study and presents preliminary findings, including the degree to which drug injectors and crack smokers use specific types of sites in Hartford. The paper also discusses the ways these findings inform development of on-site, type-specific and peer-led or structural HIV-prevention interventions.

The AIDS epidemic among impoverished, urban drug users presents unique challenges to health researchers, treatment providers, and policy makers. Individual-focused behavior modification programs and office-based one-on-one counseling sessions dominate intervention approaches developed in response to the epidemic. Recent efforts to advance prevention beyond these individual-level models have included changing the risk environment by increasing drug-user access to sterile injection equipment or otherwise changing the social context of drug use and HIV risk, and attempts to bring peer-led prevention directly to drug users in natural settings.

Innovative initiatives are impeded by the complexity of the environments in which street drug users acquire and use drugs. Better understanding of the social contexts of drug use in urban areas and the specific circumstances in which illicit drugs are used is essential for advancing the development of effective prevention approaches for various groups of drug users at high risk of exposure to HIV. Recent studies utilizing ethnographic methods to understand the social context of drug use and HIV risk have contributed greatly to this knowledge.

Our research on high-risk drug use settings in which heroin and cocaine users inject these drugs or smoke crack is one such effort. The Study of High Risk Drug Use Settings for HIV Prevention1 (or the High-Risk Settings study) documents the contexts, nature, physical structures, social relations, and natural history of various types of high-risk drug use sites in Hartford. It charts changes in the location, social organization, rules of usage, and risk patterns of these sites. Additionally, the project is designed to study the risk networks of site users. It does so by examining their organization and characteristics, the social relationships among site-users and non-site-users within risk networks, and the potential for the diffusion of risk, disease, and intervention benefits through these networks over time. The purpose of this study is to explore the potential for bringing effective HIV prevention intervention directly into these settings or otherwise addressing social and structural factors affecting the risk of HIV presence and transmission among drug users.

OVERVIEW OF SOCIAL LEVEL STREET AND SITE-BASED AIDS PREVENTION APPROACHES

Efforts to bring AIDS prevention to street drug users initially began in the mid- 1980s with outreach programs employing indigenous or community-oriented outreach workers, including in some cases former or active drug users, to address the special circumstances of risk among out-of-treatment drug users (Broadhead, Heckathorn, Grund, Stem, & Anthony, 1995; Brown & Beschner 1993; Coyle, Needle, & Normand, 1998; Needle, Coyle, Normand, Lambert, & Cesari, 1998; NOVA Research Company, 1991; Singer, 1996; Trotter, 1996; Watters, Downing, Case, Lorvick, Cheng, & Fergusson, 1990). Street-based outreach and educational efforts have had several significant benefits. First, they have increased the presence of individuals on the streets in many urban and semi-urban areas who have access to drug users at high risk, and have established rapport among them as non-judgmental, non-threatening providers of harm-reduction information and materials (such as bleach, clean water, sterile "cookers" for heating drug solutions, educational materials, and referrals to services and drug treatment). Second, they have provided a new venue for direct contact with hard-- to-find individuals who had only limited access to, or were not inclined to seek services from, established institutions for HIV and substance abuse prevention and treatment. Third, in cases in which former or active drug users provided the outreach, this approach offered an opportunity for peer-led modeling and support for harm reduction to curtail the spread of HIV among active drug users. Such street-based outreach has allowed indigenous outreach workers to conduct education in potential contexts of risk and has been shown effective in disseminating information and initiating drug- and sex-related risk reduction among drug users (Coyle, et al., 1998; Needle et al., 1998; van Ameijden, van den Hoek, van Haastrecht, & Coutinho, 1992; Watters, 1987; Watters et al., 1990).

Another community-level approach to HIV prevention has attempted to increase drug injectors' access to sterile injection equipment through legal and illegal syringe exchange programs (SEPs) (Des Jarlais & Case, 1992; Grand et al., 1992; Heimer, 1998; Koester, 1994; Lurie et al., 1993; Normand, Vlahov, & Moses, 1995; Singer, Himmelgreen, Weeks, Radda, & Martinez, 1997). Syringe exchange built upon outreach efforts to include provision of sterile syringes, access to which without a prescription is illegal in most states. The majority of SEPs conduct one-for-one exchanges of used needles for sterile new ones, offer safe disposal of used syringes, provide other harm reduction supplies (bleach, cookers, educational materials) and direct linkages to drug treatment, primary care, and other health and social service institutions (Des Jarlais & Case, 1992; Lurie et al., 1993; Normand et al., 1995). SEP evaluations generally show reduced or stabilized rates of multiple-person syringe use, reduced frequency of injection, and reductions in other risk practices among users (Grand et al., 1992; Heimer, 1998; Kaplan & Heimer, 1993; Lurie et al., 1993; Normand et al., 1995). To date, these programs are state- or locally-funded efforts because of the continued ban on the use of federal dollars for SEPs or other provision of sterile syringes to drug users (Needle et al., 1998).

Progress toward addressing the limitations of individually-oriented educational and counseling models with IDUs has been further developed in peer-- led interventions and other models designed to utilize opinion leaders and teachable moments to popularize risk reduction practices and establish HIV preventive norms (Broadhead, 1995; Friedman et al., 1992; Latkin, 1998; Levy, Gallmeier, & Weibel, 1995; Neaigus, 1998; Trautmann, 1995; Trotter, Bowen, & Potter, 1995; Zapka, Stoddard, & McCusker, 1993). One key component of peer-led interventions is the involvement of drug users themselves in conducting and promoting AIDS prevention. Studies in Europe and Australia have shown that drug users are willing and able to organize themselves around HIV prevention and for their broader interests and political rights (Crofts & Herkt, 1995: Grand et al., 1992; Trautmann, 1995; van Ameijden et al., 1992). In the United States, while political organization of drug users has been less successful (Friedman, de Jong, Des Jarlais, 1988; Friedman, Curtis, Neaijus, Jose, & Des Jarlais, 1999; Moore & Wenger, 1995), the mobilization of key opinion leaders acting as "indigenous advocates" (Power, Jones, Kearns, Ward, & Perera, 1995) for other drug users has been effective in carrying out and promoting risk reduction practices among drug using peers (Broadhead, 1995, 1998; Friedman et al., 1999; Latkin, 1995, 1998). Research suggests that intervention can be built upon rules of etiquette and peer support intrinsic to drug users and organized or controlled by these leaders (Levy et al., 1995; Page, Smith, & Kane, 1991). While identification of appropriate and influential peer leaders can be difficult (Friedman et al., 1992; Moore & Wenger, 1995; Power et al., 1995), these individuals can have a powerful and lasting influence when they see the benefit of, and are motivated to institutionalize, changes among those who respect them (Broadhead et al., 1995; Klepp, Halper, & Perry, 1986; Levy et al., 1995).

The broadest approaches to reducing HIV transmission beyond individual-- level interventions are efforts to change the structural conditions or socio-political environment of risk. These structural approaches include policy changes designed to reduce conditions conducive to viral transmission. They include such endeavors as legalizing access to sterile syringes (Groseclose et al., 1995), increasing availability, accessibility, and diversity of drug treatments (Friedman et al., 1995; Metzger, Navaline, & Woody, 1998; Needle et al., 1998), reducing emphasis on punitive and stigmatizing responses to drug use, addiction and prostitution while increasing emphasis on rehabilitative responses including community economic development, job training, and housing development, and possibly even legalizing some of the currently controlled substances or regulating their safe use, for example through the creation of safe "get-off" houses (Dom, 1992; Haemmig, 1992; Pearson, 1992; Wodak, 1992). Structural approaches to AIDS prevention with drug users are constructed to reduce the likelihood of HIV-- related risk in drug use and to reduce the potential for harm while engaging in activities needed to finance that use. Many are designed to increase alternatives to risky drug use and sexual practice by changing the social, political, and economic environment in which these activities occur.

Understanding and addressing the many contexts in which HIV risk behavior occurs and the variety of interacting and sometimes contradictory forces that influence the practices and perception of individuals in these social situations are critical to furthering our knowledge of HIV transmission. Such knowledge is needed to develop more effective AIDS prevention programs for IDUs, other drug users, and their sex partners. Ethnographic documentation of the political and economic factors, interpersonal relations, and physical conditions that constitute the social settings of drug use has contributed to understanding the circumstances under which intervention efforts are likely to be successful and determining what forms they should take.

Ethnography of the contexts within which HIV risk occurs contributed to recognition of shooting galleries as high-risk sites for HIV infection early in the AIDS epidemic (Chitwood et al., 1990; Des Jarlais & Friedman, 1990; Feldman & Biernacki, 1988; Ouellet, Jimenez, Johnson, & Weibel, 1991). Preliminary ethnographic research indicated the critical need for closer, longer examination of patterns of drug use and sexual behavior in high-risk sites and gave rise to more intensive ethnographic study of shooting galleries and related venues (Koester, 1994, 1995; Page et al., 1991; Power, Jones, Kearns, & Ward, 1996; Singer & Weeks, 1996). Taking research on the social context of drug risk a step further, several studies developed targeted models for HIV prevention in shooting galleries and advocated for public health collaboration with housemen and other key players in the drug scene (Celentano et al., 1991; Des Jarlais & Friedman, 1990; Latkin, Mandell, Vlahov, Oziemkowska, & Celentano, 1994; Ouellet et al., 1991; Page et al., 1991; Power et al., 1996; Watters & Guydish, 1994).

The ethnographic study of crack houses and base houses (where freebase cocaine is smoked) has further contributed to understanding the kinds and contexts of drug-related HIV risk that occur in those settings (Bourgois & Dunlap, 1993; Bowser, 1989; Mieczkowski, 1994; Sterk-Elifson & Elifson, 1993). The crack/base house is generally an established site where the drug is prepared, and individuals congregate to sell, buy and/or smoke it (Rather, 1993). In some such locations, users engage in sex-for-crack exchanges with people who either voluntarily frequent the site or are employed by the crack house operator (Bourgois & Dunlap, 1993; Des Jarlais et al., 1991; Inciardi, Lockwood, & Pottieger, 1993, 1995). It is the relationship between crack use and sex (generally sex-for-crack) that place not only crack users but others in their social networks and beyond at risk of HIV infection (Chaisson et al., 1991). Like studies of shooting galleries, ethnographic studies in crack/base houses show a range of site types significant in terms of the capacity for and nature of intervention that can be implemented on location (Rather, 1993; Sterk-Elifson & Elifson, 1993).

Prior ethnographic study of shooting galleries and crack houses provided us with an important foundation and framework for the conceptualization and design of our study of high-risk sites in Hartford. The following describes key components of the conceptual framework we used to develop and implement this study.

DEFINING HIGH-RISK SITES AND SITE-USER NETWORKS IN THE HARTFORD STUDY OF DRUG USE SETTINGS

High-risk sites are dynamic entities that can be characterized along several dimensions (Friedman et al., 1992; Longshore, 1996; Ouellet et al., 1991; Page et al., 1991; Sterk-Elifson & Elifson, 1993; Watters, 1989). For the purposes of our study, we defined high-risk drug use "sites" both geo-spatially and socially. A site is a spatial entity, differentiated and characterized by its location and physical qualities, such as the degree to which it is public or private, its size, location in the neighborhood and city, facilities available like running water, and whether it provides shelter and protection or is in the open (i.e., in an alley or behind a building). A site also is defined in relation to the people who create and use it for the common purpose of consuming drugs or exchanging sex for drugs or money. Thus, the individual site users, their relationships with each other, and their social organization, which may include different roles for members, also define the site and influence the course of its evolution.

The physical qualities of a site may circumscribe the activities that can take place there and leave it more or less vulnerable to outside disruptive influences. The social relationships of site users, however, are likely to be more significant than the physical space, allowing a "site" to be constituted and reconstituted in different locations without completely disrupting its social organization. Likewise, reorganization or disruption ofthe social relationships among site users (perhaps because of police targeting specific neighborhoods or individuals, or the illness or imprisonment of a site gatekeeper) may result in dissolution of the network that uses it, but the space may remain a site newly adopted by a different set of drug users for the same purpose. Both physical and social factors influence risk and the potential for intervention to reduce it.

Peer leadership or social control within high-risk sites is likely to parallel the intrinsic hierarchy of site users, as defined by their role at the site. In situations in which a proprietor or gatekeeper of the site controls access and activities, that person is likely also to control interactions among site users and may be able to affect risky or preventive drug-use practices at the site. Because the social organization of site users might be bounded within the site itself (Sterk-Elifson & Elifson, 1993), direct observation of the setting is key to identifying appropriate peer leaders who are able to maintain some degree of control over site access and use, influence the behavior of site users on location, and extend their influence beyond site users, through networks, to others who do not use the site (Page et al., 1991). Understanding the role of these individuals and factors affecting their influence over other drug users is important to the development of peer-led HIV prevention for implementation in drug-use sites.

In preparation for developing peer-led HIV prevention intervention to be implemented within drug-use locations, we characterized types of sites and their potential for inhibiting the spread of HIV. This characterization is similar to the typology of "shooting galleries" constructed by Oulette and co-workers (1991), though local conditions preclude direct application of any typology of drug-use sites (cf., Carlson, 2000, Page et al., 1991). In our conceptual framework, sites fall along a continuum of least to greatest site-use control and potential for building on intrinsic HIV prevention opportunities. This continuum includes the following: 1) open spaces with no gatekeeper and limited HIV-prevention materials or norms present; 2) semi-closed or closed spaces with a weak gatekeeper who enforces few rules or has little ability to control use of the space, and offers limited HIV-prevention materials or norms; 3) closed spaces with a strong gatekeeper who maintains strict rules for use of the space, but who has little orientation toward HIV prevention and limited available prevention materials; and 4) closed spaces with a strong gatekeeper who enforces strict rules, including rules about HIV prevention, and who maintains multiple HIV-- prevention materials and norms in his/her space. We used this framework to assess characteristics of drug-use sites and social relationships of site users, especially gatekeepers, in our analysis of Hartford drug using locations.

RESEARCH METHODS OF THE HIGH-RISK SETTINGS STUDY

On the basis of this conceptual framework, in the fall of 1997 we initiated a study of the various types of high-risk drug use sites in Hartford and the social networks of drug users encountered at those sites. In the High-Risk Settings study we used ethnography to assess and document the locations and types of sites, social dynamics of drug use and interactions among site users, the processes of drug use practices, and the social and physical environmental conditions of drug use and HIV risks over time. We also used it to track the dynamic process of high-risk site construction, establishment, modification, disintegration or dissolution, and reconstitution. An epidemiological survey of a sample of drug users repeated at three time periods six months apart provided demographic, health, risk-behavioral, and site-use information, personal (ego) network data, and changes in these over time.

The project began with a six-month exploratory period during which we used street outreach and ethnographic observation and interviewing to identify drug-- use sites around the city. This included conducting in-depth, semi-structured exploratory interviews with active drug users on their drug use patterns and the places they go to use drugs, as well as observation of interviewees in one or more of the sites they identified. These exploratory interviews were used as a means to identify new sites and encourage participants to provide field team members access to more hidden, private sites, as well as the many open drug-use areas, for observation and further study-participant recruitment.

Locations field staff visited commonly included abandoned buildings and other accessible areas recognizable as target sites by being littered with drug refuse. Evidence of use often included glycine or waxed paper wrappers that had contained heroin or other drugs, used syringes or parts of syringes, empty plastic water bottles, soda can bottoms and metal spoons used as cookers for mixing or cooking drugs, "nip" (small alcohol) bottles modified for use as crack pipes, and the discarded remainders of HIV-prevention materials like bleach bottles and condoms (used and unused). Sites visited also included the residences (rented or squatter-claimed) of drug users when these places were used as gathering sites for drug use. Information from the exploratory phase allowed identification of an initial set of different types of sites to target for survey participant recruitment and long-term, in-depth ethnographic observation. Following the exploratory period, we continued the ethnographic documentation of specific sites and site types. We also recruited a sample of active drug users to participate in the epidemiological and network survey of HIV risks among users of various types of sites. We used three recruitment strategies to identify and recruit participants for the survey. The first of these was targeted street-based recruitment, including general outreach to targeted neighborhoods of the city and especially to identified "hot spots" (areas or sites of concentrated drug-use activity). This recruitment was conducted through walk-up introduction for screening and interview appointments, and was focused by way of a targeted sampling plan similar to that used for the NIDA cooperative agreement project (Singer and Weeks 1992; Watters and Biernacki 1989). The second approach was site-based recruitment, including from specifically identified high-risk sites, selected on the basis of prior identification as a targeted site for intensive study, or by virtue of survey participants' frequent mention (five or more times). The third method was study participant referral of their drug-using network members. To encourage this referral, we offered peer incentives (i.e., a $5 "finder's fee") for drug users who identified and recruited their drug-using network members and high-risk site users, a technique similar to "respondent-driven sampling" described by Heckathorn (1997). The sampling plan for survey participant recruitment was designed to tap neighborhoods of Hartford with the highest indicators of risk (drug arrests, HIV/STD prevalence, poverty, etc.). We also selected neighborhoods to insure recruitment of a balance of African Americans and Puerto Ricans or other Latinos (the largest ethnic populations of the city), as well as a small number of nonHispanic Whites. With focused sampling we could insure at least 25% women in the study. Participants in the survey were interviewed using a standard questionnaire at intake and then two additional times at six-month intervals to track changes over time. The survey instrument measured HIV risk (drug use, needle/syringe use, sexual practices, condom use), characteristics of participant's drug-use sites, and participants' ego-networks, including member characteristics, relational (group-level) ties among ego-network members, and their HIV-related risk profiles (e.g., whether they use drugs together or have a sexual relationship and whether one or both have HIV).

Three measures were included in the survey instrument to define high-risk drug-use sites. They were the following: 1) physical site type related to public accessibility, that is, open/semi-closed/closed, and type of space (abandoned building, apartment, etc.), as well as whether it is an injection or non-injection drug-use site; 2) gatekeeper presence/absence and strength or control of the site; and 3) presence of HIV prevention materials and norms. We measured these characteristics for the two sites each participant reported using most frequently. These three dimensions (physical or use type, gatekeeper control, and HIV prevention potential) constitute the key elements upon which we chose to characterize different types of sites and drug use or HIV-risk contexts. Regarding physical type, we differentiated sites primarily as "public" or "private." Public sites were open or semi-closed sites, including abandoned buildings, hallways or stairways of occupied buildings, public bathrooms, parks, cemeteries, and vacant lots. Private sites were generally closed to the public, and included a participant's own house or apartment or someone else's house or apartment. Most sites, whether public or private, were used for both injection and non-injection drug use. Some sites were identified, however, as not used for injecting drugs. We measured gatekeeper strength on the basis of one or more of the following four characteristics: 1) someone has to approve entry to the site; 2) the user has to know someone to get in; 3) the user usually has to give someone drugs, money or something else to get in; and 4) other rules must be followed to get into or stay in and use the site. We interpreted a negative response to all these conditions as absence of a gatekeeper, and an affirmative response to any of the four items as presence of a gatekeeper. We then analyzed gatekeeper strength on the basis of the total number of these four items reported to be present at the site.

Prevalence of HIV prevention materials or norms were measured with the following: 1) new needles are available at the site; 2) bleach is available; 3) clean cookers and cotton are available; 4) clean water is available; 5) condoms are available; 6) someone is present (not necessarily a gatekeeper) who would stop users from sharing needles or other equipment at the site if he/she saw it occurring. At non-injection drug-use sites, only presence of condoms (#5) was used to measure availability of HIV prevention materials. We took a negative response to all items as absence of HIV prevention materials or norms. We measured prevalence of prevention materials or norms incrementally based on the number of these items reported to be present at the site (differentiating injection and non-injection-only sites). It is important to note that all six items are necessary components of HIV prevention, but their presence is not sufficient for prevention to occur. We did not try to measure actual prevention practices of site users, a more complex set of measures to ask study participants to construct. Thus, we only measured the potential for HIV prevention to occur at the site.

To assess the validity of the HIV prevention and gatekeeper indices we conducted factor analyses using principal components analysis. Examining the six HIV prevention items for participants' primary site revealed one underlying factor which accounted for over 48% of the variance among the items. In addition, five of the items had loadings on the factor of .6 or above, and the availability of new needles had a loading of.49. Conducting the same analysis for the six items for participants' secondary sites also revealed a single factor which accounted for over 46% of the variance, and all of the items had loadings of .50 or above. Examining the four gatekeeper items for participants' primary site suggested one underlying factor that accounted for over 72% of the variance among the items and all four of the items had loadings of .78 or above. Similar analyses for the secondary site confirmed the one factor structure, which accounted for over 59% of the variance, and all four items had factor loadings above .6. This pattern of results suggests that each of the indices are unidimensional with high face validity.

PRELIMINARY FINDINGS OF THE HIGH-RiSK SETTINGS STUDY Findings from the exploratory phase of the study and the first three months of survey recruitment revealed several unexpected characteristics of drug-use sites in Hartford. As with Carlson's ethnographic findings in Dayton, Ohio, our initial ethnographic assessment of Hartford sites indicated that the stereotypical image of the "shooting gallery" and "crack house" bore little resemblance to the majority of sites we identified and observed through street outreach, site visits, and in-depth interviews. That is, few places identified within the first several months of study were controlled, relatively stable sites in which a houseman charged a fee at the door and provided injection or crack smoking equipment and/or drugs to any who paid the fees, and where addicts gathered to use drugs and hang out with each other while getting high. Several participants indicated that such places used to be more common in Hartford, but have become relatively rare, citing increased police activity as the primary reason. Much more commonly observed was the rapid get-off site, such as an abandoned building, frequently in the vicinity of the dealer from whom the user purchased drugs, and the limited-- access use of homes or apartments.

These early ethnographic findings indicated that the key characteristic differentiating sites seemed to be whether they were private (homes or apartments) or public (abandoned buildings, parks, etc.). Most private sites were controlled by the owner or renter of the house or apartment and were accessible only to acquaintances, friends, or friends' contacts. Public sites were generally accessible to anyone, with little social interaction among the multiple users who make quick visits to these sites within the course of a day. Other site type characteristics of interest to the project, such as gatekeeper presence and strength and HIV prevention materials and norms, differentiated private sites more so than public sites. Because of their private nature - they are often the homes of "gatekeepers" private sites were very difficult for the research team to identify and access. Identification of each site often depended on the chance meeting ofthe gatekeeper through street outreach or word-of-mouth information from drug users, followed by an arranged meeting or exploratory interview. Entry required significant rapport between field staff and gatekeepers. Also necessary was a clear understanding that the researchers were not linked to the police, were there only to conduct AIDS-related research, brought prevention materials (and messages) with them, and would compensate gatekeepers monetarily over the course of the study through regular ethnographic and/or survey interviews. Because of these access barriers, the field team identified and accessed few such places during the six-month ethnographic exploration, though they continued to identify additional such sites as the project progressed. The first few months of the High-Risk Settings Study demonstrated that the instability of both private and public sites was significantly greater than we had anticipated. This instability resulted from transitions in housing and development in the city overall (including the virtual elimination of housing "projects" beginning in the mid-1990s and the overall increase of abandoned residential buildings) as well as enhanced police pressure in recent years. After five months of exploratory interviewing to identify high-use private and public sites, we selected fourteen sites, ten public and four private, expecting that we would identify additional private sites as the project proceeded. These sites were selected for intensive study and recruitment of individuals to participate in the epidemiological and social network survey. Within two weeks, two of the ten selected public sites were no longer available to the study or to drug users: one was boarded up and the other torn down. After selecting two replacement sites for these and one additional high-use public site, within the next two-week period one of the replacement sites and yet another public site on our selection list were lost to the study. Concurrently, two of the private sites were changing as one gatekeeper was being evicted and the other, having stopped paying rent, was expected to be. Subsequent ethnographic interviewing and field observations indicated that when these places disappeared, users generally moved to similar locations, either in the vicinity of their previous sites, or to newly established residential settings when these became available. Nevertheless, it appeared that as quickly as we chose sites for intensive study and participant recruitment, we needed to modify our site selection with replacements.

This discontinuity of sites raised the question of our ability to monitor sites over extended periods of time (a significant finding in itself), and had implications for what we might be able to say about specific sites or site types. It also raised the question of whether this seemingly constant flux in sites indicates that specific sites themselves (i.e., the physical entities) are meaningless from the standpoint of social conditions affecting relations among drug users. Rather, some other factor-e.g., site type, area of the city, social network of users-may be key in drug use location, "site" risk, drug user social dynamics, and HIV risk, transmission, or prevention. Finally, site discontinuity had significant implications for the development of any kind of stable, long-term, site-based intervention, peer-led or otherwise.

Over a two year period of survey sample recruitment, we interviewed 293 participants with the epidemiological and network survey. We analyzed these preliminary data regarding key characteristics of participants' self-identified primary and secondary drug-use sites. These participants were 9% non-Hispanic Whites, 35% non-Hispanic Blacks, 55% Hispanics (nearly all Puerto Rican), and less than 1% Native American. Women comprised 29% of the preliminary sample. The mean age of this sample was 37.3 years, with a range from 19 to 59 years. Also, 43% identified themselves as homeless, and 18% self-reported being HIV positive (including 33% of African Americans and 11% of Puerto Ricans). Most reported having used multiple illicit drugs in the prior 30 days: 68% injected heroin by itself, 55% reported having smoked crack, 42% injected speedball (heroin and cocaine combined), and 40% injected cocaine by itself. Injection drug using (IDU) participants reported significant use of shared injection equipment, particularly cookers and water (32%), and 20% of injectors also reported use of previously used needles.

Throughout the three-year project (including the exploratory phase), the HRS study field team visited a total of 85 drug-use sites in Hartford, and survey participants identified an additional 298 places where they used drugs (some of which are their own homes where they used alone). Survey participants reported various types of drugs used and modes of use at most multi-user sites they identified. Drug injection was reported at nearly all sites (see Table 1). However, at about one-fifth of primary-use and secondary-use sites, only non-injection drugs were reportedly used.

Over half of the survey sample's primary (51%) and secondary (60%) sites were public. Participants who used private sites were significantly more likely to use their own apartment or home as a primary site (32% of all participants reported doing so), and someone else's apartment as a secondary site (30% reported doing so). Nearly half of sites identified as primary (47%) and secondary (55%) had no gatekeeper present, though about a third of both primary and secondary sites reportedly had three or four indicators of gatekeeper control, suggesting strong gatekeeper influence. Additionally participants reported that most of their primary (69%) and secondary (59%) sites had at least some HIV prevention materials available or practices evident. Overall, survey participants reported no significant differences between primary and secondary sites they used, with the exception of use of private sites. Specifically, those who used private sites were twice as likely to use their own place primarily, and someone else's secondarily. Other characteristics of the pool of primary and secondary sites were statistically equivalent regarding types of drugs used, presence and strength of gatekeepers, and presence of HIV prevention materials and norms. We will therefore focus from here forward on the data regarding reported primary site use. Specific items measuring gatekeeper control and available on-site HIV prevention options suggest key factors for making use of indigenous social organization and harm reduction preparation to build site-based HIV prevention interventions (see Table 2). Of those primary-use sites indicated as having any gatekeeper control, the most common indicators were the presence of someone who approves entry, and the need to know someone personally in order to gain access to the site for the purpose of drug use (46% of gatekeeper sites reportedly have both characteristics, though these items were not interchangeable). The requirement to offer money or drugs was less common (about 26% of sites), though the need to follow other house rules reportedly occurs in nearly a third of sites with gatekeepers.

Among those sites where any HIV prevention materials or norms were indicated (70% of all primary sites described in the survey), clean water was most frequently mentioned, at 58% of sites. However, this basic prevention item is absent from virtually all abandoned buildings, parks, and other publicly accessible drug-use sites unless carried in. Clean cookers and cottons and bleach are reportedly available in about 40% of all sites, but the presence of condoms was reported in only about a quarter of all the sites, and clean needles in only 11% of injection drug use sites. Notably, participant-observed use of NEP needles (whether new or re-used) was reported in only 43% of sites. This limited evidence of the reach of the Hartford NEP, combined with the very low reported presence of new needles in injection sites, indicate the need for expansion of the program to reach locations where injection occurs. Also, available condoms were absent from 83% of both injection and non-injection sites, despite the regular occurrence of sex in exchange for money or drugs, particularly at crack-use sites. Neither street outreach nor the NEP (both important suppliers of free condoms) have sufficiently addressed potential sex risk in drug-use sites. Important in the dynamics of indigenous HIV prevention in drug-use locations is the presence of someone who would stop or prevent sharing of needles or other drug-use equipment, reported in 29% of injection drug use sites. This factor was unrelated to the presence of a gatekeeper, suggesting that other site users would initiate and promote preventive actions among their drug using associates even if they did not have control over the site. This is important for building on existing social conditions to enhance peer-led prevention in these high-risk sites.

A comparison of private and public site types regarding gatekeeper control and presence of HIV prevention materials and norms indicate the need to target prevention approaches in order to build on site characteristics to enhance HIV prevention effectiveness (see Table 3). Not surprisingly, most private apartments have gatekeepers with at least three of our four indicators of control over use of the site. Likewise, public sites rarely have gatekeepers, though project field staff have observed in some abandoned buildings attempts by site users (often someone squatting at the site) to control how and where others use it. Nearly half of the public sites reportedly have no on-site HIV prevention materials or mechanisms to promote prevention, in contrast to virtually all private sites. Notably, 11% of participants who use their own apartments as their primary site report no HIV prevention materials there; but at least one prevention item was reported at every private site belonging to someone else. This may indicate that those using their own place always use alone, though lack of prevention options precludes taking any kind of precaution if another injection drug user or a sex partner were ever present.

Statistical analyses showed a significant positive correlation between site type (private vs. public) and both gatekeeper control (r=-.81, p

Further, we found a significant correlation between type of place used as primary and secondary drug-use sites (r=.24, p

It is important to note in this context that actual "risk" in the sites is not a foregone conclusion in the absence of HIV prevention materials if users do not, in practice, engage in activities that could transmit the virus. So, for example, public sites with no gatekeeper and no prevention materials, but where users inject alone, always carry and use their own sterile equipment and drugs, and lack interaction with other drug users, may be "safe" from HIV transmission. By contrast, at an inside site with a strong, HIV-prevention-oriented gatekeeper and multiple materials and norms present, social interaction, opportunity, and conditions of addiction may increase the likelihood of occasions in which more than one person uses the same injection equipment or shares contaminated drug solutions. Likewise, it cannot be assumed that presence of prevention materials means these will be used consistently nor that they are always available. The distinction between private and public sites primarily suggests the need for different strategies to reach and intervene in situations in which the virus might be transmitted, rather than a mechanism to classify risky and less-risky site types. DISCUSSION AND IMPLICATIONS FOR THE DEVELOPMENT OF SITE-BASED INTERVENTIONS The HRS project conducted a preliminary assessment of the nature of drug use sites and the social organization of site users in order to design appropriate and feasible intervention activities to be implemented with the support of active drug users, including site gatekeepers, conducted in the places they use drugs and at the times they are most at risk for infection. Specifically, we plan to use information about the range of structures and social organizations of high-risk sites, relationships among site users, and the dynamic and stable components of these sites to inform development of on-site intervention, based on a peer-leader model, that could be implemented in these drug-use settings. Our initial findings regarding high-risk sites in Hartford have significant implications for developing and implementing such a program.

Perhaps the most significant finding of our study is the documented site instability, which suggests that specific sites themselves are frequently too transient to use as a base in which to build long-term intervention to reach multiple drug users. Better understanding of site characteristics, however, and patterns of their use enhances our ability to recognize the combinations of factors that call for specific responses and provide various opportunities to extend prevention efforts, both indigenous and introduced to the drug-using population. Furthermore, these diverse contexts indicate that no single approach is likely to address sufficiently the various drug-use risk settings. Rather, simultaneous multiple approaches are needed to reach drug users in different kinds of situations. Several additional findings suggest specific directions and opportunities for enhanced community-level or social-group interventions with drug users. First, the increasing rarity of traditional "shooting galleries" and "crack houses" means there is no venue comparable, for example, to the gay bars in which Kelly and colleagues (1992) were able to provide site-based intervention and reach large numbers of the target population efficiently and effectively. In the private druguse sites, it may still be possible to build on gatekeepers' influence over site users, which appears to be substantial. Access to such places, however, is very difficult. Additionally, instability of these sites makes it necessary to track and build long-term rapport with individuals who tend to play gatekeeper roles, and work with them to remount intervention activities in new sites.

Despite these limitations, the opportunities private sites offer for structured, site-based and peer-led intervention is very promising. The correlation in our survey data between presence of gatekeepers and HIV prevention materials and norms indicates the benefit of someone `taking care' of the site. Such care taking creates a foundation on which to build consistent and effective prevention modeling enabled by insuring the presence and provision of prevention materials. The general interest of site gatekeepers to maintain control over the site suggests they may be willing to act as "key opinion leaders," or peer educators to provide ongoing site-based AIDS prevention education and support. If trained in ways to model and teach risk reduction to users of their sites, for example using a curriculum like that developed by Latkin (1998) and colleagues (in press), and with access to prevention materials, they could potentially be effective interventionists situated directly in the places where risk may be present. Such intervention could also be provided on an ongoing basis, rather than in brief, oneshot encounters or a small number of sessions provided in an office-based setting. While clearly not all gatekeepers would be willing or able to receive this kind of training and commit to the prevention interventionist role, such an approach, with relatively limited resources and maintenance, could reach and affect many users over a long period of time with consistent prevention messages and materials.

Another possible approach to HIV prevention through private drug-use sites is to employ gatekeepers as "satellite distributors" of prevention materials, similar to the "Satellite Exchangers" of the Baltimore syringe exchange program (Valente 1998). In this capacity, gatekeepers can potentially provide all users of their site with sterile drug-use equipment on every occasion in which they use the site. This could increase the reach of such programs as syringe exchanges and outreach programs to bring bleach and other prevention materials to drug users at the times these materials are needed, including evenings, nights, and weekends when most prevention programs are closed.

Also potentially feasible in private sites, despite their likely long-term instability, is the use of these locations for provision of small-group social network intervention, such as those designed by Latkin and colleagues (1995) or Trotter and colleagues (1995). Rather than recruiting these site users, either as a group or individually, into an office-based program, the indigenous site offers a potential setting in which to provide small group intervention sessions, where prevention messages, practices and resources can be integrated into the regular activities and interactions of the specific site users. Furthermore, because these groups tend to be risk networks (though not necessarily close-knit nor with strong bonds and long-term commitments), provision of a group-level intervention to site users increases the likelihood that peer norms for HIV prevention would reinforce individual risk reduction practices. Thus, even if network members change over time, there may be sufficient foundation by way of group support or "site rules" to effect ongoing risk reduction among those who interact with site users or who come together in these private drug use sites and establish or reestablish networks of drug using friends and associates over time.

Most of the "public" sites identified by the project are very unstable, given Hartford's current economic and political changes, and therefore present different challenges for HIV prevention. Yet increased homelessness, demolition of lowcost housing in the region, and various welfare elimination measures mean that more drug users will be "floating," and therefore more likely to use such spaces. Likewise, heavy police activity to reduce neighborhood presence of illicit drug users means locations of convenience and rapid drug use will continue to predominate and decrease opportunities for addicts to take harm reduction precautions. Responding to this predominance of unstable, transitional, rapid-use sites requires one or more broad-reaching approaches. These can include changing the environment of risk through contextual-level or structural interventions, such as policy changes that increase access to harm reduction messages and materials or to drug treatment in response to drug-related arrests, as well as stable housing for the poor. A study in Amsterdam found lower HIV seroconversion among drug injectors who generally use private homes (van Ameijden et al. 1992). This is consistent with our finding of increased availability of prevention opportunities in private sites, though "safety" in these settings may be low for some drug users, such as women (Weeks et al., 1998, 1999). Yet, housing development and an increase in safer, more stable private residences, a reduction in abandoned buildings, and increased provision of health care and social services in association with shelters and areas with subsidized housing may reduce the general level of drug use risk among impoverished addicts. Demolition of abandoned buildings means removal of some "sites," though our study shows that this strategy does not eliminate the existence of "public" drug use locations. Rather, drug users creatively identify new sites, including basements and hallways of occupied buildings. Housing development and renovation plans generally do not include harm reduction options for impoverished addicts to remain stable and safe. This neglect contributes to the emergence of public health crises, including epidemics like HIV, hepatitis, and drug-resistant tuberculosis.

Another broad-based HIV prevention approach to target public site users is to increase the range of syringe exchange programs. Expanded accessibility through backpack distribution instead of relying solely on stationary store-front operations or structured van stops, often with limited and restricted hours, could enhance the reach of many of these programs. This extension of syringe exchange could be coupled with greater access to prevention materials-bleach, cookers, condoms, etc.-provided at more locations around the city and at more times of the day. Yet another enhancement of SEPs is to eliminate legal caps on the number of syringes exchanged per visit and allow greater drug user access to more sterile syringes. This also creates the opportunity for development ofa peerled component by encouraging "Satellite Exchangers" (SEs) (Valente 1998). SEs are able to conduct secondary syringe exchange to drug users not reached by, or reluctant to use, the Hartford NEP, thereby increasing availability of syringes and other risk-reduction materials to a broader drug-using population. If armed with training in harm reduction messages, SEs could also bring additional prevention and possibly service referral information to a wide group of "hidden" drug users.

Rapid responses to reduce risk among "public" site users are necessary to reduce transmission of the virus in this population. These include non-sitespecific means of reaching a broad spectrum of drug users. One approach is the expansion of outreach to provide multi-level harm reduction messages and linkages to syringe exchange, health services, drug treatment, and case management. Another is to utilize methods to reach large numbers of drug users possibly connected through macro-network ties. By making use of even weak network linkages among drug users who use public sites, prevention can be diffused through risk networks by peer group members or peer educators. An example is the approach developed and tested by Broadhead and colleagues (1995, 1998). In this model, drug users are trained to educate two or more contacts, and these contacts are trained to reach others, in an ever expanding chain of prevention educators. Mass campaigns using billboards and posters can reach public site users if implemented in these locations, particularly rapid get-off sites, and provided the messages are short, readily visible, and self-explanatory. Such efforts, however, are difficult to conduct with hidden populations of drug users and unlikely to be very successful if prevention materials are not also made available in these locations. Furthermore, they are hampered by the fact that abandoned buildings are not in actuality public, but rather private property where any activity (whether using drugs or leaving HIV prevention materials) on site could result in arrest for trespassing.

Enhancing prevention beyond a focus on individual responsibility for reducing risk behavior requires a broader political commitment to reducing harm among drug users. An array of HIV prevention efforts brought more directly into the contexts and locations in which drugs are used are needed to continue to reduce transmission of this deadly virus. The in-depth study of high-risk drug use sites offers unique insight into the social and environmental conditions that shape drug use in these locations, conditions that also offer opportunities for effective social-- level HIV and other disease prevention efforts. To be most effective, these efforts must build on available persons, materials, social relationships, and political organizations of the various types of drug-use sites, specific locations and network groups, and the local community. ACKNOWLEDGMENTS The authors appreciate the multiple contributions of Delia Easton, Sheryl Horowitz, Kim Blankenship, and Stephen Cabral to this study. We are indebted to all participants in the project, whose willingness to share their time with us and allow us access to their places made this study possible. We are grateful to the National Institute on Drug Abuse and the National Institute for Mental Health for funding of this study through the Center for Interdisciplinary Research on AIDS (CIRA).

NOTES

The Study of High-Risk Drug Use Settings for HIV Prevention is Project #3 of the Center for Interdisciplinary Research on AIDS (CIRA) (grant #PO lMH/DA56826), with joint funding from the National Institute on Drug Abuse and the National Institute for Mental Health. CIRA was developed by Yale University in partnership with the Institute for Community Research and the Hispanic Health Council.

REFERENCES

Bourgois, P., & Dunlap, E.

1993 Exercising sex-for-crack: An ethnographic perspective from Harlem. In M.S. Ratner (Ed.), Crack pipe as pimp: An ethnographic investigation of sex-for-crack exchanges (pp. 97-132). Lexington Books.

Bowser,BY

1989 Crack and AIDS: An ethnographic impression. Journal of the National Medical Association, 81, 538-540.

Broadhead, R.S., Heckathorn, D.D., Grund, J.C., Stem, L.K.S., & Anthony, D.L. 1995 Drug users versus outreach workers in combating AIDS: Preliminary results of a peer-driven intervention. Journal of Drug Issues, 25, 531564.

Broadhead, R.S., Heckathorn, D.D., Weakleim, D.L., Anthony, D.L., Madray, H., Mills, R.J., & Hughes, J.

1998 Harnessing peer networks as an instrument for AIDS prevention: Results from a peer-driven intervention. PublicHealth Reports,113(supp. 1), 4257.

Brown, B., & Beschner, G.

1993 Handbook on risk of AIDS. Westport: Greenwood. Carlson. R.G_

2000 Shooting galleries, dope houses, and injection doctors: Examining the social ecology of HIV risk behaviors among drug injectors in Dayton, Ohio. Human Organization, 59, 325-333.

Celentano, D.D., Vlahov, D., Cohn, S., Anthony, J.C., Solomon, L., & Nelson, K.E.

1991 Risk factors for shooting gallery use and cessation among intravenous drug users. American Journal of Public Health, 81, 1291-1295. Chiasson, M.A., Stonburner, R.L., Hildebrandt, D.S., Ewing, W.E., Telzak, E.E., & Jaffee W.H.

1991 Heterosexual transmission of HIV- I associated with the use of smokable freebase cocaine (crack). AIDS, 5, 1121-1126.

Chitwood, D., McCoy, C., Inciardi, J., McBride, D., Comerford, M., Trapido, E., McCoy, G., Page, J.B., Griffin, J., Fletcher, M., & Ashman, M.

1990 HIV seropositivity of needles from shooting galleries in south Florida. American Journal of Public Health, 80, 150-152.

Coyle, S.L., Needle, R.H., & Normand, J.

1998 Outreach-based HIV prevention for injecting drug users: A review of published outcome data. Public Health Reports, 113(Supplement 1), 1930.

Crofts, N., & Herkt, D.

1995 A history of peer-based drug-user groups in Australia. Journal of Drug Issues, 25, 599-616.

Des Jarlais, D., & Case, P.

1992 Increasing access to injection equipment: Syringe exchange and other examples of harm reduction strategies. In J. Mann (Ed.), AIDS in the World (pp. 685-699). Cambridge, MA: Harvard University Press.

Des Jarlais, D., & Friedman, S.

1990 Shooting galleries and AIDS: Infection probabilities and 'tough' policies. American Journal of Public Health, 80, 142-144.

Des Jarlais, D.C., Abdul-Quader, A., Minkoff, H., Hoegsberg, B., Landesman, S., & Tross, S.

1991 Crack use and multiple AIDS risk behaviors. Journal of Acquired Immune Deficiency Syndromes, 4, 446-447.

Dom, N

1992 Clarifying policy options on drug trafficking: Harm reduction as distinct from legalization. In P.A. O'Hare, R. Newcombe, A. Matthews, E.C. Buning, & E. Drucker (Eds.), The reduction of drug-related harm (pp. 108-121). London: Routledge.

Feldman, H.W., & Biernacki, P.

1988 The ethnography of needle sharing among intravenous drug users and implications for public policies and intervention strategies. In R. Battjes & W. Pickens (Eds.), Needle sharing among intravenous drug abusers (pp. 28-39). NIDA Research Monograph #80, Rockville, MD: National Institute on Drug Abuse.

Friedman, S.R., de Jong, W.M., & Des Jarlai, D.C.

1988 Problems and dynamics of organizing intravenous drug users for AIDS prevention. Health Education Research, 3, 49-57.

Friedman, S.R., Neaigus, A., Des Jarlais, D.C., Sotheran, J.L., Garber, J., Cohen, H., & Smith, D.

1992 Social intervention against AIDS among injection drug users. British Journal of Addiction, 87, 393-404.

Friedman, S.R., Jose, B., Deren, S., Des Jarlais, D.C., & Neaijus, A.

1995 Risk factors for HIV seroconversion among out-of-treatment drug injectors in high and low prevalence cities. The National AIDS Research Consortium. American Journal of Epidemiology. 142. 864-874.

Friedman, S.R., Curtis, R., Neaijus, A., Jose, B., & Des Jarlais, D.C.

1999 Social networks, drug injectors' lives, and HIV/AIDS. New York: Kluwer Academic / Plenum Publishers.

Groseclose, S.C., Weinstein, B., Jones, T.S., Valleroy, L.A., Fehrs, L.J., & Kassler, W.J.

1995 Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers-Connecticut, 1992-1993. Journal of Acquired Immune-Deficiency Syndrome and Human Retrovirology, 10, 50-RO

Grand, J.P.C., Blaken, P., Adriaans, N.F.P., Kaplan, C.D., Barendregt, C., & Meeuwsen, M.

1992 Reaching the unreached: Targeting hidden IDU populations with clean needles via known user groups. Journal of Psychoactive Drugs, 24, 4147.

Haemmig, R.B

1992 The streetcorner agency with shooting room ('Fixerstuebli'). In P.A. O'Hare, R. Newcombe, A. Matthews, E.C. Buning, & E. Drucker (Eds.), The reduction of drug-related harm (pp. 181-185). London: Routledge.

Heckathorn, D.D.

1997 Respondent-driven sampling: A new approach to the study of hidden populations. Social Problems, 44, 174-199.

Heimer, R.

1998 Syringe exchange programs: Lowering the transmission of syringe-borne diseases and beyond. Public Health Reports, 113(Supplement 1), 67-74. Inciardi, J.A.

1995 Crack, crack house sex, and HIV risk. Archives of Sexual Behavior, 24, 249-269.

Inciardi, J.A., Lockwood, D., & Pottieger, A.E.

1993 Women and crack-cocaine. New York: Macmillan Publishing Company. Kaplan, E., & Heimer, R.

1993 What happened to HIV transmission among drug injectors in New Haven? Chance: New Directions for Statistics and Computing, 6, 9-14.

Kelly, J.A., St. Lawrence, IS., Stevenson, L.Y., Hauth, A.C., Kalichman, S.C., Diaz, Y.E., Brasfield, T.L., Koob, J.J., & Morgan, M.G.

1992 Community AIDS/HIV risk reduction: The effects of endorsements by popular people in three cities. American Journal of Public Health, 82, 1483-1489.

Klepp, K., Halper, A., & Perry, C.L.

1986 The efficacy of peer leaders in drug abuse prevention. Journal of School Health, 406, 407-411.

Koester, S.K.

1994 Copping, running, and paraphernalia laws: Contextual variables and needle risk behavior among injection drug users in Denver. Human Organization, 53, 287-295.

Koester, S.

1995 Applying the methodology of participant observation to the study of injection-related HIV Risks. In Qualitative methods in drug abuse and HIV research (pp. 84-99). NIDA Research Monograph #157. Washington, DC: National Institute on Drug Abuse.

Lakin CA_

1995 A personal network approach to AIDS prevention: A peer group intervention for street-injecting drug users: The SAFE study. In Social networks, drug abuse, and HIV transmission (pp. 181-195). NIDA Research Monograph #151. Washington, DC: National Institute on Drug Abuse.

Latkin, C.A.

1998 Outreach in natural settings: The use of peer leaders for HIV prevention among injection drug users' networks. Public Health Reports, 113(Supplement 1). 151-159.

Latkin, C.A., & Knowlton, A.R. (In press.)

New directions in HIV prevention among drug users: Settings, norms and networks approaches to AIDS prevention (SNNAAP), a social influence approach. Advances in Medical Sociology, 7.

Latkin C.A., Mandell, W., Vlahov, D., Oziemkowska, A.K., & Celentano, D. 1994 My place, your place, and no place: Behavior settings as a risk factor for

HIV-related injection practices of drug users in Baltimore, Maryland. American Journal of Community Psychology, 22, 415-430.

Levy, J.A., Gallmeier, C.P., & Weibel, W.W.

1995 The outreach assisted peer-support model for controlling drug dependency. Journal of Drug Issues, 25, 507-529.

Longshore, D.

1996 Prevalence and circumstances of drug injection at Los Angeles shooting galleries. Crime and Delinquency, 42, 21-35.

Lurie, P., Reingold, A.L., Bowser, B., Chen, D., Foley, J., Guydish, J.

1993 The public health impact of needle exchange programs in the United States and abroad. Regents of the University of California.

Metzger, D.S., Navaline, H., & Woody, G.E.

1998 Drug abuse treatment as AIDS prevention. Public Health Reports, 113 (Supplement 1), 97-106. Mieczkowski, T. ___7. __._7. T

IViLl: , 1.

1994 The experiences of women who sell crack: Some descriptive data from the Detroit crack ethnography project. Journal of Drug Issues, 24, 227248.

Moore, L.D., & Wenger, L.D.

1995 The social context of needle exchange and user self-organization in San Francisco: Possibilities and pitfalls. Journal of Drug Issues. 25, 583-598. Neaigus, A.

1998 The network approach and interventions to prevent HIV among injection drug users. Public Health Reports, 113(Supplement 1), 140-150. Needle, R.H., Coyle, S.L., Normand, J., Lambert, E., & Cesari, H.

1998 HIV prevention with drug-using populations-current status and future prospects: Introduction and overview. Public Health Reports, 113 (Supplement 1), 4-18.

Normand, J., Vlahov, D., & Moses, L.

1995 Preventing HIV transmission: The role of sterile needles and bleach. Washington DC: National Academy Press.

NOVA Research Company

1991 Community-Based AIDS Prevention Among Intravenous Drug Users and their Sexual Partners: The Many faces of HIV Disease. Proceedings of the 2nd NADR national meeting, Bethesda MD: NOVA Research Company, Inc.

Ouellet, L.J., Jimenez, A.D., Johnson, W.A., & Weibel, W.W.

1991 Shooting galleries and HIV disease: Variations in places for injecting illicit drugs. Crime and Delinquency, 37, 64-85.

Page, JR, Smith, P.C., & Kane, N.

1991 Shooting galleries, their proprietors, and implications for prevention of AIDS. Drugs and Society, 5, 69-85.

Pearson, G.

1992 Drugs and criminal justice: A harm reduction perspective. In P.A. O'Hare, R. Newcombe, A. Matthews, E.C. Buning, & E. Drucker (Eds.), The reduction of drug-related harm (pp. 15-29). London: Routledge.

Power, R., Jones, S., Kearns, G., Ward, J., & Perera, J.

1995 Drug user networks, coping strategies, and HIV prevention in the community. Journal of Drug Issues, 25, 565-581.

Power, R., Jones, S., Kearns, G., & Ward, J.

1996 An ethnography of risk management amongst illicit drug injectors and its implications for the development of community-based interventions. Sociology of Health and Illness, 18, 86-106.

D.--- XX 0 JUA ',

1993 Crack pipe as pimp: An ethnographic investigation of sex-for-crack 1993 Crack pipe as pimp: An ethnographic investigation of sex-for-cracks. exchanges. New York: Lexington Books.)

1996 Evaluating the efficacy of HIV prevention among drug users: Models, methods, and measures. Journal of Drug Issues, 26(3).

Singer, M., & Weeks, M.R.

1992 Hartford target sampling plan. Community Alliance for AIDS Programs. Hartford, CT: Hispanic Health Council.

Singer, M., & Weeks, M.R.

1996 Preventing AIDS in communities of color: Anthropology and social prevention. Human Organization, 55, 488-492.

Singer, M., Himmelgreen, D., Weeks, M.R., Radda, K.E., & Martinez, R.

1997 Changing the environment of AIDS risk: Findings on syringe exchange and pharmacy sales of syringes in Hartford, CT. Medical Anthropology, 18, 107-130.

Sterk-El;ht-son, C., & Ellison, K.W.

1993 The social organization of crack cocaine use: The cycle in one type of base house. Journal of Drug Issues, 23, 429-441.

Trautmann, F.

1995 Peer support as a method of risk reduction in injecting drug-user communities: Experiences in Dutch projects and the "European peer support project." Journal of Drug Issues, 25, 617-628.

Trotter, R.T. (Ed.)

1996 Multicultural AIDS Prevention Programs. Drugs and Society, 9(1 and 2).

Trotter, R.T., Bowen, A.M., & Potter, J.M.

1995 Network models for HIV outreach and prevention programs for drug users. In Social networks, drug abuse, and HIV transmission (pp. 144180), Research Monograph # 151. Washington, DC: National Institute on Drug Abuse.

Valente, T.W., Foreman, R.K., Junge, G., & Vlahov, D.

1998 Satellite exchange in the Baltimore Needle Exchange Program. Public Health Reports, 113(Supplement 1), 90-96.

van Ameijden, E.J.C., van den Hoek, J.A.R., van Haastrecht, H.J.A., & Coutinho, R.A.

1992 The harm reduction approach and risk factors for human immunodeficiency virus (HIV) seroconversion in injecting drug users, Amsterdam. American Journal of Epidemiology, 136, 236-243.

Watters, J.K.

1987 A street-based outreach model of AIDS prevention for intravenous drug users: Preliminary evaluation. Contemporary Drug Problems, (Fall), 411-423.

Watters, J.K.

1989 Observations on the importance of social context in HIV transmission among intravenous drug users. The Journal of Drug Issues, 19, 9-26. Watters, J.K., & Biernacki, P.

1989 Targeted sampling: options for the study of hidden populations. Social Problems, 36, 416-430.

Watters, J.K., & Guydish, J.

1994 HIV/AIDS prevention for drug users in natural settings. In R.J. DiClemente & J.L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioral interventions (pp. 209-225). NY: Plenum Press.

Watters, J.K., Downing, M., Case, P., Lorvick, J., Cheng, Y., & Fergusson, B. 1990 AIDS prevention for intravenous drug users in the community: Street-- based education and risk behavior. American Journal of Community Psychology, 18, 587-596.

Weeks, M.R., Grier, M., Radda, K., & McKinley, D.

1999 AIDS and social relations of power: Urban African American women's discourse on the contexts of risk and prevention. In W. Elwood (Ed.), Power in the blood: AIDS, politics, and communication (pp. 181-197). Lawrence Erlbaum Press.

Weeks, M.R., Singer, M., Himmelgreen, D.A., Richmond, P., & Romero-Daza, N.

1998 Drug use patterns of substance abusing women: Gender and ethnic differences in an AIDS prevention program. Drugs and Society, 13(1, 2), 37-64.

Wodak, A.

1992 Beyond the prohibition of heroin: The development of a controlled availability policy in Australia. In P.A. O'Hare, R. Newcombe, A. Matthews, E.C. Buning, & and E. Drucker (Eds.), The reduction of drug-- related harm (pp. 49-61). London: Routledge.

Zapka, J.G., Stoddard, A.M., & McCusker, J.

1993 Social network, support, and influence: Relationships with drug use and protective AIDS behavior. AIDS Education and Prevention, 5, 352-366.

MARGARET R. WEEKS, SCOTT CLAIR, MERRILL SINGER, KIM RADDA, JEAN J. SCHENSUL, D. SCOTT WILSON, MARIA MARTINEZ, GLENN SCOTT, GLENN KNIGHT

Margaret R. Weeks, Ph.D., is an anthropologist and Associate Director at the Institute for Community Research in Hartford, Connecticut. Scott Clair, Ph.D., is a data analyst at the Hispanic Health Council in Hartford, Connecticut, and an Associate Research Scientist in the Biostatistics Department in the School of Public Health at Yale University. Merrill Singer, Ph.D. is the Associate Director and Chief of Research at the Hispanic Health Council in Hartford, Connecticut. A medical anthropologist, Dr. Singer is the president-elect of the AIDS and Anthropology Research Group of the American Anthropological Association. Kim E. Radda, R.N., M.A. is an anthropologist, registered nurse and Project Director at the Institute for Community Research in Hartford, Connecticut. Jean J. Schensul, Ph.D., a medical/educational anthropologist, has been Executive Director of the Institute for Community Research since 1987. D. Scott Wilson, Ph.D. is an anthropologist who has conducted ethnographic research on drug-related and sexual HIV risk among young hustlers and street drug addicts. Maria Martinez has conducted street outreach, interviewing, and research support for over ten years in Bridgeport and Hartford, Connecticut. Glenn Scott had been an outreach interviewer at the Hispanic Health Council in Hartford, Connecticut for over eight years, working on federally funded HIV prevention research projects in the Hartford area. Glenn Knight graduated from the University of Connecticut with a BA in Anthropology. After graduation he joined the Institute of Community Research as Data Coordinator on the High Risk Settings project.

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