Orientation Workshop Case studies by CDCdocs



         World Health Organization
          Department of HIV/AIDS     WHO DEPARTMENT OF HIV/ AIDS   1

                     The case studies provided represent various backgrounds that allow selection of the situation
                     that is closest to the culture/society/country in which the workshop is being held.

                             • Kathmandu, Nepal ___________________________________________________ 3
                             • Moscow, the Russian Federation _______________________________________ 4
                             • Buenos Aires, Argentina ______________________________________________ 5
                             • Dhaka, Bangladesh __________________________________________________ 6
                             • Brussels, Belgium ____________________________________________________ 7

                In 1991, Lifesaving and Lifegiving Society (LALS), a Nepalese nongovernmental organization
                (NGO), started outreach among injecting drug users (IDUs) in Kathmandu. Ten community
                health outreach workers were employed to go to 64 sites in Kathmandu and neighbouring
                Lalitpur on a regular basis and visit the homes (temporary or permanent) of IDUs, and the
                places where IDUs congregate.

                The outreach workers included ex-drug users, nurses and social workers, all of whom were
                trained together in outreach methods and in the skills and knowledge needed to educate
                IDUs about HIV/AIDS and injecting drug use. Outreach workers provide education, counselling
                (including sexual counselling with clients and their sex partners), and distribution of needles
                and syringes, condoms, swabs and medications for minor ailments. They also provide
                treatment for abscesses and other first aid.

                Using this system, the outreach workers reached 1 200 IDUs by 1998. The number of times
                injecting equipment was shared by those IDUs reached by the outreach workers fell from 14
                times a week in 1991 to 7 times a week or less in 1993 and 1994. The longer clients stayed
                in the programme, the less sharing they reported.

                LALS also provides group education to IDUs (all of whom are clients reached by outreach
                workers) to spread HIV-prevention messages to networks of IDUs throughout the city and
                Kathmandu Valley. In 1998, a total of 391 IDUs attended 21 training sessions on topics
                including counselling, HIV/AIDS peer education, bleach use, hepatitis, safer sex and drug-
                related harm. Bleach (to disinfect needles and syringes), sterile water, condoms and
                educational materials were provided to IDUs who attended these group education sessions
                to pass on to their friends and acquaintances.

                In a 1999 report, LALS managers noted that outreach in Kathmandu was best achieved
                through a mixed group of paid staff and active IDUs: “LALS is often not able to rely on peer
                educators to deliver all the HIV education/prevention and harm-reduction supplies (needles,
                syringes, swabs, bleach, condoms)” so that the regular delivery of education and supplies is
                done by outreach workers, with active IDUs assisting in extending messages and supplies to
                new areas and new clients whenever they can.

Sources: Singh M and Shamsuddin M. Reflection of three years: progress report of LALS April
1996 to September 1999, Kathmandu, LALS, 1999.
Peak A et al. Declining risk for HIV among injecting drug users in Kathmandu, Nepal: the impact of
a harm reduction programme. AIDS, 1995, 9:1067-1070.

                                                                                                WHO DEPARTMENT OF HIV/ AIDS   3

                     At the Bird Market in Moscow, there are many people buying and selling various items.
                     Among them are buyers and sellers of drugs—and police trying to catch them.

                     There are also outreach workers trying to provide information to drug users. These outreach
                     workers are employed by Return to Life, a local NGO. The outreach programme was begun
                     by the international medical humanitarian organization Médecins sans Frontières (Doctors
                     Without Borders) in 1996, and the project passed to Return to Life in 2001.

                     Roman, one of the outreach workers, describes outreach work at the Bird Market.

                             There is a very short time between the drug user coming into the market, finding the
                             seller, buying drugs and leaving. Police are always watching and trying to catch the
                             user and the seller. Once they have their drugs, users must leave as quickly as possible
                             to avoid being caught. So we try to spot drug users coming into the market and reach
                             them before either the drug sellers or the police do. We simply walk past them and
                             slip a brochure into their hand. We always stay in certain places so they can come up
                             and ask us questions as well.

                     Outreach workers in Return to Life are ex-drug users who contact IDUs in drug-buying and -
                     selling areas in the inner suburbs of Moscow, in subway stations and underground
                     passageways, in abandoned buildings and building sites. Where possible, the outreach workers
                     provide printed information since IDUs (like everyone in Moscow) tend to be in a hurry as 12
                     million people rush to and from work and other activities each day. The printed information
                     allows IDUs to read the explicit information, designed by IDUs and ex-IDUs for IDUs, about
                     how to prevent HIV transmission.

                     The outreach workers also visit certain zones of the city—areas where IDUs often congregate—
                     regularly each week so that they are available to answer questions, provide counselling and
                     provide bleach (to disinfect needles and syringes), alcohol swabs and condoms. The outreach
                     workers do not distribute needles and syringes.

    Sources: Burrows D. Starting and managing needle and syringe programs: a guide for Central and
    Eastern Europe/ Newly Independent States. New York, International Harm Reduction Development/
    Open Society Institute, 2000.

                        “How many ganchos are you going to use?” asks Irma.
                        “Two or three,” responds the thin man wearing no shirt, ripped shorts, and shoes
                        without soles. With this, he extends his hand.

                The woman gives him three small bags and continues her walk, while the man guards the
                bags like a treasure, hiding them in his pants.

                Gancho or pico is one of the many expressions that drug users use to refer to the act of
                injection. Irma asks “How many?” because it is her job. The bags that she hands out include
                disposable syringes, injection equipment, and condoms. Her walk, along the narrow alleys
                of a neighbourhood in Sarandi in Avellaneda (Buenos Aires), a bag in hand filled with the
                “kits,” has already become part of her routine. The 44-year-old woman is one of the
                community outreach workers for Intercambios, an NGO that hands out materials to injecting
                drug users. Twice each week the outreach workers distribute materials in three neighbourhoods
                in Avellaneda.

                “Loco, take care of yourself. Don’t share syringes.” People read this message on one of the
                stickers that is included in the kits that Irma hands out in her own neighbourhood, a collection
                of humble houses along a maze of narrow alleyways along side a small river in Sarandi that
                contains more trash than water. The kit contains two syringes, a small bottle of sterile water,
                a filter, two alcohol swabs, a bottle cap in which to place the drug before injecting, and
                educational materials about HIV prevention.

                Irma hands out the injection materials, which people use once and then throw away, just as
                they read on the stickers that they see stuck to the windows of old cars and in the streets.
                Another sticker says, “I do mine with a condom.”

                “How many do you need?” asks Irma, without hesitation, and she hands over the condoms.
                With syringes she is even more direct, “How many ganchos are you going to give yourself?”
                and she hands out the quantity for which they ask, but never more.

                Irma knows that she must never find herself without kits. Someone could always come
                knocking on her door unexpectedly, asking for a syringe, and she always needs to have a
                supply. A clean syringe can save a person’s life because “at that certain moment,” confides
                Marcelo, who defines himself only half jokingly as a “very good client of Irma’s,” “a needle
                can cost more than drugs. Everyone would prefer to spend their money on drugs than on

Sources: Fluk H. Syringes to go: A programme in Avellaneda to use drugs without risks. p 12, Buenos
Aires, 8 April 2001

                                                                                                WHO DEPARTMENT OF HIV/ AIDS   5

                     OUTREACH IN DHAKA, BANGLADESH
                     In May 1988, the international NGO CARE started an outreach programme, the SHAKTI
                     Project, in Dhaka, Bangladesh. Before starting the project, a rapid situation assessment was
                     carried out, using the WHO Rapid Assessment and Response guide on injecting drug use.

                     This assessment estimated that there were about 7 650 drug injectors and at least 11 000
                     heroin smokers in Dhaka. It found (among other information) that over 80% of IDUs had
                     shared needles and syringes while 90% had shared other injecting equipment; that 30% of
                     IDUs were homeless, that 20% had sold blood to blood banks and 46% had no education.
                     Project staff, with the help of guides (who were active IDUs) and other key informants,
                     mapped the city through extensive field visits and observations, identifying 42 drug injecting
                     places in Dhaka, some of which were also drug-selling places. This information was provided
                     in a debriefing in May 1998 attended by representatives from governmental, nongovernmental
                     and international organizations, members of the local community and IDUs.

                     The project began by training 12 active IDUs to become outreach peer educators. The training
                     lasted five days and covered a range of topics. These included education of other IDUs on
                     sexually transmitted diseases (STDs), and HIV/AIDS issues as they related to drugs as well as
                     offering health services for abscesses and STDs, exchange of needles and syringes and
                     distribution of condoms. During the training, rules for staff behaviour were developed (such
                     as no injecting while working; no carrying of drugs during work hours; and avoiding
                     involvement in criminal activities), and working hours were agreed with staff (8:00 to 14:00
                     Monday through Thursday).

                     In June 1998, SHAKTI outreach workers only managed to reach and educate 150 IDUs, and
                     gave out 1 753 syringes. At that time the project had one drop-in centre (DIC), 12 outreach
                     peer educators and no volunteer peer educators. Through a process of constant expansion,
                     of opening new drop-in centres and training volunteers peer educators, the SHAKTI team
                     was able to reach more than ten times as many IDUs a year later.

                     By June 1999, the average number of IDUs reached each day was 1 945, reaching over 2
                     200 on some days. A further 6 drop-in centres had opened and trained were 26 outreach
                     peer educators along with 160 volunteer peer educators and 20 medicine shop sellers. In
                     that month, the project distributed 16 213 condoms and 50 000 needles and syringes with
                     an average exchange rate of more than 80%.

    Sources: Beg M. Injecting drug user intervention, SHAKTI project. Bangladesh, CARE, 1999
    (Dhaka, CARE Activity Report March 1998 to June 1999).

The Boule de Neige outreach project was established by the Belgian Government for the
French community of Belgium in 1989. The project is an official public health programme,
which identifies and contacts IDUs to increase their awareness of health risks (such as HIV
transmission), to provide IDUs with alternatives to high-risk behaviour and to reinforce risk-
reduction measures.

Seven professional outreach workers recruit and train about 150 active or ex-IDUs to contact
their friends and acquaintances to pass on information. The professional outreach workers
receive part-time salaries and undergo several months of training. The active and former
drug users recruited by the professional outreach workers are paid for their work and participate
in four to six training sessions. After training, they distribute information, materials (such as
needles, syringes and condoms), and questionnaires (to learn about various drug-related risk
behaviours): more than 1 000 IDUs are contacted each year using these methods.

In addition, the Boule de Neige project has carried out more than 90 campaigns towards
IDUs, constantly finding new ways to try to reach and educate IDUs. Initiatives have included
stands at rock concerts and other events, producing leaflets, creating working groups, and
making contacts with pharmacists and community doctors.

Source: Outreach work among drug users in Europe. Insights 2. Luxembourg, European Monitoring Centre
on Drugs and Drug Addiction, 1999.

                                                                          WHO DEPARTMENT OF HIV/ AIDS   7

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