Getting clean and harm reduction : adversarial or complementary issues for injection drug users

Many contemporary HIV prevention interventions targeting injection drug users (IDUs) have been implemented using Harm Reduction as a theoretical framework. Among drug-using individuals, however, the abstinence-based “getting clean” models espoused by Narcotics Anonymous and other widely adopted approaches to drug treatment are often more readily accepted. This paper describes an ethnographic examination of the ideological dichotomy between Harm Reduction and abstinence-based “getting clean” treatment model which emerged during the piloting phase of an HIV prevention intervention in Baltimore City, Maryland, USA. This paper describes how the conflict was identified and what changes were made to the intervention to help resolve the participants’ dichotomous thinking concerning their substance abuse issues. Street Drugs; Drug Abuse; Harm Reduction Traditionally, in the United States, the predominant approaches to drug policy and drug treatment have been characterized by such phrases as “zero tolerance” and the “war on drugs”. This abstinence-based political and ideological view emerges from the substance use treatment approach embedded within the principals of the moral model 1. This approach supports the belief that abstinence is a prerequisite for substance users to modify their behavior. On the other hand, Harm Reduction, and its application within the HIV prevention and substance-use treatment arena, has met with a broad range of acceptance throughout the world 2, particularly among contemporary researchers. Harm Reduction is defined as a set of practical strategies that are used to reduce the negative consequences of substance use. Harm Reduction involves incorporating a continuous spectrum of strategies, ranging from safer use, to managed use, to complete abstinence from drugs. Harm Reduction tailors behavior change to the unique conditions of substance use along with the substance users, themselves (Ptah A. Speech presented to the Community Planning Leadership Summit by Director of Policy Harm Reduction Coalition. March 2003). Proponents of Harm Reduction have been accused of supporting continued drug use, sabotaging efforts toward achieving abstinence, undermining recovery, contradicting current social policy, and selling out or giving in to the Peterson J et al. 734 Cad. Saúde Pública, Rio de Janeiro, 22(4):733-740, abr, 2006 presence of illicit drug use in the society. However, those who adopt the principles of Harm Reduction do so with the understanding that drug use is a complex problem related to other quality of life issues such as poverty, class, racism, social isolation, and discrimination. They espouse that an approach to drug use that attempts to mitigate its negative effects on the drug-using individuals, their families, and the communities where they live, should include non-coercive intervention strategies 3 and should not paint an overly simplistic picture of the problem. In addition, Harm Reduction allows for the creation of a non-adversarial and supportive milieu that engages drug-using individuals in a process where rewards and continued supports are not just the consequence of fundamental change, but are the incentives for incremental gains. Based on a vast body of empirical research, harm reduction is widely accepted among public health professionals as the cornerstone of HIV prevention among substance abusers. For many substance users, however, an understanding of recovery from substance use is derived from the philosophy of self-help organizations such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) which promote an all-or-nothing belief concerning drug use. The NA philosophy posits that complete abstinence from all mood-changing chemicals is the mark of success and anything less than that is tantamount to failure; in a way, it can be thought of as an individual level of the “zero tolerance” policy. In this article we present salient lessons learned while conducting an ethnographically informed process evaluation during the pilot phase of an HIV prevention intervention trial aimed at injection drug users (IDUs) in Baltimore City, Maryland. We will discuss three key points which emerged during the course of our process evaluation: (1) the program participants’ abstinence orientation, which dominated their views of drug use and initially created tension with the program’s Harm Reduction orientation; (2) how the contradictions between these two orientations manifested themselves in group interactions; and (3) how the facilitators and program planners, along with the participants, augmented the intervention’s language, highlighting the similarities between the two approaches and reducing the tensions within group sessions. Piloting “STEP”: an HIV prevention intervention The “STEP” study, the Harm Reduction program in question, is a network and peer-oriented HIV prevention intervention seeking to train individuals engaged in the injection-drug-using community in Baltimore City. The study’s short-term goal is the promotion of HIV prevention behaviors among the program’s participants and their drug and sexual network members. Based on our previous intervention efficacy research 4,5,6,7, STEP utilizes social influence theory to promote the philosophy of Harm Reduction among social network members. The study design is a controlled phase II efficacy trial with an equal attention control condition. The STEP program consists of four group sessions (peer mentor training sessions), one individual session, one drug (or sex) dyad session, and periodic booster sessions up to six months after completion of the intervention. The STEP intervention was tested and revised through five waves of piloting, which occurred over the eight-month period proceeding formal program implementation. The process evaluation (upon which this paper was based) utilized ethnographic methods and was implemented during the eight-month piloting phase.


Abstract
Many contemporary HIV prevention interventions targeting injection drug users (IDUs) have been implemented using Harm Reduction as a theoretical framework.Among drug-using individuals, however, the abstinence-based "getting clean" models espoused by Narcotics Anonymous and other widely adopted approaches to drug treatment are often more readily accepted.This paper describes an ethnographic examination of the ideological dichotomy between Harm Reduction and abstinence-based "getting clean" treatment model which emerged during the piloting phase of an HIV prevention intervention in Baltimore City, Maryland, USA.This paper describes how the conflict was identified and what changes were made to the intervention to help resolve the participants' dichotomous thinking concerning their substance abuse issues.

Street Drugs; Drug Abuse; Harm Reduction
Traditionally, in the United States, the predominant approaches to drug policy and drug treatment have been characterized by such phrases as "zero tolerance" and the "war on drugs".This abstinence-based political and ideological view emerges from the substance use treatment approach embedded within the principals of the moral model 1 .This approach supports the belief that abstinence is a prerequisite for substance users to modify their behavior.
On the other hand, Harm Reduction, and its application within the HIV prevention and substance-use treatment arena, has met with a broad range of acceptance throughout the world 2 , particularly among contemporary researchers.Harm Reduction is defined as a set of practical strategies that are used to reduce the negative consequences of substance use.Harm Reduction involves incorporating a continuous spectrum of strategies, ranging from safer use, to managed use, to complete abstinence from drugs.Harm Reduction tailors behavior change to the unique conditions of substance use along with the substance users, themselves (Ptah A. Speech presented to the Community Planning Leadership Summit by Director of Policy Harm Reduction Coalition.March 2003).
Proponents of Harm Reduction have been accused of supporting continued drug use, sabotaging efforts toward achieving abstinence, undermining recovery, contradicting current social policy, and selling out or giving in to the presence of illicit drug use in the society.However, those who adopt the principles of Harm Reduction do so with the understanding that drug use is a complex problem related to other quality of life issues such as poverty, class, racism, social isolation, and discrimination.They espouse that an approach to drug use that attempts to mitigate its negative effects on the drug-using individuals, their families, and the communities where they live, should include non-coercive intervention strategies 3 and should not paint an overly simplistic picture of the problem.In addition, Harm Reduction allows for the creation of a non-adversarial and supportive milieu that engages drug-using individuals in a process where rewards and continued supports are not just the consequence of fundamental change, but are the incentives for incremental gains.Based on a vast body of empirical research, harm reduction is widely accepted among public health professionals as the cornerstone of HIV prevention among substance abusers.
For many substance users, however, an understanding of recovery from substance use is derived from the philosophy of self-help organizations such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) which promote an all-or-nothing belief concerning drug use.The NA philosophy posits that complete abstinence from all mood-changing chemicals is the mark of success and anything less than that is tantamount to failure; in a way, it can be thought of as an individual level of the "zero tolerance" policy.
In this article we present salient lessons learned while conducting an ethnographically informed process evaluation during the pilot phase of an HIV prevention intervention trial aimed at injection drug users (IDUs) in Baltimore City, Maryland.We will discuss three key points which emerged during the course of our process evaluation: (1) the program participants' abstinence orientation, which dominated their views of drug use and initially created tension with the program's Harm Reduction orientation; (2) how the contradictions between these two orientations manifested themselves in group interactions; and (3) how the facilitators and program planners, along with the participants, augmented the intervention's language, highlighting the similarities between the two approaches and reducing the tensions within group sessions.

Piloting "STEP": an HIV prevention intervention
The "STEP" study, the Harm Reduction program in question, is a network and peer-oriented HIV prevention intervention seeking to train individuals engaged in the injection-drug-using community in Baltimore City.The study's short-term goal is the promotion of HIV prevention behaviors among the program's participants and their drug and sexual network members.Based on our previous intervention efficacy research 4,5,6,7 , STEP utilizes social influence theory to promote the philosophy of Harm Reduction among social network members.The study design is a controlled phase II efficacy trial with an equal attention control condition.The STEP program consists of four group sessions (peer mentor training sessions), one individual session, one drug (or sex) dyad session, and periodic booster sessions up to six months after completion of the intervention.The STEP intervention was tested and revised through five waves of piloting, which occurred over the eight-month period proceeding formal program implementation.The process evaluation (upon which this paper was based) utilized ethnographic methods and was implemented during the eight-month piloting phase.

Method
The STEP HIV prevention intervention pilot sessions were conducted from July 11, 2003 through March 10, 2004.

Participants
Eligibility criteria for STEP participants included: (1) at least 18 years of age, (2) willing to invite at least one sex or drug network member, and (3) self-reported unprotected sex or injection drug use within previous 3 months.Pilot participants were recruited using word-of-mouth, advertising in community newspaper, flyers posted throughout the neighborhoods, and street outreach.The participants were primarily African Americans from low-income, highcrime, urban neighborhoods and all resided within Baltimore City.A total of 29 individuals were recruited and participated in the piloting phase of the intervention.Among these participants 21 were male, 8 were female.Twentyfour of the participants were African American and 5 were White.
The intervention utilized a team of two co-facilitators (one Caucasian male and one African-American female).The research team consisted of 4 ethnographers, the primary investigator of the intervention, the project's director, the two facilitators, and several staff members.

Ethnography
The use of qualitative methods in conducting process evaluations has demonstrated utility and success in the evaluation realm.Patton 8 elucidates four characteristics that make qualitative inquiry "highly appropriate" for process evaluation: (1) depicting process requires detailed descriptions of how people engage with each other; (2) the experience of process typically varies for different people, so their experience needs to be captured in their own words; (3) process is fluid and dynamic so it can not be fairly summarized on a single rating scale at one point in time; and (4) participants' perceptions are a key process which should be taken into account.
Specific to this study, LeCompte & Schensul 9 provide a detailed dialogue describing the use of ethnography in the process of developing intervention programs.Consistent with their understanding, ethnographic methods were used in the STEP HIV prevention intervention development process to (1) examine the acceptability of the intervention to the staff as well as the intervention participants; (2) assess the programmatic integrity of the intervention; (3) monitor the usefulness of the intervention; and (4) inform the design and development of the intervention outcome evaluation.
Ethnography was utilized to inform the process evaluation during the project's piloting phase, from August 2003 to March 2004.Data were collected through a variety of methods, including group observations, field observations, and the content analysis of session tapes and interviews with STEP participants.In each of the piloting waves, at least one ethnographer was present during all of the classroom sessions.An ethnographer conducted observations concerning the pilot sessions' content and the interactions among the facilitators and the participants.Detailed notes of the observation were recorded.
During session breaks an ethnographer conducted informal interviews and participated in casual conversations with the participants in order to elicit feedback about the sessions, as well as to establish and build rapport.After earning the trust of the participants, an ethnographer would individually query participants as to whether they were willing to demonstrate skills during observation activities in the community.The procedure was thoroughly explained to each participant, and additional informed consent was received prior to any field observation work.
Field work took place, by definition, out in the community.The purpose of the community-based field work was for the ethnographer to observe the STEP participant actually implementing the risk reduction skills and disseminating HIV prevention information learned in the intervention sessions.The participants were asked to conduct the sessions with either their sex partner or a drug-using network member.Detailed field notes were taken by the ethnographer and recorded immediately after leaving the field and entered into an ethnographic database.Relevant activities and conversations were audio-taped, when appropriate.
During the field observations, ethnographers also identified information-rich opinion leaders and key informants.In some cases, further interviews were scheduled to elicit more feedback concerning the participants' perspectives on relevant social and cultural factors.These interviews were also recorded.

Data analysis
Several types of ethnographic data were included in the analysis: (1) recordings and detailed notes from training sessions; (2) written notes of the session observations; (3) recordings and written field notes from the fieldwork; and (4) recordings and written notes from interviews with key informants.
The group notes, along with the field observation notes, were uploaded to an ethnographic database so that the ethnography team and the STEP intervention project planners could have easy access to the notes, track the progress of the evaluation, and make adjustments to the pilot program as necessary.Ethnographers coded the field notes using themes that paralleled the domains and/or content areas identified as "session objectives" as well as identifying new and emerging themes 9 .Detailed summaries were made with substantial retention of original quotes and notes so as minimize the "summary" bias and reproduce the true situations.
Regular meetings were scheduled with ethnographic team members in order to discuss and cross-validate preliminary insights and observations.These insights were then shared with the larger project research team and the facilitators.These discussions provided opportunities to examine preliminary findings from the perspectives of both the ethnog-raphy team members and the project planning staff and to make recommendations regarding the intervention session content.

Results
The project's focus on Harm Reduction The STEP philosophy can be summed up in the following sentence from session one, "we believe that any positive change you are willing to make is an important step towards Harm Reduction".Session content centered upon various methods and ways to reduce the participants' potential exposure to HIV by engaging in safer injection practices and using condoms.All of the sessions (group, individual, and dyad) were focused on reducing injection and sex risks for contracting HIV.This emphasis was clearly identified in the facilitators' statements and the discussions they led during the sessions.

The participants' focus on getting clean
The participants' conversations during the sessions invariably focused on their drug use and their desire to get clean or help their network member get clean.For instance, in the early piloting sessions, participants were asked about their individual goals through their participation in the STEP project.Many of the participants responded by making "not using" their primary goal rather than simply reducing HIV risks associated with their drug use.
There are some plausible explanations for this finding.The ethnographic team hypothesized that many of the participants may have talked about getting clean because they thought it was socially acceptable and what they needed to say in order to obtain personal influence within the program structure.Also, it is likely that some participants actually wanted to get clean, but may have had little or no other resources to achieve this goal.In response, they decided to utilize the Harm Reduction-based research project as if it were a treatment program.It is also likely that as drug-dependent individuals tended to focus their behavior on acquiring and using drugs, they also viewed drug use as the cause of the major problems in their lives.From this standpoint, stopping drug use would alleviate all or most of their other problems, such as poor family relationships, unemployment, and depression.
Results from observations of the group sessions suggest that many participants with a long history of drug use were more focused on the idea of getting clean than on the Harm Reduction information presented during the pilot sessions.Longer drug use history among participants also created barriers to conducting outreach.For instance, a 50-year-old African American male participant who reported a 20year drug-use history discussed, in detail, the resistance to his attempt at outreach that he had to deal with as he initiated a conversation with his drug-using partner, who he also identified as his sex partner.The conversation, as he reported, was about him articulating the information he learned while participating in the sessions.The participant was emphatic when he mentioned the argumentative and confrontational behavior he met with from his partner.The resistance the participant was experiencing may have been the result of his approach being flavored with his subjective and unrelenting understanding of getting clean, an idea that had the potential to greatly overshadow any "incremental change" notions garnered from STEP's Harm Reduction-based sessions.

The use of AA/NA language by program participants
In the conversations during group sessions, as well as in their outreach activities, the language of the participants was liberally peppered with clichés and language often heard in AA and NA meetings.Comments such as "I'm gonna keep coming back", "sick and tired of being sick and tired", and "I have to change people, places, and things", among others.Conversations with participants and their network members suggested that AA/NA significantly influenced their thinking and dialogue about their substance use and concomitant issues.In many cases, the participants incorporated AA/NA language into their risk reduction conversations with their network members and it seemed as if participants had internalized the "all-or-nothing" attitude underlying the AA/NA model of drug dependence.The following field note includes the response from one ethnographer's observation of an outreach episode that a participant had coordinated in which several of his drug-using associates were participants: "Well, I thought I was at an NA meeting and I also thought the participant planned it that way.The order that it [the conversation] fell in and the way everyone shared behind each other.Then, when they started crying right behind each other.It was strange, but then I thought maybe these people really needed to talk to someone, and they just got emotional".
The "all-or-nothing" attitude may have been a consequence of the AA/NA mindset that one has to "hit a bottom" before asking for and, in many cases, receiving help.Several of the participants articulated discussions and responses throughout the piloting of the intervention sessions which echoed the NA/AA language and seemed to further convey the getting clean philosophy rather than the program's main focus of Harm Reduction.

Blending divergent viewpoints
At first glance the views of many of the participants appeared to be diametrically opposed to the views espoused by the STEP project.However, once the "conflict" was identified, an effort was made to emphasize during the program's sessions that getting clean was just one step along the path to a Harm Reduction plan.Facilitators began to emphasize that complete abstinence was at the far end of the Harm Reduction continuum and that each incremental step towards reducing exposure to HIV was also a step towards their ultimate goal of getting clean.Other key factors added to the sessions which assisted the participants in the integration of the two perspectives were: • They were taught that the Harm Reduction information and incremental changes they made could help them get clean; • That helping others was a way to help themselves; • That there were other goals in their lives besides getting clean and that reaching those goals might assist them in getting clean; and • That getting clean is a process, not just an end result, and that it requires positive steps.
The group facilitators took special care to celebrate any small gains toward risk and harm reduction reported by participants.

Talking prevention in a Harm Reduction setting
The AA/NA abstinence model advocates that if a person does not remain clean or drug free, then a negative label is attached to their efforts.Thus the participants' perception was that they must "walk the walk" in order to "talk the talk".The participants consistently articulated their discomforts with disseminating the recently learned HIV prevention information if they were not "clean" or they continued to use drugs while participating with the outreach component of the intervention.The idea, from their perspective, was that they thought of themselves as being hypocritical if they conducted outreach work while still using drugs.This notion of hypocrisy appeared to be directly linked with the concept of getting clean in the AA/NA abstinence model.An example of this type of behavior is inferred from the following note, which describes the participants' focus on their own behavior during conversation in the group sessions.An ethnographer wrote: "In this session, the most prominent problem is the tension between 'partner' and 'myself '.Participants could not get out of the notion of 'getting clean'.Many times the discussion moved from 'helping others' to 'helping myself '".
The intervention sessions were conceived with a flexible design that allowed for tailoring the prevention intervention to the needs and satisfaction of the participants.Thus, one of the sessions in the STEP program was designed to convey that to "talk the talk" you need to "walk the walk" or you may be seen as hypocritical and less effective in your outreach activities.Such an accomplishment required the intervention planning group to reach a delicate balance between the HIV prevention practices espoused by the Harm Reduction arena and the goals of the targeted group.Thus, the STEP program emphasized that walking the walk could be about harm reduction, that is, practice and preach safer injection practices.
The group facilitators mentioned that they initially experienced some tension introducing the Harm Reduction concept to the participants.The participants, while not being able to clearly articulate their lack of understanding of the concept of Harm Reduction, demonstrated this fact in a variety of ways.During the group sessions several of the participants articulated a sense of pride when a participant announced that he or she had accumulated any amount of "clean-time" or amassed one day or more without using drugs.However, while accruing "cleantime" was a worthwhile goal, many of the participants found that maintaining these efforts at staying clean seemed insurmountable for any length of time.
As the intervention developed, the facilitators became more and more adept at eliciting Harm Reduction-based "positive steps" while acknowledging the heroic efforts that the participants were making to reduce their risks of contracting HIV and other infectious diseases and, ultimately, get clean.The conflict resolved with the concept of any positive change, which was flexible and did not focus on either the mechanics of risk reduction or the ultimate goal of getting clean.

Discussion
The design and implementation of an HIV prevention intervention is an arduous and complex undertaking.Weeks et al. 10 suggest that in communities such as the locales from where the participants of this study were recruited, issues of poverty, gender, ethnic identity, and level of acculturation come together to create a unique set of high-risk conditions for the transmission of drug-related epidemics.Strategies to reduce the high risk of disease transmission among the drug-using population have to be culturally relevant to the participants and implemented within multiple contexts 11 .The participants engaged in the pilot sessions of the STEP HIV prevention intervention show that "cultural relevance" means taking seriously the issue of getting clean and the influence of traditional abstinence models like AA/NA.
Within the context of the public health arena, the relationship between the philosophical principles underpinning the STEP approach to Harm Reduction can be seen as challenging the traditional abstinence-only models 2 .Researchers attempting to design and implement a Harm Reduction-based intervention for IDUs must ask the question, "How many drug users 'just say no' to Harm Reduction and why do they do so?".
Injection drug users who have the traditional "getting clean" ideology may initially struggle with the messages of an HIV prevention intervention that has Harm Reduction as its philosophical base.This preliminary and exploratory study shows that many of the IDUs who participated in this pilot study focused on abstinence as their only goal and not abstinence as the end result of a process, as it is viewed from the Harm Reduction perspective.
The IDU participants recruited to the STEP program were at various stages in their drugusing careers and brought a variety of needs and experiences to the intervention that impacted their receptivity to the project's Harm Reduction message.Through the use of ethnography in the process evaluation phase of the HIV prevention intervention, these needs and prior experiences became clear to the research team and provided both a need and an opportunity to include strategies merging the abstinence and Harm Reduction models.

Implications for research and program development
Process evaluations that include ethnographic methods are useful for explicating the compli-cated, interconnected components of the intervention, the relationship of those components to the program as a whole, and the immediate reactions of the participants.Using ethnographic methods to collect data, which informed a process evaluation of the implementation of an intervention program, can foster a reflexive exercise, which enables immediate and responsive feedback for program development.In the current study an ethnographically informed process evaluation was used to obtain information during the pilot sessions and assist with program development and decision-making 12 .
Traditionally, evaluation strategies have primarily been used to determine cost effectiveness and the impact of the prevention efforts on the targeted group.Thus, outcome evaluations provide a systematic method to determine (1) whether the program achieved the stated objectives and (2) whether the intervention was a cost-effective activity.Obtaining an understanding of the aforementioned aspects and characteristics of an intervention may have some usefulness for evaluating whether a program has achieved the intended objectives.However, describing key aspects of the program's dynamics has significant utility for the design, development, proper implementation, and facilitation of interventions that are tailored to meet the specific needs of its targeted group.
Designing and implementing culturally relevant HIV prevention interventions is a complex and arduous task.Contemporary prevention interventions designed to address the transmission of HIV and other diseases among specific populations are intricate and typically are implemented within multiple contexts.Consequentially, evaluating HIV prevention interventions is an indispensable component of the overall effort.
It is important for researchers and program planners to know the extent to which all components of the intervention are actually implemented as planned.The use of ethnographic methods within the process evaluation offered a strategy, which allowed for systematically documenting the step-by-step procedures involved in the implementation of the intervention, disentangling the factors that may contribute to successful outcomes, and explicating the components of the intervention that are inherent to the effectiveness and success of the intervention effort.
Delineating the particular group norms, such as language use and the means by which specific group participants get their needs met, is vital to determining the intervention strategies and structure.The course of integrated actions that are included in achieving a specific planned or stated outcome has value in duplicating those program activities that have proven to be effective, determining the integrity of the program, assessing the acceptability of the program by the targeted group, and identifying key factors of the intervention that are being carried out as planned.
Gaining an understanding of the process involved in carrying out change efforts, such as the STEP HIV prevention intervention, can prove challenging.There are complexities in-volved with deciphering the interactions between the intervention components, the participants, and the facilitators, however ethnographic methods were indispensable in obtaining information needed to mitigate these challenges and were critical in furthering our understanding of the change process within the HIV prevention intervention.Ethnographic methods not only assisted with addressing the specific questions related to obtaining an understanding of the overall project, but this approach facilitated efforts to bring those questions to light, one step at a time.

ContributorsJ.
Peterson is the primary author of the manuscript.S. G. Mitchell assisted with manuscript development and Y. Hong with consultation, proofreading, and writing.M. Agar provided conceptualization, consultation, proofreading, and scientific editing.C. Latkin performed proofreading and scientific editing.