Connecting in the community: Outreach programs for people who use drugs

It’s 5:30 a.m. and my outreach partner and I are heading out the door. Our backpacks are full of safer injection supplies and safer crack-smoking kits. We have condoms, a few pairs of socks, a handful of granola bars, a few toothbrushes and some Band-Aids. We have flyers that list resources for people who are homeless: the names and hours of drop-in centres, shelters, community health centres, food banks and other places to get a hot meal. We also have pamphlets on how to prevent an overdose and how to reduce the risks of HIV and hep C for people who use drugs.

We expect a busy morning. Many women who are involved in sex work are finishing up for the night and are coming down after using. People who are sleeping on the street and in doorways are getting ready to move on before the sidewalks fill with the morning commuters.

Many people who use drugs have stories of negative experiences with healthcare and social service professionals, and their frustration with the limited hours and inconvenient locations of clinics and agencies^.1,2,3 Outreach programs try to address these barriers by taking information, services and resources out into the community where people live, hang out and use drugs—at times when they are most in need of services. This provides opportunities for outreach workers to intervene at critical moments when ‘risk behaviours’ are more likely to occur.⁴ Some outreach programs operate out of fixed sites (such as satellite offices in social housing) and community members go there instead of having to go to a regular office.

Outreach is a crucial component for HIV prevention programs and for programs for people who use drugs (such as needle and syringe programs). It’s a way of delivering services outside of the traditional office setting and a way of making contact with people who are not connected with formal services. Outreach can penetrate into hidden and marginalized communities, expand the scope of services and deliver information and services to a greater number of people—all critical to helping reduce the transmission of HIV and other sexually transmitted infections (STIs).⁵

Outreach programs target at-risk user networks and/or individual drug users, enabling information and materials to be spread throughout the community via outreach workers and their contacts. Outreach workers typically provide services and materials to individuals, to reduce HIV-related risks and to address health and social problems related to drug use. Modifying the risk behaviours of individuals may lead to changing social norms within user networks. This may help reduce the transmission of HIV and other STIs among drug users and, by extension, within the broader community.⁶

It’s 6:30 a.m. We’ve already swung by St. James Park and met up with Andy and Allie to give them a bag of condoms and safer drug use supplies for them to pass on to their friends and acquaintances. They asked for more pamphlets on safer injecting practices and the schedule for the health bus.

I go to check on Tom while my outreach partner speaks with Bunny. Tom’s looking kind of rough—he has burns on his hands from the street grill he is sleeping on. I give him some bottles of water, a couple of granola bars, and his usual four safer injection kits. He asks for socks, but I’m already all out. I suggest he drop by the community health centre to get those burns looked at and to see if they have some clothes. He smiles and shakes his head. He doesn’t like going into buildings—especially anything that looks institutional. I make a note to call the health bus to tell the outreach nurse to look out for him. He might need some Polysporin on those burns….

Through their relationships with people in the community, outreach workers are able to connect people with formal supports or with healthcare services, and help them sustain these connections. Often, people who use drugs cycle in and out of programs, treatment and healthcare services.³ Support from an outreach worker may break this cycle and contribute to more effective, ongoing care. 

Jewel is sitting in her usual spot at the corner of the parking lot. I nod hello and look to see if she wants me to stop or to keep moving. She turns away from me and puts her hands over her head. I see she has a paper bag beside her, suggesting that Chrissy, one of the peer harm reduction workers, must have already stopped by this morning. I know that Jewel really trusts Chrissy and is more comfortable talking with her than with someone who hasn’t experienced homelessness and problems related to drug use. Chrissy and other peer workers are integral members of our outreach team. They know what resources are needed and wanted, and where to find people.

Effectiveness of outreach

Outreach has been found to be an effective way of reaching people who use drugs.⁷ For example, data from the United States estimate that between 750,000 and 1 million outreach contacts were made each year between 1995 and 2000.⁵  In Bangladesh, there are reports that up to 80% of injection drug users have been reached, and between 1998 and 1999, 50,000 needles and syringes and 16,213 condoms had been distributed per month.⁵ There are no available numbers for Canada.

Evaluations of outreach programs suggest these programs provide the means for changes in behaviour that can reduce the risks for HIV, including:^7,8,9

• Less sharing of equipment
• Increased use of condoms and less unsafe sex
• Entry into drug treatment
• People injecting less frequently or, in some cases, people stopping injection drug use

Although there is limited evidence regarding the impact of outreach on the transmission of HIV, studies have found that outreach is an effective strategy to reach people and start a process that can reduce HIV-related risks.⁵ Despite this effectiveness, studies suggest that there is a large gap between the number of people who use drugs who could benefit from outreach services and the number of people these programs reach.⁵

Challenges

Now I’m heading to the coffee shop at Queen and Victoria to have a coffee, sit next to Maria and see if she wants to talk. Maria is very private and suspicious of workers. It took more than three months of my coming here every other morning before she began talking with me. Yesterday she told me that she has a lump in her breast and she has agreed to walk over to a nearby women’s drop-in centre where there is a doctor available today. I will write up my case notes until the drop-in opens at 8:30.

Outreach programs are often poorly funded and understaffed, despite how effective they can be as HIV and STI prevention strategies. Developing a rapport with individuals and building trust takes time, and outcomes may not be easily measurable. Furthermore, ensuring privacy, confidentiality and safety can be a challenge.

An additional challenge for outreach workers is responding to issues that go beyond a program’s mandate. For example, although outreach might be focused on HIV prevention, once engaged, clients often bring up issues (for example, Maria’s lump in her breast) that go well beyond HIV prevention. This may push the personal boundaries of outreach workers and the boundaries of an organization’s mandate; programs need to be ready to address these issues through direct service and/or referrals. 

Best practices

To prevent an epidemic from spreading and becoming more difficult to combat, outreach programs need to be implemented as soon as possible and efforts need to be sustained over time.^5,7,10 Best practices for outreach include:

• Gaining the trust of people who use drugs
• Going where people who use drugs and their networks congregate
• Conducting outreach at times when risk is greatest (for example, in the evening and early morning)
• Providing multiple means for behaviour change, including information, equipment and referrals
• Providing sufficient training for workers to conduct their tasks
• Providing services and supports to outreach workers to address burnout, relapse and other health-related issues
• Providing adequate supervision for outreach workers
• Creating, or advocating for, a policy environment that supports HIV prevention programming

Options for outreach

Different models and outreach strategies have evolved over time in response to community needs, new knowledge and the availability of resources (or lack thereof). Models of service involving outreach workers with lived experience of drug use can offer advantages since they may more readily gain trust and may have a deeper understanding of drug use and homelessness issues. Adequate training, supervision and support remain critical regardless of the worker’s background experience. 

Determining the best ‘package’ of strategies for an outreach program will depend on contextual factors (such as available resources and program objectives) and an organization’s relationship with the target population. Connecting with people in the community creates bridges between services and people who use drugs who aren’t comfortable coming into institutional settings such as clinics and offices. The development of trust and relationships between service providers and people in the community opens doors for a more comprehensive approach to HIV prevention programs.

It’s been a busy day and I’m ending my shift with a much lighter bag. Despite all that we carry, there never seems to be enough supplies. I managed to see quite a few people today but still haven’t come across Debbie… Sometimes she moves on to other areas of the city, outside of our agency’s boundary area. I’d go find her but there’s only so much ground we can cover in a day. It’s getting dark and more people are showing up on street. Really, we need another shift to be heading out to work now but because we are a small team that’s impossible.

I know we do really good work, even if it can be hard at times. The rewards are numerous though. Today, for example, one of our regulars introduced us to a new guy on the street. She encouraged him to go with us to the health centre to get an abscess looked at. He hesitated, but after she sang our praises for long enough, he decided to come along. After seeing the nurse practitioner, he joined in the men’s cooking group at the health centre and decided to spend the afternoon there! When we left him, he was chatting with new friends and helping them put together some safer drug use kits. Indeed, this is exactly the kind of success we look for:  to connect people previously resistant to services to welcoming, safe spaces where they can get care and supplies to reduce the risks of harm they face. All in all, a very good day!

References

1. Barnaby L, Penn R and Erickson P. “Drugs, Homelessness and Health: Homeless Youth Speak Out about Harm Reduction” Shout Clinic report, 2010.
2. Wen CK, Hudak PL, Hwang SW. “Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters,”  Journal of General Internal Medicine, July, 2007; 22(7) 1011-1017.
3. a. b. Rajabiun S, Mallinson RK, McCoy K, et al. “Getting me back on track: the role of outreach interventions in engaging and retaining people living with HIV/AIDS in medical care,” AIDS Patient Care and STDs, 2007;21(Suppl 1):S20-9.
4. Hilfinger Messias DK, Moneyham L, Vyavaharker M, et al. “Embodied work: insider perspectives on the work of HIV/AIDS peer counselors,” Health Care for Women International, July, 2009;30(7):572-94.
5. a. b. c. d. e. f. Needle R, Burrows D, Friedman SR, et al. (2005). “Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users,” International Journal of Drug Policy, 2005;16S:45-57.
6. Rhodes T, Singer M, Bourgois P, et al. “The social structural production of HIV risk among injecting drug users,” Social Science and Medicine, September, 2005;61(5):1026-44.
7. a. b. c. World Health Organization. “Evidence for action: effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users,” Geneva, Switzerland: World Health Organization; 2004 [cited 4 February 2010]. Available from: www.who.int/hiv/pub/idu/idu/en
8. Medley A, Kennedy C, O'Reilly K, et al. “Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis,” AIDS Education and Prevention, June, 2009;21:181-206.
9. Hunt N, Trace M, Bewley-Taylor D. Reducing drug-related harms to health: an overview of the global evidence, The Beckley Foundation Drug Policy Programme [cited 4 February, 2010]. https://www.beckleyfoundation.org/resource/reducing-drug-related-harms-to-health-a-review-of-the-global-evidence/
10. Ford CL, Miller WC, Smurzynski M,et al. "Key components of a theory-guided HIV prevention outreach model: pre-outreach preparation, community assessment, and a network of key informants," AIDS Education and Prevention, April, 2007;19(2):173-86.

About the author(s)

Rebecca Penn is a PhD student at the Dalla Lana School of Public Health at the University of Toronto. She was a case manager working with homeless women with mental health and addiction issues for 10 years prior to returning to graduate work. Her research is centred on harm reduction and peer work.

Carol Strike, PhD, is an associate professor at the University of Toronto’s Dalla Lana School of Public Health, with 10 years of experience in harm reduction, addiction treatment and health services research.