Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority communities: an approach for timely community interventions

Six rapid assessments of alcohol and other substance use in populations displaced by conflict

BACKGROUND

Substance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use.

METHODS

Studies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers.

RESULTS

Widespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences.

CONCLUSIONS

The six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area.

Fumando la piedra: emerging patterns of crack use among Latino immigrant day laborers in New Orleans

The devastating effects of Hurricane Katrina have contributed to a dynamic demographic shift in the Latino composition of New Orleans. This article focuses on a particularly deleterious pattern of crack cocaine smoking associated with numerous social and health consequences. Utilizing a rapid assessment methodology, in-depth qualitative interviews were conducted with 52 Latino immigrant day laborers in New Orleans. Findings reveal that the presence of a flourishing drug market has facilitated and maintained patterns of crack use including initiation and periods of daily use. Moreover, feelings of isolation and constant exposure to victimization due to day laborers' marginal status are described as contributing to this use. This qualitative analysis reveals how social processes and contextual factors contribute to crack use among Latino day laborers in a post-disaster context. This study has important public health implications in the spread of HIV and other blood borne pathogens.

Prevention of HIV infection among injection drug users in resource-limited settings

Injection drug use contributes to considerable global morbidity and mortality associated with human immunodeficiency virus (HIV) infection and AIDS and other infections due to blood-borne pathogens through the direct sharing of needles, syringes, and other injection equipment. Of approximately 16 million injection drug users (IDUs) worldwide, an estimated 3 million are HIV infected. The prevalence of HIV infection among IDUs is high in many countries in Asia and eastern Europe and could exacerbate the HIV epidemic in sub-Saharan Africa. This review summarizes important components of a comprehensive program for prevention of HIV infection in IDUs, including unrestricted legal access to sterile syringes through needle exchange programs and enhanced pharmacy services, treatment for opioid dependence (ie, methadone and buprenorphine treatment), behavioral interventions, and identification and treatment of noninjection drug and alcohol use, which accounts for increased sexual transmission of HIV. Evidence supports the effectiveness of harm-reduction programs over punitive drug-control policies.

Rapid assessment of HIV risk behavior in drug using sex workers in three cities in South Africa

A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.

The role of formative research in the National HIV Behavioral Surveillance System

The National Human Immunodeficiency Virus (HIV) Behavioral Surveillance System (NHBS) is the Centers for Disease Control and Prevention's (CDC's) newest system for measuring HIV risk behaviors among three adult populations at highest risk for HIV infection in the U.S.: men who have sex with men, injecting drug users, and heterosexuals at risk of HIV infection. The system is implemented by state and local health departments in designated metropolitan statistical areas with the highest HIV/acquired immunodeficiency syndrome (AIDS) prevalence in the U.S. Prior to implementing the behavioral surveillance survey, project sites conduct a series of formative research activities. The data collected during this preparatory phase provide contextual information about HIV risk behaviors within the study population of interest and help project sites make decisions about field operations and other logistical issues. This article describes the activities undertaken in preparation for the first round of NHBS (2003-2007) and how those activities enhanced data collection for each behavioral surveillance cycle.

HIV-risk behavior among injecting or non-injecting drug users in Cape Town, Pretoria, and Durban, South Africa

The rapid assessment aimed to describe drug use and sexual practices that place injection and noninjection drug users (IDUs/NIDUs) at risk for HIV in South Africa. The sample comprised 85 key-informant (KI) and focus-group (FG) interviewees in or serving locations with high levels of drug use in Cape Town, Durban, and Pretoria. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. The findings indicated that commonly used drugs had differing effects on sexual and drug-use practices. Risky injecting behaviors among IDUs were common, and most interviewees engaged in sex when on drugs, some without condoms. These behaviors were also influenced by trust in intimate relationships. Injection drug users seemed more knowledgeable about HIV transmission than NIDUs, and 20% of IDUs who agreed to HIV screening tested positive. Views about drug- and HIV-intervention services, accessibility, and their efficacy were mixed. The findings suggest greater synergy is needed between drug- and HIV-intervention sectors and that consideration should be given to making various risk-reduction strategies more accessible. The study's limitations have been noted.

HIV/AIDS risk among female sex workers who use crack in Southern Brazil

OBJECTIVE: To understand the social context of female sex workers who use crack and its impact on HIV/AIDS risk behaviors. METHODODOLOGICAL PROCEDURES: Qualitative study carried out in Foz do Iguaçu, Southern Brazil, in 2003. Twenty-six in-depth interviews and two focus groups were carried out with female commercial sex workers who frequently use crack. In-depth interviews with health providers, community leaders and public policy managers, as well as field observations were also conducted. Transcript data was entered into Atlas.ti software and grounded theory methodology was used to analyze the data and develop a conceptual model as a result of this study. ANALYSIS OF RESULTS: Female sex workers who use crack had low self-perceived HIV risk in spite of being engaged in risky behaviors (e.g. unprotected sex with multiple partners). Physical and sexual violence among clients, occasional and stable partners was widespread jeopardizing negotiation and consistent condom use. According to health providers, community leaders and public policy managers, several female sex workers who use crack are homeless or live in slums, and rarely have access to health services, voluntary counseling and testing, social support, pre-natal and reproductive care. CONCLUSIONS: Female sex workers who use crack experience a plethora of health and social problems, which apparently affect their risks for HIV infection. Low-threshold, user-friendly and gender-tailored interventions should be implemented, in order to increase the access to health and social-support services among this population. Those initiatives might also increase their access to reproductive health in general, and to preventive strategies focusing on HIV/AIDS and other sexually transmitted infections.

Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using populations in Cape Town, Durban and Pretoria, South Africa

This exploratory study examines the links between drug use and high-risk sexual practices and HIV in vulnerable drug-using populations in South Africa, including commercial sex workers (CSWs), men who have sex with men (MSM), injecting drug users (IDUs) and non-injecting drug users who are not CSWs or MSM (NIDUs). A rapid assessment ethnographic study was undertaken using observation, mapping, key informant interviews and focus groups in known 'hotspots' for drug use and sexual risk in Cape Town, Durban and Pretoria. Key informant (KI) and focus group interviews involved drug users and service providers. Purposeful snowball sampling and street intercepts were used to recruit drug users. Outcome measures included drug-related sexual HIV risk behaviour, and risk behaviour related to injection drug use, as well as issues related to service use. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. Non-injection drug use (mainly cannabis, methaqualone, crack cocaine and crystal methamphetamine) and injection drug use (mainly heroin) was occurring in these cities. Drug users report selling sex for money to buy drugs, and CSWs used drugs before, during and after sex. Most (70%) of the drug-using KIs offered HIV testing accepted and 28% were positive, with rates highest among CSWs and MSM. IDUs reported engaging in needle sharing and needle disposal practices that put them and others at risk for contracting HIV. There was a widespread lack of awareness about where to access HIV treatment and preventive services, and numerous barriers to accessing appropriate HIV and drug-intervention services were reported. Multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV. Targeted interventions could play an important role in limiting the spread of HIV in and through these under-reached and vulnerable populations.

Using a rapid appraisal approach in a nationwide, multisite public involvement study in Scotland

This article reflects on the use of a multisite rapid appraisal (RA) approach with reference to the (to-date) largest qualitative study gathering the views of cancer and cancer care in a cross-section of the Scottish population. A series of ten RAs were conducted in ten communities across Scotland, reflecting the geographical and socioeconomic spread of the Scottish population and involving 507 members of the public, including the views of people who are often termed "hard to reach." The research method is evaluated with reference to principles of RA approaches: the inductive approach, triangulation, assessment and response, and participation. Presentation of the methods adopted in this study demonstrates the value of the rapid appraisal approach in engaging with members of the public in health-related issues, which belies the "quick and dirty" reputation of RA approaches and offers a model for future public involvement work in health care. This makes the reflections on the method utilized particularly relevant to policy makers and researchers wishing to achieve meaningful public involvement and/or consider a method not previously used in this context.

Rapid assessment of drug-related HIV risk among men who have sex with men in three South African cities

The current assessment was undertaken to examine the link between drug use and sexual risk behavior among men who have sex with men (MSM) in locations known to have high prevalence rates of drug use and sexual risk behavior in Cape Town, Durban and Pretoria, South Africa. Street intercepts and purposive snowball sampling were used to recruit drug-using MSM. A rapid assessment was undertaken which included observation, mapping, key informant interviews and focus group interviews with MSM. Drug using key informants were tested for HIV. The use of drugs like crack cocaine, cannabis and methamphetamine to specifically facilitate sexual encounters was evident. Drugs led to inconsistent condom use and other high-risk sexual activities despite HIV risk knowledge being high. Many injecting drug-using MSM shared needles and reused equipment. Among MSM who agreed to HIV testing, one-third tested positive. Views about drug and HIV treatment and preventive services and their efficacy were mixed. Various barriers to accessing services were highlighted including homosexual stigmatization and availability of drugs in treatment facilities. Recommendations include addressing the gap between HIV-risk knowledge and practice, extending VCT services for MSM, increasing the visibility of drug abuse services within communities, addressing concerns about drug availability in treatment centers as well as reintegration issues and the need for after-care services, reducing stigmatization in drug and HIV services for MSM and finally, strengthening the link between drug treatment services and HIV prevention by integrating HIV/drug-related risks into HIV prevention efforts and HIV risks into drug use prevention efforts.

Provider perspectives on rehabilitation of patients with polytrauma

OBJECTIVES

To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation.

DESIGN

Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison.

SETTING

The 4 VA polytrauma rehabilitation centers (PRCs).

PARTICIPANTS

Fifty-six purposefully selected PRC providers and providers from consulting services.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves.

RESULTS

According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding.

CONCLUSIONS

The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.

Community coverage and HIV prevention: assessing metrics for estimating HIV incidence through syringe exchange

BACKGROUND

Evaluations of syringe-exchange programme effectiveness that attempt to measure "coverage" by determining the percentage of the at-risk population reached by a programme are insufficient since programmes must provide syringes on a continual basis. Determining the relationship between the extent of programme coverage and its impact (i.e., reductions in disease risk or incidence) is complicated by the lack of controlled trials with cohorts of drug users and instead has to be estimated by imputation, mathematical modelling, or ecological data analysis. This report offers an approach to determine community-wide impact and discusses the limitations of that approach.

METHODS

Easily created programme tracking data were maintained by exchanges in New Haven, CT, USA and Chicago, IL, USA. Data compiled by month quantified the number of unique participants visiting syringe-exchange programmes and the number of syringes distributed. "Coverage", defined either as the percentage of individuals reached or percentage of community syringe need met, was estimated by incorporating measures of the size of the injector population or injection frequency. These measures of coverage are placed in the context of changing programme operations to estimate the effect of these changes on coverage. Finally, data on AIDS cases from New Haven and Chicago were used to estimate the community-wide impact of syringe exchange.

RESULTS

Two mobile syringe-exchange programmes operated with very different exchange policies. Programme data revealed that coverage of individuals rarely exceeded 10% and was higher in New Haven than in Chicago. On the other hand, coverage measured as the percentage of syringe need met was higher at the Chicago exchange that employed the less restrictive policy. The impact of syringe exchange in the two cities was measured by comparing subsequent AIDS cases. The relative reduction in injection-related AIDS cases as a function of all new AIDS diagnoses was 21.7% in New Haven and 41.4% in Chicago.

CONCLUSIONS

A modest investment in the collection of programme data can yield reliable and interpretable information on the extent of programme reach and retention. Limitations to the approach result from the ecological nature of the data and from the need to use data from outside the programme that may be less reliable. For the cases presented here, coverage rates will vary as a function of the programme policies; however, even modest coverage rates - well below those recommended by UNAIDS - can have significant impacts on HIV epidemics. Restrictive policies appeared to increase the coverage if measured only by the proportion of monthly participants and not by the proportion of syringe need met by a programme. More generally, programmes can collect programmatic data and some rapid assessment data (estimates of IDU population and injection frequency) to estimate of the impact of their programmes.

A participatory action research pilot study of urban health disparities using rapid assessment response and evaluation

Healthy People 2010 made it a priority to eliminate health disparities. We used a rapid assessment response and evaluation (RARE) to launch a program of participatory action research focused on health disparities in an urban, disadvantaged Black community serviced by a major south Florida health center. We formed partnerships with community members, identified local health disparities, and guided interventions targeting health disparities. We describe the RARE structure used to triangulate data sources and guide intervention plans as well as findings and conclusions drawn from scientific literature and epidemiological, historic, planning, clinical, and ethnographic data. Disenfranchisement and socioeconomic deprivation emerged as the principal determinants of local health disparities and the most appropriate targets for intervention.

Lessons learned from taking data collection to the "hood"

Culturally appropriate measures are needed to analyze the effectiveness of HIV prevention interventions. An effective strategy to ensure the culturally appropriateness of measures is the inclusion of participants from the targeted community via participatory action research. Conducting the research process within the community is one method of maximizing greater community participation. The purpose of this paper is to describe a method of pilot testing an instrument within community settings. Findings presented focus primarily on the process of the method, rather than on a statistical outcome testing of the instrument. The sample was 200 African-American women recruited in networks drawn from two rural and two mid-sized counties in North Florida. Methodological issues encountered and resolved through ongoing process evaluation are presented as lessons learned with recommendations and implications.

Integrated HIV care: HIV risk outcomes of pregnant substance abusers

Identifying contextual factors that may influence the effects of HIV risk-reduction strategies aimed at inner-city, minority female populations may be critical to interrupting the alarming trends in seroprevalence in the United States, especially among pregnant women with substance use-related problems. The objective of this Phase I, NIDA-funded project was to determine which contextual and cognitive factors were most predictive of HIV outcomes in this population. Eighty-one HIV-negative women were enrolled in a maternal addiction program with a cognitive-behavioral HIV risk-reduction component. Measures were administered between 1996 and 1998, one week post-admission, and follow-up assessments were conducted on 69 participants at 6 months post-discharge Paired t-tests were conducted to assess changes in sex risk behaviors, HIV/AIDS-related knowledge, and HIV risk-related attitudes/behaviors. Hierarchical regression analyses were conducted to investigate the relationship between attitudes/knowledge with contextual variables. At six months follow-up, there were significant increases in favorable condom attitudes (t = 3.36, p = .01) and in factual knowledge regarding HIV (t = 3.20, p = .01), with a significant decrease in the number of sexual partners (t = 2.21, p = .05). Hierarchical regression analysis revealed that the strongest predictors of the number of partners--a key outcome variable--were alcohol use, intentions to engage in safer sex behaviors, psychiatric symptoms, and a history of physical abuse (F[11, 57] = 6.58, p < .001). This study also reinforces the strategic importance of utilizing substance user treatment programs as crucial vehicles for integrating HIV risk-reduction strategies. Additionally, it will further guide the design of effective procedures to test the feasibility of an integrated HIV risk-reduction intervention for a larger randomized controlled study. The study's limitations are noted.

Behavior change and health-related interventions for heterosexual risk reduction among drug users

Prevention of heterosexual transmission of HIV between and from drug users is important for controlling the local and global HIV heterosexual epidemic. Sex risk reduction interventions and health-related interventions are important for reducing the sex risk behaviors of drug users. Sex risk reduction interventions address individual-level, peer-level, and structural-level determinants of risk reduction. Health-related interventions include HIV counseling and testing, prevention and treatment of sexually transmitted diseases, and delivery of highly active antiretroviral therapy. It is important to adapt effective interventions implemented in resource-rich countries to the realities of the resource-constrained settings and to address relevant contextual factors.

Rapid assessment and response studies of injection drug use: knowledge gain, capacity building, and intervention development in a multisite study

OBJECTIVES

We evaluated the World Health Organization's rapid assessment and response (RAR) method of assessing injection drug use and its associated health problems, focusing on knowledge gain, capacity building, and whether RAR leads to the development of interventions reducing the health effects of injection drug use.

METHODS

Data were derived from RAR studies conducted in Beijing, China; Bogotá, Colombia; Greater Rosario, Argentina; Hanoi, Vietnam; Kharkiv, Ukraine; Minsk, Belarus; Nairobi, Kenya; Penang, Malaysia; St. Petersburg, Russia; and Tehran, Iran.

RESULTS

Substantial gains in knowledge and response capacity were reported at all of the study sites. Before RAR initiation, prevention and intervention programs had been absent or inadequate at most of the sites. The RARs resulted in many new or modified interventions; 7 sites reported 24 health-related interventions that were subsequently developed and influenced by the RARs.

CONCLUSIONS

RARs, which require relatively little external funding, appear to be effective in linking assessment to development of appropriate interventions. The present results add to the evidence that rapid assessment is an important public health tool.

A situational picture of HIV/AIDS and injection drug use in Vinnitsya, Ukraine

BACKGROUND

New and explosive HIV epidemics are being witnessed in certain countries of Eastern Europe, including Ukraine, as well as a rapid and dramatic increase in the supply, use, and negative public health consequences of illicit drugs. A majority of registered HIV cases in Ukraine occur among injection drug users (IDUs), large numbers of whom report HIV risk behaviors such as needle sharing. The purpose of this study was to apply the World Health Organization's Rapid Assessment and Response on Injection Drug Use (IDU-RAR) guide to create a situational picture in the Vinnitsya Oblast, Ukraine, a region with very scarce information about the HIV/AIDS and injection drug use (IDU) epidemics.

METHODS

The IDU-RAR uses a combination of qualitative data collection techniques commonly employed in social science and evaluation research to quickly depict the extent and nature of the given health problem and propose locally relevant recommendations for improvement. The investigators focused their assessment on the contextual factors, drug use, and intervention and policy components of the IDU-RAR. A combination of network and block sampling techniques was used. Data collection methods included direct observation, review of existing data, structured and unstructured interviews, and focus group discussions. Key informants and locations were visited until no new information was being generated.

RESULTS

The number of registered HIV cases in Vinnitsya has increased from 3 (1987-1995) to 860 (1999-10/2004), 57 of whom have already died. Ten percent of annual admissions to the area's Regional Narcological Dispensary were for opiate disorders, and the number of registered IDUs rose by 20% from 1999 to 2000. The level of HIV/AIDS awareness is generally poor among the general population but high among high-risk populations. Both HIV/AIDS and injection drug use carry a strong stigma in the community, even among medical professionals. There was very little evidence of primary HIV/AIDS prevention efforts, and IDU prevention efforts focused on promotion of anti-drug messages in the schools.

CONCLUSION

Given that Ukraine has sparse resources to be devoted to this problem, action recommendations should be prioritized, realistic, and initially targeted to persons in greatest need. The following action recommendations are prioritized by the following categories: First priority: Voluntary Counseling and Testing; Second Priority: Prevention and Education; and Third Priority: Harm Reduction and Treatment. They are provided in this sequence based on what response can realistically be implemented first with limited additional resources and can make the greatest immediate impact. The persons at greatest risk, HIV positive persons and IDUs, should be attended to first.

Access and utilization of HIV treatment and services among women sex workers in Vancouver's Downtown Eastside

Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver's Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.

Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa

This paper describes the South Africa component of a World Health Organization multi-site rapid assessment and response project seeking to develop a methodology for studying factors associated with alcohol use-related sexual risk behaviour in diverse cultural settings. This report focuses on the qualitative assessments that were conducted in order to profile alcohol use and sexual behaviour in the communities concerned, ascertain the relationships between alcohol use and sexual behaviour, and develop a conceptual model of the relationships between alcohol use and sexual risk behaviour. The participants consisted of adults aged between 25 and 44 years in a township and city site in Gauteng province. The assessments involved conducting 18 key informant interviews, observations in seven drinking venues, six focus groups and 16 in-depth interviews of 'risky drinkers' and their partners. Most participants felt that there were high levels of alcohol consumption and unprotected sex among some members of their communities, with the latter occurring mainly among casual sexual partners. The findings also pointed to strong links between alcohol consumption and sexual risk behaviour. A conceptual model of the association between alcohol use and risky sexual behaviour is proposed. This study suggests a need for multi-faceted HIV intervention strategies for reducing levels of alcohol abuse in general, and enhancing protective sexual behaviours among alcohol-using populations.

Immigration and geographic access to prenatal clinics in Brooklyn, NY: a geographic information systems analysis

We compared levels of geographic access to prenatal clinics in Brooklyn, NY, between immigrant and US-born mothers and among immigrant groups by country of birth. We used birth data to characterize the spatial distribution of mothers and kernel estimation to measure clinic density within a 2-mile radius of each mother. Results showed that geographic access to clinics differs substantially by country of birth. Certain groups (e.g., Pakistani, Bangladeshi) have relatively poor geographic access despite a high need for prenatal care.

Rapid assessment: an international review of diffusion, practice and outcomes in the substance use field

'Rapid assessment' (RA) methods have the potential to generate important public health information. This potential is now the subject of debate within the substance use field. Despite this, much remains unknown about the application and outcomes of RAs on substance use, a situation compounded by the absence of published studies. Consequently, we undertook a retrospective review of the use of RA in the substance use field drawing on three methods: literature review (n=300 published and unpublished documents); survey of RA practitioners/commissioners (n=1200 contacts); in-depth expert consultation (n=10 interviews). Study findings indicated: (i) earliest identified RAs were conducted in 1993, with 83 identified studies conducted by 2001; (ii) RAs have been conducted in 70 countries, with seven out of 10 assessments undertaken between 1998 and 2001; (iii) RAs were reported as taking 9-486 days (69 weeks) to complete; and (iv) important outcomes can follow RA on substance use--one in two studies were followed by medical or non-medical interventions, workshops, training, policy change, community participation, network building, or other outcomes (45/83; 54%), whilst more than one in four RAs were followed by medical and non-medical interventions, or policy impact and change (25/83; 30%). In conclusion, we argue that to fully realise the potential of RA in the substance use field, investment has to be made in RA's evidence and knowledge base: in short, a culture of learning, reflection and discussion has to be introduced into a methodology currently premised on rapidity and pragmatism.