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What We Can Learn From the INSPIRE Study About Improving Prevention and Clinical Care for Injection Drug Users Living With HIV

Beginning in the mid-1990s, the widespread use of effective treatments for HIV infection (highly active antiretroviral therapy [HAART]) led first to dramatic declines in AIDS incidence and deaths and then to changes in the priorities for HIV prevention and treatment. The prospects for people living with HIV infection changed from expectation of premature death to the likelihood of living a longer healthier life. With widespread availability of HAART, HIV infection is now treated as a chronic disease. With substantially increased survival, the number of people living with HIV in the United States increased to an estimated 1 million in 2003. In the United States, the increasing numbers of people living with HIV brought new urgency and opportunities to develop secondary HIV prevention initiatives for people living with HIV. In 2003, the Centers for Disease Control and Prevention (CDC) introduced the Advancing HIV Prevention initiative, which included the objective of preventing new infections by working with persons diagnosed with HIV and their partners, Also, in 2003, the CDC and the Health Resources and Services Administration (HRSA) called for increased HIV prevention efforts in the medical care of persons living with HIV. Even so, the literature of published prevention interventions for people living with HIV is limited. Two meta-analyses of HIV prevention studies among persons living with HIV were published in 2006. In the 12 studies that met inclusion criteria, Crepaz and colleagues found that there was evidence of significant reductions in unprotected sex and decreased acquisition of sexually transmitted infections. Only 1 of these studies targeted injection drug users (IDUs). Among the 15 studies of interventions to prevent sexual transmission from HIV-positive persons that met inclusion criteria, Johnson and colleagues found that the interventions led to improved use of condoms but not to reducing the number of sex partners. For people living with HIV, utilizing health care well and, when antiretroviral treatment is needed, adhering to medications schedules also are important. Being able to take multiple antiretroviral medications as prescribed and to sustain good adherence for years is essential to avoid developing resistance to 1 or more of the medications and potentially serious complications of HIV infection. For those reasons, the Interventions for Seropositive Injectors—Research and Evaluation (INSPIRE) research project was a major step in testing behavioral interventions for people living with HIV. The INSPIRE project was planned in the late 1990s and was in the field from 2001 to 2005. It was a carefully designed and well-implemented randomized controlled trial of a behavioral intervention with 966 HIV-infected IDUs, a group of people living with HIV that is less frequently studied. INSPIRE was jointly funded by the CDC and HRSA to integrate testing of behavioral interventions in 2 high-priority areas, prevention of secondary transmission and improving HIV-related health care. INSPIRE was a theory-based trial of a 10-session peer mentoring intervention, including 7 small group and 2 individual sessions and a community visit to practice peer