Harm Reduction Outreach Services and Engagement of Chemically Dependent Homeless People Living with HIV/AIDS: An Analysis of Service Utilization Data to Evaluate Program Theory Benjamin Shepard California State University Long Beach Department of Social Work Long Beach, California 90840 ABSTRACT This study examines service utilization patterns among a socially vulnerable population of homeless people living with HIV/AIDS and who have a history of chemi- cal dependence, as they are engaged through outreach services. CitiWide Harm Reduction collaborates with Montefiore Medical Center to connect homeless people with health care through harm reduction outreach and low threshold medical services. Analysis of two cohorts – individuals engaged through harm reduction outreach and individuals who “walk-in” to engage in services at CitiWide Harm Reduction’s drop-in center – assesses the program’s theory that outreach engagement is a mediating variable increasing service utilization. These results demonstrate that low-threshold harm reduction outreach, a brand of outreach designed to reduce barri- ers to services, does increase access to health care and related services for a socially vulnerable, traditionally “hard-to-reach,” population. Harm reduction outreach is a valuable intervention for increasing service utilization among this highly marginalized group. LITERATURE REVIEW Harm Reduction The harm reduction approach can be defined as a set of interventions which seek to “reduce the negative conse- quences of drug use, incorporating a spectrum of strate- gies from safer use, to managed use to abstinence” (HRC, 2004). Rooted in pragmatism, harm reduction acknowl- edges the risks which accompany drug use, but recog- nizes the reality that drug use is a part of life. “Harm reduction is not making drug use solely acceptable, but its accepting that people use,” notes Allan Clear, the executive director the NY based Harm Reduction Coalition (Richardson, 2004). Thus, rather than condemn or condone, harm reduction practitioners seek to work collaboratively with the client. Rather than view addic- tion as simply a disease, drug use is viewed as a complex social phenomenon worthy of investigation (Heller et al., 2004). The client is viewed as an expert on his or her life and its relation to drug use. Like a good detective or anthropologist, harm reduction practitioners seek to make sense of the individual’s drug use within the con- text of the user’s own life story and culture (Coher, 1993; Germain and Gitterman, 1980; Steeley, 2004). Harm reduction aims to build on the ability of individuals to make decisions about their own lives. Unfortunately, countless social and economic barriers reduce the pos- sibilities for client self-determination and diminish the individual capacity to limit drug-related harm (HRC 2004). Social and economic inequalities present countless barriers to care for low-income people, including those with HIV/AIDS (Adler et al., 1993; Cunningham et al., 2005, Moore et al., 1994; Smedley et al., 2002; Williams, 2000). Keefe suggests that “understanding the economic fac- tors that affect people’s lives and seeing them reflected in the problems clients experience demand empathic skill of the highest order.” Rather than locate social prob- lems within personal weaknesses and failure to function according to social norms, harm reduction practitioners consider the structural factors which interfere with the initiation of healthier behaviors practices (Parsons, 1991; Shepard, 1997; Woods, 1998). The aim is to reduce barri- ers to health care and other services, including housing, rather than to fixate on the moral dimensions of client lives (Murray and Paine, 1988). Harm reduction recognizes that admonishments about failure to “adhere” or “comply” often function as thinly veiled narratives of social control (Keefe, 1978). Thus, rather than aim to control, harm reduction prac- titioners work to cultivate the capacities and strengths of drug users as creative partners in addressing their health needs (Marlatt, 1998). Harm reduction based interventions focus on minimizing harmful effects of drug use, rather than insisting on abstinence as the only viable treatment goal. Drug use is thus viewed along a spectrum, ranging from heavy use to abstinence. The aim is to create choice. Emmit Velten, of the Bay Area Addiction Research Center, notes: “When clients are given the choice of treatment, they do better than if they are assigned treatment by someone else,” (Marratt, 1998). To the extent that harm reduction honors self- determination and individual dignity, it can be viewed as an ideologically progressive approach (Mullaly, 1993). By emphasizing choice rather than coercion, harm reduc- tion functions as a deeply humanistic, democratic mode 4MEDICAL RESEARCH REPORT 26 Einstein J. Biol. Med. (2007) 23:26-32.