Developing an HIV Behavioral Surveillance System for Injecting Drug Users: The National HIV Behavioral Surveillance System

Since 1981, surveillance for AIDS and HIV infection has been vital for monitoring the course of the epidemic in the United States, projecting future trends, and designing prevention programs. A program of behavioral surveillance, to complement and be integrated with case surveillance, should also monitor behaviors in populations that are not infected but are at high risk for infection.1 Such data can be used by the Centers for Disease Control and Prevention (CDC) to identify populations needing HIV prevention services and to monitor progress toward goals in the HIV Prevention Strategic Plan.2 In 2002, the National HIV Behavioral Surveillance System (NHBS) was initiated to help state and local health departments establish and maintain a surveillance system to monitor selected behaviors and access to prevention services among groups at highest risk for HIV infection.3 NHBS is conducted in rotating 12-month cycles. During the first cycle of data collection, surveillance activities focused on men who have sex with men (MSM) in 17 metropolitan statistical areas (MSAs). The focus of the second cycle was on injecting drug users (IDUs), and NHBS expanded to 25 MSAs. During the third cycle, surveillance activities will focus on heterosexuals at high risk (HET). These cycles will be repeated over time such that data are collected from any given risk group every three years. Each surveillance cycle is referred to by the group of interest: NHBS-MSM, NHBS-IDU, and NHBS-HET. The purpose of this article is to provide an overview of the methods used in NHBS to conduct HIV behavioral surveillance among IDUs. NHBS-IDU is the first national system for behavioral surveillance among IDUs in the United States. In this article, we first briefly describe the HIV epidemic among IDUs and then describe the development of the IDU component of NHBS and preliminary information about implementation of the first NHBS-IDU cycle. IDUs are at high risk of becoming infected with HIV and other blood-borne pathogens through sharing injection-drug equipment or by engaging in unprotected sex with infected people. Through December 2003, 14% of HIV infection cases reported from the 41 areas with confidential, name-based HIV reporting were attributed to injection drug use; an additional 4% of cases were among MSM who inject drugs (MSM-IDU); and another 4% of the cases were attributed to sex with an IDU.4 Among AIDS cases, these proportions were, in order, 24%, 6%, and 4%. Thus, injecting drug use affects a sizeable proportion of HIV/AIDS cases in the United States.