Substance Abuse Treatment for Persons With HIV/AIDS
Treatment Improvement Protocol (TIP) Series 37
Steven L. Batki, M.D.
Consensus Panel Chair
Peter A. Selwyn, M.D., M.P.H.
Consensus Panel Co-Chair
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 00-3410
Printed 2000
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Warren W. Hewitt, Jr., M.S., served as CSAT content advisor. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., managing editor; Susan Kimner, editor/writer; Cara Smith, production editor; Erica Flick, editorial assistant; and Y-Lang Nguyen, former production editor.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http:// text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Substance Abuse Treatment for Persons With HIV/AIDS, is a revision of TIP 15, Treatment for HIV-Infected Alcohol and Other Drug Abusers (CSAT, 1995b). It is intended to help a wide range of providers become familiar with the various issues surrounding clients with both substance abuse and human immunodeficiency virus (HIV) and to foster a better understanding of the roles of other providers.
Chapter 1 provides a basic overview of HIV/AIDS, including the latest available epidemiological data from the Centers for Disease Control and Prevention. Chapter 2 discusses medical assessment and treatment of HIV/AIDS. Chapter 3 discusses the treatment of mental health disorders in substance abusers with HIV/AIDS. Chapter 4 explains HIV/AIDS prevention, and Chapter 5 provides information about how to integrate treatment services via collaboration, so that all the needs of HIV-infected clients with substance abuse disorders can be met. Chapter 6 discusses case management and how to access the services that clients need. Chapter 7 provides information about counseling clients with HIV/AIDS and substance abuse disorders, including information on staff issues, screening, and cultural competency. Chapter 8 discusses ethical issues, and Chapter 9 presents legal issues, including confidentiality and clients' access to services and programs. Chapter 10 provides information about funding sources for programs treating clients with HIV/AIDS and substance abuse treatment. The appendixes in this TIP provide additional information on several topics and include the 1993 Revised Classification System for HIV and AIDS, Federal and State codes of ethics, AIDS-related Web sites, and a list of State and Territorial health agencies and AIDS hotlines.
This TIP represents another step by CSAT toward its goal of bringing national leaders together to improve substance abuse treatment in the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Karen Allen, Ph.D., R.N., C.A.R.N.
Professor and Chair
Department of Nursing
Andrews University
Berrien Springs, Michigan
Richard L. Brown, M.D., M.P.H.
Associate Professor
Department of Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin
Dorynne Czechowicz, M.D.
Associate Director
Medical/Professional Affairs
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Rockville, Maryland
Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Abuse Directors
Director
Treatment Improvement Exchange Project
Washington, D.C.
Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
Thomas W. Hester, M.D.
Former State Director
Substance Abuse Services
Division of Mental Health, Mental Retardation and Substance Abuse
Georgia Department of Human Resources
Atlanta, Georgia
James G. (Gil) Hill, Ph.D.
Director
Office of Rural Health and Substance Abuse
American Psychological Association
Washington, D.C.
Douglas B. Kamerow, M.D., M.P.H.
Director
Center for Practice and Technology Assessment
Agency for Health Care Policy and Research
Rockville, Maryland
Stephen W. Long
Executive Director
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Rockville, Maryland
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center and Matrix Institute on Addiction
Deputy Director, UCLA Addiction Medicine Services
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia
Steven L. Batki, M.D.
Professor
Department of Psychiatry
SUNY Upstate Medical University
Syracuse, New York
Peter A. Selwyn, M.D., M.P.H.
Professor and Chairman
Department of Family Medicine and Community Health
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, New York
Deborah Wright Bauer, M.P.H., M.L.S.
Health Project Consultant
Georgia Ryan White Title IV Project
Epidemiology and Prevention Branch
Department of Human Resources
Atlanta, Georgia
Margaret K. Brooks, J.D., M.A.
New Perspectives
Montclair, New Jersey
Robert Paul Cabaj, M.D.
Medical Director
San Mateo County Mental Health Services
Mental Health Services Administration
San Mateo, California
Susan M. Gallego, M.S.S.W., L.M.S.W.-A.C.P.
Trainer, Consultant, and Facilitator
Austin, Texas
Larry M. Gant, Ph.D., C.S.W., M.S.W.
Associate Professor
School of Social Work
University of Michigan
Ann Arbor, Michigan
Brian C. Giddens, M.S.W., A.C.S.W.
Associate Director
Social Work Department
University of Washington Medical Center
Seattle, Washington
Gregory L. Greenwood, Ph.D., M.P.H.
TAPS Fellow
Center for AIDS Prevention Studies
University of California at San Francisco
San Francisco, California
Elizabeth F. Howell, M.D.
Substance Abuse Program Chief
Georgia Department of Human Resources
Division of Mental Health, Mental Retardation and Substance Abuse
Atlanta, Georgia
Martin Yoneo Iguchi, Ph.D.
Co-Director
Senior Behavioral Scientist
Drug Policy Research Center
RAND
Santa Monica, California
Susan LeLacheur, M.P.H., P.A.-C.
Assistant Professor of Health Care Sciences and Health Sciences
The George Washington University
Physician Assistant Program
Washington, D.C.
Andrea Ronhovde, L.C.S.W.
Director
Alexandria Mental Health HIV/AIDS Project
Alexandria Mental Health Center
Alexandria, Virginia
Ronald D. Stall, Ph.D., M.P.H.
Center for AIDS Prevention Studies
University of California at San Francisco
San Francisco, California
Michael D. Stein, M.D.
Associate Professor
Department of Medicine
Brown University
Providence, Rhode Island
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses its particular areas of expertise until it reaches a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
Nelba Chavez, Ph.D.
Administrator
Substance Abuse and Mental Health Services Administration
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Many significant changes have occurred in recent years in the treatment of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). In recognition of these advances and their impact on substance abuse treatment, the Center for Substance Abuse Treatment (CSAT) convened a Consensus Panel in 1998 to update and expand TIP 15, Treatment for HIV-Infected Alcohol and Other Drug Abusers (CSAT, 1995b).
Major research advances have substantially improved our understanding of the biology of HIV and the pathogenesis (i.e., origin and development) of AIDS. The pathogenesis of AIDS is now known to result from the ability of HIV to replicate at the rate of a billion new virions (viral particles) per day and nearly 10 trillion new virions over the course of HIV infection. This, countered by the ability of the body to produce CD4+ T cell lymphocytes (a primary target cell for HIV), sets the stage for the struggle between HIV and the immune system--a struggle that lasts from the first day of HIV infection to end-stage disease and death.
Early in the U.S. HIV/AIDS pandemic, the role of substance abuse in the transmission of HIV and AIDS became clear. HIV is most efficiently transmitted through exposure to contaminated blood. As a result, injection drug users represent the largest HIV-infected substance-abusing population in the United States. In addition to contracting HIV through contaminated injection equipment, sexual contact within relatively closed sexual networks is another route of HIV transmission among injection drug users. These networks are characterized by multiple sex partners, unprotected intercourse, and the exchange of sex for drugs. The use of alcohol and noninjection drugs within this environment only increases the HIV/AIDS caseload. Because substance abuse and the HIV/AIDS pandemic are so interrelated, substance abuse treatment can play an important role in helping substance abusers reduce risk-taking behavior, thus helping to reduce the incidence of HIV/AIDS.
The current trend in the HIV/AIDS pandemic shows that a disproportionate number of minorities who live in inner cities are affected by or at risk for contracting HIV. This population is poor, hard to reach through traditional public health methods, and in need of a wide range of health and human services.
The recommendations and guidelines in this TIP continue to reinforce the approach established in TIP 15, which was the creation of a comprehensive, integrated system of care for HIV-infected substance abusers. Collaborative, efficient networks must be developed among substance abuse treatment centers, medical personnel, mental health personnel, and public health officials to prevent further spread of the disease and to provide high-quality care to infected individuals. Bringing together these disciplines that traditionally work independently of each other is an enormous challenge. An additional important challenge is to overcome misunderstandings and a lack of communication based on differences in ethnicity, culture, economic status, sexual orientation, and lifestyle.
The HIV/AIDS pandemic has induced some substance abuse treatment centers in HIV epicenters (e.g., San Francisco, New York, Washington, D.C.) to increase the range of services they provide in order to attend to all the needs of their clients: substance abuse treatment; HIV/AIDS treatment; and other medical, behavioral, psychological, and social needs. As a result, these treatment centers are providing clients with comprehensive diagnosis, treatment, and management of all presenting problems. For those times when services are unavailable, these treatment centers may establish referral networks and resource links with other treatment providers in their communities.
There are various audiences for this TIP, and different chapters are targeted to some of them individually. Nevertheless, the entire TIP should be of interest to anyone who wants to improve care for HIV-infected substance abusers. Prevention and treatment of substance abuse and HIV/AIDS require a multidisciplinary approach that relies on the strengths of a variety of providers and treatment settings. It is unrealistic to expect any single provider to be competent in all areas of care; this TIP will help a wide range of providers become familiar with the various issues surrounding substance abuse and HIV/AIDS and should foster a better understanding of the roles of other providers.
The Consensus Panel for this TIP drew on its considerable experience in both the HIV/AIDS and the substance abuse treatment fields. The Panel was composed of representatives from all of the disciplines involved in HIV/AIDS and substance abuse treatment, including physicians, alcohol and drug counselors, mental health workers, State government representatives, and legal counsel.
The TIP is organized into ten chapters, the first of which provides an introduction to HIV/AIDS, including the origin, life cycle, and progression of the disease. The second part of Chapter 1 provides an overview of the changes in epidemiology since 1995 when the first edition of this TIP was published. Epidemiological data from the Centers for Disease Control and Prevention (CDC) are summarized, and readers are provided with an overview of the pandemic in the regions of the United States, the current trends and populations most affected by the disease, and a discussion of special populations.
Chapter 2, which is targeted to medical personnel, discusses the medical assessment and treatment of HIV/AIDS, including adherence to treatment, barriers to care, treatment and testing, pharmacology, and prophylaxis against opportunistic infections. Chapter 3, which is aimed at mental health workers, explores the mental health treatment of clients with substance abuse problems and HIV/AIDS and discusses common mental disorders, assessment and diagnosis, pharmacology, counseling, and staff issues. Chapter 4 presents issues concerning HIV prevention. These issues include assessing clients for risk, risk-reduction counseling, sexual risk reduction, prenatal and perinatal prevention, transmission of resistant strains of HIV, syringe sharing, rapid HIV testing, and infection control issues for programs.
Chapter 5 discusses integrating treatment services, as well as the importance of linkages between substance abuse treatment programs and other providers. Chapter 6 provides information about case management and finding resources for HIV-infected substance abusers, including resources for substance abuse treatment, mental health, medical care, and income and other financial concerns for clients. Chapter 7 examines counseling issues, including staff training and attitudes, screening, and issues specific to the substance-abusing client with HIV/AIDS. Chapter 8 explores ethical issues, and Chapter 9 discusses legal issues and provides basic information about Federal laws regarding discrimination and confidentiality. Chapter 10, geared toward program administrators, presents information about funding sources and grantwriting.
In light of the volumes of information available about HIV/AIDS, this TIP is not intended to be exhaustive. A wide array of resources is provided for those who wish to find more information on topics of interest. The appendixes in this TIP provide additional information on several topics and include the 1993 Revised Classification System for HIV and AIDS, Federal and State codes of ethics, AIDS-related Web sites, and a list of State and Territorial health agencies and AIDS hotlines.
In order to avoid awkward construction and sexism, this TIP alternates between "he" and "she" for generic examples.
Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse and substance dependence (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV] [American Psychiatric Association, 1994]). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, it will be used to denote both substance dependence and substance abuse. The term relates to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance abuse disorders as described by DSM-IV.
The recommendations that follow are grouped by chapter. Recommendations supported by research literature or legislation are followed by a (1); clinically based recommendations are marked (2).
The first cases of acquired immunodeficiency syndrome (AIDS) were reported in the United States in the spring of 1981. By 1983 the human immunodeficiency virus (HIV), the virus that causes AIDS, had been isolated. Early in the U.S. HIV/AIDS pandemic, the role of substance abuse in the spread of AIDS was clearly established. Injection drug use (IDU) was identified as a direct route of HIV infection and transmission among injection drug users. The largest group of early AIDS cases comprised gay and bisexual men (referred to as men who have sex with men(or MSMs). Early cases of HIV infection that were sexually transmitted often were related to the use of alcohol and other substances, and the majority of these cases occurred in urban, educated, white MSMs.
Currently, injection drug users represent the largest HIV-infected substance-abusing population in the United States. HIV/AIDS prevalence rates among injection drug users vary by geographic region, with the highest rates in surveyed substance abuse treatment centers in the Northeast, the South, and Puerto Rico. From July 1998 through June 1999, 23 percent of all AIDS cases reported were among men and women who reported IDU (Centers for Disease Control and Prevention [CDC], 1999b).
IDU practices are quick and efficient vehicles for HIV transmission. The virus is transmitted primarily through the exchange of blood using needles, syringes, or other IDU equipment (e.g., cookers, rinse water, cotton) that were previously used by an HIV-infected person. Lack of knowledge about safer needle use techniques and the lack of alternatives to needle sharing (e.g., available supplies of clean, new needles) contribute to the rise of HIV/AIDS.
Another route of HIV transmission among injection drug users is through sexual contacts within relatively closed sexual networks, which are characterized by multiple sex partners, unprotected sexual intercourse, and exchange of sex for money (Friedman et al., 1995). The inclusion of alcohol and other noninjection substances to this lethal mixture only increases the HIV/AIDS caseload (Edlin et al., 1994; Grella et al., 1995). A major risk factor for HIV/AIDS among injection drug users is crack use; one study found that crack abusers reported more sexual partners in the last 12 months, more sexually transmitted diseases (STDs) in their lifetimes, and greater frequency of paying for sex, exchanging sex for drugs, and having sex with injection drug users (Word and Bowser, 1997).
Following are the key concepts about HIV/AIDS and substance abuse disorders that influenced the creation of this TIP:
The first part of this chapter provides a basic overview of the origin of HIV/AIDS and the transmission and progression of the disease. The second part of the chapter presents a summary of epidemiological data from the CDC. This second part discusses the impact of HIV/AIDS in regions of the United States and the populations that are at the greatest risk of contracting HIV.
Of the many theories and myths about the origin of HIV, the most likely explanation is that HIV was introduced to humans from monkeys. A recent study (Gao et al., 1999) identified a subspecies of chimpanzees native to west equatorial Africa as the original source of HIV-1, the virus responsible for the global AIDS pandemic. The researchers believe that the virus crossed over from monkeys to humans when hunters became exposed to infected blood. Monkeys can carry a virus similar to HIV, known as SIV (simian immunodeficiency virus), and there is strong evidence that HIV and SIV are closely related (Simon et al., 1998; Zhu et al., 1998).
AIDS is caused by HIV infection and is characterized by a severe reduction in CD4+ T cells, which means an infected person develops a very weak immune system and becomes vulnerable to contracting life-threatening infections (such as Pneumocystis carinii pneumonia). AIDS occurs late in HIV disease.
Tracking of the disease in the United States began early after the discovery of the pandemic, but even to date, tracking data reveal only how many individuals have AIDS, not how many have HIV. The counted AIDS cases are like the visible part of an iceberg, while the much larger portion, HIV, is submerged out of sight. Many States are counting HIV cases now that positive results are to be gained by treating the infection in the early stages and because counting only AIDS cases is no longer sufficient for projecting trends of the pandemic. However, because HIV-infected people generally are asymptomatic for years, they might not be tested or included in the count. The CDC estimates that between 650,000 and 900,000 people in the United States currently are living with HIV (CDC, 1997c).
In 1996, the number of new AIDS cases (not HIV cases) and deaths from AIDS began to decline in the United States for the first time since 1981. Deaths from AIDS have decreased since 1996 in all racial and ethnic groups and among both men and women (CDC, 1999a). However, the most recent CDC data show that the decline is slowing (CDC, 1999b). The decline can be attributed to advances in treating HIV with multiple medications, known as combination therapy; treatments to prevent secondary opportunistic infections; and a reduction in the HIV infection rate in the mid-1980s prior to the introduction of combination therapy. The latter can be attributed to improved services for people with HIV and access to health care. In general, those with the best access to good, ongoing HIV/AIDS care increase their chances of living longer.
HIV/AIDS is still largely a disease of MSMs and male injection drug users, but it is spreading most rapidly among women and adolescents, particularly in African American and Hispanic communities. HIV is a virus that thrives in certain ecological conditions. The following will lead to higher infection rates: a more potent virus, high viral load, high prevalence of STDs, substance abuse, high HIV seroprevalence within the community, high rate of unprotected sexual contact with multiple partners, and low access to health care. These ecological conditions exist to a large degree among urban, poor, and marginalized communities ofinjection drug users. Thus, MSMs and African American and Hispanic women, their children, and adolescents within these communities are at greatest risk.
HIV cannot survive outside of a human cell. HIV must be transmitted directly from one person to another through human body fluids that contain HIV-infected cells, such as blood, semen, vaginal secretions, or breast milk. The most effective means of transmitting HIV is by direct contact between the infected blood of one person and the blood supply of another. (See Figure 1-1 for an illustration of the structure of the virus.) This can occur in childbirth as well as through blood transfusions or organ transplants prior to 1985. (Testing of the blood supply began in 1985, and the chance of this has greatly decreased.) Using injection equipment that an infected person used is another direct way to transmit HIV.
Sexual contact is also an effective transmission route for HIV because the tissues of the anus, rectum, and vagina are mucosal surfaces that can contain infected human body fluids and because these surfaces can be easily injured, allowing the virus to enter the body. A person is about five times more likely to contract HIV through anal intercourse than through vaginal intercourse because the tissues of the anal region are more prone to breaks and bleeding during sexual activity (Royce et al., 1997).
A woman is eight times more likely to contract HIV through vaginal intercourse if the man is infected than in the reverse situation (Center for AIDS Prevention Studies, 1998). HIV can be passed from a woman to a man during intercourse, but this is less likely because the skin of the penis is not as easily damaged. Female-to-female transmission of HIV apparently is rare but should be considered a possible means of transmission because of the potential exposure of mucous membranes to vaginal secretions and menstrual blood (CDC, 1997a).
Oral intercourse also is a potential risk but is less likely to transmit the disease than anal or vaginal intercourse. Saliva seems to have some effect in helping prevent transmission of HIV, and the oral tissues are less likely to be injured in sexual activity than those of the vagina or anus. However, if a person has infections or injuries in the mouth or gums, then the risk of contracting HIV through oral sex increases.
A possible link between male circumcision and HIV infectivity was first observed during studies conducted in Kenya in the late 1980s (Cameron et al., 1998; Greenblatt et al., 1988; Simonsen et al., 1988). Since then, numerous studies have been done on the possible relationship between male circumcision and HIV infectivity. Data have not revealed a direct causal link between circumcision and HIV transmission, and scientific opinion has been divided on this topic. While some studies indicate that circumcision can play a protective role in preventing HIV infection (Kelly et al., 1999; Moses et al., 1998; Urassa et al., 1997), the bulk of recent scientific research has concluded that the reverse is true and that circumcision can actually increase the rate of HIV transmission (Van Howe, 1999). Clearly, further research and analysis of circumcision as a prophylactic against HIV transmission is needed.
Several factors can increase the risk of HIV transmission. One factor is the presence of another STD (e.g., genital ulcer disease) in either partner, which increases the risk of becoming infected with HIV through sexual contact. This is because the same risk behaviors that resulted in the person contracting an STD increase that person's chance of contracting HIV. STDs also can cause genital lesions that serve as ports of entry for HIV, they can increase the number of HIV target cells (CD4+ T cells), and they can cause the person to shed greater concentrations of HIV (CDC, 1998a). For this reason, all sexually active clients, especially women, should be checked regularly for STDs such as gonorrhea and chlamydia. Many STDs that cause symptoms in men are asymptomatic in women. When genital ulcers are treated and heal, the risk of HIV transmission is reduced.
Another factor that increases risk is a high level of HIV circulating in the bloodstream. This occurs soon after the initial infection and returns late in the disease. New drug therapy can keep this level (called viral load) low or undetectable, but this does not mean that other individuals cannot be infected. The virus still exists--it is simply not detectable by the currently available tests. Because the correlation between plasma and genital fluid viral load varies, transmission may still occur despite an undetectable serum viral load (Liuzzi et al., 1996).
Once HIV passes to an uninfected person who is not taking anti-HIV drugs, the virus reproduces very rapidly. It is known that drug-resistant viruses can be transmitted from one person to another. The treatment implications for a person infected with a drug-resistant virus are not yet known, but treatment will likely be difficult.
There are many misconceptions regarding HIV transmission. For example, HIV is not passed from one person to another in normal daily contact that does not involve either exposure to blood or sexual contact. It is not carried by mosquitoes and cannot be caught from toilet seats or from eating food prepared by someone with AIDS. No one has ever contracted AIDS by kissing someone with AIDS, or even by sharing a toothbrush (although sharing a toothbrush still is not advised). Other misconceptions people may have include the following:
It is possible to prevent transmission even after exposure to HIV. In San Francisco, postexposure prophylaxis is being offered to people who believe they have high risk for HIV transmission because of exposure with a known or suspected HIV-infected individual. Treatment is started within 72 hours of exposure and includes combination therapy, which may include a protease inhibitor, for a period of 1 month and followup for 12 months.
Once an HIV particle enters a person's body, it binds to the surface of a target cell (CD4+ T cell). The virus enters through the cell's outer envelope by shedding its own viral envelope, allowing the HIV particle to release an HIV ribonucleic acid (RNA) chain into the cell, which is then converted into deoxyribonucleic acid (DNA). The HIV DNA enters the cell's nucleus and is copied onto the cell's chromosomes. This causes the cell to begin reproducing more HIV, and eventually the cell releases more HIV particles. These new particles then attach to other target cells, which become infected. Figure 1-2 illustrates how HIV enters a CD4+ T cell and reproduces.
Physicians can measure the presence of HIV in a person by means of (1) the CD4+ T cell count and (2) the viral load count. The CD4+ T cell count measures the number of CD4+ T cells (i.e., white blood cells) in a milliliter of blood. These are the cells that HIV is most likely to infect, and the number of these cells reflects the overall health of a person's immune system.
CD4+ T cells act as signals to inform the body's immune system that an infection exists and needs to be fought. Because HIV hides inside the very cells responsible for signaling its presence, it can survive and reproduce without the infected person knowing of its existence for many years. Even though the body can produce sufficient CD4+ T cells to replace the billions that are destroyed by untreated HIV each day, eventually HIV kills so many CD4+ T cells that the damaged immune system cannot control other infections that may make the person sick. This is the late stage of HIV, when AIDS is often diagnosed based on the presence of specific illnesses (i.e., opportunistic infections).
The viral load represents the level of HIV RNA (genetic material) circulating in the bloodstream. This level becomes very high soon after a person is initially infected with HIV, then it drops. Viral load tests measure the number of copies of the virus in a milliliter of plasma; currently available tests can measure down to 50 copies per milliliter, and even more sensitive tests can measure down to 5 copies per milliliter.
To explain the relationship between CD4+ T cell count and viral load count and how together they are used to gauge a person's stage in disease progression, a "moving train" analogy can be used. The CD4+ T cell count is used to measure the person's distance to the point of high risk of contracting opportunistic infections, or death. The viral load count is used to measure the rate at which CD4+ T cells are being destroyed. Therefore, the CD4+ T cell count is the train's position on the track, and the viral load is the train's speed toward the outcome (i.e., AIDS and then death).
After a person is infected with HIV, the body takes about 6 to 12 weeks and sometimes as long as 6 months to build up proteins to fight the virus. These proteins are called HIV antibodies (disease-fighting proteins) and are detected by an HIV test called the ELISA (enzyme-linked immunosorbent assay). The ELISA is very sensitive--it almost always detects HIV if it is there. Rarely, ELISA tests will give false-positive readings (a positive test in someone uninfected). For this reason, a positive ELISA test must always be confirmed with a second, more specific test called the Western blot. According to the CDC, the accuracy of the ELISA and the Western blot together is greater than 99 percent. Rapid HIV tests and home sample collection tests also are options for clients; see Chapter 2 for a more detailed discussion of these types of tests.
The 6 to 12 weeks between the time of infection and the time when an ELISA test for HIV becomes positive are called the "window period." During this period, the individual is extremely infectious to any sexual or needle-sharing partner but does not test positive unless a more expensive viral load test is performed.
The level of virus is determined by using a viral load test; three types of viral load tests are HIV-RNA polymerase chain reaction (PCR), HIV branched DNA (bDNA), and HIV-RNA nucleic acid sequence-based amplification (NASBA). Each of these tests measures the amount of replicating or reproducing virus in the bloodstream; thus a lower value signifies less risk of rapid progression. The best viral load test result is "none detected," although this does not mean the virus is gone, only that it is not actively reproducing at a measurable level.
Once a person is infected with HIV, she should understand the progression of the disease from initial infection, through the latency period, symptomatic infections, and finally AIDS. The course of untreated HIV is not known but may go on for 10 years or longer in many people. Several years into HIV infection, mild symptoms begin to develop, then later severe infections that define AIDS occur. Treatment appears to greatly extend the life and improve the quality of life of most patients, although estimating survival after an AIDS diagnosis is inexact.
Primary HIV infection can cause an acute retroviral syndrome that often is mistaken for influenza (the flu), mononucleosis, or a bad cold. This syndrome is reported by roughly half of those who contract HIV (Russell and Sepkowitz, 1998) and generally occurs between 2 and 6 weeks after infection. Symptoms may include fever, headache, sore throat, fatigue, body aches, weight loss, and swollen lymph nodes. Other symptoms are a rash, mouth or genital ulcers, diarrhea, nausea and vomiting, and thrush. The CD4+ T cell count can drop very low during the early weeks, although it usually returns to a normal level after the initial illness is over. The initial illness can last several days or even weeks.
The greatest spread of HIV occurs throughout the body early in the disease. Approximately 6 months after infection, the level of virions produced every day may reach a "set point." A higher set point usually means a more rapid progression of HIV disease. Early treatment may be recommended to reduce the set point, potentially leading to a better chance of controlling the infection.
Alcohol and drug counselors should discuss symptoms that suggest initial HIV infection with their clients and encourage clients to be tested for HIV if they experience such symptoms. This not only will encourage clients who are infected to enter treatment early but also will provide an opportunity for the counselor to help uninfected clients remain that way.
After initial infection comes the latency period, or incubation period, during which untreated persons with HIV have few, if any, symptoms. This period lasts a median of about 10 years. The most common symptom during this period is lymphadenopathy, or swollen lymph nodes. The lymph nodes found around the neck and under the arms contain cells that fight infections. Swollen lymph nodes in the groin area may be normal and not indicative of HIV. When any infection is present, lymph nodes often swell, sometimes painfully. With HIV, they swell and tend to stay swollen but usually are not painful.
After the first year of infection, the CD4+ T cell count drops at a rate of about 30 to 90 cells per year. When the CD4+ T cell count falls below 500, mild HIV symptoms may occur. Many people, however, will have no symptoms at all until the CD4+ T cell count has dropped very low (200 or less). Bacteria, viruses, and fungi that normally live on and in the human body begin to cause diseases that are also known as opportunistic infections.
Early symptoms of infection may include chronic diarrhea, herpes zoster, recurrent vaginal candidiasis, thrush, oral hairy leukoplakia (a virus that causes white patches in the mouth), abnormal Pap tests, thrombocytopenia, or numbness or tingling in the toes or fingers. Most of these infections occur with a CD4+ T cell count between 200 and 500. Symptoms of these infections usually signal a problem with the immune system but are not severe enough to be classified as AIDS. Please refer to Appendix D for a complete checklist of symptoms.
In the 1980s, AIDS was defined to include a depressed immune system and at least one illness tied to HIV infection. AIDS-defining conditions are diseases not normally manifest in someone with a healthy immune system. These should prompt a confirmatory HIV test. The additional 1993 AIDS-defining conditions led to the diagnosis of more AIDS cases in women and injection drug users. Since 1993, the list of AIDS-defining conditions has included pulmonary tuberculosis (TB), recurrent bacterial pneumonia, and invasive cervical cancer. HIV-infected persons with a CD4+ T cell count of 200 or less are classified as persons with AIDS (CDC, 1992).
TB and invasive cervical cancer are two AIDS-defining conditions that warrant special mention. Pulmonary TB is the one AIDS-related infection that is contagious to those without HIV. It generally causes a chronic dry cough (sometimes with blood), fatigue, and weight loss. Pulmonary TB requires ongoing treatment for at least 6 months, and close associates of the infected person must be tested for TB. If TB is only partially treated (i.e., the TB patient does not take all of the medications), resistant TB will develop, which can then be passed to others. Although TB, coupled with a positive HIV test, is an AIDS-defining diagnosis, it also can occur while the CD4+ T cell count is still high. If TB occurs late in the disease after the CD4+ T cell count has dropped, it may not be found in the lungs, and symptoms may include only weight loss and fever, without a cough. It should be noted, however, that the Mantoux PPD test (a test routinely administered to screen for TB by determining reaction to intradermal injection of purified protein derivative) may not be positive if the patient is anergic (i.e., if he has sufficient immune system damage to cause inability to respond to the PPD).
Cervical cancer may progress rapidly in women with HIV but usually is asymptomatic until it is too late for successful treatment. Women who are HIV positive should have Pap tests at least once every 6 months and more often if any abnormality is found.
Most AIDS-defining diseases are severe enough to require medical care, sometimes hospitalization. Some of these diseases, however, can be treated earlier on an outpatient basis if symptoms are reported when they are mild. (Please refer to Appendix C for a complete list of AIDS-defining conditions.)
Cough is a symptom common to several AIDS-related infections, the most frequent of which is Pneumocystis carinii pneumonia (PCP--not to be confused with the drug by that name, phencyclidine). PCP is characterized by a dry cough, fever, night sweats, and increasing shortness of breath. Recurrent bacterial pneumonia (i.e., two or more infections within a year) also is an AIDS-defining condition. It often causes a fever and a cough that brings up phlegm. Coughing is also a symptom of TB. As a general guideline, if a cough does not resolve after several weeks, it should be checked by a medical practitioner.
Several skin problems can occur in HIV/AIDS. Kaposi's sarcoma (KS), a rare malignancy outside of HIV disease, may be the best-known skin condition in HIV infection. KS is a cancer of the blood vessels that causes pink, purple, or brown splotches, which appear usually as firm areas on or under the skin. KS also grows in other places, such as the lungs and mouth. KS is highly prevalent among men with AIDS, of whom 20 to 30 percent may develop the condition in contrast to 1 to 3 percent of women with AIDS (Kedes et al., 1997). However, since the introduction of combination anti-HIV therapy, KS is seen less frequently.
Diarrhea is a very common symptom of AIDS. Many AIDS-defining conditions cause diarrhea, including parasitic, viral, and bacterial infections. HIV itself can cause diarrhea if it infects the intestinal tract. Diarrhea also is a common side effect of HIV/AIDS medications. Weight loss can be caused by inadequate nutrition, untreated neoplasms and opportunistic infections (which often are associated with diarrhea), and deranged metabolism (Dieterich, 1997).
Changes in vision, particularly spots or flashes (known as "floaters"), may indicate an infection inside the eye. A virus called cytomegalovirus (CMV) is the most common cause of blindness in people with HIV/AIDS. CMV progresses very rapidly if not treated and is among the most feared of AIDS-related infections. Fortunately, it almost never occurs until the immune system is almost completely destroyed, so it is not usually the first symptom. Counselors can screen for early signs of CMV using the Amsler Grid (see Appendix D). The client also can be taught to screen himself using this screening tool.
A severe headache, seizure, or changes in cognitive function may herald the onset of a number of infections or cancers inside the brain. The two most common brain infections in HIV/AIDS are cryptococcal meningitis, a fungus that usually causes a severe headache, and toxoplasmosis, which can present with focal neurologic deficits or seizure. Seizures also can be caused by the cancer of the central nervous system called lymphoma. Progressive multifocal leukoencephalopathy (PML), a brain disease that causes thinking, speech, and balance problems and dementia also can occur as a result of HIV infection.
A person with HIV/AIDS can live an active and productive life, even with a CD4+ T cell count of zero, if infections and cancers are controlled or prevented. The newer antiviral medicines can even help the body restore much of its lost immune function. In the past few years, a phenomenon called the Lazarus syndrome has developed among patients with AIDS, wherein, because of optimal drug therapy, someone who had seemed very near death improves and returns to fairly normal function. Untreated, the disease eventually overwhelms the immune system, allowing one debilitating infection after another. Sometimes the possible combinations of medication are no longer effective, the side effects are intolerable, or no further therapy is available.
Hospice care is an appropriate choice for those who have run out of therapeutic options. In hospice care, the individual is treated for pain and other discomforts and allowed to die of the disease. Pain therapy at this stage invariably requires narcotics. It is crucial that the client and other treatment professionals understand that using opiates for pain is entirely different from using them to feed an addiction. The client will develop a need for high doses and will have withdrawal symptoms if the drug is stopped, but will not "get high." If drugs must be stopped (which is uncommon), they can be tapered under medical supervision. See Chapter 2 for a more in-depth discussion of pain management.
Hospice care allows the person with end-stage HIV/AIDS a peaceful death and a chance to address those relationships or experiences that are important. Hospice goals involve maintaining dignity and allowing the client's significant others to dictate how they will cope with this final stage.
With the advent of new and effective treatments, the epidemiology of HIV/AIDS is changing. The study of HIV/AIDS epidemiology helps to identify the trends of the disease. Surveillance of AIDS cases since 1996 shows substantial declines in AIDS-related deaths and increases in the number of persons living with AIDS, although the decline is slowing (CDC, 1999b). As people live longer with HIV/AIDS, the ability to use AIDS surveillance data alone to represent trends has diminished. It is difficult but important to track the distribution of prevalence (i.e., existing) and incidence (i.e., new) of both HIV and AIDS cases to detect changes in geographic, demographic, and risk/exposure trends (Ward and Duchin, 1997-1998).
With the mid-year 1998 edition, the CDC started to include information from both HIV infections and AIDS cases in the HIV/AIDS Surveillance Report (CDC, 1998c). It should be noted that the number of HIV cases in the report is a conservative estimate of the number of people living with HIV because not all people with HIV/AIDS have been tested (and those who have been tested anonymously are not reported to State health departments' confidential, name-based HIV registries). At the end of June 1999, 30 States and the U.S. Virgin Islands were reporting HIV cases.
This section presents an overview of the trends in the HIV/AIDS pandemic and discusses how the pandemic intertwines with substance abuse. The information is organized to provide a general look at the pandemic in the United States and its Territories, a discussion of the trends and the populations which are most at risk for contracting the infection, and a regional look at the pandemic (the regions are defined by the CDC). Finally, there is a discussion of special populations and how they are affected by the HIV/AIDS pandemic. For more detail about HIV/AIDS epidemiology, readers are encouraged to visit the CDC's Divisions of HIV/AIDS Prevention Web site, at www.cdc.gov/nchstp/hiv_aids/dhap.htm. The latest CDC HIV/AIDS surveillance reports can be downloaded, and the site provides a wealth of information about the pandemic.
To see the distribution of HIV/AIDS in the United States, see Figures 1-3 through 1-6. Figure 1-3 shows the AIDS rates for male adults and adolescents reported from July 1998 through June 1999. Figure 1-4 shows the number of adult and adolescent male AIDS and HIV cases reported from July 1998 through June 1999. Figure 1-5 illustrates the AIDS rate for female adults and adolescents reported from July 1998 through June 1999, and Figure 1-6 shows the number of female adult and adolescent AIDS and HIV cases reported from July 1998 through June 1999.
Current trends in HIV/AIDS disproportionally affect racial minority populations, especially women, youth, and children within those populations. HIV prevalence is higher among African Americans than in other ethnic groups; from July 1998 through June 1999, African Americans accounted for 46 percent of adult AIDS cases, while representing 12 percent of the total U.S. population. Hispanics accounted for 20 percent of adult AIDS cases from July 1998 through June 1999, while making up only 11 percent of the total U.S. population (CDC 1999b; U.S. Bureau of the Census, 1998). Together, African Americans and Hispanics represent the majority of AIDS cases thus far in the pandemic (CDC, 1999b, 1999c). In addition, of the HIV cases reported from the 30 States and one Territory from July 1998 through June 1999, 54 percent were among adult and adolescent African Americans, and 10 percent were among adult and adolescent Hispanics. Substance abuse is a primary mechanism by which these vulnerable groups become HIV-infected populations.
It is important to be aware that, although it is customary to categorize cases based on broad ethnic labels, this procedure glosses over fundamental ethnic and cultural differences among people of color and fails to address the underlying economic and social infrastructure that fuels the spread of substance abuse and HIV (National Commission on AIDS, 1992). Categorizing all persons with African racial heritage as "black" mixes together people of distinct ethnic and cultural heritage (e.g., ethnic descendents of African slaves, Caribbean immigrants) as well as individuals from different socioeconomic groups. Similarly, "Hispanic" refers to a multiethnic and multicultural blend of people from more than 30 geographic regions. Social, political, and economic forces have led to the "ghettoization" of African Americans and Hispanics in the inner cities where there are high rates of drug trafficking, unemployment, poverty, racism, and a lack of access to health care, all of which contribute to high rates of addiction and HIV/AIDS (National Commission on AIDS, 1992). It is within urban, poor, African American and Hispanic communities that HIV/AIDS is most prevalent.
These oppressive socioeconomic factors also have led to high rates of incarceration, sex work, and homelessness for members of African American and Hispanic communities. Drug offenses account for the highest number of Federal crimes for which people are incarcerated (Mumola, 1999). For example, a survey of new commitments to California State prisons found that more than 75 percent of the offenders had histories of drug use (California Department of Corrections, 1998). Not surprisingly, these individuals also have high rates of HIV infection (Stryker, 1993). Sex workers, many of whom are poor, homeless, and substance dependent, are likely to be more concerned with immediate needs such as housing, food, or substance abuse than HIV or substance abuse prevention and intervention (Kail et al., 1995). This is also true for the homeless or marginally housed who often are dealing with both substance abuse and mental health or mental retardation problems (St. Lawrence and Brasfield, 1995).
However, the highest HIV and AIDS rates among at-risk populations are still found among MSMs (CDC, 1999b), who from July 1998 through June 1999 represented 38 percent of AIDS cases and 30 percent of HIV cases. Minority MSMs especially are at high risk for contracting the infection. See the section "HIV/AIDS Epidemiology Among Groups" later in this chapter for further discussion of HIV/AIDS and MSMs.
HIV/AIDS is epidemic among the heterosexual population as well and is fueled by sexual contact with HIV-infected, injection drug-using, or bisexual partners. Heterosexuals located in communities with high prevalence of HIV/AIDS and addiction are at greatest risk for contracting HIV/AIDS from heterosexual contact. This type of heterosexual contact, defined generally as sexual contact with an "at-risk" person (e.g., injection drug users, bisexual man) or an HIV-infected person whose risk was not specified, from July 1998 through June 1999 accounted for about 15 percent of all adult and adolescent AIDS cases and about 17 percent of reported adult and adolescent HIV infection cases (CDC, 1999b). Of these, 61 percent of AIDS cases were women and 39 percent were men; of HIV infection cases, 68 percent were women and 32 percent were men.
From July 1998 through June 1999, there were 4,296 new AIDS cases and 2,321 new HIV cases among women who reported heterosexual contact (CDC, 1999b). Of these, 28 percent of AIDS cases and 21 percent of HIV cases were among women who reported sexual contact with injection drug users, 5 percent of AIDS cases and 6 percent of HIV cases who reported sexual contact with bisexual men, and 66 percent of AIDS cases and 72 percent of HIV cases who reported sexual contact with an HIV-infected person, without reporting the origin of the partner's infection. Of the 2,754 AIDS cases and 1,070 HIV cases for men who reported heterosexual contact, the majority reported sexual contact with an HIV-infected person without reporting the origin of the partner's infection (77 percent of AIDS cases and 80 percent of HIV cases). These data are supported by earlier research that found that HIV infection among heterosexual clients in alcohol abuse treatment, who were primarily male, was largely caused by unsafe sexual behaviors (Avins et al., 1994; Woods et al., 1996).
Figures 1-7 and 1-8 illustrate the trend of male and female AIDS cases contracted through heterosexual exposure from 1993 to 1998 by ethnicity. These figures depict only self-identified heterosexual men and women.
Early in the U.S. AIDS pandemic, the Northeast region of the United States had the most AIDS cases, followed by the South, Midwest, and the West (Figure 1-9 contains a breakdown of the States that make up these four regions plus the U.S. Territories, as defined by the CDC). In all regions, AIDS incidence increased through 1994, with the most dramatic increases occurring in the South. Between 1997 and 1998, AIDS incidence dropped for all regions, but in 1998 the South still had the highest rate (43 percent), followed by the Northeast (28 percent), the West (17 percent), the Midwest (8 percent), and the U.S. Territories (3 percent) (CDC, 1999b). Figure 1-10 demonstrates the change in AIDS incidence of the regions for 1996, 1997, and 1998.
The HIV/AIDS pandemic is evolving differently in different regions of the United States, just as drug use varies from region to region. Therefore, alcohol and drug counselors should become familiar with HIV/AIDS prevalence, incidence, and trends in their local areas, their States, and their regions. Appendix G contains a list of State and Territory departments of health (including addresses, phone numbers, and Web sites where readers can obtain information about their State). When available, State AIDS hotlines also are listed.
The 10 States and Territories reporting the most AIDS cases, in descending order, are New York, California, Florida, Texas, New Jersey, Puerto Rico, Illinois, Pennsylvania, Georgia, and Maryland. The 10 metropolitan areas reporting the highest number of AIDS cases, in descending order, are New York City, Los Angeles, San Francisco, Miami, the District of Columbia, Chicago, Houston, Philadelphia, Newark, and Atlanta (CDC, 1999b). Not surprisingly, these major metropolitan areas also are high-intensity drug-trafficking areas as defined by the Office of National Drug Control Policy (ONDCP, 1998).
The primary route of HIV transmission for MSMs is through sexual contact, which may occur while the participants are engaged in substance abuse, including IDU. Within this group, the focus of the pandemic among MSMs has shifted from older, white, urban men to poorer African American and Hispanic men, men with substance abuse problems (including IDU), and young men. Repeated studies have found that MSMs who abuse alcohol, speed, MDMA (3,4-methylene-dioxymethamphetamine), cocaine, crack cocaine, inhalants, and other noninjection street drugs are more likely than those who do not use substances to engage in unprotected sex and become infected with HIV (Paul et al., 1991b, 1993, 1994). One hypothesis about the reason for higher rates of HIV/AIDS among MSMs is that substance abuse may increase sexual risktaking. This is because substance abusers experience decreased inhibition, new learned behaviors (such as using substances and then having unprotected anal intercourse), low self-esteem, altered perception of risk, lack of assertiveness to negotiate safe practices, and perceived powerlessness (Paul et al., 1993).
As of June 1999, more than half of all cumulative male adult and adolescent AIDS cases were among MSMs who reported sexual risk only (57 percent) or sexual risk and IDU (8 percent). Of cumulative HIV cases among adult and adolescent males, 45 percent reported sexual risk only and 6 percent reported sexual risk and IDU (CDC, 1999b). Even though the cumulative total of AIDS cases among MSMs is still highest in white men (62 percent white, 23 percent African American, 14 percent Hispanic), new AIDS cases among MSMs indicate that the disparity between cases among whites and among minorities is narrowing. From July 1998 through June 1999, 53 percent of AIDS cases were among white men, 29 percent were among African American men, and 16 percent were among Hispanic men. Figure 1-11 illustrates the trend of MSM AIDS cases by ethnicity from 1993 to 1998.
As with injection drug users, minority MSMs are disproportionately affected by HIV disease. African American and Hispanic MSMs, compared with their white counterparts, are more likely to inject drugs, to be substance abusers, to be poor, to be paid for sex, and to engage in higher rates of unprotected anal intercourse (National Commission on AIDS, 1992; Peterson et al., 1992). Sociocultural factors, combined with some community values (e.g., machismo, family loyalty, sexual silence) and lack of access to health care and substance abuse treatment, strongly compete with safe sex and drug practices among gay and bisexual men of color (Diaz and Klevens, 1997).
Sex networks and sexual mixing patterns (Renton et al., 1995) are hypothesized to explain the higher risk of HIV infection related to substance abuse among MSMs. MSM substance abusers may form tight groups characterized by higher HIV seroprevalence rates, higher sexual mixing, greater IDU, and more trading of sex for money, food, and drugs. These factors are another way to account for higher HIV risk-taking sexual behaviors among MSM substance abusers.
A recent study reported that the confirmed rate of AIDS cases among incarcerated people in State and Federal prisons is more than six times higher than in the general population. About 2.3 percent of all persons incarcerated in the United Sates in 1995 were HIV positive, and about 0.51 percent had confirmed AIDS (MacDougall, 1998; Maruschak, 1997). According to the Bureau of Justice Statistics in the U.S. Department of Justice, in 1997, 57 percent of State prisoners and 45 percent of Federal prisoners said they had used drugs in the month before committing their offense. In addition, 83 percent of State prisoners and 73 percent of Federal prisoners said they had used drugs at some time in the past. Even with these high rates, which increased between 1991 and 1997, substance abuse treatment services declined during the same time period (Mumola, 1999).
In 1991, only 1 percent of Federal prison inmates with substance abuse disorders received appropriate treatment. For those who completed treatment there were no aftercare services in place to help them remain abstinent after they got out of prison (U.S. General Accounting Office, 1998).
Most incarcerated people who have HIV are infected before they enter prison. One study of 46 prisons found an HIV infection rate of 1.7 percent among people entering prison (Withum, 1993). In some correctional facilities, HIV infection rates are as high as 20 percent among women and 15 percent among men. For MSMs, HIV infection rates ranged from 9 to 34 percent; among injection drug users the infection rate ranged from 6 to 43 percent.
HIV/AIDS and substance abuse interventions implemented in prisons have a great potential to impact the HIV/AIDS pandemic (MacDougall, 1998). Like the HIV-infected population, the incarcerated population has an overrepresentation of minority groups and is characterized by high poverty, overcrowding, IDU, high-risk sexual activities, and poor access to health care. Incarceration presents an opportunity to screen, counsel, and educate inmates about HIV/AIDS, and to provide substance abuse treatment as well. For many incarcerated persons, this may be their first contact with medical interventions as well as with substance abuse treatment.
When prison inmates return to society, their health status will have an effect on the community to which they return. A study of Hispanic inmates in California found that 51 percent reported having sex within the first 12 hours after release and that they preferred not to use condoms (Morales et al., 1995). In addition, 11 percent reported IDU in the first day after release.
The sex workers who are most vulnerable to contracting and transmitting HIV are street workers, who often are poor or homeless, may have a history of childhood abuse, and are likely to be alcohol or drug dependent. A CDC study of female sex workers in six U.S. cities found an HIV seroprevalence of 12 percent, ranging from 0 to 50 percent depending on the city and the level of IDU (CDC, 1987a). A study of male sex workers in Atlanta found an HIV seroprevalence of 29 percent, with the highest rates among those who had receptive anal sex with nonpaying partners (Elifson et al., 1993).
IDU was the main risk factor for HIV infection for female sex workers in six U.S. cities (CDC, 1987a). Female injection drug users who trade sex for money or drugs are more likely to share needles than female injection drug users who do not engage in sex trading (Kail et al., 1995). The circumstances in which sex workers live also increase their chances of contracting HIV. For example, they may agree to unprotected sex if a client offers more money, if they are desperate for money to buy drugs, or if business has been slow. Violent clients may force unsafe sex, and in many cities police confiscate condoms when they arrest or stop sex workers. HIV prevention outreach to sex workers is difficult because prostitution is illegal. Immediate attention to concerns about food, housing, and drug addiction often take precedence over HIV prevention.
Homelessness often occurs in conjunction with substance abuse, chronic mental illness, and unsafe sexual behavior. All of these factors increase homeless people's risk for contracting HIV. A survey of 16 U.S. cities found that 3 percent of homeless people were HIV positive, compared with less than 1 percent of the general adult population (Allen et al., 1994). In other studies, 19 percent of homeless mentally ill men in New York City were HIV positive (Susser et al., 1993), and an 8 percent HIV infection rate was found among homeless adults in San Francisco (Zolopa et al., 1994).
A survey of homeless adults in a storefront medical clinical found that 69 percent were at risk for HIV because of the following factors: (1) unprotected sex with multiple partners, (2) IDU, (3) sex with an injection drug-using partner, or (4) exchanging unprotected sex for money or drugs. Almost half reported at least two of these risk factors, and one fourth reported three or more risk factors (St. Lawrence and Brasfield, 1995). Substance abuse can exacerbate HIV risks because abusers are more likely to forget to use condoms, to share needles, and to exchange sex for drugs. A survey of homeless adults in St. Louis found that 40 percent of men and 23 percent of women reported drug use, and 62 percent of men and 17 percent of women reported alcohol use (North and Smith, 1993).
Because the average period of time from HIV infection to AIDS is about 10 years, most young adults with AIDS were likely infected as adolescents (National Institute of Allergy and Infectious Diseases [NIAID], 1999). Through June 1999 in the United States, 3,564 cases of AIDS in people aged 13 through 19 were reported (CDC, 1999b). In the 13- to 19-year-old age group, 60 percent were male and 40 percent were female. When broken down by ethnic group, 30 percent were white, 49 percent were African American, 20 percent were Hispanic, and 1 percent were Asian/Pacific Islander or American Indian/Alaskan Native.
Most adolescents are exposed to HIV through unprotected sex or IDU. Through June 1999, HIV surveillance data show that there were 4,470 cases reported in the 13- to 19-year-old age group. Of those, 45 percent were male, and 55 percent were female. When broken down by ethnic group, 27 percent were white, 66 percent were African American, 5 percent were Hispanic, and less than 1 percent each were Asian/Pacific Islander or American Indian/ Alaskan Native (CDC, 1999b). Half of the infected male adolescents reported exposure through sex with men.
Almost half (42 percent) of female adolescents were exposed to HIV through heterosexual contact. Another significant trend is the number of STDs reported among adolescents: About two thirds of the 12 million cases of STDs reported in the United States each year are among individuals under the age of 25, and one quarter are among teens. This is significant because the presence of an STD can increase the risk of HIV transmission threefold to ninefold, depending on the type of STD (NIAID, 1999).
Adolescents tend to believe they are "invincible" and therefore engage in risky behaviors. Because of this belief they also may delay HIV testing, and, if they do test and are positive, they may delay or refuse treatment. Alcohol and drug counselors who work with adolescents should encourage them to be tested for HIV if they are at risk. Adolescents can be helped by having information about HIV/AIDS explained to them clearly, by drawing out information about behaviors that may have put them at risk for HIV, and by emphasizing the success of newly available treatments.
Treating HIV/AIDS is extremely complex. It can be difficult to keep abreast of the latest recommendations for the care of HIV-infected individuals at a time when knowledge of the nature and course of HIV infection is changing quickly. Therefore, it is important to seek out qualified physicians who have a history of providing services to HIV-infected individuals. This chapter is designed to assist clinicians and medical staff in providing effective medical assessment and treatment of their HIV-infected substance-abusing clients.
It is important that the medical care team have experience with substance-abusing clients because the combination of substance abuse and HIV/AIDS poses special challenges. Practitioners who do not understand the nature of substance abuse may be hesitant to prescribe potent antiretroviral therapy, fearing that substance abusers will not take the medications correctly. There are also special physical considerations for substance abusers. For example, injection drug use (IDU) is associated with very high rates of hepatitis B and C, which can damage the liver. Some medications used to treat HIV/AIDS and its complications can affect treatment for hepatitis, and their use should be planned carefully. Many HIV/AIDS treatment drugs are processed through the liver, and their effects can be either increased or decreased because of hepatitis or chronic alcohol use.
If there is no specialized practice available to the client, alcohol and drug counselors should establish a relationship with a specialty group that can be consulted by the medical care team. The most crucial time for consulting a specialist is when the client is starting, stopping, or changing HIV/AIDS treatment.
There is little doubt that adherence to antiretrovirals plays a more important role in long-term outcome than does choice of antiretroviral medications. A client who adheres to the medications will likely have a better outcome, and adherence also is important for preventing the development of drug resistance. Many barriers prevent HIV-infected substance abusers from receiving appropriate, timely medical care (see the section, "Barriers to Care for HIV-Infected Substance Abuse Disorder Clients"). However, once in treatment, their compliance may not be worse than that of other HIV-infected clients (Broers et al., 1994). A client's belief in the effectiveness of anti-retroviral therapy is positively associated with adherence to treatment (Samet et al., 1992). This shows how important it is to educate clients and include them in all aspects of the treatment process. Although a long-term relationship with a provider is based on trust, continuity and availability will also make it more likely that clients take their medications properly.
Health care providers seldom can predict which clients will comply with complex medication schedules. Primary care providers should be aware, however, that a client's relapse into substance abuse is likely to result in noncompliance with medical care. It is important that linkages be maintained between primary care and substance abuse treatment providers so that primary care providers are aware of relapses when they occur; however, it is also important to remember confidentiality rules (see Chapter 9 for more information). Other factors may prevent clients from taking medications as prescribed, such as living in an institution (e.g., a halfway house, homeless shelter, or prison). Psychiatric disorders among drug abusers may also hamper adherence (Ferrando et al., 1996).
Techniques to achieve optimal compliance among HIV-infected clients include the following:
Have support persons (e.g., case managers, family members) reinforce the importance of keeping appointments and adhering to medication regimens.
The key to encouraging client adherence is education, not only of the clients themselves but also of their families and peers. The client and those who surround her must understand why she is taking these drugs, what they do, and what side effects she may experience. The client should also understand that she may have to take additional medications or use nonmedicinal methods to alleviate the side effects, which can include nausea, vomiting, headaches, rashes, muscle pain, and diarrhea.
The clinician should familiarize the client with the names of all the medications she will be taking, including generic names, brand names, and common abbreviations. It is also important that the medical staff discuss with the client why the timing of the doses is important and how food can affect the ability of the medication to work properly. Staff members should fill out a weekly medication timetable for the client so she can easily see and remember when and how to take her medications.
Because the HIV-infected individual must take antiretroviral medications several times a day for the rest of his life, the drugs must be chosen with care. The choice should be based on the client's daily patterns and on any other medical conditions besides HIV/AIDS. Generally, the fewer doses per day and the fewer restrictions for taking the drugs, the better. (Currently, there is one once-a-day medication available--efavirenz [Sustiva]. Another drug, adefovir dipivoxil [Preveon], has been in development but is not now available.) For example, a person who is using opiates, amphetamines, or cocaine is not likely to be eating regularly, so a medicine that must be taken with food may not be the best option. Before prescribing medications, the medical care team could consult the substance abuse counselor about the client's living patterns. If the therapy is effective, clients who are well will remain so, possibly indefinitely, and those who are ill will generally improve, sometimes becoming well enough to return to or stay at work or begin seeking employment.
Side effects from medications can be difficult or frightening, but the client should not stop taking the medications without first contacting her medical practitioner. Substance-abusing clients are particularly intolerant of unexpected effects such as diarrhea or nausea but usually will continue the medication if they have been informed about such possibilities. Given the tradeoff for a healthier life, most will continue their medications as long as they know that this is less dangerous to them than the HIV itself.
Although injection drug users are one of the groups at high risk for contracting HIV, the majority of them are not in drug treatment. People who provide medical care to HIV-infected substance abusers must work to overcome the barriers that keep many of these clients out of the health care and substance abuse treatment systems and enlist clients who are in these systems to actively participate in their own care.
Substance abuse treatment programs, because of their relatively intense interaction with clients, are in a unique position to help deliver such medication-related services as supervised therapy. Different models for supervised therapy can be effective and should be developed for specific substance abuse treatment settings.
Daily dispensing has been shown to improve adherence to zidovudine (Retrovir--abbreviated as AZT), but its applicability may be limited (Wall et al., 1995). If supervised therapy is already part of a client's substance abuse treatment, it need not be changed because of HIV infection. While important for clients with tuberculosis (TB), supervised therapy also is a significant issue for clients who have difficulty following antiretroviral and Pneumocystis carinii pneumonia (PCP) prophylactic regimens because of homelessness, cognitive impairment, or lack of health insurance or money to obtain medications. This kind of supervision is particularly useful for medications that can be given only once daily or less (e.g., trimethoprim-sulfamethoxazole [abbreviated as TMP-SMX] [Bactrim DS, Septra], fluconazole [Diflucan], dapsone [Dapsone]). A potent once-a-day combination antiretroviral therapy that can be easily administered may soon be available.
Adherence to medical care means more than simply taking medications as prescribed. The foremost challenge in providing HIV/AIDS and substance abuse treatment is engaging clients and encouraging them to be active participants in their own care.
Many HIV-infected substance abuse clients may be deeply distrustful of medical providers, and some will refuse or resist treatment for fear that their HIV status will be disclosed. Strict observance of client confidentiality is an essential element of creating an atmosphere of trust in which clients can make the choices that are best for them. Encouraging clients to discuss their fears can help build trust between clients and providers. Client education facilitates client engagement and empowerment, and empowerment results in better adherence to medical care.
The client may also receive help from social support systems that can involve family members, partners, peer support groups, and local AIDS service organizations, which often provide "check-in" telephone calls. It is also likely that the client will respond well to continued positive feedback about her improving condition. For instance, knowing that her viral load has declined while her CD4+ T cell count has increased can help the client continue to tolerate unpleasant side effects (San Francisco AIDS Foundation, 1997b).
The following list of elements of a comprehensive client education program is adapted from Human Immunodeficiency Virus (HIV-1) Guidelines for Chemical Dependency Treatment and Care Programs in Minnesota (Pike, 1989). Clients who are HIV infected, whether they are symptomatic or not, should receive education about their disease status, prognosis, and treatment options. All clients with substance abuse disorders, whether HIV infected or not, should receive education about
Using support groups to connect with other clients facing similar problems can promote empowerment by helping individuals feel less isolated and overwhelmed by their problems. Specific strategies for empowering and engaging clients may include
Bringing substance abusers with HIV infection into the health care system is a significant challenge. Early treatment provides the maximum potential benefits for both individual and public health (Carpenter et al., 1997; Centers for Disease Control and Prevention [CDC], 1997c). Yet HIV-infected clients often delay seeking medical care. The longest delay occurs in the period of time before testing, which is why getting clients to test is so important. Many clients also delay treatment after they receive positive test results. According to one study, most enter medical care within 3 months of receiving positive test results, but 39 percent delay for more than 1 year (Samet et al., 1998). This study also showed that people with a history of IDU on average delayed entering medical care 19 months longer than those with no history of IDU. In the same study, men who abused alcohol delayed 15 months longer than men who did not. As a result, clients who delayed seeking treatment had lower CD4+ T-lymphocyte counts (also referred to as CD4+ T cells, T-cells, or T-4 helper cells); the median CD4+ T cell count in the study was 280, below the threshold at which HIV/AIDS-related medical therapy should be considered.
Why clients wait so long to seek medical treatment is not well understood. Factors may include lack of financial resources, fear of disclosure, lack of health insurance, lack of social support, difficulty in admitting they may need treatment, an underlying psychiatric disorder, and past problems with the treatment system. Women, in particular, may delay because of responsibilities to care for others or concerns for their children and families. Many parents from low-income families, especially those without a support system, may fear that they will be deemed unworthy because of their substance abuse and subsequently lose custody of their children. Also, individuals' feelings of helplessness about addressing their substance abuse issues may compound a general sense of helplessness about taking care of their health problems. When HIV-infected substance abusers do seek medical attention, they may do so erratically, making excessive use of acute and emergency care services and underusing primary care medical services (Stein et al., 1993).
HIV among incarcerated adults in the U.S. is six times higher than in the general population (Maruschak, 1997). The behaviors that place persons, particularly women, at high risk for incarceration (e.g., substance abuse, commercial sex work) are also behaviors that place them at high risk for contracting HIV. Continuity of medical care for incarcerated persons using anti-HIV medications is critical (Dixon et al., 1993).
Ideally, all substance abuse treatment programs should be capable of conducting HIV risk assessments and providing basic HIV/AIDS education and counseling to clients. However, this ideal has not always been achieved. Among 2,315 clients interviewed on presentation for addiction treatment in 1992-1993, only 53 percent reported previous HIV testing (Samet et al., 1999). In addition, all programs should provide access to HIV testing and pre- and posttest counseling. If programs cannot provide testing and related counseling onsite, they must have referral relationships with other agencies that will provide these services. For guidance on structuring HIV/AIDS counseling programs, providers should consult the CDC's Technical Guidance on HIV Counseling (CDC, 1993).
An integrated approach to caring for HIV-infected substance abuse disorder clients requires developing collaborations and maintaining communication among alcohol and drug counselors, HIV/AIDS medical care providers, and mental health providers. Existing links, such as those established in some managed care organizations, must be developed to expand services and improve access to care (O'Connor et al., 1992a; Selwyn et al., 1989).
The 1993 Substance Abuse Prevention and Treatment Block Grants Interim Final Rule, administered by the Substance Abuse and Mental Health Services Administration, reinforces the importance of links between substance abuse treatment and primary care services, particularly when providing services to injection drug users. For example, the regulations require that injection drug users on a waiting list for substance abuse treatment receive interim services within 48 hours of requesting them. Interim services must include referrals to HIV/AIDS health care services as well as HIV/AIDS counseling and education (see the section "Substance Abuse Prevention and Treatment Block Grant Funding" in Chapter 10).
Primary care staff providing services to HIV-infected substance abuse disorder clients should understand and be responsive to clients' needs (O'Connor and Samet, 1996). They should be aware that a client's relapse into substance abuse may result in noncompliance with medical care. In addition, staff must be sensitive to clients' prior experiences with the medical care community, cultural and language variations and issues related to race and ethnicity, sexual orientation, life experiences, and gender (see the section "Cultural Competency Issues" in Chapter 7).
At each medical visit, primary care providers should ask about the status of the client's substance abuse treatment. Documentation of ongoing substance abuse treatment is important. In certain situations, such as when a client of a program is hospitalized for medical illness, primary care physicians are required to make arrangements to ensure continuation of methadone maintenance. Also, clients need continuous reinforcement of the message that by continuing to abuse substances, they are further damaging their own health as well as placing others at risk of HIV infection (for more information about enhancing client motivation, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment, [CSAT, 1999d]).
Chapter 6 provides an overview of substance abuse treatment settings and modalities. Figure 2-1 contains a description of the various models for the provision of medical care commonly found in different substance abuse treatment settings.
Involving an HIV-infected substance abuser in a primary medical care system that provides ongoing and preventive care can be frustrating (Wartenberg, 1991). It is common for clients to lack primary medical care during periods of intense drug use. Outside of university medical centers, finding primary care physicians or clinics willing to accept HIV-infected substance abuse disorder clients can be difficult. This is partly because few primary care sites are willing to take on the financial strain of caring for uninsured or underinsured clients. Also, primary care providers generally are not educated on issues related to substance abuse or the evolving specialty of HIV/AIDS care (Samet et al., 1997). The Consensus Panel recommends connecting HIV-infected drug abusers with HIV/AIDS care providers during their substance abuse treatment. Even here, the barriers to primary medical care are apparent.
Existing primary care models should still be evaluated in order to identify how they can be modified and expanded to address the special needs of the HIV-infected, substance-abusing population (O'Connor et al., 1992b; Samet, 1995). To date, there is only one study of outcomes for clients seen in substance abuse treatment settings who are referred to available community primary care resources (Stein et al., 2000). One study that compared onsite with offsite primary care for a small group of subjects found that onsite care provided in a substance abuse treatment setting had significant continuity-of-care advantages (Umbricht-Schneiter et al., 1994).
Well-defined models exist for providing primary care to HIV-infected substance abuse disorder clients (Figure 2-2). Methadone treatment programs that provide onsite primary care medical services (whether sharing the same space or the building next door) often have been hospital- or university-affiliated programs and have benefited from a close association with affiliated medical specialists (O'Connor et al., 1992b; Selwyn et al., 1989; Sorensen et al., 1989). Onsite systems enhance client followup and adherence to therapies.
The practice of distributing clients from substance abuse treatment programs to various clinical sites for primary medical care is called a distributive care system. Optimally, primary care should be multidisciplinary, with social workers, physicians, physicians-in-training, nurses, mental health professionals, and alcohol and drug counselors included in the treatment staff. A case manager may be helpful in facilitating communication among treatment personnel (see Chapter 6 for more information). For newly diagnosed clients, linkage to accessible medical care is important to prevent delay in seeking care. Counselors and nurses must continue to encourage early entry into treatment for those people who are reluctant or face barriers such as lack of transportation or child care.
When clients are sent to referral sites for primary medical care, a communication system should be in place to ensure that appointments are kept and that information about medical care is sent back to the referral point.
A memorandum of understanding between the referral site and the primary care provider is recommended to ensure that this feedback occurs systematically. Forms for transfer of confidential information should be signed by clients at their initial visits to both primary care and substance abuse treatment sites (see Chapter 9 for additional information).
The 1993 Substance Abuse Prevention and Treatment Block Grants Interim Final Rule requires States to coordinate substance abuse disorder prevention and treatment activities with other services, including HIV/AIDS services. MOUs may be used as evidence that such coordination is being sought.
Some HIV/AIDS services may have contractual arrangements with other health care facilities. For example, clients with identified health problems, such as positive tuberculin skin test results, may be sent to a local hospital with which the referring facility has a contractual arrangement. The contractual arrangement guarantees that the client will be seen and specifies services to be rendered. Unlike referrals, a contractual arrangement contains a built-in mechanism that ensures continuity of care. Detoxification programs often have such an arrangement with medical providers.
Recommended elements of a contractual arrangement for primary medical care services are described in Figure 2-3.
This section describes a range of practices endorsed by Consensus Panel members of this TIP. Where specific treatment recommendations exist or where data strongly indicate that a particular intervention is better than alternative treatments, this information is clearly stated. Where there are arguments for and against a particular intervention, both the advantages and disadvantages are provided.
The Consensus Panel wishes to provide clinicians treating HIV-infected substance-abusing clients with current information on which to base clinical decisions that are in the best interests of their clients. This section also provides basic information to treatment personnel who are not physicians. Many excellent online sources of information about current HIV/AIDS care are listed in Appendix F, with special reference to primary care and outpatient management.
See Appendix C for a description of the clinical categories of HIV and AIDS. See Chapter 1 for a discussion of the origins and development of HIV and AIDS.
The best time to treat HIV is as early as possible. The sooner an HIV-infected individual receives treatment, the more likely his survival will be prolonged and his symptoms less dire. In the 1980s and early 1990s, researchers focused on determining the best time to begin HIV treatment. Initially, this was thought to be the stage at which a CD4+ T cell count of 500 is reached. However, due to the inadequacy of viral suppression, the virus quickly developed resistance and resumed reproduction, and the benefits were lost. Now, however, combinations of three or more different medicines are used to treat HIV, each medicine working in a different way to fight the virus. Figure 2-4 illustrates how drug therapy works at various stages in the life cycle of HIV. Most researchers agree that an HIV-infected individual with a detectable viral load who is ready to begin treatment should do so at once. The availability of new antiretroviral agents and rapid acquiring of new information have led to updates in treatment guidelines on a regular basis. Some clinicians prefer to wait until the CD4+ T cell count drops below 500 or the viral load rises above 10,000 (CDC, 1998h). Before beginning HIV treatment, however, the client must be ready to commit to taking these medicines every day for the rest of her life (i.e., must be in a stage of "treatment readiness"). Any deviation from the medication schedule can foster the development of drug resistance and hasten the appearance of AIDS.
The client should also be mentally and emotionally ready to undergo treatment because compliance will depend on his willingness to adhere to the medication schedule. Self-efficacy theory (Bandura, 1977) describes the necessity that an individual believe not only that an action will achieve its desired goal but also that he will be able to perform the action effectively. If the individual receives reinforcement from many sources that the medications are effective and that it will be possible to take them correctly, he is more likely to make the attempt. Substance abuse treatment professionals can play a key role in this process. With their understanding of the day-to-day realities of their clients' lives (e.g., barriers such as homelessness), alcohol and drug counselors can aid the clinician in choosing a drug regimen that the client will be able to follow.
Although combination therapy is the most effective treatment to date, once an individual begins this form of treatment, she cannot stop taking any of the medications because the virus can then develop resistance to that medication and possibly to other related antiretroviral medications. Resistant viruses can be transmitted to others and may make treatment difficult or impossible. Although combination therapy can be complex, the counselor should strongly discourage the client from taking only some of the pills, taking "drug holidays" (which was a common practice and recommendation with AZT monotherapy), or skipping doses because these practices lead to resistance. If there is a need to discontinue any antiretroviral medication for an extended time, clients should be advised of the theoretical advantages of stopping all anti-HIV medications rather than continuing one or two agents.
Resistance occurs when a virus no longer responds to a drug. All viruses have the ability to learn from and possibly outwit human immune system defenses. As HIV multiplies, it makes random changes in its genetic code, which allow it to escape human immune system defenses and the suppressive effects of anti-HIV therapy. An anti-HIV drug regimen that is not followed properly can speed up this process. When a therapy does not completely suppress HIV replication, the virus produces mutations that can replicate despite the presence of anti-HIV medications. If unchecked, these mutations will significantly change the original virus, and this new, stronger version of the virus is considered to be drug resistant.
Cross-resistance occurs when a virus develops resistance to one medication, which automatically makes it resistant to other related medications. When HIV develops resistance to indinavir (Crixivan), for instance, it can also become resistant to ritonavir (Norvir). If resistance develops to one protease inhibitor (PI), then it is likely that HIV has become cross-resistant to other PIs (San Francisco AIDS Foundation, 1997b). Resistance and cross-resistance have become the most serious setbacks in the struggle against HIV/AIDS since the development of combination therapy.
Postexposure prophylaxis (PEP) is an HIV treatment administered within 72 hours after exposure to HIV. An individual who has been exposed to the virus can prevent it from becoming established in her body if she treats it very quickly. PEP involves taking a multidrug combination that will stop the virus before it damages the immune system.
When someone is exposed to HIV, his immune system cells carry the virus to the lymph nodes, where it begins to rapidly replicate. Within 3 to 5 days, new virus particles then spill out into the bloodstream and flood the body. This is the stage of acute HIV infection that PEP is aimed to prevent. If this can be averted, the individual may be able to clear the virus, and his immune system can safely destroy what remains (CDC, 1998f).
PEP must begin before the individual tests HIV positive and before HIV is detected on a blood viral load test. However, early treatment even after this 3- to 5-day "window of opportunity" can still slow the advance of the disease. The standard PEP treatment is a combination of three antiretroviral medications.
PEP is not a "morning-after" drug. It requires a month of daily treatments, which can produce unpleasant side effects. It is expensive, and it is not FDA-approved. Because of these factors, many insurance plans do not cover it. Also, there are concerns within the HIV treatment field that using powerful anti-HIV drugs too often may create resistance in the virus. Consequently, PEP should be administered only to health care workers who have received significant occupational exposure and in cases of accidental sexual exposure (for example, if a condom breaks or someone is raped) (San Francisco AIDS Foundation, 1997a).
Counseling and testing prior to and after HIV antibody testing has multiple goals. It is used to explain the limitations of the HIV test, to help persons assess their risks, to encourage and reinforce behavior change, and to refer infected individuals to clinical care. All counseling should be performed by a counselor trained in HIV counseling. Test results should be discussed face to face with the client (rather than by telephone or mail), and appropriate precautions must be taken regarding confidentiality of test results and potential adverse effects of testing, such as psychological stress.
Testing for HIV is a difficult decision and always an individual one. Because more effective HIV therapy is now available, an individual has more treatment choices. Treating HIV when it is discovered late is more difficult. Typically, it takes a few weeks to obtain results from standard HIV tests; unfortunately, many people who are tested do not return to learn their results. However, new rapid HIV tests are being developed (e.g., OraSure_) that can produce reliable results in hours instead of days; this may substantially increase the number of individuals who learn about their HIV status (CDC, 1998h). The sensitivity and specificity of rapid HIV tests are comparable to enzyme immunoassay tests.
Another testing option is home sample collection (HSC) tests, which allow people to test themselves for HIV. Currently, two HSC tests have been approved by the FDA. The user performs a finger stick and mails the specimen, identified by an anonymous code number, directly to the laboratory. The user later calls a toll-free number to obtain test results, counseling, and referrals (Branson, 1998). All positive home tests should be confirmed by a supplemental test.
If a person at high risk is unprepared for a positive result or unwilling to consider treatment, an HIV test may not be helpful. On the other hand, if a person has an overwhelming fear or preoccupation with HIV, it may be wise to test, even if the risk is fairly low. For those clients who may be unprepared for a positive test result, pretest counseling may be necessary. Usually more than one pretest counseling session is held to better prepare the client before she takes the test. Another alternative is group counseling for preparing clients for HIV testing before formal pretest counseling begins.
HIV testing may be either anonymous or confidential, depending on the local laws, or both types of testing may be available. Confidential testing means that the person tested will give his name, which is reported to the State health department. Anonymous testing means that the person does not have to give his name, and no name is reported to anyone. There is much controversy surrounding HIV reporting systems.
By the beginning of 1999, 30 States had established name-based reporting systems for HIV. Of these, 11 also eliminated their anonymous testing sites. New York's law, passed in 1998, includes a partner notification provision. Three other States use unique identifier systems, where, instead of by name, clients are identified by a code combining their gender, race/ethnicity, birth date, and social security number. Three more States introduced HIV reporting bills in the 1998 legislative session that never became laws (CDC, 1999a; Fuentes, 1999). Supporters of name-based reporting, including the CDC, believe that these programs will help generate more accurate statistics concerning the spread of HIV. Opponents argue that these systems will deter people at high risk from being tested. For example, populations such as immigrants or women may not be tested because of the social risk involved in disclosure (Shelton, 1998). Alcohol and drug counselors and HIV primary care personnel should be aware of the reporting requirements in their States.
Before testing, the client's level of risk for HIV should be considered. This level can be determined by how often the client has engaged in risky behaviors. Anyone with a history of drug use should be tested because the seroprevalence in this group is much higher than in the general population. Someone who has a higher number of lifetime sexual partners is at higher risk for HIV, especially if she has engaged in high-risk behaviors. Anyone with a sexually transmitted disease (STD) should be tested. Whatever a person's risk level, it is important to remember that it only takes one exposure to HIV to become HIV-infected.
Certain symptoms might also indicate the need for an HIV test. If someone who has engaged in risky behavior has flulike symptoms, this might indicate a recent infection with HIV and the need for testing. Shingles (herpes zoster) also is a common early sign of HIV infection, causing a painful rash that occurs in a line on only one side of the body. Oral thrush in a nonpregnant adult also indicates immune dysfunction, as does chronic diarrhea, night sweats, weight loss, or fevers. Recurrent vaginal yeast infections are a common sign of HIV infection in women. TB is increasingly problematic among those with HIV infection and can occur even when the immune system is in good condition. Symptoms of TB include a chronic cough and fever.
After initial infection, there often is a long period of time (several years) during which an infected person may appear and feel healthy. Unfortunately, this means that the signs of later stage HIV disease will be the first signals that something is wrong. Many people, especially injection drug users, are hospitalized for HIV-related pneumonia or other serious diseases before they even discover they have HIV.
CD4+ T cells are the subset of white blood cells in the immune system that are specifically targeted by HIV. Although HIV also infects other types of cells, the virus's effects on CD4+ T cells cause most of the immunosuppression characteristic of HIV disease.
CD4+ T cell counts generally are the markers for the stage of a client's HIV disease. A normal CD4+ T cell count ranges from 500 to 1,400 (Laurence, 1993). Although they reflect the overall status of the immune system and are presumed to reflect the stage of illness, CD4+ T cell counts can fluctuate over time. Results can also vary among different laboratories and be affected by factors such as coexisting illnesses and time of day. (Measuring CD4+ T cell counts during acute coexisting illness is not generally recommended.) To obtain the most accurate information about trends in a client's CD4+ T cell levels over time, counts should be taken twice initially at intervals a few days apart and periodically thereafter. To increase reliability and consistency of results, tests should be done at the same laboratory each time, if possible. The CD4+ T cell percentage, or the percentage of lymphocytes that are CD4+ helper cells, is an additional measurement often performed as part of basic CD4+ lymphocyte subset studies. The CD4+ T cell percentage, which includes the CD4+ helper cell count, may show less variability than the CD4+ T cell count. Long-term therapy may be based on the results of these tests.
It is important to remember that CD4+ T cell counts are only an indirect measure of viral activity; they measure the effects of the virus on the target cell, not the activity or virulence (capability of causing disease by breaking down protective mechanisms of the host) of the virus itself. Viral load tests, described in the next section, quantify viral levels in blood and determine strain type and other indicators of virulence.
Despite their limitations, CD4+ T cell measurements are useful for indicating points at which treatment decisions should be made. The average yearly decline of CD4+ T cell counts in HIV-infected clients is 30 to 90 cells per year; however, the rate of decline can vary (Mellors et al., 1997). Some clients' CD4+ T cell counts decline rapidly, while others remain stable for long periods. There is no evidence that CD4+ T cell counts decline more rapidly in HIV-infected substance abusers than in other HIV-infected populations (Graham et al., 1992; Margolick et al., 1992; Saag, 1994).
The plasma HIV RNA level has been shown to be the strongest predictor of the progression to AIDS (Mellors et al., 1997). The test measures the number of viral particles per milliliter of plasma. As with CD4+ T cell counts, test results can vary depending on many factors. Viral load testing should not be done during a coexisting infection or within 4 weeks of a vaccination. Currently available commercial test kits can measure down to 50 copies per milliliter, and more sensitive viral load assays are available with a sensitivity of 5 copies (U.S. Department of Health and Human Services [DHHS] and the Henry J. Kaiser Family Foundation, 1997).
Quantification of HIV RNA is the best method of monitoring the client with HIV infection, particularly when antiretroviral therapy has begun. However, viral load tests are expensive, and some insurance plans do not cover repeated use of these tests. Higher levels of HIV RNA suggest greater viral replication and correlate with the number of acutely infected cells as well as with an accelerated rate of disease progression. Therefore, reducing the viral load as closely as possible to undetectable levels is the optimal goal. By using viral load data along with the client's CD4+ T cell count, clinicians can estimate the time to AIDS or death for clients who choose not to take or are unable to take antiretroviral medications.
Medical care provided to HIV-infected individuals varies depending on the stage of the infection, but all clients should receive evaluation and followup (O'Connor et al., 1994b; O'Connor and Samet, 1996). Assessment of the behaviors associated with HIV transmission, such as unsafe sex and substance abuse practices, is an important part of the initial client assessment.
At the initial assessment and periodically thereafter, substance-abusing clients should receive risk assessments and comprehensive medical examinations. These examinations can be performed onsite or at another facility through referral or a contractual arrangement.
A thorough medical history is an important first step that helps the clinician proceed to clinical evaluation and formulate a treatment plan. Taking the history may occupy an entire client visit, particularly if it is combined with education and counseling. When taking a medical history, health professionals should consider the following:
Although HIV and its complications may involve nearly every organ, the HIV-directed general physical exam should focus on (1) the skin, (2) the eyes, (3) the mouth, (4) the anogenital region, (5) the nervous system, (6) the lymphatic system, and (7) client weight and temperature. Knowledge of a client's immune status may also direct the physician toward screening other areas. For example, the eyes should be examined for retinitis in clients with very low CD4+ T cell counts. If the client has particular complaints or other chronic conditions such as diabetes or asthma, the exam should focus on those conditions.
Topical fungal infections are common (e.g., candidiasis, angular cheilitis at corners of lips).
Most HIV-infected persons have palpable lymph nodes at some point during the course of disease. Such nodes--which may involve multiple sites--do not predict disease progression but often cause discomfort and distress. Clients should be reassured that these nodes are common and often spontaneously increase and decrease in size. If a client experiences a rapid or continuous enlargement, worsening pain, or drainage in a particular node, it should be examined to rule out an opportunistic infection or malignancy. In the case of unexplained constitutional symptoms, node biopsies can be useful to search for evidence of systemic infection.
Before antiretroviral therapy is initiated in any client, certain laboratory studies should be done. The suggestions listed here should be adapted to the particular circumstances of a client and physician.
Clinicians providing care to HIV-infected substance abusers must be familiar with the clinical manifestations of HIV disease and also be aware that these manifestations can be difficult to distinguish from common medical complications of substance abuse. Differential diagnoses in HIV-infected substance abusers can be challenging because both HIV infection and substance abuse have clinical effects on a wide range of organ systems. It is important to consider the possibility of adverse drug reactions or interactions for those clients who are taking HIV medications (see the section, "Pharmacologic Interactions," later in this chapter). To provide optimal care to this population, clinicians must be fully aware of the combined medical effects of substance abuse, HIV infection, and HIV medications (O'Connor et al., 1994a). Figure 2-6 lists the common symptoms that may be related to either HIV infection or substance abuse.
Anorexia, weight loss, and fatigue may be complications of chronic cocaine use, caused by HIV infection, symptoms of specific AIDS-related opportunistic infections (e.g., mycobacterium avium complex [MAC], cytomegalovirus, TB, or side effects of medications). Tachycardia, flulike illness, fatigue, abdominal pain, and diarrhea may be symptoms of drug withdrawal, particularly opioid withdrawal, or they may be symptoms of acute or chronic HIV-related conditions.
Chest pain, coughing, and shortness of breath may be symptoms of crack cocaine use, bacterial pneumonia, or HIV-related pulmonary infections such as PCP. Bacterial endocarditis with fever, night sweats, and chest pain or other pulmonary effects may result from unsterile intravenous injection or may indicate HIV-related opportunistic infection. Heavy cigarette smoking in injection drug users may also make it difficult to interpret symptoms such as shortness of breath or the results of pulmonary function tests. HIV and its related opportunistic infections commonly affect the nervous system, resulting in conditions such as HIV-related dementia, CNS cryptococcosis, toxoplasmosis, and HIV-related peripheral neuropathy. Drug intoxication or withdrawal also can affect consciousness, cognition, and behavior. Heroin and cocaine use may cause stroke syndromes and other cerebrovascular diseases. Alcoholic, nutritional, and traumatic peripheral neuropathy syndromes may also be more common in substance abusers than in the population as a whole.
In 1998 the prevalence of depression among HIV-infected persons was estimated at 30 to 40 percent. It may be higher among persons with substance abuse disorders and those symptomatic with AIDS. Increasing symptoms, progressive disability, and decline in function may bring sadness, anxiety, fear, insomnia, and a feeling of being overwhelmed. Substance-dependent persons may have few coping resources (other than substance abuse). Grief over the loss of loved ones (who may also have had AIDS) can be severe. Clinicians should make every effort to make definitive diagnoses. Situational anxiety or depressive symptoms can be treated with supportive psychotherapy. Support groups, both HIV-related and others, and encouragement toward social and family interaction are important parts of treatment. Pharmacologic interactions may be needed in severe, persistent sleep disturbances, major depression, generalized anxiety, and posttraumatic stress disorders.
HIV disease is now seen to fit the pattern of a chronic disease (with complications and remissions) rather than an illness that appears suddenly and progresses rapidly to death. Clients periodically need acute care inpatient resources, especially in the latter stages of the disease. However, as clients experience longer asymptomatic periods between illnesses, the emphasis increasingly is on ambulatory management and primary care for HIV infection.
Medications to control HIV infection have become more available. The most effective treatment is a combination of three or more different medications. Most often, two of the medications are nucleoside reverse transcriptase inhibitors (NRTIs), and the third can be either a nonnucleoside reverse transcriptase inhibitor (NNRTI) or a PI. Combination therapy with three or more medicines generally reduces the viral load to near or below the level of detection. There are currently six FDA-approved NRTIs, one nucleotide, five PIs, and three NNRTIs, and thus many potential combinations would seem to be possible. However, once a medication from a certain class is used (e.g., PIs, NRTIs), the likelihood increases that the virus will develop resistance to some or all other drugs in that class, so the options quickly become very limited. This is known as cross-resistance. For this reason, it is widely believed that the best chance for success in HIV treatment is with the first treatment regimen, which is why adherence and followup are so critical.
All the medications administered in combination therapy have side effects and specific requirements for use. For example, AZT may be given with lamivudine (Epivir, also known as 3TC) as the two NRTIs. These both can be taken either with or without meals. A possible side effect of AZT is anemia. The clinician may add the PI indinavir, which cannot be taken with food or with other medications and also requires the client to drink a great deal of water because it causes kidney stones. A newly described side effect of PIs is weight gain in the trunk, while the arms and legs become thinner (lipodystrophy), and for women the central distribution of weight often causes breast enlargement.
Care strategies have incorporated both antiretroviral therapy and a wide range of prophylactic regimens to effectively prevent opportunistic infections. A recent study found, however, that preventive interventions such as TB prophylaxis and pneumococcal vaccine were used by only about 30 percent of eligible clients, and use of preventive interventions was lowest among HIV-infected injection drug users (Glassroth et al., 1994).
Little is known about interactions of HIV medications with street drugs, and a specialist should be consulted about interactions, even for over-the-counter drugs. PIs have the greatest potential for interacting with other drugs. For example, PIs can prevent amphetamines from leaving the system, which then build up to toxic or deadly levels. Heroin, on the other hand, may be metabolized more quickly (Horn, 1998). See Figure 2-7 for a listing of interactions between HIV medications and street drugs.
The goal of antiretroviral therapy is to improve the length and quality of the client's life. None of the medications currently available to treat HIV-infected clients is a cure, but, used in combination, they can decrease viral replication, improve immunologic status, delay infectious complications, and prolong life. The ideal time to begin antiretroviral therapy remains debatable; immune damage occurs over time, which suggests that all HIV-infected people may eventually benefit from treatment. However, given that the virus has not been eradicated, antiretroviral medications once started must be taken for the rest of the client's life.
Although there is theoretical benefit to treating asymptomatic clients with CD4+ T cell counts greater than 500, no long-term benefit has yet been demonstrated. Those with high CD4+ T cell counts and very low HIV RNA levels may consider delaying therapy. The major dilemma confronting clients and providers is that the antiretroviral regimens with the greatest potency in viral suppression and CD4+ T cell count preservation are the most medically complex and are associated with a wide array of side effects and drug interactions (see the section, "Pharmacologic Interactions").
The decision to begin antiretroviral therapy in the asymptomatic client is difficult and often involves multiple visits to review treatment options. The factors to consider include(1) client willingness and readiness to begin therapy and remain adherent; (2) the degree of immunodeficiency; (3) the risk of disease progression as determined by plasma HIV RNA; (4) the risk of side effects; (5) the ongoing treatment of other medical conditions, such as diabetes; (6) barriers to care, such as lack of insurance and unstable housing; and (7) stability in drug use patterns and substance abuse treatment (see Figure 2-8). It is important to remember that combination therapies do not work for everyone, even for those who do follow the directions. Many long-term survivors of HIV have experienced very little improvement on the new medications.
Once the client has decided to undergo treatment, the goal of therapy should be to suppress plasma viral load to undetectable levels. Based on current data, the preferred treatment regimen is two nucleoside analogs and one PI (Figure 2-9). Alternative regimens have been used, including two PIs together with one or two NRTIs or substituting an NNRTI for the PI in a three-drug regimen. Monotherapy, the standard of care before 1995, is now outdated. If a client is only on one medication, the provider should examine this further and educate the client on current standards of care.
Highly active antiretroviral therapy (HAART) is a combination of antiretroviral regimens that incorporates at least three antiretroviral drugs. Treatment with HAART has resulted in longer survival and improved quality of life for many people with HIV. This therapy is now considered the standard of care by most HIV specialists.
Resting CD4+ T cells are among the "safe havens" where HIV may persist for years interwoven into the cells' genes despite aggressive three-drug antiretroviral therapy. New therapies to attack these "safe havens" are under study. In resting CD4+ T cells taken from the bloodstream of a small number of study clients receiving interleukin-2 plus HAART, researchers were unable to find HIV that was capable of replicating, even when they looked for the virus in millions of cells with sensitive laboratory procedures (Folkers, 1998).
HAART may be beneficial at all stages of HIV disease, from initial exposure through acute and chronic infection and when AIDS symptoms are present. In general, people at earlier stages of HIV disease receive the most long-lasting benefits from HAART, particularly those individuals who have never undergone HIV treatment. Those with advanced AIDS and those who have used anti-HIV drugs for years generally benefit less from HAART. For reasons that are not yet completely understood, some HIV-infected persons cannot tolerate the side effects of therapy with PIs or do not benefit from them (San Francisco AIDS Foundation, 1997c).
A typical HAART regimen includes a PI when used with two NRTI analogs. Many three- and four-drug combinations can reduce HIV to very low levels for sustained periods. For example, the NNRTI class of medication may be added to or substituted for a PI in combination with two NRTI analogs. Some physicians recommend using didanosine plus hydroxyurea, an anticancer drug, in combination with a PI and an additional NRTI analog. When beginning anti-HIV therapy with ritonavir (six 100-mg capsules twice a day for a total of 1,200 mg daily) and nevirapine (Viramune) (one 200-mg tablet daily for 2 weeks, then twice daily), these drugs are first administered at lower doses, then slowly increased to lessen the possibility of side effects. Medications used in the treatment of HIV (including those expected to become available shortly) are summarized in Figure 2-10. Figure 2-11 presents a schedule and side effects for NRTIs, NNRTIs, and PIs.
AZT, the first approved antiretroviral agent, taken in combination with didanosine or lamivudine is more effective than AZT alone in slowing progression to AIDS and prolonging survival. AZT plus lamivudine with or without a PI has been recommended for prevention of HIV infection after a needlestick or sexual exposure. AZT alone given to pregnant HIV-infected women at 14 to 34 weeks of gestation reduces transmission of the virus to their babies from 26 to 8 percent, but many clinicians now favor combination treatment for pregnant women. Adverse effects include anemia, neutropenia, nausea and vomiting, headache, and muscle aches. For many substance abusers, the side effects of AZT mimic substance withdrawal, especially from opioids.
Lamivudine used with AZT decreases viral load and may decrease the emergence of AZT-resistant isolates. It also is commonly used in combination with stavudine (abbreviated as D4T) (Zerit) and didanosine. Side effects include headache, nausea, diarrhea, abdominal pain, and insomnia. Lamivudine and AZT have been combined into a single pill (Combivir) for convenience.
Stavudine is most often used as a substitute for AZT in initial combination therapy, or after failure of AZT-containing regimens. When combined with didanosine or lamivudine, stavudine has potent effects. It causes dose-related peripheral sensory neuropathy, which often disappears when the drug is stopped and may not recur when it is restarted at a lower dose. Subjective complaints are infrequent and include headache, gastrointestinal intolerance with diarrhea, or esophageal ulcers. Liver function tests may increase, and pancreatitis has occurred but is rare.
Didanosine is mainly used in combination with AZT and stavudine, plus a PI or NNRTI. Treatment-limiting toxicities of didanosine include peripheral neuropathy, pancreatitis, and diarrhea. Severe lactic acidosis and retinal depigmentation also can occur. Clients with a history of pancreatitis should avoid didanosine.
Onset of abdominal pain should prompt an evaluation for possible pancreatitis. Miscellaneous side effects include rash, marrow suppression, hyperuricemia, hypokalemia, hypocalcemia, and hypomagnesemia.
Zalcitabine (Hivid) can be used in combination with AZT but is the least potent of the nucleoside analogs. Side effects include peripheral neuropathy, rash, stomatitis, esophageal ulceration, and pancreatitis.
Abacavir (Ziagen) is used primarily in combination with AZT and lamivudine. It may be part of a regimen containing a PI. The side effect of greatest concern is a hypersensitivity reaction that appears within the first 6 weeks of therapy, most commonly in the second week. Fever, nausea and vomiting, malaise, diarrhea, and sometimes rash occur. These symptoms intensify with each dose to the point of intolerability. If abacavir is discontinued because of hypersensitivity, rechallenge can result in serious, rapid, and possibly deadly recurrence of symptoms.
Like NRTI analogs, these drugs inhibit reverse transcriptase but by a different mechanism.
Neviripine (Viramune) acts synergistically with nucleosides but must be combined with other medications to avoid rapid development of resistance. Trials of neviripine with AZT and didanosine have been effective in lowering HIV RNA to undetectable levels for up to 1 year.
Delavirdine (Rescriptor) acts synergistically with nucleosides and PIs. It should be used in combination with at least two other medications. The main side effect is a rash.
Efavirenz (Sustiva) also acts synergistically with nucleosides and PIs. It can be given in one daily dose and is used by many physicians as a first-line treatment for HIV. Side effects include rash and central nervous system disturbances, of which the most common is "disconnected" sensations such as confusion, abnormal thinking, impaired concentration, depersonalization, abnormal dreams, and dizziness. Other side effects include somnolence, insomnia, amnesia, hallucinations, and euphoria.
PIs prevent the cleavage of protein precursors, which is essential for HIV maturation, infection of new cells, and replication. In clients with advanced HIV infection, a PI has led to marked improvement and prolonged survival. However, all PIs can cause increased bleeding in hemophiliacs, hyperglycemia, and new onset or worsening of diabetes.
Ritonavir is a potent HIV inhibitor, and when given to clients with advanced disease who are being treated with nucleosides, decreases progression to death compared with placebo (8 percent versus 5 percent) (Cameron et al., 1998). Common side effects include nausea (sometimes severe), diarrhea, asthenia, circumoral and peripheral anesthesia, altered taste, renal failure, and elevation in cholesterol and triglycerides.
Indinavir is a potent PI when used with AZT (or stavudine) and lamivudine, lowering the rate of disease progression and mortality more than
two nucleoside analogs alone. This triple combination effect has been durable; an early fall in plasma HIV RNA to undetectable levels can last more than 2 years. Kidney stones have been reported in 4 percent of clients, and asymptomatic elevation of indirect bilirubin occurs in about 10 percent of clients.
Nelfinavir (Viracept) is active in combination with many other nucleosides and PIs. Diarrhea has been the main side effect.
Saquinavir (Fortovase) combined with Ritonavir and a NRTI analog has been clinically effective. Diarrhea, nausea, abdominal pain, and increased aminotransferase activity can occur. The hard gel capsule is Invirase, and the soft gel capsule is Fortovase. Fortovase was introduced in November 1997 as the preferred formulation due to improved bioavailability.
Hundreds of clinical trials have confirmed the durable reduction in HIV RNA levels using three-drug combinations. Although the number of medication combinations is growing and new plans for initial and second-line therapies continue to evolve, client compliance remains a major concern. In addition to developing simple regimens, it is appropriate for the clinician to choose antiretrovirals at least in part on the basis of their side effects. For example, in clients with preexisting pancreatitis, didanosine should be used with extreme caution. For those with neuropathy, didanosine, zalcitabine, and stavudine should be used with caution.
Altered body fat distribution occurs commonly in persons with HIV on long-term antiretroviral therapy. Once thought to be seen only in PI users, changes in body dimensions--including increase in abdominal girth and breast size and wasting of leg muscles--have been noted in many patients independent of PI use and may be especially common in those who are on NNRTIs. The underlying mechanism for these troubling symptoms remains unclear, and an effective therapy is elusive (Gervasoni et al., 1999).
Criteria for changing therapy include (1) suboptimal initial reduction in HIV RNA level, (2) reappearance of viremia after suppression to undetectable levels, (3) persistent and progressive decline in CD4+ T cells, (4) development of intolerable side effects, or (5) inability to remain adherent. In all cases, the clinician must determine whether the treatment failure is caused by imperfect adherence (due to toxicity, lack of resources, or client's lack of understanding), altered absorption or metabolism of one or more drugs in a combination, multidrug pharmacokinetics, or viral resistance to one or more agents. When the decision to change therapy is based on HIV RNA, a second viral load test is needed before the decision is made.
In general, it is preferable to change all the drugs used in the failing combination, except in those instances when viral loads are undetectable and a side effect can be traced to a specific medication. In some cases where the viral load is not suppressed completely, it may be best to continue the present regimen because it has been partially effective and the client's options are limited. If the initial combination therapy was effective but the client later developed detectable viral loads, second-line (salvage) combinations are less likely to be effective.
Clients temporarily discontinue antiretroviral therapy for many reasons (Singh et al., 1996). However, there are no studies estimating the number of doses, days, or weeks missed that would increase the likelihood of drug resistance. If clients must discontinue any antiretroviral medication for an extended time, stopping all their medications simultaneously may minimize the chance of developing resistant viral strains.
Combination therapy commonly requires the client to take large numbers of pills, up to 20 per day. Arranging schedules to take medication with or away from meals, timing doses, having access to refrigeration, and keeping adequately hydrated can be a full-time job. This may be difficult for clients who are homeless, currently using drugs, relapsing, and so on, and these issues must be assessed prior to changing regimens.
Drug resistance remains an obstacle to achieving the full benefits of antiretroviral agents. HIV's rapid replication rate fuels continual production of HIV variants (mutations) that thrive under the selective pressure of antiretroviral therapy. Combination therapy that suppresses HIV replication can delay the emergence of drug-resistant virus. However, a viral load below the
limit of detection does not always mean that viral replication has completely halted, particularly in areas such as lymph nodes. Assays to measure whether HIV can grow despite the presence of a specific medication (resistance assays) are now available, but their application remains to be established.
HIV infection does not change the need for medications to treat substance abuse. The most common medications used to treat substance abuse are methadone, disulfiram (Antabuse), buprenorphine (Buprenex), and naltrexone (ReVia). In addition, benzodiazepines, barbiturates, clonidine hydrochloride, and other medications commonly are used in detoxification. These medications can be used by HIV-infected substance abusers in the same way they are used by uninfected clients. Neither maintenance nor detoxification treatment need be altered by the presence of HIV infection.
The best-documented interaction between substance abuse medication and HIV infection medication is that of methadone with rifampin (Rifadin), a drug used to treat TB or, less commonly, MAC (Kreek et al., 1976). Rifampin causes a faster breakdown of methadone in the liver and a faster decrease in plasma methadone level. This results in rapid onset of classic opioid withdrawal symptoms, usually within several days of taking rifampin. Increasing clients' daily methadone doses will prevent this outcome. Typically, the dosage is increased by 10 mg every 1 to 2 days, beginning on the day rifampin is started and increasing as needed to prevent symptoms of opioid withdrawal, titrated to prevent this oversedation. It often is necessary to continue this pattern until the dosage is at least 50 percent greater than the original daily dose. It is important for the client or the physician to inform the methadone program of changes in the client's medication.
Rifabutin (Mycobutin) is a medication structurally related to rifampin and frequently used for prophylaxis and treatment of MAC in HIV-infected clients. Rifabutin may have a pharmacologic interaction with opioids similar to that of rifampin.
Phenytoin (Dilantin) and phenobarbital (Phenob) have a similar but less dramatic effect on plasma methadone levels, causing opioid withdrawal symptoms over a period of days to weeks. It may be necessary to increase methadone dosage, but usually this increase does not have to be as great or as rapid as for rifampin. Other interactions are in Figure 2-12.
When therapy with rifampin or phenytoin is discontinued, methadone doses should, in most cases, gradually be lowered to avoid oversedation. Clients usually arrive at a final stable dose that is higher than the original dosage level before the other medications were introduced (Selwyn and O'Connor, 1992).
No clinically significant interactions have been found between AZT and either methadone or disulfiram. One study suggested, however, that elimination of AZT may be slower in methadone-maintained clients compared with a control group not receiving methadone. However, this study found no evidence that clinical toxicity from AZT was worse in the methadone-maintained group (Schwartz et al., 1990).
Only a few studies have investigated the interactions of other antiretrovirals with methadone. Early laboratory studies showed that ritonavir and indinavir may increase methadone levels; nevirapine may decrease methadone levels, and saquinavir has no effect.
However, only one study has been reported using client plasma levels; here, ritonavir decreased methadone levels by 35 percent, the opposite of what was expected from laboratory studies. Two case reports of nelfinavir decreasing methadone levels have been documented. Further work on drug interactions is needed because in vitro data may not accurately predict in vivo results. If drowsiness or other symptoms associated with methadone excess are reported, clinicians might consider lowering methadone dose using trough methadone blood levels to guide treatment. Similarly, trough levels can be used to establish whether withdrawal symptoms are due to increased methadone metabolism (Gourevitch and Friedland, 1999a).
Managing acute and chronic pain in HIV-infected, substance-abusing clients can be a challenging clinical problem (Selwyn and O'Connor, 1992). Although providers may have well-founded concerns about potential drug-seeking behavior, these concerns may interfere with clinical judgment about the appropriateness of using narcotic analgesics. Like other clients, substance abusers often are undertreated for acute pain. Medication for pain control, including narcotics, should never be withheld merely because a client has a history of substance abuse.
As with all clients in pain, the provider's primary goal is to maximize comfort while minimizing side effects. Local measures (rest, heat, ice, analgesic rubs) should be used as a first line of pain treatment where appropriate.If these measures fail to adequately relieve the pain, a systematic pharmacologic approach is recommended. Initially, over-the-counter medications such as aspirin, acetaminophen (Tylenol), and nonsteroidal anti-inflammatory agents should be used, with dosages increased as needed. Caution must be used in employing acetaminophen in clients with liver diseases such as hepatitis C, as it can worsen liver disease.
If these medications prove inadequate for pain relief, narcotic analgesia may be necessary. Because of their tolerance for narcotics, clients with opiate use disorders generally require higher doses of narcotic analgesia and more frequent dosing intervals for effective pain control. This is especially true for clients maintained on methadone. See also the section below, "Use of Unapproved Medications or Alternative Therapies."
Agents used for persistent neuropathic pain include anticonvulsants (phenytoin, carbamazepine [Tegretal], gabapentin [Neurontin]), tricyclic antidepressants (amitriptyline [Elavil], desipramine [Norpramin]), or topical agents (capsaicin [Capzasin]). These agents may be used alone or in combination with other analgesics. Acupuncture may be particularly helpful in some cases of neuropathic pain.
The treatment plan and the reason for using narcotics for pain control must be clear to both provider and patient. It is important not only that the patient know that her pain is taken seriously but also that narcotic use will not be extended beyond a time-limited period required for analgesia. Late-stage clients with AIDS who have chronic, severe pain syndromes may require long-term analgesia. Attempting to manage pain in methadone-maintained clients by increasing their daily dose of methadone is a common error. Instead, if narcotic analgesics are indicated, providers should continue the client's usual methadone dose and add a shorter acting narcotic for acute pain control. Pentazocine (Talwin) and other mixed opiate agonist-antagonists should not be used for analgesia in methadone-maintained clients because they may precipitate withdrawal.
Chronic pain management in substance abuse disorder clients is most effective if there is close primary care followup and coordination of a treatment plan with substance abuse treatment professionals. Pain management specialists should be consulted as needed to examine alternative management strategies (Selwyn and O'Connor, 1992).
Currently, no validated protocol for HIV/AIDS pain therapy exists. Because clients with HIV/AIDS often have pain problems similar to clients with cancer, the World Health Organization's (WHO's) "cancer pain analgesic ladder" is a useful starting point for managing pain in HIV-infected persons.
Additional points are as follows:
When opioids are required for pain control, the dual diagnosis of HIV/AIDS and a substance abuse disorder produces a challenge for even the most experienced clinician. Specific principles, listed below, must be followed to ensure fair assessment of the pain complaint (e.g., clients may fabricate pain to obtain drugs) and to provide the best chance of achieving satisfactory pain relief (Portenoy and Payne, 1992).
Setting clear limits and devising a consistent treatment plan help reduce the risk of medication abuse by substance-abusing clients. The following strategies are recommended:
Informal verbal "contracting" with patients about the need to discuss symptoms openly and not seek prescriptions from multiple providers should occur once trust in the primary care relationship is established. Discussing the risks of serious drug interactions may allow patients to understand provider concerns.
Clients symptomatic with AIDS are frequently prescribed narcotic analgesics and may even have an indwelling intravenous line for infusion therapy. Injection drug users are at very high risk of using this indwelling intravenous line to administer heroin, cocaine, and other drugs of abuse. It is therefore essential that clients with such lines who are at risk for misuse be cared for in residential health care settings, including hospice-based home care, where adequate monitoring and support can be provided.
Good physician-client relationships can foster client participation in clinical trials. Ongoing efforts are needed to educate clients and their families about the importance of clinical trials and to alleviate any suspicion of the medical profession. Clinicians should be aware that HIV-infected substance abusers in abstinence-based treatment programs may be reluctant to participate in clinical trials of unapproved medications because such participation reminds them of taking illicit drugs. Also, recovering substance abusers in abstinence-based treatment programs may not want to take drugs of any kind.
Specific efforts should be made to incorporate more clients with substance abuse disorders, women, and minorities into HIV clinical trials. All of these groups currently are underrepresented.
To avoid conflicts of interest, it is recommended that the clinician responsible for the clinical trial not be the client's primary care provider, if possible. When a client enters a trial, followup mechanisms for results must be in place so that this information is available to substance abuse treatment staff.
In the face of life-threatening, chronic illness, when a cure is not available, many clients will seek unapproved medications or alternative therapies. Care providers must be aware that HIV-infected clients may be using alternative or complementary therapies, for example, acupuncture, meditation, and vitamin and herbal dietary supplements. According to one study of clients with HIV in Boston (Fairfield et al., 1998), these clients used alternative therapies at a high rate; they frequently visited alternative therapy providers, incurred substantial expenditures, and reported improvement with these treatments.
Unless a therapy is known to be harmful, however, clients need not be discouraged from trying it. Clinicians have a responsibility to find out, in a nonjudgmental manner, what alternative or unapproved therapies clients are using and then to obtain as much information as possible about these therapies. This information should be shared with clients, emphasizing that the risks and benefits of these therapies cannot always be predicted. Certain alternative therapies (e.g., acupuncture, meditation, herbal teas) may actually help to decrease clients' reliance on or need for controlled substances, narcotic analgesics, sleeping medication, and so forth.
Unsupervised antibiotic use can complicate the diagnosis and treatment of bacterial infections in HIV-infected substance abuse disorder clients. Clinicians should specifically ask clients about unsupervised antibiotic use because clients may not consider the information relevant to their medication or drug use histories (Selwyn and O'Connor, 1992).
Current strategies for HIV/AIDS care include the use of prophylactic regimens to help prevent specific opportunistic infections. As clients survive for longer periods with lower CD4+ T cell counts, it is important to develop additional prophylactic regimens for infections that occur at more advanced stages of HIV (Figure 2-13). A recent review summarizes current practice regarding prophylaxis of opportunistic infections in HIV-infected clients (CDC, 1997c).
Because of the range of medications that an HIV/AIDS patient may take, another critical strategy for HIV/AIDS care is to designate someone (other than the physician) as a medication "case manager." This person would communicate with all the specialists a patient is seeing and monitor all the drugs prescribed so that no harm is done to the patient.
Pneumocystis carinii pneumonia (PCP) was the first opportunistic infection for which prophylactic regimens were developed. Since the late 1980s, widespread use of PCP prophylaxis has resulted in a dramatic decrease in incidence of this opportunistic infection. However, despite the availability of effective prophylaxis, PCP is still the most common opportunistic infection; many clients who develop PCP are unaware of their HIV status and hence are not receiving prophylaxis.
The risk of PCP increases significantly when a client's CD4+ T cell count drops to around 200. It is recommended that all clients with CD4+ T cell counts of 200 or below receive ongoing PCP prophylaxis. Because of their high risk of progressing to AIDS, HIV-infected clients with histories of oral candidiasis or other AIDS-defining infections should be offered PCP prophylaxis regardless of their CD4+ T cell levels. This includes clients who have had PCP before because there is a high rate of recurrence of PCP (more than 30 percent within 1 year).
Trimethoprim-sulfamethoxazole (TMP-SMX) (Bactrim DS, Septra) is the most effective anti-PCP medication (Bozzette et al., 1995). A single daily dose of one double-strength tablet is most commonly prescribed, although thrice-weekly dosing may be adequate. A daily single-strength tablet may also be effective and may improve adherence.
Clients who comply with this prophylactic regimen have only a 5-percent chance of developing PCP. Additionally, clients taking TMP-SMX for PCP prophylaxis may also decrease their chances of contracting cerebral toxoplasmosis and pyogenic bacterial infections. This may be especially important for HIV- infected substance abusers who are at high risk for sinusitis, bacterial pneumonia, and endocarditis.
For clients who cannot tolerate TMP-SMX, dapsone is a reasonable alternative. Dapsone, however, can cause hemolytic anemia in clients who are deficient in the enzyme glucose 6-phosphate dehydrogenase (G6PD), especially people of African descent. Therefore, clients must be screened for this deficiency before beginning therapy. The minimal effective dose of dapsone is unknown; regimens of 50 mg per day, 100 mg per day, and 100 mg three times per week are common.
Aerosolized pentamidine, in a single dose of 300 mg per month, is another option for PCP prophylaxis. The advantages of aerosolized pentamidine are that it has little, if any, systemic toxicity, and it may be the only medication a client can tolerate. However, it is clearly inferior to TMP-SMX for persons with CD4+ T cell counts below 50. Secondary breakthrough rates of PCP in clients on pentamidine may exceed 15 percent a year. In addition, extrapulmonary pneumocystosis, where clients show evidence of PCP infection outside the lung, has been seen. These manifestations occur more commonly in clients receiving only inhaled pentamidine rather than systemic prophylaxis with TMP-SMX or dapsone.
Pentamidine should be administered only in settings with adequate ventilation that are consistent with CDC standards. Not only can pentamidine administration produce bronchospasm and cough, but the coughing has been associated with transmission of TB in inadequately ventilated settings. Some substance abuse treatment programs offering onsite aerosolized pentamidine use specially designed sputum induction and pentamidine administration booths equipped with strong exhaust systems and high-efficiency particulate air filters to decrease the risk of contamination.
TMP-SMX is well tolerated, with a low incidence of side effects. However, clients with HIV infection have a higher risk of allergy to sulfonamides than other client populations and must be monitored for adverse effects. Possible side effects, which tend to be dose related, include fever, rash, leukopenia, anemia, nausea, and vomiting. Serious reactions such as Stevens-Johnson syndrome, mucous membrane ulceration, hepatitis, and serum sickness are unlikely but potentially serious.
Clients on dapsone may experience rash, gastrointestinal upset, and anemia. Less common side effects include mental state changes and peripheral neuropathy. Sulfa allergy is generally not a contraindication to dapsone. Many clients who have developed rashes on TMP-SMX are able to tolerate dapsone without adverse effects; however, they should be monitored as part of routine followup.
The current standard of care is to offer a pregnant woman PCP prophylaxis if she would be so treated if not pregnant (e.g., CD4+ T cell count less than 200, or preexisting HIV-related disease). Although the possible risks or benefits to the fetus are uncertain, it has become standard to use TMP-SMX until 36 weeks of gestation and then change to aerosolized pentamidine to prevent neonatal exposure to sulfonamides (which can cause jaundice in the newborn).
Cerebral toxoplasmosis, another common opportunistic infection in clients with AIDS, occurs most frequently in people who previously had a positive antitoxoplasma antibody test. Serologic testing for toxoplasma antibody is recommended as part of the basic primary care approach to HIV infection, in order to detect clients at high risk for this opportunistic infection.
For clients with CD4+ T cell counts below 100, a positive antitoxoplasma antibody test is reason to consider toxoplasmosis prophylaxis. TMP-SMX also offers protection against the development of toxoplasmosis, but for clients who cannot tolerate TMP-SMX it has been suggested that dapsone plus pyrimethamine may provide effective prophylaxis against toxoplasmosis as well as PCP. Practitioners may also want to remind clients who own cats that changing cat litter without gloves and a mask may put them at higher risk for toxoplasmosis. Clients with a history of toxoplasmic encephalitis and other diseases from toxoplasmosis are maintained on chronic suppressive therapy with sulfadiazine (Sulfadine) and pyrimethamine plus folinic acid.
Clients with AIDS also are at risk for infection with atypical mycobacteria, especially MAC. This is a late-stage complication of HIV disease that generally occurs in its disseminated form (e.g., in the blood) only in clients with CD4+ T cell counts less than 50. As clients survive longer with low CD4+ T cell counts, prevention and treatment of this common complication will be increasingly important. Started at CD4+ T cell counts of 75 to 100, there are three options for prophylaxis against MAC. The macrolide antibiotics, clarithromycin (Biaxin) (500(1,000 mg daily) and azithromycin (Zithromax) (1,200 mg once a week), are effective. The rifampin-like drug rifabutin also is approved for prophylaxis (300 mg daily). Rifabutin, like rifampin, causes accelerated metabolism of methadone; as a result, caution should be exercised in prescribing rifabutin to methadone-maintained clients. Rifabutin may also interact with other HIV medications. For a list of methadone interactions with HIV medications, see Figure 2-12.
Because of the potential for adverse drug interactions and the overload of daily pills for clients with low CD4+ T cell counts, some clinicians opt to wait until the CD4+ T cell count drops to 50 before initiating prophylaxis for MAC, and others do not use prophylaxis at all. Because MAC generally responds well to treatment (although treatment usually requires two medications), prophylaxis options should be discussed.
Cryptococcal meningitis is a relatively infrequent complication of HIV infection, but it is one of the more common AIDS-defining opportunistic infections of the CNS. Treatment of cryptococcal meningitis has been greatly aided by the introduction of new systemic triazole antifungal medications such as fluconazole and itraconazole (Sporanox). These agents have made it possible to shorten the initial course of intravenous therapy with amphotericin B for cryptococcosis and certain other systemic fungal infections (e.g., histoplasmosis) and have allowed chronic suppressive therapy with oral agents that do not require chronic intravenous administration.
Because cryptococcosis is not a common infection (occurring in fewer than 10 percent of clients with AIDS), routine prophylaxis is not cost-effective. However, intermittent prescription of triazoles for the more common oral candidiasis may unintentionally be leading to the decrease in cryptococcal disease.
Routine prophylaxis of cryptococcosis carries a risk of promoting development of resistant organisms, including resistant candida and other fungal species. In addition, in parts of the country where histoplasmosis and coccidioidomycosis are more common fungal complications of AIDS, the use of fluconazole has not been associated with decreased risk of occurrence of these infections.
HIV-infected clients with herpes simplex virus (HSV) may be prone to recurrent genital HSV infection, and those symptomatic with AIDS may develop widespread cutaneous disease. There is no strict threshold for initiation of prophylaxis. Clients may receive chronic prophylaxis with acyclovir (Zovirax) (generally from 1,000 to 1,500 mg daily in two or three doses) or famciclovir (Famvir) (500 mg twice daily) as might be given to clients without HIV infection. The likelihood of recurrent HSV infection increases with a declining CD4+ T cell count. Acyclovir, taken together with antiretroviral therapy, may benefit late-stage AIDS clients (Stein et al., 1994; Youle et al., 1994), although this remains controversial.
There has been much interest in potential prophylactic agents against cytomegalovirus (CMV), which, like MAC, has been increasingly common in clients surviving for longer periods of time at low CD4+ T cell counts. CMV most commonly causes retinitis, which can lead to blindness if untreated, and may also cause neurologic, gastrointestinal, adrenal, pulmonary, and other systemic diseases.
An oral form of ganciclovir (Cytovene), used as a prophylactic, may reduce CMV incidence although data on its effectiveness are conflicting. This medication has low serum levels that may promote CMV resistance; it has many side effects, requires careful monitoring, and requires the client to take many pills. In addition, initial retinitis is rarely sight-threatening; therefore, primary prophylaxis is not widely recommended. Currently, the treatment options for active CMV are intravenous ganciclovir, foscarnet (Foscavir), cidofovir (Vistide), or intraocular formivirisen.
Researchers noted the presence of bacterial pneumonia and sepsis in injection drug users before the HIV/AIDS pandemic, but they occur more frequently in HIV-infected substance abusers. Bacterial pneumonia in this population is most often caused by Streptococcus pneumonia and Haemophilus influenzae. Both bacterial pneumonia and related bacteremia tend to occur in the earlier stages of HIV and can be predictors of subsequent HIV-related illness in previously asymptomatic clients. Drug smoking and cigarette smoking may account for at least some of the increased risk. Persons with HIV develop invasive pneumococcal disease at a rate of 150 to 300 times higher than uninfected persons.
Bacterial endocarditis is a well-recognized complication of IDU. Several studies have suggested that HIV infection may aggravate the frequency and severity of endocarditis, and others have shown a similar endocarditis course in HIV-positive and HIV-negative drug abusers (Nahass et al., 1990). Active injection drug users also are at risk for a variety of serious bacterial infections involving the skin, soft tissues, bones, joints, central and peripheral nervous systems, and other anatomical sites. Proper needle hygiene and skin disinfection before drug injection may help prevent some of these complications.
STDs are common in substance abusers, especially crack cocaine abusers. Women and men involved in commercial sex work or the exchange of sex for drugs have particularly high rates of STDs.
Baseline assessment should include taking the client's history of STDs and any involvement in sex-for-sale or sex-for-drugs transactions. Inspection for genital and perianal lesions should be part of the baseline physical examination. Serologic testing for syphilis, including both treponemal and nontreponemal tests (e.g., Venereal Disease Research Laboratory and fluorescent treponemal antibody-absorption, should be included in the initial laboratory testing screen.
Female substance abusers should be offered a complete pelvic examination and testing for gonorrhea, chlamydia, and HSV as well as the more common bacterial vaginosis, trichomonas, and candidiasis. (See section on women's health issues below.) Women should also have Pap smears at least annually because of the risk of cervical cancer.
HIV-infected clients with primary and secondary syphilis should receive three weekly doses of benzathine penicillin or treatment with supplemental antibiotics (e.g., amoxicillin or ampicillin with or without probenecid) in some cases.
While lumbar puncture and cerebrospinal fluid (CSF) examination would be required to formally rule out neurosyphilis in persons with latent syphilis, a more practical plan for treatment of an HIV-infected substance abuse population is as follows:
Evidence of infection with HBV and hepatitis C virus (HCV) has been found in more than two thirds of long-term injection drug users (Esteban et al., 1989; Stimmel et al., 1975). Chronic substance abusers are also at increased risk for infection with hepatitis A virus (HAV) and hepatitis delta virus (HDV), which coexists with HBV. Concurrent alcohol use may also cause liver-function abnormalities, thus complicating clinical diagnoses. Because many commonly used HIV medications--including TMP-SMX, pentamidine, dapsone, rifampin, and ritonavir--may cause liver toxicity, liver function tests are required.
There is no consistent evidence that coexisting chronic HBV infection adversely affects the course of HIV disease or, conversely, that HIV disease adversely affects coexisting HBV infection. However, individuals who are coinfected with HIV and HBV may have higher blood levels of HBV than individuals who are not HIV infected. Consequently, these coinfected individuals may be at higher risk of transmitting HBV infection. HIV does seem to accelerate the course of HCV infection, leading to more rapid progression to cirrhosis (Soto et al., 1997).
Drugs used in treating HIV and its complications affect HBV (lamivudine, famciclovir, interferon-alpha) and HCV (interferon). Ribavirin, which is used in the treatment of HCV, should not be used with AZT. Flares of HCV have been reported with initiation of potent antiretroviral therapy. Rebound of HBV can occur in clients with HBV when they stop taking lamivudine.
Clinicians caring for HIV-infected clients must frequently assess clients for altered mental state and other neurologic and neuropsychiatric syndromes. Differential diagnosis in such clients may include HIV-related dementia or encephalopathy, specific opportunistic infections affecting the CNS, metabolic or toxic encephalopathy, and the effects of substance abuse (see also Chapter 3). In HIV-infected clients, underlying neurologic conditions associated with substance abuse can obscure or complicate diagnosis of the varied causes of peripheral nervous system disease.
These retroviruses are "cousins" of HIV. Human T-lymphotropic retrovirus type 1 (HTLV-I) has been associated with adult T-cell leukemia/lymphoma and with certain chronic degenerative neurologic diseases. Human T-lymphotropic retrovirus type 2 (HTLV-II) is less clearly associated with specific disease outcomes.
In the United States, infection with HTLV-I and HTLV-II is concentrated among injection drug users. Seroprevalence studies in the mid-1980s found that more than one-third of substance abusers in selected groups sampled in the New York City metropolitan area and in the southeastern United States were infected with HTLV-I or HTLV-II.
In at least one study, HTLV-II coinfection was associated with rapid progression of HIV disease in substance abusers infected with both viruses (Page et al., 1990). Clinicians caring for HIV-infected substance abusers should suspect coexisting HTLV-I or HTLV-II infection and consider serologic testing in clients with degenerative neurologic disease, T-cell leukemias, or rapidly progressing HIV disease.
Three types of cancer--Kaposi's sarcoma, malignant lymphoma, and invasive cervical cancer--are considered AIDS-defining conditions under the classification system for HIV infection and AIDS established by the CDC in 1993 (see Appendix C). HIV-infected substance abusers are at relatively low risk for Kaposi's sarcoma; however, malignant lymphomas have been documented in this population. Persistent generalized lymphadenopathy is common in HIV-infected clients, and palpable lymphadenopathy is common in injection drug users, particularly those who continue to inject drugs. Nevertheless, the presence of large (greater than 2 cm), firm, tender, or rapidly growing lymph nodes in an HIV-infected injection drug user should always prompt further diagnostic evaluation. The women's issues section in this chapter provides discussion of cervical cancer. In addition to these AIDS-defining cancers, other malignancies have been found to occur with greater frequency in HIV-infected substance abusers. These non-AIDS-defining cancers (reported in several case studies and one population-based study) include solid tumors of the lung, head and neck, and gastrointestinal tract, of which lung tumors are the most common (O'Connor et al., 1994b).
The CDC recommends that HIV infection be considered an indication for pneumococcal vaccination because of the markedly increased risk of pneumococcal pneumonia among HIV-infected clients. The effectiveness of this vaccine in clients with severely weakened immune systems is questionable, but it has been found to provide moderate immunity when given in the earlier stages of HIV infection.
Vaccination against H. influenzae type B should also be considered because HIV-infected individuals, particularly injection drug users, are at increased risk for H. influenzae pneumonia.
Vaccination for viral influenza is potentially useful for two reasons:
The CDC also recommends that all HIV-infected individuals and the health care workers who provide their care should receive the hepatitis B vaccine. Clients with HIV infection, if they have not already been exposed to HBV, are at high risk of acquiring it and are more likely than non-HIV-infected individuals to become chronic HBV carriers. Furthermore, HIV-infected HBV carriers may be more infectious because they are likely to have higher blood levels of HBV (see information under "Laboratory Tests"). A complete HBV serologic profile should be part of the baseline assessment of all substance abusers with or at risk for HIV infection, and clients who are negative for HBV antibody markers should be considered eligible for HBV vaccine.
All the vaccines mentioned above are more effective when administered early in the course of HIV infection. The benefits outweigh the risks, and there is little evidence that these vaccines are harmful to HIV-infected clients.
Few data exist on the safety or effectiveness of vaccinating HIV-infected adults for diphtheria, tetanus, mumps, rubella, polio, and measles. Inactivated polio, diphtheria, and tetanus vaccines are likely to be safe. Because these infections may cause illness in clients with suppressed immune systems, vaccination appears warranted according to standard guidelines for their use in non-HIV-infected adults.
Vaccination with the live, attenuated mumps, rubella, and measles vaccines may pose a greater risk to HIV-infected persons, and the benefit is less certain. However, these vaccines are used routinely in HIV-infected children whose immune systems are not suppressed, and in recent years the measles vaccine has been safely given to HIV-infected adults during local measles epidemics (see Figure 2-14).
Primary care providers should be aware that, in general, the incidence of gynecological disorders is likely to be higher among female substance abusers than among non-substance-abusing women (DeHovitz et al., 1994; Millstein and Moscicki, 1995). Some disorders (such as STDs) result indirectly from substance abuse, while others may result from living conditions that influence the overall health status of women, such as the lack of regular medical care.
Drug-using women, with and without HIV infection, have high rates of vaginitis. The most common causes include bacterial vaginosis followed by candidiasis and trichomonas, with no difference in incidence between HIV-positive and high-risk (e.g., drug-using) women. Among HIV-infected women, the risk of severe or refractory vaginal candidiasis increases with a declining CD4+ T cell count, but in most cases the treatment is the same as for HIV-negative women.
Since 1993, invasive cervical cancer has been considered an AIDS-defining condition. HIV-infected women are at high risk for cervical dysplasia and cervical cancer associated with human papillomavirus. Women who are current or former substance abusers constitute approximately 50 percent of AIDS cases in women in the United States. Clinicians treating substance-abusing women should therefore be particularly alert to the possibility of cervical cancer.
A cervical Pap test should be performed at least yearly, and abnormalities should be evaluated with colposcopy. Facilities treating HIV-infected women must either provide Pap smears and gynecologic followup onsite or have contractual arrangements for provision of these services.
A large number of women become pregnant after they are diagnosed with HIV disease. There is no evidence that HIV disease progression is accelerated during pregnancy, after an abortion, or in the postpartum period (Alliegro et al., 1997). A woman's options should be discussed in a way that empowers her to make her own decision about whether to continue the pregnancy with optimal prenatal care or seek a termination. The infant initially will have a positive HIV antibody test result because of the presence of maternal antibodies in its blood. New DNA-PCR tests of infants' blood can diagnose HIV infection in infants soon after birth.
Maternal-fetal transmission of HIV can occur at any stage of gestation, although it is believed to occur primarily during labor and delivery. Use of AZT during pregnancy and in the neonate postpartum decreases the rate of vertical transmission of HIV by 65 percent. AZT does not appear to have any adverse fetal effects. Cesarean sections in HIV-infected women show a reduction in risk of transmission to the newborn as well (International Perinatal HIV Group, 1999).
Treatment providers should note that the 1993 Substance Abuse Prevention and Treatment Block Grants: Interim Final Rule requires prevention and treatment programs to link pregnant clients with prenatal services. See Chapter 4 for more information about pregnancy and HIV.
Substance abuse treatment personnel must be aware of the special nutritional needs of HIV-infected substance abusers. Poor oral intake and malabsorption of nutrients, caused by diarrhea and alteration of levels of endogenous anabolic hormones (especially in men), contribute to wasting. Staff should also be familiar with guidelines concerning nutritional supplements and with interventions to address the causes of inadequate food consumption. (See Figure 2-15 for a summary of factors that must be considered in relation to the client's food consumption.) Clients who are losing weight and for whom oral nutritional supplements are inadequate or ineffective should be referred to an HIV specialist. There are different nutritional concerns for clients on PIs, such as weight gain, "protease paunch," and elevated triglyceride levels. Significant weight loss is a predictor of poor survival. It is important to combine approaches to weight loss, including treating underlying illness, attention to nutrition, and correcting metabolic abnormalities that cause loss of muscle mass. This can be particularly challenging for inpatient treatment centers because the schedules for snacking and eating will have to be more flexible, and the usual rules may not work for someone who is HIV positive and in substance abuse treatment.
Smoking is highly prevalent among substance abusers. HIV-infected smokers are more likely to develop bacterial pneumonia, oral candidiasis, and hairy leukoplakia, and heavy smokers are more likely to develop these conditions than are light smokers. Smoking cessation strategies should be pursued in substance-abusing populations (Conley et al., 1996).
Individuals with substance abuse disorders, whether or not they are HIV infected, are subject to higher rates of mental disorders than the rest of the population. In some studies of substance abusers, the lifetime prevalence of such disorders is as high as 51 percent (Kessler et al., 1996). However, the percentage of HIV-infected substance abusers with psychiatric disorders has not been ascertained. One study found that 79 percent of HIV-infected injection drug users in treatment required psychiatric consultation and 59 percent had psychiatric disorders other than substance abuse. Forty-five percent of these individuals had organic mental disorders, such as cognitive impairment, anxiety disorders, and mood disorders (Batki et al., 1996). Another study of inner-city adult HIV/AIDS clinics concluded that rates of psychiatric distress in patients of these clinics were much higher than in the general population or in other outpatient medical clinics (Lyketsos et al., 1996). There is some evidence that certain psychiatric disorders such as depression and antisocial personality disorder may be more common among HIV-infected persons with substance abuse disorders than among HIV-infected gay men (Ferrando and Batki, 1998).
Evidence is mounting that psychiatric disorders are common in persons with HIV/AIDS. Preliminary data from the Federal HIV/AIDS Mental Health Services Demonstration Program show high levels of co-occurring substance abuse and psychiatric disorders (the program is administered by the Center for Mental Health Services [CMHS] and funded jointly by CMHS, the Health Resources and Services Administration, and the National Institute of Mental Health). More than 5,000 persons with HIV/AIDS received services in 11 projects across the country between 1994 and 1998. The demographic characteristics of those served mirror the emerging profile of the pandemic: large numbers of disadvantaged minorities, persons with substance abuse disorders, women, and heterosexuals. As the health care delivery system plans for the 21st century, it confronts the complex challenge of designing and implementing cost-effective programs for persons with HIV/AIDS that provide medical, mental health, and substance abuse treatment.
Counselors working with HIV-infected substance abusers should be aware of the variety of both HIV- and substance-induced psychiatric symptoms. It is also important to recognize that psychiatric symptoms may be caused by substance abuse, HIV/AIDS, or the medications used to treat HIV/AIDS, as well as by pre-existing psychiatric disorders.
Programs that integrate substance abuse and mental health treatment provide both mental health and substance abuse services in the same setting, with the same team of clinicians, and with common treatment plans. However, integrated programs are not always possible or available. Therefore, substance abuse treatment programs that do not have the resources to adequately assess and treat mental illness should be closely linked to mental health services to which clients can be referred. Also, many mental health services are not equipped to treat substance abuse disorders but can refer clients to substance abuse treatment programs. Open lines of communication will enable personnel in both locations to be informed about clients' treatment plans and progress (see Chapter 9 for a discussion of confidentiality issues). Treatment staff should maintain contact with the client and continue treatment during and after the psychiatric referral. Providing concrete assistance, such as transportation to the psychiatric referral site, may increase the likelihood of clients' success in following through on referrals to psychiatric services.
Because it may be difficult for any one clinician to address the complex mental health and counseling needs of HIV-infected substance abusers, the care of these clients is likely to involve multiple providers. A coordinated, holistic approach should be taken to address the multiple problems of this population. (Chapter 6 includes a discussion of how case management can provide this approach.)
Neuropsychiatric effects of HIV infection are relatively common and can significantly influence treatment planning for substance abuse disorders (American Society of Addiction Medicine, 1998). In general, mental disorders of concern in HIV-infected substance abusers may be divided into three broad categories:
Mental disorders may fall into one or more of these categories. Following is a discussion of common mental disorders among individuals with HIV infection, particularly those with concurrent substance abuse disorders (Ferrando and Batki, 1998). (Terms used are those found in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV].)
Often characterized by anxious or depressed mood, adjustment disorders tend to be time-limited (i.e., 3 to 4 weeks) responses to acute stresses, such as receiving news of HIV infection or experiencing worsened disease severity, a partner's diagnosis or death, job loss, or other life event. Stages of adjustment to the stress of life-threatening HIV infection have been described as similar to the stages of adjustment to other illnesses. These stages generally begin with a crisis and then progress to acceptance and adaptation.
Sleep disorders can result from substance abuse, psychiatric disorders, or physical illness. Sleep disorder in the form of insomnia is a common problem associated with some types of substance abuse such as intoxication from central nervous system stimulants (e.g., cocaine or methamphetamine) or withdrawal from central nervous system depressants such as alcohol, benzodiazepines, or from opioids such as heroin. Occasionally, maintenance on methadone can be associated with insomnia.
Psychiatric illness is a common cause of sleep disturbance. Depression is most often associated with insomnia, although less commonly it can lead to excessive sleep. Anxiety disorders also are associated with insomnia, and posttraumatic stress disorder commonly leads to sleep disturbance in the form of nightmares and other symptoms.
Medical illness such as pulmonary disease or the side effects of medications such as bronchodilators can lead to insomnia. Finally, HIV disease itself appears to be associated with an increased incidence of sleep disorders (Wiegand et al., 1991).
Depression is common among patients with substance abuse disorders, even without the impact of HIV/AIDS. Depression is a common response to learning that one is HIV infected or is becoming more ill, and also may be related to substance abuse or to withdrawal. For example, clients may become depressed for prolonged periods of time after withdrawal from use of alcohol, opiates, stimulants, and other substances (Kanof et al., 1993).
Mania occurs frequently in clients who are HIV positive. In one study of an HIV/AIDS medical clinic, the incidence of mania was as high as 8 percent (Lyketsos et al., 1993). Mania also can be a complication of substance abuse, particularly the use of cocaine and other stimulants. It can be difficult to determine whether mania is induced by substance abuse or HIV infection (Lyketsos et al., 1993; Mirin et al., 1988).
Dementia can be defined as the loss of cognitive and intellectual functions without impairment of consciousness and characterized by disorientation, impaired memory, and disordered judgment. Dementia may occur because of chronic alcoholism, head trauma, and numerous other causes, in addition to HIV disease.
Differentiating these dementias can be difficult. All forms of dementia can be present with cognitive, behavioral, and motor abnormalities. However, effective HIV treatment, particularly highly active antiretroviral therapy (HAART), substantially decreases the occurrence of dementia. AIDS dementia complex (ADC) is a severe form of dementia and is one of the most challenging and anxiety-provoking manifestations of HIV disease for the client and his significant others, as well as for the treatment provider.
The diagnosis of dementia in the HIV-infected substance abuser is based on the presence of significant and disabling impairment of functioning. Usually, impairment occurs in three areas:
A neuropsychological examination is a necessary part of the assessment of dementia. However, a brief cognitive capacity examination such as the Mini Mental State Examination (MMSE) should not be relied upon to diagnose dementia (see Appendix H for a copy of the MMSE), although poor performance on such a screening instrument may indicate that dementia is present and that further testing is advisable.
HIV-related neurocognitive loss usually progresses gradually. Figure 3-1 indicates the degrees of impairment that may be seen at different stages in the course of dementia.
Early signs and symptoms of neurocognitive impairment include
In later stages of dementia, major impairments become obvious, such as
The risk of dementia and other cognitive deficits is highest in HIV-infected clients who are severely immunocompromised. The CD4+ T cell count is a useful index of an individual's risk for AIDS dementia. Generally, dementia is most likely to occur in clients with CD4+ T cell counts below 200 (Boccellari et al., 1993a, b). Neuropsychological testing can establish what stage of impairment a patient has reached, and this information is helpful in treatment planning, treatment expectations, and placement decisions. HIV-related dementia has been reported to respond to treatment with zidovudine (AZT) (Retrovir) and also to treatment with HAART (see Chapter 2).
Delirium is an altered state of consciousness manifesting in confusion, disorientation, disordered cognition and memory, agitation, faulty perception, and autonomic nervous system activity. Delirium is an emergent medical problem with a high mortality rate and requires immediate investigation of its cause and immediate initiation of treatment. Sudden development of mental confusion associated with acute encephalopathy or delirium can stem from many sources, including infection, substance intoxication or withdrawal, toxicity from medication, or metabolic disturbances. Delirium is more common than dementia in HIV-infected substance abusers.
Psychotic symptoms may be seen in advanced HIV/AIDS dementia or in delirium and can be difficult to differentiate from substance-induced hallucinations and delusions (e.g., paranoid psychosis resulting from the use of "crack" cocaine).
HIV-infected substance abusers have higher rates of maladaptive personality traits. These generally correlate with early onset of the substance abuse. Antisocial traits also are common. Traits and actual personality disorders may require a more directive and supervisory role for the treatment team. For information on the interaction of personality disorders with substance abuse treatment, see TIP 9, Assessment and Treatment of Clients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994b).
It is possible that HIV-infected individuals are more susceptible to the side effects of psychotropic medications than are non-HIV-infected persons. Medical staff should therefore exercise restraint in prescribing sedatives, antipsychotics, antidepressants, or antianxiety agents for their HIV-infected clients.
Both substance abuse and HIV infection may cause cognitive impairment that can reduce adherence to medical care. The care provider should take into account any possible cognitive impairment when beginning client education. For example, it is important to allow clients time to recover from the acute effects of substance intoxication or withdrawal. Clients' ability to understand the content of counseling sessions should be assessed before the counseling occurs (Forstein, 1992).
To determine the substance abuse and mental health treatment needs of persons with HIV/AIDS, the care provider must understand the impact HIV infection has on the brain itself. Even during the early stages of infection, brain function associated with tasks related to memory, attention, concentration, planning, and prioritizing may be affected by the HIV virus. The client who complains of forgetfulness, gets lost on the way to appointments, or has difficulty adhering to schedules or medication dosing should be carefully assessed. These symptoms of possible cognitive impairment could be the result of HIV/AIDS or they could result from other mental health and substance abuse disorders such as depression, substance-induced dementia, or mental retardation. Poorly controlled diabetes or liver disease can also lead to cognitive impairments. It may not be possible to determine the cause of the impairment, but recognizing its presence and its effects on functioning are essential to knowing how best to help the client.
Neuropsychological testing can search for the presence of specific cognitive impairments. Screening and testing instruments assess intellectual functioning, reading and math skills, speed of mental processing or problemsolving, and status of long- and short-term memory and recall. The neuropsychologist interprets the test results to help formulate a diagnosis when symptoms are complex and to assess previous and current capabilities relating to memory, attention, problemsolving, concentration, and the ability to plan and prioritize.
Communication between medical and counseling staff will help to ensure that cognitively impaired clients are not perceived as deceitful or manipulative. Care providers must keep in mind that cognitively impaired clients' nonadherence to treatment may be a result of the impairment and not caused by denial, resistance, or unwillingness to accept care.
Psychiatric symptoms in HIV-infected substance abusers may result from the use of prescription medication. For example, high doses of AZT can produce anxiety, insomnia, or hyperactivity. Similarly, efavirenz (Sustiva) is associated with a variety of central nervous system symptoms, such as very vivid dreams or nightmares (see the section below on drug interactions). The use of steroids in HIV/AIDS treatment also has risen, and these medications may induce psychosis.
In cognitively impaired substance abusers with late-stage HIV disease, memory and other cognitive functions may be worsened by certain combinations of medications, particularly central nervous system depressants such as benzodiazepines (e.g., diazepam [Valium]) and anticholinergic medications such as the tricyclic antidepressants (e.g., amitriptyline [Elavil]). The interaction of some antiretroviral agents, such as the protease inhibitor ritonavir (Norvir), can interfere with the metabolism of benzodiazepines, antipsychotics, and other medications, further aggravating the adverse effects of the antiretroviral agents in the central nervous system.
Assessment and diagnosis of mental illness in HIV-infected substance-abusing clients is a daunting challenge because of these clients' complex problems. It is important to evaluate clients' behavior in context. For example, acute depression is relatively common among clients who have just learned they are HIV positive. This type of time-limited adjustment disorder can lead to worsened substance abuse. In turn, depression can be made more severe or prolonged by substance abuse.
It can be difficult to determine whether substance abuse preceded a client's psychiatric disorder or vice versa. Substance abuse may occasionally be an attempt at self-medication in response to an underlying psychiatric disorder (Khantzian, 1985). Although mental disorders may predate substance abuse, generally the reverse is true. Because an accurate and complete history cannot always be obtained from the client, corroborative sources of information (such as the client's significant others or a previous health care provider) are essential to a complete assessment. Making inquiries of collaborative sources of information will mean disclosing the client's substance abuse or HIV/AIDS status, and the client's written consent is required. See Chapter 9 for more information on consent issues.
Figure 3-2 outlines the major categories of information necessary for a basic mental health assessment.
Assessment of the HIV-infected substance abuse treatment client should begin with rapport and trust building and then proceed to a psychosocial history that is as judgment free as possible. The assessment should move from open-ended questions to more specific questions. This questioning should acknowledge and respect gender, ethnic, and cultural differences, as well as sexual orientation. The provider also should keep in mind that history taking may require more than one sitting, depending on the emotional and mental capacity of the client. Many clients with comorbid disorders cannot or will not tolerate long questioning sessions. A complete medical history focusing on both HIV/AIDS and substance abuse should be taken when a client enters treatment. A recent physical examination and laboratory test results should be readily accessible because they may help in assessment of the client's counseling needs. For example, a CD4+ T cell count below 200 informs the mental health or counseling professional that the client is at higher risk for HIV-related dementia (Boccellari et al., 1994). Clients should be reassessed periodically. Fluctuating health status and functional capacity mean that clients' treatment needs will change over time.
A comprehensive mental state examination can detect mental disorders. The cognitive portion of the mental state examination can be performed by using standardized questionnaires such as the MMSE (see Appendix H). The most important part of the mental state exam is the section regarding cognitive impairment and danger to self or others (Cockrell and Folstein, 1988; Folstein et al., 1975).
It is helpful to have a psychiatrist or psychologist perform the examination, but most general practitioners are familiar with the basic components of a brief mental state examination. Nursing staff and counselors can also be taught to administer screening exams. A well-designed screening exam will assist clinicians in asking appropriate questions. In addition to the MMSE, other examinations such as the Beck Depression Inventory may be useful in assessing the severity of depressive symptoms (Beck, 1993). Repeated mental state examinations will help determine changes in a client's cognitive or behavioral status.
It is essential to set realistic treatment goals that correspond to the client's functional capacities. For example, immediate abstinence from substances may be an excessive expectation of severely psychologically disturbed substance abusers, and treatment programs may have to consider a range of goals for such clients.
Therapeutic interventions must be sensitive to the culture and ethnicity of the client population. Whenever possible, therapists and support group leaders should share the culture of their clients and should speak the same language. Cultural compatibility among therapists, case managers, service providers, and clients is important in creating an atmosphere of trust in which sensitive issues, such as family support and group mores, can be addressed.
Cultural factors may have to be taken into consideration in the assessment of psychiatric symptoms. For example, some individuals may have strong spiritual beliefs that can be labeled delusional if their cultural context is not understood.
Generally, the clinician's best guide is the client's significant others or the community context. If the client's beliefs are consistent with her community or culture, it is less likely that she is delusional (Perez-Arce et al., 1993). See Chapter 7 for further discussion of cultural issues.
Standard pharmacologic approaches may be used to treat psychiatric disorders in HIV-infected substance abuse clients, with some specific considerations. Without exception, a medical and psychiatric diagnostic evaluation should always be carried out before medication is provided.
Some substance abuse treatment staff may have concerns regarding pharmacologic interventions because they believe that psychiatric medications may place clients at risk for relapse to substance abuse. Although these concerns must be acknowledged, it is necessary to distinguish between medications and drugs of abuse. An approach that withholds psychiatric medications when they are appropriate deprives clients of the opportunity to benefit from a legitimate and necessary treatment option.
When prescribing medications to HIV-infected substance abusers, physicians should use a graduated approach that increases the level and type of medication slowly, a step at a time. Low doses of safer and less abusable medications should be tried first, and higher doses or less safe agents used only if the initial approach is ineffective. Figure 3-3 offers a guide to appropriate pharmacologic therapy for clients with HIV/AIDS and substance abuse disorders.
For more in-depth information about pharmacology and mental illness, see TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (CSAT, 1994a).
In animal and human testing, most of the major classes of psychiatric medications have been shown not to have abuse potential. Studies have shown that neither animals nor humans will self-administer them and that humans will not rate their effects as pleasurable or euphoric. Examples include antipsychotic medications such as chlorpromazine, mood stabilizers such as lithium, and nonpsychostimulant antidepressants such as fluoxetine.
Clearly there are exceptions, and occasionally individuals do misuse even these medications, but on the whole the medications have no or very low abuse potential. However, two classes of psychiatric medications do have high abuse potential:
Figure 3-4 lists both abusable and nonabusable drugs. When working with any substance-abusing client, it is reasonable to expect that some misuse of legally prescribed controlled substances may take place. A hierarchical approach to prescribing is recommended to minimize the potential for abuse. In this approach, the least abusable medications are prescribed first, and the most potentially abusable are used only when other agents have not been effective. Dispensing medication in small amounts helps limit overuse, misuse, or abuse of potentially abusable medications.
HIV-infected persons may be more sensitive to prescription medications as well as to drugs of abuse. When prescribing, clinicians should attempt to use the lowest effective dose to minimize side effects. With clients symptomatic with AIDS, it may be wise to start out with very low doses of the magnitude generally associated with geriatric psychiatry.
Substance abusers are at increased risk of suicide (Tondo et al., 1999). Comorbidity is common among suicide victims, and substance abuse disorders are most frequently combined with depressive disorders (Berglund and Ojehagen, 1998). HIV-infected individuals may also be at risk of suicide, especially if they are suffering from a mood disorder. In a study of HIV-positive heterosexuals recently diagnosed with HIV, anxiety, depression, and suicidal ideation were assessed. Depression was observed in 40 percent of study participants, anxiety in 36 percent, and serious suicidal intent in 14 percent (Chandra et al., 1998).
Studies have shown that both psychiatric and medical treatment can diminish rates of suicidal ideation among HIV-infected substance abusers. One study administered the Beck Hopelessness Scale (BHS) to 2,379 intravenous drug abusers who were not in treatment, unaware of their HIV status and seeking HIV testing and counseling. Results revealed that seropositivity was closely linked to self-reported depression and suicidal ideation (Steer et al., 1994). When substance abusers are diagnosed with HIV, their first reaction is often terror and panic. As the infected individual envisions a life with AIDS, suicidal ideation becomes more common. If a client is not acutely suicidal but wants to talk about suicide, the counselor should maintain genuine interest, assess the severity, obtain help if needed, and acknowledge the reality of the client's feelings and the severity of the situation. The counselor should not minimize the client's experiences because talking openly about suicide decreases isolation, fear, and tension, and may allow the client to move toward acceptance and commitment to life (Siegel and Meyer, 1999).
Suicidal ideation has been demonstrated to decrease with psychiatric counseling (Perry et al., 1990). When working with an HIV-infected substance abuser who has shown signs of suicidal ideation, the treatment provider should dispense medication in small amounts until the client's level of responsibility can be fully assessed.
Prescribers should be aware that some medications such as TCAs (e.g., amitriptyline) are especially likely to be lethal in overdose.
As HIV infection progresses, certain medications may cause adverse side effects in some clients.
Any sudden behavior change or new physical symptom in a client on medication may be medication related. With some medications such as lithium, the TCAs (e.g., amitriptyline), and certain antipsychotics (e.g., haloperidol), blood levels should be tested periodically to avoid drug toxicity.
Clinicians must be aware of the potential for adverse interactions between HIV/AIDS treatment medications and psychiatric medications. HIV-infected clients often are prescribed complex medication regimens. Medications, either alone or in various combinations, may cause confusion and other psychiatric symptoms.
For example, a client may be prescribed fluoxetine for depression plus an antianxiety medication such as lorazepam and may also be taking AZT and the antibiotic trimethoprim-sulfamethoxazole (Septra), as well as other medications. In any individual client, it is difficult to predict the outcome of interactions among so many medications.
HIV/AIDS medications, such as the protease inhibitors, can potentially interfere with the metabolism both of psychiatric medications and of medications used in the treatment of substance abuse (e.g., methadone). Finally, they can interfere with the metabolism of abused substances--one example is the elevated levels of methylene dioxymethamphetamines (MDMA) that have been found to be associated with ritonavir use (Henry and Hill, 1998).
Because of the potential for adverse interactions among medications, it is essential that medical and psychiatric care providers communicate with each other when treating an HIV-infected substance abuse disorder client (see "Case Management" section in Chapter 6). Pharmacists also can help educate clients and reduce possible adverse effects of drug interactions; they are invaluable sources of information on what medications other health care providers may have prescribed to the client. If a client appears adversely affected by multiple medications, the alcohol and drug counselor must report the observed physical or behavioral change to the client's primary medical provider as soon as possible so the problem can be addressed. However, the counselor cannot contact either the primary care physician or the pharmacist unless the patient signs a consent form (see Chapter 9).
Methadone maintenance (or agonist) therapy is the most effective and widely available treatment for opioid abuse (U.S. General Accounting Office, 1998). It is the preferred method of treatment for HIV-infected opioid abusers because it substitutes an oral medication for an injected drug, and it involves regular attendance at a clinic that may offer access to medical care, psychiatric consultation and treatment, neuropsychological evaluation, and social services (Ball et al., 1988; Batki, 1988; Cooper, 1989). Furthermore, longer acting opioid substitutes appear to have a normalizing effect on the immune and endocrine systems, which are disrupted by irregular use of heroin or other abused opioids (Kreek, 1991). Overall, methadone maintenance therapy is associated with a reduced risk of contracting HIV/AIDS and may prevent infection of those patients not yet exposed to the virus (Baker et al., 1995; Iguchi, 1998; Lowinson et al., 1992; Metzger et al., 1993). For more detailed information about methadone maintenance therapy, refer to TIP 20, Matching Treatment Needs to Patient Needs in Opioid Substitution Therapy (CSAT, 1995f), and to TIP 22, LAAM in the Treatment of Opiate Addiction (CSAT, 1995g).
Counseling is an important part of treatment for all substance abusers, including those with comorbid psychiatric disorders. The goal of counseling is to help the HIV-infected substance abuser maintain health, achieve recovery from the substance abuse, build coping skills, and attain the best possible level of psychological functioning. Counseling may be done individually, in groups, or with clients' family members and significant others. (See Chapter 7 for more information about counseling HIV-infected clients with substance abuse.)
Individual therapy can be particularly helpful for a client who may not be ready to share intimate information with a group. Individual counseling allows clients to discuss subjects such as sexual behavior, fear of death, and other issues related to HIV infection, substance abuse disorders, or sexual identity. For some substance abusers, however, individual therapy may not be as potent as group intervention in reducing the sense of isolation, shame, and guilt that many clients feel because of HIV infection. One possible aim of individual therapy is to prepare clients to participate in group therapy.
Most treatment programs working with HIV-infected substance abusers find that supportive group therapy can be highly beneficial. Groups can be structured in a variety of ways, but generally involve a dozen participants with one or two group leaders. Both heterogeneous and homogeneous groups can work well; however, there are occasional exceptions. For example, HIV-infected substance abusers who are strongly self-identified as heterosexual may not feel comfortable in a group with openly gay members, and vice versa. Substance abusers in a group setting may be more restrained about exploring sexuality and sexual behavior.
In general, however, it is not absolutely necessary to segregate group members on the basis of sexual orientation or HIV/AIDS status. Good results can be achieved in a group that includes both HIV-infected and non-HIV-infected substance abusers, as has been shown in the Stimulant Treatment Outpatient Program at San Francisco General Hospital (Perez-Arce et al., 1993).
A current model for structuring groups, based on the clients' stage of diagnosis, has been used successfully by Boston's Fenway Community Health Center. In this model, clients are grouped as follows:
The first two groups focus on healthy lifestyles and improving quality of life. As the sessions progress, clients often exchange information about treatment. The latter type of group focuses more on adapting to illness, grief, and coming to terms with death and dying.
In addition to their therapeutic role, groups may play important roles in educating clients about risk reduction. Because it is important to promote behavior change among all substance abuse disorder clients, those who are not HIV infected should also have the opportunity to attend HIV/AIDS education groups, or should be provided HIV/AIDS education by their individual therapist.
For some clients, "family" needs to be defined as broadly as possible. Some clients have traditional nuclear families. For other clients, family may include a nonmarital partner and additional significant others. Adult clients have the right to define their families and to decide whether to include the people they regard as family in the treatment process. For a socially isolated person, a friend from an AIDS service organization may fill the role of significant other.
Supporting clients in their recovery from substance abuse often is a principal goal of family therapy. Questions about partner or child abuse may also be addressed. In addition, family therapy may provide a useful opportunity to address issues of risk reduction for family members who are not (or not yet) HIV infected. This therapeutic setting is uniquely positioned to offer risk-reduction education to people who may not have been identified either as HIV-infected or as substance abusers.
Support groups fulfill a wide range of needs. They are useful in reducing anxiety and depression and can help with both the substance abuse recovery process and in HIV/AIDS treatment. They also have an educational function, helping clients gain knowledge and skills about the systems they must negotiate. Some support groups have a client advocacy role, helping link programs and lobbying for funding to fill gaps in services. No single organization can provide all the services needed by HIV-infected substance abusers with mental health problems. Substance abuse treatment programs should actively refer clients to appropriate outside support groups where their specialized needs can be met.
Among the factors that must be considered in structuring support groups are the need to protect client confidentiality and the possible stigmatizing effect of identifying a group for HIV-infected clients.
Among the issues to consider in establishing and maintaining support groups are language, ethnicity, gender, sexual orientation, type of substance abuse, stage of recovery from substance abuse, and stage of HIV infection. Occasionally, homogeneity is desirable and effective. Single-sex groups may be beneficial for both women and men in certain circumstances. Women who have suffered abuse may feel more able to divulge this information in a women-only group. Many HIV-positive women have not told their partners about their HIV/AIDS status, and some may be afraid of losing custody of their children if their status becomes known. Women who have been involved in the sex industry or in sex-for-drugs transactions may have difficulty speaking about these experiences in mixed settings and would benefit from participation in specialized single-sex groups. Single-sex groups are also beneficial for men who have difficulty discussing issues of sexuality, such as sexual abuse and incest, in a mixed-gender group.
Some clients have difficulty achieving full recovery from substance abuse without addressing issues related to sexual orientation. Homosexual and heterosexual clients may not always be comfortable with one another in groups. Ideally, if resources allow, specialized groups defined by both sexual orientation and gender should be offered.
Clients' perceptions and prejudices about the use of different substances are likely to surface in groups and affect the treatment process. For example, alcohol abusers may consider themselves less addicted than cocaine abusers and may be unwilling to admit that they also are abusing substances. In general, it is preferable to hold separate groups for alcohol abusers, heroin abusers, cocaine abusers, and so on.
An individual's stage of recovery may be as important as the type of substance abused. Although most substance abuse treatment programs stress abstinence, clients in early recovery who are also dealing with HIV infection may find total abstinence difficult to achieve. Many programs across the country use a risk-reduction model (see Chapter 4) when working with clients with substance abuse, recognizing that dealing with substance abuse, HIV/AIDS, and possible mental health issues often makes abstinence difficult. Figure 3-5 describes a group developed to assist HIV-infected substance abuse treatment clients.
In addition to facing the prospect of disability and death from AIDS, many HIV-infected substance abusers experience grief and bereavement as a result of the deaths of friends, lovers, spouses, and other family members. There also is a need for grief and bereavement counseling for the client's family. For substance abuse treatment programs, there are at least three goals in addressing grief and bereavement:
Primary HIV prevention reduces the incidence of transmission (e.g., fewer people become HIV infected), whereas secondary HIV prevention reduces the prevalence and severity of the disease through early detection and prompt intervention (e.g., fewer HIV-positive people progress to AIDS). For HIV-infected clients in substance abuse treatment, a comprehensive approach to HIV prevention must include three goals: (1) living substance free and sober, (2) slowing or halting the progression of HIV/AIDS, and (3) reducing HIV risktaking.
This third goal is crucial for the client in several ways:
In addition to the ways in which HIV prevention efforts directly help the client, the benefit to family and community is obvious. HIV prevention for those already infected is a key component of treatment for both the client and community.
Substance abuse treatment personnel may be among the few people the recovering abuser trusts. By taking the opportunity to advise each client on HIV risk reduction, whether that client is known to be HIV infected or not, the substance abuse treatment professional assists both the individual and all those connected to him. HIV has been spreading rapidly among substance abusers since the start of the pandemic but can be slowed if they are taught the skills to prevent transmission.
Risk reduction originally was called "harm-reduction counseling" by its creator, Edith Springer, in the late 1980s and was popularized by pioneering syringe exchange advocates David Purchase and Dan Bigg in the early 1990s. The term "harm reduction" was first associated with the approach of identifying and supporting "any positive change" by substance abusers toward less frequent substance use or abstinence. In this respect, the harm-reduction approach endorsed the social work adage of "meeting the client where he is."
In the mid-1990s, the term "harm reduction" was unfortunately associated with a brief and unsuccessful drug legalization/decriminal- ization movement. In an effort to distinguish the more specific service provision response from the larger, disparate political movement, advocates renamed the approach "risk reduction." The concept of risk reduction was further expanded to include both substance-related and sex behavior-related risks for HIV infection. Risk-reduction interventions have included media campaigns (Bortolotti et al., 1988; Power et al., 1988), syringe exchange programs (Des Jarlais et al., 1996; Watters et al., 1994), and substance abuse treatment (Ball et al., 1988; Booth et al., 1998; Hartgers et al., 1992; Iguchi et al., 1996).
Numerous risk assessment protocols exist and may be used with a minimum of training and familiarity (Chen et al., 1998). The goal of HIV/AIDS risk assessment should be to identify behaviors that place the client at risk for HIV infection. Figure 4-1 contains a brief HIV/AIDS risk assessment checklist that has been used successfully with a wide variety of populations at risk.
A comprehensive sexual practices history is important and should be taken early in counseling, although not necessarily at the first session. Clients must be reassured of the confidentiality of the information they provide.
Counselors should address the full range of potential risk behaviors in their questioning, including both syringe sharing and unsafe sex. They should take into account a wide range of sexual practices, including homosexual, bisexual, and heterosexual, as well as those of transgender clients. Condom use must be a special focus of counseling. The power issues over use/nonuse of condoms that can often occur in sexual relationships should be discussed as well.
After taking the client's history, the counselor can often proceed to HIV/AIDS education and then to risk reduction. A client who was diagnosed with HIV before seeing the counselor may already have discussed sensitive issues and risk reduction with someone else. Nonetheless, it is important that the substance abuse treatment counselor discuss these issues with the client as well.
Changing risk behaviors such as substance abuse and unsafe sex requires more than a knowledge of why these are risky. Clients' attitudes and beliefs also must be addressed, as well as the beliefs and attitudes of their sexual partners. Substance abuse can lower inhibitions and increase impulsiveness, which may significantly contribute to risk behaviors.
In promoting risk reduction, the alcohol and drug counselor's goals are to
Discussion of risk behaviors should take place in language that is culturally appropriate, clear, and understandable. Substance abuse treatment providers should know how to refer family members for HIV antibody testing and how to provide appropriate pre- and posttest counseling to clients. If onsite testing is not possible, referral should be available to an easily accessible site.
Risk-reduction counseling can be particularly difficult when a client is sent back to a nonsupportive community where high-risk substance abuse and sexual behaviors are not discouraged. Issues such as poverty and homelessness must be acknowledged and addressed when attempting to change high-risk behavior, and counseling should be provided for personal problems such as perceived powerlessness and low self-esteem. Practical assistance, such as providing emergency housing, is usually required before behavior change can occur.
Encouraging risk-reduction practices in women can sometimes be problematic for treatment providers. HIV-infected women in substance abuse treatment are likely to be poorly educated about their sexual and reproductive health, financially dependent on a man, and consequently reluctant to challenge the status quo. A recent study examined the relationship between partner violence and sexual risk behaviors in a sample of predominantly Hispano/Latino and African American women. Nearly one half of participants reported having been abused by a partner or spouse in the past. It was discovered that abused women were five times more likely than unabused women to have reported a sexually transmitted disease (STD) and four times more likely to have engaged in sex with a risky sexual partner (El-Bassel et al., 1998).
One promising means of promoting risk reduction as well as treatment entry is known broadly as brief intervention. Brief interventions are a large class of interventions, all of which involve the use of approximately three sessions of assessment and motivational counseling intended to diminish substance abuse or promote treatment entry (Heather, 1995). Most brief intervention studies have focused on alcohol and nicotine use, but brief interventions are also effective for drug treatment programs (Miller, 1993; Schuster and Silverman, 1993). (For more information, see TIP 34, Brief Interventions and Brief Therapies for Substance Abuse [CSAT, 1999c], and TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999d].)
Sexual risk reduction is best approached in a stepwise manner. The greatest protection (and best step) is either to have one monogamous, HIV-negative partner or to abstain from sex. The next best step is to always use a latex condom if one is having sex with more than one partner, with a partner who is HIV positive, or with a partner who may not be monogamous. Male condoms are effective when used correctly, but female condoms, while showing some promise in preventing STDs, have not yet been scientifically established as effective in preventing transmission of HIV.
A condom can be cut open and used like a sheet for oral intercourse. Plastic kitchen wrap can also be used, except for the microwave type, which has tiny holes in it. Anal intercourse is safer if two condoms are used, and spermicides containing nonoxynol-9 appear to give additional protection. Only water-based lubricants (such as K-Y Jelly_ or Surgilube_) should be used because oil-based lubricants (such as petroleum jelly or vegetable oil) can cause a condom to deteriorate enough to allow HIV to pass through.
Providers should also remind clients that contraceptives such as Norplant and the birth control pill provide effective birth control when used correctly but provide no protection against HIV transmission. Clients should use condoms to protect themselves and others from HIV in addition to whatever birth control devices they may be using.
Another way to reduce risk is to avoid activities that cause trauma or bleeding (however, if clients engage in these activities, a latex condom should be used). Instances of trauma can include not only obvious bleeding but also microscopic abrasions produced by excessive teeth brushing just before oral sex, which could cause the gums to bleed. Anything that touches cut or irritated body tissue should be sterile, if possible. To date, there are no known cases of HIV transmission through kissing, but if both partners have cut or irritated areas on the lips or in the mouth, it is technically possible for the virus to be transmitted.
HIV sexual risk-reduction programs should be integrated into substance abuse treatment programs. Stall and colleagues found that among men who have sex with men in substance abuse treatment, substantial HIV risk reductions occurred after initiation of treatment but that lapses into unsafe sex were common during treatment (Stall et al., 1999). HIV sexual risk (e.g., unprotected anal sex) was most likely to occur among men who were riskier at intake, who continued to be more sexually active, and who were more likely to combine substance abuse and sexual behavior (Stall et al., 1999).
Paul and project staff from the New Village Program in San Francisco have developed an HIV sexual risk-reduction program for substance abusers, especially for gay men (Paul, 1991a). Components of the "Clean and Sober and Safe" program may be useful to substance abuse treatment staff in general. Its group-format design allows it to be easily incorporated into group treatment settings to help substance abusers deal more effectively with situations that could lead to HIV risk. The format of the program incorporates many of the group principles used in substance abuse treatment settings, such as self-monitoring techniques, relapse prevention, building coping strategies, enhancing perceived self-efficacy, and developing necessary social support structures.
In general, Paul and colleagues recommend that the focus of these groups should be on "identifying high-risk situations for relapse into substance abuse and unsafe sex" and developing relapse prevention strategies to maintain abstinence and safer sex (Paul, 1991a). The same skills that clients learn when dealing with high-risk alcohol and drug situations can be adapted for situations that present high risk for unsafe sex. Group members should be encouraged to talk about sex and relationship issues, as well as the intersection of these issues with alcohol and drug use. Discussions should occur within a "sex-positive" framework, in which sex is viewed as healthy and natural.
Adapted from the sexual risk-reduction program developed by Paul and colleagues, Figure 4-2 contains a topic outline that can be used in substance abuse treatment settings to reduce HIV sexual risk among HIV-infected persons (Paul, 1991a).
Sexual risk-reduction programs should provide clients with basic information about safer sex, as well as an array of alternative strategies and choices that are client controlled. For example, a client who engages in unprotected anal intercourse should be encouraged to reduce risk by either using a condom or switching to oral intercourse. Or a client who engages in unprotected oral sex might reduce risk by using a condom or switching to mutual masturbation. Such self-protection strategies should be encouraged and explored throughout the risk-reduction sessions.
Risk reduction for injection drug use (IDU) is best approached strategically; for example, abstinence is the best step, no syringe use is the second best step, not sharing syringes is the third best step, using only clean syringes is the fourth best step, and so on. Successful drug treatment optimally will stop IDU and HIV risk. However, if abstinence is not working, the next best method is never to share IDU equipment with others and always to use clean equipment (including cookers, filters, water, and syringes). Some areas offer syringe exchange programs (SEPs) to assist in this effort, but if absolutely necessary a used syringe can be bleached (see Figure 4-3 for instructions on this). Another risk-reduction practice is not to allow others to contaminate drugs or equipment by putting a contaminated syringe into the prepared drug.
Under the terms of the Departments of Labor, Health and Human Services DHHS), and Education, and the Related Agencies Appropriations Act, 1998, (42 U.S.C. §§300ee(300ff), Federal funds to support SEPs are conditioned on a determination by the DHHS Secretary that such programs reduce transmission of HIV and do not encourage use of illegal drugs.
In a 1997 report to Congress, the DHHS Secretary reported that a review of scientific research findings indicated that SEPs were an effective component of a comprehensive strategy to prevent HIV and other blood-borne infectious diseases in communities that included SEPs in their HIV prevention strategy. The Secretary also announced that research findings indicated that SEPs do not encourage use of illegal drugs (U.S. Department of Health and Human Services, 1998). To date, the restriction on Federal funding has not been lifted.
DHHS has decided that the best course at this time is to have local communities that choose to implement their own programs use their own money to fund SEPs and to communicate available research results on the subject so that communities can construct the most successful programs possible to reduce transmission of HIV, while not encouraging illegal drug use (U.S. Department of Health and Human Services, 1998).
Three major expert reviews of the scientific literature on SEPs conclude that such programs can provide a pathway for linking injection drug users to other important services such as HIV risk-reduction counseling, substance abuse treatment, and support services (Lurie et al., 1994; Normand et al., 1995; U.S. General Accounting Office, 1993). Other studies strengthen the conclusion that SEPs do not encourage the use of illegal drugs (Brooner et al., 1998; National Institutes of Health, 1997a, b).
A particularly important point at which to address HIV prevention is during pregnancy. From July 1997 to June 1998, women accounted for 22 percent of AIDS cases; of those, 30 percent were infected through substance abuse and 37 percent through heterosexual contact (CDC, 1998b). It is estimated that between 6,000 and 7,000 HIV-infected women give birth each year (Stoto et al., 1998). Without any treatment, the risk of an HIV-infected woman passing the infection to her child is between one chance in three and one in four. A child's chances of being infected during pregnancy and childbirth drops to less than 1 chance in 10 when the mother receives proper prenatal care and treatment (CDC, 1994).
In addition to preventing HIV transmission, prenatal care and treatment of the HIV-infected woman will help her maintain her own health. Current recommendations are that a woman receive optimal HIV/AIDS treatment for herself during pregnancy (CDC, 1995). If a woman becomes pregnant and does not know whether she is infected with HIV, it is crucial that she be tested for HIV. Alcohol and drug counselors can help clients enter into prenatal care, be tested for HIV if they have not yet done so, and can encourage them to follow medical recommendations.
Data indicate that AZT therapy has a key role in preventing perinatal transmission of HIV from mothers to infants. The Pediatric AIDS Clinical Trials Group Protocol 076, a multicenter, randomized, double-blind, placebo-controlled trial conducted by the National Institutes of Health AIDS Clinical Trials Group, found that only 8 percent of infants born to HIV-infected women treated with AZT were infected with HIV, compared with 26 percent of infants born to women treated with a placebo (CDC, 1994). A recent study evaluated the long-term effects of in utero exposure to AZT in 234 uninfected children who were born to women enrolled in the Protocol 076 program (Culnane et al., 1999). No adverse effects were observed in these children, who were followed for as long as 5.6 years, and the researchers advised further evaluations of children who were exposed to antiretroviral agents in utero or neonatally. At San Francisco General Hospital's program for pregnant women, there has not been an HIV-positive infant born in more than 2 years to mothers on Protocol 076.
Clinical experience with AZT has not revealed any fetal toxicity other than transient anemia, although theoretical risks remain. However, the benefits seem to outweigh the unproven risks. The Centers for Disease Control and Prevention (CDC) now recommend that pregnant HIV-infected women receive AZT therapy. More recent clinical trial data from Thailand using a simpler regimen (600 mg orally daily from 36 weeks' gestation to labor, then 300 mg every 3 hours until delivery) produced a 51 percent decrease in HIV transmission risk (Shaffer et al., 1999). Given the large number of childbearing women among clients in substance abuse treatment programs, these data indicate an immediate need for expanded HIV/AIDS counseling, testing, and education for women who are pregnant or likely to become so. Although antiretroviral combination therapy is more potent than AZT monotherapy, it is not necessarily more effective in preventing mother-to-infant HIV transmission. In some subgroups, viral load is closely associated with transmission risk, lending support to the move toward combination therapy. Studies of prototypic triple-therapy protocols for safety and tolerance have just begun.
Breast milk transmits HIV efficiently, which is one reason why so many children in developing countries are HIV positive. Breast-feeding is therefore contraindicated for HIV-positive women.
Neonatal HIV transmission through breast-feeding remains a problem, especially in countries where safe and affordable alternatives to breast milk are not available and antenatal HIV prevalence tends to be highest. The rate of acquisition of HIV through breast-feeding was 7.4 percent in a study of infants who had a negative virus test in the first 3 months of life and was 7.4 percent in one study and 9.6 percent in another study at 24 months. Oral AZT prophylaxis during pregnancy may produce children more at risk for acquiring HIV through breast-feeding. Also, it is possible that viral load rebounds in mothers after they stop taking AZT, which results in increased virus concentration in breast milk.
The World Health Organization (WHO) issued a recommendation that women with HIV should not breast-feed (World Health Organization, 1998). The report recognized, however, that in some cultures women are stigmatized for failure to breast-feed and that in underdeveloped countries, breast-feeding may be the only way in which an infant can survive the first few months of life. This is a complex and delicate issue.
Various studies that recently compared transmission rates between vaginal delivery and cesarean section demonstrate that elective cesarean section reduces the risk of vertical transmission of HIV from mother to child (European Mode of Delivery Collaboration, 1999). Elective cesarean sections were defined as those performed before onset of labor and rupture of membranes. According to a meta-analytic review of 15 research studies, after adjustment for factors such as receipt of antiretroviral therapy, maternal stage of disease, and infant birth weight, the risk of vertical transmission was decreased by roughly 50 percent with elective cesarean section (International Perinatal HIV Group, 1999).
Transmission of forms of HIV that are resistant to one or another of the cluster of antiretroviral medications has already been well documented. However, whether it is possible to sexually transmit forms of HIV that are resistant to triple combination therapy remained an open question until recently; genetic analysis demonstrated the transmission of triple-combination resistant virus between a serodiscordant gay male couple (one HIV positive and one HIV negative) (Hecht et al., 1998b).
The implications of this finding are serious. Given the cross-resistance problems of many protease inhibitors, individuals newly infected with triple-combination-resistant forms of HIV may have few antiretroviral treatment options available to them. If it is possible to efficiently transmit triple-combination-resistant HIV during unprotected sexual encounters, it follows that certain at-risk populations may return to the situation that existed before protease inhibitor treatments became available. Thus, primary and secondary AIDS prevention may turn out to be as important as the discovery of triple-combination treatment therapies themselves.
The AIDS pandemic poses a number of challenges for infection control policy and practice in substance abuse treatment programs. Effective institutional infection control is more relevant for preventing the transmission of tuberculosis than for preventing the spread of HIV, although the latter often has received a greater amount of attention.
Adherence to universal precautions for exposure to blood and bodily fluids--as recommended by the CDC, the National Institute of Occupational Safety and Health, and several other organizations--has been well established as the necessary standard of practice for all settings in which exposure to bodily fluids is a potential hazard. Substance abuse treatment programs should apply the same universal precautions that are in place in hospitals and other health care facilities (CDC, 1987b) (see Figure 4-4). Prompt referral of substance abuse treatment staff members who have been exposed to contaminated blood and bodily fluids is critical because antiviral therapy can be initiated within hours of exposure to reduce dramatically the risk of transmission.
Programs should seek guidance from local public health authorities or infection control staff of an affiliated institution on adhering to universal precautions. In settings such as freestanding community-based treatment programs, safe disposal of infectious waste may require a deviation from standard waste disposal practices.
The best way to reduce the risk of occupational HIV transmission is to prevent exposures. However, exposures occasionally occur, so every clinic should have a plan for postexposure prophylaxis (PEP). One consideration in postexposure management is to administer antiretroviral medications. The use of AZT as a PEP has been shown to be safe and associated with decreased risk for HIV infection (CDC, 1998e). Newer antiretroviral medications may be effective, but there is less experience with their use as PEP. The key to PEP is to initiate therapy immediately after the exposure. Some agencies keep PEP medications onsite so that they can administer them quickly if an exposure occurs. The San Francisco Department of Public Health is making combination therapy available to people who believe they have had an HIV exposure (within 72 hours). It must be noted, however, that because of side effects, very few individuals who attempt to follow the PEP regimen are able to stay on it for 30 days.
Rapid HIV tests are becoming more available, and these tests will change how and when HIV prevention counseling is delivered. Clinical studies have shown that the sensitivity and specificity of rapid HIV tests are comparable to those of the enzyme immunoassays currently used. Because these tests can provide results in hours instead of days, counseling could increase from one session per client (risk assessment) to two sessions (risk assessment accompanied by test results) per client in a single day.
Counselors must understand the technical aspects of these screening tests and be able to assess each client's likelihood of being infected. Reactive rapid tests must still be confirmed by a supplemental test (either Western blot or immunofluorescence assay).
The CDC recommends that counseling before using rapid HIV tests should
Several new, rapid HIV tests currently in use outside of the United States may soon be submitted for approval by the Food and Drug Administration. Many of these new tests require only a single step. When these tests become available, clinicians will have more options for delivering HIV testing and prevention counseling services.
Substance abuse treatment is moving away from more intensive treatment programming toward less intensive, shorter term treatment; HIV/AIDS treatment also has shifted from intensive inpatient care to focus more on primary, clinic-based care. Providers are under pressure to perform with less money, less time, and more challenges. As a result, substance abuse treatment and HIV/AIDS treatment should reflect their interconnected relationship by coordinating as much as possible to maximize care for persons having both HIV/AIDS and substance abuse disorders. Substance abuse treatment programs and their personnel must stretch their dwindling resources by integrating the care they provide with that of other service providers.
HIV prevention is an essential part of substance abuse treatment and relevant to any treatment setting. Addressing HIV/AIDS issues beyond prevention, however, is much more complicated. For the person who abuses substances and has HIV/AIDS, the complicated physical and mental health problems--such as tuberculosis (TB); hepatitis A, B, and C; sexually transmitted diseases (STDs) other than HIV/AIDS; dental problems; diabetes; poor nutrition; dementia; and depression--require that each substance abuse treatment setting incorporate a holistic, integrated model of treatment. Treatment for the client with HIV/AIDS must be carefully reviewed. Important areas to examine are issues of confidentiality, quality of services to clients, complex treatments, staff training, client readiness, and use and allocation of limited resources.
Persons with HIV/AIDS and substance abuse disorders require more than the typical physical examination and TB test. The addition of nontraditional treatment components--such as nutritional counseling, exercise regimens, education about testicular self-examination (for men), breast exams (for women), and ways to lower cholesterol--will greatly enhance the mental and physical health of persons with HIV/AIDS. For persons with a long history of substance abuse, the possibility of mental health issues and psychiatric disorders should be explored. Many inpatient treatment and detoxification settings use a nurse to assist with physical withdrawal symptoms, medications, and occasional medical concerns. This type of care can be augmented by (1) incorporating some of the treatment components listed above, (2) using health educators and nutritionists, and (3) cross-training the treatment staff.
People with HIV/AIDS are in need of all levels of treatment for substance abuse disorders. In the early days of the HIV pandemic, individuals with HIV/AIDS did not have access to a full range of substance abuse treatment services; even today, some providers still do not offer all levels of care. Often, clients with HIV/AIDS present only their substance abuse for treatment. Their fear of disclosing HIV/AIDS status, their denial of having a substance abuse disorder, the lack of training of staff and clients, and homophobia make treatment of the "whole" person very difficult. Furthermore, the fact that HIV/AIDS case managers and health care providers are not adequately trained to screen and assess for either substance abuse disorders or psychiatric disorders and refer to appropriate treatment has limited the range of services for clients with HIV/AIDS who have substance abuse disorders.
Treatment of HIV/AIDS continues to become more complex and specialized. The resources and time needed to provide ongoing HIV/AIDS medical care are great. For the most part, it is unrealistic to expect these services to be provided within substance abuse treatment settings, but it is imperative that every substance abuse treatment program maintain a close relationship with HIV/AIDS medical care providers within its community and surrounding area. Drug and alcohol counselors and HIV/AIDS service providers must continue to develop their skills in assessing and establishing appropriate treatment plans that support the "whole" person. Medical providers and counselors can work together closely to support medical and substance abuse treatment and adherence to treatment goals. This includes establishing agency agreements and creating formal referral mechanisms.
Early intervention often can be the first step in addressing HIV/AIDS issues in substance abuse treatment, or vice versa. The practice in early intervention for persons with substance abuse disorders has been to provide HIV pre- and posttest counseling to stop the spread of AIDS. Today the emphasis is on testing, treatment, and followup. The latest medical research indicates that beginning combination therapy early in the pathogenesis of HIV/AIDS may enhance the health of the client over a long period (Hodgson, 1999). This will result in fewer opportunistic infections and, as revealed by the latest statistics from the Centers for Disease Control and Prevention (CDC), fewer people dying of HIV/AIDS-related illnesses (Vittinghoff et al., 1999). Now that there are known benefits to early treatment, counselors can feel justified in encouraging clients to be tested and then begin treatment (see Chapter 2 for information about treatment).
Another trend in early intervention is increased use of medical case management for persons with HIV/AIDS and of case management for those at high risk for becoming infected with HIV, specifically persons with substance abuse disorders. The complex regimens associated with HIV/AIDS care, along with the challenges of substance abuse treatment and aftercare, make it essential to include case managers as part of a substance abuse treatment program's responses. Many treatment centers and HIV/AIDS service organizations are receiving funding for case managers, who are sometimes called early interventionists. (See Chapter 6 for a more in-depth discussion of case management.) This service component targets those at high risk for HIV infection and provides long-term case management services focusing on risk reduction and supportive services. Risk reduction is defined with the client and based on the client's specific needs. This might mean, for example, that the case manager and client are focusing on other care needs such as dental care, mental health care, or finding stable housing. See Chapter 4 for discussion of risk reduction.
Once the client with HIV/AIDS is ready to obtain HIV-specific medical care, the case manager or early interventionist will focus on supporting medical adherence and maintenance of sobriety along with assisting with the psychosocial adjustments and the need for continued support and resources.
Early intervention also can be supported through the efforts of outreach workers or other community-based workers. Outreach workers have been an important part of HIV prevention work for many years. They have been involved in many high-risk communities and have learned much about the specific needs of high-risk clients. Outreach workers can have a great impact in helping people obtain substance abuse and HIV/AIDS treatment. Outreach workers also recognize that many people at high risk have ongoing medical, housing, and social problems and that neither HIV/AIDS nor substance abuse treatment may be the client's most pressing and immediate need.
Many clients from poorer, disenfranchised communities are dealing with basic survival needs (see Maslow's Hierarchy of Needs, in Maslow, 1970), such as food, escaping violence from an abusive partner, or keeping the electricity from being cut off. Early intervention within the context of the "culture of poverty" begins with tangible concrete service provision and establishment of trust and rapport. From this perspective--"starting where the client is"--the worker may spend time talking and getting to know the client while helping to find emergency assistance for the electricity bill and food. The worker will gradually shift from helping with the "here-and-now" challenges to developing a trusting relationship based on mutuality, which will allow the client and worker to eventually discuss long-term goals that may lead to sobriety, safer sex practices, and establishment of a more stable environment.
Because of the many overlapping issues related to substance abuse and HIV/AIDS treatment and prevention, agencies providing both services must coordinate their efforts to offer clients a full array of services. There are, however, significant barriers to complete integration of services. Some of these are:
Any effort to develop integrated treatment for substance abuse disorders and HIV/AIDS, either within a single agency or through individual care plans, should include the following components:
Developing integrated services is rarely accomplished at the administrative level. Although solid, formal understandings and agreements are helpful, most success actually is achieved at the direct-care staff level. When working with two closely linked diagnoses that are also tied to other diseases such as TB, hepatitis, and mental disorders, the care provider cannot afford to think or work solely within the confines of his own agency or personal experience. Instead, the provider must build bridges to other providers that enable clients to address all of their needs.
Many HIV-infected substance abusers are unable to maintain total abstinence from substance abuse after the abrupt discontinuation at the start of treatment. In dealing with clients' ongoing substance abuse, treatment programs must find a balance between abstinence and public health approaches to substance abuse treatment.
This approach traditionally uses confrontation, consistency of expectations, behavioral contracting, and limit-setting as treatment modalities, with the goal of achieving abstinence from all substance abuse. This approach might require termination from treatment if abstinence is not achieved.
This approach, sometimes called the risk- reduction model, emphasizes incremental decreases in substance abuse or HIV risk behaviors as treatment goals and tries to keep clients in treatment even if complete abstinence is not achieved. The public health model sacrifices some of the consistency of expectations that is such an important part of abstinence-oriented treatment. Instead, it seeks to keep substance abusers in treatment and to reduce, if not eliminate, substance abuse- and HIV-related risk behaviors. Each increment of change is viewed as a success, which helps clients see that they can positively affect their lives. By contrast, a model that regards less than complete abstinence as failure may reinforce clients' feelings of helplessness and hopelessness at their inability to sustain behavior change.
If substance abuse is placed on a continuum from abstinence to severe abuse, any move toward moderation and lowered risk is a step in the right direction and not incongruous with a goal of abstinence as the ultimate goal of risk reduction (Marlatt et al., 1993). Moreover, research indicates that substance-abusing individuals who are employed and generally functioning well in society are unlikely to respond positively to some forms of traditional treatment that, for example, tell them that they have a primary disease of substance dependency and must abstain from all psychoactive substances for life (Miller, 1993).
Flexibility is needed with HIV-infected clients because of the importance to public health of keeping them in substance abuse treatment; they are likely to continue to put others at risk if they leave treatment and resume injection or other drug use. In order to reduce the spread of HIV, clinicians may need to work with these clients even if they continue to abuse substances.
Every substance abuse treatment program must establish a balance between the abstinence and public health approaches, based on the needs of the community it serves. For example, even a program that stresses abstinence may use a risk-reduction model to educate active injection drug users about safer sex and drug use practices, such as using condoms and sterilizing syringes with bleach.
One current example of a flexible approach to substance abuse treatment of HIV-infected clients is the differential standards of care approach used by the Opiate Treatment Outpatient Program at San Francisco General Hospital's Substance Abuse Services. This approach applies varying clinical expectations and levels of care to clients based on assessment of the clients' level of functioning in the areas of physical health, mental health, social support, and housing.
The treatment staff use a "standards of care" assessment tool to determine the level of severity of impairment among methadone treatment patients with HIV (see Appendix I for a copy of this tool.) Impairment is assessed along three domains of functioning--physical health, mental health, and social resources. The latter domain represents both social support and housing. Assessment of severity of impairment takes place during a team meeting in which substance abuse counselors, the program physician, nurses, and the program social worker offer input regarding each domain. Treatment decisions are subsequently made by consensus in accordance with this assessment. Clients with evidence of severe impairment are generally approached with lower expectations for treatment outcome (i.e., applying risk-reduction principles), and higher functioning clients are approached with higher expectations (e.g., maintaining substance-negative urine tests, attending self-help group activities).
Counselors who work with HIV-positive individuals with substance abuse disorders should familiarize themselves with the local AIDS Service Organizations (ASOs) and substance abuse treatment services. Listed below are questions that all counselors who treat substance-abusing individuals with HIV/AIDS should be able to answer:
Creating medical referral networks or institutional linkages is essential and must be a top priority for anyone working with a person with HIV/AIDS. Counselors and case managers can often make the job of working with persons with substance abuse disorders easier for medical care providers by providing consultations, followup, and help acquire resources that affect the client's ability to obtain prescriptions, come to appointments, and so on. Service providers and agencies must coordinate with medical providers, including private doctors, public health clinics, and specialized HIV/AIDS facilities and treatment centers. (See Chapter 6, "Accessing and Obtaining Needed Services.") Providers should also explore the possibility of becoming members of their community's Ryan White Title II consortium of providers. There are usually two key areas in which providers can begin making contacts:
When attempting to coordinate a service plan between several agencies or resources, counselors may encounter barriers, both expected and unexpected. Here are several issues that could arise:
Networking with other agencies is a valuable tool for the counselor who is attempting to coordinate a service plan for a client with HIV/AIDS and a substance abuse disorder. It is essential to find out what services are offered in the local and surrounding areas.
In addition to standard treatment services, less traditional therapeutic interventions or culturally based interventions may be available to clients. For instance, acupuncture is being used for detoxification and outpatient treatment for addictive behavior. Massage is a nurturing, hands-on therapy that can promote a positive attitude in the client. Yoga and breath training may be available to help a client stay focused on sobriety and a path toward health.
Holistic knowledge of living systems, both physical and mental (the mind(body connection), can be integrated into the treatment plan. Helping the client "tune into" the connections between thoughts, emotions, and physical health can facilitate treatment regimens.
The Internet can provide helpful treatment information and resources to the client. Many public libraries offer free Internet access. Local colleges usually have Internet access available to the public for free or for a small fee. If a remote area lacks resources but a client must live there, the counselor faces challenges in networking and resource coordination that are clearly different from those in urban settings.
When establishing a network of care coordination, the provider must consider the issue of confidentiality (see Chapter 9). Providers must be aware of State and Federal laws and professional codes of ethics, along with agency and community policies and agreements (see also Appendix E for sample codes of ethics). Confidentiality raises issues of consent, disclosure, and release of information. Because linkages and referrals for needed resources are part of the client's overall treatment plan, the client should not be surprised that other treatment providers will be contacted and that releases of information will be needed. The client might have fears about disclosure--talking about this fear with the client is important. The counselor and client must develop a partnership that places the client in an active, empowered position so that she understands the value of connecting with other agencies. Eligibility for services at another agency may be based on need, and the agency may inquire about the client's condition to ascertain whether it pertains to the agency's services.
The counselor should also understand the difference between the terms "informed consent" and "consent." "Informed consent" refers to a client's consent to begin treatment after she understands her treatment options and the advantages and disadvantages of each option. "Consent" refers to the client's consent to allow confidential information to be disclosed as needed (see Chapter 9).
Case finding, or identification of individuals at higher risk for HIV infection, involves multiple levels of effort. Substance abusers may be located at public welfare agencies, emergency medical care facilities, other medical care settings, the criminal justice system, homeless shelters, STD clinics, churches, in the street, or in community settings. For example, hair and nail salons in regions with high numbers of injection drug users are common settings for locating women at risk. In traditional health care settings, case finding may consist of basic questions to determine risk-group membership (for more information on this topic, refer to TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997]). In the criminal justice system, urine samples may be collected to identify substance abusers, and, again, basic screening questions regarding risk behaviors may be helpful.
Confidential HIV/AIDS counseling and testing (C & T) locations represent a major part of the screening effort, with as much as 25 percent of the CDC HIV prevention budget going to C&T (Phillips and Coates, 1995). Unfortunately, many individuals at highest risk for HIV infection are unlikely to seek HIV testing for a number of reasons, including distrust of institutional settings, fear that the test results will not remain confidential, and fear that test results might be positive for HIV, thereby resulting in increased stigma, discrimination, and changed social relationships (Hull et al., 1988; Myers et al., 1993). The impact of C&T by itself on risk behaviors is unclear (Higgins et al., 1991; Wolitski et al., 1997).
Another means for locating this hidden population is through the use of community-based street outreach (Booth and Wiebel, 1992; Iguchi et al., 1992; Watters et al., 1990). A common form of community-based street outreach is the indigenous leader outreach model, which uses recovering substance abusers to locate and contact injection drug users. Indigenous outreach workers have the advantage of knowing the local substance-abusing community and the informal rules governing their behavior. These workers are therefore able to develop trusting relationships with active substance abusers, allowing them to more effectively intervene. However, this can occasionally trigger relapse in outreach workers; consequently, outreach programs should provide a forum in which workers can discuss the potential for relapse so that they will be prepared to revisit old issues while working with active substance abusers.
Early versions of this approach stressed HIV/AIDS prevention and the distribution of items to facilitate compliance with risk reduction, such as condoms, bleach, sterile water, or alcohol swabs. Injection drug users were encouraged to reduce AIDS-related risk along a hierarchy of behavioral options that emphasized taking some action, no matter how small, to reduce overall injection drug-related harm (see Chapter 4 for more information on risk reduction). Although outreach workers counseled abstinence and "getting off the needle," they recognized that in the real world, abstinence is not always immediately achievable and that a range of risk-reduction behaviors should be promoted (Wiebel et al., 1993). Once injection drug users took steps in the right direction, further steps were encouraged. One risk-reduction message is that injection drug users should always use new, sterile syringes when injecting (Normand et al., 1995). (See Chapter 4 for discussion of syringe exchange programs.)
Some outreach programs also used street outreach workers to distribute coupons redeemable for free treatment (Booth et al., 1998; Bux et al., 1993; Jackson et al., 1989; Sorensen et al., 1993). These interventions demonstrated that injection drug users will enter treatment in large numbers once barriers to treatment entry are diminished. In the case of the treatment coupons, financial barriers were lessened. Other investigators removed barriers, for example, by decreasing the typically long delay between first contact with a treatment program and the scheduled treatment intake. This "rapid intake" approach significantly increased the number of injection drug users entering treatment, without impact on rates of treatment retention (Dennis et al., 1994; Festinger et al., 1996; Woody et al., 1975).
Recent breakthroughs in treatment medications, which can potentially extend the life expectancy of someone with HIV/AIDS, have raised expectations that HIV/AIDS can be managed as a chronic disease instead of a terminal one. However, many substance abusers, even the most disciplined followers of the daily, multidosed medication regimen, are discovering that their bodies do not respond positively to these treatments. Many more people with HIV/AIDS lack basic access to these medications because of an historical lack of access to health care services.
This lack of positive response and access to life-extending treatments causes many clients, their families, and their health care providers to examine end-of-life issues. Clients with end-stage HIV/AIDS present a challenge for counselors, who must create partnerships with other health care providers to integrate treatment services for these clients and who must deal with multiple stressors related to home-based caregiving.
Such partnerships involve working with home health staff, hospice staff, and family caregivers. To define the relationship between the professional and the other health care team members, and to create goals and integrate treatment services, it is important to recognize the role of each member of the health care team.
The home health care team provides skilled nursing care for patients who are homebound. These services may also include social work, physical therapy, occupational therapy, respiratory therapy, and home health aides. Clients receiving Medicare benefits can receive home care services if they are homebound, have services provided under a plan of care, have only reasonable and necessary services reimbursed, require a skilled service, and require service only on a part-time or intermittent basis. Some coverage also is provided by Medicaid and private insurance policies (which may differ from State to State).
The hospice care team provides all the same services as home health but with a focus on palliative or comfort care for the client. The physician's order must certify a life prognosis of fewer than 6 months. The hospice team members focus on spiritual, psychosocial, and emotional issues as well as the physical needs of the client. Coverage is provided by Medicare, Medicaid, and some insurance policies (this may differ somewhat from State to State).
Many in the health care field find it difficult to educate clients about home health and hospice services; Figure 5-1 should help distinguish between these two options.
Whether home health or hospice services are used by the family at home, competent family members will likely be the primary caregivers for the client with end-stage HIV/AIDS and should not be supplanted by professional health care providers. It is helpful to define "family" broadly to include nontraditional families. Family may include significant others--individuals who may be unrelated but have a close relationship with the client and provide for the client's physical, emotional, and spiritual well-being. Family caregivers can include same-sex partners, friends, and fellow support group members.
It is important for counselors to remember that family members who provide close support to the seriously ill client often need support themselves. Social service support for the family is a cornerstone in the provision of coordinated, comprehensive care to HIV-infected substance abuse disorder clients. Home-based services may be critical in enabling a family to remain together and may be more cost-effective than institutionalizing the ill family member.
The counselor must be aware of the stressors that can make home-based service delivery more difficult.
Many professional caregivers lack education and experience in working with homebound clients with HIV/AIDS and substance abuse disorders. Even though some home-based service providers employ staff with mental health/substance abuse experience, many do not, and it is important that the counselor intervene in providing coordinated home-based services.
The client may have a relapse, especially when faced with approaching end-of-life decisions. Both professional and family providers may be unable to continue to provide needed care when faced with a client/family member who has relapsed and who is not capable of following the plan of care. It is critical in these situations that the client and caregivers continue receiving substance abuse counseling and intervention in the home setting. However, providers should be aware that the home setting can present certain problems, including the possibility that other substance-abusing persons in the client's home are stealing or utilizing opioids intended for the client.
Even though home-based services are covered by some Federal, State, and private resources, additional stressors can affect the delivery of services. The loss of income from either the client or the family caregiver can create potential problems with housing, health insurance, nutrition, and medications. The counselor must be aware of how these conditions can disrupt the plan of care.
As the client continues to need more interventions, the roles of family caregivers change, and health care professionals must be aware of the need to adapt to these changes. Family caregivers will need support in processing the anticipatory grief of losing their family members. After the client's death, help with funeral arrangements and further support of family members, who may also be dealing with their own addiction issues, may be needed.
Provided below are examples of successful programs th