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:
- Substance abuse increases
the risk of contracting HIV. HIV infection is substantially associated
with the use of contaminated or used needles to inject heroin. Also,
substance abusers may put themselves at risk for HIV infection by
engaging in risky sex behaviors in exchange for powder or crack cocaine.
However, this fact does not minimize the impact of other substances
that may be used (e.g., hallucinogens, inhalants, stimulants, prescription
medications).
- Substance abusers are
at risk for HIV infection through sexual behaviors. Both men and
women may engage in risky sexual behaviors (e.g., unprotected anal,
vaginal, or oral sex; sharing of sex toys; handling or consuming body
fluids and body waste; sex with infected partners) for the purpose
of obtaining substances, while under the influence of substances,
or while under coercion.
- Substance abuse treatment
serves as HIV prevention. Placing the client in substance abuse
treatment along a continuum of care and treatment helps minimize continued
risky substance-abusing practices. Reducing a client's involvement
in substance-abusing practices reduces the probability of infection.
- HIV/AIDS, substance
abuse disorders, and mental disorders interact in a complex fashion.
Each acts as a potential catalyst or obstacle in the treatment of
the other two--substance abuse can negatively affect adherence to
HIV/AIDS treatment regimens; substance abuse disorders and HIV/AIDS
are intertwining disorders; HIV/AIDS is changing the shape and face
of substance abuse treatment; complex and legal issues arise when
treating HIV/AIDS and substance abuse; HIV-infected women with substance
abuse disorders have special needs.
- Risk reduction allows
for a comprehensive approach to HIV/AIDS prevention. This strategy
promotes changing substance-related and sex-related behaviors to reduce
clients' risk of contracting or transmitting HIV.
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 can't happen to
me."--HIV can infect anyone who has sex with, or shares injection
equipment with, someone who is infected.
- "I would know if my
sex partner (injection partner) were infected."--Most people infected
with HIV do not look or feel sick and do not even know they are infected.
- "As long as I get treated
for any sexual infections I pick up, I'll be safe."--No current
form of treatment can cure or prevent HIV, and although treating other
infections reduces risk, there is still a high chance of getting HIV
through unprotected sex or sharing injection equipment.
- "If I'm only with one
sexual partner, and don't share injection equipment, I don't need
to worry about HIV."--This is true only if the partner is uninfected
and has no ongoing risk of infection. If the partner is or becomes
infected, then anyone who has sex with him or shares his injection
equipment is at high risk for HIV, and the only way to detect infection
is to be tested.
- "If I douche or wash
after sex, I won't get HIV."--Douching and washing will not prevent
HIV.
- "If I don't share my
own syringe, I won't get HIV."--HIV can also be spread through
shared cookers, filters, and the prepared drug.
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.
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:
- Differences in priority.
A client entering either substance abuse treatment or HIV/AIDS treatment
faces a myriad of required activities and treatments. Some of these
activities may appear mutually exclusive, creating significant challenges
in developing a treatment plan for clients seeking treatment in both
areas.
- Differences in philosophy.
Substance abuse treatment agencies often operate from an abstinence
model. HIV/AIDS service and medical treatment organizations and public
health professionals frequently use a risk-reduction model. This philosophical
difference can create dramatic conflict in programs and approaches.
- Differences in funding.
Public funding of prevention and treatment of substance abuse has
generally focused on drug interdiction and prevention. Conversely,
HIV/AIDS funding has focused on treatment and research. Although still
inadequate, higher levels of social service funding are available
for persons diagnosed with HIV/AIDS. Funding sources rarely recognize
the challenges of coexisting disorders; however, some resources exist.
Although funding amounts are difficult to obtain, both Title I and
Title II of Ryan White allow for the funding of substance abuse treatment
for HIV-positive individuals (see Chapter
10).
- Differences in training.
Many substance abuse treatment providers are experts at detecting
substance abuse disorders and developing treatment goals for substance-dependent
clients but at the same time do not thoroughly address their clients'
medical needs. Similarly, many public health providers do not address
a client's possible substance abuse while dealing with the client's
latest STD. Clearly there is a need for ongoing staff inservices and
cross-training. The recently published CDC/CSAT cross-training curriculum,
HIV/AIDS, TB, and Infectious Diseases: The Alcohol and Other Drug
Abuse Connection, A Practical Approach to Linking Clients to Treatment,
is an excellent resource for both mental health treatment providers
and alcohol and drug counselors.
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:
- Shared philosophy and
priorities between the care providers in regard to the client.
The client must receive clear and consistent messages if he is to
act as a full partner in his care.
- A strong case management
model. One professional within the care system should be designated
to work with the client as the lead case manager across all agencies.
The case manager must be empowered to negotiate schedules and control
resources to develop a care plan with the client. Within each client
care team, only one provider should have the title of case manager.
(For more
information on case management, please refer to TIP 27, Comprehensive
Case Management for Substance Abuse Treatment [CSAT, 1998b].)
- Social services at
the core of the treatment plan. For many clients, the first priority
is day-to-day survival. The individual's definition of survival may
vary and may include housing, food, financial services, family maintenance,
or work. Without addressing these basic client priorities, treatment
cannot be successful.
- All providers within
HIV/AIDS and substance abuse treatment trained about the services
available and requirements of the other setting. For example,
several federally funded programs subsidize housing costs for persons
with HIV/AIDS. These same services may not be available to an individual
who is in recovery for substance abuse only. Availability of housing
for an individual with coexisting disorders could be the determining
factor in maintaining treatment adherence.
- Cooperative eligibility
determinations, which often are a key barrier to achieving integrated
care. Every agency establishes requirements for its own purposes,
including varied documentation. It is essential that the client newly
in recovery or recently diagnosed with HIV/AIDS be assisted in dealing
with bureaucratic requirements that are often redundant. Workers from
each agency must be willing to cross agency lines to cooperate with
colleagues and advocate on behalf of the client.
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:
- What area physicians or
clinics with experience in HIV/AIDS issues accept HIV-positive patients?
Which ones accept Medicaid, Medicare, or specific insurance plans?
- What ASOs exist in the
area?
- Are Ryan White Funds available
in the area? If so, who administers them?
- Are Housing Opportunities
for People with AIDS (HOPWA) funds available in the area and if so,
who administers them?
- Does the State provide
medical coverage for single adults who have no dependents, for indigent
patients, or for undocumented workers?
- Where can an individual
with HIV/AIDS obtain inpatient, residential, intensive outpatient,
extended outpatient, or detoxification treatment for substance abuse
disorders?
- Are area substance abuse
treatment programs prepared to deal with a client's complicated HIV/AIDS
treatment regimen?
- What forms of support
are offered in the area to help with loss, death, and dying? Are there
community mental health centers that can provide psychiatric evaluation,
medication management, neuropsychological testing, or case managers
with skill and sensitivity toward those with mental disorders?
- Are culturally appropriate
local support groups available for persons living with HIV/AIDS and
substance abuse disorders?
- What financial assistance
is available to clients to pay for expensive HIV/AIDS treatment?
- What are the eligibility
guidelines for the State's AIDS Drug Assistance Program (ADAP), and
what drugs are covered by the program?
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:
- Local city, county, and
State health departments. Every State has an HIV/AIDS or substance
abuse treatment coordinator, or both (perhaps through the State department
of mental health services or substance abuse treatment services).
These coordinators should be able to provide information about medical
resources and special funding.
- Regional and area teaching
hospitals and medical schools. These programs often have special indigent
care funding and specialized HIV/AIDS treatment programming and funding.
They might also be research sites for HIV/AIDS clinical trials that
could not only help clients access newer treatments but also provide
high-quality, specialized HIV/AIDS care within their specific substance
abuse treatment protocols.
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:
- The clinic or service
provider from whom the counselor is attempting to obtain services
may be too busy to talk. The counselor may have difficulty communicating
the request directly to a person (rather than voice mail).
- The service provider may
consider HIV/AIDS a specialty condition and thus may be unable to
provide the level of care the client needs.
- Long waiting lists and
applicant pools for services and resources may exist.
- Other service providers
may be judgmental or discourteous because the client is HIV positive
or substance dependent.
- Few or no services are
available for the HIV-positive client living in rural or isolated
areas.
- "Turf" issues may cause
providers to make inappropriate referrals or be resistant to serving
a referred client.
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 that have linked HIV/AIDS and mental health treatment.
Also discussed are common elements of effective programs and future
challenges to building effective treatment programs.
A successful program in Seattle,
Bailey Boushey is a skilled nursing facility originally created for
persons with AIDS (given the more recent changes in AIDS treatment,
the facility's beds are sometimes used for other kinds of patients such
as transplant or oncology patients). The facility's most relevant feature
is its day health program, which provides services mostly to HIV/AIDS,
mentally ill, and substance-abusing persons. Treatment includes the
services of mental health professionals as well as substance abuse treatment
specialists.
Montrose Center, in Houston,
Texas, has years of experience working with and strong linkages to the
Thomas Street HIV/AIDS Clinic, private doctors, and area substance abuse
treatment programs. It includes intensive treatment services, outpatient
support/therapy groups at various locations, and outreach programs.
Its providers have a good reputation for working with dually and triply
diagnosed clients (i.e., HIV/AIDS, mental health disorders, and substance
abuse). The staff consists primarily of therapists with licensed professional
counselors (LPCs) and masters-level social workers.
Hilltop Center, in Longview,
Texas, is a new program offering inpatient treatment services for multiply
diagnosed clients throughout Texas. The program has developed a strong
linkage to traditional treatment programs, but also focuses on a variety
of alternative models. Its providers have a positive relationship with
funders and a strong commitment from the State drug and alcohol services
department. This program also includes an evaluation component. The
staff are well trained, motivated, and focused on the importance of
preventing clients from "falling through the cracks."
The AIDS Health Project in
San Francisco offers mental health services to HIV-infected clients
with and without substance abuse disorders. It works in collaboration
with Shanti and the San Francisco AIDS Foundation through the HIV Services
Partnership. Shanti provides volunteers for practical and emotional
support, and the AIDS Foundation provides case management housing in
a treatment-centric model that includes treatment advocates to work
one-on-one or in groups with clients struggling with HIV and substance
abuse issues and/or mental health issues. The Project is committed to
working toward a fully funded "treatment on demand" service for residents
with substance abuse treatment challenges.
The Opiate Treatment Outpatient
Program (OTOP) at San Francisco General Hospital treats nearly 160 HIV-positive
patients as part of its 250-patient methadone treatment program. OTOP
offers substance abuse treatment combined with onsite psychiatric care
and HIV/AIDS primary care.
The challenges to developing
effective treatment programs that meet the needs of those who are dually
and triply diagnosed continue to be substantial. Few programs across
the United States have been able to maintain a high level of success
along with the needed funding levels. The cost of these types of programs
is a continuing challenge. Some programs are just now exploring new
methods of treatment, although some began providing new services simply
out of desperation and frustration.
Effective treatment programs,
although they vary greatly, have common elements that contribute to
their success. These traits, discussed below, include the program's
treatment philosophy, outreach efforts, staff training, support groups,
community linkages, and funding.
The clear and repeated message
from effective programs is that counselors must "start where the client
is." Offering what the client wants is the key. It is essential that
counselors shift from the rigid thinking that there is only one way
for clients to become healthier and to recover. Effective programs have
discovered that different treatment modalities are not mutually exclusive
and can indeed coexist, particularly when it comes to risk reduction.
Nontraditional treatment, neurotherapy, biofeedback, acu-detox, and
other alternative therapies can be encouraged and integrated into clients'
treatment programs.
Also, counselors and therapists
in effective programs believe that labeling clients, confronting them
too strongly or too often, and talking "at them" rather than "to them"
are counterproductive approaches, create too much distance, and may
be a major factor why many clients never return to programs. One clinic's
approach to this problem is outlined in Figure
5-2.
Some effective programs send
a newsletter to their dually diagnosed clients. The newsletter discusses
topics that are supportive; for example, stress might be discussed,
including how stress affects the immune system and can trigger relapse,
and ways to reduce stress. The newsletter also can be distributed to
every treatment program in the community, thus serving as an outreach
tool. Although using a newsletter may sound simple, it is not a common
practice.
Some treatment programs have
brought in HIV/AIDS pre- and posttest counselors and educators to their
treatment programs. These counselors are encouraged to run support or
therapy groups for dually diagnosed clients. Because of stigmas and
confidentiality, the roles of the HIV/AIDS counselors can vary; for
example, one person may conduct the testing, another may serve as the
educator, and a third may lead a support group, so that clients have
less fear of disclosure of their HIV/AIDS status.
Effective treatment programs
also are strong proponents of staff cross-training. One view is that
substance abuse treatment providers should become experts in mental
health and HIV/AIDS, and the HIV/AIDS providers should learn about substance
abuse and mental health, and so on. Staff working with HIV-positive
clients must pay vigilant attention to the constantly changing world
of medications, side effects, and new discoveries. The main point is
that the issues of HIV/AIDS, mental health, and substance abuse disorders
coexist, and the only way to really effect long-term change is to combine
treatments. The best integrated programs encourage continuing education
for staff. Continuing education may include buying journal subscriptions,
allowing staff time off for coursework, and providing frequent inservice
training sessions. It is also important that programs hire highly trained,
flexible, open-minded staff. To be successful, these staff must see
beyond traditional substance abuse treatment modalities and be able
to accept and affirm all cultures and lifestyles.
An effective treatment program
will integrate support groups. For instance, a special group for HIV-positive
substance abusers might integrate relapse prevention with adherence
to combination therapy. The aim is to connect the milestones of HIV/AIDS
disease with triggers for relapse, so that the group becomes relevant
and provides the support needed.
One of the most important
community linkages in successful programs is the relationship with the
medical community and practicing physicians. This includes nurse practitioners,
psychiatrists, internists, nutritionists, and others. Choosing medications,
assessing medical status, and ruling out a diagnosis can be very challenging
with dually or triply diagnosed clients. When service providers work
closely with the medical care team to solve problems and formulate treatment
plans, this allows clients and providers to be more proactive. Service
providers may have to educate medical care providers about addictions
and recovery. Working together is essential so that clients are not
overmedicated or medicated in a way that jeopardizes their recovery.
The most successful programs
that effectively treat HIV/AIDS, substance abuse, and mental health
problems have learned how to obtain funds from a variety of funding
streams. Successful programs apply for funding from sources such as
the CDC, the Health Resources and Services Administration, the Substance
Abuse and Mental Health Services Administration, and many local and
State programs. Chapter
10 provides a more in-depth discussion about funding resources.
Substantial challenges continue
to face providers who wish to develop effective treatment programs that
meet the needs of clients who are dually and triply diagnosed (HIV/AIDS,
mental health, and substance abuse). Few programs across the United
States have been able to develop highly successful programs and maintain
the needed funding levels. For the most part, it is believed that these
types of programs are quite costly.
When providers examine multiply
diagnosed clients, they can see that these clients are a highly vulnerable
group of people at great risk: risk for death, as well as risk for numerous
medical problems and chronic illnesses, other infectious diseases, physical
abuse, rape, poverty, starvation, and so on. They are also often the
same clients who most easily "fall through the cracks" and challenge
treatment providers' knowledge, skills, and patience. Efforts to create
more effective programs that decrease the number of people "falling
through the cracks" must be encouraged and these programs thoroughly
evaluated in order to ensure that every client receives the best treatment
possible.
The HIV-infected substance
abuser can have multiple psychosocial and medical care needs that require
extensive community resources. In areas where few or no resources exist,
the treatment professional may have to be especially creative in working
within existing systems. Because of the number of issues encountered
in both substance abuse and HIV/AIDS, this chapter emphasizes the case
management approach in dealing with this client population and encourages
cooperation between mental health and HIV/AIDS service systems. Facts
about general categories of resources are also provided to assist the
substance abuse treatment professional with information on possible
services.
The term "case management"
has been used to describe a wide range of interventions for a diverse
number of populations. Mental health, aging, developmental disabilities,
and primary care are just a few examples of systems that use a case
management approach. For the purposes of this chapter, case management
is the term used for coordinated care of the HIV-infected substance
abuser and involves attempting to meet the multiple psychosocial and
physical needs of individuals seeking assistance.
The purpose of case management
is to ensure that all the needs of an HIV-infected substance abuser
are recognized and met in a coordinated manner and that there are no
gaps in, or duplication of, services provided by the many professionals
who are involved in meeting the client's needs. When gaps do occur in
services, this should not be because a need or resource was overlooked
but because the resource was unavailable. In short, the purpose of case
management is to make working with the client more efficient and more
effective.
A case management approach
recognizes that obtaining basic needs when an individual is actively
using substances can be overwhelming and that substance-abusing behavior
impairs a person's ability to gain access to a formalized system of
services (Lidz et al.,
1992). Drug abusers often have multiple, chronic problems beyond
the need for substance abuse treatment alone, which require the coordination
of services that case management provides (Bokos et al.,
1992). The multiple problems often experienced by a substance abuser
such as poor health, lack of housing, and a transient lifestyle can
also inhibit seeking treatment (Cox et al.,
1993). Not only does a case management approach provide realistic
support for an individual's needs, but it has the potential to enhance
the effectiveness of reatment by helping to manage the life stressors
that can impede treatment progress (Graham and
Timney, 1995).
While there has clearly been
a trend in substance abuse treatment programs toward integrating case
management into the repertoire of interventions (Brindis and
Theidon, 1997), there is still little information about the outcome
of such interventions with substance abusers, especially those with
HIV/AIDS (Brindis et
al., 1995). Studies have suggested that case management may improve
health care access and delivery of services to injection drug users
and also may decrease a drug abuser's risks for HIV infection and thus
lengthen survival time (McCoy
et al., 1992). Case management also has been shown to help injection
drug users gain access to treatment (Bokos et al.,
1992)
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