Research indicates that drug use increases an individual's risk of
contracting a number of infectious diseases, or leads to behaviors that
increase that risk. The incidence and prevalence of human immunodeficiency
virus (HIV) and acquired immunodeficiency syndrome (AIDS), tuberculosis,
hepatitis B, syphilis and other sexually transmitted diseases (STDs),
in addition to other medical conditions, is high in persons enrolled
in drug treatment programs. Integrating screening for infectious diseases
with drug treatment is an important response to the growing public health
concern about these high rates of infection, and of HIV in particular.
Screening for infectious diseases in the treatment setting requires
not only medical management but supportive counseling. Beyond the direct
physical effects of disease, a number of psychosocial problems may be
present and need to be addressed.
The counselor in a drug treatment setting can play a key role in assessing
risk, providing pre- and post-test counseling, facilitating contact
tracing and partner notification, implementing risk reduction and retention
in treatment strategies, and interfacing with medical, public health,
and other agencies. Training that improves awareness of infectious disease
issues can provide counselors and other treatment staff with needed
skills for improved patient care.
The drug treatment counselor
is trained to assist patients to enter, participate in, and complete
a treatment program. It is the counselor who typically prepares or participates
in preparing the treatment plan and monitors patient progress toward
treatment goals. Services offered by the counselor may include individual,
group, and family counseling, as well as followup case management.
To these well-established
functions, the counselor is encouraged to add the following services
that support the screening of patients for infectious diseases.
- Assess patient risk
factors. A complete history is needed if medical and treatment
staff are to adequately assess the patient's risk for infectious disease.
During the initial intake or assessment interview with the patient,
the counselor can help solicit sensitive drug-taking and sexual practice
information (see "The Initial Patient Contact").
- Provide pre- and post-test
counseling. Counseling is especially critical prior to and following
HIV-antibody testing. Patients may relapse or drop out of treatment
entirely when considering testing or immediately after testing. Positive
test results are frequently devastating to patients and their families.
Counselors should be alert to the concerns and vulnerability of patients
during this time. Counseling and referral assistance may be especially
helpful for those previously known to be infected or for those whose
test results are positive while in treatment.
- Provide and follow
up patient referrals. Patients infected with certain diseases
after the initial screening will require medical care. If medical
care is offered by the treatment program, the counselor can arrange
for this care. When patients must be referred to other sources of
medical care, such as a hospital or STD clinic, the counselor should
act as the patient's advocate in arranging for treatment and tracking
followup care with the medical facility. In addition to coordinating
the care of the patient and acting as the patient's advocate, the
counselor can encourage the patient to complete prescribed therapy.
- Conduct and support
risk reduction and treatment retention interventions. These interventions
are essential components of the patient's treatment plan and should
be designed with the needs and goals of the patient in mind. The counselor
can deliver or provide for the delivery of education, counseling,
and other support services that reduce the patient's risk of contracting
or transmitting infectious diseases.
- Facilitate contact
tracing and partner notifications. Patients who have evidence
of certain infectious diseases after the initial screening should
be encouraged to identify and, when possible and advisable, inform
sexual and drug-using partners or others of their risk for infection
due to exposure to the patient. The counselor should support and encourage
the patient during this process.
- Participate in staff
development activities. Treating individuals who use drugs continues
to be challenging and rewarding work. However, the increase in the
incidence of infectious diseases, and HIV/AIDS in particular, has
intensified the emotional impact of the treatment process for many
staff members, including counseling professionals. Awareness training,
skills development, and supportive group activities give counselors
opportunities to enhance their professional abilities and improve
services to patients. In addition, all staff should take part in the
treatment program's regular infection control and prevention efforts
(see "Issues for Treatment Program Administrators: Staff and Community
Development and Environmental Safety").
- Participate in and
support community-based interventions. The effectiveness of a
treatment program is enhanced by well-developed links with other service
organizations. In addition to providing direct services to patients
and their families, the counselor can inform other service providers
about drug use and infectious diseases, and participate on behalf
of the treatment program in the community's service delivery network
(see "Issues for Treatment Program Administrators").
Proper identification of
infected persons is the first line of defense in limiting the spread
of infectious diseases. A major hindrance to public health efforts to
prevent infectious diseases is the inability or failure to identify
cases among drug users and to adequately treat them and their contacts.
The drug treatment setting
is an ideal place to identify individuals with infectious disease problems
and to initiate and maintain appropriate management. Many treatment
programs need to have a clear understanding of their patients' risk
status.
As individuals enter treatment,
a careful assessment of their risk for infectious disease is essential
(see "The Initial Patient Contact"). The counselor should be alert to
the presence of
- Injection drug use.
Injection drug users are at particularly high risk for HIV disease,
hepatitis B, and sexually transmitted diseases because of unsafe sexual
and risky drug-taking practices, including frequent needle sharing.
Injection drug users who are HIV positive are also more likely to
develop infectious tuberculosis than those not infected with HIV.
- Sexual partners of
injection drug users. Sexual partners of injection drug users,
predominantly women, are at high risk for HIV, hepatitis B, and sexually
transmitted diseases. In some cases, these individuals may not realize
that their partner's drug use places them at risk for infection. Many
of these women may use other, noninjectable drugs. Their own drug
use can lead to unsafe sexual practices that increase their risk of
infection.
- Unprotected sexual
contacts. Drug users who do not practice safer sex increase their
risk for HIV and other sexually transmitted diseases. Especially high-risk
sexual practices are the failure to use or the improper use of condoms,
and contact that involves anal penetration.
- Multiple sex partners.
Having multiple sex partners increases the risk of hepatitis B, HIV,
and sexually transmitted diseases. The practice of providing sex for
drugs, money, or shelter is associated with a higher risk of infection.
- Poor urban dwellers.
Poor urban dwellers who have substandard housing and lack access to
good medical care are vulnerable to many diseases. Tuberculosis, which
is spread by airborne infectious particles, occurs with the greatest
frequency in crowded urban areas.
- Homelessness. Poor
hygiene, inadequate nutrition and medical care, chronic drug use,
crowded shelters, and unsanitary living conditions contribute to the
incidence of infectious diseases among the homeless. Homeless youth
have high rates of drug use and sexual risk-taking behaviors, placing
them at particularly high risk for HIV infection.
- History of incarceration
and institutionalization. Having been imprisoned or having been
a resident in an institutional setting increases the likelihood of
having been exposed to HIV, tuberculosis, and hepatitis. Lower socioeconomic
status. Research has repeatedly demonstrated strong associations between
ill health, including infectious diseases, and lower income. Individuals
with lower incomes have poor access to health care and to risk reduction
information. Support for the implementation of risk reduction strategies
is frequently not available.
- Disease history. Repeated
infection with sexually transmitted diseases is associated with increased
risk for HIV infection. A history of recurrent sexually transmitted
diseases, reactive tuberculosis skin test or diagnosed active tuberculosis,
or dermatomal herpes zoster should all raise the level of suspicion
at the treatment setting that the person may be HIV infected.
Drug use can place patients
at increased risk for infectious diseases. The Centers for Disease Control
and Prevention (CDC) recommends that treatment programs screen all patients
for tuberculosis (CDC n.d.) and all injection drug users for the human
immunodeficiency virus (HIV) (CDC 1987). For methadone
programs, Federal regulations presently require that all patients have
a serologic test for syphilis as well as a tuberculin skin test on entry
and annually thereafter.1
An initial medical history
and physical examination on admission to treatment will help determine
the need for and advisability of testing and treatment for other infectious
diseases.
The counselor has an important
role in preparing patients for testing and in providing or arranging
for supportive counseling and case management following testing. The
counselor should
- Create an environment
that conveys trust and acceptance, encourages communication, and validates
feelings. Establish a positive and open relationship with patients
to help them express, discuss, and overcome any barriers to involvement
with the health care system.
- Discuss the process
of testing, test procedures, possible outcomes, and treatment resources.
Entry into drug treatment presents an opportunity for the patient
to focus on health matters and to take time to seek diagnosis and
treatment for medical concerns.
- Explain confidentiality
procedures and reporting requirements. Patients may be unaware
of their rights to confidentiality and how contact tracing and/or
partner notification impinge on this protection.
- Discuss infection containment
and risk reduction strategies. Educational instruction on how
the various infectious diseases are transmitted and on methods to
reduce the potential of transmission to family contacts is helpful
for the patient. The patient should be told how soon the infection
responds to therapy to eliminate transmission and told about precautions
that can be employed until the infection has been eliminated or controlled.
If the infection is chronic and communicable, the patient needs information
on how to protect the health of close contacts. Patients need to be
advised on how to protect themselves from reinfection or a new infection.
- Discuss retesting.
Retesting may be indicated when there is suspicion about a false-positive
or false-negative result, when the indication for testing is recurrent
or ongoing, or to determine whether intervention has been successful
in eliminating the causative agent of the infectious disease.
- Discuss contact tracing
and partner notification. Patients need to be informed of instances
in which contact tracing of close household contacts is required and
when sexual partner notification follows a positive result of a test.
This information is ideally made available prior to testing; the patient's
reservations regarding involvement can be addressed with a counselor
who has established a relationship with the patient. The counselor
then can help the patient in accepting the assistance of health authorities
in informing contacts and partners.
- Assist the patient
to make the best decision regarding obtaining medical care. When
an untreated infection poses a threat to self or others (for example,
a patient suspected of having tuberculosis or untreated syphilis in
a pregnant woman), immediate testing and treatment should be initiated.
If the patient wants or needs to prioritize health concerns, support
addressing those concerns that pose the most imminent danger (for
example, alcohol withdrawal seizures before HIV testing). Fear of
a test result is not a valid reason to delay diagnosis of a potentially
life-threatening infection for which there is an available cure or
way to lessen the severity and course of the infection.
Testing requires the participation
of the patient, and in some cases can be done only with the informed
consent of the patient.
The CDC recommends that all
injection drug users be screened for HIV. Drug treatment providers also
need to assess the risk of HIV in noninjection drug users who enter
treatment and should work with the patient to determine if HIV serologic
testing is needed. Testing for HIV should be performed only with the
consent of the patient. For persons being tested for HIV, pre- and post-test
counseling is the standard of care. The counselor has an important role
in preparing patients for testing and in providing or arranging for
supportive counseling and case management following testing.
Drug treatment providers
should be aware of the importance of pre- and post-test counseling and
should ensure that counseling is available in the on-site program or
that the basic elements of counseling are being offered by the referral
provider.
If testing is indicated,
the counselor can prepare the patient in the following ways:
- Create an environment
that conveys trust and acceptance, encourages communication, and validates
feelings. When they enter treatment, patients may suspect that
they are infected, they may have a high risk for infection, or they
may be symptomatic. The counselor can establish a positive and open
relationship with patients to help them overcome any fears they may
have about testing and the testing process.
- Discuss risk factors,
modes of transmission, purpose of the test(s), test procedures, possible
outcomes, and treatment. To facilitate testing, and the patient's
decision regarding testing, the counselor and the patient can discuss
the patient's risk factors for infection, as well as the symptoms
and modes of transmission of HIV.
The benefits of testing should
be stressed. For example, testing may prevent serious health consequences,
even death, for the patient, family members, and others in the community.
Early diagnosis of disease provides an opportunity for the patient to
obtain effective medical care that can prevent or delay serious illness.
Testing also provides an opportunity for the patient to modify personal
risk behaviors and reduce the possibility of subsequent infections.
Patients need information
about the testing process and the specific tests that are used to diagnose
and confirm HIV infection. The counselor can emphasize that the only
way to diagnose HIV is to be tested. Information offered to patients
may include a description of the test(s) that will be performed, the
procedures involved, the location and hours of operation of testing
facilities, and the qualifications and type of staff who perform the
tests.
Patients may be particularly
anxious about how and when test results will be provided. The counselor
can discuss possible test outcomes, the usual length of time between
testing and availability of results, reasons for possible retesting,
and the importance of post-test counseling.
Patients should be reassured
that medical treatment is available and can be effective. The counselor
can explain that recovery and subsequent disease prevention depend on
the patient's compliance with prescribed regimens.
- Assess possible reactions
to test results. Patients may experience some distress while waiting
for test results. Once received, test results can cause further distress,
fear, anger, or denial. The counselor can assess the responses of
patients to testing and provide referrals to mental health service
providers, social service agencies, and others as appropriate.
- Explain confidentiality
procedures and reporting requirements. Patients may be unaware
of informed consent procedures, their rights to confidentiality, and
the exceptions to these protections. The counselor can inform and
assure patients that all testing is voluntary and that treatment services
cannot be withheld if testing is refused. Consent should be obtained
before any testing procedure takes place and is required for HIV testing
in some jurisdictions.
HIV test results may be reportable
(see "Legal and Ethical Issues"), and AIDS cases with patient identifiers
must be reported to health authorities.
- Discuss risk-reduction
strategies. Educational instruction on risk reduction behaviors
provides patients, their sexual partners, and their family members
with strategies to reduce the possible transmission of infection.
The counselor can stress the importance of following these strategies
whether or not patients test positive for HIV.
- Discuss retesting.
Testing for HIV consists of an initial screening test and one or two
additional confirmatory tests. This combination of tests is sensitive
and specific.
In addition to immediate
retesting in cases in which there is concern that the test results may
be a false positive or false negative, retesting in several months may
be appropriate for individual patients. HIV antibodies, for example,
may not be detectable for up to 12 months or longer following infection.
The counselor should urge patients to be retested if they have another
potential exposure to the HIV virus, such as drug use, needle sharing,
unsafe sexual practices, or sexual victimization. A more detailed discussion
on retesting follows in the discussion on counseling the HIV-positive
patient and in the screening section of "Human Immunodeficiency Virus
and the Acquired Immunodeficiency Syndrome."
- Discuss contact tracing
and partner notification. Patients need to be prepared to assist
health authorities to inform their contacts and partners if test results
are positive.
The counselor can encourage
and support patients who test positive for HIV to notify contacts and
partners of the implications of the test results and to bring partners
in for testing or refer them to other sites for testing. At the request
of the patient, health department personnel can be asked to assist in
this notification process.
- Support patient decisions
on testing. The patient may choose not to be tested for HIV the
first time it is discussed. While the uncertainty of waiting for test
results or positive indications of infection can be stressful and
may threaten the patient's efforts to abstain from the use of drugs,
this alone should not be viewed as a valid reason to delay testing.
The counselor can acknowledge and convey an acceptance of the patient's
decision regarding testing, but should continue to educate the patient
about HIV and other infectious diseases, and encourage testing at
a future date, the earlier the better.
The following discussion
addresses post-test counseling issues, especially concerning positive
outcomes. The issues of positive results for HIV that need addressing
are so different from those associated with other infectious diseases
that they are dealt with separately. These issues are addressed again
in the chapter on
HIV and AIDS.
Because of the severe distress
patients experience while waiting for test results, counselors are advised
that they only have 10 to 60 seconds to communicate information that
will be comprehended by their patients after their test result is reported
to them. A second post-test session may be needed after the patient
gets over the initial elation or depression of finding out test results.
Patients who are HIV positive
need acceptance, information, medical care, and supportive counseling
that allows for the expression of painful feelings and promotes the
development of coping mechanisms. The counselor can assist patients
in the following ways:
- Explain the meaning
of positive results. Patients with a positive HIV test result
have HIV infection and will develop AIDS. The progression of illness
in individual patients is unpredictable, but proper medical care may
significantly slow this process. The counselor should advise the patient
that he or she is infectious and must follow precautions to prevent
the transmission of the virus to others, especially via sexual contact
or injection drug use.
- Discuss the need for
retesting to confirm initial test results. Although HIV-antibody
tests are extremely accurate when properly done, false-positive and
false-negative results may occur and retesting may be advisable for
some patients. Because false-positive results do occur, retesting
is advisable for persons who strongly deny any risk factors and are
unwilling to accept an initial positive result. Retesting is also
advisable for patients who are in a state of denial and need further
evidence of a positive test. Although false-positive results may be
found for one of the tests used to confirm that a patient is HIV-infected,
the presence of a positive HIV EIA and a positive Western blot confirms
HIV infection.
For a patient who may have
been infected with HIV in the recent past (that is, 8to 12 weeks ago),
the HIV tests may be falsely negative because that patient is in the
incubation period before seroconversion. For a person with known HIV
risk factors, the HIV test should be repeated in 3 months and again
in 6 to 12 months. As long as a patient engages in behavior associated
with risk of exposure to HIV, that person should be retested every 3
to 6 months.
In the face of overwhelming
evidence of an HIV- or AIDS-related infection and a negative test, the
test should be repeated.
- Refer the patient for
medical care. Even when there are no symptoms, monitoring for
disease progression and the start of appropriate treatment may delay
the development of AIDS.
- Help the patient to
decide whom to tell about the results. It is important to encourage
patients who test positive for HIV to inform their sexual and drug-using
partners. Not only are these individuals at risk for infection, they
may be already infected. Partners should be tested and referred to
medical care and other supportive resources. The children of HIV-infected
women must also be tested for HIV.
The counselor can assist
patients in making decisions about informing family members, friends,
and others of their HIV status and anticipating and preparing for the
range of responses. As part of this process, the counselor and patient
should carefully discuss the possibility of abuse by a spouse or sexual
partner. Health department personnel may be helpful for these and other
patients who do not choose to notify their sexual and drug-using partners.
- Explore feelings about
the disease. After finding out that one is HIV infected, the responses
may include intense anxiety; feelings of physical and social isolation;
fear of death, illness, and discrimination; concern about loss of
relationships and support systems; guilt and self-blame; a negative
self-image; obsession with symptoms; anger; and depression.
The counselor can reassure
patients that their feelings, including initial shock and denial, are
understandable and normal. A drug-injecting user may feel guilty about
infecting his drug-free sexual partner; parents may feel particular
guilt if their child has been infected perinatally. Individual and group
counseling can facilitate and encourage the expression of difficult
feelings, including anger, guilt, and anxiety.
Patients also may need referral
to other counseling resources in the community.
- Discuss withdrawal
and self-imposed isolation as reactions to disease. Being HIV
positive is associated with being viewed as someone who engages in
high-risk sexual behavior and/or drug abuse. Patients are often faced
with extreme isolation because of misunderstandings about modes of
transmission. Patients may need assistance to maintain an existing
network of friends and family or to develop such a support network.
- Assess suicide potential
and provide referral to mental health care. Patients who are HIV
positive may contemplate suicide at some point following their diagnosis,
but most overcome these thoughts. The counselor should be aware that
some patients may have higher rates of mood disorders. It is imperative
that drug treatment programs have a well-defined protocol to respond
to all suicidal thoughts or gestures.
- Emphasize risk-reduction
behaviors. Safer sexual practices and abstinence from drugs are
important risk-reduction behaviors. The counselor should constantly
emphasize the importance of risk-reduction behaviors and their benefits.
- Help the patient to
set priorities and goals. Patients who test positive for HIV are
at high risk for a return to drug use. The counselor can emphasize
the fact that abstinence is critical for maximum health and physical
well-being. Drug use may further impair the immune system.
Resumption of and continued
use of drugs place the patient at risk for needle sharing and unsafe
sexual practices that may lead to exposure to infectious diseases. Of
particular concern is the risk of infection with a different and potentially
more virulent and resistant strain of HIV. Exposure to such a strain
may hasten the progression of HIV to AIDS.
- Support the patient
in joining an HIV support group. The patient who is HIV positive
may benefit from the help and understanding provided by a community-based
HIV support group. The counselor can provide information about such
groups and encourage and facilitate attendance by patients and family
members during treatment and after its completion.
- Support the patient
and family members in anticipatory mourning and expression of other
feelings about this life-threatening infection. Feelings of impending
loss and grief can be frightening and may lead to the further debilitation
and isolation of the patient. Patients need assurance that these feelings
are a part of a healthy coping process.
- Help the patient and
family members recognize their own capacities and limitations. Faced
with a life-threatening disease, patients and their family members
struggling to cope with feelings of loss may also confront employment,
physical, and financial concerns. Counseling and referrals to community-based
resources can provide the assistance needed to maintain a positive
lifestyle.
- Provide and follow
up referrals to mental health, social service, and other community
resources. Following treatment for drug use, patients benefit
from a comprehensive continuum of care. For patients who are also
HIV positive, the following types of referrals may be of assistance:
specialized medical care; mental health care, including medication
management; financial assistance; housing; child care; and legal consultation.
Patients infected with tuberculosis,
viral hepatitis, and syphilis or other sexually transmitted diseases
also need emotional support and counseling. The counselor can assist
these patients in the following ways:
- Provide and follow
up referrals for medical care. Patients who test positive for
infectious diseases need medical treatment. The counselor can prepare
patients for specific treatment regimens by explaining and discussing
the importance of following all procedures, keeping appointments for
checkups, and taking medications. Anticipated treatment outcomes can
be reviewed to assure patients of the efficacy of the medical plan
and to allay concerns about any necessary procedures. Followup with
patients is critically important to ensure that appointments are kept.
- Discuss procedures
for and implications of mandatory reporting of test results to health
officials. Patients need to be informed about the community's
mandatory reporting requirements for positive test results. They should
be thoroughly familiar with their right to confidentiality, while
being aware of the need to inform health department infectious disease
practitioners of all contacts and partners who may be at risk for
infection. This reporting can be done without stating that the patient
is in drug treatment.
- Explore feelings about
the disease. Patients need to be well informed about the signs
and symptoms of disease, routes of transmission, and short- and long-term
effects. Some patients may be inappropriately unconcerned about infection,
and others may have erroneous fears and anxieties about these infections.
- Emphasize risk-reduction
behavior. Discuss safer sexual partners and abstinence from drugs
as important risk-reduction behaviors. The counselor should constantly
emphasize the importance of these behaviors and their benefits. For
viral infections such as HIV and herpes simplex, for which there is
no cure, prevention of transmission is the most effective approach.
- Provide and follow
up referrals to community resources. The counselor can provide
and follow up on referrals to medical care, social services, mental
health care, and other community resources to assist patients in their
recovery from drug use and to maintain risk-reduction behaviors.
Patients need a careful explanation
of the meaning of negative test results. In some cases, repeat tests
may be needed on a regular basis. With many patients, a negative test
result provides a nonthreatening window of opportunity for important
education and counseling about protection from infectious disease. This
window of opportunity may be particularly important for adolescent drug
users who might otherwise continue high-risk behaviors without being
concerned about the possibility of being at risk for infection.
Risk-reduction education
and counseling are needed by all patients who receive treatment. Patients
who agree to be tested for an infectious disease and who test negative
should be reminded about the need to change their high-risk behaviors
so that they will not be exposed and infected.
Contact tracing and partner
notification are activities intended to interrupt the transmission of
disease. Once positive test results are received, patients should be
encouraged to provide the names and locations of sexual partners, injection
drug-sharing partners, or contacts at risk for infection. The counselor
may play an important role in notifying contacts of nonreportable infections.
Contact tracing and partner notification are conducted by health department
personnel for reportable diseases regardless of the wishes of the infected
person.
In most jurisdictions, HIV
test results are reported for epidemiological reasons but are reported
without patient identifiers and no contact tracing is done. In some
jurisdictions, a positive HIV test result is reportable and contact
notification is required. In other jurisdictions, health department
personnel, at the request of the patient, may assist in tracing and
notifying contacts and partners of HIV-positive patients. Contacts who
test HIV negative may be motivated to make and maintain changes in behavior
to reduce their risk for infection in the future.
Throughout this informing
process the counselor can assist and support patients in the following
ways:
- Discuss the processes
of contact tracing and partner notification. Health care providers
must report specific infectious disease cases to health authorities.
Subsequent contact tracing and partner notification are then conducted.
Patients need to be fully informed of these requirements and assured
that identifying information is kept confidential. The counselor can
assist the patient to review current or past behaviors that may have
placed others at risk for infection. The importance of full disclosure
of the names and locations of potentially at-risk contacts and sexual
and drug-using partners can be reinforced.
- Assist the HIV-positive
patient in reaching a decision to notify (or have notified) contacts
and partners. When the reporting of positive test results is not
required by law, patients should be counseled about the benefits of
contact and partner notification. For example, exposed persons can
seek testing and early medical care; women who are pregnant can obtain
reproductive counseling or appropriate prenatal care; high-risk sexual
and drug-using behaviors can be modified or discontinued; and unhealthy
environments can be improved or changed.
It is helpful for patients
to have opportunities to discuss their fears about contact and partner
notification. For example, patients may fear the loss of a relationship,
physical violence, the loss of housing or other physical or emotional
support, and the loss of confidentiality and misuse of the information.
When patients choose to notify
contacts and partners, they may need assistance to develop effective
ways to communicate with these individuals. Using such techniques as
role playing, patients can be prepared for uncomfortable situations
that might arise.
- Discuss patient fears,
feelings of embarrassment, and guilt. Patients may be fearful
about exposure and rejection by sexual partners, guilty over possible
infection of others, and embarrassed about being infected, homeless,
or other circumstances. Adolescents may be particularly embarrassed
about their infection and continue their risk-taking behaviors. The
counselor can discuss referral options to community-based services
to address these needs, such as housing and financial assistance,
peer support groups, and mental health care.
- Explore the risk of
violence, other abuse, loss of housing, or loss of emotional support.
Some women, particularly those with children, may fear abandonment
and physical or emotional abuse from a partner if their test results
are revealed. Some men may be afraid that their wives or partners
will leave them. The counselor can discuss referral options to community-based
services to address needs such as legal intervention, housing assistance,
child care services, and financial assistance.
- Discuss confidentiality
issues. Patients may be fearful that contacts will be able to
discern their identity and that confidential and sensitive information
will be misused. Patients may be unwilling to provide information,
or they may provide incorrect or incomplete contact and partner information.
In some cases, when sex is exchanged for drugs or for money to buy
drugs, partners are anonymous. The counselor can reassure patients
concerning the confidentiality of treatment records and acknowledge
the concerns that are expressed.
Many patients in treatment
will be free of infectious diseases. Others may test positive for one
or more diseases and need medical care and other services. Every patient
should receive risk-reduction education and counseling. These efforts
will help prevent future infection in patients who currently test negative
for infectious diseases and reduce the risk to others from those patients
who currently test positive for HIV and other infectious diseases.
The experiences of drug treatment
programs suggest that the following broad principles guide counselor-based
risk-reduction activities:
- Establish a warm and trusting
relationship with the patient, based on mutual respect and regard.
- Incorporate risk-reduction
approaches into the overall treatment program that emphasize the benefits
of preventive health behaviors for a variety of health concerns.
- Provide risk-reduction
education and counseling that is sensitive to the cultural values,
religious beliefs, and traditions of the individuals being served,
as well as the socioeconomic and day-to-day realities of their lives.
- Understand that it is
fairly easy to change knowledge, more difficult to change attitudes,
and extremely difficult to change behavior.
- Acknowledge that some
risk-reduction programs will not work or will not work in the way
it was assumed that they would work.
- Do not focus on scare
tactics. Scare tactics are usually ineffective, especially when dealing
with adolescents and young adults.
- Expect modest levels of
change.
The prevention of certain
infectious diseases, such as HIV, tuberculosis, hepatitis B, and syphilis
and other sexually transmitted diseases, requires that patients permanently
alter their risk-associated behaviors, especially drug use and unsafe
sexual practices. In addition, patients need to be aware of environmental
risks for exposure to tuberculosis.
Risk-reduction strategies
can be implemented in a variety of settings, including drug treatment
programs, STD clinics, and other service facilities. These strategies
can include group and individual sessions designed to provide information
about risk factors, evaluate personal risk, overcome barriers to behavioral
change, and develop skills. A combination of these strategies may be
necessary to facilitate change by individuals in treatment. For example,
the counselor may consider the following strategies:
- Provide patients with
information about the relationship between drug use, particularly
injection drug use, and the transmission of infectious diseases. Discuss
with patients the likelihood of their having unprotected, high-risk
sexual contact while under the influence of alcohol and other drugs.
- Provide patients with
information about the various routes of infectious disease transmission,
including unprotected sexual contact, sharing of contaminated needles
and equipment, transmission from an infected mother to her fetus or
infant, and by exposure to airborne droplets containing the mycobacteria
that cause tuberculosis. Review ways that patients can avoid or minimize
exposure and infection, and the risks associated with repeated exposure
to infection.
- Encourage participation
in an HIV/AIDS self-help group for HIV-positive patients. These groups
offer information and encourage and facilitate risk reduction behaviors,
and are effective in relieving the isolation and stigmatization that
still accompany HIV/AIDS.
The initiation of safer sexual
practices is a primary risk reduction strategy that can help protect
patients from a variety of infectious diseases.
Other than sexual abstinence,
the consistent and proper use of condoms is currently the most effective
way to prevent HIV and other sexually transmitted diseases. Guidelines
on how to use a condom are available and can be discussed with patients
(see
table 1). Condoms containing spermicides, especially nonoxynol-9,
offer some additional protection against bacterial sexually transmitted
diseases. Vaginal use of spermicides along with condoms is likely to
provide still greater protection. Spermicides alone also offer some
protection against sexually transmitted diseases. The following examples
of counselor-based activities can also promote safer sexual behavior
by patients.
- Educate patients about
the risk of infection through unprotected sex, particularly with injection
drug users and multiple partners.
- Discuss possible barriers
to safer sexual practices and ways to overcome these barriers. Incorporate
ethnic and cultural perspectives to circumvent barriers to the use
of condoms.
- Provide materials that
offer sex-positive messages, that make safer sex messages appealing
to patients, and that link pleasurable sex with safer sex. Materials
with these messages have been shown to increase favorable attitudes
toward the use of condoms.
- Educate both women and
men about the potential impact of infection on a developing fetus
or on a newborn infant. The risk of HIV infection occurs through unprotected
sexual activity with an infected partner. The risk of infection to
either partner or the fetus remains throughout the pregnancy. Infection
may occur at conception, but there is continued risk throughout the
pregnancy. There is a need to use condoms for the barrier protection
throughout pregnancy to prevent HIV infection of mother and unborn
child.
- Recognize that sometimes
there is an imbalance of power in a relationship; a patient may be
reluctant to insist on safer sex practices, including barrier methods,
out of fear of being battered. A counselor may need to explore the
cultural and social norms of the patient and recognize whether these
might have an impact on the patient's ability to recognize being at
risk for abuse or ability to acknowledge verbal, sexual, or physical
abuse. Assist women to assess and avoid possible domestic violence
should they initiate unwelcome changes in sexual practices. Explore
options for protective measures for these patients. Appropriate pre-
and post-test counseling should be offered to all patients.
- Provide adolescent patients
with information about the relationship among infectious diseases,
drug use, and such risk-taking behaviors as the failure to use condoms;
the exchange of sex for drugs, money, or shelter; and multiple sexual
partners.
Many studies and common clinical
experience indicate that the longer patients stay in treatment, the
better the patient outcome and the less likely patients are to experience
negative sequelae of their drug use. Dependence on drugs is considered
a chronic and relapsing disease. Relapse is the inability of patients
to maintain abstinence from drugs and is one of the core features of
addiction. Maintaining the patient in treatment long enough to establish
abstinence and working with the patient through sometimes multiple episodes
of drug use is the overall theme of treatment. It is never appropriate
to discharge a patient solely on the basis of drug use while in treatment.
Preventing the patient's
return to drug use is an important strategy for reducing the incidence
of infectious diseases. Maintenance efforts are also needed to help
patients who initiate safer sexual behaviors to maintain them. Return
to high-risk sexual behaviors, as well as drug use, can expose the patient
and others to infection.
For patients not in long-term
therapy such as methadone maintenance or a long-term therapeutic community,
a powerful intervention - some would say the most powerful intervention
- is to teach the patient during the time that he or she is in treatment
how to access health care. Competent health utilization skills include
the patient's knowing who the local health care provider is and how
to get there. The counselor should work out insurance benefits with
the patient, and if the patient is not eligible for insurance, that
patient should know how to get care for medical emergencies. The patient
should be in the habit of accessing care and making return visits. The
patient should also know how and where to reenter the drug treatment
system. During treatment, information should be provided about community-based
programs that deal with ongoing recovery needs. These self-advocacy
skills will serve the patient well once he or she is no longer in a
treatment program.
The following are examples
of counselor-based activities that can support the patient in treatment
and reduce the possibility of a return to drug use:
- Develop a positive and
trusting relationship with the patient to encourage retention in treatment.
- Encourage and support
the patient to make a commitment to use no nonprescribed drugs by
the end of treatment.
- Encourage the patient's
participation in self-help groups.
- Provide skills training
that is oriented to chronic and complex life problems, such as job-seeking.
- Provide aggressive diagnosis
and treatment for comorbid psychiatric disorders, particularly depression
and anxiety.
Provide comprehensive counseling
that includes drug avoidance skills. Help patients to identify individual
risk factors for specific drugs. Define and develop coping strategies
- such as anger management and social skills development - for different
situations that the patient is likely to encounter. Teach patients self-management
and social skills that assist them to create steady and self-affirming
social supports and drug-free contacts, resist coercion, and improve
decisionmaking. Teach patients relaxation and meditation techniques
to mitigate the effects of stress and tension that may lead to the use
of drugs.
Safer sex requires a lifelong
change in behavior. Maintaining these safer sexual practices and not
returning to high-risk behaviors is a continuing challenge.
Factors that are associated
with a return to high-risk sexual practices include higher levels of
unsafe sexual activity prior to behavioral change, perceptions that
behavioral change does not offer protection from infection, failure
to use condoms with a steady and "safe" sexual partner, negative attitudes
concerning condom use, use of alcohol and other drugs, a lack of enjoyment
of the sexual activity using safer sex methods, a strong preference
for high-risk sexual activities such as unprotected anal intercourse,
and social support for high-risk behavior.
The following examples of
counselor-based activities can support the patient in maintaining safer
sexual practices.
- Counsel patients and their
sexual partners regarding safer sexual practices, impediments to safer
sex, and possible options for overcoming these impediments.
- Conduct educational and
counseling sessions that incorporate different ethnic and cultural
perspectives concerning the use of condoms.
- Offer coping skills and
assertiveness training that assists patients in resisting pressures
from partners to engage in unsafe sexual practices.
- Provide counseling and
other support for patients who test positive for HIV disease. Patients
may give up previous safer sex behaviors once positive test results
are received. Discuss the patient's risk for recurring infection,
possible acceleration of disease, and the risk of infecting sexual
partners if safer sexual practices are not maintained.
Provide case management services
and followup support for patients, including referrals to medical care
and social service agencies for housing, financial, educational, child
care, employment, and legal assistance.
1.
21 CFR 291.505(d)(3)(i).
- Centers
for Disease Control.
- What Drug Treatment
Centers Can Do To Prevent Tuberculosis. Atlanta, GA: U.S.
Department of Health and Human Services, n.d.
- Centers
for Disease Control.
- Public Health Service
guidelines for counseling and antibody testing to prevent HIV infection
and AIDS. Morbidity and Mortality Weekly Report
36(31):509'515, Aug. 14, 1987.
Screening for infectious diseases among drug treatment populations
offers an opportunity to identify infected individuals, provide timely
medical care, and halt or slow the progression of disease. The screening
process, however, may raise many difficult legal and ethical questions
with respect to testing, reporting, and access to care. The implications
of testing for human immunodeficiency virus (HIV), in particular, are
complex. The privacy rights of patients, treatment needs, and protection
of innocent parties are aspects of treatment that are not always comfortably
integrated.
The following discussion is intended to provide direction for treatment
providers concerning issues of access to treatment, confidentiality
and informed consent, confidential and anonymous testing, testing of
treatment staff, reporting of infectious diseases, contact tracing and
partner notification, recordkeeping, the duty to warn, and environmental
safety.
This is the end of the text. Now you may take the HIV, Hepatitis C, and STDs Quiz
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