ethics

HIV, Hepatitis C, and STDs

(The text for this section is from the National Institute On Drug Abuse, 2011)

 

What Is HIV/AIDS and How Is It Spread?

The human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), is a virus that lives in and can severely deplete white blood cells (CD4+ lymphocytes), which are part of the immune system. HIV can be transmitted by contact with the blood or other body fluids of an infected person. In addition, infected women can pass HIV to their infants during pregnancy, delivery, and breastfeeding.

An HIV-infected person may look and feel fine for many years and may therefore be unaware of the infection. However, as the immune system weakens, the individual becomes more vulnerable to illnesses and common infections. Over time, a person with untreated HIV is likely to develop AIDS and succumb to multiple, concurrent illnesses. Because HIV/AIDS is a condition characterized by a defect in the body’s natural immunity to diseases, infected individuals are at risk for severe illnesses that would not normally pose a threat.

Although no vaccines or medications yet exist to prevent a person from acquiring HIV, and AIDS still has no cure, effective medications are available to treat HIV infection and help prevent the progression to AIDS.

What Is the Extent and Impact of HIV/AIDS?

Approximately 1.1 million adults and adolescents are living with HIV infection in the United States, with an estimated 56,300 more becoming infected each year, according to the Centers for Disease Control and Prevention (CDC).

A number of complex and interacting biological, social, and economic factors place some populations at increased risk for HIV/AIDS. For example: Although African Americans make up about 12 percent of the U.S. population, they accounted for nearly half of all people living with HIV/AIDS at the end of 2007. At some point in their lives, 1 in 16 African American men will be diagnosed with HIV infection, as will 1 in 30 African American women.

In 2006, HIV/AIDS infection was the third leading cause of death for both African American men and women aged 35–44 and the ninth leading cause of death for African Americans of all ages.

The rate of new HIV infections for African American men was about 6 times that of White men and 3 times that of Hispanic American men. The HIV prevalence rate for African American women was nearly 15 times that of White women and nearly 4 times that of Hispanic American women.

Hispanic Americans make up about 15 percent of the population, yet they accounted for 17 percent of people living with HIV in the United States in 2006. In 2007, HIV/AIDS was the fifth leading cause of death among Hispanic American men and women aged 35–44. Men having sex with men remains the primary avenue for HIV transmission in the United States, accounting for over half of all new HIV infections each year, as well as nearly half of all those living with HIV. Men who have sex with men (MSM) constitute the only risk group for which new HIV infections are increasing.

Individuals infected through heterosexual contact account for about 30 percent of new HIV infections and more than a quarter of persons living with HIV. Furthermore, CDC estimates that in 2006 about one in five HIV-infected persons in the United States were unaware of their infection, down from an estimated one in four who were unaware in 2003. Not only are these infected individuals at high risk for transmitting HIV to others but they are also not taking advantage of effective medical treatments for HIV that can slow disease progression and reduce AIDS-related illnesses.

How Are HIV/AIDS and Drug Abuse Linked?

Drug abuse and addiction have been inextricably linked with HIV/AIDS since the beginning of the pandemic. HIV transmission can occur by sharing needles and other injection paraphernalia. In fact, about one-fourth of AIDS cases in the United States have resulted from injection drug use. However, any drug and alcohol use can put people at risk for HIV by interfering with their judgment, leading to risky sexual behaviors:

  • According to combined data from 2005 to 2009, 64 percent of those living with HIV/AIDS had used an illicit drug, but not intravenously; only 19 percent had never used an illicit drug.
  • One in four of those living with HIV in 2009 reported use of alcohol or drugs at a level that warranted treatment.
  • Drug abuse and addiction can also worsen the progression of HIV and its consequences, especially in the brain. For example, animal studies have shown that stimulants can increase HIV viral replication, and in a human study, HIV caused greater neuronal injury and cognitive impairment in drug users than in nondrug users.

Drug-Associated HIV Transmission Continues in the United States

(This text is from the Centers for Disease Control and Prevention)

Sharing syringes and other equipment for drug injection is a well known route of HIV transmission, yet injection drug use contributes to the epidemic’ s spread far beyond the circle of those who inject. People who have sex with an injection drug user (IDU) also are at risk for infection through the sexual transmission of HIV. Children born to mothers who contracted HIV through sharing needles or having sex with an IDU may become infected as well.

Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 42,156 new cases of AIDS reported in 2000, 11,635 (28%) were IDU-associated.

Racial and ethnic minority populations in the United States are most heavily affected by IDU-associated AIDS. In 2000, IDU-associated AIDS accounted for 26% of all AIDS cases among African American and 31% among Hispanic adults and adolescents, com-pared with 19% of all cases among white adults/ adolescents.

IDU-associated AIDS accounts for a larger propor­tion of cases among adolescent and adult women than among men. Since the epidemic began, 57% of all AIDS cases among women have been attributed to injection drug use or sex with partners who inject drugs, compared with 31% of cases among men.

Non-injection drugs (such as “crack” cocaine) also contribute to the spread of the epidemic when users trade sex for drugs or money, or when they engage in risky sexual behaviors that they might not engage in when sober. One CDC study of more than 2,000 young adults in three inner-city neighborhoods found that crack smokers were three times more likely to be infected with HIV than non-smokers.

Integrating HIV/AIDS and Alcohol Research

(The following text is from the National Institute on Alcohol Abuse and Alcoholism)

The acquired immune deficiency syndrome (AIDS) was first recognized in 1981; subsequently, researchers determined that it was caused by infection with the human immunodeficiency virus (HIV). Since then, the disease has become a pandemic, with the virus infecting almost 60 million people worldwide, killing 25 million of them (Doran 2009). Although researchers have learned much about the nature of the virus, the course of the disease, the routes of transmission, and strategies to suppress viral replication and disease progression, the epidemic continues unabatedly, particularly in less developed countries. Even in the United States, where many prevention campaigns have been implemented and awareness of the transmission routes is relatively high, between 55,000 and 60,000 people become newly infected with HIV every year (Centers for Disease Control and Prevention [CDC] 2008a).

With improved treatment options, HIV infection in the United States and other Western countries has evolved from an acute illness with rapid progression and death to a chronic condition with, in many cases, a life expectancy of 20 to 40 years, thanks to the knowledge gained from research. Globally, however, approximately 2 million people died from the disease in 2008 (Doran 2009). Nevertheless, many challenges remain in preventing both infection with the virus and progression of the disease.

One of the many factors contributing to the difficulties of preventing the spread of the infection and treating infected patients is the acute or chronic alcohol use of people who are at risk for infection or who already are infected. The alcohol–HIV/ AIDS literature has grown extensively over the past 15 years, and a variety of recent reviews of this literature have summarized the interactions of alcohol use and HIV/AIDS in behavioral, biological, and biomedical areas (e.g., Bryant 2006; Van Thieu and Koblin 2009). This attention to the effects of alcohol consumption and mechanisms of impairment reflects an increasing desire to fully address a broader scope of the epidemic in strategic ways.

A plethora of studies has demonstrated that alcohol use can impact the risk and consequences of HIV infection on a variety of levels. For example, both acute and chronic alcohol use, as well as the venues where people consume alcohol, can increase the likelihood of risky sexual behavior, thereby influencing the incidence of infection. After infection has occurred, alcohol use may hasten the progression of the disease to full-blown AIDS, for example, because alcohol-abusing patients may delay testing for infection, accessing appropriate medical care, and initiating antiretroviral therapy (ART). All of these factors can amplify the risk that the infection goes untreated and that other people are infected. Furthermore, chronic alcohol use and the presence of alcohol use disorders (i.e., alcohol abuse or dependence) also contribute to various comorbid conditions (e.g., liver disease, other co-occurring infections, or cognitive dysfunction) that have an impact on the progression of the HIV infection.

Finally, alcohol interacts with many of the medications used to treat HIV infection/AIDS, and chronic alcohol use impairs patients’ adherence to ART regimens, thereby contributing to greater morbidity and mortality among the affected patients. In fact, studies found that even nonhazardous alcohol use (i.e., less than five standard drinks per drinking day) once a week or more can reduce survival of HIV-infected people by 1 year, and daily hazardous use (i.e., five or more standard drinks per day) reduces survival by 6.4 years (Braithwaite et al. 2007). To date, however, HIV/AIDS prevention and treatment strategies do not adequately take into consideration patients’ drinking behaviors. Moreover, prevention specialists and health care providers dealing with alcohol-consuming patients at risk of or already infected with HIV need additional information in order to implement effective interventions in both uninfected (i.e., HIV-negative) and infected (i.e., HIV-positive) populations.

Only through the development of an integrative and translational framework for HIV/AIDS and alcohol research can the devastating consequences of the HIV/AIDS epidemic be ameliorated in the future. Such a framework is presented here, which— although by no means complete— can illustrate the complexity of the interactions of alcohol use and alcohol-related behaviors with overall exposure and susceptibility to HIV infection. This framework represents an adaptation of an operations research model for HIV infection, transmission, and progression developed by Dr. Scott Braithwaite and his colleagues. The primary aim of that model is to examine and compare the contributions of individual, group, and social–structural factors in increasing exposure and susceptibility to HIV infection and to compare the effects of interventions targeting one or more of these factors. This work extends and integrates analyses that look at simple relationships between alcohol use and sexual risk behavior to a “systems” multi-factorial approach.

Scope of the HIV/AIDS Epidemic

The population primarily affected by HIV infection and AIDS has changed since the beginning of the epidemic. According to the U.S. Surgeon General, “the epidemic has evolved from one centered on white gay men to one increasingly impacting people of color, women, and the young” (Shelton 2000, p. 1). Particularly worrisome is the increase in the number of women infected by HIV and the number who go on to develop AIDS. For example, in the United States, the proportion of women among newly reported AIDS cases increased from 7 percent in 1985 to 25 percent in 2000 (National Institute on Allergy and Infectious Diseases [NIAID] Fact Sheet HIV/AIDS 2002) and 27 percent in 2005 (CDC 2008b). Thus, in 2005, almost 96,000 women were living with AIDS in the United States, representing 23 percent of all AIDS cases that year (CDC 2008b). Particularly, non-White women now are disproportionately affected. Thus, whereas African-American and Hispanic women together represent approximately 24 percent of all U.S. women, they accounted for more than 82 percent of AIDS diagnoses for women reported in 2005 (CDC 2008b). Moreover, HIV/AIDS now is associated with high mortality among women, coming only behind deaths from cancer or heart disease. Thus, in 2004 it was the fifth leading cause of death among all women ages 35–44 years and the sixth leading cause of death among all women ages 25–34 years. These numbers are comparable with those found in men of the same age-groups. In Black women, the situation was even more dramatic, with HIV/AIDS being the leading cause of death among Black women ages 25–34 (compared with fourth leading cause among men of that age-group) and the third leading cause of death among Black women ages 35–44 (second leading cause in men of that age-group) in 2004 (CDC 2008b).

These numbers underscore the need to understand the evolving epidemic, particularly among women and minority groups, in order to develop sustainable prevention and intervention approaches. For example, the fact that more women become infected, particularly women of child-bearing age, implies that the risk of mothers transmitting the disease to their children before, during, and after birth also increases, which necessitates appropriate prevention and treatment approaches.

Impact of Alcohol Use on the HIV/AIDS Epidemic

Alcohol use is common in all population subgroups in the United States, and data show that 4.4 percent of American adults meet the criteria of alcohol dependence (Grant et al. 2004). In addition, as many as 35 percent of adult drinkers may experience mild to moderate problems related to alcohol without physical dependence and therefore may be considered problem drinkers. Many of these drinkers are at risk for HIV infection, are in the early stages of infection without their knowledge and have not sought treatment but continue to drink, or have received a diagnosis of HIV/AIDS and have begun treatment with varying success. Studies also identified a strong association among women between alcohol and other drug abuse and acquisition and progression of HIV/AIDS. Thus, studies sponsored by NIAID found that in the United States, alcohol use, history of childhood sexual abuse, current domestic abuse, and use of crack/cocaine all are associated with an increased risk of heterosexual transmission of HIV (NIAID 2004). To date, however, no systematic estimates of alcohol use, abuse, and dependence using a variety of sensitive measures have been carried out in at-risk or infected populations. In an analysis of an HIV treatment population in the Veteran’s Aging Cohort Study in the United States, 35 percent of the patients were classified as currently or previously alcohol dependent (Justice et al. 2006). In Kenya, a study of people participating in a voluntary counseling and testing program (who can be considered at risk of HIV infection or may be infected) determined that more than 60 percent of the current drinkers could be classified as hazardous drinkers (Mackenzie et al. 2008). The article by Scribner and colleagues (pp. 179–183, in this issue) summarizes the existing information on the epidemiology of HIV/AIDS, including alcohol use patterns in the affected population subgroups. However, a better understanding of alcohol use patterns in at-risk and infected populations clearly is needed to more accurately define the scope of the problem and evaluate the consequences of alcohol use in these populations.

Rehm and colleagues (2009) recently related alcohol consumption to the global burden of disease and injury. The analyses demonstrated, for example, that alcohol consumption increases the risk for contracting infectious diseases, including tuberculosis (TB) and HIV/AIDS, as well as exacerbates the consequences of these diseases, such as more rapid progression, development of multidrug-resistant forms, and premature mortality from failed treatment. In absolute terms, alcohol use accounts for 13.5 percent of global mortality from infectious diseases, with the largest impact found in low-income countries with elevated rates of alcohol consumption, such as South Africa. Overall, alcohol use can contribute to HIV/AIDS deaths directly or indirectly—for example, through alcohol-related unintentional and intentional injuries, cardiovascular or hepatic damage, or neuropsychiatric disorders. These consequences of excessive alcohol use have not been assessed adequately in HIV-positive populations. Some analyses of cohorts of HIV-infected patients indicate that the role of alcohol-related hepatic and cardiovascular effects in HIV/AIDS progression and death are underappreciated and need to be addressed systematically (e.g., Conigliaro et al. 2003; also see the article by Freiberg and colleagues, pp. 237–246, in this issue). Clearly, research addressing the role of both direct and indirect alcohol effects needs to be developed further.

Impact of Alcohol Use on HIV/AIDS Prevention

Alcohol consumption is prevalent in nearly every population group at high risk for HIV infection. In all of these groups, alcohol use can affect the risk of infection and the effectiveness of prevention efforts as well as exacerbate the consequences of an infection and progress of the disease. There are several ways to look at strategies to prevent these alcohol effects. One way is to compare behavioral prevention efforts (e.g., reduction of risky sexual behavior) and biomedical prevention efforts (e.g., vaccination or prophylactic treatment) and evaluate alcohol’s impact on both areas. A second way is to look at alcohol’s contribution at different stages of the patient’s infection process (i.e., risk of exposure to the virus, risk of infection once exposure occurs, and risk of HIV progression and organ damage once infection occurs). The following sections discuss both of these perspectives.

Influence on Behavioral Versus Biomedical Prevention Strategies

Influence on Behavioral Prevention Strategies. Alcohol use may increase people’s likelihood of risky behavior and undermine the effectiveness of many prevention efforts through a variety of pathways:

  • Alcohol has a direct impact on risk behaviors by impairing judgment and cognition and by disinhibiting behavior, thereby potentially increasing the likelihood of unprotected sex and other risky behaviors. In addition, alcohol-related outcome expectancies, perceived social norms, and other beliefs can influence behavior more indirectly.
  • People who drink frequently also use other drugs that may enhance the risk of direct exposure to HIV, for example, by injection drug use.
  • Alcohol consumption frequently occurs in settings (e.g., bars, clubs, and informal drinking places) where unprotected sex with several partners is likely to occur (Kalichman et al. 2007b). In general, drinking (particularly heavy drinking) is associated with risky sexual behaviors. For example, one study (Mackenzie and Kiragu 2007) reported that in a Kenyan sample, current drinkers were four times more likely to have multiple sexual partners than nondrinkers. Other studies found that alcohol-serving establishments often also are the places where sex partners meet, resulting in the formation of “sexual networks” in which HIV can spread rapidly (Chersich and Rees 2010; Weir et al. 2003). Finally, alcohol dependence may lead to trading sex for drinks, as has been reported in South Africa (see Kalichman et al. 2007a)
  • Alcohol (like other drugs) often is a tool of sexual coercion, resulting in increased risk of HIV infection. For example, Stockman and colleagues (2009) reported that women who had been sexually coerced by use of alcohol and other drugs had a 1.5 times higher risk of having multiple sex partners than women who had not been coerced using drugs.

Based on the knowledge of these pathways, researchers have developed numerous prevention measures targeted at high-risk groups (e.g., men who have sex with men, injection drug users, or victims of sexual coercion) or high-risk settings. The article by Kalichman (pp. 184–194, in this issue) describes some of these behavioral interventions and the evidence for their effectiveness.

It is important to note, however, that despite the known effects of alcohol use on HIV transmission risk, alcohol use commonly is treated only as a background characteristic in HIV prevention measures, so that many behavioral HIV prevention interventions targeting people who drink do not seriously address alcohol use as a risk factor, thereby potentially reducing intervention effectiveness. Indeed, there are numerous examples where drinking may have reduced the potential benefits of an intervention or confounded interpretation of the results (e.g., Carey et al. 2010). Consistent with these findings, studies that have examined alcohol use as a moderator of HIV risk behavior outcomes have suggested that risk reduction interventions are more effective for participants who do not drink heavily compared with participants who report heavy drinking (e.g., Kalichman et al. 2008). Thus, future studies need to pay greater attention to the role of alcohol as a contributor to HIV transmission risk when designing and testing new prevention approaches.

Influence on Prevention at Different Stages of the Infection Process

Reducing Risk of Exposure. Reducing people’s risk of being exposed to HIV infection obviously is important for stemming the HIV/AIDS epidemic in the United States and internationally. One approach to achieving this is using ecological models that synthesize the influences of a variety of factors underlying exposure to people with active HIV infection, particularly if they represent the interactions between these factors and alcohol use. Among the factors to be considered are the following (see figure 1 in the sidebar):

  • Social network characteristics that include factors such as the number of partners, concurrency of alcohol and other drug use and sexual relationship, and age symmetry within a relationship, where an older HIV-positive partner may influence the risk behavior of the younger partner. All of these characteristics establish or change social norms (for a more detailed discussion, see Latkin et al. 2009).
  • Demographic characteristics that interact with these social network characteristics and may be used to classify individuals in terms of their overall susceptibility to infection as well as their group identity (e.g., minority women, young Black men).
  • Psychosocial characteristics that may influence drinking behaviors by altering expectations for engaging in risk behaviors, contributing to psychosocial disinhibition, and influencing settings and situations for alcohol use and risk behaviors.
  • Biological factors, such as hormonal, neurological, and other characteristics, that also can impact risk of exposure.

Among these, social network characteristics are of particular interest because models representing social networks can help discover specific risk patterns and suggest targeted interventions. Such models may capture complex interactions between such diverse factors as alcohol levels over time in a specific geographic environment (determined using spatial mapping of specific alcohol-related venues), sex and alcohol or other drug use (using social network mapping), and individual-level characteristics. The article by Scribner and colleagues (pp. 179–183, in this issue) describes the development of such ecological models in more detail.

To interfere with this complex range of influences and thus reduce risk of exposure, interventions at multiple levels may be necessary. These may include structural interventions at the economic and policy levels, such as microeconomic interventions for women in underresourced countries that allow the women to generate sufficient income so they do not have to work as sex workers. Other interventions may be tailored to specific settings, including both formal (i.e., bars and nightclubs) and informal (i.e., “shebeens” or corner gathering places for adolescent drinking) settings in which alcohol consumption occurs and that may provide a source of employment, profit, and socializing. Of particular concern here are settings that facilitate mixing of higher-risk and lower-risk populations (e.g., cross-border settings where truck drivers rest). Interventions that have been used in these diverse settings are described in the article by Kalichman (pp. 184–194, in this issue).

Reducing Risk of Transmission/ Infection Given Exposure. Not all people who are exposed to the virus actually become infected, and certain models are evaluating how transmission risk can be reduced. Important behavioral characteristics that augment the likelihood of infection and therefore are important targets of prevention efforts include alcohol consumption, lack of condom use or other protection (e.g., microbicides), and behaviors that result in untreated sexually transmitted infections (STIs) (see figure 2 in the sidebar). Alcohol consumption is a particularly important factor in this context because it may affect behavioral mediators of transmission (e.g., likelihood of condom or microbicide use) as well as nonbehavioral mediators (e.g., function of the person’s immune system). Therefore, research on the impact of alcohol use on the use and effectiveness of microbicides, vaccines, and preventive therapeutics has great potential to inform interventions to reduce the risk of infection. This is discussed in more detail in the article by Mayer and colleagues (pp. 195–202, in this issue). Equally important is research on the role of alcohol use in immune function impairment and in the effectiveness of agents striving to reconstitute the immune function of tissues and organs impacted by both alcohol and HIV/AIDS. In all cases, research on strategies that also can be used in settings with limited resources is of particular interest.

Another important area of study concerns approaches to reduce transmission risk that have both a behavioral and a biological component, such as prophylactic treatment with HIV medications. These medications are thought to reduce the risk of transmission if taken before or after exposure to the virus (“morning after” use). However, their use also has a behavioral component because the success of this approach depends on the patient adhering to the treatment regimen. The success of this pharmacological intervention still is under investigation; particularly, there is as yet no information on how drinkers will use this chemical prophylaxis approach. Because alcohol use is known to reduce treatment adherence and because of beliefs about the medications’ toxicity (i.e., some people report discontinuing these medications when they go to a party), it is unlikely that prophylactic treatment will be widely accepted by people with alcohol use disorders. However, because these pharmacological interventions potentially are important tools for preventing an infection in people exposed to HIV, they need to be investigated further in different patient groups.

Reducing Risk of Progression and Organ/Tissue Injury. Once people are infected with HIV, alcohol use may impact progression of the infection and other diseases through its effects on access to and effectiveness of ART, interaction with viral characteristics, and contribution to organ and tissue damage (see figure 3 in the sidebar). Alcohol use may impede access to ART at several steps in the sequence of events that must occur for a person to begin treatment:

  • Alcohol use may delay willingness to be tested for HIV, increasing the likelihood that infection will only be detected after serious HIV-related disease develops.
  • Alcohol use may make it less likely that people with a diagnosed HIV infection link with appropriate care and show up for regular appointments; these people therefore are less likely to be considered suitable candidates for starting ART.
  • Alcohol-abusing people may be less willing to start ART because of concerns over symptoms, toxicity, or anticipated adherence problems.

All of these factors limit access to ART and therefore contribute to the risk of HIV/AIDS progression and death. In addition to these effects on ART and its effectiveness, alcohol abuse also has been shown to accelerate and magnify the organ and tissue damage resulting from the HIV infection and from comorbid diseases. Some of the acute and chronic interactions of alcohol with HIV/AIDS progression and associated conditions are reviewed in more detail in the article by Pandrea and colleagues (pp. 203– 218, in this issue). Because the life expectancy of HIV-infected people has been prolonged as a result of ART, comorbid conditions, such as hepatic, pulmonary, neurological, cardiovascular, and metabolic diseases; certain tumors; and other clinical manifestations associated either with long-term HIV or prolonged ART, have assumed greater importance as causes of morbidity and mortality in HIV-positive people. Most of these conditions, but particularly liver disease and neurological disorders, can be exacerbated by alcohol abuse and dependence. For example, ART frequently has hepatotoxic effects; moreover, many HIV-positive patients also are infected with hepatitis B and C viruses that also damage the liver (Goedert et al. 2002). Chronic alcohol consumption also causes liver injury and may therefore accelerate the development of serious liver disease in patients coinfected with HIV and hepatitis viruses. Thus, understanding liver disease progression in the context of HIV infection and alcohol abuse is becoming an important issue in caring for these patients. For example, research is needed on the response of alcohol-abusing HIV patients to treatment of liver disease. These and other issues are reviewed in the article by Barve and colleagues (pp. 229–236, in this issue).

Another area of growing concern among HIV-positive patients is neurological injury. Both HIV infection and alcohol abuse have detrimental effects on brain function, which are reviewed in the article by Rosenbloom and colleagues (pp. 247–257, in this issue). Another common neurological disorder is peripheral neuropathy. This typically painful and debilitating condition, which is characterized by inflammation or degeneration of nerves outside the brain and spinal cord, severely compromises quality of life and productivity. It is found in approximately 30 percent of HIV-infected patients and almost 100 percent of AIDS cases (Ferrari et al. 2006). Similarly, peripheral neuropathy is the most common neurological complication in alcoholism (Diamond and Messing 1994). Although both HIV infection and alcohol abuse can induce peripheral neuropathy, they may do so through different mechanisms, and this issue requires further investigation.

Research also is needed to characterize the synergistic interactions of alcohol, HIV infection, and ART in other body systems. For example, as described by Drs. Freiberg and Kraemer (pp. 237–246, in this issue), these interactions can play a significant role in the development of cardiovascular disease. Similarly, lung health also can be impaired in alcohol-abusing HIV-infected patients, as explained in the article by Quintero and Guidot (pp. 219–28, in this issue). Research that will lead to a better understanding of the effects of alcohol on various HIV-associated comorbidities is a high priority and may be promoted by the emerging field of systems biology. In addition, translational and clinical studies are needed to translate basic research results into improved strategies for preventing and treating these HIV-associated comorbidities and their consequences.

Treatment of Concurrent HIV/AIDS and Alcohol Problems

Treatment of patients with concurrent HIV/AIDS and alcohol problems is complicated and often ineffective. As mentioned earlier and further described in the article by Drs. Braithwaite and Bryant (pp. 280–287, in this issue), alcohol-abusing patients exhibit reduced adherence to their treatment regimens, which typically have to be followed exactly in order to be most effective. Failure to adhere to the regimen enhances the likelihood that the virus becomes resistant to the medications used and that HIV disease progresses more rapidly. At the same time, alcohol can interact with the HIV medications and may exacerbate the toxic effects associated with the long-term use of some of these agents. Fear of this toxicity leads many patients to stop taking their medications when they know they will be drinking or discourage them from initiating treatment at all.

A second aspect of the comorbidity of HIV/AIDS and alcohol abuse or dependence is whether alcoholism treatment should be initiated as part of the HIV/AIDS intervention. Alcoholism therapy requires substantial investments of time, effort, and expense also at the part of the patient, which may seem unreasonable to patients with less severe drinking problems. In addition, it is conceivable that patients may be afraid of stigmatization if they seek treatment for problem drinking, whereas seeking treatment for a medical condition may be considered more acceptable. Finally, many problem drinkers at early stages of change may not think they have a drinking problem and therefore do not think they require treatment. Thus, perceptions regarding the need for and usefulness of treatment for problem drinking may keep many affected patients from seeking treatment in the first place. Even if treatment is initiated, which typically involves behavioral approaches, the effectiveness of these interventions often is limited, as described in the article by Samet and Walley (pp. 267–279, in this issue).

These considerations underscore the need to develop pharmacological and low-threshold interventions, particularly for patients who are not prepared to invest in formal alcohol treatment or who need to seek treatment outside of the usual alcohol treatment settings (e.g., in HIV/AIDS testing and treatment settings). Moreover, new approaches are needed for effectively encouraging problem drinkers to initiate treatment—for example, by modifying their perceptions of the acceptability of their drinking as well as of the attractiveness of various intervention options for people at risk of HIV infection, of unknown HIV status, or with active HIV infection. Finally, medications for alcohol-abusing and alcohol-dependent HIV-positive patients are needed that ideally impact drinking behavior as well as improve the patient’s immune function and decrease progression of the HIV infection. Chronic alcohol use is associated with impairment of the immune system. Among other effects, alcohol impairs the functioning of the exact cells that are the targets of HIV—cells called CD4 T-lymphocytes and macrophages. Thus, it would be desirable to have medications that inhibit the alcohol-mediated spread of the HIV infection among the CD4 T-lymphocytes and which at the same time address the underlying alcohol disorder, thereby enhancing adherence to ART. In fact, such an effect has been observed with the medication naltrexone, which is used in the treatment of alcoholism (Wang et al. 2006). However, additional treatment options are needed, and novel pharmacologic approaches to the treatment of disorders affecting the immune system have been suggested (Tuluc et al. 2009).

Conclusion

Despite 30 years of research, HIV/AIDS still is one of the greatest health challenges worldwide and continues to take an enormous toll both in terms of human suffering and mortality and with respect to the associated economic costs. Alcohol use and misuse continues to play an important role in the acquisition, progression, and transmission of HIV. Therefore, in order to reduce the number of new HIV cases and improve the prognosis of those already infected with the virus, it is essential to bring the two fields of alcohol research and HIV research together to allow for advances in both prevention and treatment.
The articles in this issue of Alcohol Research & Health present specific findings from current research into the interactions of alcohol use and HIV/AIDS, providing an overview of behavioral and biomedical prevention approaches, the physiological consequences of concurrent alcohol use and HIV infection on the body, and treatment challenges and strategies to address both conditions. Some articles summarize research and offer models from relatively broad problem areas, whereas others focus on specific problems that to date have received little attention. Together, the articles provide a foundation for a discussion of future research and new directions in these areas. Although this journal issue can only represent a few of the multiple approaches to the problems associated with alcohol use and HIV/AIDS, it begins to sketch out the current way of thinking about the relationship of alcohol use to the HIV epidemic both in the United States and abroad.

Much has been learned about this relationship in the past three decades. For example, it is now clear that it takes a combination of medications to control the infection; similarly, it may take a such a “cocktail approach” combining vaccines and behavioral interventions to prevent the acquisition and transmission of HIV infections. The challenge for researchers and clinicians now is to understand how to develop the optimal combination of preventive and therapeutic measures that remain effective over time. Meeting this challenge will require the development of broad models that incorporate all relevant perspectives; this can only be achieved by intensive and multidisciplinary collaboration between the alcohol and HIV/AIDS fields.


Hepatitis C

(Hepatitis C text is from the Substance Abuse and Mental Health Services Administration –SAMHSA-TIP 53, 2011)

Hepatitis C can be acute or chronic, but it starts as an acute infection (that may go unrecognized). Unlike people with hepatitis A and B, people who have hepatitis C and clear the virus do not develop immunity; they can become reinfected with the virus at a later date.

Modes of Transmission

Hepatitis C is a blood-borne disease. IDU is the most common risk factor for acquiring hepatitis C. The virus can enter the body through any puncture in the skin (e.g., cuts, burns, sores), and travels, via the blood, to the liver. Risks of sexual transmission are unclear but appear to be low, especially compared with sexual transmission rates of HIV or HBV. Nonetheless, HCV infection rates are higher in people who have multiple sex partners. Infections have been reported in individuals with no known risk factors.

Disease Burden

HCV infection is the most prevalent chronic, blood-borne infection in the United States (Alter et al., 1999). Approximately 3.2 million U.S. residents have chronic HCV infection (CDC, 2010c). Forty percent of chronic liver disease—the 10th leading cause of death in the United States—is caused by HCV.
Hepatitis C is most prevalent among people born between 1945 and 1965, the majority of whom were likely infected during the 1970s and 1980s, when infection rates were the highest. CDC (2010c) estimated 17,000 new infections in 2007, and people who inject drugs account for more than half of the new cases.

Disease Course

HCV can be detected in the blood within 1–3 weeks of transmission. However, the majority of people with hepatitis C are asymptomatic. Of people who contract hepatitis C, 15 percent to 25 percent clear the infection, but 75 percent to 85 percent do not and the infection becomes chronic (CDC, 2010c) (Exhibit 1-4). Chronic HCV is insidious, usually progressing very slowly and with few or no symptoms for the first 20–30 years after infection. Symptoms often do not occur until the liver damage has advanced. As the disease progresses, the liver may develop fibrosis, which can progress to cirrhosis. Approximately 12,000 people die each year from HCV-related liver disease (IOM, 2010). HCV infection appears to progress more quickly in men, people older than 50 at the time of infection, and people with concur­rent HBV or HIV (Hézode et al., 2005). Mortality is high in people with HCV/HIV co-infection.

Hepatitis C and Substance Use

HCV is highly contagious; people who inject drugs are more likely to contract hepatitis C than HIV (Garfein, Vlahov, Galai, Doherty, & Nelson, 1996). People who inject drugs are at high risk for becoming infected with HCV from sharing needles and drug use parapher­nalia. Up to 91 percent of people who inject drugs and share needles or other paraphernalia over a prolonged period will eventually acquire HCV infection (Abou-Saleh & Foley, 2008; Macias et al., 2008; Maxwell, Shinderman, Miner, & Bennet, 2002; Tseng et al., 2007). Liver disease progresses more quickly in people who have HCV and abuse alcohol than in people with only one of the condi­tions (Bhattacharya & Shuhart, 2003; Felsen, Fishbein, & Litwin, 2010).

Prevention

There is no vaccine against hepatitis C. It can be prevented only by avoiding contact with contaminated blood.

Hepatitis C Screening

The most common test for hepatitis C virus (HCV) detects antibodies to HCV in the blood, but the results are not clear cut and should be interpreted carefully. A “positive” HCV antibody test could mean the person is a chronic carrier of HCV (75 percent to 85 percent), has been infected but has resolved infection (15 percent to 25 percent), or is one of the few recently (acutely) infected (CDC, 2010c). Following HCV infection, it usually takes at least 6–8 weeks for the body to develop enough antibodies to be measured in a screening test, but it can take longer. For example, people who have suppressed immune systems (e.g., people who have HIV infection) may not test positive for 15 weeks–6 months after exposure to the virus. An infection that has been present for less than 6 months may not be detected with an antibody test. However, an infection that has been present for 6 months is almost always detectable with an antibody test.

A positive HCV antibody test means the person was infected with the virus; it does not always mean the person is still infected. Up to 25 percent of people infected with HCV successfully clear the virus from their systems within 6 months after being infected, but the antibody remains present in the screening test.

Most antibody testing requires a blood sample that is sent to a laboratory for processing. However, in 2010, the U.S. Food and Drug Administration (FDA) approved a rapid antibody blood test for HCV (the first in the United States) that is available in some medi­cal offices. The rapid test is for individuals 15 years and older who are at risk for HCV infection or who have hepatitis symptoms. The test still requires a blood sample, but it involves the use of a “test strip” that provides results in approximately 20 minutes. However, the rapid test is not sufficient to make a final diagnosis of HCV infection. If the rapid test is positive, more traditional and sophisticated tests will be necessary to confirm the diagnosis (FDA, 2010b).

People who have a positive result on an HCV antibody screening test should receive addi­tional tests to get more information. The most common follow up test is a qualitative HCV RNA (ribonucleic acid) test. RNA is the genetic material of the virus, and the qualitative test determines whether the virus is present. A quantitative RNA test—or quantitative viral load test—measures how much of the virus is present. Because of the difficulty in interpreting an HCV antibody screening test, some medical care providers ask for a follow up test before reporting the results of the antibody test to their patients. If HCV RNA is present for at least 6 months, the HCV infection is considered chronic.

In people who are at risk of HCV infection, false positive antibody test results are rare. Therefore, a positive result in a person with a history of drug use, particularly injection drug use (IDU), is a true positive more than 99 per­cent of the time—meaning that the person has been infected with HCV.

The accuracy of a negative HCV antibody test result is very high. However, to account for the 6-month window period, people who inject drugs or engage in other high-risk behaviors should be retested every year (Backmund, Reimer, Meyer, Gerlach, & Zachoval, 2005).

Treatment for Hepatitis C

Because most people who have hepatitis C have mild symptoms or no symptoms, clients often do not know they are infected and, therefore, do not seek hepatitis treatment until severe hepatitis C virus (HCV)-related diseases have produced other symptoms or their infections are found in a screening test. Approximately 1 in 5 people clears HCV infection without treatment. In rare cases, acute HCV infection quickly leads to liver failure (for example, following reinfection after a liver transplant). Therefore, any client diagnosed with hepatitis C is a potential candidate for antiviral treatment.

Acute Hepatitis C

Treating hepatitis C early might greatly increase a patient’s chances of sustained virologic response (SVR) and prevent long-term liver damage (Kresina et al., 2008). Response rates in acute HCV infection are radically better than in chronic infection, but to maximize the likelihood of viral clearance, treatment should be initiated within the first 20 weeks. Therefore, counselors should encourage clients who have hepatitis C to seek specialized care immediately. No clear regimen exists for treat­ing acute hepatitis C. Currently, treatment is a shortened form (approximately 12 weeks) of the antiviral treatment for chronic hepatitis C.

Chronic Hepatitis C

Treatment options for people who have chronic hepatitis C include:

  • Antiviral treatment. A course of potent medications might slow disease progres­sion or eliminate the disease.
  • Deferring treatment. Not all patients want treatment, even if it is advised.
  • Liver transplantation. For people who have end-stage liver disease, transplanta­tion surgery might be the only option. However, the waiting list for such surgery can be long.

Antiviral Treatment

Antiviral treatment helps the body fight off HCV infection (i.e., weakens the virus). When the virus is not detected in the blood of a patient who is receiving antiviral treatment, and when it remains undetected for 6 months after treatment is completed, the patient is said to have an SVR. The virus does not return in 95 percent to 99 percent of patients who achieve an SVR, and it does not appear to cause further damage (McHutchison et al., 2006; Swain et al., 2007).

However, an SVR does not make a person immune to reinfection. If reexposed to HCV, a person could be reinfected. Clearing HCV does not make a person immune to other forms of hepatitis or to liver disease. For instance, drinking heavily can still cause liver damage, even after successful treatment of hepatitis C.

The standard recommended treatment for hepatitis C is a combination of pegylated interferon injections and ribavirin (Exhibit 5-3). However, in 2011, the FDA approved two new oral medications, boceprevir and tela­previr. They represent a new type of medica­tion for HCV infection that works differently than interferon and ribavirin and works in combination with those traditional medications (FDA, 2011a; FDA, 2011b).

Hepatitis C treatment works well for most people, whereas for a minority it produces little or no improvement. Counselors can help their clients improve their chances for successful hepatitis treatment by encouraging them to:

  1. Take all medications as prescribed, keep all medical appointments, and reschedule missed appointments as soon as possible.
  2. Maintain a healthful lifestyle.
  3. Learn about HCV medications, includ­ing special risks and warnings even after antiviral treatment has finished.
  4. Always carry a list that includes the prescribing medical care provider’s name and phone number and the names and dosages of the medications.
  5. Check with their medical care provider before starting new medicines, including vitamins, supplements, herbal remedies, prescription medications, and over-the-counter medications.
  6. Avoid drinking alcohol or taking drugs with no known medical use.
  7. Maintain as many recovery activities as possible.
  8. Report side effects to their medical care provider.

Side effects of antiviral medication differ from person to person. Some side effects are mild to moderate and remain so. But in some people, side effects become more severe with continued hepatitis treatment. HCV treatment is long, and having to manage side effects for the duration of treatment can strain individu­als and those they turn to for support. Side effects—particularly flu-like symptoms and depression, which are common side effects of interferon—are the primary reason people stop hepatitis C treatment. Because people are more likely to clear the virus if they complete their antiviral treatment, it is crucial that they get the support they need to manage side effects so the side effects do not cause them to discontinue treatment (Exhibit 5-4).
Although most side effects are manageable by the patient, others require medical interven­tion. Conditions requiring medical attention include the following:

  1. Depression or mania. Counselors need to be particularly attuned to the develop­ment of these neuropsychiatric symptoms, routinely assess for them, and refer clients for mental health treatment as appropriate.
  2. Anemia (reduced red blood cell count). Ribavirin often leads to anemia that can cause fatigue and increase the risk of chest pain, shortness of breath, or heart attack.
  3. Neutropenia (reduced white blood cell count resulting in an increased risk of infections). Neutropenia is rarely severe enough to terminate antiviral treatment.
  4. Pulmonary conditions. Shortness of breath or cough might develop during hepatitis treatment. People who develop these symptoms should consult their medical care provider to rule out other causes.
  5. Eye problems. Antiviral treatment can induce or aggravate eye problems, especially in people who have diabetes or hypertension. Clients who complain of blurry vision, any obstruction to vision, or loss of vision should receive an immediate medical examination.

Deferring Treatment

Some clients might choose to postpone antiviral treatment. They might have more urgent health problems to tend to, or they might feel they are not strong enough in their SUD recovery to undergo hepatitis treatment.

Medical care for clients who choose to defer treatment generally involves:

  1. Getting regular medical evaluations.
  2. Having liver enzyme and cancer screening tests once or twice every year.
  3. Getting a liver biopsy every 3–5 years.
  4. Adopting a lifestyle that promotes liver health.

It is critical for clients with compromised liver functions to take precautions against contracting HIV and to get vaccinated against HAV and HBV. Clients who are co-infected with HCV and HIV should be encouraged to get treated for their HIV. Clients who are HIV negative should be retested for HIV at the advice of their medical care provider. Counseling tips for working with clients who have chronic hepatitis include:

  1. Help clients understand that they should see a medical care provider regularly. “When was the last time you saw your doctor about your hepatitis?”
  2. Encourage patients to adopt habits that support liver health, such as avoiding alcohol and eating a healthful diet.
  3. Help clients think about how to create or improve their support networks so that no matter what hepatitis treatment choices they eventually face, they have help from others. “Would you like to create a list of people you know and list the help they could provide you as you cope with hepatitis?”

Liver Transplantation

Although many people who have hepatitis C respond to antiviral treatment or can live indefinitely with their illness, in some people, liver damage will be extensive and a liver transplantation is needed. Counselors should be prepared to support clients who have been told that liver transplantation surgery is necessary. They might also need to educate the transplantation team about the value of medication-assisted treatment (MAT) for opioid dependence. The following factors influence a patient’s acceptance to a transplant waiting list:

  1. Urgency of need
  2. Willingness and ability to endure the extensive preoperative and postoperative tests and     procedures
  3. Willingness and ability to follow physi­cian’s instructions
  4. Willingness to adjust to the postoperative lifestyle
  5. Access to caregivers who can provide support during the lengthy transplanta­tion process
  6. Ability to stop all alcohol use

Patients obtaining a liver transplant generally go through the following phases:

  1. Contacting a transplant center. People who have been told that a liver transplant is their only hope should obtain a physi­cian’s referral to a transplant center as soon as possible. Each transplant center has its own criteria for placing patients on its waiting list. Clients who are not accepted for a waiting list might be deferred until the conditions that pre­vented the client from being accepted are resolved.
  2. Waiting for the transplant. The time between being put on a waiting list and receiving the transplant can be as short as a few days or as long as several years. While waiting, patients must keep their records updated at the transplant center and stay as healthy as possible to be ready for surgery when a liver becomes available. They must avoid consuming alcohol or drugs and continue to take medications as prescribed.
  3. Getting the transplant. The surgery itself takes up to 12 hours. Recovery can take months.
  4. Living with the transplant. Following a transplantation procedure, patients must take medication for the rest of their lives to reduce the chance of their bodies rejecting the donated liver. This medication weakens the immune system. Patients might experience an array of intense emotions following the surgery. Counselors can help clients explore their emotions while developing realistic expec­tations for their futures. Liver transplants buy some time, but not necessarily a lot of it. Within 5–10 years, many patients contract hepatitis C again and, because medications suppress their immune response, the disease progresses much more rapidly (Berenguer et al., 2006; National Institutes of Health [NIH], 2002). In fact, the recurrence of HCV after a transplant is universal unless viral eradication occurs before the transplant. In such cases, progression of the disease might be rapid, sometimes resulting in cirrhosis within 1 year of transplant.

Counselors can play a critical role with clients who have end-stage liver disease or liver cancer and are not likely to obtain a liver transplant in time, who have been rejected from waiting lists, or who cannot go through the procedure. Specifically, counselors can help clients with end-of-life decisions, help ensure that those decisions are respected, and obtain palliative care. This work might be enhanced by collaboration with medical care providers, social workers, ethicists, family, hospice care, spiritual advisors, and therapists. Resources for liver transplantation are provided in Appendix C.

People Receiving Medication- Assisted Treatment for Opioid Dependence

Some medical care providers and clients believe that people on methadone or buprenorphine are ineligible for, or will not benefit from, antiviral treatment. However, research suggests that treatment for hepatitis C can be effective for people receiving MAT for opioid dependence (Kresina, Bruce, Cargill, & Cheever, 2005; Mauss, Berger, Goelz, Jacob, & Schmutz, 2004; Sylvestre, Litwin, Clements, & Gourevitch, 2005). NIH (2002) hepatitis C treatment guidelines state that MAT has been shown to reduce risky behaviors that can spread HCV infection, and it is not a contra­indication to HCV treatment.
Many clients receiving methadone, buprenor­phine, or naltrexone might want antiviral treatment, but it is not offered to them by their medical care providers. Counselors can provide a crucial service by informing clients that their receipt of MAT for opioid depen­dence does not exclude them from hepatitis treatment. Counselors can help clients search for medical care providers who are open to assessing them for hepatitis treatment, and counselors can advocate treatment if they perceive that clients are being discriminated against because of their past or current sub­stance use status.
Adherence to antiviral treatment is an important factor in treatment success, and studies show that individuals receiving metha­done treatment can adhere to treatment for hepatitis C (Schaefer et al., 2007; Sylvestre & Clements, 2007). Modifying treatment for clients receiving MAT for opioid dependence might help them adhere to antiviral treatment (Exhibit 5-5). Chapter 7 provides more infor­mation on program-level modifications.

People Who Relapse to Substance Use

People who relapse, continue to use, or have only recently quit using drugs or alcohol are often denied treatment for viral hepatitis. One study found that more than one-third of substance abuse treatment programs listed recent drug use as a reason their clients had not been treated for HCV infection (Astone- Twerell, Strauss, Hagan, & Des Jarlais, 2006). Several factors determine whether a person is a good candidate for antiviral treatment, and recovery status is just one factor. Clients should not be denied hepatitis treatment for this reason alone. Other misperceptions abound. NIH (2002) indicates that treatment of chronic hepatitis C can be successful even when patients have not abstained from active drug use.
Strategies for helping clients who relapse to substance use include:

  1. Developing an SUD treatment plan that includes a range of effective treatment options; additional testing to evaluate HAV, HBV, and HCV status; and a hepatitis treatment referral.
  2. Using motivational interviewing to engage clients in treatment to improve their quality of life.
  3. Providing education on HCV transmis­sion and treatment and helping with psychosocial difficulties.
  4. Recognizing clients’ ambivalence, efforts in SUD treatment, and attempts to reduce substance use.
  5. Referral to mental health treatment, if warranted.

People Who Have HCV/HIV Co-Infection

People who are co-infected with HCV and HIV must adjust to two major diagnoses that can have difficult treatment regimens. In cli­ents with HIV, hepatitis C treatment is gener­ally advised when the likely benefits outweigh the risks of serious side effects (Ghany et al., 2009). Approximately 35 percent of people who have HCV/HIV co-infection achieve an SVR (Sherman, 2007), and this success rate might be improved with new medications.
Counselors can help clients understand the implications of HCV/HIV co-infection and provide support. Strategies to address the issues include the following:

Educate clients about HCV/HIV co-infection. Many people who have HIV might be aware of the health conse­quences of HIV but be unaware that HIV infection greatly increases the progression of HCV, increasing the likelihood of cirrhosis, end-stage liver disease, and liver cancer. In fact, liver disease—from under­lying hepatitis B, C, or alcohol abuse—is the major non-AIDS cause of death in HIV-infected persons.

  • Stress the importance of being tested for hepatitis and receiving antiviral treatment as soon as possible. All individuals who are infected with HIV should be screened annually for HCV.
  • Screen for and address cognitive deficits. People who are co-infected are more likely to suffer cognitive deficits in mul­tiple areas, including learning, abstraction, motor abilities, memory, and informa­tion processing (Cherner et al., 2005). Counselors should be attentive to signs of these problems, conduct assessments, help clients cope with these issues, and advocate on behalf of their clients with HCV treatment providers.
  • Help clients manage side effects. Individuals who have HIV often receive medications that can have significant side effects. People who are co-infected with HCV and HIV might experience many side effects with antiviral treatment (Gish, Afdhal, Dieterich, & Reddy, 2005).
  • Encourage clients to seek and receive compassionate medical care. Medical care providers who have not received training in managing HCV/HIV co-infection can present barriers to effective hepatitis treatment. Clients might also be negatively influenced by judgmental approaches, frustration, and unrealistic expectations for treatment (Kresina et al., 2005). These attitudes can result in distrust and poor communication between client and provider, as well as in frustration and lack of adherence by the client. Counselors can help clients find medical care providers who are familiar with and able to treat this population.
  • Help coordinate care. People who have HCV/HIV have multiple needs requiring an array of medication and treatment. Counselors can coordinate with medical care providers to address these needs. A multidisciplinary approach can help clients access the treatment that they need and increase treatment retention.
  • Emphasize adherence to treatment. Effective results depend on close adherence to all treatment regimens. Counselors should explain the importance of taking medications exactly as directed.

People Who Have Co-Occurring Behavioral Health Disorders
Studies have demonstrated that completion and outcome of antiviral treatment can be similar for clients who have co-occurring substance use and mental disorders com­pared with clients who do not have these co-occurring conditions (Chainuvati et al., 2006; Guadagnino, Trotta, Carioti, Caroleo, & Antinori, 2006; Sylvestre & Clements, 2007). People who have and do not have psychiatric histories had similar rates of HCV treatment adherence. In people who have depressive symptoms, medications to treat depression should be given early in HCV treatment to improve treatment adherence. Freedman and Nathanson (2009) suggest that optimal results are obtained when coordinated substance abuse and psychiatric treatment occurs before and during treatment for hepatitis C.
Counselors can help their clients with co-occurring substance use and mental disorders cope with hepatitis. Suggestions for initiating conversations follow:

  1. “Your doctor expressed some concern about your candidacy for treatment because of your depression. How do you see things?” “What would be helpful for your depression?”
  2. “Your doctor says you can go ahead with hepatitis treatment. What do you think you need to do for this to be successful?”

 

Counseling Approaches for People Who Have Viral Hepatitis

The Need for Counseling Strategies

Counselors are in a unique position to provide education, emotional support, and other types of assistance for clients who have hepatitis and substance use disorders (SUDs). However, most treatment pro­grams do not have components in place to address viral hepatitis. According to the 2007 National Survey of Substance Abuse Treatment Services, only 22 percent of treatment facilities offer onsite screening tests for hepatitis B; 23 percent offer onsite screen­ing for hepatitis C (Office of Applied Studies, 2007). Other studies have shown that only 54 percent of treatment programs provide education about hepatitis, and many counselors are uninformed or misinformed about the disease (Astone, Strauss, Vassilev, & Des Jarlais, 2003).
Depending on the resources available, counselors might be able to implement only some of the strategies presented for supporting clients who have hepatitis. Readers are encouraged to accomplish what they can to improve SUD treatment practices for their clients and to advocate for client access to services that cannot be imple­mented immediately.

Ensuring Safety

If a client with infectious hepatitis becomes injured and bleeds, staff members are at risk of contracting the infection. Counselors should use universal precautions, such as wearing gloves and other protective gear when exposure to infected blood or other body fluids is pos­sible. Counselors should take care to avoid accidental needle sticks, which can transmit hepatitis and HIV. Counselors should also know their hepatitis status and take cautions to protect clients and coworkers, if necessary.

Providing Reliable Information

Providing current, accurate information is an important counseling service. Misinformation obtained by word of mouth or on the Internet can increase clients’ fears and feelings of hope­lessness. Counselors can dispel misinformation about hepatitis by providing educational ses­sions incorporated into treatment program­ming. Chapter 1 gives an overview of viral hepatitis, and Appendix C provides a list of resources that are available on the Internet.

Building the Therapeutic Relationship

Counselors can discuss hepatitis in ways that build the therapeutic relationship. Clients are more likely to ask questions and express con­cerns and fears about screening, a diagnosis of chronic hepatitis, and its treatment if the counselor and client have a good working rela­tionship. There are a number of ways in which a counselor can help clients (Astone, Strauss, Munoz-Plaza, Hagan, & Des Jarlais, 2005).

These include:

  1. Being well informed about hepatitis, especially chronic hepatitis C.
  2. Talking to clients about their diagnoses and medical treatment with empathy.
  3. Assuring clients that the counselor will help them negotiate necessary services, either within or outside the treatment program.
  4. Helping clients overcome possible barriers to hepatitis treatment.
  5. Interpreting information clients receive from medical care providers, the Internet, family, friends, and other clients.
  6. Repeating information in different ways until clients understand it.
  7. Asking about clients’ families’ responses to their diagnoses and helping clients cope with those responses.
  8. Educating clients about the liver and how to stay healthy with hepatitis and stating that the majority of people who have chronic hepatitis C and who do not use alcohol will not develop life-threatening complications.
  9. Offering messages of hope about living with hepatitis.
  10. Emphasizing consistently the importance of clients’ addressing their health-related issues.
  11. Explaining complex hepatitis treatment and test results or collaborating with medical professionals who can provide necessary explanations to clients.
  12. Helping to make medical appointments and advocating for clients with medical care providers.
  13. Helping clients devise strategies for remembering medical and other scheduled appointments.

Helping Clients Understand Their Diagnoses

Clients’ reactions to a diagnosis of viral hepatitis vary. For some clients, the possibility that they might become ill in 20–30 years might be the least of their concerns as they face the imme­diacy of their potentially life-threatening SUD and other life stressors. For others, a diagnosis might present a crisis. Those who have been in substance abuse treatment for many years, for example, might view a diagnosis as a threat to their hard-won sense of stability (Litwin et al., 2005). New clients might feel overwhelmed by the extra complications placed on the already daunting prospect of recovery. Some might use their diagnoses of hepatitis as an excuse to start using substances again.

Counselors need to be prepared for a range of reactions. Some clients might need to talk through fears and anger many times before moving forward with medical treatment. In these situations, counselors might need to schedule more individual sessions with clients to discuss these issues. Other clients might need prodding to understand their diagnoses and take appropriate steps to reduce their risks of spreading the illness or worsening their prognosis. Clients might be concerned about how to tell loved ones about their diag­noses and worried about transmitting the virus to others. Women might be concerned about pregnancy and hepatitis treatment or viral transmission.

Incorporating Client Needs in Substance Abuse Treatment Planning

Substance abuse treatment planning might be complicated by both hepatitis symptoms and potential side effects of the antiviral treatment. Counselors might need to adjust substance abuse treatment for clients who have hepatitis-related symptoms or antiviral treatment side effects.

Facets of substance abuse treatment might need to be flexible for clients who have hepatitis (within accreditation and licensing guidelines) and allow for the following:

  1. Individualized, flexible substance abuse treatment planning to permit missed sessions resulting from hepatitis symp­toms, antiviral treatment, or medical appointments
  2. Time for clients to rest
  3. Time for hepatitis-specific support groups for clients in residential treatment (individual sessions could be scheduled to replace missed group sessions)
  4. More frequent sessions or more intensive programs
  5. Longer duration of substance abuse treat­ment to make up for missed sessions and to provide ongoing support during the hepatitis treatment regimen

Ongoing screening and assessment for depression and other mental disorders are necessary for all clients but are particularly important for clients with hepatitis who are receiving interferon. Depression is a major side effect of interferon treatment, and clients with a history of depression are at particular risk for worsening of symptoms. Treatment plans for clients who have co-occurring substance use and mental disorders should include:

  1. Periodic screening for depression, referral for evaluation by a mental health profes­sional, and consideration of initiating antidepressant treatment, if warranted.
  2. Regular medication adherence checks for clients who are taking antidepressant medication.
  3. Frequent communication among substance abuse, mental health, and medical care providers, with permission of the client.

Developing a Prevention Plan

Clients might continue to put themselves or others at risk for contracting viral hepatitis, especially early in recovery. By identifying a client’s risky past or current behavior, the counselor can help the client create a plan to reduce the chances of contracting or spread­ing viral hepatitis. The following steps are suggested:

  1. Identify a specific high-risk incident. Focusing on past behavior might be diffi­cult for a client who feels shame or regret. Discussing one specific incident might be less onerous for the client. Ask the client to describe the “who, what, where, when, and how” of the most recent risky experience. Ask whether the client talked about hepatitis risks with partners. Try to determine whether the client’s patterns of risky behavior are chronic, episodic, or a single incident. Ask, for example, “Was that the first time you let someone inject you?”
  2. Start where the client is. Keep in mind that some clients will not know how they became infected. Developing a risk-reduction plan for this type of cli­ent might require a gradual, supportive approach to identifying risk factors.
  3. Identify a situation when the client mini­mized his or her risk. Ask the client to describe what precautions he or she took and why. Offer positive reinforcement, such as “So you refused to share a needle. That must have been hard to do. Good for you.”
  4. Synthesize patterns of behavior. Identify the client’s pattern of risky behavior and the specific circumstances that lead to the behavior.
  5. Negotiate a prevention plan. Clients might feel besieged by the many changes they are asked to make. Develop incremental and achievable steps to minimize risk for transmitting viral hepatitis. Put the behavioral change plan in writing, and give a copy to the client.
  6. Revisit the plan periodically, and assess progress. Check with the client periodi­cally to determine whether new behaviors, stressors, or circumstances need to be addressed in the plan. Renegotiate the plan if necessary.
  7. Include vaccinations against hepatitis A or hepatitis B and prevention strategies for other infections, such as HIV, that are spread in the same way as different types of hepatitis.

Using Motivational Approaches

Using motivational approaches, the counselor can help clients understand the relationship between good health and recovery (Litwin et al., 2005). Counselors can identify the strengths clients have demonstrated in counseling sessions and encourage clients to develop ways to use those strengths to cope with current health challenges. Appendix G provides sources of information about motivational interviewing and counseling.

Confronting the Social Factors of Hepatitis

Many people who have viral hepatitis report that the social ramifications of a hepatitis C diagnosis are severe (Astone-Twerell, Strauss, & Munoz-Plaza, et al., 2006). Many people who have SUDs and chronic hepatitis feel they are judged as immoral and blameworthy because the infection results primarily from the sharing of contaminated injection drug use equipment (Astone-Twerell, Strauss, Munoz-Plaza et al., 2006). People who have hepatitis C virus (HCV) infection might be viewed by some as having made poor choices because they engaged in dangerous and illegal behaviors that resulted in their illnesses. Negative attitudes about people who have chronic hepatitis remain, even among some medical professionals (Brener, Von Hippel, & Kippax, 2007; Paterson, Backmund, Hirsch, & Yim, 2007; Von Hippel, Brener, & Von Hippel, 2008). Counselors can advocate non­discriminatory treatment for clients who have hepatitis.

For some clients, a diagnosis of hepatitis can generate feelings of low self-worth. Some clients who have viral hepatitis report that their diagnoses caused them to develop a negative sense of self (Astone-Twerell, Strauss, Munoz-Plaza, et al., 2006). The majority of clients reported experiencing fear, shame, and social rejection (Brener et al., 2007; Conrad, Garrett, Cooksley, Dunne, & MacDonald, 2006; Zickmund, Ho, Masuda, Ippolito, & LaBrecque, 2003).

Clients might need to use discretion in revealing their diagnoses. Counselors can help clients decide whom they can tell by encouraging clients to ask themselves the following questions:

    1. Does this person need to know? Household members need to know, particularly if they are sex partners or likely to share things like razors or hair clippers. Extended family members might not need to know.
    2. Under some circumstances employers might need to know. For example, if a client’s work is affected by the illness or if he or she frequently misses work because of illness or medical appoint­ments, a supervisor might need to be told.
    3.  What is the person likely to do with the information? Is this person trustworthy?
    4. Is this the right time to tell this person?
    5. What are the risks in telling the person? Is a negative reaction likely?
    6. What questions might the person have about the client’s diagnosis? Can the cli­ent answer those questions?

A diagnosis of viral hepatitis might increase a client’s potential for relapse to alcohol or drug use.

Clients might need help with talking to their families, employers, and friends about their hepatitis. Counselors can help by:

  1. Role playing with clients, allowing them to practice how they tell various people.
  2. Offering to be present when clients talk to family members.
  3. Providing family members and friends with information about the symptoms, treatment, and transmission of the disease.

Addressing Relapse

A diagnosis of viral hepatitis might increase a client’s potential for relapse to alcohol or drug use. The diagnosis might also exacerbate depression and anxiety, which are known trig­gers for an SUD relapse. Treatment for HCV infection itself also can trigger relapse. The reasons for this are unknown, although the act of injecting medication might trigger crav­ings in clients who injected drugs. Side effects from antiviral treatment might also mimic withdrawal. Increases in methadone doses might be appropriate (Sylvestre & Clements, 2007).
The counselor can start conversations about relapse by asking the client the following questions:

  1. “What kinds of things make you think about using again?”
  2. “Do you consider getting injections during treatment a possible trigger to drug use?”
  3. “What kinds of things could help you avoid substance use?”
  4. “Who could support you in these efforts?”
  5. “How worried are you about the possibil­ity of a relapse?”

 

Clients might need the counselor’s help in telling family members about a hepatitis diagnosis.

Counselors can give clients the following tips (U.S. Department of Veterans Affairs, 2004):

  1. “Remind yourself that interferon is work­ing to heal your liver from the damage caused by HCV infection.”
  2. “Try not to isolate yourself while injecting interferon. It might be helpful to inject interferon around people you trust, such as family members.”
  3. “Talk openly about your feelings of inject­ing interferon with members of your sup­port group and other people you trust.”
  4. “Remind yourself that being abstinent is the best thing you can do to keep yourself healthy when you have HCV infection.”
  5. “Get help managing side effects. Remember to talk with your doctor if you are experiencing side effects from your HCV treatment.”
  6. “Do not skip or change doses of interferon. Try to make the injections part of your routine.”

Building Support Systems

Support Groups

Hepatitis groups are a widely used source of ongoing support for clients living with hepa­titis and might help demystify treatment for participants. In these groups, clients educate and support one another about the infection, the treatment process, and managing medica­tion side effects. Support groups help clients “believe that good outcomes are attainable” (Litwin et al., 2005, p. S342).
Support groups in substance abuse treatment settings can be facilitated by a counselor, nurse, or peer. The choice of facilitator should be based on a program’s resources and the needs of its clients. Support groups can also be found at hospitals and clinics. Appendix C lists national organizations that help people find local resources or that offer online sup­port communities. Counselors can help clients get the support they need by asking clients the following questions:

  1. “How can you get professional help if you need it?”
  2. “It takes courage to take on this chal­lenge. Would you be interested in the names and numbers of people you could talk to?”
  3. “Talking to others in drug recovery who have successfully been through hepatitis treatment can be really helpful. Do you see this as being part of your hepatitis recovery?”

Peer Counseling and Support

In a study at a residential treatment program (Munoz-Plaza et al., 2004), clients most frequently recommended the use of peer counselors as a way to enhance hepatitis treat­ment services. These clients found that peers who had experience with HCV infection were more valuable than “even the most knowledge­able and well-trained staff person” (Munoz- Plaza et al., 2004, p. 874). Peers can facilitate or co-facilitate support groups; act as mentors to newly diagnosed clients; and provide infor­mation, support, and assistance (e.g., provide transportation, accompany clients to medical appointments). Peers can be clients who are farther along in hepatitis treatment, graduated clients, or volunteers from the community.

Family Support

Families might be supportive or might react badly to a family member’s diagnosis of hepati­tis. Clients might need the counselor’s help in telling family members about a hepatitis diag­nosis. Families might not be willing or able to support the client (e.g., family members might be using drugs). However, counselors can reduce families’ fears and encourage families through the following:

  1. Educate family members about hepatitis. Families need the same information as clients about the illness, its treatment, the potential effects on a client’s SUD recovery, and the increased risk of relapse to substance use.
  2. Help families adjust to lifestyle changes. Some clients might make lifestyle changes, particularly in diet and sexual behavior, following a diagnosis of hepatitis or as part of their substance abuse treat­ment (Castera, Constant, Bernard, de Ledinghen, & Couzigou, 2006; Fabris et al., 2006). These changes affect family members.
  3. Help family members adopt new roles and routines. Clients might need time away from their families to attend support group meetings and medical appointments. These added demands, coupled with the symptoms of the disease and possible side effects of antiviral treatment, can affect a person’s ability to meet family obligations. Clients might need help negotiating with family members to establish new roles and routines that accommodate the client’s treatment for hepatitis and an SUD.
  4. Help family members determine how best to support their loved one. Counselors can help the client identify needs and encourage family members to decide what they can do to support the client.
  5. Help family members recognize changes in behavior. Family members living with the client might be the first to notice an adverse reaction to antiviral treatment. Ask family members to provide feedback on any changes in mood, either elevated or depressed, and encourage the client to heed a family member’s observations.
  6. Help family members find support for themselves. Family members who have lived with a client who abused substances are now faced with helping that individu­al cope with another illness. Some might resent the additional burden. Family members can find support at hepatitis support groups. Some families need more education and support than do others. Counselors should be prepared to make referrals to local resources for couples or family therapy, if needed.

Providing Effective Case Management

Clients who have hepatitis might need intensive case management. Some clients receive case management services through their medical care providers, but many do not. Some substance abuse treatment programs have designated case managers to assist clients. Counselors or program nurses sometimes perform these functions. A program’s struc­ture and administrative decisions about staff roles influence the level of case management counselors provide. Counselors should clearly convey the expectations of their programs to clients. If they cannot provide the level of case management a client needs, they should do what they can to connect the client with a case manager in another healthcare or social services system.
Case management for clients who have hepatitis is often the same as that for clients with SUDs, but clients who have hepatitis might need more intensive and specialized help. Some clients who have hepatitis might be unable to work because of illness or hepatitis treatment side effects. Counselors can help by:

  1. Working with clients on budgeting or referring clients to consumer counseling agencies for debt management.
  2. Referring clients to local food banks, utility assistance programs, and rent assistance programs.
  3. Assisting in negotiating short-term disability claims or emergency family assistance.

Clients might need help accessing and navigating medical care systems. Counselors can help by:

  1. Identifying local providers who treat hepatitis; have experience working with people who have SUDs; and, when rel­evant, are comfortable treating people in medication-assisted treatment.
  2. Establishing relationships with clients’ medical care providers and staying abreast of clients’ hepatitis treatment.
  3. Helping clients understand and complete written documents and consent forms.
  4. Working with clients to establish proce­dures that help them remember medical appointments and adhere to medication regimens.
  5. Ensuring that clients have transportation to medical appointments.

Clients might need help understanding insur­ance requirements and, possibly, challenging insurers’ coverage decisions. If clients are unin­sured, counselors can:

  1. Identify government sources of healthcare and support benefits (e.g., Medicaid, Medicare, food stamps, unemployment insurance). (See Appendix H.)
  2. Look for assistance programs in medical centers and clinics.
  3. Identify local, private nonprofit clinics that offer many types of services; public health departments might be a source of information about community health resources.

Even if clients are insured, co-payments might be very high. Counselors can help clients identify sources of assistance, such as State medication assistance programs and local and national medication assistance pro­grams. Appendix H lists resources for patient financial assistance with medications and transplantation surgeries.
Sources of information on SUD treatment and medical case management procedures include Treatment Improvement Protocol 27, Comprehensive Case Management for Substance Abuse Treatment (Center for Substance Abuse Treatment, 1998) and Case Management Adherence Guidelines, Version 2.0 (Case Management Society of America, 2006).

 


 

Sexually Transmitted Diseases

(The following text is from the Centers for Disease Control and Prevention: STD Trends in the United States: 2010 National Data for Gonorrhea, Chlamydia, and Syphili)

STDs are one of the most critical health challenges facing the nation today. CDC estimates that there are 19 million new infections every year in the United States.

STDs cost the U.S. health care system $17 billion every year—and cost individuals even more in immediate and life-long health consequences.

CDC’s surveillance report includes data on the three STDs that physicians are required to report to local or state public health authorities—gonorrhea, chlamydia, and syphilis—which represent only a fraction of the true burden of STDs. Some common STDs, like human papillomavirus (HPV) and genital herpes, are not required to be reported.

The latest CDC data show troubling trends in three treatable STDs:

  • Gonorrhea: While reported rates are at historically low levels, cases increased slightly from last year and more than 300,000 cases were reported in 2010. There are also signs from other CDC surveillance systems that the disease may become resistant to the only available treatment option.
  • Chlamydia: Case reports have been increasing steadily over the past 20 years, and in 2010, 1.3 million chlamydia cases were reported. While the increase is due to expanded screening efforts, and not to an actual increase in the number of people with chlamydia, a majority of infections still go undiagnosed. Less than half of sexually active young women are screened annually as recommended by CDC.
  • Syphilis: The overall syphilis rate decreased for the first time in a decade, and is down 1.6 percent since 2009. However, the rate among young black men has increased dramatically over the past five years (134 percent). Other CDC data also show a significant increase in syphilis among young black men who have sex with men (MSM), suggesting that new infections among MSM are driving the increase in young black men. The finding is particularly concerning as there has also been a sharp increase in HIV infections among this population.

Less than half of people who should be screened receive recommended STD screening services.

Undetected and untreated STDs can increase a person’s risk for HIV and cause other serious health consequences, such as infertility. STD screening can help detect disease early and, when combined with treatment, is one of the most effective tools available to protect one’s health and prevent the spread of STDs to others.

STDs in the United States: A Look Beyond the Data

STDs primarily affect young people, but the health consequences can last a lifetime.

Young people represent 25 percent of the sexually experienced population in the United States, but account for nearly half of new STDs. The long-lasting health effects are particularly serious for young people:

  • Untreated gonorrhea and chlamydia can silently steal a young woman’s chance to have her own children later in life. Each year, untreated STDs cause at least 24,000 women in the U.S. to become infertile.
  • Untreated syphilis can lead to serious long-term complications, including brain, cardiovascular, and organ damage. Syphilis in pregnant women can also result in congenital syphilis (syphilis among infants), which can cause stillbirth, death soon after birth, and physical deformity and neurological complications in children who survive. Untreated syphilis in pregnant women results in infant death in up to 40 percent of cases.
  • Studies suggest that people with gonorrhea, chlamydia, or syphilis are at increased risk for HIV. Given the increase in both syphilis and HIV among young black gay and bisexual men, it is particularly urgent to diagnose and treat both diseases.

A range of factors place some populations at greater risk for STDs.

STDs affect people of all races, ages, and sexual orientations, though some individuals experience greater challenges in protecting their health. When individual risk behaviors are combined with barriers to quality health information and STD prevention services, the risk of infection increases. While everyone should have the opportunity to make choices that allow them to live healthy lives regardless of their income, education, or racial/ethnic background, the reality is that if an individual lacks resources or has difficult living conditions, the journey to health and wellness can be harder. Even with similar levels of individual risk, African Americans and Latinos sometimes face barriers that contribute to increased rates of STDs and are more affected by these diseases than whites.

CDC and Partners Working to Expand STD Prevention Efforts

CDC closely tracks STDs to guide prevention programs and clinical recommendations for STD services. CDC also funds state and local health departments and community-based organizations to implement and support local prevention efforts to reduce risk behavior and increase STD and HIV testing among populations at greatest risk. Through the Get Yourself Tested multimedia campaign, CDC, MTV, and the Kaiser Family Foundation are raising STD awareness among young people.

  • CDC assists health departments in local gonorrhea prevention efforts to best reach at-risk persons in areas where disease burden is greatest. CDC recently conducted a series of regional gonorrhea control discussions with STD program directors to help identify the most at-risk populations and develop action plans to reduce disparities.
  • CDC supports the Infertility Prevention Project, which promotes chlamydia screening and treatment for low-income, sexually active women in family planning and STD clinics.
  • CDC and public health partners are working to implement CDC’s Syphilis Elimination Plan, including using local data to create targeted action plans to reach those at greatest risk, particularly young black men and MSM.

(The following text is from SAMHSA)
Heavy Drinking and Drug Use Linked to Higher Rates of Sexually Transmitted Diseases Among Young Adults

Heavy drinking is linked to higher rates of sexually transmitted diseases among young adults, according to a new report by the Substance Abuse and Mental Health Services Administration. Combined drug and alcohol use were associated with even higher STD rates.

Sexually Transmitted Diseases and Substance Use, based on data from the National Survey on Drug Use and Health 2005, showed that 3.1 percent of past month heavy drinkers ages 18 to 25 had an STD in the previous year, compared with 1.4 percent of young adults who did not drink in the past month. Heavy alcohol use involves consuming five or more drinks on the same occasion on five or more days in the past month.

When young adults used both illicit drugs and alcohol in the past month, the rate of reported STDs rose to 3.9 percent. Reported STDs in young adults were lowest for those who did not drink or use drugs during the past month (1.3 percent). Rates of reported STDs for those who used either an illicit drug or alcohol, but not both, were similar at 2.1 percent for both categories.

“Substance abuse and risky sexual behavior are closely connected,” said Terry Cline, PhD, SAMHSA Administrator. “This report puts into sharp focus just one of the many potential lifetime consequences for young adults of heavy drinking and drug use.  Unchecked heavy drinking and drug use can lead to serious dependence-related problems, including loss of friends and family, employment, housing, health, and even life. Young adults need to seriously consider the choices they are making and the impact those choices can have on their futures.”

Overall, 0.8 percent of those 12 or older, about 2 million people, reported that they had been told by a doctor or other health professional that they had an STD in the past year. The rate was highest for 18 to 25 year olds (2.1 percent). Among adults, those 35 or older had the lowest rate of reported STDs at 0.5 percent.

Women had higher rates than men in all age groups, with women 18-25 being four times more likely than men in the same age group to have reported an STD. Other research shows that young women are more susceptible to certain STDs than are older women.

While both men’s and women’s STD rates rose with increasing alcohol use, the rate of reported STDs among female heavy drinkers reached 7.3 percent, compared with  1.3 percent of male heavy drinkers. A similar pattern of STD rates among young adults was found when illicit drug use and alcohol were combined. Women who used both alcohol and illicit drugs had a reported STD rate of 7.9 percent; for men who used both the rate was 1.5 percent. Because studies show that women are more likely to be tested for STDs than men, comparing rates of diagnosed STDs may not provide the full picture of the difference in risk by gender.

The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by SAMHSA.  The survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their residences. STDs mentioned in the survey questions include chlamydia, gonorrhea, herpes, syphilis and others. HIV/AIDS was not included.

 


 

Issues for Counselors

 (The following text is from the Substance Abuse and Mental Health Services Administration)

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 Critical Role of the Counselor

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 follow-up 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.
  • 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").

Assessing Risk for Infection

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. 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.

Infectious Disease Testing

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) . 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.
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.

Preparation for Testing

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.

Testing for HIV

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.

Pre-Test Counseling

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.
  • 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 several months 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.

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.

Post-Test Counseling

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.

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.

Counseling the HIV-Positive Patient

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. 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, 8 to 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.
  • 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.

Counseling the Patient With Positive Test Results for Other Infectious Diseases

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.

Counseling the Patient With Negative Test Results

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

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.
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.

Risk Reduction

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.

Principles of Risk Reduction

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.

Risk-Reduction Strategies

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.

Safer Sexual Practices

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.

  • 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.
  • 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.

Retention in Treatment

Many studies and common clinical experience indicate that the longer patients stay in treatment, the better the patient outcome. 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 decision making. Teach patients relaxation and meditation techniques to mitigate the effects of stress and tension that may lead to the use of drugs.

Maintaining Safer Sexual Practices

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 follow up support for patients, including referrals to medical care and social service agencies for housing, financial, educational, child care, employment, and legal assistance.

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