Role of the Consensus Panel

The purpose of the Center for Substance Abuse Treatment consensus panel that met in New York City in January 1993 was to develop a basic set of recommendations and guidelines for quality care for AOD abusers in treatment who are infected with HIV. These guidelines identify a spectrum of core services and treatment approaches that ideally should be available to all HIV-infected AOD abusers, regardless of the setting in which they receive care. The panel also addressed screening and referral issues for mental health, social, and other services needed to ensure the delivery of a comprehensive range of care to this patient population.

There are various audiences for this TIP, and different chapters are targeted to some of them individually. Nevertheless, the entire document should be of interest to any persons interested in improving HIV care for people who have alcohol and other drug problems. Prevention and treatment of AOD abuse and HIV disease require a multi-disciplinary approach that relies on the strengths of a variety of providers and treatment settings to provide a comprehensive range of effective services. It is unrealistic to expect any single treatment provider to be competent in all areas of care; likewise, it is unrealistic to expect any single treatment facility, whether a drug treatment center or a primary care clinic, to possess the full range of expertise required to meet all of the medical, mental health, and social service needs of this population. Thus, coordination and collaboration between health, mental health, and social service agencies and providers at all levels is imperative.

Prevention and treatment of AOD abuse and HIV disease require a multidisciplinary approach that relies on the strengths of a variety of providers and treatment settings to provide a comprehensive range of effective services.

The recommendations in this TIP identify a spectrum of treatment approaches and services that are essential to provide to HIV-infected individuals in treatment for AOD abuse. Guidelines are provided for bringing about linkages among the many separate agencies that make up the treatment system; such interagency collaboration is now required for States to receive Federal substance abuse block grants. See Appendix B for a summary of the 1993 Substance Abuse Prevention and Treatment Block Grants: Interim Final Rule (45 C.F.R. Part 96).

Chemical dependence and HIV infection are both chronic diseases with remissions and exacerbations. "A framework of providing a spectrum of services for long-term healthcare is needed when conceptualizing the treatment of either or both illnesses" (Karan, 1990). Treatment may include both pharmacologic therapies and nonpharmacologic modalities such as individual counseling, group therapy, support groups, family therapy, cognitive and behavioral therapies, psychotherapy, and psychodrama. Nonclinical activities such as attendance at Alcoholics and Narcotics Anonymous meetings, spiritual development, stress management, and relaxation are also important elements of successful treatment.

Epidemiology of HIV Infection in AOD Abusers

Definitive data on the prevalence of HIV infection among AOD abusers are scarce. Available data may not be generalizable because they are usually derived from different, often small, populations. However, it is clear from the available data that chemically dependent persons are at high risk for acquiring HIV infection. Among chemically dependent persons, the highest seropositivity—evidence of HIV in the blood -- for HIV infection or AIDS is among IDUs, and noninjecting AOD users put themselves at risk when they use unsafe sex practices. Fear and/or denial may cause noninjecting AOD users to inappropriately consider themselves excluded from risk groups.

There are an estimated 1.2 million IDUs in the United States. According to the U.S. Centers for Disease Control and Prevention (CDC), 34 percent of the CDC-defined AIDS cases diagnosed in the United States as of June 30, 1993, were linked to injection drug use. Twenty-three percent were heterosexual IDUs, 6 percent were homosexual or bisexual IDUs, 3 percent were heterosexual partners of IDUs, and 1 percent were perinatal cases where the mother either was an IDU or had been the sex partner of an IDU (CDC, 1993b). Specific high-risk behavior, such as injecting drugs in a shooting gallery, can be identified in these groups.

The seroprevalence of HIV infection among IDUs varies from region to region in the United States.

Levels of HIV infection have been highest in the Northeast, the middle Atlantic States and, to a slightly lesser extent, the Southeast, with generally decreasing levels in the Midwest, Southwest, and Northwest. Since early in the HIV epidemic, the Northeast (in particular New York City) has tended to have the highest seroprevalence rates among IDUs. One recent study found that the HIV seroprevalence rate among IDUs in New York remained stable at slightly more than 50 percent from 1984 through 1992 (Des Jarlais et al., 1994b).

Among drug injectors, specific practices such as needle sharing and injection in shooting galleries have been clearly identified as important HIV risk behaviors (Schoenbaum et al., 1989). One study, involving heterosexual IUDs who were enrolled in public methadone treatment programs in San Francisco in 1986 and 1987 before the advent of crack cocaine, showed that persons who injected cocaine had a higher risk of being HIV seropositive than those who did not inject cocaine (Chaisson et al., 1989). This increased risk can probably be associated with frequency of injections resulting from the short-term effect and highly addictive nature of cocaine. In addition, a subgroup of cocaine users may be more likely to engage in high-risk sexual behavior and to exchange sex for drugs (Weiss, 1989).

Among drug injectors, specific practices such as needle sharing and injection in shooting galleries have been clearly identified as important HIV risk behaviors.

The risk of HIV infection is lower among AOD users who do not inject. However, one study found a substantial prevalence of HIV infection among heterosexual patients in San Francisco alcohol treatment programs; much of this prevalence was not associated with injection drug use. The overall rate of HIV seroprevalence in this population was 5 percent. Unsafe sexual practices were common in the study population (Avins et al., 1994). Alcohol, like other psychoactive substances, may have a disinhibiting effect on sexual behavior.

African American and Hispanic communities are being extremely hard hit by the twin epidemics. According to the National Commission on AIDS, 45 percent of cases of HIV infection in AOD abusers occurred among African Americans and 26 percent among Hispanics in 1991. By comparison, African Americans and Hispanics accounted for 28 and 16 percent, respectively, of AIDS cases not involving AOD abuse.

Recognition of the crucial interrelationship between substance abuse and HIV infection has led to the establishment of needle exchange programs (NEPs) in some parts of the country, particularly large population centers with high rates of both substance abuse and HIV infection. NEPs are programs in which drug injectors can obtain sterile needles and syringes and return used injecting equipment (Donoghoe et al., 1992). Although much controversy surrounds the practices of NEPs, a study sponsored by the CDC concluded in 1993 that NEPs may prevent HIV infections and that they do not appear to change overall community levels of injection drug use (Lurie et al., 1993). (See Appendix C, on the elements of a needle exchange program.)

Obstacles to the Provision of Integrated Care to HIV-Infected AOD Abusers

Staff of most AOD abuse treatment programs have faced the need to provide medical treatment of HIV infection and AIDS to patients in the populations they serve. Treatment options in an individual case will depend on factors such as the availability of hospital and outpatient treatment for HIV infection and nonhospital residential facilities and halfway houses for those who are medically stable but need structure and support away from their home environments. Intensive outpatient counseling is often needed, along with home visits and nursing home and hospice care.

However, the life circumstances of many HIV-infected AOD abusers make continuity of care difficult or impossible to achieve. AOD abusers often suffer from poor health and nutrition and inadequate living conditions as well as a stressful lifestyle and lack of self-care. They may be very ill by the time they seek treatment. Individuals who live in poverty, in homeless shelters, on the street, or in correctional facilities generally lack access to good medical care, especially good primary care. Without financial resources, they have difficulty following dietary advice. Exposure to TB and STDs is common. A variety of factors, including lifestyle stressors and the effects of drug use, may cause individuals to deny their need for treatment for AOD abuse or HIV and to resist seeking or remaining in treatment.

The most important features of any program providing primary care to HIV-infected patients are minimal barriers to access and a "user friendly" environment. Patients may be deterred from adhering to care if they have to travel a long distance from the referral point to the source of primary care, or if the primary care providers are unfamiliar with or unresponsive to their needs. Language barriers and financial barriers may also exist. Special resources such as transportation and case management services facilitate patient followup of medical care if primary care is delivered offsite.

The most important features of any program providing primary care to HIV-infected patients are minimal barriers to access and a "user friendly" environment.

Systemic barriers to care for HIV-infected AOD abuse patients result from the separate functioning of treatment and prevention programs for AOD abuse and HIV infection, as well as the separation of funding streams for such programs. Consequently, program design and organizational and staffing structures may be inadequate and unidimensional when the demographic profile of the treatment population demands a multidimensional approach.

Multiple service needs are the norm for HIV-infected persons with AOD abuse problems. The AOD abuse treatment program may be able to play a lead role in coordinating care for HIV-infected AOD abusers, given their understanding of the preexisting substance use disorder and the fact that the client may trust and identify more with the AOD abuse treatment program than with other providers. However, AOD treatment programs can only take on such responsibility if they achieve competence in providing case management services. Historically, AOD programs have not provided case management services or have done so poorly. This situation could be improved by redefining the mission of AOD agencies beyond narrow recovery goals and allocating resources to professional social-work or trained counselor/case management staff.

For example, access to mental health and social services will vary depending on whether treatment programs have established linkages with providers of such services. Obtaining housing or homemaker services for a patient with AIDS can be a logistical nightmare for AOD abuse treatment staff. Even when services are finally located, the patient may not have access to transportation to go to the specified clinic or agency. Other barriers to integrated care include lack of healthcare coverage and a lack of entitlement programs directed at the specific problems of HIV-infected AOD abusers.

Physicians and their staffs often lack the knowledge and experience needed to access social service resources for AIDS or AOD abuse patients. No systems exist to coordinate the provision of medical services with other services outside the medical setting. A further problem is that AOD abuse treatment program staff who lack expertise in HIV issues may fail to refer patients to appropriate HIV treatment services.

Physicians and their staffs often lack the knowledge and experience needed to access social service resources for AIDS or AOD abuse patients. A further problem is that AOD abuse treatment program staff who lack expertise in HIV issues may fail to refer patients to appropriate HIV treatment services.

Philosophical differences between substance abuse treatment and primary healthcare providers may cause confusion for patients and providers alike. For example, a patient's physician may prescribe an antidepressant to treat the patient's severe depression. However, a substance abuse treatment provider, overly concerned about the danger of addiction, may tell the patient not to take the medication even though it is not addictive and it may improve the patient's quality of life.

Whereas a primary care provider may consider any decrease in drug use as an improvement in the patient's health status, a substance abuse provider may view anything short of total abstinence from drug use as a continuation of the patient's addiction. By contrast, the primary care provider, focusing on the need to bring about an improvement in the patient's health status, may fail to appreciate the effect of addiction on the patient's behavior.

For example, an individual may do well in a residential detoxification program, a very structured setting. Outside of that setting, however, and without the support of AOD detoxification staff, the individual may have difficulty staying motivated to continue treatment. If the individual stops attending Narcotics Anonymous meetings, misses outpatient appointments, and perhaps slips back into drug-seeking behavior, continuity of care suffers.

Preferential Admission to AOD Abuse Treatment for HIV-Infected Patients

When the number of treatment slots is inadequate for the numbers of AOD abusers seeking treatment, programs are faced with deciding whether to give priority to the admission of HIV-positive patients in order to try to stop the use of needles and halt the further spread of HIV. Alternatively, they may decide to admit non-HIV-infected patients in the hope of preventing them from being exposed to the virus through continued needle use. Where preferential admission is practiced, non-HIV-infected AOD abusers may claim to be HIV positive in order to get into highly valued treatment slots, particularly for methadone treatment.

Programs are sometimes faced with deciding whether to give priority to the admission of HIV-positive patients to try to stop their use of needles and halt the further spread of HIV. Or, they may decide to admit non-HIV-infected patients in the hope of preventing them from being exposed to the virus through continued needle use.

Under the 1993 substance abuse block grants interim final rule, programs receiving block grant funds must create a waiting list for patients who are seeking AOD treatment and are at risk for HIV, sexually transmitted diseases, and tuberculosis. Patients on the waiting list are to be given preferential treatment in the following order: pregnant IDUs, other pregnant substance abusers, other IDUs, and all others. People with HIV infection are not specifically identified in the Federal regulations as a group mandated to receive preferential treatment.

The appropriateness of a preferential admission policy for HIV-infected AOD abuse patients will depend upon the HIV seroprevalence rate among the population served by a treatment program. Programs should consult with local health departments and other community agencies when deciding whether to adopt a preferential admissions policy.

Cultural Competence of Providers

AOD abuse treatment staff need to be sensitive to the culture in which their patients live. However, cultural sensitivity by itself is not enough. Staff also must be competent in providing services to people from cultures other than their own. Cultural sensitivity and competence are crucial to the recruitment and retention of HIV-infected AOD abuse patients in treatment. Acquiring this competence may require staff to participate in training courses that focus on developing skills in cultural competence. Appendix D provides a Cultural Proficiency Questionnaire disseminated by the San Francisco Department of Public Health AIDS Office. It is a management tool to help agencies determine the degree to which their staffs and services are credible to members of the various communities to be served.

Cultural sensitivity and competence are crucial to the recruitment and retention of HIV-infected AOD abuse patients in treatment.

Staff must be able to provide services that are acceptable within the context of the culture of the persons they serve. Treatment staff who understand how patients define and regard sexual orientation, family, community, gender, and religion or spirituality are best able to develop positive relationships with patients and help empower them to overcome high-risk behavior. The treatment staff's understanding of and sensitivity to issues related to sexual orientation are very important. Staff should be aware of the pressures experienced by gay, lesbian, and bisexual patients in the employment setting and in the local community. Some treatment staff may have limited ability to deal with matters of sexual orientation, and this limitation can be a barrier to access to treatment for gay, lesbian, or bisexual patients.

The fact that many AOD treatment providers are themselves recovering from AOD abuse and are members of the ethnic and cultural communities they serve is an important element of cultural competence. Training and affirmative action hiring can help to ensure that therapists, counselors, and group leaders are sensitive to patients' culture, ethnicity, and language or language style. Cultural compatibility between group leaders and patients facilitates group interaction and discussion of sensitive issues—effective counseling about HIV risk reduction must take account of both drug-using and sexual behaviors. Patients may have significant socioeconomic problems related to housing, employment, and legal and entitlement issues; these problems can be identified and addressed in culturally competent programs. It is also important for treatment staff to be prepared to provide appropriate treatment to women. Alcohol is often the link in transmission of HIV disease to women, since it can lead to sexual disinhibition. A similar effect on sexual feelings is associated with the use of cocaine and crack cocaine.

Care providers need an understanding of the nature and role of the family in minority cultures. This understanding includes acceptance of the family as defined by the patient. Sometimes, the patient's family may include or consist entirely of persons who are not related to the patient by blood or marriage. The notion and understanding of family take on added importance in view of the fact that rates of heterosexual and perinatal transmission of HIV are highest in African American and Hispanic communities. Thus, the families with whom AOD treatment staff come into contact are likely to be of low socioeconomic status, particularly in urban areas. Such families may be headed by women, often very young women with children. An extended family may be in place that assists with the provision of shelter, childcare, and emotional support. Care providers should seek to involve family members appropriately in information sharing and in education about HIV and AOD abuse.

Care providers should understand and accept how the patient defines his or her family. Sometimes, the patient's family may include or consist entirely of persons who are not related to the patient by blood or marriage.

Appropriate utilization of AOD and other health services can be increased when services are sited in affected communities and when local resources such as clergy and traditional healers are involved in activities such as outreach, advocacy, and the promotion of healthy lifestyles. Involving patients in program evaluation through the use of consumer satisfaction surveys can help to ensure that services are meeting patients' self-identified needs in a culturally appropriate way.

Finally, an understanding of the place of spirituality and religion in patients' communities is important. Leaders and members of churches and other sources of spiritual counseling and support can be important allies in bringing patients into treatment and gaining their compliance with treatment regimens.

Conclusion

To provide comprehensive, coordinated care to HIV-infected AOD abusers, treatment programs must assess their existing resources and identify gaps. Ideally, a multidisciplinary professional team -- including a family physician or an internist, an obstetrician-gynecologist, a psychiatrist, a midlevel practitioner such as a physician's assistant or a nurse practitioner, a nurse, an AOD abuse treatment counselor, and a social worker -- should be available and should work together to meet patients' needs.

Case management at both hospital and community levels is important in achieving coordinated care. Increasingly, staff in AOD abuse treatment programs are finding that they need to conduct case management. Tracking and outreach teams composed of community volunteers are also vital, as is a telephone "hotline" to increase access to care. Developing programs to provide outreach to affected communities, providing home care, and furnishing transportation to health and AOD services can promote AOD abstinence and increase compliance with treatment regimens.

Substance abuse treatment, particularly opioid substitution therapy, of HIV-infected AOD abusers has been shown to be effective in reducing the spread of HIV (Ball et al., 1988; Hartel et al., 1988). In addition, addiction treatment can improve HIV-infected AOD abusers' quality of life by increasing their self-esteem, improving their sense of well-being, and helping them develop spiritually. Treatment can help them gain strength in making peace with themselves and their families and in determining how they want to spend the remaining portion of their lives.

Substance abuse treatment of HIV-infected AOD abusers has been shown to be effective in reducing the spread of HIV. In addition, addiction treatment can improve HIV-infected AOD abusers' quality of life by increasing their self-esteem, improving their sense of well-being, and helping them develop spiritually.

Contents of This TIP

While developed primarily to assist providers in AOD treatment facilities, this TIP may also be useful to providers in other settings, such as public health clinics, in improving the range and quality of services provided to AOD abusers. Staff of State agencies who are responsible for planning and administering AOD and HIV treatment programs may also find the TIP helpful in developing their own guidelines and providing technical assistance and quality assurance services.

Many service providers in other programs are confused by the profusion of different types and settings of care for AOD abuse. Chapter 2 Overview of AOD Treatment Services provides them with a brief description of the types, settings, levels, and intensities of treatment provided in each type of program.

Chapter 3 Primary Medical Care for HIV-Infected AOD Abuse Patients is primarily for physicians, nurses, and others responsible for the provision of medical care, but others may find it helps them understand the scope of medical care needed by patients. The standards of medical care and infection control that should be met by programs providing medical services are clearly spelled out. Also discussed are program and policy issues and issues in engaging HIV-infected AOD patients in medical care.

Chapter 4 Mental Health and Counseling Needs of HIV-Infected AOD Abusers describes the counseling needs of HIV-infected AOD abusers and provides guidelines for meeting them effectively. It also provides important guidelines for treatment as well as referral. This chapter is very important to counselors who must be familiar with both AOD-induced and HIV-induced psychiatric symptoms. Programs without the ability to assess and treat mental illness must have the capacity to make appropriate referrals.

Populations already having complex social service needs because of AOD abuse have additional needs as a result of HIV infection and disease. These populations frequently do not want to receive services from any agency but the AOD program. This dilemma is addressed in Chapter 5 Social Services for HIV-Infected AOD Abusers. Attention is focused specifically on the provision of case management and housing, family support, and outreach services.

Chapter 6 Linkages and Services Integration: Policy and Implementation focuses on the linkages and collaboration with community service providers needed by AOD programs to meet patients' needs effectively. These needs include the medical, mental health, and social service needs outlined in previous chapters. This chapter is very important for AOD programs that do not have the resources to provide all needed services.

Chapter 7 addresses legal issues in AOD and HIV treatment as they are related to treatment, confidentiality, HIV counseling, and tuberculosis testing. Key Legal Issues in HIV/AIDS and AOD Abuse Treatment deals with issues that arise when treating patients who are HIV-positive, perceived to be HIV-infected, or diagnosed with AIDS. Also covered are legal requirements for dealing with infectious diseases frequently associated with HIV disease.

Appendix A is a list of references cited in the TIP. Appendix B contains a brief summary of the 1993 Substance Abuse Prevention and Treatment Block Grants: Interim Final Rule. The public health impact of needle exchange programs and the elements of such programs are described in Appendix C. A questionnaire used by the San Francisco Department of Public Health AIDS Office to help programs assess their cultural proficiency is included in Appendix D.

Information about the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (the CARE Act) is provided in Appendix E. Appendix F contains an instrument used by the Opiate Treatment Outpatient Program at San Francisco General Hospital to assess a client's level of functioning in order to provide an appropriate level of care. Appendix G provides a list of national AIDS/HIV organizations and hotlines. A sample memorandum of understanding, used to establish interagency relationships, is presented in Appendix H. The names and affiliations of members of the Federal Resource Panel who guided the planning of this document are included in Appendix I. Appendix J lists names and affiliations of experts who reviewed the first draft of the TIP and provided valuable comments.

Endnote

Footnotes

1

. This chapter was written for the TIP by Coralee Hoffman and Carolyn Davis.