Presented by John W. Hogan, MD
Unity Health Care, Inc., Regional Addiction Prevention

At the end of the presentation participants will:
 Discuss the difference between substance abuse and
substance dependence/addiction.
 State the relationship between substance use and HIV.
 Discuss barriers that prevent minorities from accessing
care for substance use.
 Discuss various substance abuse interventions.
 Discuss why drug treatment is also HIV prevention.
•
SUBSTANCE ABUSE:
–
Recurrent substance use resulting in failure to fulfill role
obligations at work, school, or home.
–
Recurrent use in physically hazardous situations.
–
Recurrent substance-related legal problems.
–
Continued use despite social or interpersonal problems
caused by the substance.
American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. Fourth Edition, Text Revision. Washington, DC; 2000.

SUBSTANCE DEPENDENCE (Addiction)-Need to satisfy
three or more of the following in the same 12 month
period:
– Tolerance: need for use of increasing amounts of the
substance in order to achieve intoxication.
– Withdrawal symptoms typical for the substance.
– Substance taken in larger amounts or over a longer period
of time than intended.
– Desire to cut down or control use.
– Great deal of time spent on using, obtaining, or recovering
from the substance.
– Reduced social, occupational or recreational activities
because of substance use.
– Continued use despite adverse physical or psychological
consequences.

DSM-IV criteria for substance dependence include several
specifiers, one of which outlines whether substance dependence
is:
 with physiologic dependence (evidence of tolerance or withdrawal) or
 without physiologic dependence (no evidence of tolerance or
withdrawal).

In addition, remission categories are classified into four subtypes:




(1) full,
(2) early partial,
(3) sustained, and
(4) sustained partial.
This is based on whether any of the criteria for abuse or
dependence have been met and over what time frame.
 The remission category can also be used for patients receiving
agonist therapy (such as methadone maintenance) or for those
living in a controlled, drug-free environment.


Addiction is a chronic medical disorder that
includes:
 multifactorial genetic components,
 biologic changes due to exposure to addictive
substances, and
 behavioral components.

Treatment for addictive disorders frequently
must address both neurobiological and
behavioral components.

Recovery
 This is the SAMHSA definition:
▪ Recovery from alcohol and drug problems is a process of
change through which an individual achieves
abstinence and improved health, wellness and quality of
life.
 It is a voluntarily maintained lifestyle
characterized by sobriety with a healthy and
productive way of life.
Drug Name (Class)
Cocaine
(Stimulant)
Heroin
(Opiate)
Route of
Administration
Cognitive Effects
Snorted, injected,
or smoked
• Binge patterns of use may lead to irritability, restlessness,
anxiety, and paranoia
• Cocaine abusers can suffer a temporary state of paranoid
psychosis, in which they lose touch with reality and may
experience auditory hallucinations
Snorted, injected,
or smoked
• Users report feeling a surge of euphoria (“rush”)
accompanied by dry mouth, a warm flushing of the skin,
and a heaviness of the extremities
• Following initial euphoria, the user goes “on the nod,”
an alternately wakeful and drowsy state during which mental
functioning becomes clouded
Marijuana
Smoked
Methamphetamine
(Stimulant)
Snorted, injected,
or smoked
• Use is associated with distorted perceptions, impaired
coordination, difficulty in thinking and problem solving,
and problems with learning and memory
• Use is associated with reduced motor performance, impaired
verbal learning, emotional and cognitive problems
Drug Name
(Class)
Route of
Administration
MDMA-Ecstasy
(Stimulant and
hallucinogen)
Orally ingested as a
capsule or tablet
• Use associated with confusion, depression, sleep
problems, drug craving, and severe anxiety
GHB/Ketamine/
Rohypnol
(Club drugs)
Orally ingested,
snorted, or injected
(Ketamine only)
• Use associated with anterograde amnesia, distorted
perceptions of sight/sound, and feelings of detachment
Inhalants
Sniffed (fumes),
sprayed (aerosols)
into the
nose/mouth, or
soaked rag placed
in mouth (“huffing”)
• Effects are similar to those of alcohol, including euphoria,
slurred speech, lack of coordination, and dizziness
Orally ingested,
snorted, or smoked
• Users report seeing images, hearing sounds, and feeling
sensations that seem but are not real
• Some hallucinogens produce intense emotional swings
LSD/Peyote,
Psilocybin/PCP
(Hallucinogens)
Cognitive Effects



Outside of sub-Saharan Africa, an estimated 10% of all new
HIV infections are attributed to injection drug use (IDU)
despite significant regional variations.
According to the Joint United Nations Program on HIV/AIDS,
IDU is responsible for more than 80% of all HIV infections in
eastern Europe and central Asia.
The epidemic in countries in the Middle East and North
Africa have been largely attributed to IDU, and it is currently
linked to the growing epidemic in Indonesia, Vietnam, and
Malaysia.
Joint United Nations Program on HIV/AIDS (UNAIDS). AIDS Epidemic Update
'09. UNAIDS; November 2009. Geneva, Switzerland: UNAIDS, WHO;
November 2009. UNAIDS/09.36E/JC1700E.

In the U.S. Drug abuse is a significant risk factor for
HIV/AIDS
 An estimated 1 million people in the U.S. are living with HIV/AIDS;
about one-third of these cases are linked directly or indirectly to
injection drug use.
 In 2003, more than one quarter (11,326) of the 43,171 AIDS cases
reported in the U.S. involved injection drug use.

Linked Epidemics: Drug Abuse and HIV/AIDS
 A Research Update from the National Institute on Drug Abuse —
October 2005

National Survey on Drug Use and Health 2008
 In 2008, an estimated 20.1 million Americans aged 12 or
older were current (past month) illicit drug users
 This estimate represents 8.0 percent of the population
aged 12 or older.
 The overall rate of current illicit drug use among persons
aged 12 or older in 2008 (8.0 percent) was the same as the
rate in 2007 and has remained stable since 2002
(8.3percent).
•
•
•
•
•
Marijuana was the most commonly used illicit drug (15.2 million
past month users).
In 2008, marijuana was used by 75.7 percent of current illicit
drug users and was the only drug used by 57.3 percent of them.
Illicit drugs other than marijuana were used by 8.6 million
persons or 42.7 percent of illicit drug users aged 12 or older.
Current use of other drugs but not marijuana was reported by
24.3 percent of illicit drug users, and 18.4 percent used both
marijuana and other drugs.
Among persons aged 12 or older, the overall rate of past month
marijuana use in 2008 (6.1 percent) was similar to the rate in
2007 and the rates in earlier years going back to 2002 (Figure
2.2).
An estimated 8.6 million people aged 12 or older
(3.4 percent) were current users of illicit drugs
other than marijuana in 2008.
 The majority of these (6.2 million persons or 2.5
percent of the population) used
psychotherapeutic drugs nonmedically.
 An estimated 4.7 million persons used pain
relievers nonmedically in the past month in
2008, 1.8 million used tranquilizers, 904,000
used stimulants, and 234,000 used sedatives.

Among pregnant women aged 15 to 44 years, 5.1 percent
used illicit drugs in the past month based on data averaged
for 2007 and 2008.
 This rate was significantly lower than the rate among women
in this age group who were not pregnant (9.8 percent).
 The rate of current illicit drug use in the combined 2007-2008
data was lower for pregnant women than for nonpregnant
women among those aged 18 to 25 (7.1 vs. 16.2 percent,
respectively) and among those aged 26 to 44 (3.0 vs. 6.7
percent).
 Among women aged 15 to 17, however, those who were
pregnant had a higher rate of use than those who were not
pregnant (21.6 vs. 12.9 percent).

Current illicit drug use among persons aged 12 or older
varied by race/ethnicity in 2008, with the lowest rate
among Asians (3.6 percent).
 Rates were:

–
–
–
–
–
–

14.7 percent for persons reporting two or more races,
10.1 percent for blacks,
9.5 percent for American Indians or Alaska Natives,
8.2 percent for whites,
7.3 percent of Native Hawaiians or Other Pacific Islanders, and
6.2 percent for Hispanics.
There were no statistically significant changes between
2007 and 2008 in the rate of current illicit drug use for any
racial/ethnic group among persons aged 12 or older.
The level of alcohol use was associated with illicit
drug use in 2008.
 Among the 17.3 million heavy drinkers aged 12 or
older, 29.4 percent were current illicit drug users.
 Persons who were not current alcohol users were
less likely to have used illicit drugs in the past month
(3.3 percent) than those who reported:

 (a) current use of alcohol but did not meet the criteria
for binge or heavy use (6.1 percent),
 (b) binge use but did not meet the criteria for heavy
use (16.4 percent), or
 (c) heavy use of alcohol (29.4 percent).




Use of illicit drugs and alcohol was more common among
current cigarette smokers than among nonsmokers in 2008, as
in prior years since 2002.
Among persons aged 12 or older, 20.4 percent of past month
cigarette smokers reported current use of an illicit drug
compared with 4.2 percent of persons who were not current
cigarette smokers.
Past month alcohol use was reported by 67.4 percent of current
cigarette smokers compared with 46.7 percent of those who
did not use cigarettes in the past month.
The association also was found with binge drinking (44.6
percent of current cigarette smokers vs. 16.5 percent of current
nonsmokers) and heavy drinking (16.8 vs. 3.8 percent,
respectively).
Past year illicit drug use in 2008 was higher among adults aged 18
or older with past year SMI (serious mental illness) (30.3 percent)
than among adults without SMI (12.9 percent).
 Similarly, the rate of past year cigarette use was higher among
adults with SMI (50.5 percent) than among adults without SMI
(28.5 percent).
 Among adults aged 18 or older with past year SMI in 2008, the rate
of binge alcohol use (drinking five or more drinks on the same
occasion [i.e., at the same time or within a couple of hours of each
other] on at least 1 day in the past 30 days) was 29.4 percent,
which was higher than the 24.6 percent among adults who did not
meet the criteria for SMI.
 Similarly, the rate of heavy alcohol use (drinking five or more
drinks on the same occasion on each of 5 or more days in the past
30 days) among adults with SMI in the past year (11.6 percent) was
higher than the rate reported among adults without SMI in the
past year (7.3 percent).


In 2008, of the 2.9 million persons aged 12 or older who used illicit
drugs for the first time within the past 12 months, a majority
reported that their first drug was marijuana (56.6 percent).
 The average age at initiation among persons aged 12 to 49 was 18.8
years.
Nearly one third initiated with psychotherapeutics (29.6 percent,
including 22.5 percent with pain relievers, 3.2 percent with
tranquilizers, 3.0 percent with stimulants, and 0.8 percent with
sedatives).
 A sizable proportion reported inhalants (9.7 percent) as their first
drug, and a small proportion used hallucinogens as their first illicit
drug (3.2 percent).
 Between 2007 and 2008, the percentage of past year illicit drug
initiates whose first drug was tranquilizers decreased from 6.5 to
3.2 percent, while the percentage whose first drug was inhalants
decreased between 2003 and 2008 from 12.9 to 9.7 percent.





Although IDU-related HIV transmission is most closely
related to sharing injection equipment, a significant portion
of transmission is related to sexual behaviors.
Even after controlling for other potential risk factors, HIV
infection rates tend to be higher among individuals who
abuse alcohol.
Individuals who abuse one drug or alcohol are more likely to
use/abuse other substances as well.
Over half of cocaine-dependent and 17–50% of heroindependent individuals abuse alcohol and alcohol use is
associated with needle sharing in both heroin- and cocaineabusing persons (Petry, 1999).
 Drug use and drug abuse play other, less recognized, roles in
HIV transmission.
 Drug and alcohol intoxication affects users' mental status
and judgment, which, in turn, can increase the likelihood that
they will engage in high-risk sexual behavior.
 Addiction to drugs, as documented for crack cocaine, can
further increase users' exposure to unprotected sex as a
means to obtain drugs.
 Physiological consequences of drug abuse may alter
susceptibility to infection and interact with HIV treatment
drugs.
– Linked Epidemics: Drug Abuse and HIV/AIDS
– A Research Update from the National Institute on Drug Abuse — October 2005




The role of non-injection substance use (non-IDU) to the
HIV/AIDS epidemic is important.
Research has shown that among heterosexuals, alcohol and
non-injection drug use are consistent predictors of HIV risks
and new infections.
Among MSM, substance use is more prevalent compared with
the general population and is a known risk factor for HIV
infection.
In prospective studies, substance abuse is consistently found to
be a powerful predictor of new HIV infections.




The use of crack cocaine has been associated with high-risk
behaviors and has disproportionately affected African
American women.
Studies have shown that smoking crack cocaine and
exchanging sex for money are co-factors for the risk of HIV
infection, especially for women.
Women who smoke crack are more likely than non-crackusing women to
 1) sell sex,
 2) have more sexual partners,
 3) have an STD.
Women who use crack are also more likely to be assaulted
during a sex exchange.
Culture is a set of shared behaviors, ideas and values
which are symbolic, systematic, cumulative and
transmitted from generation to generation.
“Culture is a particular set of values, norms, attitudes,
and expectations about the world that shapes the
personalities of those reared in that culture.” Marin, 1991
(
)
Cultural Competency has been defined as a “set of
academic and interpersonal skills that allow
individuals to increase their understanding and
appreciation of cultural differences and similarities
within, among, and between groups.”
(L.A. County, Dept. of Health Services)
Primary Dimensions
1. Age
2. Ethnicity
3. Gender
4. Race
5. Language
6. Physical Abilities and Qualities
7. Sexual /Affectional Orientation
8. Childhood Experiences and Family Factors
(Family religion, place of birth and household location,
family social class, parents occupations, etc.)
Secondary Dimensions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Education
Geographic Location
Income
Marital Status
Military Experience
Parental Status
Religion
Work Experience
Current Social Class
Tertiary Dimensions
1. Experiences with Immigration, Exile, etc.
2. Lifestyle
3. Degree of Assimilation

“Cultural Competency in the Context of ALL
RISE”

S. Wolfgram , H. Teuber
*Kinship bonds and extended family
*Takes a “Village” mentality-Grandparents key
*Value balance between nurture-discipline
*Women social equals and interdependent
relationships
 *Importance of the Black Church and religiousity
 *History oppression = mistrust of the dominant
majority and system.





(Wolfgram, 2010)









Familial/tribal communities as support- Collectivists
Sharing- Humble – “Place” (Role) in WORLD
Cooperation VS. Competition
Deep spirituality/ritual-Living in harmony with all creation
Communal sharing of childcare responsibilities
Respect for elderly
Mistrust of whites because of oppression history
Boarding school history has contributed to Native families
displacement
(Wolfgram, 2010)









Patriarchy
Suffering/sacrificing self
Fatalism: things are meant to happen the way they happen
Shamanism
Conflict Avoidance
Collectivism: protecting family name at all costs-harmony
Saving Face/Avoiding Shame
Obligation of younger generation to care for older
generation, “filial piety”
(Wolfgram, 2010)
Familism; extended family as sole support system
Machismo: head of household protector, provider,
honor, pride, hyperaggressive sign of strength
(Marianismo)
 Respeto: respect owed to others who are older
 Catholic Fatalism, “suffering expected on earth and
reward in heaven”
 Santeria: an Afro-Cuban belief system= cultural
medicinal practice



(Wolfgram, 2010)


Understanding racial and ethnic differences and disparities
in drug treatment is necessary in order to develop a more
effective referral system and to improve the accessibility of
treatments (Saunders et al, 2006)
Racial and ethnic minorities appear to have significantly
higher rates of unmet needs for substance use disorders and
are less likely to seek or complete treatment (Campbell et al,
2006)

Studying Black and Hispanic populations is particularly
important given their anticipated growth and that they make
up the majority of the nation's urban population (Kang et al,
2006)

Blacks utilized multiple service types that have strong
community and network connections (Perron et al, 2009)


Underestimation of the extent of the problem
Underutilization of treatment services (delaying or
not seeking treatment) due to:
 Shame
 Stigma
 Lack of knowledge
 Health insurance

Lack of cultural & language appropriate treatment
programs






Different historical background
Different family structure, inter-personal
relationships
Different cultural values
Different substance abuse preferences
Different help-seeking patterns
Different languages & dialects



This study investigated the time between HIV testing and
presentation to primary care.
One hundred eighty-nine consecutive outpatients without
prior primary care for HIV infection were assessed at 2 urban
hospitals: Boston City Hospital, Boston, Mass, and Rhode
Island Hospital, Providence.
Socio-demographics, alcohol and drug use, social support,
sexual beliefs and practices, and HIV testing issues were
examined in bivariate and multivariate analyses for
association with delay in presentation to primary care after
positive test results for HIV.
 Samet JH, Freedberg KA, Stein MD, et al. Trillion virion delay: time from
testing positive for HIV to presentation for primary care.
 Arch Intern Med. 1998;158(7):734-740

Delay After Positive HIV Test Results and Patient
Characteristics on Initial Presentation to Primary Medical
Care:
 Not having a spouse or partner
 Injection drug use
8.6 mo
13.9 mo
18 mo
30.4 mo
19.2 mo
 Interaction of sex and CAGE
▪ Men, positive CAGE results
▪ Women, positive CAGE results
14.6 mo
-10 mo
 Not having a living mother
 Not aware of HIV risk at testing
 Not told positive status in person
Strong stigma for substance abuse problems
Communities hold moralistic attitude towards
individuals with addiction problems
 Insufficient outreach & prevention services
 Substance abuse treatment & recovery not
communities’ priority
 Lack of recovery support services & organizations



The stigma and discrimination associated with drug
and alcohol abuse, as well as the disorganization
often seen in the lifestyle of those with active
substance abuse, can lead to denial, delay in
diagnosis of HIV, and reluctance to seek care.
Accurate information about HIV transmission, as
well as the reduction of stigmas associated with
infection, is a critical measure for prevention.
 Research has shown that people who fear HIV
related stigma and discrimination are less likely to
seek information about prevention, may delay
being tested for HIV and implementing treatment,
and may be reluctant to discuss their HIV status.




Women with drug and alcohol abuse are more likely to
experience poor health and are less likely to access services,
receive treatment, or seek health care, partially because of
the stigma of substance abuse.
Suspicion, fear, and distrust of the health care system result
in reluctance among drug users to disclose medically
necessary information.
Negative sanctions, such as mandatory HIV testing during
pregnancy and incarceration of drug-using pregnant women
for child abuse, have intensified fears about contact with the
health system.
•
•
•
•
•
Often they do not consider alcohol as a harmful
drug, using it with herbal medicine & cooking.
Moderate use of alcohol at social & ceremonial
occasions.
Outward drunkenness and acting out behavior is not
tolerated.
Some use of substance at some communities for
special groups of people is acceptable.
Alcohol and drug problems, especially related to
criminal activities considered extreme shame &
disgrace to family.





There is insufficient credible research data & small
sample sizes make meaningful analysis impossible.
Generally they drink less, ”Flush Syndrome” & high
percentage of persons not drinking at all.
Less illicit drug use.
Drug treatment admissions among AAPI increased
by 37% (SAMHSA 2000) between 1994 and 1999
There is a different pattern of use for different
ethnic groups, American or foreign born, age
groups.
Mental Health problems
 Close relations to addiction problems
 Strong stigma
 Long waiting list for MH services
 Gambling problems
 Asian-Americans and American Indians have a long history
of accepting gambling as a community and family
recreation
 High prevalence of problem gambling & pathological
gambling








Understanding the cultural and practical barriers that exist
are the first step in reducing them.
Increase & enhance language & culturally appropriate
community education, outreach, screenings & interventions.
Increase language & cultural appropriate treatment services
in all levels of care.
Improve linkages within the providers networks and with
community based organizations.
Address the workforce issues for the communities.
Create alternative self-help/support group that is less
confrontational and more supportive & educational.
Work with families separately, to reduce enabling and
negative feelings.

HIV infected substance abusers have more:
 Bacterial infections:
▪ Cellulitis, abscesses, endocarditis, pneumonia, Tb
 Viral hepatitis:
▪ Chronic Hepatitis B and C
 Renal disease:
▪ HIVAN, chronic kidney disease
 Neurologic disorders:
▪ Toxoplasmosis, Cryptococcus, Tb

Some specific self-care concerns among HIV patients that
impact quality of life and HIV outcomes for the patients
themselves include:
 medication adherence,
 depression,
 sexual risk-taking, and
 substance abuse.


These concerns can sometimes be additive if and when they
co-occur.
Depression and substance abuse may decrease quality of life
and can impact adherence to medical regimens.
 “Behavioral Aspects of HIV Care: Adherence, Depression,
Substance Use, and HIV-Transmission Behaviors”
BergCJ, et al:Infectious Disease Clinics of North America - Volume 21, Issue 1 (March 2007)
What is the relationship between drug use and overall
adherence?
 Is there an association between drug use and rate of decline
in adherence rates?
 What is the differential impact of stimulant use versus other
drugs on adherence?
 Do adherence rates vary as a function of recent of use?
 What is the impact of substance abuse and dependence on
adherence?

 Hinkin CH et al:AIDS and Behavior. 2007;11(2):185-194




Drug use was associated with a 4.1 times greater risk of
being a poor adherer (adherence <90%).
During the 6-month study, the drug-negative group's
adherence rate was 79% as compared to 63% for the drugpositive group.
The adherence rates for the drug-using group dropped more
than twice as much as the non drug users.
The stimulant positive group's adherence rate was
significantly lower than both the other-drug-positive group
(P = .001) as well as the non-drug group (P < .001).
The three-day mean adherence rate for participants who
tested positive for recent stimulant use was 51.3% compared
to a three-day mean adherence rate of 71.7% for the same
participants when they had not recently used stimulants.
 The abuse/dependence group evidenced poorer medication
adherence than did the non-abuse group (61.0% vs. 72.7%,
respectively).

•
•
•
Both substance use disorders and HIV/AIDS individually
impact tens of millions of people adversely, with explosive
epidemics of both described worldwide.
Management of HIV infection among chemically dependent
individuals requires considerable knowledge about multiple
disciplines, including expertise in addiction medicine and
psychiatry because of the overlapping epidemics of HIV,
substance abuse, and mental illness .
The capability of managing these conditions varies
considerably between resource-rich and resource-limited
regions of the world
– Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics
of North America - Volume 21, Issue 1 (March 2007)
The clinician should incorporate selected brief screening
instruments into the history-taking process.
 The chosen screening instruments should be tailored for
optimal use at initial, annual, and interim visits and adjusted
for the patient’s substance use history.
 To obtain more reliable results, the clinician should perform
screening tests when patients are not under the influence of
substances.
 The clinician should carefully screen patients who are heavy
smokers for other addictions because heavy smoking is often
a surrogate marker of other substance and alcohol
dependence.


When a patient’s response to a query indicates substance
use, clinicians should inquire about drug use, both currently
and anytime in the past.

The clinician should use nonjudgmental language when
inquiring about substance use.



Screening for Drug Use in Primary Care
 A single question could be useful
"How many times in the past year have you used an illegal
drug or used a prescription medication for non-medical
reasons?“
Compared with the structured interview, the sensitivity of
the single-question screen was 100%, and the specificity was
74% for detecting current drug use.
 A single-question screening test for drug use in primary care.
 Smith PC et al: Arch Intern Med 2010 Jul 12; 170:1155.

History
– History of referrals or participation in substance/alcohol
treatment programs
– Trauma, especially after drinking/substance use
– Legal problems
– Job loss, turnover, downward mobility
– Relationship problems
– Medical history: seizures, pancreatitis, liver disease, cytopenias,
tachyarrhythmias, endocarditis, abscesses
– History of psychiatric symptoms, especially affective disorders
– History of or current heavy smoking

Physical signs:
–
–
–
–
–
–
–
–
–
–
–
Hypertension (alcohol, cocaine, methamphetamine)
Resting tachycardia (alcohol, cocaine, marijuana, methamphetamine)
Tremor (alcohol withdrawal or stimulant intoxication)
Alcohol on breath
Dilated pupils (stimulant use or sedative withdrawal)
Small pupils (opiate use)
Needle marks/tracks (any injection use)
Bruises or healed fractures, especially of the ribs (alcohol)
Puffy facies (alcohol)
Hepatomegaly (alcohol)
Weight loss (cocaine, methamphetamine)

Laboratory Tests
 Elevated mean cell volume (MCV), if not taking zidovudine
 Elevated GGT (associated with alcoholic liver disease, and




a more sensitive marker than AST)
AST>ALT
Decreased serum B12
Urine drug screens
Blood alcohol levels


To prevent the spread of HIV and other blood-borne
infections, drug users must reduce or eliminate those
behaviors that place them and others at risk.
Research has shown that appropriately designed prevention
programs can reduce transmission of not only HIV but of
other blood-borne diseases (e.g., hepatitis B [HBV], hepatitis
C [HCV], and other sexually transmitted diseases [STDs]) as
well.
 Principles of HIV Prevention in Drug-Using Populations
 NIDA's HIV Prevention Research Activities:
Center on AIDS and Other Medical Consequences of Drug Abuse
(CAMCODA),


Given the diversity of drug users and their sexual partners,
no single prevention strategy will work for everyone.
A comprehensive approach that can readily adapt to
changing needs and circumstances is the most effective
approach for preventing HIV/AIDS and other blood-borne
infections in drug users, their sexual partners, and their
communities.

This approach should include such services as:
 community outreach,
 HIV testing and counseling,
 drug abuse treatment,
 access to sterile syringes, and
 services delivered through community health and social
service providers.

Services must be carefully coordinated within a community.

Pregnant HIV-infected substance users should be
co-managed by an HIV Specialist and an obstetrical
care provider experienced in the care of HIVinfected women.



In studies of substance abuse treatment among women,
pregnancy and childbearing are important events because
they may represent barriers to seeking, receiving, or
completing treatment.
Women with substance use disorders may avoid seeking
treatment for fear of losing custody of their children due to
well-publicized cases of drug use during pregnancy resulting
in prosecutions for child abuse, delivery of drugs to a minor,
and other charges.
14 states consider substance use during pregnancy to be
child abuse under civil child-welfare statutes, and 9 states
require health care professionals to report suspected
prenatal substance abuse.
Substance abusers vary in their readiness to change their
behaviors.
 Providers who are attuned to the patient’s stage of readiness
(precontemplative to action-oriented) will have the greatest
success in facilitating behavior change.
 Motivating factors for treatment readiness in women are
most commonly associated with difficulty in raising their
children or in response to interventions by social services
departments.
 Unlike men, women are more likely to express their
treatment readiness in nonsubstance use settings, especially
in mental health care sites.
 Drug and alcohol treatment readiness should be evaluated in
all health care settings.



Evidence-based treatment: Why, what,
where, when and how? Journal of Substance
Abuse Treatment, 29, 267-276.
Miller, W. R., Zweben, J. & Johnson, W. R.
(2005).





Cognitive-behavioral treatment
Community reinforcement approach
Motivational interviewing
Relapse prevention (cognitive-behavioral)
Social skill training






Educational lectures and films
Exploratory psychotherapies
Undifferentiated counseling
Confrontation
Mandated AA
Time in milieu (inpatient/residential)
stress
demoralization
CNS inflammation
substance abuse
subcortical injury
cognitive impairment
Depression
impulsivity
hopelessness
carelessness
demoralization
substance abuse
cognitive impairment
HIV
Precontemplation
Uninformed about the risk and
need for change, uninterested in
changing behavior
Contemplation
Thinking about change in the near
future (next six months)
Preparation
Ready to make a change in the
next month
Action
Implementation of specific action
plans for six months
Maintenance
Continuation of desirable actions
for greater than six months, or
repeating periodic recommended
step(s)
Relapse*
Successfully accomplished a
behavior change in the past, but
later returned to the unhealthy
behavior


The close association between drug use and HIV
transmission suggests that the treatment of drug abuse can
be considered primary HIV prevention.
By helping drug users to reduce their frequency of use,
participation in substance abuse treatment has been
associated with the prevention of HIV infection.
 Human immunodeficiency virus prevention and the
potential of drug abuse treatment.
Metzger DS - Clin Infect Dis - 15-DEC-2003; 37 Suppl 5:
S451-6
Treatment encourages users to see beyond the immediate
“positive” effects gained from drug use toward the negative
consequences of drug use that inevitably follow.
 Alternative coping mechanisms are then devised that will
provide positive effects without the negative consequences
of drug use.
 Finally, recovering addicts learn to manage their lives more
successfully, increase their confidence and self-esteem, and
set positive personal goals.
 Treatment also addresses other medical or mental health
issues facing the user and includes education on the risks of
HIV and AIDS associated with meth use.




Both substance use disorders and HIV/AIDS individually
impact tens of millions of people adversely, with explosive
epidemics of both described worldwide.
Management of HIV infection among chemically dependent
individuals requires considerable knowledge about multiple
disciplines, including expertise in addiction medicine and
psychiatry because of the overlapping epidemics of HIV,
substance abuse, and mental illness [2]
The capability of managing these conditions varies
considerably between resource-rich and resource-limited
regions of the world
– Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics
of North America - Volume 21, Issue 1 (March 2007)
The research literature of the past 25 years substantiates
that methadone treatment is an effective HIV prevention
intervention.
 Patients in methadone treatment use opiates significantly
less often compared with those not in treatment.
 They also use significantly less while in treatment compared
with what they were using pre- and post-treatment.
 Consistent with the observed reductions in opiate use,
available data suggest that methadone patients will have
40% to 60% fewer instances of opiate injection and needlesharing events compared with those not in treatment.

 Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)
The association of drug treatment with decreased drug use
has been reported in studies designed to compare
methadone patients with heroin users not in drug treatment
and in those assessing changes in cohorts of methadone
patients during drug treatment.
 Research has also shown that rates of injection among
patients who remain in treatment are significantly lower
than those among patients who leave treatment.

 Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)




Strong associations have been reported for methadone
participation and lower rates of HIV prevalence and
incidence.
Heroin users who remain in methadone treatment during
periods of rapid HIV transmission in their surrounding
communities have a dramatically lower prevalence of
infection compared with those who do not.
HIV prevalence rates are also correlated with length of time
in treatment.
Both prospective and retrospective studies have shown that
the incidence of HIV infections is significantly and inversely
associated with patient participation in and the duration of
methadone treatment.
Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease Clinics of
North America - Volume 21, Issue 1 (March 2007)


Recent reports on buprenorphine as HIV prevention show
significant reductions in risk behaviors among adults and
adolescents who receive the medication through both officeand clinic-based practices, consistent with reports on
methadone maintenance treatment.
A randomized double-blind trial among heroin injectors in
Malaysia found significantly fewer risk behaviors and longer
treatment stays in those assigned to buprenorphine
compared with those assigned to naltrexone or placebo.
 Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)



Research on drug treatment as HIV prevention has focused
on the impact of treatment participation on the frequency of
drug use and related behaviors, including injecting and
sharing syringes, rinse water, and cotton.
For HIV-infected drug users, accessing drug treatment can
link them to HIV testing, antiretroviral treatment (ART), and
HIV care.
Not only are risk behaviors lower among patients in HIV care,
but sustained reductions in viral load are achieved by the
majority of adherent patients, regardless of mode of initial
infection.
 Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)


700 alcohol-dependent subjects completed a baseline
assessment and a follow-up assessment an average of 13
months after receiving treatment.
In comparing baseline and follow-up data, significant
reductions in both sexual and drug-related risks were found:
 58% reduction in injecting drug use,
 15% reduction in reports of multiple sex partners,
 26% reduction in the number of partners who were IDUs, and
 77% increase in the use of condoms with all secondary sexual partners.

Changes in HIV-related behaviors among heterosexual
alcoholics following addiction treatment. AlvinsAL et al:Drug
Alcohol Depend:1997;44:47-55.



232 cocaine-abusing or cocainedependent individuals who
received up to six months of weekly drug counseling.
Despite the fact that no formal HIV prevention interventions
were delivered, individuals who completed treatment
showed significant decreases in sexual risk behavior,
primarily the result of a reduction in the number of sexual
partners.
Among those who demonstrated a treatment effect, the
sexual risk reductions accompanied reductions in cocaine use
as monitored by urinalysis.
 Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)

Data from research on the treatment of opiate dependence
provide strong evidence on the effectiveness of medicationassisted treatment for reducing the frequency of:
– drug use,
– risk behaviors, and
– HIV infections.


Use of medications other than methadone (such as
buprenorphine/naloxone and naltrexone) has increased in
recent years with promising data on their effectiveness as HIV
prevention and as new treatment options for communities
heavily affected by opiate use and HIV infection.
Few treatment interventions for stimulant abuse and
dependence have shown efficacy in reducing HIV risk.
– Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)


Use of medications other than methadone (such as
buprenorphine/naloxone and naltrexone) has increased in
recent years with promising data on their effectiveness as
HIV prevention and as new treatment options for
communities heavily affected by opiate use and HIV
infection.
Few treatment interventions for stimulant abuse and
dependence have shown efficacy in reducing HIV risk.
 Bruce RD et al:Clinical Care of the HIV-Infected Drug
User:Infectious Disease Clinics of North America - Volume 21, Issue 1
(March 2007)
Risky sexual behaviors often co-occur with drug use,
particularly in the setting of cocaine and other stimulant use.
 Few studies have found that participation in drug treatment
is associated with reductions in sexual risk behaviors.
 Interventions to reduce sexual risks among drug users have
had poor results or at least have not differed from basic
educational intervention approaches.

 Bruce RD et al:Clinical Care of the HIV-Infected Drug
User:Infectious Disease Clinics of North America - Volume 21, Issue 1
(March 2007)



Positive findings have emerged from studies of sexual risk
reduction interventions that are delivered within the drug
treatment program setting with the drug treatment program as
the platform for intervention delivery.
Findings have thus far held for both individual and group
sessions as well as for gender-specific and gender-mixed,68-70
yet these results are less consistent than those on the effects of
drug treatment on reducing injection-related risks.71,72
Effective approaches for reducing sexual risk behaviors have
been and continue to be elusive, possibly attributable in part to
the link between sexual risk behaviors and stimulant use and
the absence of effective medication assisted treatments for
stimulant use.
– Bruce RD et al:Clinical Care of the HIV-Infected Drug User:Infectious Disease
Clinics of North America - Volume 21, Issue 1 (March 2007)

Eddie
 28 yr old AA male dx HIV+ 5 years ago at a mobile van. His
risk was unprotected sex with women.
 No hx of an OI. No hx of ARV’s. Missed the last 2
appointments.
 He is a heavy alcohol user mostly on weekends.
 Occasional use of Estacy.
 Latest labs
▪ CD4-145
▪ HIV RNA-288,000
 How do you proceed?

Emma
 35 yo AA woman dx HIV+ 3 mo ago. Last test was 5 yr ago,




did not return for the results.
15 yr hx of IVDA. Last used 12 hrs ago.
Highest grade-10. Homeless, mother of 4.
Hx of Schizophrenia. Residential treatment x 5.
Several close friends died of AIDS.
▪ CD4-49
▪ HIV RNA-88,000
 What do you do next?
Mario
26 yo Latina transgender dx 1 mo ago. Recently employed.
Lives with parents. Kept appointment.
 Admit to multiple sex partners in the past.
 Adimts to alcohol and crystal meth use and often attend
drug/sex parties.
 No hx of mental illness.


 CD4-410
 HIV RNA-79,000
 Hep C Ab-Positive

How do you proceed?




48 yo AA Male dx 17 yrs ago. Hx of IVDA. Hx of ARV’s while
incarcerated. Hx of IDDM, HTN, DJD. Wants to restart ARV’s.
Incarcerated x 16 yrs until 9 mo ago.
Returned to active alcohol/drug use after his release.
College degree. Unemployed. Hx of treatment for
depression.
 CD4-550
 HIV RNA-29,000

How do you proceed?




58 yo AA man dx HIV+ 5 yrs ago. No hx of an OI. No hx of
ARV’s. Hx of HTN, hyperlipidemia, obesity.
20 yr hx of crack cocaine addiction.
 Treatment x 6.
 Last drug use was 5 yrs ago at the time of dx.
Comes with his fiance (HIV-).
Currently taking herbals. Unsure about taking ARV’s.
 CD4-490
 HIV RNA-56,000

How do you proceed?

Substance Abuse and HIV
 IAS 2003

Substance Use Disorders in HIV-Infected Patients:
Impact and New Treatment Strategies
 Topics in HIV Medicine 2004: 3;77-82

Substance Abuse Treatment for Persons with HIV
 SAMHSA/CSAT

A Guide to the Clinical Care of Women with
HIV/AIDS, 2005 edition
 HRSA

HIV and SUBSTANCE ABUSE
 New York State Department of Health AIDS Institute

MEDICAL CARE OF HIV-INFECTED SUBSTANCE-USING
WOMEN
 New York State Department of Health AIDS Institute

Methamphetamine Abuse
 American Family Physician - Volume 76, Issue 8 (October
2007)

Clinical Care of the HIV-Infected Drug User
 Infectious Disease Clinics of North America - Volume 21,
Issue 1 (March 2007)
Kerry Hawk Lessard, MAA
Michael R. Noss, DO
Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN

Goulda Downer, Ph.D., RD, LN, CNS - Principle
Investigator/Project Director (AETC-NMC)

I Jean Davis, PhD, PA, AAHIVS

John I. McNeil, M.D

Michael R. Noss, DO

Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTNA, FAAN
1840 7th Street NW, 2nd Floor
Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
Goulda Downer, Ph.D., RD, LN, CNS
Principle Investigator/Project Director (AETC-NMC)
www.AETCNMC.org
HRSA Grant Number: U2THA19645
98