Substance abuse treatment should be key component of HIV treatment plan
Substance abuse treatment should be key component of HIV treatment plan
Experts explain some best-practice strategies
Treating HIV patients who have substance use or abuse problems is far from new and has been a part of HIV treatment for the past two decades. However, research is making it increasingly clear that continued alcohol and drug use can negatively affect treatment outcomes in some cases. This in turn means that clinicians and HIV specialists need to assess HIV patients for drug and alcohol use adequately and then adjust treatment plans accordingly.
"There has been a dramatic increase in the number of substance abusers with HIV over the past decade," says Bruce Agins, MD, MPH, medical director of the AIDS Institute of the New York State Department of Health in New York City. "But it’s not a new phenomenon, and the New York State Health Department had the foresight to develop programs to provide care to substance abusers with HIV early on," Agins says.
The issue of treating HIV patients who are chronic drug or alcohol users has become more complex in recent years, with some literature pointing to adherence problems and even medical problems related to the combination of antiretroviral therapy and alcohol or drug use. (See "Heavy alcohol use hinders HIV therapy: Study," in this issue.)
"As HIV therapies are becoming more effective than ever and more complex than ever, it’s becoming more important than ever that clinicians don’t try to sweep the issue of their patients’ drug use under the rug," says Marc Gourevitch, MD, an internist and director of Addiction Medicine at the Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, NY.
Compounding the problem is the fact that providers sometimes are unaware that substance abuse is having an impact on a particular patient’s treatment and adherence, notes Joseph Masci, MD, director of AIDS Services at Queens Health Network and chief of Infectious Diseases at Elmhurst (NY) Hospital Center. "The best we can do as a primary care provider is to establish as close of a relationship as possible so that the person feels safe in discussing substance abuse issues with us," Masci says. "Then we have a basis for establishing a management plan for them."
Treating substance users is controversial
HIV treatment for patients who are substance users is a controversial topic, especially in light of conflicting studies about adherence among these populations. Some studies show that substance abusers are just as adherent to their medication as those who are in recovery, says Mary Jane Rotheram-Borus, PhD, professor and associate director of the AIDS Institute at the University of California - Los Angeles. "In general, adherence is sporadic with people, and substance abusers are no different," Rotheram-Borus says.
The controversy extends even to the terminology to describe these patients. Some AIDS service organizations abstain from using the term "substance abuse" because it has a negative connotation. They prefer to refer to such activity as "substance use." Also, at some major clinics, it’s stipulated that HIV treatment is not withheld when patients continue to use or abuse drugs or alcohol, regardless of adherence problems that might arise.
Treatment must be individualized because studies have shown that some drug users do benefit markedly from antiretroviral therapy despite ongoing drug use, Gourevitch says. "So you cannot simply apply one standard to all people who have been identified somewhere along the way as drug users," Gourevitch adds.
Many clinicians consider that it would be problematic from a public-health perspective to prescribe an antiretroviral regimen to a patient whose drug or alcohol use suggests that he or she might have major adherence problems. "In general, the substance abuse is a bigger issue and a more urgent issue to take care of then these patients’ HIV," says R. Scott Hitt, MD, president of the American Academy of HIV Medicine in Los Angeles. "The idea is to get their lives stabilized in terms of drug or alcohol addiction prior to initiating therapy, if one can."
Exceptions would have to be made in the cases of patients who have very low CD4 cell counts and who have an opportunistic infection, Hitt says. "With all patients, as compliance is becoming a large problem, if counseling or changing the regimen does not improve compliance greatly, then I would stop their medications until their life situation shows they can be more compliant on their medications," Hitt adds. "Not only are they hurting themselves, but if they develop drug resistance, then there is a potential harm to society."
Look at drug use on case-by-case basis
The San Francisco AIDS Foundation in California addresses substance use on a case-by-case basis, looking more at other markers of whether a particular client is ready for antiretroviral treatment, says Susan Haikalis, LCSW, director of HIV Services and Treatment Support. "There are some clients whose substance use is in a controlled way that doesn’t interfere with their taking their medications on a regular basis," Haikalis explains. "We have seen patients with a current history of using speed or crack who are less able to manage the kind of adherence you need to be successful in treatment, but others in methadone or some heroin users who use on some form of regular schedule seem to be able to adhere to HIV medication regimens."
Also, not everyone who uses necessarily abuses, and it’s important for providers to refrain from judgments and make patients feel comfortable enough to share information about their substance use, says Sheila H. Mabry, CSW, assistant director of HIV Prevention for the Gay Men’s Health Crisis in New York City. "I have heard that some clients are not comfortable talking about both sexuality and substance use in some clinics because they feel they are being judged, and there is an expectation from some providers that clients should stop before someone will work with them," Mabry adds.
The Lower Eastside Harm Reduction Center in New York did a study on accessibility and acceptability of health care for substance users and found that drug users have learned that it’s not safe to be honest about their substance use, says Mark Gerse, deputy executive director for the program, which is serves people who are actively using substances. "They know they will be treated better if they don’t talk about their substance use," Gerse says. "If someone mentions using substances or being a heavy, regular drinker, then the focus right away gets put on the substances."
Another problem that appears to be increasing among the HIV population is an increase in medical and social complexity. Patients increasingly have mental health problems, and in San Francisco there also is an increase in homelessness among HIV-infected individuals, Haikalis says.
It’s become quite common for the San Francisco AIDS Foundation to see clients who have multiple diagnoses, in addition to substance abuse, and this makes it difficult to assess and find available referral sources to handle these complex problems, Haikalis adds. (See "Assess, refer, and treat: Keys for substance abusers," in this issue.) "They commonly have had very little work histories, and until they become disabled by HIV or AIDS, they are often stuck at the level of being only eligible for general assistance, which complicates access to care in most parts of the country," Haikalis says. "What we don’t have sufficient services for is the substance use treatment area and particularly inpatient care."
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