How some HIV clinics handle substance abuse

Service integration is key element

(Editor’s note: This article is the second part of a series on HIV and substance use. The first article in the series appeared in the July issue of AIDS Alert.)

HIV providers routinely deal with substance use issues that sometimes affect patients’ ability to adhere to antiretroviral therapy. For this reason, some HIV clinics and AIDS service organizations in major cities have started their own substance use programs, ranging from inpatient care to day treatment and counseling. Here’s a quick look at what is being offered:

Whitman-Walker Clinic, Washington, DC.

This large HIV health care facility provides extensive substance use services for HIV patients, including an inpatient unit called the Lambda Center that provides psychiatric and addiction services for gay, lesbian, bisexual, and transgendered patients. A step down in service intensity from the Lambda Center is a partial-hospitalization program that is much more intensive than typical day treatment, says Anne Clements, LICSW, director of mental health, addiction, and day treatment services for the Whitman-Walker Clinic. "That service has patients in a hospital setting, but they don’t spend the night," Clements explains.

The clinic also has a six-month residential treatment program for people who are diagnosed with HIV, substance abuse, and mental illness. Patients will stay in an eight-bed house within the community, Clements says. "For the first 30 days, they are on restrictions and are getting more complete detoxification care," she adds.

Because these patients are mentally ill, they often are incapable of following the typical 12-step substance use program. So the residential treatment program has a cognitive-behavioral approach that challenges patients’ faulty thought processes and teaches them alternatives to drinking or using drugs, Clements explains. "Therapists use behavioral contracts with patients, and they can go back to the contract if the patient strays," Clements says. Patients in the residential treatment program include people diagnosed with mood disorders, adjustment disorders, and depression.

The clinic also has a new program called Women’s Healthy Connection. The program is funded through a grant that targets services toward African-American mothers who have HIV and an addiction. "Women who have kids just naturally prioritize the needs of their children first, and when you’ve got an addiction and HIV, you can’t do that and ignore yourself, or you can’t expect to live very long," Clements says. "So this is a program that accommodates children."

The program helps women find respite child care, whether through Head Start, a day care center, or temporary child care provided by the program, which has four child care workers. "A major component of the program is to heal the attachment between the mom and the kid," Clements says, adding that addiction often interferes with that attachment. "We model healthy ways to interact with children," she says. Mothers attend the program between 8 a.m. and 3 p.m. in two shifts over a nine-month period. The program is divided into three phases.

Another substance use program that was started by the clinic years ago as a special service for gays and lesbians is a three-month outpatient program that recently has received funding to include HIV-positive patients. "It’s just a step down from the intensive outpatient program or the residential program," Clements says. "It’s for building a support network that will help you keep on your recovery, and it’s very Alcoholics Anonymous-oriented." That program meets three nights a week.

Accepting the patient’s substance use

Lower Eastside Harm Reduction Center, New York City.

The center provides services for people who are actively using substances. "We start with the assumption that someone is using, and we don’t add stigma to that," says Mark Gerse, deputy executive director. "We talk about other issues, such as housing, how to manage HIV treatment, and legal problems." The center provides a mental health assessment because of the high rate of depression among people who use substances.

Unlike detox and treatment centers, the center does not make it a goal to help a person stop all substance use. The harm reduction approach takes the philosophy that a counselor will accept the patient and the substance use and does not expect the patient to stay completely sober despite treatment for the substance use, Gerse explains. "Nobody’s perfect, and any improvement in the person’s well-being or living situation is a success," he adds.

Gerse is a strong advocate of providing antiretrovirals to HIV patients who inject drugs or abuse alcohol, despite potential problems with adherence. "We all use substances of one order or another, so they’re really talking about people who demonstrate signs of poverty," Gerse says. "If someone goes to a doctor and has some resources, the doctor is going to assume that person can take care of himself, and so the doctor will prescribe drugs."

Gay Men’s Health Crisis, New York City.

GMHC provides harm reduction services through trained counselors and has a substance abuse program that includes alternative health approaches, such as acupuncture, says Sheila H. Mabry, CSW, assistant director of HIV Prevention. The AIDS service organization also may hold a harm reduction conference in the near future, Mabry says. Conference participants could share the work they’re doing in helping HIV patients with substance use problems, providing a network of referrals and new ideas for treatment and counseling.

AIDS providers who have harm reduction or substance use programs need more information about how various substances may affect HIV treatment because the problem is growing, Mabry notes. "It’s important to have that information and share with clients how something is going to be impacting them."