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HIV / AIDS: What Providers Need to Know What We’ll Cover • Current Context • Basic Immunology • HIV/AIDS basic biology • Transmission and prevention • Risk reduction strategies • Integrating HIV/AIDS treatment and prevention in substance abuse treatment programs HIV Context: The Why HIV Infection Rates in U.S. Rate per 100,000 40.1–129.3 129.4–202.4 202.5–319.3 319.4–428.0 428.1–3,365.2 Data classed using quintiles. Overall total rate = 417.5 Data source: National HIV Surveillance System. Rates are not adjusted for reporting delays. Inset maps not to scale. Source: Adapted from the Centers for Disease Control and Prevention – Morbidity and Mortality Weekly Report, December 2nd, 2011. The Immune System: An Overview What Does a Healthy Immune System Do? Innate Immune System Adaptive Immune System • Response is non-specific • Exposure leads to • Pathogen and antigen immediate response • No immunological memory specific • Lag time between exposure and maximal response • Exposure leads to immunological memory Overview of Immune System Cells T Cells: What do they do? Helper T (CD4) Cells • Bind to antigen presenting cells. • Release signals to coordinate other immune responses. Photo Credit: Lawrence Berkeley national laboratory Killer T (CD8) Cells • Bind to proteins on the surface of malfunctioning cells. • Release signals that trigger the destruction of the damaged cell. What is HIV / AIDS? Human Immunodeficiency Virus is the cause of Acquired Immuno-deficiency Syndrome HIV • A unique type of virus - a retrovirus • Invades the helper T cells (CD4 cells) • Preventable, manageable, but not curable Human Immunodeficiency Virus P120 Envelope Protein P41 Envelope Protein P24 Capsule Proteins Reverse Transcriptase RNA P17 Matrix Proteins Lipid Membrane Viral Replication • First: HIV attaches to susceptible host cells – Site of attachment is the CD4 antigen found on a variety of cells helper T cells macrophages monocytes B cells microglial brain cells intestinal cells • Later: T cells are infected CD4+ T Cell Attacked by HIV http://betastuffs.blogspot.com AIDS Disease Progression • Course of untreated HIV infection can go on for 10 years or more – Initial infection – Latency period – Early symptomatic infections – AIDS Initial Infection • Primary HIV infection can cause an acute retroviral syndrome that is often mistaken for the flu, mononucleosis or a bad cold • CD4+ T cell count can drop very low in the early weeks, though it usually returns to normal • HIV spread is rapid in this stage • Early treatment is best Latency Period • A period of incubation-very few symptoms • Median length of 10 years • After initial infection, CD4+ T cell counts drops at a rate of 30-90 cells per year • Most common symptoms swollen lymph nodes • Good time for testing and treatment Early Symptomatic Infection • When CD4+ T cells drops below 500, mild HIV symptoms begin • Early symptoms might include: chronic diarrhea, herpes zoster (shingles), yeast infections, thrush, abnormal PAP tests, numbness or tingling in toes or fingers • If recurrent, these symptoms suggest problems with the immune system AIDS • HIV-infected people who have a CD4+ T cell count of less than 200 (cells/mL blood) • Opportunistic infections and aggressive cancers • Tuberculosis, recurrent bacterial pneumonia and invasive cervical cancer AIDS • CD4 count drops below 200 person is considered to have advanced HIV disease • If preventative medications not started the HIV infected person is now at risk for: – Pneumocystis carinii pneumonia (PCP) – cryptococcal meningitis – toxoplasmosis • If CD4 count drops below 50: – – – – – Mycobacterium avium Cytomegalovirus infections lymphoma dementia Most deaths occur with CD4 counts below 50. End-Stage Disease • Untreated disease eventually overwhelms the immune system • Sometimes combinations of medicines are ineffective or side effects are intolerable • Hospice care is available for those who have run out of therapeutic options How is HIV Transmitted? HIV is transmitted through: • Body fluids: – Blood – Semen/ Pre-ejaculate – Vaginal fluids – Breast milk HIV is transmitted through: • Behaviors: – Unprotected sex – Sharing needles – Using unsterile needles and blades • Condition: – Mother-baby transmission AIDS Diagnoses by Transmission Category: USA Heterosexual 4% Other 6% Other 13% IDU 17% Heterosexual 31% IDU 19% MSM 64% MSM 47% 1985 2007 MSM = Men who have sex with men (gay and bisexual men); IDU = Injection drug use. NOTE: Data are estimates. SOURCE: Kaiser Family Foundation, based on CDC, Presentation by Dr. Harold Jaffe, “HIV/AIDS in America Today”, National HIV Prevention Conference, 2003; CDC, HIV/AIDS Surveillance Report, Vol. 19, 2009. Transmission Route by Gender: USA New Infections by Population: USA 2010 Why are People who Use Substances at an Increased Risk for HIV Infection? Screening and Testing for HIV One in five of the estimated 1.2 million people in the U.S. who are HIV-positive are unaware of their infection, and the majority of new HIV infections transmitted by people who are unaware of their infection Addiction Treatment as an Opportunity • Screening and testing for HIV and other STDs • Risk assessments for HIV and other STDs • Harm reduction interventions (prevention) – Education – Counseling – Risk reduction plan Benefits of HIV Testing • Decreases HIV transmission – HIV diagnosis is associated with reduction in high risk sexual and injection behaviors • Improves survival – Linkage to care and treatment – Lower viral load associated with decreased infectivity • Advances in HIV Rapid Testing Technologies Despite relatively high prevalence of HIV infection and the known, well-established link among substance use, sex risk behaviors, and HIV, fewer than half of U.S. drug treatment programs offer HIV testing on-site The National HIV/AIDS Strategy (NHAS) recommends coupling HIV screening with substance abuse treatment programs Testing for HIV The most common HIV test is the antibody screening test (immunoassay), which tests for the antibodies that your body makes against HIV. The immunoassay may be conducted in a lab or as a rapid test at the testing site Testing for HIV The rapid test is an immunoassay used for screening, and it produces quick results, in 30 minutes or less. Rapid tests use blood or oral fluid to look for antibodies to HIV. On-Site Rapid HIV Testing Research has shown that offering on-site rapid HIV testing in substance abuse treatment centers substantially increased receipt of HIV test results and identified persons who were unaware of their HIV infection Metsch et al., 2012 HIV/AIDS Risk Assessment 1. Sexual practices assessment with risk reduction counseling 2. Drug use assessment with risk reduction counseling Sexual Practices Assessment • Comprehensive sexual practices history • Critical to ask direct questions such as, “Have you had any unprotected sex?” “How many partners have you had in the past 36 months • Listen carefully for clients’ attitudes and beliefs Possible Questions • Have you had sex? (oral, vaginal, anal) • How often do you use condoms? • Have you ever exchanged sex for money, drugs, place to stay, or something else you needed? • How often do you have sex while using drugs/ alcohol? (a few times, often, always, never) • Have you ever had an STI? (if so, what, and were you treated) Drug Practices Assessment • Substance abuse treatment programs often do this at intake • Focus on injection drug use and the potential for infection through blood • Abstinence, clean works (cookers, filters, water and syringes) • Often drug and sex practices are interwoven Possible Questions… • How often do you use the following drugs? (daily, few times per week, few times per year, used in the past…) • What ways have you used? (orally, smoked, anally, injected) • Has anything changed about your use in the last 3 months? HIV Risk-Reduction Counseling • Help the client understand the need for behavior change • Provide support for behavior change • Assist the client in developing the skills needed to sustain behavior change • Consider environmental and personal factors Behavior change is determined by 1. Perceived seriousness (or severity, consequences) of condition. 2. Perceived susceptibility to (or risk of) condition. 3. Knowledge, attitudes, and beliefs about condition. 4. Perceived and actual social norms related to the behavior (influence of peers, family, cultural and religious norms). 5. Self-efficacy (belief in one's ability to carry out a specific behavior). Behavior change is determined by 6. Skills required to implement the behavioral change. 7. Barriers and facilitators to intended change. 8. Perceived and actual cost (financial or personal). 9. Access to services or support. 10. Power dynamics within relationships, including distribution of power between partners. Harm Reduction Strategies: Sexual Behaviors • Abstinence • Monogamy • Condoms • Lower risk sexual behaviors • Getting tested • Communication with partners Harm Reduction Strategies: Drug/ Alcohol Use • Clean works • Safe injections • Know what you’re using • Don’t mix • Don’t use alone • Reduce amount • Abstinence PEP and PrEP • Pre- and Post- Exposure Prophylaxis • PrEP: Pre-Exposure Prophylaxis. HIV negative people can take an oral pill (Truvada) once per day before coming into contact with HIV to reduce risk of infection. • PEP: Post-Exposure prophylaxis, taking anti-HIV medications after possible exposure to reduce risk of infection . Must be started within 72 hours after exposure, and is taken for 28 days. Common Elements of Risk Reduction Counseling • Aim for a realistic riskreduction plan: – Risk reduction steps should be acceptable to the person, appropriate to his/her situation, explicit and achievable – Offer options, not directives – Recognize the counselor's limited role Integrating Addiction Treatment and HIV/AIDS Treatment • Essential Services: – Testing – Treatment – Case management – Social services • Within a single agency or multiple agencies, coordinated with case management Values of Effective “Case Management” • Self-determination • Support • Skills • Connection Supports for a Person Living with HIV and a Substance Use Disorder People • Helper • Nurse • Sisters • Mother • Peer Coach • Niece • Librarian Places • Dunkins • The “Living Room” and clinic • Library • Pool and gym • The park Things • Cell phone • Bus pass • Coffee!! • Medicine • Newspaper • ipod Activities • Reading • Watching television • Walking my sister’s dog • Recovery group • Listening to music Common Elements of Effective Programs • Treatment philosophy • Outreach efforts • Staff cross-training • Support groups • Community linkages Thank You! Contact Information Cheryl Gagne [email protected] Marc Dones [email protected]