Download HIV/AIDS: What People with Substance Use Disorders Need to

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]