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HIV Risk Reduction
A quarterly newsletter of the Division of Addictive Diseases for professionals in HIV and SA prevention
Volume 9, Issue 3
How to Deliver an HIV+ Diagnosis
And Precautions to Take for Those with Mental Health
and Substance Abuse Issues
Delivering an HIV diagnosis to a client is a huge
responsibility. In one moment, the person receiving
the news is entrenched in a familiar way of living;
in the next, the individual plunges into completely new territory and a life that will never be the same. The transformation
happens in an instant, and you may be the only witness – and
guide. What you do and say can have a profound impact on
the way the patient handles the news of his or her diagnosis.
“This is a very sensitive and delicate issue,” says Sanjay
Sharma, M.D., Assistant Professor, Department of Psychiatry
and Behavioral Sciences, Emory University School of Medicine. Dr. Sharma also serves as Associate Director of Mental
Health/Substance Abuse Treatment Services for the Grady
Infectious Disease Program. First and foremost, be empathic
as you listen and try to understand what the patient may be
experiencing at that moment. He says there is no “right” way
to perform this task. One method will not work for every
individual. In fact, he strongly advises against having a set
agenda or using a prepared script.
“The most important thing to realize is that the HIV diagnosis
is the beginning of a lifelong process,” says the psychiatrist.
“It will impact the patient physically, psychologically, emotionally, psychosocially, and spiritually.” There is a tremendous amount of information to convey, but don’t attempt to
do it entirely during this initial session. “If you give them too
much information,” he says, “they may become overwhelmed.
Let their questions and concerns guide you.”
Patients may need to be educated about the disease and treatment options. They may have concerns about physical health
decline, mental health and psychological impact of the illness,
Sanjay Sharma, MD
Iyearn 1997,
during the fourthof his psychiatric resi-
dency, Sanjay Sharma, M.D.,
had been searching for a way
to continue his interest in both
psychiatry and medicine when
he was given the opportunity
to serve as a co-therapist for a
support group for HIV-positive
men at Grady Health System’s
Infectious Disease Program. Dr.
Sharma’s interactions with the
patients and professional staff at
that time turned into a career-defining experience. “Everything
clicked,” he recalls because he
was able to combine his professional areas of interest to help
Continued on Back
HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA
medications, loss of function and independence,
being stigmatized by those close to them, and
death and dying-related issues. Some may wonder where they got the disease and whether they
have passed it along. Rather than having formulaic or scripted responses, it is important to convey that an HIV-positive diagnosis is not a death
sentence, that there are support resources (including spiritual resources, support groups, counseling
resources, etc) to help HIV-positive individuals
adjust to their new circumstances, and that they
are not alone.
While this news is challenging to anyone who receives it, for those suffering from mental health or
substance abuse issues the situation can be much
more complex. The news may trigger episodes
of stress, anxiety, hopelessness, isolation, anger,
panic, depression, and possibly relapse in those at
risk for substance abuse/dependence.
When an individual receives his or her diagnosis,
it may be impossible to determine if the patient
fully comprehends the diagnosis and associated
aspects. Some techniques to consider to assist
may include providing
the client with written
educational materials
and peer support resources, and enlisting
the help of a trusted
family member or
friend, paying close attention to confidentiality
and related issues.
higher prevalence of substance abuse, precautions
are necessary. Dr. Sharma shares these examples
to illustrate his point:
• Alcohol is tremendously damaging to the liver
and HIV medications also put a heavy burden
on this organ, leading to deleterious consequences. One HIV drug (DDI) can inflame the
pancreas when combined with alcohol.
• There has been some preliminary laboratory
documentation that cocaine can cause the HIV
virus to replicate 20 times faster than normal.
• Cocaine and crystal meth cause the protective
blood-brain barrier to break down, possibly exposing the brain to toxicities and infections.
• Some illegal substances interact with HIV
medications. The combination might produce
toxicities – or render helpful drugs less effective. For example, one case study examined
the death of a patient who took ecstasy while on
an HIV drug regimen. The interaction somehow increased the level of ecstasy by 10 times
the dose taken, with lethal consequences.
In short, when HIV
strikes someone with
a substance abuse
problem, controlling
the addiction becomes imperative.
Drug Interactions
Illegal drugs are not
the only issue. Many
Issues with Substance
patients in this popuAbusers
lation take prescriptions for mental
HIV-positive individuals
illness or addiction
with substance abuse/
Geraldine White gives HIV test results to a consumer.
treatment. Because
dependence issues may
the
vast majority of
face enormous chalmedications are metabolized through the liver,
lenges. Alcohol, as well as marijuana, cocaine,
ecstasy, crystal methamphetamine and other drugs potential drug-drug interactions can occur. These
interactions may prove to be clinically significant
can interfere with a patient’s physical condition
and emotional state, plus cause complications with and cause either a notable increase in side effects
medication. Because this patient population has a and toxicities or a possible decrease in therapeutic
HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA
Prevention with Positives
B
efficacy. In other cases, however, the interaction
ecause HIV transmission can be prevented,
may prove to be clinically insignificant and incon- those who have been diagnosed positive are in a
sequential. Therefore, physicians have to consider unique position to halt the spread of the disease.
these circumstances frequently and on a case-byHIV testing is integral to HIV prevention because
case basis, particularly when a potential conflict
once someone knows that they are positive, they
exists between medications.
are far more likely to take steps to avoid infecting
others.
Supplements and herbal treatments also may pose
a risk. Patients often try natural alternatives,
Between July 2008 and March 2009, HIV Early
believing they will cause no harm, however, this is Intervention Services (EIS) counselors identified
not always the case. St. John’s Wort, for example, 44 new HIV-positive consumers and served an
which some people take to relieve the symptoms
additional 109 who were already aware of their
of depression, can decrease
positive status.
the therapeutic efficacy of
HIV EIS counselors have resome HIV medications. In
ported that most newly diagthis case, a regimen that
nosed consumers need more
was once effective in fightthan
a single post-test counseling disease has its overall
ing session. Offering the neceffectiveness diminished.
essary counseling and support
This can lead to an increase
to help HIV-positive consumin viral loads, a decrease in
ers reduce risk to themselves
CD4 counts, and decline in
and others is one of the most
overall health and well-being.
effective interventions any
Patients should be encourHIV worker can provide.
aged to share information
about all substances they are
In addition to offering refertaking, whether prescribed or
ral to appropriate medical and
otherwise, so that healthcare
social services, many HIV EIS
professionals can provide apcounselors also provide some
propriate counsel.
form of case management.
For example, Geraldine White
When delivering news about
Drug interactions stem from the fact that all
of River Edge in Macon curan HIV diagnosis, and helpdrugs are metabolized through the liver.
rently maintains contact with
ing clients through the early
17
HIV-positive clients.
stages of disease, one of the
Jacqueline Ruth Johnson, who serves those inmost important things health professionals can
carcerated in the DeKalb County Jail, follows up
do is to remember there is a definite mind-body
with HIV-positive inmates after they leave the faconnection. Emotions impact a patient’s physicility. And Ron DeLay of GRN in Snellville has a
cal state; illness impacts the psyche. “There is
weekly drop-in group for HIV-positive consumers.
constant interplay between the mind and body,”
says Dr. Sharma. “In diseases such as HIV, diabetes, and cancer, we need to approach the patient
from a holistic standpoint.” Patients do best when
providers communicate and work together to help
the patient focus on the potential of his or her life,
rather than their disease.
People who are living with HIV are confronted
with numerous complex issues including disclosure, adherence, and the amplified risk of sexually
transmitted diseases. For more on these and other
related issues, visit www.hiveis.com and click on
AIDS/HIV Positive to find links to information
and resources for HIV-positive consumers.
HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA
Sanjay Sharma, MD, continued
a patient population with considerable needs. He joined the
Emory University faculty in 1999 and is now Assistant Professor, Department of Psychiatry and Behavioral Sciences, Emory
University School of Medicine and also serves as Associate
Director of Mental Health/Substance Abuse Treatment Services
for the Grady Infectious Disease Program (IDP).
Based in Atlanta, Grady Health System is
one of the largest public health systems in
the United States, and
the IDP is one of the
largest, most comprehensive facilities in the
nation dedicated to the
treatment of advanced
HIV/AIDS. Founded
Grady Infectious Disease Program - Atlanta
in 1986, the IDP and its
onsite affiliates provide
medical and support services to approximately 5,000 eligible
men, women, adolescents, and children living with HIV/AIDS.
To qualify for care in the IDP, adult referrals must have a previous AIDS diagnosis and/or a nadir CD4 count below 200. Pediatric and adolescent patients have no such restrictions.
HIV Risk Reduction
imagin
a newsletter of
HIV Early Intervention Services (EIS)
Georgia Department of Behavioral
Health and Developmental Disabilities
Division of Addictive Diseases
ITC Leawood
Produced by:
Imagine Hope Inc.
Marie Sutton
President/CEO
404.874.4040 P
Winona Holloway
Senior Program Specialist
678.752.9571 P
For more information, visit www.hiveis.com
Opioid Treatment and
HIV Medications: Drug
Interactions
O
ne of the most challenging
issues facing providers treat-
ing patients with HIV is the
problem of drug interactions
associated with highly active
antiretroviral therapy (HAART).
Guidelines for the initial treatment of HIV infection recommend the use of at least three
antiretroviral medications, each
of which is associated with significant drug interactions.
At the same time, because
injection drug use carries a
significant risk for HIV infection, substance abuse treatment
including methadone or opioid
treatment, can play an important
part in reducing the risk of HIV/
AIDS transmission. Also known
as medication-assisted therapy,
opioid treatment substitutes
medication for heroin or other
morphine-like drugs.
Interactions between HAART
and methadone can reduce the
a t isoi tne
effects of methadone and lead to
narcotic withdrawal or increase
the effects of methadone and
cause over-sedation. Methadone
may also cause unnecessary side
effects when combined with
ITC Giovanni
HAART. While the potential
for drug-interactions must be
Imagine Hope Inc.
addressed, medications used to
Marie Sutton
President/CEO
treat HIV may be used concur393 Sixth
Street with opioid treatment
rently
Atlanta, Georgia
30308
therapies like methadone. For
404.874.4040
P on this topic, visit
more
404.874.3800 F
IDP, view from North Avenue
http://www.thebody.com/content/art1822.html.