COMMENTARY

HIV Guidelines: Working With the Active Substance User

Staff of the NYSDOH AIDS Institute HIV Clinical Guidelines Program

Disclosures

July 22, 2015

Editor's Note:
This article was written by the staff of the NYSDOH AIDS Institute HIV Clinical Guidelines Program at Johns Hopkins University School of Medicine, Baltimore, Maryland, in collaboration with Kelly S. Ramsey, MD, MPH, Clinical Director of Special Programs at Hudson River Health Care in Poughkeepsie, New York.

The effectiveness of health services for active substance users, coupled with growing evidence of the benefits of early antiretroviral therapy (ART) to improve the health of HIV-infected persons and reduce transmission, underscore the importance of engaging active substance users in treatment. Acknowledging the challenges inherent in doing so, the NYSDOH AIDS Institute's clinical guideline Working With the Active User (WWAU) offers practical recommendations to assist clinicians in ensuring that HIV-infected active substance users are engaged in care.

In 2013, nearly 2 million Americans aged 12 years or older either abused or were dependent on opioid painkillers.[1] That same year, the United States saw 43,982 deaths from drug overdose, which represented a 6% increase from the preceding year. Of those deaths, 22,767 (51.8%) were related to prescription drugs; 16,235 (71.3%) involved opioid painkillers, and 6973 (30.6%) involved benzodiazepines.[1]

Many opioid abusers begin by taking pills, but as physical dependence and tolerance increase, users often progress to sniffing or injecting drugs to achieve a more rapid and intense high. It is well established that injection drug users (IDUs) who share needles are at increased risk for blood-borne infectious diseases, such as HIV, hepatitis C virus (HCV), and hepatitis B virus, but many new IDUs are not aware of these risks. This is especially true in areas where criminalization, rather than education and public health intervention, is the primary response to illicit drug use.

In early 2015, a combination of high rates of injection drug use; lack of education about increased transmission of infectious diseases; and limited access to healthcare, including drug treatment and counseling services, led to an outbreak of HIV infections in Austin, Indiana. Indiana state officials confirmed 169 new cases of HIV diagnosed in the southeastern portion of the state between late February and late June 2015.[2] The primary mode of HIV transmission in these cases was shared use of drug paraphernalia. Before this outbreak, HIV infection rates in this Indiana county were low, but misconceptions about HIV and the stigma of drug use seem to have facilitated a perfect storm of risk factors.

Once the epidemic was recognized, Indiana's governor, Mike Pence, declared a public health emergency and implemented a limited syringe exchange program (SEP). The efficacy of SEPs in decreasing HIV transmission and risk behavior without increasing substance use is well documented,[3] but use of SEPs is often limited by political considerations that are not grounded in science. The epidemic in Indiana offers important lessons about substance use, stigma, and prevention, and underscores the crucial role of working effectively with active substance users to reduce transmission of HIV.

As is emphasized in WWAU, substance users may encounter multiple barriers to healthcare engagement, including low health literacy, mental illness, limited financial resources, stigma, and discrimination from healthcare providers. Clinicians who are uncomfortable or conflicted about working with substance users should enlist help from care providers who are experienced in treating active users and strive to approach substance users nonjudgmentally. Substance users should be offered a variety of interventional strategies to encourage engagement in care. Co-located, multidisciplinary services that may include mental health, harm reduction strategies, substance use treatment, HIV and HCV treatment, case management, and peer support can facilitate patient engagement and prevent fragmentation of care.

Active substance use is not a contraindication to ART. Because highly active ART can improve the health of substance users, reduce community viral load, and decrease risk for HIV transmission, ART should be discussed and offered to HIV-infected substance users. To engage HIV-infected substance users early in treatment planning, clinicians should focus on building strong therapeutic relationships through open, respectful communication that conveys positive regard for the patient, concern for his or her health and well-being, and willingness to address the patient's needs. WWAU describes patient/provider communication as a collaborative process that entails building trust, avoiding shame, and providing positive feedback when desired behaviors are adopted and undesired behaviors are reduced or eliminated.

Also stressed in WWAU is the importance of assessing treatment readiness and recognizing that addiction is a remitting and relapsing disorder. Clinicians can help individuals identify relapse triggers and strategies to prevent or recover from relapse. It is strongly recommended that clinicians ask patients about their substance use and about relapse, especially during the first year of recovery.

The spectrum of interventions recommended by WWAU includes the following:

  • Education to help patients understand the detrimental effects of substance use;

  • Motivational interviewing to help patients understand how the consequences of current behavior may conflict with personal values; and

  • Promotion of safer-sex practices to prevent transmission of sexually transmitted infections.

Patients who are not ready for abstinence or who are at risk for relapse should be educated about harm reduction approaches. When patients are not yet ready or able to stop using illicit drugs, clinicians should offer an array of strategies, including the following:

  • Stopping use of all or some illicit drugs;

  • Refraining from injecting illicit drugs;

  • Using new needles and syringes for every injection;

  • Cleaning injection equipment with bleach and water;

  • Avoiding sharing any injection paraphernalia; and

  • Taking steps to prevent overdose.

In New York State, IDUs can acquire new needles and syringes via the Expanded Syringe Access Program (ESAP) from registered pharmacies, healthcare facilities, and healthcare practitioners, without a prescription. Laws vary across states and jurisdictions, so clinicians should be aware of applicable laws and programs in their region of practice.

Although the treatment of HIV-infected substance users can be clinically challenging, by accessing the resources of multiple services and programs, implementing brief interventions, educating patients about the risks of substance use, and using harm-reduction and motivational interviewing techniques, clinicians can effectively address the complex conditions that active substance users experience.

Kelly S. Ramsey, MD, MPH, has disclosed receiving income in an amount equal to or greater than $250 from Gilead Sciences, Inc. (HCV Advisory Board).

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