Substance Abuse Treatment, Integrated Care, & the HIV Care Continuum Sherry Larkins, Ph.D. University of California, Los Angeles Integrated Substance Abuse Programs May 22, 2014
Does your agency offer routine HIV testing? 50% A. Yes 50% B. No
Do you ask questions about HIV status on your standard intake forms? 50% A. Yes 50% B. No
What percentage of new HIV/AIDS cases are associated with a primary transmission mode of injection drug use? 20% A. 5% 20% B. 9% 20% C. 15% 20% D. 25% E. More than 50% 20%
An Urgent Need Despite substantial increases in effective HIV management over the past 15 years, new HIV cases have appeared in the United States at a steady rate In 2009, there were approximately 50,000 new cases of HIV in 2009. Nearly 21% of persons who are HIV infected are unaware of their infection The majority of new HIV infections are transmitted by these individuals
Substance Use and HIV risk: What s the Link? About 25% of AIDS cases in the United States have resulted from injection drug use; 9% of new cases Drug use affects users' mental status and judgment, increases the likelihood that they will engage in high-risk sexual behavior Drug addiction increases users' exposure to unprotected sex as a means to obtain drugs Physiological consequences of drug abuse may alter susceptibility to infection and interact with HIV treatment drugs Drug abuse and addiction can also worsen the progression of HIV and its consequences, especially in the brain Studies show that there is a high HIV prevalence among persons who are in SUD treatment programs (3% in noninjection drug users to 27% in IDUs)
Target Populations? Narrowing our Focus Seriously/Persistently Mentally Ill Transgenders Racial & Ethnic Minorities Age / Youth
Mental Illness and HIV Studies estimate higher prevalence rates of HIV infection in the Severe Mental Illness (SMI) population (4%-22%) than in the general population (0.3%-0.8%) HIV transmission rates are 13 to 76 times higher than rates in the general population Nearly one half of all receiving care for HIV screened positive for a mental health disorder. Concurrent diagnoses of HIV, substance use, and mental health disorders may affect one another, complicating the course of HIV infection
Mental Illness and HIV Individuals with SMI and substance-use disorder combined have been found to be at greater risk of HIV infection than are persons with SMI alone Adults with SMI engage in high rates of sexual and drug use behaviors associated with HIV transmission, including unprotected intercourse, multiple partners, sex trade, and injection drug use Women with SMI are more likely to report HIV risk behaviors Patients with SMI experienced more problems with HIV care than patients without severe mental illness
Transgenders at Risk In 2008, an estimated 28% of transgender women had HIV An estimated 56% of transgender African American women were infected Transgender women had 21% prevalence of other sexually transmitted infection (gonorrhea, chlamydia, herpes, syphilis, trichomoniasis, and hepatitis B and C) Risk behaviors for transgender women include: Multiple partners Unprotected receptive anal intercourse Commercial sex Sex under the influence of alcohol and drugs Needle use for injecting drugs and gender-related hormones or silicone
Transgenders at Risk African American and Hispanic transgender women report greater risk behaviors compared with white and Asian and Pacific Islander transgender women High rates of depression, emotional distress, loneliness, and social isolation High rates of alcohol and drug use including injection drug use Increased risk for violence and victimization, including physical and sexual abuse High levels of poverty, unemployment, and homelessness in transgender women and men
Racial/Ethnic Disparities: HIV Rates among IDUs Racial/ethnic minority IDUs are twice as likely to be HIV seropositive than non minorities Addressing racial/ethnic disparities in HIV infection among IDUs is a fundamental issue in the fight against HIV SOURCE: Des Jarlais et al. (2012). Current Opinion in HIV and AIDS, 7(4), 354-361. 12
Age Disparities: Issues of Young Injection Drug Users Young IDUs are not the same as their older counterparts Peer influence Limited awareness Limited access to services Perceived lack of confidentiality at services Economic instability SOURCE: UNODC. (2004). HIV Prevention among Young Injection Drug Users. 13
And Yet Despite this high prevalence, 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
Why is it important that Programs Screen for risk behavior and offer HIV testing? We have responsibilities to screen for risky behaviors to aid in HIV prevention & HIV Care Comorbid conditions: HIV prevention/care, mental health problems, substance abuse, and other medical conditions interact and exacerbate each other Complications for treatment (add to current problems) Risk Groups MSM heterosexual contact Drug use Minority infection rate *Providers should be able to identify risk and treat, coordinate care, & help connect clients with resources*
Treatment Programs Can be Part of the Solution
The Headline 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 17
Advances in HIV Testing Technology HIV testing is more readily accessible with faster results, minimizing loss to follow-up and ensuring that those who are tested receive their results. Test results can now be obtained within community settings in as little as 1-20 minutes. This provides persons who test positive with preliminary information about their HIV status, allowing them to get the care they need to slow the progression of their disease and to take precautionary measures and medications that help prevent the spread of the HIV virus.
New STD diagnoses Project RESPECT Results *: HIV Prevention Counseling Effective 250 225 200 175 150 125 100 75 50 25 0 211 173 149 107 6 months* 12 months* RESPECT Control (*p<0
Results of Project RESPECT The results of RESPECT demonstrated that client-centered, RRC is effective in reducing STD incidence and risk behaviors and can be conducted in busy public health clinics.
Our Current System: Silos Mental Health Substance Use Disorders CLIENT HIV prevention /care General Medical Care
The Trouble With Silos Coordination Providers in different systems rarely communicate Limits on what each system can do Clients may have difficulty coordinating services, medications, etc. Each system only addresses part of clients overall health needs Care divided into silos is not holistic
Why Integrated Prevention & Treatment Services? Treat people, not disorders and conditions. Substance use, HIV, mental health, and other behavioral and physical health issues frequently co-occur. Addressing behavioral and medical issues within the treatment setting can improve overall health
What Can Integrated Prevention Do? The Evidence BETTER physical health, mental health, social functioning and health-related quality of life LESS use of drugs, alcohol, hospital, emergency rooms BETTER outcomes than non-integrated treatment SOURCE: Unutzer 2001, Druss 2010, Lewin 2011, Madras 2009, Weisner 2001, Parthasarathay 2003
The Solution?: The One Stop Shop / Health Home HIV Prevention & Health Promotion Services Medical care MH and SUD Services Social Services Case Management Public Assistance Dental Care SOURCE: TRI 2010
Integration Involves Major Change to Business As Usual Requires working around silo walls or tearing them down Reorienting care from specific disorders and service systems to more holistic care Mental health/substance abuse HIV Testing & Care Physical health Socioeconomic factors that impact health Involves change at several levels of service delivery System level (federal, state, county) Clinic level (service delivery organizations) Provider level (doctors, nurses, social workers, case managers, etc.)
Provider: The Keys to Integrated Prevention Services Learn about areas outside specialty: overcome stigma and misunderstandings about certain conditions. Get comfortable talking about sex, sexuality, HIV disclosure, substance use, and their interconnectivity - BEFORE, DURING and AFTER treatment: Learn how to screen and assess for a variety of conditions HIV Risk, Mental Health, etc. Integrate HIV testing and risk reduction into individual and group treatment Research shows it works! Discharge planning should include on-going support for risk reduction, and linkages to community resources that support risk reduction.
Provider: The Keys to Integrated Prevention Services Incorporate HIV and STI testing into routine service Reduces HIV transmission; early intervention Better HIV outcomes when HIV+; prev late diagnosis Supportive, knowledgeable counseling staff available Helps individualize SUD treatment planning and continue risk reduction measures Learn how to provide effective brief intervention services Learn about resources available for clients who need specialty services HIV testing, prevention and/or care; Mental Health, etc.
Provider: The Keys to Integrated Prevention Services Learn how to effectively link clients to services they need if services are not integrated warm hand-offs and followthrough Ensure services are culturally and linguistically appropriate to the target population
Take Home Points for Clinicians Know - your local resources (HIV care, substance use treatment facilities, 12-step meetings, mental health resources, etc.). Engage screen risky substance use and practice ways to communicate effectively with patients. Remember - every clinic visit is an opportunity for intervention and prevention messages (HIV, substance use, mental health). Encourage Patients and staff to discuss the challenges of substance use and remind them of the importance of continued HIV prevention and care. 30
Sherry Larkins, Ph.D. UCLA Integrated Substance Abuse Programs larkins@ucla.edu www.uclaisap.org www.psattc.org 31