J:\Committees\Quality Assurance\FY16 How To Best\Workgroups\Workgroup 2\TOC - WG2.doc
Substance Abuse Treatment/Counseling
Pg
Service Category Definition - Part A
1
Patients With HIV More Likely to Smoke, Less Likely to Quit –
Medscape.com, March 2015
4
Recreational Drugs and HIV - AIDSinfonet.org, December 2014
6
HIV and Substance Use - HIV Mental Health Treatment Issues,
FY 2015 Houston EMA/HSDA Ryan White Part A Service Definition
Substance Abuse Services - Outpatient
(Revision Date: 06/03/14)
HRSA Service Category
Title: RWGA Only
Substance Abuse Services Outpatient
Local Service Category
Title:
Substance Abuse Treatment/Counseling
Budget Type:
RWGA Only
Fee-for-Service
Budget Requirements or
Restrictions:
RWGA Only
Minimum group session length is 2 hours
HRSA Service Category
Definition:
RWGA Only
Substance abuse services outpatient is the provision of medical or
other treatment and/or counseling to address substance abuse
problems (i.e., alcohol and/or legal and illegal drugs) in an outpatient
setting, rendered by a physician or under the supervision of a
physician, or by other qualified personnel.
Local Service Category
Definition:
Treatment and/or counseling HIV-infected individuals with substance
abuse disorders delivered in accordance with State licensing
guidelines.
Target Population (age,
gender, geographic, race,
ethnicity, etc.):
HIV-infected individuals with substance abuse disorders, residing in
the Houston Eligible Metropolitan Area (EMA/HSDA).
Services to be Provided:
Services for all eligible HIV/AIDS patients with substance abuse
disorders. Services provided must be integrated with HIV-related
issues that trigger relapse. All services must be provided in
accordance with the Texas Department of Health Services/Substance
Abuse Services (TDSHS/SAS) Chemical Dependency Treatment
Facility Licensure Standards. Service provision must comply with the
applicable treatment standards.
Service Unit
Definition(s):
RWGA Only
Individual Counseling: One unit of service = one individual
counseling session of at least 45 minutes in length with one (1)
eligible client. A single session lasting longer than 45 minutes
qualifies as only a single unit – no fractional units are allowed. Two
(2) units are allowed for initial assessment/orientation session.
Group Counseling: One unit of service = one session of group
treatment for one eligible client. A single session must last a minimum
of 2 hours. A maximum of one unit may be billed per person per
group session. Support Groups are defined as professionally led
groups that are comprised of HIV-positive individuals, family
members, or significant others for the purpose of providing Substance
Abuse therapy.
Financial Eligibility:
Refer to the RWPC’s approved FY 2015 Financial Eligibility for
Houston EMA/HSDA Services.
Client Eligibility:
HIV-infected individuals with substance abuse
co-morbidities/disorders.
Agency Requirements:
Agency must be appropriately licensed by the State. All services must
be provided in accordance with applicable Texas Department of State
Health Services/Substance Abuse Services (TDSHS/SAS) Chemical
Dependency Treatment Facility Licensure Standards. Client must not
be eligible for services from other programs or providers (i.e.
MHMRA of Harris County) or any other reimbursement source (i.e.
Medicaid, Medicare, Private Insurance) unless the client is in crisis
and cannot be provided immediate services from the other
programs/providers. In this case, clients may be provided services, as
long as the client applies for the other programs/providers, until the
other programs/providers can take over services. All services must be
provided in accordance with the TDSHS/SAS Chemical Dependency
Treatment Facility Licensure Standards. Specifically, regarding
service provision, services must comply with the most current version
of the applicable Rules for Licensed Chemical Dependency
Treatment. Services provided must be integrated with HIV-related
issues that trigger relapse.
Provider must provide a written plan no later than 3/30/13
documenting coordination with local TDSHS/SAS HIV Early
Intervention funded programs if such programs are currently funded in
the Houston EMA.
Staff Requirements:
Must meet all applicable State licensing requirements and Houston
EMA/HSDA Part A/B Standards of Care.
Special Requirements:
RWGA Only
FY 2016 RWPC “How to Best Meet the Need” Decision Process
Step in Process: Council
Date:
06/11/2015
Recommendations: Approved: Y:_____ No: ______
Approved With Changes:______
If approved with changes list
changes below:
1.
2.
3.
Step in Process: Steering Committee
Date:
06/07/2015
Recommendations: Approved: Y:_____ No: ______
Approved With Changes:______
If approved with changes list
changes below:
1.
2.
3.
Step in Process: Quality Assurance Committee
Date:
05/21/2015
Recommendations: Approved: Y:_____ No: ______
Approved With Changes:______
If approved with changes list
changes below:
1.
2.
3.
Step in Process: HTBMTN Workgroup
Date:
04/14/2015
Recommendations:
Financial Eligibility:
1.
2.
3.
www.medscape.com
March 03, 2015
Of the estimated 419,945 US adults receiving medical care for HIV infection, more than 4 in 10 are current smokers,
almost twice as many as in the general population, according to a surveybased Centers for Disease Control and
Prevention (CDC) analysis. Furthermore, patients with HIV are less likely to quit smoking than their general population
counterparts, notes the study,
published
in the March 3 issue of the Annals of Internal Medicine.
Smoking's negative synergistic effects with HIV substantially reduce the benefits of effective antiviral treatment and
increase the risk for illness and death.
There is clearly a role for professionals treating this population. "For persons with HIV who receive care regularly,
providers have a unique opportunity to promote smoking cessation interventions during visits," write Rennatus Mdodo,
DrPH, from the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, Office of Infectious Diseases, CDC, Atlanta, Georgia, and colleagues.
To estimate smoking prevalence in adults with HIV vs the general population, the authors used data collected in 2009
by the Medical Monitoring Project, an HIV surveillance system, and data from the 2009 National Health Interview
Study, a crosssectional household survey. Results for patients with HIV were based on facetoface interviews plus
medical record abstractions from 461 responding Medical Monitoring Project facilities in which 4217 individuals
completed interviews linked with medical record abstractions. The researchers compared data, which included several
sociodemographic and behavioral variables, with information from 27,731 National Health Interview Study participants.
HIV adults were predominantly male (71.2%), older than 40 years (75.4%), and nonHispanic black (41.4%). Half had
more than a high school education (50.6%), and 54.3% lived at or above the federal poverty level.
In the HIV group, 42.4% (95% confidence interval [CI], 39.7% 45.1%) were current smokers compared with 20.6%
(95% CI, 19.9% 21.3%) of the National Health Interview Study adults. Fewer participants in the HIV group were
neversmokers (37.3% [95% CI, 34.9% 39.6%] vs 57.5% [95% CI, 56.6% 58.4%]). About one in five participants in
both groups were former smokers.
In the HIV group, the smoking rate was lowest in among Hispanics and Latinos (35.0%) and highest among persons
incarcerated in the 12 months before interviewing (67.8%). Factors, some of which are modifiable, independently
associated with current smoking included male sex, age 40 to 49 years, nonHispanic white/black ethnicity, having no
more than a high school education, living below the poverty level, and homelessness or incarceration in the last 12
months. Other factors fuelling smoking likelihood were noninjectable drug use, binge drinking, and failure to achieve
viral suppression.
In the general population as well, male sex, older age, nonHispanic white/black ethnicity, and low education levels
were associated with smoking.
Patients With HIV More Likely to Smoke, Less Likely to Quit
Diana Swift http://www.medscape.com/viewarticle/840774_print 1/2http://www.medscape.com/viewarticle/840774_print 2/2
"Providerinitiated quitting discussions and expanded access to evidencebased smoking cessation interventions for
adults with HIV may help increase quit rates and reduce morbidity and mortality rates associated with smoking," they
write.
This work was supported by the CDC under an agreement with the Medical Monitoring Project. The CDC had no input
into the study design and execution but approved the final version. The authors have disclosed no relevant financial
relationships.
Ann Intern Med. 2015;162:335344.
Abstract
Medscape Medical News © 2015 WebMD, LLC
Send comments and news tips to
news@medscape.net
.
Cite this article: Patients With HIV More Likely to Smoke, Less Likely to Quit. Medscape. Mar 03, 2015.As for cessation, the HIV group was also less likely than the general adult population to quit: 32.4% (95% CI, 29.6%
35.3%) of eversmokers vs 51.7% (95% CI, 50.3% 53.0%) of all adults.
Although evidencebased smoking cessation interventions and clinical guidelines have been developed for the
population at large, they have not been fully implemented for HIVinfected persons, who may face additional
challenges such as substance abuse and poverty. The CDC has recently launched a national antismoking campaign for
smokers with HIV.
The authors recommend that smoking cessation programs be a routine component of healthcare for patients with HIV.
A Project of the International Association of Providers of AIDS Care. Fact Sheets can be downloaded from the Internet at http://www.aidsinfonet.org
DRUG USE AND HIV
HOW DOES DRUG USE RELATE
TO HIV?
Injection drug and alcohol use are major factors in the spread of HIV infection. Outside of Africa, injection drug use now accounts for 1 in 3 new HIV infections. Shared equipment for using drugs can carry HIV and hepatitis viruses, and drug and alcohol use is linked with unsafe sexual activity.
Drug and alcohol use can also be dangerous for people who are taking antiretroviral medications (ARVs). Drug users are less likely to be adherent to their medications, and street drugs may have dangerous interactions with ARVs. Fact sheet 494 has more information on individual drugs and HIV. Drug and alcohol treatment to stop drug use can lower your risk of HIV infection.
INJECTION AND INFECTION
HIV infection spreads easily when people share equipment to inject drugs. Sharing equipment also spreads hepatitis B, hepatitis C, and other serious diseases. Infected blood can be drawn up into a syringe and then get injected along with the drug by the next user of the syringe. This is the easiest way to transmit HIV during drug use because infected blood goes directly into someone’s bloodstream.To reduce the risk of HIV and hepatitis infection, never share any equipment used with drugs, and keep washing your hands. Carefully clean your cookers and the site you will use for injection. See fact sheet 155 for more information on ways to reduce the harm of drug use.
A recent study showed that HIV can
survive in a used syringe for at least 4 weeks. If you have to re-use equipment,
you can reduce the risk of infection by cleaning it between users. If possible, re-use your own syringe. It still should be cleaned because bacteria can grow in it.
The most effective way to clean a syringe is to use water first, then bleach and a final water rinse. Try to get all blood out of the syringe by shaking vigorously for 30 seconds. Use cold water because hot water can make the blood form clots. To kill most HIV and hepatitis C virus, leave bleach in the syringe for two full minutes. Cleaning does not always kill HIV or hepatitis. Always
use a new syringe if possible.
ACCESS TO CLEAN NEEDLES
Access to clean needles and syringes reduces the spread of HIV and viral hepatitis. In some states, adults can purchase new syringes in pharmacies without a prescription. Some communities have started needle exchange programs to give free, clean syringes to people so they won’t need to share.Programs that provide easier access to new syringes are controversial because some people think they promote drug use. However, research on needle exchange shows that this is not true. Rates of HIV infection go down where there are needle exchange programs, and more drug users sign up for treatment programs.
The North American Syringe Exchange Network has a web page listing several needle exchange programs at
http://www.nasen.org/
DRUG USE AND UNSAFE SEX
For a lot of people, drugs and sex go together. Drug users might trade sex for drugs or for money to buy drugs. Some people connect having unsafe sex with their drug use. Research shows that sexual behavior is the main HIV risk factor for injection drug users.Drug use, including methamphetamine or alcohol, increases the chance that people will not protect themselves during sexual activity. Someone who is trading sex for drugs might find it difficult to set limits on what they are willing to do. Drug and alcohol use may reduce condom use and safer sex practices.
Often, substance users have multiple sexual partners. This increases their risk of becoming infected with HIV or another sexually transmitted disease. Also, substance users may have an increased risk of carrying sexually transmitted diseases. This can increase their risk of becoming infected with HIV, or of transmitting HIV infection.
MEDICATIONS AND DRUGS
It is very important to take every dose of ARVs. People who are not adherent (miss doses) are more likely to have higher levels of HIV in their blood, and to develop resistance to ARV medications. Drug use is linked with poor adherence, which can lead to treatment failure and disease worsening.Some street drugs interact with ARVs. The liver breaks down some medications used to fight HIV, especially the protease inhibitors and the non-nucleoside reverse transcriptase inhibitors. It also breaks down some recreational drugs, including alcohol. When drugs and medications are both “in line” to use the liver, they might both be processed much more slowly. This can lead to a serious overdose of the medication or of the recreational drug.
An overdose of a medication can cause serious side effects. An overdose of a recreational drug can be deadly. At least one death of a person with HIV has been blamed on mixing a protease inhibitor with the recreational drug Ecstasy.
Some ARVs can change the amount of methadone in the bloodstream. It may be necessary to adjust the dosage of methadone in some cases. See the fact sheets for each of the medications you are taking, and discuss your HIV medications with your methadone counselor and your HIV health care provider.
THE BOTTOM LINE
Drug use is a major cause of new HIV infections. Shared equipment can spread HIV, hepatitis, and other diseases. Alcohol and drug use, even when just used recreationally, contribute to unsafe sexual activities and an increase in sexually transmitted infections.
To protect yourself from infection, never re-use any equipment for using drugs. Even if you re-use your own syringes, clean them thoroughly between times. Cleaning is only partly effective.
In some communities, new syringes can be bought without a prescription. Also, needle exchange programs in some areas provide free, new syringes. These programs reduce the rate of new HIV infections.
Drug use can lead to missed doses of ARVs. This increases the chances of treatment failure and resistance to medications.
Mixing recreational drugs and ARVs can be dangerous. Drug interactions can cause serious side effects or dangerous overdoses.
A strong link between HIV and substance abuse.
Substance abuse has been associated with HIV/AIDS since the beginning of the pandemic. It is well known that sharing injection equipment is a leading cause of HIV transmission among those who inject drugs. But drug and alcohol use also put people at higher HIV risk by disinhibiting them and making it more likely they will engage in unprotected sex. The National Institute on Drug Abuse (NIDA) reports that from 2005 to 2009, 64 percent of HIV+ people in the U.S. had used an illicit drug, but not intravenously; only 19 percent had never used an illicit drug. A 2009 study found one in four of those living with HIV reported alcohol or drug use at a level warranting treatment. Besides injection drugs, other substances associated with HIV risk include cocaine (“coke, crack”), amphetamines (“speed”), alcohol, inhaled nitrates (“poppers”), and “party” or “club” drugs, such as crystal methamphetamine (meth) or MDMA (“ecstasy”). NIDA further reports that drug abuse and addiction can worsen the progression of HIV and its consequences, especially in the brain. Animal studies have shown that stimulants can increase HIV viral replication. A human study found HIV caused greater neuronal injury and cognitive impairment in drug users than non-users.How does substance abuse complicate
HIV treatment?
Concurrent (or dual) diagnoses of HIV, substance use, and mental health disorders may affect one another, complicating the course of HIV infection. Problematic drug and alcohol use can undermine both prevention and treatment adherence. A substance-using patient is less likely to adhere to antiretroviral medications, increasing the risk for viral resistance.
Needle-exchange programs and information about cleaning injection equipment has reduced new HIV infections among injection drug users. But injection drug users, often with limited access to care, don’t tend to seek medical care for HIV until the disease has progressed, complicating treatment.
Drugs such as heroin, cocaine, and alcohol can suppress the immune system. Drugs can also interfere with HIV medications, and vice versa. Amphetamines, ketamine (“Special K”) and heroin can interact with specific antiretrovirals, while Ritonavir can increase the potency of MDMA to a fatal degree.
HIV+ patients who are injection drug users are more likely to have comorbid psychiatric conditions. Studies have found
that between 70-90% had a psychiatric condition before being diagnosed with HIV. These patients also have high rates of prior suicidal behavior. The multifaceted symptoms of psychiatric conditions can sometimes mask the signs of substance abuse, and vice versa. When there is a comorbid psychiatric disorder, the treating physician should carefully prescribe medications, particularly those that tend to be habit-forming.
Medical complications are also a serious concern when treating an HIV+ patient who has a substance use disorder. A treating clinician must be aware of the risk of severe bacterial infections including tuberculosis, hepatitis C and sexually transmitted diseases.
How is substance abuse treated?
Effective treatment for substance abuse
improves thequality of life for HIV+ patients, and reduces the spread of HIV infection. Substance abuse treatment can also make it more likely that patients will adhere to their HIV treatment. Clincians need to screen all HIV+ patients for ongoing or recurrent drug and alcohol use and abuse. There are a variety of screening tools that can be used to identify these problems. Most important to a good history is for the clinician to use a nonjudgmental attitude in asking questions.
The main goal of substance abuse treatment is to reduce or stop drug use, followed by a sustained reduction of high-risk behaviors. A longer-term goal is to develop the ability to quickly control relapse or relapse behaviors, and to maintain the positive behaviors learned in treatment.
The ideal treatment setting for an HIV+ person with a substance use disorder treats both diseases in an integrated fashion. Even when this is not possible, treating physicians and other health care professionals must communicate with one another to ensure a successful outcome.
Outpatient substance abuse treatment is the most common method, and can be quite effective. If the outpatient method is unable to help an individual stay off drugs, residential treatment should be considered. Twelve-step programs can be helpful in the recovery process, especially meetings where discussion of HIV is welcome or accepted.
The pharmacological treatments that are a standard part of substance abuse rehabilitation (e.g. disulfiram, naltrexone, acamprosate, buprenorphine, and methodone) can be administered to HIV+ patients as long as care is taken to monitor
HIV and Substance Use
Maintenance Therapy (MMT) is recommended for severe addicts. Drug-drug interactions should be carefully monitored for those on methodone. A number of medications used to treat HIV and related conditions may raise or lower the levels of methodone in a patient’s bloodstream. Naltrexone may not be the right treatment for patients who require pain management with opiods.
References
Chaffee, Barbara, Screening and Ongoing Assessment for
Substance Abuse in HIV: Guideline for Care (April 5, 2011):
http://www.medscape.com/viewarticle/739855.
National Institute on Drug Abuse (http://www.drugabuse.gov/ related-topics/hivaids)
______________________
About this Fact Sheet
This fact sheet was revised by John-Manuel Andriote, based on an earlier version by Kerry Flynn Roy in collaboration with the APA Commission on AIDS. For more information contact American Psychiatric Association, Office of HIV Psychiatry, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209; phone: 703.907.8668; fax: 703.907.1089; or e-mail AIDS@psych.org. Visit our web site at www.psychiatry.org/AIDS.
