CDC Advises on Integrating Management of HIV, Other STDs, and Illicit Drug Use

Rates of human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs), tuberculosis (TB), and viral hepatitis are substantially higher in individuals who use drugs illiticly (those who use prescription drugs illicitly or those who use illicit drugs) than in those who do not. Numerous federal agencies have issued recommendations for preventing these infections in those who use drugs illiticly, treating them, and addressing the myriad medical and social issues they face, which makes providing comprehensive, integrated health management of these populations difficult.

Now a report in CDC's Morbidity and Mortality Weekly Reports reviews and summarizes those disparate approaches, highlighting the components of a successful, integrated approach.¹

Salaam Semaan DrPH of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, who led and managed the development and publication of the guidance, shared details about the recommendations and how primary care practices can implement them among their own patient populations.

TheAIDSReader: What do you mean by "integrated services?"

Dr. Semaan: Integrated services are defined as providing multiple prevention services at a single venue, or actively coordinating referrals and linkage of care for services that are delivered at multiple venues. The goal is to organize and combine interrelated health issues, activities, and prevention strategies so we can optimize prevention services and reduce the number of patients who do not receive follow-up care after a diagnosis.

We find that such integration can improve the prevention behaviors and the timeliness of service delivery, access to quality and comprehensive services, and receipt of services at a single health-care entry point. We also find that integrated services can have synergistic effects in enhancing efforts to optimize prevention and treatment needs and to improve health outcomes  especially in this population, which is often battling other contextual and social determinants of health.

In addition, such collaboration and integration of prevention services can save time, money, effort, and lives.

TheAIDSReader: We talk about the need to provide coordinated care to everyone in our healthcare system. What are some of the barriers specific to patients who use illicit drugs, particularly those with the infections your paper highlights?

Dr. Semaan: Several factors are integral to the success in preventing these infections among persons who use drugs illicitly. They include understanding how contextual factors such as laws and policies, as well as social factors including social status, stigma, education, mental health needs, and fear of stigmatization, affects prevention and treatment efforts. It is also critical to understand the role of an effective patient-provider relationship and communication.

This recently published guidance provides a summary of recommendations that includes 13  principles for managing healthcare relationships with those who use drugs illicitly. These principles  can also be used for preventing and treating infectious diseases  in persons who use any drug illicitly. Here are a few of the principles that were included:

•    Develop a professional relationship that shows mutual respect and avoids blame or judgment
•    Include persons who use drugs illicitly in decisions about their treatment
•    Have a primary care provider responsible for coordinating care
•    Reduce barriers to accessing health care
•    Establishe realistic healthful behaviors goals that patients can commit to
•    Recognize that success in building relationships and healthful behaviors might require several attempts
•    Avoidecommon pitfalls in treating persons who use drugs illicitly, such as having unrealistic expectations, becoming frustrated or angry, moralizing, assigning blame, and withholding therapy
 
TheAIDSReader: How can community practitioners  provide their patients with such an integrated menu of services?
 
Dr. Semaan: The guidance provided in our paper is designed to support the implementation of science-based public health strategies for integrated prevention services wherever this population is served.

Many healthcare settings, including primary care and those that provide prevention and treatment or diagnosis and management for hepatitis, STD, TB, and HIV diagnosis and management, substance abuse and mental health, are important venues for providing integrated services.

Clinicians practicing in these settings can recommend a comprehensive suite of services for preventing and treating the comorbid substance abuse and mental health needs even as they address the underlying infection. These services are:  

1.    Prevent and treat substance use and mental disorders.
2.    Refer to outreach programs.
3.    Assess risk for illicit drug use.
4.    Assess risk for infectious diseases.
5.    Screen, diagnose and counsel patients regarding infectious disease risk.
6.    Provide available vaccines.
7.    Prevent mother-to-child transmission of infectious diseases.
8.    Provide or refer to interventions to reduce risk behaviors.
9.    Provide partner services and contact follow-up.
10.  Provide referrals and linkage to care.
11.  Provide medical treatment for infectious disease(s).
12.  Deliver integrated prevention services.

TheAIDSReader: You note that "Persons who use this guidance should adapt it to meet the specific prevention needs of their communities, while preserving the core missions of the organizations, programs, and venues that provide these services." Can you expand on that in terms of what it means for individual practitioners?
 
Dr. Semaan: Many clinical care and public health settings have a core mission that typically includes one of the following:  the provision of primary care, infectious disease diagnosis and treatment,  substance abuse prevention or treatment, or prevention or treatment for mental disorders. Any of these services can be integrated successfully as needed. The core mission of the clinical setting combined with the needs of the patient population should determine which integrated services are delivered. These decisions should be influenced by 3 factors: the local epidemiology of infectious diseases and substance use and mental disorders, the spectrum of existing services, and the patterns of using drugs illicitly.