TIP 37 Addictions Treatment with Persons with HIV

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  • 650,000 to 900,000 people in the U.S. are living with HIV Many people who are infected don’t know itHIV is most easily transmitted by exposure to contaminated bloodDrug use can result in poor judgment, unprotected sex and to sharing needles
  • Alcohol and drug use can: interfere with HIV medications inhibit the body’s immune system lead to poor health behaviors further compromising immunity
  • Medical providersMental healthSubstance abusePublic healthSocial support groups
  • Myth: If you are HIV positive, it does not matter what you do.Myth: You can avoid HIV if you are careful and avoid repeated risky behaviors.Myth: You can tell whether your sex (or injection) partners are infected. Myth: As long as you get treated for any sexually transmitted diseases, you won’t get HIV. Myth: Washing after sex will prevent HIV. Myth: If you don’t share syringes, you can’t catch HIV.
  • Within the past 3 to 6 months, have you had unprotected: Vaginal sex? Anal sex? Oral sex? Sex for money or drugs? Sex with more than three people? Sex with an injection drug user? Sex with someone you think has HIV/AIDS? When you have sex, do you sometimes or never use condoms?
  • Do you use drugs before or after sex? When you use drugs, do you: Use syringes? Share syringes? Clean your works? Use crack or powder cocaine? Use several drugs at the same time? If your client answers positively for half or more of these questions, then your client has a high risk of having HIV or getting HIV.
  • Use condoms Don’t share syringes Use new syringes Disinfect drug paraphernalia Get proper medical care before, during and after pregnancy Elect to have cesarean delivery Avoid reinfection Observe universal precautions as directedIf exposed, begin postexposure prophylaxis
  • In promoting risk reduction, the clinician’s goals are to:Help and support the client in understanding the need for behavior change Assist the client in addressing cultural practices or beliefs that might contribute to resisting change Assist the client in developing skills to sustain behavior change
  • HIV testing
  • Pre- and posttest counseling should be performed by a trained HIV clinicianCounseling should:Explain the limitations of HIV tests Help clients assess their risks Encourage and reinforce behavior change Refer infected clients for medical care
  • ELISA (enzyme-linked immunosorbent assay)typically used as a first testWestern blottypically a second testRapid HIV tests Home sample collection tests Positive resulta second test is needed to confirmNegative resulta second test is needed in about 6 months to make rule out a false-negative
  • All States require AIDS cases to be reported Some States also require that new cases of HIV infection be reportedReports are forwarded to the CDCState laws vary regarding whether reports must include client-identifying information
  • CD4 (T-CELL) TESTSWHAT ARE CD4 CELLS?WHY ARE CD4 CELLS IMPORTANT IN HIV?WHAT FACTORS INFLUENCE A CD4 CELL COUNT?HOW ARE THE TEST RESULTS REPORTED?WHAT DO THE NUMBERS MEAN?WHAT ARE CD4 CELLS?CD4 cells are a type of lymphocyte (white blood cell). They are an important part of the immune system. CD4 cells are sometimes called T-cells. There are two main types of T-cells. T-4 cells, also called CD4+, are \"helper\" cells. They lead the attack against infections. T-8 cells, (CD8+), are \"suppressor\" cells that end the immune response. CD8+ cells can also be ?killer? cells that kill cancer cells and cells infected with a virus. Researchers can tell these cells apart by specific proteins on the cell surface. A T-4 cell is a T-cell with CD4 molecules on its surface. This type of T-cell is also called ?CD4 positive,? or CD4+. WHY ARE CD4 CELLS IMPORTANT IN HIV?When HIV infects humans, the cells it infects most often are CD4 cells. The virus becomes part of the cells, and when they multiply to fight an infection, they also make more copies of HIV.When someone is infected with HIV for a long time, the number of CD4 cells they have (their CD4 cell count) goes down. This is a sign that the immune system is being weakened. The lower the CD4 cell count, the more likely the person will get sick.There are millions of different families of CD4 cells. Each family is designed to fight a specific type of germ. When HIV reduces the number of CD4 cells, some of these families can be totally wiped out. You can lose the ability to fight off the particular germs those families were designed for. If this happens, you might develop an opportunistic infection (See Fact Sheet 500). WHAT FACTORS INFLUENCE A CD4 CELL COUNT?The CD4 cell value bounces around a lot. Time of day, fatigue, and stress can affect the test results. It's best to have blood drawn at the same time of day for each CD4 cell test, and to use the same laboratory.Infections can have a large impact on CD4 cell counts. When your body fights an infection, the number of white blood cells (lymphocytes) goes up. CD4 and CD8 counts go up, too. Vaccinations can cause the same effects. Don't check your CD4 cells until a couple of weeks after you recover from an infection or get a vaccination.HOW ARE THE TEST RESULTS REPORTED?CD4 cell tests are normally reported as the number of cells in a cubic millimeter of blood, or mm3. There is some disagreement about the normal range for CD4 cell counts, but normal CD4 counts are between 500 and 1600, and CD8 counts are between 375 and 1100. CD4 counts drop dramatically in people with HIV, in some cases down to zero.The ratio of CD4 cells to CD8 cells is often reported. This is calculated by dividing the CD4 value by the CD8 value. In healthy people, this ratio is between 0.9 and 1.9, meaning that there are about 1 to 2 CD4 cells for every CD8 cell. In people with HIV infection, this ratio drops dramatically, meaning that there are many times more CD8 cells than CD4 cells.Because the CD4 counts are so variable, some health care providers prefer to look at the CD4 percentages. These percentages refer to total lymphocytes. If your test reports CD4% = 34%, that means that 34% of your lymphocytes were CD4 cells. This percentage is more stable than the number of CD4 cells. The normal range is between 20% and 40%. A CD4 percentage below 14% indicates serious immune damage. It is a sign of AIDS in people with HIV infection. A recent study showed that the CD4% is a predictor of HIV disease progression. WHAT DO THE NUMBERS MEAN?The meaning of CD8 cell counts is not clear, but it is being studied.The CD4 cell count is a key measure of the health of the immune system. The lower the count, the greater damage HIV has done. Anyone who has less than 200 CD4 cells, or a CD4 percentage less than 14%, is considered to have AIDS according to the US Centers for Disease Control.CD4 counts are used together with the viral load to estimate how long someone will stay healthy. See Fact Sheet 125 for more information on the viral load test.CD4 counts are also used to indicate when to start certain types of drug therapy:When to start antiretroviral therapy (ART):When the CD4 count goes below 350, most health care providers begin ART (see Fact Sheet 403). Also, some health care providers use the CD4% going below 15% as a sign to start aggressive ART, even if the CD4 count is high. More conservative health care providers might wait until the CD4 count drops to near 200 before starting treatment. A recent study found that starting treatment with a CD4% below 5% was strongly linked to a poor outcome.When to start drugs to prevent opportunistic infections:Most health care providers prescribe drugs to prevent opportunistic infections at the following CD4 levels:Less than 200: pneumocystis pneumonia (PCP)Less than 100: toxoplasmosis and cryptococcosisLess than 75: mycobacterium avium complex (MAC). Because they are such an important indicator of the strength of the immune system, official treatment guideline in the US suggest that CD4 counts be monitored every 3 to 4 months. See Fact Sheet 404 for more information on the treatment guidelines.
  • Medical issues
  • First combination of medications prescribed for the patient will be the most effectiveAdherence leads to:a healthier, longer life prevention of the development of drug-resistant strain(s) of HIV
  • Addiction or mental health relapseLiving in an institutionSide effectsAffordability
  • Write down instructionsUse a timer to ensure proper dosingUse a check-sheet to notate dosageProvide positive feedbackEmpathize and advocate regarding medication side effectsUse visual cues for persons with impaired language/cognitive abilities
  • Take all medications as prescribedAvoiding Drug Resistance
  • Culture/gender/sexuality
  • Socioeconomic statuslevelwhether it impacts client’s illnessDegree of acculturationHeterogeneity of cultural, racial and ethnic groups
  • Role of the family in treatment Importance of spirituality in treatment Degree of trust in the health care system Views toward injection drug use and unprotected sexReliance on verbal communication in medical treatment Ways in which safer sex practices are negotiated
  • Identity as caregiver is a powerful factor in her reluctance to seek testing Reproductive decision makingGay, lesbian, bisexual and transgender clients deal with the social stigma
  • Listen with empathy and understanding Elicit cultural information from the client Acknowledge and discuss differences and similarities between culturesRecommend action, treatment and intervention that incorporate cultural knowledgeNegotiate agreements and differences with the client
  • Counseling considerations
  • Events which may initiate client relapse:Taking an HIV test Receiving HIV test results Experiencing the first symptoms of HIV Experiencing the first AIDS-related hospitalization Being diagnosed with AIDS A friend or significant other dying from AIDS Beginning the medication regimen for HIV Experiencing little or no response to various medicationsDecreasing CD4+ T cell count or increasing viral load
  • Peer supportMedical intervention for painRelaxation and stress managementRecreation
  • Consider organizing separate groups for: Clients who are newly aware of their positive HIV status Clients who are asymptomatic or mildly symptomatic Clients with more advanced disease
  • Issues: Loss Unfinished business Pain management Religious and cultural traditions Clients can be encouraged to: Make a will Arrange for child custody Decide about health care directives
  • 5 stages when coping with death or lossDenialAngerBargainingDepressionAcceptanceNormalize their reactions
  • Acknowledge deaths attendance at memorial services, if appropriate Encourage the expression of grief both verbally and nonverballyart therapy Provide grief group supportfor clients and significant othersHelp clients leave a legacy of living memoriesvideo or cassette recordings for others
  • MedicalDentalHospiceHIV organizations and support groups Local health departments Legal assistance providers Agencies providing housing, financial assistance, medical care fundingMental health providers Members of the criminal justice community Spiritual caregivers
  • Equal access to health care and substance abuse treatment is guaranteedState laws regulate the disclosure of patient information related to HIV/AIDS which differ from other health informationIf in doubt, always consult your legal counsel
  • HIV/AIDS as a second, third or fourth diagnosis to be integrated into comprehensive treatmentHIV/AIDS counseling and education should be available at every treatment facility or detoxification unitPatients who receive adequate early intervention can live longer, healthier lives
  • TIP 37 Addictions Treatment with Persons with HIV

    1. 1. Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    2. 2.  650,000 to 900,000 in the U.S. with HIV  Many don’t know it  Most easily transmitted by exposure to contaminated blood  Drug use results › poor judgment, unprotected sex, sharing needles Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    3. 3.  Alcohol and drug use can: › Interfere with HIV medications › Inhibited immune system › Lead to poor health behaviors further compromising immunity Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    4. 4.  Medical providers  Mental health  Substance abuse  Public health  Social support groups Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    5. 5.  HIV positive, doesn’t matter what you do  Avoid HIV if you’re careful and don’t repeat risky behaviors  You can tell whether your sex (or injection) partners are infected  Treat any sexually transmitted diseases and you won’t get HIV  Washing after sex will prevent HIV  Not sharing syringes so can’t catch HIV Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    6. 6.  Ask: Unprotected in the last 3 to 6 months: › Vaginal sex? › Anal sex? › Oral sex? › Sex for money or drugs? › Sex with more than three people? › Sex with an injection drug user? › Sex with someone you think has HIV/AIDS?  Ask: When you have sex, do you sometimes or never use condoms? Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    7. 7.  Ask: Do you use drugs before or after sex?  Ask: When you use drugs, do you: › Use syringes? › Share syringes? › Clean your works? › Use crack or powder cocaine? › Use several drugs at the same time?  If client answers positively for half or more, client has a high risk of having or getting HIV Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    8. 8.  Use condoms  Don’t share syringes  Use new syringes  Disinfect drug paraphernalia  Medical care before, during, after pregnancy  Elective cesarean delivery  Avoid reinfection  Observe universal precautions as directed  If exposed, begin postexposure prophylaxis Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    9. 9.  Clinician’s goals in promoting risk-reduction: › Help and support client understanding need for behavior change › Assist client address cultural practices or beliefs that contribute to resisting change › Assist client develop skills to sustain behavior change Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    10. 10. Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    11. 11.  Pre- and posttest counseling by a trained HIV clinician  Counseling should: › Explain limitations of HIV tests › Help clients assess their risks › Encourage and reinforce behavior change › Refer infected clients for medical care Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    12. 12.  ELISA (enzyme-linked immunosorbent assay) › typically used as a first test  Western blot › typically a second test  Rapid HIV tests  Home sample collection tests  Positive result › a second test is needed to confirm  Negative result › second test needed in about 6 months to rule out a false-negative Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    13. 13.  All states require reporting AIDS cases  Some states also require reporting new cases  Reports forwarded to CDC  State laws vary regarding client- identifying information Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    14. 14.  Testing needed to determine disease progression › CD4+ T cell count (More info) › Viral load count Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    15. 15. Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    16. 16.  First combination of medications prescribed for patient are most effective  Adherence leads to: › healthier, longer life › prevention of developing drug-resistant strain(s) of HIV Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    17. 17.  Addiction or mental health relapse  Living in an institution  Side effects  Affordability Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    18. 18.  Write instructions  Use timer, ensuring proper dosing  Use check-sheet, notating dosage  Provide positive feedback  Empathize / Advocate regarding medication side effects  Visual cues for persons with impaired language/cognitive abilities Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    19. 19. Take all medications as prescribed Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    20. 20. Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    21. 21.  Socioeconomic status › Level › Impact on client’s illness  Degree of acculturation  Heterogeneity of cultural, racial, ethnic groups Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    22. 22.  Family role in treatment  Spirituality in treatment  Trust in the health care system  Views toward injection drug use and unprotected sex  Reliance on verbal communication in medical treatment  Negotiating safer sex practices Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    23. 23.  Identity as caregiver, reluctant to seek testing  Reproductive decision making  Gay, lesbian, bisexual, transgender clients’ social stigma Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    24. 24.  Listen with empathy and understanding  Elicit cultural information  Acknowledge and discuss cultural differences and similarities  Recommend action, treatment, intervention incorporating cultural knowledge  Negotiate agreements and differences with client Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    25. 25. Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    26. 26.  Events which may initiate client relapse: › Taking an HIV test › Receiving HIV test results › Experiencing first symptoms of HIV › Experiencing first AIDS-related hospitalization › Being diagnosed with AIDS › Friend or significant other dying from AIDS › Beginning medication regimen for HIV › Experiencing little or no response to various medications › Decreasing CD4+ T cell count or increasing viral load Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    27. 27.  Peer support  Medical intervention for pain  Relaxation and stress management  Recreation Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    28. 28.  Consider organizing separate groups for: › Clients newly aware of their positive HIV status › Clients asymptomatic or mildly symptomatic › Clients with more advanced disease Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    29. 29.  Issues: › Loss › Unfinished business › Pain management › Religious and cultural traditions  Clients can be encouraged to: › Make a will › Arrange for child custody › Decide about health care directives Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    30. 30.  5 stages when coping with death or loss 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance  Normalize their reactions Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    31. 31.  Acknowledge deaths › attendance at memorial services, if appropriate  Encourage expression of grief both verbally and nonverbally › art therapy  Provide grief group support › clients and significant others  Help clients leave a legacy of living memories › video or cassette recordings for others Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    32. 32.  Medical  Dental  Hospice  HIV organizations and support groups  Local health departments  Legal assistance providers  Agencies providing housing, financial assistance, medical care funding  Mental health providers  Members of the criminal justice community  Spiritual caregivers Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    33. 33.  Equal access to health care and substance abuse treatment guaranteed  State laws regulate disclosure of patient information related to HIV/AIDS; differ from other health information  If in doubt, always consult your legal counsel Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    34. 34.  HIV/AIDS as a second, third or fourth diagnosis integrated into comprehensive treatment  HIV/AIDS counseling and education available at every treatment facility or detoxification unit  Patients receiving adequate, early intervention live longer, healthier lives Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    35. 35.  The Ryan White CARE Act › HRSA Grant Application Center  (877) 477-2123  http://www.hrsa.gov › Title I Information (301) 443-9086 › Title II Information (301) 443-6745 › Title III Information (301) 443-0735 › Title IV Information (301) 443-9051 › See TIP 37 Appendix F for further information Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC
    36. 36.  Significantly reduces  May affect methadone methadone levels levels › • Rifampin › • Nelfinavir › • Dilantin › • Phenobarbital  No significant effect on methadone levels  Reduces methadone levels › • Clarithromycin / › • Carbamazepine Azithromycin › • Ritonavir › • Didanosine › • Rifampin › • Lamivudine › • Nevirpine › • Saquinavir › • Efavirenz › • Stavudine › • Sulfamethoxazole  May raise methadone › • Zalcitabine levels › • AZT › • Delavirdine › • Fluconazole Copyright 2008-2012 AllCEUs.com A subsidiary of CDS Ventures, LLC

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