Advocacy

Primary Medical Care for HIV Infected Patients in Addiction Treatment

Adoption Date:
October 1, 1994; rev. December 1, 2000

Public Policy Statement on Primary Medical Care for HIV Infected Patients in Addiction Treatment

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Background

The AIDS epidemic has profoundly and disproportionately affected injection drug users in the United States and in many industrialized countries. In the United States, drug users entering addiction treatment programs, especially methadone maintenance programs, have been found to have a high prevalence of HIV infection. In some regions of the country, over 42% of all methadone treatment entrants are HIV-seropositive. HIV infection has had a dramatic negative impact on patterns of morbidity and mortality among drug injectors in these treatment program settings.

Among patients dependent on alcohol and other non-injected drugs, there is clear evidence of increased risk of HIV infection secondary to substance use-related sexual behaviors. Women, in particular, are often not aware of their male partners' histories of risky behavior, and women who use and /or are addicted to alcohol and other drugs often have sexual partners themselves at risk for having acquired HIV infection. The use of crack cocaine in particular has been associated with a high risk of sexually acquired HIV infection among women whether or not they have a history of injection drug use. Psychostimulants, including cocaine and methamphetamine, as well as alcohol, are clearly associated with risky sexual behavior.

In recent years, HIV/AIDS medical care has shifted increasingly towards primary care and outpatient management. Addiction treatment programs are well situated to provide or coordinate primary medical care for their patients. A growing number of addiction treatment programs have succeeded in providing primary medical care services including, but not limited to, HIV services, on-site. The rationale for co-location of medical and mental health services on-site at addiction treatment programs includes the following elements:

1. Drug users are often not engaged in coordinated primary care within the mainstream medical care system and often rely instead on episodic care or acute/emergency room settings.

2. Addiction treatment programs provide a strategic opportunity for organizing and providing medical care to drug dependent individuals in treatment settings. Co-location of services fosters integration of the diverse elements of patients’ treatment (e.g. medical, mental health and addiction treatment), thereby reducing fragmentation of care. Adherence to complicated antiretroviral regimens may be enhanced by strategies which link the support of adherence to the context of the alcohol/drug treatment program. Directly observed therapy is made feasible and expertise in the complex interactions among pharmacotherapies for addiction (e.g. methadone) and antiretroviral and other medications is more likely to be present. Recent clinical data support the effectiveness of outpatient and primary care-based medical regimens on the course and prognosis of HIV infection.

3. Infectious diseases, which are highly prevalent in this population, present important
opportunities to implement prevention and treatment strategies:

a. Viral Hepatitis. Addiction treatment programs are ideal for preventing infection with, transmission of, and disease progression from hepatitis viruses.

b. Tuberculosis. The high risk of tuberculosis infection and disease among drug dependent persons and it’s potential for spread within drug treatment facilities makes such programs optimal settings for screening, prophylaxis and treatment of tuberculosis. Supervised chemotherapy is possible in many drug treatment settings.

c. Sexually transmitted diseases. Many STDs including human papilomma virus (HPV), syphilis, gonorrhea, chlamydia and others are associated with increased risk of HIV transmission and are important causes of morbidity in this population.

The National Commission on AIDS has acknowledged the need for a coordinated approach to addictive disorders and HIV infection to help stem the AIDS epidemic. The National Association of State Alcohol and Drug Abuse Directors (NASADAD) has affirmed the importance of addiction treatment programs attending to the medical care needs of their patients. Such linkages between addiction treatment programs and medical services may be achieved by co-location of these services on-site, formal referral systems between facilities, or other mechanisms that ensure adequate follow-up.

ASAM Policy

In light of the issues and justifications outlined above, the American Society of Addiction Medicine recommends that:

All addiction treatment providers should be aware of and make all efforts to attend to the medical care needs of their patients with HIV infection. Addressing these medical care needs may involve providing a supportive environment for voluntary HIV testing and counseling, providing on-site primary medical care services, providing organized referrals to medical care institutions with expertise in the treatment of HIV/AIDS, and making arrangements with outside providers who might be brought in to provide on-site medical services within treatment programs. ASAM recognizes that treatment programs may need additional resources to provide these necessary services.

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