Screening for Infectious Diseases Among Substance Abusers
Treatment Improvement Protocol (TIP) Series 6

Infectious Diseases Linked With Drug Use

Using drugs is an important risk factor for disease. Drug use is associated with such risk behaviors as the sharing of contaminated needles and other drug paraphernalia, and unsafe sexual practices that contribute to transmission of certain infectious diseases.

For example, research indicates

• There has been a steady increase in the incidence of hepatitis B, despite the availability of a vaccine since 1982. Most of the increase is attributed to injection drug use (CDC 1988). The prevalence of hepatitis C in injection drug users is also high (Donahue 1991).
• Injection drug use is closely linked to the spread of HIV. Patients infected with HIV, because of their impaired immune systems, are at increased risk of developing numerous infections, the majority of which represent reactivation of prior infection. However, HIV-infected persons are far more likely to develop active TB after exposure to TB than HIV-negative persons.
• An increase in cases of tuberculosis appears to be related to HIV infection and is seen primarily in the 25- to 44-age group. Multidrug-resistant tuberculosis has been detected in a growing number of States and is seen especially in large cities with high rates of drug use, homelessness, and HIV infection.
• The association between syphilis and drug use has been substantiated by retrospective studies and is particularly strong among cocaine users (Haverkos 1990).

Other Infectious Diseases Common in Treatment Populations

Persons enrolled in drug treatment programs are vulnerable to a range of debilitating diseases in addition to those that are the focus of this TIP. Detection and treatment of the following diseases should not be overlooked by treatment providers, although their prevalence will vary by risk behavior and, for some infections, by geographic area:

• Endocarditis - an infection of the heart valves by certain bacterial and fungal organisms. Immediate medical evaluation, including laboratory tests as indicated, and treatment of patients who exhibit persistent, unexplained fever are crucial to prevent further damage to the heart and other organs, or death. Persons with pre-existing valvular heart disease are at increased risk for developing endocarditis. Among drug users, endocarditis occurs primarily in persons who inject drugs. In most cases, the skin is the source of the infecting organism, but contamination of the injected drug and the drug paraphernalia may also be the source of the infection.
• Bacteremia/septicemia - bacterial invasion of the bloodstream that may result from use or sharing of contaminated needles and other drug paraphernalia. Patients exhibiting persistent fever should be medically evaluated and tested as indicated. Hospitalization and treatment with intravenous antibiotics and other appropriate supportive care are required.
• Fungal infections - such infections, including candidiasis and histoplasmosis, which can be relatively harmless in patients with normal immune systems, are persistent infections in HIV-infected patients. Cryptococcus and histoplasmosis may be life-threatening for AIDS patients, while Candida is rarely life-threatening. Medical evaluation and testing of patients with persistent fever, unusual skin problems, headache, or other systemic complaints are necessary.
• Body lice/scabies - have long been a concern of drug treatment providers, because an undetected case of body lice or scabies could spread to the treatment population. Disinfection of the patient and the patient's clothing and bedding is indicated. The occurrence of one case should trigger an investigation to see if there are additional cases among other patients that require treatment.
• Venereal warts - may occur among sexually active treatment program populations. Venereal warts are caused by DNA viruses and are most typically manifested as fleshy growths in the genital and rectal areas. Venereal warts are frequently more severe and less responsive to treatment in HIV-infected persons. Persons with venereal warts should be screened for syphilis because condyloma lata, which may be confused with viral warts, may occur in secondary syphilis. Venereal warts may be treated topically with cryotherapy or may require surgical excision.

Special Problems of Sexually Transmitted Diseases in Younger People and Women

Sexually transmitted diseases other than AIDS have the greatest impact on younger people under the age of 25, especially teenagers, and women. The Guttmacher Institute reports that one in five persons in the United States - 56 million people - have a viral sexually transmitted disease (such as genital herpes, human papillomavirus). Women account for about half of all sexually transmitted infections that occur each year, but they suffer more frequent and severe long-term consequences than men.

Sexually transmitted diseases (STDs) affect women disproportionately, because women tend to show fewer symptoms and as a consequence they go untreated for longer periods of time. A bacterial STD can usually be cured if treated early. However, these diseases are often undetected. Many of the most serious problems from STDs come from undetected chlamydia and gonorrhea; many of these cases lead to bacterial infection of the uterus, fallopian tubes, or lining of the pelvic organs, sometimes causing infertility. The transmission of an STD to an unborn child or during childbirth can have devastating effects (Guttmacher Institute 1993).

Infectious Disease Screening and Drug Treatment

Many drug users are reluctant to become involved with traditional medical providers because of previous poor treatment and insensitive care. As a result, they may not seek testing for and treatment of infectious diseases. In addition, lack of access to health care, either because of financial or other socioeconomic reasons, may mean that drug users may have had minimal or no medical care before enrolling in a treatment program.

Drug treatment providers are ideally situated to reach out to their patient populations and provide infectious disease screening, medical services, and preventive counseling. Program staff have a good understanding of the lifestyles of individuals who use drugs and are sensitive to and knowledgeable about their concerns and needs.

Screening for infectious diseases in patients may be especially important to their recovery effort, may result in improved health and improved treatment compliance, and may prevent the spread of debilitating and life-threatening infectious diseases. Integration of drug treatment and infectious disease screening offers an important therapeutic intervention for patients, their families, and the broader community.

Guidelines for Infectious Disease Screening

All patients in treatment should have access to infectious disease screening, risk-reduction education and counseling, and therapeutic medical services. To provide these services, treatment programs are encouraged to develop appropriate procedures and identify local resources.

Upon entering treatment and periodically thereafter, patients should receive an assessment, physical examination, serologic and other laboratory screening, TB screening, counseling, and followup medical care as appropriate. Clinicians in treatment programs must be suitably trained to provide medical testing and care for patients with infectious diseases. Program administrators should strive for access to laboratory facilities, hospitals, community-based primary health care programs, and public health agencies if necessary services cannot be provided on site by the treatment programs.

Strategies for infectious disease screening and related services should reflect local conditions. Local epidemiological data can be helpful in identifying trends in the prevalence of particular diseases and in developing screening and counseling priorities. Essential referral networks established with local public health and other resources can serve the needs of the treatment population.

Data from treatment programs on the incidence and prevalence of infectious diseases among patient populations support surveillance efforts that are the basis for developing broadly based, effective public health policies and services.

An important source of epidemiological information and support for treatment providers is each State's public health contacts for infectious diseases. They can assist and collaborate with drug treatment staff to establish and maintain effective infectious disease screening programs.

The Consensus Development Process

The Center for Substance Abuse Treatment (CSAT) has sponsored the development of Treatment Improvement Protocols (TIPs) to provide guidance for the care of patients in drug treatment. The TIP development process was modeled on similar efforts undertaken by the Federal Government to address complex health and social service delivery issues. The consensus model that was used to develop these guidelines drew on the experience and expertise of representative specialists from across the Nation.

The process began with CSAT's appointment of a Federal Resource Panel of medical personnel, drug treatment experts, social service providers, and representatives of national organizations. The Federal Panel established the overall scope and direction for the subsequent work of a Consensus Panel of experts charged with preparing guidelines covering medical screening and the treatment of infectious diseases.

The members of the Consensus Panel worked together in teams to prepare these screening and service guidelines. The draft guidelines were reviewed by additional field specialists. The final recommendations of the Consensus Panel reflect the diversity of experience and, most importantly, the agreement of many of the Nation's foremost experts as to the basic principles and guidelines for programs that should be used to provide screening and supportive care needed by patients in drug treatment.

Recommendations of the Consensus Panel

These guidelines are intended to provide direction for the many disciplines involved in drug treatment, including physicians, physician's assistants, nurses, nurse practitioners, social workers, psychologists, counselors, and other health and social service providers. They are designed to improve the screening of patients and staff for infectious diseases; to improve treatment for these diseases through better coordination of drug treatment programs, primary health care facilities, public health agencies, and infectious disease programs; and to reduce the incidence and consequences of these diseases by changing or modifying behavior. The guidelines may be used in a variety of settings, including inpatient, outpatient, and hospital-based drug treatment programs.

The Consensus Panel supports these key recommendations:

• Screening and counseling for HIV, tuberculosis, multidrug-resistant tuberculosis, hepatitis B and C, syphilis, and other infectious diseases, if indicated, that are prevalent in treatment populations should be offered to patients upon entry into treatment.
• Appropriate medical care is essential for infected patients.
• Patients have the right to refuse to be tested for infectious diseases and should not be denied treatment services based solely on that refusal, except where there is a potential public health threat to other patients or treatment staff. Treatment providers must evaluate the potential exposure risk for other patients and treatment staff, particularly for potential exposure to infectious tuberculosis. In all instances, patients should be educated about the benefits to themselves and others from proper and early diagnosis and treatment of infectious diseases.
• Pre- and post-test counseling services are needed to assist patients in preparing for and completing infectious disease screening and treatment, especially with reference to HIV.
• Risk reduction education and counseling interventions are vital to the prevention of infectious diseases. These interventions must be sensitive to and appropriate for the cultural and religious background of patients in treatment.
• Treatment program staff must be knowledgeable about and adhere to Federal and State confidentiality laws and regulations.
• Patients should be encouraged to provide information for contact tracing and partner notification.
• Treatment staff should be screened and treated as appropriate for tuberculosis. Screening should also be done for hepatitis B, with vaccination for those not previously vaccinated for or infected with hepatitis B.

The Consensus Panel encourages drug treatment staff and other service providers to use these guidelines to identify and coordinate their roles in the care of patients in treatment and after discharge.

Using These Guidelines

This TIP is intended to guide and instruct a broad spectrum of treatment and other health and public health care providers caring for drug treatment patients who are at risk for infectious diseases. Some of the guidelines provide information for specific disciplines such as counselors and physicians or other medical staff. Other parts, such as the legal and ethical guidelines, are pertinent to all service providers. A review of the entire TIP will help providers create and maintain the continuum of care that is vital to the well-being and recovery of their patients.

The first part of this TIP addresses issues that affect and support the entire infectious disease screening and treatment process. The remaining chapters provide protocols for specific infectious diseases that are common in treatment populations. The protocols include information on prevalence and disease symptoms, screening procedures, and treatment regimens.

Some chapters include a list of sources. The vast majority of information presented in this TIP is not referenced, however, because it was developed through a consensus process and is the unique product of the experience and expertise of Panel members.

• "Issues for Counselors" presents a discussion of counseling issues relevant to infectious disease screening for treatment populations. The chapter reviews the critical role of the counselor in providing pre- and post-test counseling and risk reduction interventions.
• "Legal and Ethical Issues" provides a discussion of legal and ethical issues such as confidentiality, recordkeeping, reporting, and the duty to warn.
• "Issues for Treatment Program Administrators" offers guidance for treatment program administrators concerning staff training and community development issues and environmental safety.
• "The Initial Patient Contact" discusses establishing a therapeutic relationship, assessing risk, and issues pertaining to taking a history.
• Protocols for the screening and treatment of tuberculosis and multidrug-resistant tuberculosis are presented.
• HIV/AIDS screening and referrals for continuing medical management are discussed.
• Hepatitis B, C, A, and D are discussed.
• The sexually transmitted diseases syphilis, gonorrhea, chlamydia, herpes simplex, and chancroid are discussed.

A variety of other sexually transmitted diseases, prevalent in treatment populations including many that are common to women, are not addressed in this TIP. For more information, the reader is referred to the Centers for Disease Control, Sexually Transmitted Diseases: Clinical Practice Guidelines.

The TIP also includes several appendixes that were developed outside the Consensus Panel process.

• Appendix A consists of a bibliography of references that can provide additional information for treatment providers.
• Appendix B identifies participants in the CSAT Federal Resource Panel.
• Appendix C lists field reviewers of this TIP.
• Appendix D is a resource list.
• Appendix E presents models for State drug agencies and local treatment programs to use in estimating the costs of implementing screening guidelines for infectious diseases. The models include recommendations for specific services and staffing patterns to create or enhance existing screening services.
• Appendix F discusses quality assurance.
• Appendix G is an HIV/AIDS Prevention Bulletin from the Centers for Disease Control and Prevention, the Center for Substance Abuse Treatment, and the National Institute on Drug Abuse. The bulletin, dated April 19, 1993, discusses the limitations of bleach in eradicating or inactivating HIV in injection equipment. The bulletin lists updated bleach recommendations as well as other disinfection methods for injection equipment.

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