Research indicates that drug use increases an individual's risk of contracting a number of infectious diseases, or leads to behaviors that increase that risk. The incidence and prevalence of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), tuberculosis, hepatitis B, syphilis and other sexually transmitted diseases (STDs), in addition to other medical conditions, is high in persons enrolled in drug treatment programs. Integrating screening for infectious diseases with drug treatment is an important response to the growing public health concern about these high rates of infection, and of HIV in particular.
Screening for infectious diseases in the treatment setting requires not only medical management but supportive counseling. Beyond the direct physical effects of disease, a number of psychosocial problems may be present and need to be addressed.
The counselor in a drug treatment setting can play a key role in assessing risk, providing pre- and post-test counseling, facilitating contact tracing and partner notification, implementing risk reduction and retention in treatment strategies, and interfacing with medical, public health, and other agencies. Training that improves awareness of infectious disease issues can provide counselors and other treatment staff with needed skills for improved patient care.
The drug treatment counselor is trained to assist patients to enter, participate in, and complete a treatment program. It is the counselor who typically prepares or participates in preparing the treatment plan and monitors patient progress toward treatment goals. Services offered by the counselor may include individual, group, and family counseling, as well as followup case management.
To these well-established functions, the counselor is encouraged to add the following services that support the screening of patients for infectious diseases.
Assess patient risk factors. A complete history is needed if medical and treatment staff are to adequately assess the patient's risk for infectious disease. During the initial intake or assessment interview with the patient, the counselor can help solicit sensitive drug-taking and sexual practice information (see "The Initial Patient Contact").
Provide pre- and post-test counseling. Counseling is especially critical prior to and following HIV-antibody testing. Patients may relapse or drop out of treatment entirely when considering testing or immediately after testing. Positive test results are frequently devastating to patients and their families. Counselors should be alert to the concerns and vulnerability of patients during this time. Counseling and referral assistance may be especially helpful for those previously known to be infected or for those whose test results are positive while in treatment.
Provide and follow up patient referrals. Patients infected with certain diseases after the initial screening will require medical care. If medical care is offered by the treatment program, the counselor can arrange for this care. When patients must be referred to other sources of medical care, such as a hospital or STD clinic, the counselor should act as the patient's advocate in arranging for treatment and tracking followup care with the medical facility. In addition to coordinating the care of the patient and acting as the patient's advocate, the counselor can encourage the patient to complete prescribed therapy.
Conduct and support risk reduction and treatment retention interventions. These interventions are essential components of the patient's treatment plan and should be designed with the needs and goals of the patient in mind. The counselor can deliver or provide for the delivery of education, counseling, and other support services that reduce the patient's risk of contracting or transmitting infectious diseases.
Facilitate contact tracing and partner notifications. Patients who have evidence of certain infectious diseases after the initial screening should be encouraged to identify and, when possible and advisable, inform sexual and drug-using partners or others of their risk for infection due to exposure to the patient. The counselor should support and encourage the patient during this process.
Participate in staff development activities. Treating individuals who use drugs continues to be challenging and rewarding work. However, the increase in the incidence of infectious diseases, and HIV/AIDS in particular, has intensified the emotional impact of the treatment process for many staff members, including counseling professionals. Awareness training, skills development, and supportive group activities give counselors opportunities to enhance their professional abilities and improve services to patients. In addition, all staff should take part in the treatment program's regular infection control and prevention efforts (see "Issues for Treatment Program Administrators: Staff and Community Development and Environmental Safety").
Participate in and support community-based interventions. The effectiveness of a treatment program is enhanced by well-developed links with other service organizations. In addition to providing direct services to patients and their families, the counselor can inform other service providers about drug use and infectious diseases, and participate on behalf of the treatment program in the community's service delivery network (see "Issues for Treatment Program Administrators").
Proper identification of infected persons is the first line of defense in limiting the spread of infectious diseases. A major hindrance to public health efforts to prevent infectious diseases is the inability or failure to identify cases among drug users and to adequately treat them and their contacts.
The drug treatment setting is an ideal place to identify individuals with infectious disease problems and to initiate and maintain appropriate management. Many treatment programs need to have a clear understanding of their patients' risk status.
As individuals enter treatment, a careful assessment of their risk for infectious disease is essential (see "The Initial Patient Contact"). The counselor should be alert to the presence of
Injection drug use. Injection drug users are at particularly high risk for HIV disease, hepatitis B, and sexually transmitted diseases because of unsafe sexual and risky drug-taking practices, including frequent needle sharing. Injection drug users who are HIV positive are also more likely to develop infectious tuberculosis than those not infected with HIV.
Sexual partners of injection drug users. Sexual partners of injection drug users, predominantly women, are at high risk for HIV, hepatitis B, and sexually transmitted diseases. In some cases, these individuals may not realize that their partner's drug use places them at risk for infection. Many of these women may use other, noninjectable drugs. Their own drug use can lead to unsafe sexual practices that increase their risk of infection.
Unprotected sexual contacts. Drug users who do not practice safer sex increase their risk for HIV and other sexually transmitted diseases. Especially high-risk sexual practices are the failure to use or the improper use of condoms, and contact that involves anal penetration.
Multiple sex partners. Having multiple sex partners increases the risk of hepatitis B, HIV, and sexually transmitted diseases. The practice of providing sex for drugs, money, or shelter is associated with a higher risk of infection.
Poor urban dwellers. Poor urban dwellers who have substandard housing and lack access to good medical care are vulnerable to many diseases. Tuberculosis, which is spread by airborne infectious particles, occurs with the greatest frequency in crowded urban areas.
Homelessness. Poor hygiene, inadequate nutrition and medical care, chronic drug use, crowded shelters, and unsanitary living conditions contribute to the incidence of infectious diseases among the homeless. Homeless youth have high rates of drug use and sexual risk-taking behaviors, placing them at particularly high risk for HIV infection.
History of incarceration and institutionalization. Having been imprisoned or having been a resident in an institutional setting increases the likelihood of having been exposed to HIV, tuberculosis, and hepatitis. Lower socioeconomic status. Research has repeatedly demonstrated strong associations between ill health, including infectious diseases, and lower income. Individuals with lower incomes have poor access to health care and to risk reduction information. Support for the implementation of risk reduction strategies is frequently not available.
Disease history. Repeated infection with sexually transmitted diseases is associated with increased risk for HIV infection. A history of recurrent sexually transmitted diseases, reactive tuberculosis skin test or diagnosed active tuberculosis, or dermatomal herpes zoster should all raise the level of suspicion at the treatment setting that the person may be HIV infected.
Drug use can place patients at increased risk for infectious diseases. The Centers for Disease Control and Prevention (CDC) recommends that treatment programs screen all patients for tuberculosis (CDC n.d.) and all injection drug users for the human immunodeficiency virus (HIV) (CDC 1987). For methadone programs, Federal regulations presently require that all patients have a serologic test for syphilis as well as a tuberculin skin test on entry and annually thereafter.1
An initial medical history and physical examination on admission to treatment will help determine the need for and advisability of testing and treatment for other infectious diseases.
The counselor has an important role in preparing patients for testing and in providing or arranging for supportive counseling and case management following testing. The counselor should
Create an environment that conveys trust and acceptance, encourages communication, and validates feelings. Establish a positive and open relationship with patients to help them express, discuss, and overcome any barriers to involvement with the health care system.
Discuss the process of testing, test procedures, possible outcomes, and treatment resources. Entry into drug treatment presents an opportunity for the patient to focus on health matters and to take time to seek diagnosis and treatment for medical concerns.
Explain confidentiality procedures and reporting requirements. Patients may be unaware of their rights to confidentiality and how contact tracing and/or partner notification impinge on this protection.
Discuss infection containment and risk reduction strategies. Educational instruction on how the various infectious diseases are transmitted and on methods to reduce the potential of transmission to family contacts is helpful for the patient. The patient should be told how soon the infection responds to therapy to eliminate transmission and told about precautions that can be employed until the infection has been eliminated or controlled. If the infection is chronic and communicable, the patient needs information on how to protect the health of close contacts. Patients need to be advised on how to protect themselves from reinfection or a new infection.
Discuss retesting. Retesting may be indicated when there is suspicion about a false-positive or false-negative result, when the indication for testing is recurrent or ongoing, or to determine whether intervention has been successful in eliminating the causative agent of the infectious disease.
Discuss contact tracing and partner notification. Patients need to be informed of instances in which contact tracing of close household contacts is required and when sexual partner notification follows a positive result of a test. This information is ideally made available prior to testing; the patient's reservations regarding involvement can be addressed with a counselor who has established a relationship with the patient. The counselor then can help the patient in accepting the assistance of health authorities in informing contacts and partners.
Assist the patient to make the best decision regarding obtaining medical care. When an untreated infection poses a threat to self or others (for example, a patient suspected of having tuberculosis or untreated syphilis in a pregnant woman), immediate testing and treatment should be initiated. If the patient wants or needs to prioritize health concerns, support addressing those concerns that pose the most imminent danger (for example, alcohol withdrawal seizures before HIV testing). Fear of a test result is not a valid reason to delay diagnosis of a potentially life-threatening infection for which there is an available cure or way to lessen the severity and course of the infection.
Testing requires the participation of the patient, and in some cases can be done only with the informed consent of the patient.
The CDC recommends that all injection drug users be screened for HIV. Drug treatment providers also need to assess the risk of HIV in noninjection drug users who enter treatment and should work with the patient to determine if HIV serologic testing is needed. Testing for HIV should be performed only with the consent of the patient. For persons being tested for HIV, pre- and post-test counseling is the standard of care. The counselor has an important role in preparing patients for testing and in providing or arranging for supportive counseling and case management following testing.
Drug treatment providers should be aware of the importance of pre- and post-test counseling and should ensure that counseling is available in the on-site program or that the basic elements of counseling are being offered by the referral provider.
If testing is indicated, the counselor can prepare the patient in the following ways:
Create an environment that conveys trust and acceptance, encourages communication, and validates feelings. When they enter treatment, patients may suspect that they are infected, they may have a high risk for infection, or they may be symptomatic. The counselor can establish a positive and open relationship with patients to help them overcome any fears they may have about testing and the testing process.
Discuss risk factors, modes of transmission, purpose of the test(s), test procedures, possible outcomes, and treatment. To facilitate testing, and the patient's decision regarding testing, the counselor and the patient can discuss the patient's risk factors for infection, as well as the symptoms and modes of transmission of HIV.
The benefits of testing should be stressed. For example, testing may prevent serious health consequences, even death, for the patient, family members, and others in the community. Early diagnosis of disease provides an opportunity for the patient to obtain effective medical care that can prevent or delay serious illness. Testing also provides an opportunity for the patient to modify personal risk behaviors and reduce the possibility of subsequent infections.
Patients need information about the testing process and the specific tests that are used to diagnose and confirm HIV infection. The counselor can emphasize that the only way to diagnose HIV is to be tested. Information offered to patients may include a description of the test(s) that will be performed, the procedures involved, the location and hours of operation of testing facilities, and the qualifications and type of staff who perform the tests.
Patients may be particularly anxious about how and when test results will be provided. The counselor can discuss possible test outcomes, the usual length of time between testing and availability of results, reasons for possible retesting, and the importance of post-test counseling.
Patients should be reassured that medical treatment is available and can be effective. The counselor can explain that recovery and subsequent disease prevention depend on the patient's compliance with prescribed regimens.
Assess possible reactions to test results. Patients may experience some distress while waiting for test results. Once received, test results can cause further distress, fear, anger, or denial. The counselor can assess the responses of patients to testing and provide referrals to mental health service providers, social service agencies, and others as appropriate.
Explain confidentiality procedures and reporting requirements. Patients may be unaware of informed consent procedures, their rights to confidentiality, and the exceptions to these protections. The counselor can inform and assure patients that all testing is voluntary and that treatment services cannot be withheld if testing is refused. Consent should be obtained before any testing procedure takes place and is required for HIV testing in some jurisdictions.
HIV test results may be reportable (see "Legal and Ethical Issues"), and AIDS cases with patient identifiers must be reported to health authorities.
Discuss risk-reduction strategies. Educational instruction on risk reduction behaviors provides patients, their sexual partners, and their family members with strategies to reduce the possible transmission of infection. The counselor can stress the importance of following these strategies whether or not patients test positive for HIV.
Discuss retesting. Testing for HIV consists of an initial screening test and one or two additional confirmatory tests. This combination of tests is sensitive and specific.
In addition to immediate retesting in cases in which there is concern that the test results may be a false positive or false negative, retesting in several months may be appropriate for individual patients. HIV antibodies, for example, may not be detectable for up to 12 months or longer following infection. The counselor should urge patients to be retested if they have another potential exposure to the HIV virus, such as drug use, needle sharing, unsafe sexual practices, or sexual victimization. A more detailed discussion on retesting follows in the discussion on counseling the HIV-positive patient and in the screening section of "Human Immunodeficiency Virus and the Acquired Immunodeficiency Syndrome."
Discuss contact tracing and partner notification. Patients need to be prepared to assist health authorities to inform their contacts and partners if test results are positive.
The counselor can encourage and support patients who test positive for HIV to notify contacts and partners of the implications of the test results and to bring partners in for testing or refer them to other sites for testing. At the request of the patient, health department personnel can be asked to assist in this notification process.
Support patient decisions on testing. The patient may choose not to be tested for HIV the first time it is discussed. While the uncertainty of waiting for test results or positive indications of infection can be stressful and may threaten the patient's efforts to abstain from the use of drugs, this alone should not be viewed as a valid reason to delay testing. The counselor can acknowledge and convey an acceptance of the patient's decision regarding testing, but should continue to educate the patient about HIV and other infectious diseases, and encourage testing at a future date, the earlier the better.
The following discussion addresses post-test counseling issues, especially concerning positive outcomes. The issues of positive results for HIV that need addressing are so different from those associated with other infectious diseases that they are dealt with separately. These issues are addressed again in the chapter on HIV and AIDS.
Because of the severe distress patients experience while waiting for test results, counselors are advised that they only have 10 to 60 seconds to communicate information that will be comprehended by their patients after their test result is reported to them. A second post-test session may be needed after the patient gets over the initial elation or depression of finding out test results.
Patients who are HIV positive need acceptance, information, medical care, and supportive counseling that allows for the expression of painful feelings and promotes the development of coping mechanisms. The counselor can assist patients in the following ways:
Explain the meaning of positive results. Patients with a positive HIV test result have HIV infection and will develop AIDS. The progression of illness in individual patients is unpredictable, but proper medical care may significantly slow this process. The counselor should advise the patient that he or she is infectious and must follow precautions to prevent the transmission of the virus to others, especially via sexual contact or injection drug use.
Discuss the need for retesting to confirm initial test results. Although HIV-antibody tests are extremely accurate when properly done, false-positive and false-negative results may occur and retesting may be advisable for some patients. Because false-positive results do occur, retesting is advisable for persons who strongly deny any risk factors and are unwilling to accept an initial positive result. Retesting is also advisable for patients who are in a state of denial and need further evidence of a positive test. Although false-positive results may be found for one of the tests used to confirm that a patient is HIV-infected, the presence of a positive HIV EIA and a positive Western blot confirms HIV infection.
For a patient who may have been infected with HIV in the recent past (that is, 8to 12 weeks ago), the HIV tests may be falsely negative because that patient is in the incubation period before seroconversion. For a person with known HIV risk factors, the HIV test should be repeated in 3 months and again in 6 to 12 months. As long as a patient engages in behavior associated with risk of exposure to HIV, that person should be retested every 3 to 6 months.
In the face of overwhelming evidence of an HIV- or AIDS-related infection and a negative test, the test should be repeated.
Refer the patient for medical care. Even when there are no symptoms, monitoring for disease progression and the start of appropriate treatment may delay the development of AIDS.
Help the patient to decide whom to tell about the results. It is important to encourage patients who test positive for HIV to inform their sexual and drug-using partners. Not only are these individuals at risk for infection, they may be already infected. Partners should be tested and referred to medical care and other supportive resources. The children of HIV-infected women must also be tested for HIV.
The counselor can assist patients in making decisions about informing family members, friends, and others of their HIV status and anticipating and preparing for the range of responses. As part of this process, the counselor and patient should carefully discuss the possibility of abuse by a spouse or sexual partner. Health department personnel may be helpful for these and other patients who do not choose to notify their sexual and drug-using partners.
Explore feelings about the disease. After finding out that one is HIV infected, the responses may include intense anxiety; feelings of physical and social isolation; fear of death, illness, and discrimination; concern about loss of relationships and support systems; guilt and self-blame; a negative self-image; obsession with symptoms; anger; and depression.
The counselor can reassure patients that their feelings, including initial shock and denial, are understandable and normal. A drug-injecting user may feel guilty about infecting his drug-free sexual partner; parents may feel particular guilt if their child has been infected perinatally. Individual and group counseling can facilitate and encourage the expression of difficult feelings, including anger, guilt, and anxiety.
Patients also may need referral to other counseling resources in the community.
Discuss withdrawal and self-imposed isolation as reactions to disease. Being HIV positive is associated with being viewed as someone who engages in high-risk sexual behavior and/or drug abuse. Patients are often faced with extreme isolation because of misunderstandings about modes of transmission. Patients may need assistance to maintain an existing network of friends and family or to develop such a support network.
Assess suicide potential and provide referral to mental health care. Patients who are HIV positive may contemplate suicide at some point following their diagnosis, but most overcome these thoughts. The counselor should be aware that some patients may have higher rates of mood disorders. It is imperative that drug treatment programs have a well-defined protocol to respond to all suicidal thoughts or gestures.
Emphasize risk-reduction behaviors. Safer sexual practices and abstinence from drugs are important risk-reduction behaviors. The counselor should constantly emphasize the importance of risk-reduction behaviors and their benefits.
Help the patient to set priorities and goals. Patients who test positive for HIV are at high risk for a return to drug use. The counselor can emphasize the fact that abstinence is critical for maximum health and physical well-being. Drug use may further impair the immune system.
Resumption of and continued use of drugs place the patient at risk for needle sharing and unsafe sexual practices that may lead to exposure to infectious diseases. Of particular concern is the risk of infection with a different and potentially more virulent and resistant strain of HIV. Exposure to such a strain may hasten the progression of HIV to AIDS.
Support the patient in joining an HIV support group. The patient who is HIV positive may benefit from the help and understanding provided by a community-based HIV support group. The counselor can provide information about such groups and encourage and facilitate attendance by patients and family members during treatment and after its completion.
Support the patient and family members in anticipatory mourning and expression of other feelings about this life-threatening infection. Feelings of impending loss and grief can be frightening and may lead to the further debilitation and isolation of the patient. Patients need assurance that these feelings are a part of a healthy coping process.
Help the patient and family members recognize their own capacities and limitations. Faced with a life-threatening disease, patients and their family members struggling to cope with feelings of loss may also confront employment, physical, and financial concerns. Counseling and referrals to community-based resources can provide the assistance needed to maintain a positive lifestyle.
Provide and follow up referrals to mental health, social service, and other community resources. Following treatment for drug use, patients benefit from a comprehensive continuum of care. For patients who are also HIV positive, the following types of referrals may be of assistance: specialized medical care; mental health care, including medication management; financial assistance; housing; child care; and legal consultation.
Patients infected with tuberculosis, viral hepatitis, and syphilis or other sexually transmitted diseases also need emotional support and counseling. The counselor can assist these patients in the following ways:
Provide and follow up referrals for medical care. Patients who test positive for infectious diseases need medical treatment. The counselor can prepare patients for specific treatment regimens by explaining and discussing the importance of following all procedures, keeping appointments for checkups, and taking medications. Anticipated treatment outcomes can be reviewed to assure patients of the efficacy of the medical plan and to allay concerns about any necessary procedures. Followup with patients is critically important to ensure that appointments are kept.
Discuss procedures for and implications of mandatory reporting of test results to health officials. Patients need to be informed about the community's mandatory reporting requirements for positive test results. They should be thoroughly familiar with their right to confidentiality, while being aware of the need to inform health department infectious disease practitioners of all contacts and partners who may be at risk for infection. This reporting can be done without stating that the patient is in drug treatment.
Explore feelings about the disease. Patients need to be well informed about the signs and symptoms of disease, routes of transmission, and short- and long-term effects. Some patients may be inappropriately unconcerned about infection, and others may have erroneous fears and anxieties about these infections.
Emphasize risk-reduction behavior. Discuss safer sexual partners and abstinence from drugs as important risk-reduction behaviors. The counselor should constantly emphasize the importance of these behaviors and their benefits. For viral infections such as HIV and herpes simplex, for which there is no cure, prevention of transmission is the most effective approach.
Provide and follow up referrals to community resources. The counselor can provide and follow up on referrals to medical care, social services, mental health care, and other community resources to assist patients in their recovery from drug use and to maintain risk-reduction behaviors.
Patients need a careful explanation of the meaning of negative test results. In some cases, repeat tests may be needed on a regular basis. With many patients, a negative test result provides a nonthreatening window of opportunity for important education and counseling about protection from infectious disease. This window of opportunity may be particularly important for adolescent drug users who might otherwise continue high-risk behaviors without being concerned about the possibility of being at risk for infection.
Risk-reduction education and counseling are needed by all patients who receive treatment. Patients who agree to be tested for an infectious disease and who test negative should be reminded about the need to change their high-risk behaviors so that they will not be exposed and infected.
Contact tracing and partner notification are activities intended to interrupt the transmission of disease. Once positive test results are received, patients should be encouraged to provide the names and locations of sexual partners, injection drug-sharing partners, or contacts at risk for infection. The counselor may play an important role in notifying contacts of nonreportable infections. Contact tracing and partner notification are conducted by health department personnel for reportable diseases regardless of the wishes of the infected person.
In most jurisdictions, HIV test results are reported for epidemiological reasons but are reported without patient identifiers and no contact tracing is done. In some jurisdictions, a positive HIV test result is reportable and contact notification is required. In other jurisdictions, health department personnel, at the request of the patient, may assist in tracing and notifying contacts and partners of HIV-positive patients. Contacts who test HIV negative may be motivated to make and maintain changes in behavior to reduce their risk for infection in the future.
Throughout this informing process the counselor can assist and support patients in the following ways:
Discuss the processes of contact tracing and partner notification. Health care providers must report specific infectious disease cases to health authorities. Subsequent contact tracing and partner notification are then conducted. Patients need to be fully informed of these requirements and assured that identifying information is kept confidential. The counselor can assist the patient to review current or past behaviors that may have placed others at risk for infection. The importance of full disclosure of the names and locations of potentially at-risk contacts and sexual and drug-using partners can be reinforced.
Assist the HIV-positive patient in reaching a decision to notify (or have notified) contacts and partners. When the reporting of positive test results is not required by law, patients should be counseled about the benefits of contact and partner notification. For example, exposed persons can seek testing and early medical care; women who are pregnant can obtain reproductive counseling or appropriate prenatal care; high-risk sexual and drug-using behaviors can be modified or discontinued; and unhealthy environments can be improved or changed.
It is helpful for patients to have opportunities to discuss their fears about contact and partner notification. For example, patients may fear the loss of a relationship, physical violence, the loss of housing or other physical or emotional support, and the loss of confidentiality and misuse of the information.
When patients choose to notify contacts and partners, they may need assistance to develop effective ways to communicate with these individuals. Using such techniques as role playing, patients can be prepared for uncomfortable situations that might arise.
Discuss patient fears, feelings of embarrassment, and guilt. Patients may be fearful about exposure and rejection by sexual partners, guilty over possible infection of others, and embarrassed about being infected, homeless, or other circumstances. Adolescents may be particularly embarrassed about their infection and continue their risk-taking behaviors. The counselor can discuss referral options to community-based services to address these needs, such as housing and financial assistance, peer support groups, and mental health care.
Explore the risk of violence, other abuse, loss of housing, or loss of emotional support. Some women, particularly those with children, may fear abandonment and physical or emotional abuse from a partner if their test results are revealed. Some men may be afraid that their wives or partners will leave them. The counselor can discuss referral options to community-based services to address needs such as legal intervention, housing assistance, child care services, and financial assistance.
Discuss confidentiality issues. Patients may be fearful that contacts will be able to discern their identity and that confidential and sensitive information will be misused. Patients may be unwilling to provide information, or they may provide incorrect or incomplete contact and partner information. In some cases, when sex is exchanged for drugs or for money to buy drugs, partners are anonymous. The counselor can reassure patients concerning the confidentiality of treatment records and acknowledge the concerns that are expressed.
Many patients in treatment will be free of infectious diseases. Others may test positive for one or more diseases and need medical care and other services. Every patient should receive risk-reduction education and counseling. These efforts will help prevent future infection in patients who currently test negative for infectious diseases and reduce the risk to others from those patients who currently test positive for HIV and other infectious diseases.
The experiences of drug treatment programs suggest that the following broad principles guide counselor-based risk-reduction activities:
Establish a warm and trusting relationship with the patient, based on mutual respect and regard.
Incorporate risk-reduction approaches into the overall treatment program that emphasize the benefits of preventive health behaviors for a variety of health concerns.
Provide risk-reduction education and counseling that is sensitive to the cultural values, religious beliefs, and traditions of the individuals being served, as well as the socioeconomic and day-to-day realities of their lives.
Understand that it is fairly easy to change knowledge, more difficult to change attitudes, and extremely difficult to change behavior.
Acknowledge that some risk-reduction programs will not work or will not work in the way it was assumed that they would work.
Do not focus on scare tactics. Scare tactics are usually ineffective, especially when dealing with adolescents and young adults.
The prevention of certain infectious diseases, such as HIV, tuberculosis, hepatitis B, and syphilis and other sexually transmitted diseases, requires that patients permanently alter their risk-associated behaviors, especially drug use and unsafe sexual practices. In addition, patients need to be aware of environmental risks for exposure to tuberculosis.
Risk-reduction strategies can be implemented in a variety of settings, including drug treatment programs, STD clinics, and other service facilities. These strategies can include group and individual sessions designed to provide information about risk factors, evaluate personal risk, overcome barriers to behavioral change, and develop skills. A combination of these strategies may be necessary to facilitate change by individuals in treatment. For example, the counselor may consider the following strategies:
Provide patients with information about the relationship between drug use, particularly injection drug use, and the transmission of infectious diseases. Discuss with patients the likelihood of their having unprotected, high-risk sexual contact while under the influence of alcohol and other drugs.
Provide patients with information about the various routes of infectious disease transmission, including unprotected sexual contact, sharing of contaminated needles and equipment, transmission from an infected mother to her fetus or infant, and by exposure to airborne droplets containing the mycobacteria that cause tuberculosis. Review ways that patients can avoid or minimize exposure and infection, and the risks associated with repeated exposure to infection.
Encourage participation in an HIV/AIDS self-help group for HIV-positive patients. These groups offer information and encourage and facilitate risk reduction behaviors, and are effective in relieving the isolation and stigmatization that still accompany HIV/AIDS.
The initiation of safer sexual practices is a primary risk reduction strategy that can help protect patients from a variety of infectious diseases.
Other than sexual abstinence, the consistent and proper use of condoms is currently the most effective way to prevent HIV and other sexually transmitted diseases. Guidelines on how to use a condom are available and can be discussed with patients (see table 1). Condoms containing spermicides, especially nonoxynol-9, offer some additional protection against bacterial sexually transmitted diseases. Vaginal use of spermicides along with condoms is likely to provide still greater protection. Spermicides alone also offer some protection against sexually transmitted diseases. The following examples of counselor-based activities can also promote safer sexual behavior by patients.
Educate patients about the risk of infection through unprotected sex, particularly with injection drug users and multiple partners.
Discuss possible barriers to safer sexual practices and ways to overcome these barriers. Incorporate ethnic and cultural perspectives to circumvent barriers to the use of condoms.
Provide materials that offer sex-positive messages, that make safer sex messages appealing to patients, and that link pleasurable sex with safer sex. Materials with these messages have been shown to increase favorable attitudes toward the use of condoms.
Educate both women and men about the potential impact of infection on a developing fetus or on a newborn infant. The risk of HIV infection occurs through unprotected sexual activity with an infected partner. The risk of infection to either partner or the fetus remains throughout the pregnancy. Infection may occur at conception, but there is continued risk throughout the pregnancy. There is a need to use condoms for the barrier protection throughout pregnancy to prevent HIV infection of mother and unborn child.
Recognize that sometimes there is an imbalance of power in a relationship; a patient may be reluctant to insist on safer sex practices, including barrier methods, out of fear of being battered. A counselor may need to explore the cultural and social norms of the patient and recognize whether these might have an impact on the patient's ability to recognize being at risk for abuse or ability to acknowledge verbal, sexual, or physical abuse. Assist women to assess and avoid possible domestic violence should they initiate unwelcome changes in sexual practices. Explore options for protective measures for these patients. Appropriate pre- and post-test counseling should be offered to all patients.
Provide adolescent patients with information about the relationship among infectious diseases, drug use, and such risk-taking behaviors as the failure to use condoms; the exchange of sex for drugs, money, or shelter; and multiple sexual partners.
Many studies and common clinical experience indicate that the longer patients stay in treatment, the better the patient outcome and the less likely patients are to experience negative sequelae of their drug use. Dependence on drugs is considered a chronic and relapsing disease. Relapse is the inability of patients to maintain abstinence from drugs and is one of the core features of addiction. Maintaining the patient in treatment long enough to establish abstinence and working with the patient through sometimes multiple episodes of drug use is the overall theme of treatment. It is never appropriate to discharge a patient solely on the basis of drug use while in treatment.
Preventing the patient's return to drug use is an important strategy for reducing the incidence of infectious diseases. Maintenance efforts are also needed to help patients who initiate safer sexual behaviors to maintain them. Return to high-risk sexual behaviors, as well as drug use, can expose the patient and others to infection.
For patients not in long-term therapy such as methadone maintenance or a long-term therapeutic community, a powerful intervention - some would say the most powerful intervention - is to teach the patient during the time that he or she is in treatment how to access health care. Competent health utilization skills include the patient's knowing who the local health care provider is and how to get there. The counselor should work out insurance benefits with the patient, and if the patient is not eligible for insurance, that patient should know how to get care for medical emergencies. The patient should be in the habit of accessing care and making return visits. The patient should also know how and where to reenter the drug treatment system. During treatment, information should be provided about community-based programs that deal with ongoing recovery needs. These self-advocacy skills will serve the patient well once he or she is no longer in a treatment program.
The following are examples of counselor-based activities that can support the patient in treatment and reduce the possibility of a return to drug use:
Develop a positive and trusting relationship with the patient to encourage retention in treatment.
Encourage and support the patient to make a commitment to use no nonprescribed drugs by the end of treatment.
Encourage the patient's participation in self-help groups.
Provide skills training that is oriented to chronic and complex life problems, such as job-seeking.
Provide aggressive diagnosis and treatment for comorbid psychiatric disorders, particularly depression and anxiety.
Provide comprehensive counseling that includes drug avoidance skills. Help patients to identify individual risk factors for specific drugs. Define and develop coping strategies - such as anger management and social skills development - for different situations that the patient is likely to encounter. Teach patients self-management and social skills that assist them to create steady and self-affirming social supports and drug-free contacts, resist coercion, and improve decisionmaking. Teach patients relaxation and meditation techniques to mitigate the effects of stress and tension that may lead to the use of drugs.
Safer sex requires a lifelong change in behavior. Maintaining these safer sexual practices and not returning to high-risk behaviors is a continuing challenge.
Factors that are associated with a return to high-risk sexual practices include higher levels of unsafe sexual activity prior to behavioral change, perceptions that behavioral change does not offer protection from infection, failure to use condoms with a steady and "safe" sexual partner, negative attitudes concerning condom use, use of alcohol and other drugs, a lack of enjoyment of the sexual activity using safer sex methods, a strong preference for high-risk sexual activities such as unprotected anal intercourse, and social support for high-risk behavior.
The following examples of counselor-based activities can support the patient in maintaining safer sexual practices.
Counsel patients and their sexual partners regarding safer sexual practices, impediments to safer sex, and possible options for overcoming these impediments.
Conduct educational and counseling sessions that incorporate different ethnic and cultural perspectives concerning the use of condoms.
Offer coping skills and assertiveness training that assists patients in resisting pressures from partners to engage in unsafe sexual practices.
Provide counseling and other support for patients who test positive for HIV disease. Patients may give up previous safer sex behaviors once positive test results are received. Discuss the patient's risk for recurring infection, possible acceleration of disease, and the risk of infecting sexual partners if safer sexual practices are not maintained.
Provide case management services and followup support for patients, including referrals to medical care and social service agencies for housing, financial, educational, child care, employment, and legal assistance.
Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. Morbidity and Mortality Weekly Report 36(31):509'515, Aug. 14, 1987.
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