Drug use places individuals at risk for infectious diseases. As a result, treatment providers are increasingly aware that patients may need medical care, psychosocial services, and other resources, in addition to drug treatment. Treatment staff must be knowledgeable about infectious disease risk factors, screening procedures, and the impact such diseases may have on the course of drug treatment. In addition, treatment providers must be prepared to access a range of community-based services on behalf of their patients.
The following section addresses staff and community development issues for consideration by treatment program administrators. These issues include
Training staff to identify patients who are at risk for infectious diseases
Testing and vaccinating staff for certain infectious diseases
Assisting staff to overcome denial and resistance that may inhibit infectious disease screening and prevention efforts
Developing support networks for staff
Participating in community-based infectious disease screening and prevention efforts
Drug treatment staff are in an advantageous position to ensure that infectious disease screening is available to their patients. Many staff, however, may have little knowledge of or training in infectious disease screening.
Treatment staff need to be knowledgeable about infectious diseases that are common in treatment populations. It is essential to provide training on the risk factors for infection, risk reduction and retention in treatment strategies, symptoms of disease, screening procedures, and the range of appropriate medical treatments. Staff must also receive any assistance that may be needed to explore and resolve uncomfortable feelings and negative attitudes concerning the sexual practices and risk-taking behaviors of patients that may lead to infection.
Infectious diseases, particularly life-threatening ones such as AIDS and multidrug-resistant tuberculosis, can evoke strong reactions in staff. For example, some staff may feel uncomfortable and poorly equipped to interact with patients who are HIV positive. Feelings of anger toward women whose infants have been infected with sexually transmitted diseases and HIV may surface. The strong denial and depression of some infected patients may frustrate and discourage staff members who reach out to them. Self-doubt about their effectiveness can affect even well-trained and experienced treatment professionals.
Many of the infectious diseases addressed by this TIP are transmitted through sexual practices. Straightforward discussions with patients of their sexual practices can be important to their recovery and reduce the risk of infection.
Staff may encounter sexual orientations, behaviors, attitudes, and language quite different from their own. Behavioral standards held by staff may vary considerably from those held by some patients, and may be influenced by strongly held religious beliefs, cultural values, and other factors. Staff must be comfortable with their own sexuality and be willing to accept, without judgment, the differences of others.
Group discussions, informal seminars, and individual counseling can encourage staff to bring to the surface, acknowledge, and examine their own feelings and attitudes about sexual behaviors. Treatment programs that offer supportive training for staff can help them to develop accepting and nonjudgmental attitudes and create a climate of understanding in which patients can explore and change their behaviors.
It is one thing to theorize about the issues raised by HIV infection, but another to confront them when treating people living with HIV and AIDS. The HIV epidemic has led to increased psychological demands on drug treatment staff: patients do not get permanently well; the disease process is uncertain; and personal fears of infection may surface.
Some staff may find themselves angry and resentful about having to work with patients who are ill and even dying. Other staff may be able to support individuals in their recovery from drug use, but may not be prepared to work with patients who never get well.
Treatment programs with HIV-positive patients can take a variety of actions to support staff and patients:
Develop a program to continually inform staff and discuss with them the rapidly changing scientific information about HIV infection, including disease manifestations, opportunistic infections, and available treatments. Display brochures and toll-free telephone numbers for the Centers for Disease Control and Prevention (CDC) National AIDS Clearinghouse, and the AIDS Clinical Trials Information Service (ACTIS) so that staff can easily obtain information.1Place the program on mailing lists to receive updated materials on HIV and AIDS.
Train staff regarding the CDC's universal blood and body fluid precautions to prevent exposure to HIV, hepatitis B, and other bloodborne pathogens2,3and the Occupational Safety and Health Administration (OSHA) standards.4
Provide structured opportunities in a supportive atmosphere for individual staff to discuss their feelings regarding the demands and pressures that are placed on them.
Develop and maintain an updated resource file of community services.
Establish referral relationships with caregivers who specialize in HIV and AIDS.
Many staff of treatment programs are recovering from drug use and may view themselves as being at increased risk for infectious diseases. Some staff may be unable to face their own concerns about infection. As a result, they may resist discussing HIV and AIDS with patients, or avoid patients who test positive for this and other diseases. Staff who previously viewed themselves as competent may now consider themselves incompetent to work with some patients, particularly those who are HIV positive.
Treatment program administrators must be prepared to help staff acknowledge and gain insight into their feelings about possible infection with HIV and other infectious diseases. Strong resistance to and denial of these feelings can destroy the therapeutic relationship. These staff members will be less able to cope with the transference of patient feelings or may react to a patient with inappropriate emotional responses. Such unresolved feelings can also undermine staff retention.
Administrators need to understand that individual staff may not be able to work with every patient. Some staff may need additional training; others may require reassignment.
Treatment program staff who are in contact with patients are at increased risk for infection. The CDC recommends that treatment programs regularly test both staff and patients for tuberculosis and provide for appropriate medical care (CDC n.d.). The Consensus Panel is in accordance with the Occupational Safety and Health Administration Guidelines (OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030), which states that all employees whose jobs involve the risk of directly contacting blood or other potentially infectious materials (OSHA Categories I and II) must be offered hepatitis B vaccine free of charge. An employee who refuses to receive the hepatitis B vaccine must sign a vaccination declination form.
Risk-reduction strategies require patients to change their behavior to prevent disease and to promote a healthier lifestyle. Two highly successful strategies to reduce the risk of infectious diseases are abstinence from drugs and use of safer sexual practices. Research indicates, however, that some patients may not implement these risk-reduction behaviors and, if they are implemented, may relapse often.
Staff may find it frustrating to treat patients who do not follow their suggestions about risk-reduction behaviors and, as a result, jeopardize their own and others' health. Treatment programs can address these frustrations by creating an open and supportive environment, establishing internal staff support groups, and identifying professional support groups in the community that can be resources for staff.
Throughout treatment, patients respond to staff and the treatment process from the perspective of their cultural and religious values, beliefs, and traditions. For example, the meaning and significance of certain sexual practices and expressions may differ sharply in various cultures. Religious teachings about relationships, contraception, and other issues can be diverse.
The cultural and religious backgrounds of patients provide the context in which recovery from addiction and infectious disease risk-reduction efforts take place. It is especially critical that staff are aware of the nature and implications of the cultural and religious values, beliefs, and traditions of patients.
The high demand for drug treatment can place extraordinary demands on program personnel. The chronic nature of drug dependence, a lack of resources in the community, and other factors may lead to staff burnout and turnover. The emotional demands of treating the growing number of patients who are living with HIV and AIDS may contribute to staff demands.
To assist staff in their treatment efforts, treatment programs can provide for and support professional networking activities. They can
Establish informal support groups within the program that provide staff with opportunities to share their individual experiences and problems.
Provide information about existing community-based and professional groups and associations that offer opportunities for professional training and education.
Inform staff about referral resources for individual counseling, volunteer experiences, and other personal development activities.
Treatment providers need to provide for the safety of patients and staff by having in place policies and procedures that minimize the risk of infectious disease transmission, whether the setting is outpatient, residential, or hospital based.
The magnitude of the risk of disease transmission for staff varies considerably by type of treatment setting, patient population served, job duties, and area of the facility in which a person works. For example, the risk of tuberculosis infection may be higher in areas where patients are congregated, such as waiting rooms, prior to any examination.
The risk to patients of infection from treatment staff exists as well. Hepatitis B may be spread to a patient by an infected health care worker during certain invasive procedures where the health care worker may sustain a needlestick or laceration, resulting in possible exposure of the patient to infected blood. Although transmission of HIV from infected workers to patients has been extremely rare, transmission during invasive procedures remains a possibility. The use of universal precautions during the drawing of blood or other invasive procedures should be implemented.
The screening of patients in treatment for infectious diseases reduces the risk of disease transmission to other patients. The early identification, placement in respiratory isolation, and treatment of persons with active tuberculosis, in particular, should be an important consideration for treatment providers. For patients with acute viral hepatitis, guidelines on the precautions for handling blood and body fluids must be followed. For a patient with suspected or confirmed secondary syphilitic dermatitis, contact isolation is appropriate and, therefore, gloves should be worn by the caregiver.
In addition to testing and medical treatment, other precautions may be needed to prevent or reduce the spread of tuberculosis and, more recently, multidrug-resistant tuberculosis, among treatment populations and staff. These methods include
Local exhaust ventilation to the outside that removes airborne contaminants at or near their sources.
General ventilation that provides for dilution, air mixing, and negative air flow in rooms where a patient with possible tuberculosis may be coughing or sneezing as well as in rooms where sputum is induced or aerosolized pentamidine is administered.
Use of HEPA filters if air is recirculated.
Installation of ultraviolet (UV) lamps in exhaust air ducts as well as in patient care areas. In patient care areas, the UV light source must be shielded to prevent possible exposure of patients or employees to UV light.
Cleaning, disinfecting, and sterilizing patient-care equipment (CDC 1990).
State or local health departments can help drug treatment centers set up programs to protect their patients and themselves. The Centers for Disease Control and Prevention also publishes relevant guidelines and educational materials, including What Drug Treatment Centers Can Do To Prevent Tuberculosis. This document provides information about tuberculosis infection, screening, and preventive therapy, and provides recommendations for prevention of the spread of tuberculosis in drug treatment centers.
Drug treatment providers can play an important part in the screening and treatment of patients and staff for infectious diseases. Treatment populations are at high risk for certain infections, and their recovery and well-being can be improved by the careful application of screening policies, provision of appropriate care, and the implementation of environmental and procedural safeguards.
A variety of guidelines and advisories have been prepared to assist health care professionals and treatment providers in the prevention, screening, and treatment of infectious diseases. The following guidelines and advisories provide information and direction for treatment programs:
Centers for Disease Control. Recommendations for Prevention of HIV Transmission in Health-Care Settings, August 1987 - presents the universal blood and body fluid precautions to be used for all patients regardless of their bloodborne infection status. Precautions are pertinent for HIV, hepatitis B, and other bloodborne pathogens.
Centers for Disease Control. Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens In Health-Care Settings, June 1988 - clarifies and supplements the preceding report as it relates to particular body fluids, use of protective barriers, use of gloves for phlebotomy, selection of gloves, and changes in waste management programs.
Title 29 Code of Federal Regulations, Part 1910.1030. Occupational Exposure to Bloodborne Pathogens 1991 - presents the Occupational Safety and Health Administration's bloodborne pathogens standard and informs employees and employers of the risks of occupational exposure to such pathogens and how to reduce these risks.
Centers for Disease Control. Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS, August 1987 - presents recommendations for HIV testing, pre- and post-test HIV counseling, and the confidentiality of personal information.
Centers for Disease Control. Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Settings, with Special Focus on HIV-Related Issues. Morbidity and Mortality Weekly Report. Vol. 39, No. RR-17, December 7, 1990 - makes recommendations for reducing the risk of transmission to persons in health-care settings - including workers, patients, volunteers, and visitors.
Centers for Disease Control. Prevention and Control of Tuberculosis in U.S. Communities With At-Risk Minority Populations. Morbidity and Mortality Weekly Report. Vol. 1, No. RR-5, April 17, 1992 - recommendations of the Advisory Council for the Elimination of Tuberculosis for programs and services that will contribute to the elimination of tuberculosis in communities with at-risk racial/ethnic minorities.
Centers for Disease Control. National Action Plan to Combat Multidrug-Resistant Tuberculosis; Meeting the Challenge of Multidrug-Resistant Tuberculosis: Summary of a Conference; Management of Persons Exposed to Multidrug-Resistant Tuberculosis. Morbidity and Mortality Weekly Report. Vol. 41, No. RR-11,June 19, 1992 - presents three reports on MDR-TB: National Action Plan to Combat MDR-TB; summary of a CDC-sponsored national conference on MDR-TB; and practical guidelines for clinicians who manage persons exposed to patients infected with MDR-TB.
Centers for Disease Control. Update on Adult Immunization - Recommendations of the Immunization Practices Advisory Committee (ACIP). Morbidity and Mortality Weekly Report. Vol. 40, No. RR-12, November 15, 1991 - provides information on vaccine-preventable diseases; indications for use of vaccines, toxoids, and immune globulins recommended for adults; and specific side effects, adverse reactions, precautions, and contraindications. Provides immunization recommendations for adults in specific age groups and for adults with special immunization requirements because of occupation, lifestyle, travel, environmental situations, and health status.
Title 42 Code of Federal Regulations, Part 2. Federal Regulations on Confidentiality of Alcohol and Other Drug Treatment Records - presents regulations concerning the disclosure of patient information, including the limited conditions under which disclosures are permitted.
Centers for Disease Control. Recommendations for Prophylaxis Against Pneumocystis carinii Pneumonia for Adults and Adolescent Infection With Human Immunodeficiency Virus, by U.S. Public Health Service Task Force on Antipneumocystis Prophylaxis for Patients With Human Immunodeficiency Virus Infection. Morbidity and Mortality Weekly Report. Vol. 40, No. RR-12, 1992 - prophylactic agents and regimens for adults and adolescents are recommended and discussed.
Centers for Disease Control. Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures. Morbidity and Mortality Weekly Report. Vol.40, No. RR-8, July 12, 1991 - presents recommendations to provide guidance for prevention of human immunodeficiency virus and hepatitis B virus transmission during exposure-prone invasive procedures.
The use of drugs and incidence of infectious diseases are not restricted to certain population groups or geographic areas. They are problems that exist in all communities, and group efforts are needed to prevent and treat them.
Drug treatment programs must be part of the fabric of community life. The recovery of their patients depends, in part, on how well they contribute to and are linked with the resources of the community. The following initiatives can strengthen community and treatment program resources and responsiveness to patient needs:
Initiating and participating in education and training efforts to inform community residents and other service delivery staff about drug use and infectious diseases, including incidence and prevalence data, transmission routes, high-risk behaviors, symptoms, and treatments. Education and training sessions can be offered in schools and for church groups, civic organizations, and professional associations.
Seeking information and training support from community-based organizations and targeting audience groups. Community members can be invited to share and discuss with staff their traditions, cultural values, and religious perspectives.
Facilitating and participating in networking among health care agencies, social service organizations, mental health providers, patient support groups, and representatives of populations at risk for use of drugs and infectious diseases.
Assigning staff to represent the treatment program as part of interagency efforts to develop and enhance the service delivery system. Opportunities can be identified to foster greater understanding, develop new initiatives, consolidate resources, identify and fill gaps in service, and create referral agreements.
1. Centers for Disease Control and Prevention National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20850. 1-800-458-5231.AIDS Clinical Trials Information, P.O. Box 6421, Rockville, MD 20850. 1-800-874-2572.See also Appendix D - Resource List. 2. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. Morbidity and Mortality Weekly Report 36 (Supplement No. 2):1987. 3. Centers for Disease Control. Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. Morbidity and Mortality Weekly Report 37(24):377'388, June 24, 1988. 4. 29 CFR, Part 1910.1030.
Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related issues. Morbidity and Mortality Weekly Report 39 (RR-17):1-29, 1990.
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