Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases
Treatment Improvement Protocol (TIP) Series 11

Purpose and Scope

For practical considerations, the screening instrument presented here does not attempt to identify the range of health problems that are common in persons with AOD abuse problems. Rather, it focuses specifically on those infectious diseases that are significant public health problems because of the risk of transmission to others.

That the scope of the screening instrument has been limited in this manner does not negate the importance of the many other health concerns in individuals with AOD abuse problems. Nevertheless, because many individuals with AOD abuse problems have poor access to general health care, any evaluation for STDs and HIV infection in these persons should include an overall assessment of reproductive health, including contraceptive needs, and education about disease prevention, including promotion of condom use.

Like the AOD screening instrument, the screening instrument for infectious diseases cannot, and is not intended to, replace a clinical evaluation. It should not be used as a substitute for laboratory tests or a thorough history and physical examination. Neither should it be used in an attempt to diagnose a particular disease or diseases. Rather, it is designed to identify aspects of an individual's lifestyle and behavior that may place him or her at risk for certain infectious diseases.

The presence of such risk factors, however, does not necessarily indicate that an individual has an infectious disease, just as their absence does not rule out this possibility. When such risks are identified, therefore, the individual should be referred for further assessment and a more thorough clinical evaluation. A basic standard of care, including assessment for the infectious diseases targeted by specific questions, should be met in all populations being screened.

In settings where certain clinical laboratory tests for infectious diseases are mandated (such as for TB or STDs), however, the purpose of a screening instrument is obviously not to determine which patients should receive those tests. Rather, the goal is to determine the level of risk for particular diseases and to identify those individuals who have active infection and for whom further clinical assessment is indicated.

Administration of the Infectious-Disease Screening Instrument

Two versions of the screening instrument for infectious diseases are presented in this chapter. The field version of the instrument (Exhibit 3-1), which contains only the screening questions themselves, can be used by workers in the field who may be working within time constraints. The annotated version (Exhibit 3-2) provides additional information with which screeners should become familiar before administering the instrument. This version indicates, for each question, the diseases for which an increased risk is present when an affirmative answer is given and the recommended referral actions to be taken. It also contains notes to the interviewer and suggested introductory statements that may be used to explain the purpose of the questions to the interviewee.

Linkages and Service Integration Models

Clinical linkages between the AOD treatment agency using the screening instrument and the clinical facilities providing diagnostic services for infectious diseases are essential to the effectiveness of any instrument. In the annotated version of the screening instrument (Exhibit 3-2), potential referral sites for infectious-diseases assessment or related care services are identified.

For a screening program for infectious diseases to be successful, a liaison is needed between the organization doing the screening and these facilities. In some cases, screening and clinical laboratory services may be provided in the same location, depending on local practice.

Program managers should periodically review the clinical services needed by clients and should identify providers of those services (see Chapter 4, section on "Referral"). In identifying providers to whom at-risk individuals can be referred, treatment programs should seek out those who are capable of providing prompt evaluations for infectious disease. Examples of provider agencies include:

• Primary-care clinics
• Community health centers
• STD clinics
• TB clinics
• Clinics providing prenatal care, family planning, and child health care
• Clinics providing early intervention for HIV infection

Training Resources

Treatment for AOD abuse and infectious diseases is a dynamic field. Workers in both of these areas must remain updated on the rapidly changing information in these disciplines, as well as the changes and trends in the populations with which they work.

Some resources for training are given here:

• "The Three R's of STDs: Risk, Recognition, and Response" (see Appendix B) is an introductory course offering information on prevalent STDs. Designed to meet the basic needs of outreach workers who deal with populations at risk for STDs and HIV, this course could be expanded andmodified for both infectious disease and AOD abuse workers.
• Many health departments operate outreach training efforts for staff involved in STD, HIV, and TB control. Many of these training courses are also open to nonclinical providers.
• "Core Curriculum on Tuberculosis" is available from the American Lung Association as a resource for background information about training.
• To assist in the training of AOD abuse workers, it may be possible in some areas for local infectious-disease workers to visit AOD abuse treatment sites to offer training in how to screen for infectious diseases.

Glossary for Infectious-Disease Screening

Chlamydia: A type of sexually transmitted infection; frequently asymptomatic in women, it can cause infertility, pelvic inflammatory disease, and

complications during pregnancy.

Diarrhea lasting >1 week: For the purposes of this screening instrument, this is defined as watery diarrhea, without any formed stool, occurring more than three times a day for a week or more.

Genital sore: An open, infectious sore, or chancre (not warts) on the genitals.

Genitals: The outer sexual or reproductive organs, including the vulva in women and the penis and testicles in men.

Gonorrhea ("the clap"): An STD that causes a discharge from the penis in men and can cause vaginal discharge, pain, infertility, and pelvic inflammatory disease (PID) in women.

NGU (nongonococcal urethritis): A sexually transmitted infection whose symptoms are similar to those of gonorrhea and can be differentiated only on the basis of laboratory tests. NGU is most commonly caused by the same organism that causes chlamydia.

Penile discharge: "Drip"; a discharge (not ejaculation or semen) from the penis, often associated with pain; it can be a symptom of infections such as gonorrhea or NGU.

Period: Menstruation; the time during the menstrual cycle when the lining of the uterus is shed. In most women, periods occur every 23-35 days and may last 3-7 days. A period should be distinguished from "spotting," which refers to small, intermittent amounts of bleeding. A missed period is often the first sign of pregnancy; a woman who has missed two periods in a row should receive a pregnancy test.

Positive HIV test: A blood test that is positive for antibodies to HIV, the virus that causes AIDS.

Positive skin test (Tine test, PPD test): A test for TB in which an injection is made into the skin of the forearm; a positive result is marked by a hard, red swelling at the injection site within 3 days. A PPD test must be interpreted by a nurse or doctor.

Rash (symmetrical): The rash of secondary syphilis. It can take many forms but is most commonly seen on the palms of the hands and the soles of the feet and is often scaly. Any rash affecting large parts of the body should be considered suspicious and should be evaluated. This type of rash should not be confused with track marks or abscesses from skin popping.

Sexual contact: Having sex of any kind: oral, rectal, or vaginal sex between any two people, regardless of their gender.

Sexually transmitted disease (STD): A disease that is spread through sexual contact.

Syphilis: An STD that can cause an ulcer or lesion on the genitals but can also spread to other parts of the body. The most common systemic form of syphilis is marked by a symmetrical rash on the palms of the hands and the soles of the feet. In its advanced stages, syphilis can cause major health problems, including central nervous system disorders, and death.

Tuberculosis (TB): A highly infectious disease that is spread through airborne droplets to people who have had close contact with an infected individual. TB is found most commonly in the lungs but can also be present in other parts of the body. It is characterized by fevers, night sweats, and weight loss, and is more common in HIV-infected and AOD abuse patients.

Vaginal discharge: A discharge of mucus and secretions from the vagina. Many women have a normal vaginal discharge; a "change" in vaginal discharge refers to alterations in quantity or characteristics such as odor, color, or consistency that differ from a woman's usual discharge.

Notes on the Screening Questions

1. This question is a lead-in intended to put the interviewee at ease.
   1. This question is asked because there is an increase in the incidence of TB among homeless individuals that is related to their crowded conditions and limited access to medical care. There have also been TB outbreaks in these settings.
   2. In certain jurisdictions, there is an increased risk of exposure to TB and HIV among individuals who have been incarcerated. This increased risk is related to crowded conditions (for TB) and to the common occurrence of sexual assault and unprotected sex among prison inmates. A positive response to this question should prompt referral of the individual for HIV testing and counseling in those jurisdictions where HIV is prevalent among prison inmates.
2. HIV-infected persons are at increased risk for TB and STDs. The individual's response to this question should be handled with sensitivity and care. Many HIV-positive individuals have not sought care because of lack of resources, fear of alienation from family and friends, or denial.
3. This question is intended to identify women who may be pregnant and who, in the setting of AOD abuse or infectious-disease outreach, have an increased risk of maternal-fetal transmission of syphilis or HIV.
4. This question is intended to identify individuals with latent TB who are, as a consequence, at risk for active TB. Although most individuals with positive TB skin tests do not have active TB, individuals who are in outreach populations likely to be screened for STDs and AOD abuse and who have positive skin tests should be referred for evaluation to determine whether they have active TB or HIV infection or should receive preventive chemotherapy for TB. Some individuals with a positive skin test may already have been treated for TB prevention; however, it is recommended that a further history be taken by the TB facility to which the individual is referred.
5. This question is intended to identify individuals with TB who are not already in contact, or have fallen out of touch, with their treatment facility. It is also intended to identify individuals who have been in contact with someone who has TB and who thereby have an increased risk of developing latent or active TB. In the non-HIV-infected population, the highest risk of developing active TB occurs within the first year after exposure and infection. In the HIV-infected population, however, development of active disease does not diminish dramatically with subsequent years.
   1. Although the first four symptoms listed in this question (fever, drenching night sweats, coughing up blood, and shortness of breath) are common among individuals with active TB, they are nonspecific and are also consistent with other diagnoses, including bacterial pneumonia, acute bronchitis, lung cancer, and HIV-related lung disease. In the setting of screening performed by AOD and STD service workers, HIV testing should be performed in addition to a general medical evaluation. Other symptoms include lumps or swollen glands in the neck or armpits, which may be present in individuals with extrapulmonary TB or AIDS-related conditions. Unintentional weight loss may identify individuals with latent or active TB or HIV infection; this is a very nonspecific symptom, however, and multiple other diagnoses are possible. Diarrhea lasting more than a week may be a sign of HIV infection but is also nonspecific.
   2. This question is intended to identify individuals who may be in contact with someone who has TB. These symptoms have been selected from those included in 7a. as being somewhat more specific and more likely to indicate a high degree of infectious risk.
6. Injecting drug users are at highest risk for HIV infection, whether or not needle-sharing is acknowledged. In addition, these individuals are at increased epidemiologic risk for other STDs and TB.
7. Cocaine has been linked to the presence of STDs, especially syphilis, and, in some parts of the United States, another genital-ulcer STD, chancroid. These diseases need specific treatment, are not easily diagnosed, and require that sexual contacts also be treated. Both the increased level of sexual activity associated with cocaine use and the presence of other STDs, such as syphilis, increase the risk of HIV infection.
8. A number of well-controlled studies have demonstrated that persons who have had an STD within the past 6 months are at risk for acquiring another STD. This supports the common-sense dictum that changing all aspects of sexual behavior, including increasing condom use, changing sex partner-selection practices, and reducing the number of sexual partners, is difficult.
   1. Genital sores could be symptoms of syphilis, herpes, condyloma, or chancroid, all of which are potentially serious STDs. Persons with genital ulcers also are at risk for HIV infection.
   2. Dermatologic problems are associated with secondary syphilis (especially in the case of a rash on the soles and palms) or HIV infection, which is associated with a large number of skin conditions. It is important to differentiate these skin conditions from chronic skin conditions and from dermatologic manifestations of drug use (e.g., abscesses from skin popping).
   3. Although most STDs in women are asymptomatic, vaginal discharge can be indicative of gonorrhea, chlamydia, trichomoniasis, or other STDs. It can also, however, be a symptom of a yeast infection that is not an STD.
   4. Painful intercourse, or dyspareunia, especially abdominal pain associated with penetration or orgasm, may be a symptom of early pelvic inflammatory disease. This condition is an inflammation that may involve the fallopian tubes, uterus, and other pelvic structures and, if left untreated, can lead to infertility.
   5. Penile discharge is nearly always a symptom of an STD. The discharge is usually persistent and may be associated, although not necessarily, with painful urination (dysuria). It usually represents either gonococcal urethritis (gonorrhea) or nongonococcal urethritis (NGU), which is often caused by chlamydia.
9. Having multiple sexual partners is associated with an increased risk of STDs and HIV infection.
10. This question is especially important in assessing an individual's risk for HIV infection. Approximately 50 percent of men who have acquired HIV infection via homosexual intercourse admit to this risk factor only after testing positive for HIV. The interviewer may need to talk about a male client's jail experiences in order to determine whether he has had active or recipient anal intercourse. Many men do not think of themselves as having "had sex" if they have been raped by another man or if they have had active anal intercourse (forced or otherwise) with another man in prison. All gay men (whether or not they are also substance abusers) should be targeted for STD education and prevention.
11. These activities are associated with an increased risk of STDs and HIV infection.
12. These activities are associated with an increased risk of STDs and HIV infection.