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Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with HIV/AIDS. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2000. (Treatment Improvement Protocol (TIP) Series, No. 37.)

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Substance Abuse Treatment for Persons with HIV/AIDS.

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Chapter 5—Integrating Treatment Services

Substance abuse treatment is moving away from more intensive treatment programming toward less intensive, shorter term treatment; HIV/AIDS treatment also has shifted from intensive inpatient care to focus more on primary, clinic-based care. Providers are under pressure to perform with less money, less time, and more challenges. As a result, substance abuse treatment and HIV/AIDS treatment should reflect their interconnected relationship by coordinating as much as possible to maximize care for persons having both HIV/AIDS and substance abuse disorders. Substance abuse treatment programs and their personnel must stretch their dwindling resources by integrating the care they provide with that of other service providers.

HIV/AIDS Services in Substance Abuse Treatment

HIV prevention is an essential part of substance abuse treatment and relevant to any treatment setting. Addressing HIV/AIDS issues beyond prevention, however, is much more complicated. For the person who abuses substances and has HIV/AIDS, the complicated physical and mental health problems--such as tuberculosis (TB); hepatitis A, B, and C; sexually transmitted diseases (STDs) other than HIV/AIDS; dental problems; diabetes; poor nutrition; dementia; and depression--require that each substance abuse treatment setting incorporate a holistic, integrated model of treatment. Treatment for the client with HIV/AIDS must be carefully reviewed. Important areas to examine are issues of confidentiality, quality of services to clients, complex treatments, staff training, client readiness, and use and allocation of limited resources.

Persons with HIV/AIDS and substance abuse disorders require more than the typical physical examination and TB test. The addition of nontraditional treatment components--such as nutritional counseling, exercise regimens, education about testicular self-examination (for men), breast exams (for women), and ways to lower cholesterol--will greatly enhance the mental and physical health of persons with HIV/AIDS. For persons with a long history of substance abuse, the possibility of mental health issues and psychiatric disorders should be explored. Many inpatient treatment and detoxification settings use a nurse to assist with physical withdrawal symptoms, medications, and occasional medical concerns. This type of care can be augmented by (1) incorporating some of the treatment components listed above, (2) using health educators and nutritionists, and (3) cross-training the treatment staff.

People with HIV/AIDS are in need of all levels of treatment for substance abuse disorders. In the early days of the HIV pandemic, individuals with HIV/AIDS did not have access to a full range of substance abuse treatment services; even today, some providers still do not offer all levels of care. Often, clients with HIV/AIDS present only their substance abuse for treatment. Their fear of disclosing HIV/AIDS status, their denial of having a substance abuse disorder, the lack of training of staff and clients, and homophobia make treatment of the "whole" person very difficult. Furthermore, the fact that HIV/AIDS case managers and health care providers are not adequately trained to screen and assess for either substance abuse disorders or psychiatric disorders and refer to appropriate treatment has limited the range of services for clients with HIV/AIDS who have substance abuse disorders.

Treatment of HIV/AIDS continues to become more complex and specialized. The resources and time needed to provide ongoing HIV/AIDS medical care are great. For the most part, it is unrealistic to expect these services to be provided within substance abuse treatment settings, but it is imperative that every substance abuse treatment program maintain a close relationship with HIV/AIDS medical care providers within its community and surrounding area. Drug and alcohol counselors and HIV/AIDS service providers must continue to develop their skills in assessing and establishing appropriate treatment plans that support the "whole" person. Medical providers and counselors can work together closely to support medical and substance abuse treatment and adherence to treatment goals. This includes establishing agency agreements and creating formal referral mechanisms.

Issues of Integrated Care

Early Intervention Settings

Early intervention often can be the first step in addressing HIV/AIDS issues in substance abuse treatment, or vice versa. The practice in early intervention for persons with substance abuse disorders has been to provide HIV pre- and posttest counseling to stop the spread of AIDS. Today the emphasis is on testing, treatment, and followup. The latest medical research indicates that beginning combination therapy early in the pathogenesis of HIV/AIDS may enhance the health of the client over a long period (Hodgson, 1999). This will result in fewer opportunistic infections and, as revealed by the latest statistics from the Centers for Disease Control and Prevention (CDC), fewer people dying of HIV/AIDS-related illnesses (Vittinghoff et al., 1999). Now that there are known benefits to early treatment, counselors can feel justified in encouraging clients to be tested and then begin treatment (see Chapter 2 for information about treatment).

Another trend in early intervention is increased use of medical case management for persons with HIV/AIDS and of case management for those at high risk for becoming infected with HIV, specifically persons with substance abuse disorders. The complex regimens associated with HIV/AIDS care, along with the challenges of substance abuse treatment and aftercare, make it essential to include case managers as part of a substance abuse treatment program's responses. Many treatment centers and HIV/AIDS service organizations are receiving funding for case managers, who are sometimes called early interventionists. (See Chapter 6 for a more in-depth discussion of case management.) This service component targets those at high risk for HIV infection and provides long-term case management services focusing on risk reduction and supportive services. Risk reduction is defined with the client and based on the client's specific needs. This might mean, for example, that the case manager and client are focusing on other care needs such as dental care, mental health care, or finding stable housing. See Chapter 4 for discussion of risk reduction.

Once the client with HIV/AIDS is ready to obtain HIV-specific medical care, the case manager or early interventionist will focus on supporting medical adherence and maintenance of sobriety along with assisting with the psychosocial adjustments and the need for continued support and resources.

Early intervention also can be supported through the efforts of outreach workers or other community-based workers. Outreach workers have been an important part of HIV prevention work for many years. They have been involved in many high-risk communities and have learned much about the specific needs of high-risk clients. Outreach workers can have a great impact in helping people obtain substance abuse and HIV/AIDS treatment. Outreach workers also recognize that many people at high risk have ongoing medical, housing, and social problems and that neither HIV/AIDS nor substance abuse treatment may be the client's most pressing and immediate need.

Many clients from poorer, disenfranchised communities are dealing with basic survival needs (see Maslow's Hierarchy of Needs, in Maslow, 1970), such as food, escaping violence from an abusive partner, or keeping the electricity from being cut off. Early intervention within the context of the "culture of poverty" begins with tangible concrete service provision and establishment of trust and rapport. From this perspective--"starting where the client is"--the worker may spend time talking and getting to know the client while helping to find emergency assistance for the electricity bill and food. The worker will gradually shift from helping with the "here-and-now" challenges to developing a trusting relationship based on mutuality, which will allow the client and worker to eventually discuss long-term goals that may lead to sobriety, safer sex practices, and establishment of a more stable environment.

Obstacles to Integrated Care

Because of the many overlapping issues related to substance abuse and HIV/AIDS treatment and prevention, agencies providing both services must coordinate their efforts to offer clients a full array of services. There are, however, significant barriers to complete integration of services. Some of these are:

  • Differences in priority. A client entering either substance abuse treatment or HIV/AIDS treatment faces a myriad of required activities and treatments. Some of these activities may appear mutually exclusive, creating significant challenges in developing a treatment plan for clients seeking treatment in both areas.
  • Differences in philosophy. Substance abuse treatment agencies often operate from an abstinence model. HIV/AIDS service and medical treatment organizations and public health professionals frequently use a risk-reduction model. This philosophical difference can create dramatic conflict in programs and approaches.
  • Differences in funding. Public funding of prevention and treatment of substance abuse has generally focused on drug interdiction and prevention. Conversely, HIV/AIDS funding has focused on treatment and research. Although still inadequate, higher levels of social service funding are available for persons diagnosed with HIV/AIDS. Funding sources rarely recognize the challenges of coexisting disorders; however, some resources exist. Although funding amounts are difficult to obtain, both Title I and Title II of Ryan White allow for the funding of substance abuse treatment for HIV-positive individuals (see Chapter 10).
  • Differences in training. Many substance abuse treatment providers are experts at detecting substance abuse disorders and developing treatment goals for substance-dependent clients but at the same time do not thoroughly address their clients' medical needs. Similarly, many public health providers do not address a client's possible substance abuse while dealing with the client's latest STD. Clearly there is a need for ongoing staff inservices and cross-training. The recently published CDC/CSAT cross-training curriculum, HIV/AIDS, TB, and Infectious Diseases: The Alcohol and Other Drug Abuse Connection, A Practical Approach to Linking Clients to Treatment, is an excellent resource for both mental health treatment providers and alcohol and drug counselors.

Any effort to develop integrated treatment for substance abuse disorders and HIV/AIDS, either within a single agency or through individual care plans, should include the following components:

  • Shared philosophy and priorities between the care providers in regard to the client. The client must receive clear and consistent messages if he is to act as a full partner in his care.
  • A strong case management model. One professional within the care system should be designated to work with the client as the lead case manager across all agencies. The case manager must be empowered to negotiate schedules and control resources to develop a care plan with the client. Within each client care team, only one provider should have the title of case manager. (For more information on case management, please refer to TIP 27, Comprehensive Case Management for Substance Abuse Treatment [CSAT, 1998b].)
  • Social services at the core of the treatment plan. For many clients, the first priority is day-to-day survival. The individual's definition of survival may vary and may include housing, food, financial services, family maintenance, or work. Without addressing these basic client priorities, treatment cannot be successful.
  • All providers within HIV/AIDS and substance abuse treatment trained about the services available and requirements of the other setting. For example, several federally funded programs subsidize housing costs for persons with HIV/AIDS. These same services may not be available to an individual who is in recovery for substance abuse only. Availability of housing for an individual with coexisting disorders could be the determining factor in maintaining treatment adherence.
  • Cooperative eligibility determinations, which often are a key barrier to achieving integrated care. Every agency establishes requirements for its own purposes, including varied documentation. It is essential that the client newly in recovery or recently diagnosed with HIV/AIDS be assisted in dealing with bureaucratic requirements that are often redundant. Workers from each agency must be willing to cross agency lines to cooperate with colleagues and advocate on behalf of the client.

Developing integrated services is rarely accomplished at the administrative level. Although solid, formal understandings and agreements are helpful, most success actually is achieved at the direct-care staff level. When working with two closely linked diagnoses that are also tied to other diseases such as TB, hepatitis, and mental disorders, the care provider cannot afford to think or work solely within the confines of his own agency or personal experience. Instead, the provider must build bridges to other providers that enable clients to address all of their needs.

Dealing With Ongoing Substance Abuse

Many HIV-infected substance abusers are unable to maintain total abstinence from substance abuse after the abrupt discontinuation at the start of treatment. In dealing with clients' ongoing substance abuse, treatment programs must find a balance between abstinence and public health approaches to substance abuse treatment.

Abstinence model

This approach traditionally uses confrontation, consistency of expectations, behavioral contracting, and limit-setting as treatment modalities, with the goal of achieving abstinence from all substance abuse. This approach might require termination from treatment if abstinence is not achieved.

Public health model

This approach, sometimes called the risk- reduction model, emphasizes incremental decreases in substance abuse or HIV risk behaviors as treatment goals and tries to keep clients in treatment even if complete abstinence is not achieved. The public health model sacrifices some of the consistency of expectations that is such an important part of abstinence-oriented treatment. Instead, it seeks to keep substance abusers in treatment and to reduce, if not eliminate, substance abuse- and HIV-related risk behaviors. Each increment of change is viewed as a success, which helps clients see that they can positively affect their lives. By contrast, a model that regards less than complete abstinence as failure may reinforce clients' feelings of helplessness and hopelessness at their inability to sustain behavior change.

If substance abuse is placed on a continuum from abstinence to severe abuse, any move toward moderation and lowered risk is a step in the right direction and not incongruous with a goal of abstinence as the ultimate goal of risk reduction (Marlatt et al., 1993). Moreover, research indicates that substance-abusing individuals who are employed and generally functioning well in society are unlikely to respond positively to some forms of traditional treatment that, for example, tell them that they have a primary disease of substance dependency and must abstain from all psychoactive substances for life (Miller, 1993).

Flexibility is needed with HIV-infected clients because of the importance to public health of keeping them in substance abuse treatment; they are likely to continue to put others at risk if they leave treatment and resume injection or other drug use. In order to reduce the spread of HIV, clinicians may need to work with these clients even if they continue to abuse substances.

Every substance abuse treatment program must establish a balance between the abstinence and public health approaches, based on the needs of the community it serves. For example, even a program that stresses abstinence may use a risk-reduction model to educate active injection drug users about safer sex and drug use practices, such as using condoms and sterilizing syringes with bleach.

Differential standards of care

One current example of a flexible approach to substance abuse treatment of HIV-infected clients is the differential standards of care approach used by the Opiate Treatment Outpatient Program at San Francisco General Hospital's Substance Abuse Services. This approach applies varying clinical expectations and levels of care to clients based on assessment of the clients' level of functioning in the areas of physical health, mental health, social support, and housing.

The treatment staff use a "standards of care" assessment tool to determine the level of severity of impairment among methadone treatment patients with HIV (see Appendix I for a copy of this tool.) Impairment is assessed along three domains of functioning--physical health, mental health, and social resources. The latter domain represents both social support and housing. Assessment of severity of impairment takes place during a team meeting in which substance abuse counselors, the program physician, nurses, and the program social worker offer input regarding each domain. Treatment decisions are subsequently made by consensus in accordance with this assessment. Clients with evidence of severe impairment are generally approached with lower expectations for treatment outcome (i.e., applying risk-reduction principles), and higher functioning clients are approached with higher expectations (e.g., maintaining substance-negative urine tests, attending self-help group activities).

Referral to and Coordination Of Linkages

Development of care networks

Counselors who work with HIV-positive individuals with substance abuse disorders should familiarize themselves with the local AIDS Service Organizations (ASOs) and substance abuse treatment services. Listed below are questions that all counselors who treat substance-abusing individuals with HIV/AIDS should be able to answer:

  • What area physicians or clinics with experience in HIV/AIDS issues accept HIV-positive patients? Which ones accept Medicaid, Medicare, or specific insurance plans?
  • What ASOs exist in the area?
  • Are Ryan White Funds available in the area? If so, who administers them?
  • Are Housing Opportunities for People with AIDS (HOPWA) funds available in the area and if so, who administers them?
  • Does the State provide medical coverage for single adults who have no dependents, for indigent patients, or for undocumented workers?
  • Where can an individual with HIV/AIDS obtain inpatient, residential, intensive outpatient, extended outpatient, or detoxification treatment for substance abuse disorders?
  • Are area substance abuse treatment programs prepared to deal with a client's complicated HIV/AIDS treatment regimen?
  • What forms of support are offered in the area to help with loss, death, and dying? Are there community mental health centers that can provide psychiatric evaluation, medication management, neuropsychological testing, or case managers with skill and sensitivity toward those with mental disorders?
  • Are culturally appropriate local support groups available for persons living with HIV/AIDS and substance abuse disorders?
  • What financial assistance is available to clients to pay for expensive HIV/AIDS treatment?
  • What are the eligibility guidelines for the State's AIDS Drug Assistance Program (ADAP), and what drugs are covered by the program?

Creating medical referral networks or institutional linkages is essential and must be a top priority for anyone working with a person with HIV/AIDS. Counselors and case managers can often make the job of working with persons with substance abuse disorders easier for medical care providers by providing consultations, followup, and help acquire resources that affect the client's ability to obtain prescriptions, come to appointments, and so on. Service providers and agencies must coordinate with medical providers, including private doctors, public health clinics, and specialized HIV/AIDS facilities and treatment centers. (See Chapter 6, "Accessing and Obtaining Needed Services.") Providers should also explore the possibility of becoming members of their community's Ryan White Title II consortium of providers. There are usually two key areas in which providers can begin making contacts:

  1. Local city, county, and State health departments. Every State has an HIV/AIDS or substance abuse treatment coordinator, or both (perhaps through the State department of mental health services or substance abuse treatment services). These coordinators should be able to provide information about medical resources and special funding.
  2. Regional and area teaching hospitals and medical schools. These programs often have special indigent care funding and specialized HIV/AIDS treatment programming and funding. They might also be research sites for HIV/AIDS clinical trials that could not only help clients access newer treatments but also provide high-quality, specialized HIV/AIDS care within their specific substance abuse treatment protocols.

When attempting to coordinate a service plan between several agencies or resources, counselors may encounter barriers, both expected and unexpected. Here are several issues that could arise:

  • The clinic or service provider from whom the counselor is attempting to obtain services may be too busy to talk. The counselor may have difficulty communicating the request directly to a person (rather than voice mail).
  • The service provider may consider HIV/AIDS a specialty condition and thus may be unable to provide the level of care the client needs.
  • Long waiting lists and applicant pools for services and resources may exist.
  • Other service providers may be judgmental or discourteous because the client is HIV positive or substance dependent.
  • Few or no services are available for the HIV-positive client living in rural or isolated areas.
  • "Turf" issues may cause providers to make inappropriate referrals or be resistant to serving a referred client.

Networking with other agencies is a valuable tool for the counselor who is attempting to coordinate a service plan for a client with HIV/AIDS and a substance abuse disorder. It is essential to find out what services are offered in the local and surrounding areas.

In addition to standard treatment services, less traditional therapeutic interventions or culturally based interventions may be available to clients. For instance, acupuncture is being used for detoxification and outpatient treatment for addictive behavior. Massage is a nurturing, hands-on therapy that can promote a positive attitude in the client. Yoga and breath training may be available to help a client stay focused on sobriety and a path toward health.

Holistic knowledge of living systems, both physical and mental (the mind(body connection), can be integrated into the treatment plan. Helping the client "tune into" the connections between thoughts, emotions, and physical health can facilitate treatment regimens.

The Internet can provide helpful treatment information and resources to the client. Many public libraries offer free Internet access. Local colleges usually have Internet access available to the public for free or for a small fee. If a remote area lacks resources but a client must live there, the counselor faces challenges in networking and resource coordination that are clearly different from those in urban settings.

When establishing a network of care coordination, the provider must consider the issue of confidentiality (see Chapter 9). Providers must be aware of State and Federal laws and professional codes of ethics, along with agency and community policies and agreements (see also Appendix E for sample codes of ethics). Confidentiality raises issues of consent, disclosure, and release of information. Because linkages and referrals for needed resources are part of the client's overall treatment plan, the client should not be surprised that other treatment providers will be contacted and that releases of information will be needed. The client might have fears about disclosure--talking about this fear with the client is important. The counselor and client must develop a partnership that places the client in an active, empowered position so that she understands the value of connecting with other agencies. Eligibility for services at another agency may be based on need, and the agency may inquire about the client's condition to ascertain whether it pertains to the agency's services.

The counselor should also understand the difference between the terms "informed consent" and "consent." "Informed consent" refers to a client's consent to begin treatment after she understands her treatment options and the advantages and disadvantages of each option. "Consent" refers to the client's consent to allow confidential information to be disclosed as needed (see Chapter 9).

Case Finding

Case finding, or identification of individuals at higher risk for HIV infection, involves multiple levels of effort. Substance abusers may be located at public welfare agencies, emergency medical care facilities, other medical care settings, the criminal justice system, homeless shelters, STD clinics, churches, in the street, or in community settings. For example, hair and nail salons in regions with high numbers of injection drug users are common settings for locating women at risk. In traditional health care settings, case finding may consist of basic questions to determine risk-group membership (for more information on this topic, refer to TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians [CSAT, 1997]). In the criminal justice system, urine samples may be collected to identify substance abusers, and, again, basic screening questions regarding risk behaviors may be helpful.

Confidential HIV/AIDS counseling and testing (C & T) locations represent a major part of the screening effort, with as much as 25 percent of the CDC HIV prevention budget going to C&T (Phillips and Coates, 1995). Unfortunately, many individuals at highest risk for HIV infection are unlikely to seek HIV testing for a number of reasons, including distrust of institutional settings, fear that the test results will not remain confidential, and fear that test results might be positive for HIV, thereby resulting in increased stigma, discrimination, and changed social relationships (Hull et al., 1988; Myers et al., 1993). The impact of C&T by itself on risk behaviors is unclear (Higgins et al., 1991; Wolitski et al., 1997).

Another means for locating this hidden population is through the use of community-based street outreach (Booth and Wiebel, 1992; Iguchi et al., 1992; Watters et al., 1990). A common form of community-based street outreach is the indigenous leader outreach model, which uses recovering substance abusers to locate and contact injection drug users. Indigenous outreach workers have the advantage of knowing the local substance-abusing community and the informal rules governing their behavior. These workers are therefore able to develop trusting relationships with active substance abusers, allowing them to more effectively intervene. However, this can occasionally trigger relapse in outreach workers; consequently, outreach programs should provide a forum in which workers can discuss the potential for relapse so that they will be prepared to revisit old issues while working with active substance abusers.

Early versions of this approach stressed HIV/AIDS prevention and the distribution of items to facilitate compliance with risk reduction, such as condoms, bleach, sterile water, or alcohol swabs. Injection drug users were encouraged to reduce AIDS-related risk along a hierarchy of behavioral options that emphasized taking some action, no matter how small, to reduce overall injection drug-related harm (see Chapter 4 for more information on risk reduction). Although outreach workers counseled abstinence and "getting off the needle," they recognized that in the real world, abstinence is not always immediately achievable and that a range of risk-reduction behaviors should be promoted (Wiebel et al., 1993). Once injection drug users took steps in the right direction, further steps were encouraged. One risk-reduction message is that injection drug users should always use new, sterile syringes when injecting (Normand et al., 1995). (See Chapter 4 for discussion of syringe exchange programs.)

Some outreach programs also used street outreach workers to distribute coupons redeemable for free treatment (Booth et al., 1998; Bux et al., 1993; Jackson et al., 1989; Sorensen et al., 1993). These interventions demonstrated that injection drug users will enter treatment in large numbers once barriers to treatment entry are diminished. In the case of the treatment coupons, financial barriers were lessened. Other investigators removed barriers, for example, by decreasing the typically long delay between first contact with a treatment program and the scheduled treatment intake. This "rapid intake" approach significantly increased the number of injection drug users entering treatment, without impact on rates of treatment retention (Dennis et al., 1994; Festinger et al., 1996; Woody et al., 1975).

Home-Based Services for Clients With End-Stage HIV/AIDS

Recent breakthroughs in treatment medications, which can potentially extend the life expectancy of someone with HIV/AIDS, have raised expectations that HIV/AIDS can be managed as a chronic disease instead of a terminal one. However, many substance abusers, even the most disciplined followers of the daily, multidosed medication regimen, are discovering that their bodies do not respond positively to these treatments. Many more people with HIV/AIDS lack basic access to these medications because of an historical lack of access to health care services.

This lack of positive response and access to life-extending treatments causes many clients, their families, and their health care providers to examine end-of-life issues. Clients with end-stage HIV/AIDS present a challenge for counselors, who must create partnerships with other health care providers to integrate treatment services for these clients and who must deal with multiple stressors related to home-based caregiving.

Roles of health care team members

Such partnerships involve working with home health staff, hospice staff, and family caregivers. To define the relationship between the professional and the other health care team members, and to create goals and integrate treatment services, it is important to recognize the role of each member of the health care team.

Home health

The home health care team provides skilled nursing care for patients who are homebound. These services may also include social work, physical therapy, occupational therapy, respiratory therapy, and home health aides. Clients receiving Medicare benefits can receive home care services if they are homebound, have services provided under a plan of care, have only reasonable and necessary services reimbursed, require a skilled service, and require service only on a part-time or intermittent basis. Some coverage also is provided by Medicaid and private insurance policies (which may differ from State to State).


The hospice care team provides all the same services as home health but with a focus on palliative or comfort care for the client. The physician's order must certify a life prognosis of fewer than 6 months. The hospice team members focus on spiritual, psychosocial, and emotional issues as well as the physical needs of the client. Coverage is provided by Medicare, Medicaid, and some insurance policies (this may differ somewhat from State to State).

Many in the health care field find it difficult to educate clients about home health and hospice services; Figure 5-1 should help distinguish between these two options.

Figure 5-1: Medicare and Medicaid Coverage of Home Health and Hospice Services.


Figure 5-1: Medicare and Medicaid Coverage of Home Health and Hospice Services.

Family caregivers

Whether home health or hospice services are used by the family at home, competent family members will likely be the primary caregivers for the client with end-stage HIV/AIDS and should not be supplanted by professional health care providers. It is helpful to define "family" broadly to include nontraditional families. Family may include significant others--individuals who may be unrelated but have a close relationship with the client and provide for the client's physical, emotional, and spiritual well-being. Family caregivers can include same-sex partners, friends, and fellow support group members.

It is important for counselors to remember that family members who provide close support to the seriously ill client often need support themselves. Social service support for the family is a cornerstone in the provision of coordinated, comprehensive care to HIV-infected substance abuse disorder clients. Home-based services may be critical in enabling a family to remain together and may be more cost-effective than institutionalizing the ill family member.

Stressors in home-based caregiving

The counselor must be aware of the stressors that can make home-based service delivery more difficult.

Stigma of HIV/substance abuse

Many professional caregivers lack education and experience in working with homebound clients with HIV/AIDS and substance abuse disorders. Even though some home-based service providers employ staff with mental health/substance abuse experience, many do not, and it is important that the counselor intervene in providing coordinated home-based services.

Substance abuse in the home

The client may have a relapse, especially when faced with approaching end-of-life decisions. Both professional and family providers may be unable to continue to provide needed care when faced with a client/family member who has relapsed and who is not capable of following the plan of care. It is critical in these situations that the client and caregivers continue receiving substance abuse counseling and intervention in the home setting. However, providers should be aware that the home setting can present certain problems, including the possibility that other substance-abusing persons in the client's home are stealing or utilizing opioids intended for the client.

Economic needs

Even though home-based services are covered by some Federal, State, and private resources, additional stressors can affect the delivery of services. The loss of income from either the client or the family caregiver can create potential problems with housing, health insurance, nutrition, and medications. The counselor must be aware of how these conditions can disrupt the plan of care.

Emotional needs

As the client continues to need more interventions, the roles of family caregivers change, and health care professionals must be aware of the need to adapt to these changes. Family caregivers will need support in processing the anticipatory grief of losing their family members. After the client's death, help with funeral arrangements and further support of family members, who may also be dealing with their own addiction issues, may be needed.

Examples of Integrated Treatment

Provided below are examples of successful programs that have linked HIV/AIDS and mental health treatment. Also discussed are common elements of effective programs and future challenges to building effective treatment programs.

Active Referral Linkages for HIV/AIDS and Mental Health Treatment

Bailey Boushey

A successful program in Seattle, Bailey Boushey is a skilled nursing facility originally created for persons with AIDS (given the more recent changes in AIDS treatment, the facility's beds are sometimes used for other kinds of patients such as transplant or oncology patients). The facility's most relevant feature is its day health program, which provides services mostly to HIV/AIDS, mentally ill, and substance-abusing persons. Treatment includes the services of mental health professionals as well as substance abuse treatment specialists.

Montrose Center

Montrose Center, in Houston, Texas, has years of experience working with and strong linkages to the Thomas Street HIV/AIDS Clinic, private doctors, and area substance abuse treatment programs. It includes intensive treatment services, outpatient support/therapy groups at various locations, and outreach programs. Its providers have a good reputation for working with dually and triply diagnosed clients (i.e., HIV/AIDS, mental health disorders, and substance abuse). The staff consists primarily of therapists with licensed professional counselors (LPCs) and masters-level social workers.

Hilltop Center

Hilltop Center, in Longview, Texas, is a new program offering inpatient treatment services for multiply diagnosed clients throughout Texas. The program has developed a strong linkage to traditional treatment programs, but also focuses on a variety of alternative models. Its providers have a positive relationship with funders and a strong commitment from the State drug and alcohol services department. This program also includes an evaluation component. The staff are well trained, motivated, and focused on the importance of preventing clients from "falling through the cracks."

The AIDS Health Project

The AIDS Health Project in San Francisco offers mental health services to HIV-infected clients with and without substance abuse disorders. It works in collaboration with Shanti and the San Francisco AIDS Foundation through the HIV Services Partnership. Shanti provides volunteers for practical and emotional support, and the AIDS Foundation provides case management housing in a treatment-centric model that includes treatment advocates to work one-on-one or in groups with clients struggling with HIV and substance abuse issues and/or mental health issues. The Project is committed to working toward a fully funded "treatment on demand" service for residents with substance abuse treatment challenges.

Opiate Treatment Outpatient Program

The Opiate Treatment Outpatient Program (OTOP) at San Francisco General Hospital treats nearly 160 HIV-positive patients as part of its 250-patient methadone treatment program. OTOP offers substance abuse treatment combined with onsite psychiatric care and HIV/AIDS primary care.

Common Elements of Effective Programs

The challenges to developing effective treatment programs that meet the needs of those who are dually and triply diagnosed continue to be substantial. Few programs across the United States have been able to maintain a high level of success along with the needed funding levels. The cost of these types of programs is a continuing challenge. Some programs are just now exploring new methods of treatment, although some began providing new services simply out of desperation and frustration.

Effective treatment programs, although they vary greatly, have common elements that contribute to their success. These traits, discussed below, include the program's treatment philosophy, outreach efforts, staff training, support groups, community linkages, and funding.

Treatment philosophy

The clear and repeated message from effective programs is that counselors must "start where the client is." Offering what the client wants is the key. It is essential that counselors shift from the rigid thinking that there is only one way for clients to become healthier and to recover. Effective programs have discovered that different treatment modalities are not mutually exclusive and can indeed coexist, particularly when it comes to risk reduction. Nontraditional treatment, neurotherapy, biofeedback, acu-detox, and other alternative therapies can be encouraged and integrated into clients' treatment programs.

Also, counselors and therapists in effective programs believe that labeling clients, confronting them too strongly or too often, and talking "at them" rather than "to them" are counterproductive approaches, create too much distance, and may be a major factor why many clients never return to programs. One clinic's approach to this problem is outlined in Figure 5-2 .

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Figure 5-2: Listening to Clients. The Hilltop Center program in Longview, Texas, has clearly laid out the expectation that staff members must listen to clients from the beginning to gain a real understanding of where these clients are in their lives. (more...)

Outreach efforts

Some effective programs send a newsletter to their dually diagnosed clients. The newsletter discusses topics that are supportive; for example, stress might be discussed, including how stress affects the immune system and can trigger relapse, and ways to reduce stress. The newsletter also can be distributed to every treatment program in the community, thus serving as an outreach tool. Although using a newsletter may sound simple, it is not a common practice.

Some treatment programs have brought in HIV/AIDS pre- and posttest counselors and educators to their treatment programs. These counselors are encouraged to run support or therapy groups for dually diagnosed clients. Because of stigmas and confidentiality, the roles of the HIV/AIDS counselors can vary; for example, one person may conduct the testing, another may serve as the educator, and a third may lead a support group, so that clients have less fear of disclosure of their HIV/AIDS status.

Staff cross-training

Effective treatment programs also are strong proponents of staff cross-training. One view is that substance abuse treatment providers should become experts in mental health and HIV/AIDS, and the HIV/AIDS providers should learn about substance abuse and mental health, and so on. Staff working with HIV-positive clients must pay vigilant attention to the constantly changing world of medications, side effects, and new discoveries. The main point is that the issues of HIV/AIDS, mental health, and substance abuse disorders coexist, and the only way to really effect long-term change is to combine treatments. The best integrated programs encourage continuing education for staff. Continuing education may include buying journal subscriptions, allowing staff time off for coursework, and providing frequent inservice training sessions. It is also important that programs hire highly trained, flexible, open-minded staff. To be successful, these staff must see beyond traditional substance abuse treatment modalities and be able to accept and affirm all cultures and lifestyles.

Support groups

An effective treatment program will integrate support groups. For instance, a special group for HIV-positive substance abusers might integrate relapse prevention with adherence to combination therapy. The aim is to connect the milestones of HIV/AIDS disease with triggers for relapse, so that the group becomes relevant and provides the support needed.

Community linkages

One of the most important community linkages in successful programs is the relationship with the medical community and practicing physicians. This includes nurse practitioners, psychiatrists, internists, nutritionists, and others. Choosing medications, assessing medical status, and ruling out a diagnosis can be very challenging with dually or triply diagnosed clients. When service providers work closely with the medical care team to solve problems and formulate treatment plans, this allows clients and providers to be more proactive. Service providers may have to educate medical care providers about addictions and recovery. Working together is essential so that clients are not overmedicated or medicated in a way that jeopardizes their recovery.


The most successful programs that effectively treat HIV/AIDS, substance abuse, and mental health problems have learned how to obtain funds from a variety of funding streams. Successful programs apply for funding from sources such as the CDC, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, and many local and State programs. Chapter 10 provides a more in-depth discussion about funding resources.

Current Challenges

Substantial challenges continue to face providers who wish to develop effective treatment programs that meet the needs of clients who are dually and triply diagnosed (HIV/AIDS, mental health, and substance abuse). Few programs across the United States have been able to develop highly successful programs and maintain the needed funding levels. For the most part, it is believed that these types of programs are quite costly.

When providers examine multiply diagnosed clients, they can see that these clients are a highly vulnerable group of people at great risk: risk for death, as well as risk for numerous medical problems and chronic illnesses, other infectious diseases, physical abuse, rape, poverty, starvation, and so on. They are also often the same clients who most easily "fall through the cracks" and challenge treatment providers' knowledge, skills, and patience. Efforts to create more effective programs that decrease the number of people "falling through the cracks" must be encouraged and these programs thoroughly evaluated in order to ensure that every client receives the best treatment possible.


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