From heroin and crack cocaine to alcohol and Ecstasy, substance abuse has been a companion to HIV infection since the start of the epidemic. A dual diagnosis of HIV and substance abuse presents a complex challenge to HIV care providers. Substance abuse in HIV infection is associated with poor treatment outcomes. However, some clients perceive substance use and abuse as a positive coping strategy that improves quality of life in relation to symptom relief, mental status, and sense of well-being. In addition, in the reality of the world of the substance abuser, immediate addiction needs always outweigh long-term healthcare needs.1

Two studies of women  in particular reveal the issues experienced by HIV-positive substance abusers. These women often face numerous psychosocial issues in their daily lives, including depression, bereavement and survivor's guilt, housing and financial problems, confidentiality issues, and uncertainty about the future.2 A study from South Florida revealed that HIV-positive women substance abusers characterized attempts to adhere to their HIV medication regimens as "taking it one day at a time." The women described themselves as disorganized, which made taking scheduled medications problematic. Substance abuse interfered with and took priority over taking HIV medications. As one woman noted, "When I go on a binge, I don't remember to take my drugs, and some days, I'd rather drink than take my pills." Factors that helped adherence included support groups, drug treatment programs, medications (methadone and anti-depressants), and relationships with primary care providers.2

A study from South Carolina asked women to discuss their HIV/AIDS and substance abuse.3 Five themes emerged from the focus group discussions:

"     AIDS as a life-altering event

"     Spirituality

"     Mental health issues

"     Barriers to healthcare services

"     Environmental influences

The coexistence of HIV and substance abuse added to the complexity of the women's treatment needs. The study findings demonstrated that dually diagnosed women have unique needs that require integration of physical and psychosocial interventions. In addition, drug treatment services need to be expanded, need to be made more comprehensive, and need to be developed specifically for women.3

As noted in these two studies, the co-existence of HIV and substance abuse reveals multiple adverse mental health effects. These adverse effects have been associated with causation and exacerbation of depression, psychosis, and suicidal tendencies, along with isolation from social support systems, stigmatization, and poor self-esteem.

HIV treatment outcomes for substance abusers are negatively affected by many barriers, such as poor underlying health condition, poor nutrition, and poor adherence to treatment plans. Drug-drug interactions can occur between HIV medications and either prescribed methadone or illicit "street" drugs. There are also psychosocial issues, such as cravings for substances (which can be triggered by stress) and coexisting psychiatric conditions.1 From the substance abuser's perspective, there is distrust of the medical system, fear of arrest, anger about "labeling," inadequate pain management, and treatment programs that include a "Clean and Sober" clause for provision of care. The attitudes of healthcare providers are often perceived as negative and judgmental.

To provide care effectively, healthcare providers must understand the substance abusers' subculture. Clinical implications include awareness that substance users often do not keep appointments, so they may need reminders and follow-up, along with flexible scheduling. Scheduling may need to take time of month into consideration. Financial assistance checks are often issued on the first of the month, and keeping an appointment may not be the priority when the substance abuser has money. Therefore, it may be more effective to schedule appointments toward the middle or end of the month. The location of the service provider is also important, since complicated transportation arrangements to get to the care provider may discourage keeping an appointment.

When caring for HIV-positive substance abusers, provider skills must also include an understanding of the client's "Street Survival Tools," which include manipulation and scamming. Instead of taking personal affront, care providers need to use respect, trust, and renegotiation to help minimize manipulation by the patient. Care providers also need to use common sense; for example, they should keep controlled substances and prescription pads in locked areas not accessible to clients.

Successful treatment approaches also include a unified multidisciplinary team approach, recognition and interventions for treatment of underlying psychiatric disorders, multimodality interventions, and integrated care strategies.1 If a trusting relationship is not established with a care provider, then the acute-care and emergency departments may become the primary healthcare settings for clients.

Acute-care providers will need to assess the client for recent substance use, and will also need to anticipate and treat withdrawal symptoms.

Signs and symptoms will vary according to the substance, but often include chills, sweating, piloerection, nausea, diarrhea, abdominal cramping, rhinorrhea, lacrimation, myalgias, tremulousness, and anxiety.1

The acute-care provider also needs to anticipate substance cravings and to assess and treat pain adequately. While setting clear, realistic limits and expectations for client safety while hospitalized, the acute-care provider needs to convey a nonjudgmental, nonpunitive attitude and be perceived as a patient advocate. Distrust of the motivations of medical personnel has made many HIV-positive clients wary of signing Advanced Directives.4

In summary, there are various reasons for substance abuse in HIV-positive persons, and no easy answers or simple solutions. Dually diagnosed clients lead complex lives, with multiple psychosocial issues, and have unique needs that require integration of physical and psychosocial interventions. While many barriers hinder care, knowledgeable and culturally competent healthcare providers can use their skills to overcome these barriers and facilitate successful treatment outcomes.

Sande Gracia Jones, PhD, ARNP, BC, ACRN, is an Assistant Professor at the School of Nursing, College of Health and Urban Affairs, Florida International University in Miami. She has worked in primary care as a nurse practitioner for an HIV physician practice, and in acute care as the HIV/TB clinical nurse specialist at Mount Sinai Medical Center, Miami Beach, Florida.

References

     1.   Lucas GM. Management of HIV infection in injection-drug users. HIV/AIDS: Annual Update 2001. Available online at: <www.medscape.com/ viewarticle/418652>.

     2.   Jones SG.  Life in a pill bottle: the experience of taking HIV medications. The Florida Nurse. 2002;50(1):23.

     3.   Moser KM, Sowell RL, Phillips KD. Issues of women dually diagnosed with HIV infection and substance use problems in the Carolinas. Issues in Mental Health Nursing. 2001;22(1):23-49.

     4.   Jones SG, Messmer PR, Charron SA, Parns M.  HIV-positive women and minority patients' satisfaction with inpatient hospital care. AIDS Patient Care and STDs. 2002;16(3):.