HIV Risk Reduction A quarterly newsletter of the Division of Addictive Diseases for professionals in HIV and SA prevention Volume 9, Issue 3 How to Deliver an HIV+ Diagnosis And Precautions to Take for Those with Mental Health and Substance Abuse Issues Delivering an HIV diagnosis to a client is a huge responsibility. In one moment, the person receiving the news is entrenched in a familiar way of living; in the next, the individual plunges into completely new territory and a life that will never be the same. The transformation happens in an instant, and you may be the only witness – and guide. What you do and say can have a profound impact on the way the patient handles the news of his or her diagnosis. “This is a very sensitive and delicate issue,” says Sanjay Sharma, M.D., Assistant Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine. Dr. Sharma also serves as Associate Director of Mental Health/Substance Abuse Treatment Services for the Grady Infectious Disease Program. First and foremost, be empathic as you listen and try to understand what the patient may be experiencing at that moment. He says there is no “right” way to perform this task. One method will not work for every individual. In fact, he strongly advises against having a set agenda or using a prepared script. “The most important thing to realize is that the HIV diagnosis is the beginning of a lifelong process,” says the psychiatrist. “It will impact the patient physically, psychologically, emotionally, psychosocially, and spiritually.” There is a tremendous amount of information to convey, but don’t attempt to do it entirely during this initial session. “If you give them too much information,” he says, “they may become overwhelmed. Let their questions and concerns guide you.” Patients may need to be educated about the disease and treatment options. They may have concerns about physical health decline, mental health and psychological impact of the illness, Sanjay Sharma, MD Iyearn 1997, during the fourthof his psychiatric resi- dency, Sanjay Sharma, M.D., had been searching for a way to continue his interest in both psychiatry and medicine when he was given the opportunity to serve as a co-therapist for a support group for HIV-positive men at Grady Health System’s Infectious Disease Program. Dr. Sharma’s interactions with the patients and professional staff at that time turned into a career-defining experience. “Everything clicked,” he recalls because he was able to combine his professional areas of interest to help Continued on Back HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA medications, loss of function and independence, being stigmatized by those close to them, and death and dying-related issues. Some may wonder where they got the disease and whether they have passed it along. Rather than having formulaic or scripted responses, it is important to convey that an HIV-positive diagnosis is not a death sentence, that there are support resources (including spiritual resources, support groups, counseling resources, etc) to help HIV-positive individuals adjust to their new circumstances, and that they are not alone. While this news is challenging to anyone who receives it, for those suffering from mental health or substance abuse issues the situation can be much more complex. The news may trigger episodes of stress, anxiety, hopelessness, isolation, anger, panic, depression, and possibly relapse in those at risk for substance abuse/dependence. When an individual receives his or her diagnosis, it may be impossible to determine if the patient fully comprehends the diagnosis and associated aspects. Some techniques to consider to assist may include providing the client with written educational materials and peer support resources, and enlisting the help of a trusted family member or friend, paying close attention to confidentiality and related issues. higher prevalence of substance abuse, precautions are necessary. Dr. Sharma shares these examples to illustrate his point: • Alcohol is tremendously damaging to the liver and HIV medications also put a heavy burden on this organ, leading to deleterious consequences. One HIV drug (DDI) can inflame the pancreas when combined with alcohol. • There has been some preliminary laboratory documentation that cocaine can cause the HIV virus to replicate 20 times faster than normal. • Cocaine and crystal meth cause the protective blood-brain barrier to break down, possibly exposing the brain to toxicities and infections. • Some illegal substances interact with HIV medications. The combination might produce toxicities – or render helpful drugs less effective. For example, one case study examined the death of a patient who took ecstasy while on an HIV drug regimen. The interaction somehow increased the level of ecstasy by 10 times the dose taken, with lethal consequences. In short, when HIV strikes someone with a substance abuse problem, controlling the addiction becomes imperative. Drug Interactions Illegal drugs are not the only issue. Many Issues with Substance patients in this popuAbusers lation take prescriptions for mental HIV-positive individuals illness or addiction with substance abuse/ Geraldine White gives HIV test results to a consumer. treatment. Because dependence issues may the vast majority of face enormous chalmedications are metabolized through the liver, lenges. Alcohol, as well as marijuana, cocaine, ecstasy, crystal methamphetamine and other drugs potential drug-drug interactions can occur. These interactions may prove to be clinically significant can interfere with a patient’s physical condition and emotional state, plus cause complications with and cause either a notable increase in side effects medication. Because this patient population has a and toxicities or a possible decrease in therapeutic HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA Prevention with Positives B efficacy. In other cases, however, the interaction ecause HIV transmission can be prevented, may prove to be clinically insignificant and incon- those who have been diagnosed positive are in a sequential. Therefore, physicians have to consider unique position to halt the spread of the disease. these circumstances frequently and on a case-byHIV testing is integral to HIV prevention because case basis, particularly when a potential conflict once someone knows that they are positive, they exists between medications. are far more likely to take steps to avoid infecting others. Supplements and herbal treatments also may pose a risk. Patients often try natural alternatives, Between July 2008 and March 2009, HIV Early believing they will cause no harm, however, this is Intervention Services (EIS) counselors identified not always the case. St. John’s Wort, for example, 44 new HIV-positive consumers and served an which some people take to relieve the symptoms additional 109 who were already aware of their of depression, can decrease positive status. the therapeutic efficacy of HIV EIS counselors have resome HIV medications. In ported that most newly diagthis case, a regimen that nosed consumers need more was once effective in fightthan a single post-test counseling disease has its overall ing session. Offering the neceffectiveness diminished. essary counseling and support This can lead to an increase to help HIV-positive consumin viral loads, a decrease in ers reduce risk to themselves CD4 counts, and decline in and others is one of the most overall health and well-being. effective interventions any Patients should be encourHIV worker can provide. aged to share information about all substances they are In addition to offering refertaking, whether prescribed or ral to appropriate medical and otherwise, so that healthcare social services, many HIV EIS professionals can provide apcounselors also provide some propriate counsel. form of case management. For example, Geraldine White When delivering news about Drug interactions stem from the fact that all of River Edge in Macon curan HIV diagnosis, and helpdrugs are metabolized through the liver. rently maintains contact with ing clients through the early 17 HIV-positive clients. stages of disease, one of the Jacqueline Ruth Johnson, who serves those inmost important things health professionals can carcerated in the DeKalb County Jail, follows up do is to remember there is a definite mind-body with HIV-positive inmates after they leave the faconnection. Emotions impact a patient’s physicility. And Ron DeLay of GRN in Snellville has a cal state; illness impacts the psyche. “There is weekly drop-in group for HIV-positive consumers. constant interplay between the mind and body,” says Dr. Sharma. “In diseases such as HIV, diabetes, and cancer, we need to approach the patient from a holistic standpoint.” Patients do best when providers communicate and work together to help the patient focus on the potential of his or her life, rather than their disease. People who are living with HIV are confronted with numerous complex issues including disclosure, adherence, and the amplified risk of sexually transmitted diseases. For more on these and other related issues, visit www.hiveis.com and click on AIDS/HIV Positive to find links to information and resources for HIV-positive consumers. HIV Risk Reduction — A quarterly newsletter of the Office of Addictive Diseases for professionals in HIV & SA Sanjay Sharma, MD, continued a patient population with considerable needs. He joined the Emory University faculty in 1999 and is now Assistant Professor, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine and also serves as Associate Director of Mental Health/Substance Abuse Treatment Services for the Grady Infectious Disease Program (IDP). Based in Atlanta, Grady Health System is one of the largest public health systems in the United States, and the IDP is one of the largest, most comprehensive facilities in the nation dedicated to the treatment of advanced HIV/AIDS. Founded Grady Infectious Disease Program - Atlanta in 1986, the IDP and its onsite affiliates provide medical and support services to approximately 5,000 eligible men, women, adolescents, and children living with HIV/AIDS. To qualify for care in the IDP, adult referrals must have a previous AIDS diagnosis and/or a nadir CD4 count below 200. Pediatric and adolescent patients have no such restrictions. HIV Risk Reduction imagin a newsletter of HIV Early Intervention Services (EIS) Georgia Department of Behavioral Health and Developmental Disabilities Division of Addictive Diseases ITC Leawood Produced by: Imagine Hope Inc. Marie Sutton President/CEO 404.874.4040 P Winona Holloway Senior Program Specialist 678.752.9571 P For more information, visit www.hiveis.com Opioid Treatment and HIV Medications: Drug Interactions O ne of the most challenging issues facing providers treat- ing patients with HIV is the problem of drug interactions associated with highly active antiretroviral therapy (HAART). Guidelines for the initial treatment of HIV infection recommend the use of at least three antiretroviral medications, each of which is associated with significant drug interactions. At the same time, because injection drug use carries a significant risk for HIV infection, substance abuse treatment including methadone or opioid treatment, can play an important part in reducing the risk of HIV/ AIDS transmission. Also known as medication-assisted therapy, opioid treatment substitutes medication for heroin or other morphine-like drugs. Interactions between HAART and methadone can reduce the a t isoi tne effects of methadone and lead to narcotic withdrawal or increase the effects of methadone and cause over-sedation. Methadone may also cause unnecessary side effects when combined with ITC Giovanni HAART. While the potential for drug-interactions must be Imagine Hope Inc. addressed, medications used to Marie Sutton President/CEO treat HIV may be used concur393 Sixth Street with opioid treatment rently Atlanta, Georgia 30308 therapies like methadone. For 404.874.4040 P on this topic, visit more 404.874.3800 F IDP, view from North Avenue http://www.thebody.com/content/art1822.html.