Fact Sheet Series > Substance Abuse Treatment

Linking HIV Prevention Services and Substance Abuse Treatment Programs
February 2002

HIV Prevention Should be an Integral Component of Substance Abuse Treatment

HIV and other blood-borne infections and injection drug use are intersecting epidemics.

Many people, including drug users themselves, have mistaken beliefs about drug addiction and recovery from addiction. Two of the most pervasive myths are that "a person can get off drugs alone" and that "most addicts can become permanently drug-free." These ideas stem in part from notions that continued drug use is voluntary and that a person's inability to overcome addiction stems solely from character flaws or a lack of willpower.

Society has differing standards of success for treating chronic conditions or nicotine or alcohol addictions than for treating addiction to injection drugs.

• About 1 million people are active users of injection drugs (primarily heroin, cocaine, and amphetamines).

• Sharing syringes, drug solution, and drug preparation equipment are primary routes for drug users to acquire and transmit HIV and hepatitis B and C. High-risk sexual behaviors often accompany high-risk drug use, further increasing the chances of transmission.

• About one-third of AIDS cases every year are related to injection drug use.

Substance abuse treatment is key to helping IDUs reduce HIV transmission risk.

Numerous studies, primarily focused on methadone maintenance treatment (MMT), have shown that substance abuse treatment programs can have a dramatic effect on HIV transmission among opiate injectors, reducing their risk as much as 4- to 6-fold. Substance abuse treatment works principally because it helps injection drug users (IDUs) decrease the number of injections or helps them stop injecting altogether. Less use leads to fewer drug-related risk behaviors, and that in turn leads to fewer exposures to HIV.

The beneficial effects of MMT are most evident when treatment lasts a sufficiently long time and when methadone doses are high enough to effectively block drug craving:

• One study showed that 3.5 percent of methadone patients who had been in treatment continuously for 18 months had become infected with HIV, compared to 22 percent of out-of-treatment IDUs; another study showed that at 36 months, 8 percent of IDUs in treatment had become infected, as compared to 30 percent of injectors not in treatment.

• An analysis of 20 years' of social and medical data on 622 MMT patients in New York City showed that those patients who received methadone doses of 80 mg or more were significantly less likely to have HIV infection than were those patients who received smaller doses. The protective value of higher doses was independent of a number of other risk factors, including year of last cocaine injection, needle sharing in shooting galleries, number of IDU sex partners, income, and race/ethnicity.

Integrating HIV Prevention with Substance Abuse Treatment Faces Challenges

Even the best substance abuse treatment programs don't work for everyone to reduce injection drug use and other HIV risk factors; relapse occurs even among those who have successfully completed treatment.

Patients with drug problems often improve substantially after entering substance abuse treatment. However, many continue to abuse drugs while in treatment and many do not complete their specified length of treatment. For example, nationally, half of those admitted to MMT leave within a year. Relapses to drug use after MMT are common, although these are less likely when adequate doses of methadone are used. Moreover, though substance abuse treatment has been shown to reduce risks associated with needle use, it is less certain that treatment leads to less risky sexual behaviors. More effort may be needed to achieve this goal.

Some substance abuse treatment providers see major conflicts between HIV prevention and their treatment goals.

Professionals who provide substance abuse treatment, HIV services, and other services to IDUs vary in their training, experience, attitudes, and approaches. This has led to profound differences of opinion about how to reconcile HIV risk reduction messages with substance abuse treatment. For example, most substance abuse treatment models focus exclusively on abstinence as the only acceptable short- and long-term outcome of treatment. Risk reduction messages, such as the one-time-only use of sterile syringes, may seem to be contradictory.

However, many IDUs are unwilling or unable to completely stop using injection drugs, even after repeated episodes of treatment. Risk reduction approaches focus on ways to help IDUs reduce the adverse consequences of injection practices, such as providing access to sterile syringes, emphasizing never sharing needles and "works," and encouraging IDUs to use bleach to disinfect equipment. Providers who seek to integrate HIV prevention into substance abuse treatment need to find ways to bridge these opposing views.

Providers in either substance abuse treatment and HIV prevention may have limited knowledge and expertise in the other area.

Traditionally, many substance abuse treatment facilities and services have been completely separate from HIV and sexually transmitted disease (STD) facilities and services. Staff trained in one area may have little or no knowledge or expertise in the other. In addition, federal confidentiality protections prohibit substance abuse treatment staff from sharing information about patients with public health staff. A number of cross-training initiatives are seeking to bridge this chasm. By bringing together public health, substance abuse treatment, primary care, and staff from other services and providing "101" and skills-building training in each set of issues, these professionals have been able to learn other points of view, create personal and professional links, forge effective communications, and improve services to IDUs.

Adequate coverage, access, and quality are difficult to achieve.

Studies have repeatedly shown that many IDUs want to stop their injection drug use and change other behaviors to reduce their risks of HIV and improve their lives. For IDUs to accomplish these goals, however, substance abuse treatment and HIV prevention services must be available to all those who need or request them. However, only a small fraction of IDUs who could benefit from substance abuse treatment are able to obtain it.

Services also have to be accessible. Providers must address issues such as: Are HIV prevention and substance abuse treatment services free or do they charge fees? Are they open at the same time, close to each other, and complementary? Are they located in areas convenient to IDUs? Do waiting lists and referral requirements pose insurmountable barriers?

Quality is a critical issue as well. Competency of staff, provision of all necessary services, length of treatment, treatment dose (whether medication or number of counseling sessions), and cultural appropriateness of messages and messengers are examples of issues that must be addressed in providing high-quality substance abuse treatment and HIV prevention services.

Resources for substance abuse treatment are limited at a time when demands are increasingly complex.

Many IDUs now come to substance abuse treatment with multiple social, physical, and mental health problems in addition to their addiction. These complex situations require sophisticated, multidisciplinary services. Efforts to control costs and budgetary constraints limit the ability of public and private sector providers to respond comprehensively to the needs of IDUs who are also at high risk of HIV.

HIV Prevention and Substance Abuse Treatment Can Be More Fully and Effectively Integrated Through a Variety of Approaches

A recent study compared changes in HIV risk behaviors between IDUs who entered and remained in MMT and those who did not. The authors found that the IDUs in MMT reduced the number of injections much more than IDUs who weren't in treatment. However, changes in other risk behaviors - using contaminated needles and sharing other drug preparation equipment - weren't significantly different between the two groups.

A closer examination of this finding reveals that both groups of IDUs received HIV testing, counseling, and HIV risk reduction interventions. After the counseling, both groups substantially reduced their HIV risk behaviors. This suggests that integrating HIV prevention messages and substance abuse treatment may have a powerful, positive effect on IDUs. Integrating these two approaches can be done in several ways:

• providing HIV counseling and testing services as part of substance abuse treatment programs;

• incorporating HIV prevention messages (those related to high-risk drug use as well as high-risk sexual behavior) into substance abuse treatment education and counseling;

• encouraging IDUs to enter substance abuse treatment as part of HIV prevention outreach efforts; outreach programs have been shown to help out-of-treatment IDUs reduce their risk behaviors, in part by entering treatment;

• using syringe exchange and access programs as a means of linking IDUs to substance abuse treatment and other needed health services; and

• using family counseling to work with patients' sex partners and children.

To Learn More About This Topic

Read the overview fact sheet in this series on drug users and substance abuse treatment - "Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits." It provides basic information, links to the other fact sheets in this series, and links to other useful information (both print and web).

Visit websites of the Centers for Disease Control and Prevention and the Academy for Educational Development for these and related materials:

• Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach, which provides extensive information on HIV and viral hepatitis infection in IDUs and the legal, social, and policy environment, and describes strategies and principles of a comprehensive approach to addressing these issues.

• Interventions to Increase IDUs' Access to Sterile Syringes, a series of six fact sheets.

• Drug Use, HIV, and the Criminal Justice System, a series of eight fact sheets.

Check out these sources of information:

Abdul-Quadar AS, Friedman SR, Des Jarlais DC, et al. Methadone maintenance and behaviors in intravenous drug users that can transmit HIV. Contemporary Drug Problems 1987;14:425-434.

Brown BS. HIV/AIDS and drug abuse treatment services. [Literature Review] September 1998.

Centers for Disease Control and Prevention. Public health and injection drug use. Morbidity and Mortality Weekly Report 2001;50(19):377.

Galanter M, Keller DS, Dermatis H, Egelko S. The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine. Journal of Addictive Diseases 2000;19(3):13-34.

Hartel DM, Schoenbaum EE. Methadone treatment protects against HIV infection: two decades of experience in the Bronx, New York City. (PDF 116 KB, 9 pages) Public Health Reports 1998;113(Suppl 1):107-115.

Hser YI, Polinsky ML, Maglione M, Anglin MD. Matching patients' needs with drug treatment services. Journal of Substance Abuse Treatment 1999;16(4):299-305.

Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment (MMT): a review of historical and clinical issues. The Mt. Sinai Journal of Medicine 2000;67(5&6):347-364.

Kwiatkowski CF, Booth RE. Methadone maintenance as HIV risk reduction with street-recruited injecting drug users. Journal of Acquired Immune Deficiency Syndromes 2001;26(5):483-489.

Magura S, Rosenblum A. Leaving methadone treatment: lessons learned, lessons forgotten, lessons ignored. The Mt. Sinai Journal of Medicine 2001; 68(1):62-74. www.mssm.edu/msjournal/68/681.shtml

Metzger DC, Navaline H, Woody GE. Drug abuse treatment as AIDS prevention. Public Health Reports 1998; 113(Suppl 1):97-106.

The National Center on Addiction and Substance Abuse at Columbia University (CASA). Shoveling up: the impact of substance abuse on state budgets. New York: CASA; January, 2001.

Sorensen JL, Copeland AL. Drug abuse treatment as an HIV prevention strategy: a review. Drug Alcohol Dependence 2000; 59(1):17-31.

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