HIV Frontline : no.36(1999:Feb.)
- Title
- HIV Frontline : no.36(1999:Feb.)
- Description
- HIV Frontline is "a newsletter for professionals who counsel people living with HIV." The February 1999 issue examines the intersection of HIV and addiction, with a focus on addressing the unique challenges faced by injection drug users (IDUs). It highlights the prevalence of co-occurring psychiatric disorders, medical complications such as hepatitis and tuberculosis, and barriers to accessing care. The issue explores models of care, including harm reduction and abstinence-based approaches, emphasizing the importance of compassionate and individualized treatment plans. It also discusses the impact of addiction on adherence to antiretroviral therapy (ART) and strategies to optimize treatment. The publication includes a detailed focus on hepatitis types A, B, and C, addressing their transmission, prevention, and treatment within the context of HIV care.
- Date Issued
- 1999
- Relation
- HIV Frontline
- Rights
- Contact UCO Chambers Library's Digital Initiatives Working Group at diwg@uco.edu for the permission policy on the use, reproduction or distribution of this material.
- Is Part Of
- HIV Frontline
- Creator
- Ferri, Richard S.
- Contributor
- World Health CME
- Date
- 2025-05-01T15:03:06Z
- Date Available
- 2025-05-01T15:03:06Z
- Subject
- HIV/AIDS
- HIV treatment
- Type
- Periodical
- extracted text
-
Property of the Center
•
This newsletter is supported through an independent educational grant from
ISSUE NO. 36
6/axoWel/come
HIV and Addiction:
Providing Co111passionate Care
to a Complex Population
arious addictive behaviors, particularly addiction to injection drugs, have been associated with
HIV/AIDS since the early days of the epidemic. Today, however, injection-drug users (IDUs)
account for an increasingly large proportion of those diagnosed with the infection. Despite the
enormous body of literature that has been amassed on the subject of HIV, relatively little has
been published to guide the HIV counselor in working with this population. Therefore, this issue of
HIV Frontline focuses on the substance-using HIV-infected client.
1111 The Scope of the Substance-Use
Problem
Injection-drug use, the second most common risk factor
for HIV, is a source of viral transmission in an everincreasing number of patients with HIV. As of December
1996, 36% of all reported AIDS cases were attributable to
injection-drug use; half of all new infections occur in this
population. With HIV hitting disproportionately hard in
the Latino and African-American communities, it has
been estimated that an African-American IDU is at four
times greater risk of contracting HIV than of dying of a
drug overdose. Eight out of 10 women with AIDS
reported injection-drug use or sexual contact with an
IDU as their primary risk factors for contracting the virus.
1111 A Unique Set of Needs
For a variety of reasons, substance-using and -addicted
clients with HIV tend to present more significant care
complexities than their non-su bstance-using cou nter-
Inside ...
• HIV and Addiction
• Focus on Hepatitis
*
* New Features
Introduction to
• HIV News Briefs
•
parts. Often marginalized and stigmatized, they may
have little access to preventive care and may not seek
treatment until later in the disease process. When these
clients do seek treatment, they may lack the resources to
meet its demands and the demands placed on them by
the medical establishment.
"Medical systems are not created for some of the people
they serve," noted Edith Springer, ACSW, a trainer at New
York's Harm Reduction Institute, and formerly clinical
director of the New York Peer AIDS Education Coalition,
also in New York City. "They are created for high-functioning, highly organized, appointment-book-carrying,
middle-class-ideology kinds of people. But because substance users have been kept out of the societal mainstream, because they've been stigmatized by every
segment of society including their own families, they
don't have the cultural norms and skills that would allow
them to work within the traditional medical system. And
the system, in general, doesn't consider their needs."
Ms Springer offered an example of a hospital in New York
th at schedules each of its female patients with HIV for a
9:00 AM appointment. If she shows up on time, she's
expected to sit and wait to be seen-sometimes all day.
"So there are 80 women with their kids running around,
with no activities, nothing to keep them occupied, and
no food. The women who are addicted are, at some point
during this long day, going to go into withdrawal, but
there are no provisions for that either. And then we say
that drug users don't follow through."
(continued on page 2)
www.HIVLine.com
February 1999
HIYfcontline
Editorial
Advisory 1°@rd
Richard S. Ferri, PhD,
ANP, ACRN
HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts
-
Michele Fontaine, MA, CASAC
Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York
Susan M . Gallego, MSSW,
LMSW-ACP
Private Practitioner/Consultant
Austin, Texas
Vincent J. Lynch, DSW
Director,
National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts
John G. O'Brien, PharmD
Assistant Clinical Professor
University of California, San Francisco
HIV Pharmacist Specialist
Ira Greene Positive PACE Clinic
San Jose, California
-
George Perez, MD
Director of Virology
St Michael's Medical Center
Medical Director
North Jersey Community
Research Initiative
Newark, New Jersey
Michael E. Sheran, MD
Assistant Professor of Medicine
New York Medical College
Associate Attending Physician
Department of Medicine
St Vincent's Hospital
New York, New York
Angela Shiloh-Cryer, MSW
Director
Office of Health Policy and
AIDS Funding
New Orleans, Louisiana
-
Barry Zevin, MD
Medical Director
Tom Waddell Health Center
San Francisco, California
This newsletter is published by World Health CME, a division of World Health Communications Inc., and is supported tluough an independent educational grant from
Glaxo Welkome. The views and opinions expressed herein do not necessarily reflect those of Glaxo Wellcome,
World Health CME, or the Editorial Advisory Board.
Statements regarding drugs,, dosages, and procedures are
not meant to serve as guidelines in the treatment of
patients. Please see the full prescribing information before
using any agent mentioned in this publication.
© 1999, World Health CME. All rights reserved. Printed in
the USA. Permission granted tor noncommercial reproduction of this material.
HIV and Addiction (continued from page 1)
For substance users who are poor, as many are, the correlates of poverty-inadequate housing, lack of access to transportation, poor nutrition-further complicate the picture. There is substantial evidence that many substance-using clients
with HIV carry triple diagnoses of HIV, addiction, and psychiatric disorders. Four
common psychological factors have been observed in drug-using patients with
HIV who are enrolled in substance-abuse treatment programs: denial, anger
(sometimes accompanied by antisocial behavior), depression, and isolation.
Certain medical problems are considerably more common among IDUs
with HIV than among their nonusing counterparts (Table 1). Some of these
problems, such as skin abscesses and viral hepatitis, are related directly to
injection-drug use. Others, such as tuberculosis, are particularly common
among homeless drug users and shelter residents. These problems are associated with crowded living conditions, such as those found in correctional
facilities. According to Peter Selwyn, MD, MPH, professor and chairman,
Unified Department of Family Medicine, Montefiore Medical Center, Albert
Einstein College of Medicine, Bronx, NY, sexually transmitted diseases are
common among IDUs with HIV, because many HIV-infected drug users
may continue to practice unsafe sex even after they have adopted safer
drug-use practices.
Although there is some laboratory evidence to indicate that cocaine may
facilitate replication of HIV in the test tube, HIV does not appear to progress
more rapidly in drug users. It is therefore important, according to Dr Selwyn,
to avoid a two-class system of care in which vulnerable and disenfranchised
populations are not benefiting fully from the range of antiretroviral
(continued on page 3)
Introducing Two New Features
Do you have thoughts or questions about topics covered in HIV Frontline that you would
like to express? Do you have ideas or suggestions for future articles or features that you
would like to see in this publication?
We are pleased to introduce the "Reader's Column," a new feature that will appear
beginning with our next issue (April 1999). The Reader's Column will offer you a chance to
share your thoughts, ideas, and opinions with your fellow HN counselors. We will answer
your questions and air your concerns.
The column will only be as valuable as its content, however. We need your input to make
it work. Whether you like or disagree with something you read here, or learn something
useful from an article that appears here, we want to hear from you.
Another new feature we are introducing is "Tips for Counselors," which will also make
its debut in the April issue of HIV Frontline. If you have had any experiences working
with clients that you think would be instructive for your fellow HN counselors, "Tips for
Counselors" will provide you with an opportunity to share them. Any ideas or pointers for
dealing with a difficult counseling situation, any specialized knowledge you have regarding
a particular counseling issue, or techniques or approaches you've used that have proved
successful will be welcome.
Please fax your questions, comments, and tips to Frontline Editor at (212) 481-8532.
Thanks for your continued interest in HIV Frontline.
HIYfrontline
HIV and Addiction (continued from page 2)
treatments available. "Drug users are certainly among
the vulnerable and disenfranchised, and the challenge
is to ensure that we work diligently to extend treatment
benefits to these individuals,"
11111
Substances and Highly Active
Antiretroviral Therapy: Can They
Go Together?
One factor that can interfere with substance-addicted
patients' receiving full access to highly active antiretroviral therapy (HAART) is concern that these medications
may interact if taken concomitantly with "street" drugs.
Dr Selwyn acknowledged that the potential for drug
interactions is something to be aware of and considered.
This concern, however, should not deter healthcare
providers from prescribing HAART for their substanceusing clients. "For the most part, there seems to be not
much of an interaction effect. This issue has really been
overblown. In this country, the drugs that are most comTABLE 1
Common Medical Problems in
HIV-Infected IDUs
• Severe bacterial infections (including those of the
respiratory system, heart, and/or blood)
• Mycobacterium tuberculosis (including multidrug
resistant)
• Sexually transmitted diseases
-Herpes simplex virus (genital; chronic
mucocutaneous)
-Human papillomavirus (oral; genital; cervical
dysplasia/carcinoma in women)
-Syphilis (genital; neurosyphilis)
-Pelvic inflammatory disease
• Others
-Skin abscesses, cellulitis (from "skin popping")
- Viral hepatitis (B, C)
-Alcohol-induced hepatitis and cirrhosis
-Alcohol-induced gastritis
-Intoxication and withdrawal states
-Other central nervous system complications
-Hepatic (liver-related) encephalopathy
-Cocaine-induced ischemia (local anemia)
and seizures
Adapted with permission from Ferrando SJ, Batki SL. HIV infection: From
dual to triple diagnosis . In: Kranzler HR, Rounsaville BJ, eds. Dual
Diagnosis and Treatment. New York, NY: Marcel Dekker; 1998:515.
monly abused are, overwhelmingly, heroin and
cocaine-and neither one of those is likely to have a
major effect.
"Having said that," Dr Selwyn added, "there have been
some case reports of serious problems in individuals taking ritonavir with the recreational drug Ecstasy, because
some protease inhibitors can inhibit the metabolism of
Ecstasy, allowing it to build up to toxic levels."
Dr Selwyn stated that there is also concern that some of
the antiretroviral agents might reduce methadone levels
in some patients. As a result, these patients either will
need more methadone or will not take their antiretrovirals in an effort to avoid withdrawal. "So far, though," he
said, "it looks as if this is only an issue with nevirapine,
for which methadone doses may need to be increased,
and possibly also with efavirenz. But in general, the
nucleoside analogs, such as [ZDV], 3TC, ddI, and d4T,
have been used without problematic interactions with
methadone, as have some of the protease inhibitors,
such as indinavir, saquinavir, and possibly nelfinavir."
In the absence of complete information on this issue, Dr
Selwyn said, the best approach is to be honest with
clients. "We need to tell them that, number one, it's
harmful to use street drugs, and number two, we just
don't know for sure whether or not they can interfere
with your HIV therapy or vice versa. We don't think so,
but we can't be absolutely sure it won't happen."
Simplicity is another issue to be considered when antiretroviral regimens are designed for substance-using
clients, because clients' lifestyles may complicate adherence. One regimen recommended by Dr Selwyn that preserves the protease option, offers the effectiveness of
triple-drug therapy with the ease of only four pills daily,
and encourages adherence is lamivudine (3TC)/zidovudine (ZDV) and nevirapine, two nucleoside reverse transcriptase inhibitors (NRTis) and one nonnucleoside RTI
(NNRTI), respectively. Although nevirapine may necessitate an increase in methadone dosage, it is still a good
choice for this population because of its easy dosing and
minimal side effects. Another possible combination,
requiring further study, is 3TC/ZDV and abacavir, a tripleNRTI regimen that offers the advantage of preserving the
options of NNRTis and protease inhibitors for future use,
if necessary. Other regimens that preserve the protease
option and offer simplified dosing include 3TC/stavudine plus nevirapine (two NRTis and one NNRTI) and
3TC/ZDV plus efavirenz (two NRTis and one NNRTI).
(continued on page 4)
HIYfrogtlige
HIV and Addiction (continued from page 3)
Dr Selwyn noted that with substance-using clients, as with
any client, it is crucial to assess commitment to and readiness for treatment. "It doesn't really matter whether they're
using drugs or not. What matters is whether they are willing and able to deal with the demands [and possible side
effects] of taking antiretroviral medication effectively."
1111 Abstinence or Harm Reduction?
A somewhat controversial issue is whether commitment
to antiretroviral therapy also requires a commitment to
abstinence from substance use. The crux of this issue
(and this applies to the non-HIV-infected substance user
as well) is determining which of two major approaches to
treatment is more appropriate for the addicted client:
standard substance-abuse treatment (the "moral" or "disease" model) or treatment within the context of the
"harm reduction" model.
1111 The Standard Model
The moral model of standard treatment holds that substance users tend to be weak and/or lazy or that they lack
moral character. Interventions have traditionally
included incarceration and scapegoating of the user. The
disease model contends that drug use is an incurable,
progressive medical condition in which the first step in
■ Counseling Addicted
HIV-Infected Clients
Regardless of whether one subscribes to the harm-reduction model
in total, in part, or not at all, there are elements of its clientfocused approach that can be helpful when counselors work with
substance-using HIV-positive clients in any setting.
• Break down the barriers. One of the simplest things
healthcare providers can do to place themselves and their
clients on equal footing, Ms Springer said, is to ask that
clients call them by their first names. "I've had doctors
really object to this advice, insisting that they need to set
boundaries. My response is that boundaries are not the
same as barriers."
• See the client's drug use as what it is-a coping
mechanism-and respect it as such. According to Ms
Springer, people may start using drugs recreationally, but
once they become dependent, the drugs are used as coping mechanisms. "The first thing we learn in our training
as counselors is that you don't take away one coping
mechanism before there's another in its place."
treatment is admitting one's powerlessness over one's
addiction. Interventions include complete abstinence
supported by peer groups or other treatment programs
and controlled prescription of cross-tolerant drugs.
Recovery is regarded as a lifetime process.
For substance users with HIV, the standard model maintains that elimination of substance use itself is crucial. It
not only improves the quality of life but also decreases
the risk of HIV transmission. The initial phase of such
treatment focuses on detoxification, after which the goals
of treatment become maintenance of abstinence and
rapid recovery from relapses. Self-help programs, such as
Alcoholics Anonymous and Narcotics Anonymous, are
generally encouraged as part of this treatment.
An expectation of abstinence is pivotal to the treatment
of substance-using clients, asserted Michele Fontaine,
MA, CASAC, former director of Greenwich House's AIDS
Mental Health Project in New York, and a member of the
Frontline Editorial Advisory Board. To approach treatment otherwise is to feed into the denial that is central to
substance use and addiction. That denial becomes
extremely destructive to the lives of substance users.
They are "already societally stigmatized by virtue of having HIV," Fontaine said. "Their substance use stigmatizes
them further and makes their lives even more difficult.
• Be absolutely accepting and genuinely nonjudgmental. "These individuals are constantly hypervigilant,
because they live in 'survival mode' on a daily basis, and
they are so accustomed to feeling stigmatized that they'll
pick up anything in your behavior that even hints at disapproval of them or their drug use. So, you have to be
conscious of your eyes, your hands, your facial expressions
-everything. You can't just pretend; you have to mean it."
• Be understanding of your clients' needs. For clients
who are homeless, said Ms Springer, that means understanding that survival needs must be met first. "For drug
users, especially those who are homeless, the needs of the
moment are so overwhelming that they can only worry
about today, this minute. While you might be talking
about the importance of their doctor's appointment
tomorrow, they're thinking, 'How am I going to eat
today? Where am I going to sleep? How am I going to not
get murdered tonight?"' In that context, medical appointments might not be their first priority-unless, of course,
you can help them meet some of those survival needs.
"A warm shower, clean socks, and a good meal go
a long way."
(continued on page 5)
HIVFrontline
HIV and Addiction (continued from page 4)
"Saying that abstinence is an unrealistic goal minimizes
the power of the client and the idea that he or she can
achieve sobriety and live without substance use,"
continued Ms Fontaine. "The abstinence approach is
preferable, because in the long run, it allows clients to
obtain a better picture of who they really are and to
achieve more honesty in their lives."
"Harm reduction is value neutral on the issue of substance use," Edith Springer said. "It does not try to make
people change. It allows people to change if they want to.
In the harm-reduction client-worker relationship, the
client has the power, makes the choices, and chooses the
goals. The worker acts as a consultant to help the client
reach those goals."
The harm-reduction philosophy has several basic tenets:
Ill The Harm-Reduction Model
At the other end of the spectrum is a relatively newer
approach, referred to as the harm-reduction model. The
harm-reduction philosophy was developed in the 1980s,
when countries such as The Netherlands, Great Britain,
and Australia began to recognize the need for more realistic and effective ways of reducing the spread of HIV
infection among IDUs. Harm-reduction-based programs,
including decriminalization of drug use and needle- and
syringe-exchange programs, had the desired effect of dramatically reducing HIV transmission in those communities in which the programs were implemented.
■
r
l
• HIV prevention takes priority over drug-use prevention
because of the high cost of AIDS medications to the
patient, the community, and society
• Although eventual abstinence is desirable, it should not be
the only goal of services for drug users, because abstinence
excludes the large proportion of people who will continue
to use drugs in the long term
• Abstinence should be viewed as the final goal in a series of
objectives that seek to reduce the harm that drug use causes
• An important method for helping people minimize the
harmful effects of their drug use is to provide services
that are attractive, easily accessed, and empowering
Associated Addictions: Food and Sex
Although substance use is certainly the addiction of
greatest concern regarding HIV-positive clients, it is
important to note that these people may be dealing
with other addictions as well. Addictions to food and
sex are not uncommon among substance users and are
often at the root of all substance addictions.
when people go off drugs, they tend to eat more and
put on weight. In some cases-particularly those
involving women, gay men, transgendered men, and
sex workers-they may actually go back on the drugs
in order to lose the weight, which they believe has made
them less attractive."
According to Edith Springer, "The drug-use career of
many substance-addicted women starts with early
issues around food and weight. They have an addictive relationship with food, they overeat, they become
concerned about being 'too fat,' they're put on diet
pills at the age of 13, and by the age of 17 they're
shooting heroin or using cocaine." Although this pattern may be more prevalent among white, middleclass women, Springer noted that eating disorders can
affect homeless and substance-using AfricanAmerican women as well. Springer described another
troubling phenomenon she has observed: "Often,
Where sex is the source of the addiction, the dynamics
are similar. "In my experience working with gay and
transgendered street [drug] users, their sexual compulsivity, when it is present, frequently results from a sexually traumatic experience in childhood. The sexual
compulsivity becomes a coping mechanism, just as
drug use would be. So there is a direct relationship
between sexual trauma and risk for HIV infection. 11
Of course, drug use also increases the likelihood that
individuals will engage in unsafe sex, which
also increases risk of HIV. As Springer said, "It's all
connected."
(continued on page 7)
HIYfrontline
HIV-Related COndltlons Focus On: Hepatitis
Now that advances in treatment have significantly lengthened survival duration for patients with HIV infection, healthcare providers
will increasingly find themselves working with clients who are coinfected with HIV and another potentially life-threatening infection
that has become a growing cause for concern: hepatitis. This article focuses on the three most common forms of viral hepatitis.
Types of Hepatitis
Hepatitis is defined as inflammation of
the liver. Although hepatitis can also be
caused by nonviral substances such as
chemicals, drugs, and alcohol, viral
hepatitis is the most common form of
the disease. Approximately 70,000 cases
of viral hepatitis are reported to the
Centers for Disease Control and
Prevention each year; howev er, this
number probably represents only a
fraction of the actual incidence rate of
the disease.
At least five types of viral hepatitis are
known, each one caused by a different
virus. The most common by far, however,
are hepatitis A (HAV), B (HBV), and C
(HCV). Use of contaminated needles is a
risk factor for HBV and HCV; thu s, all
IDUs must be considered at risk.
All forms of hepatitis cause fairly similar
symptoms, when they cause any at all.
The most common symptoms are
fatigue, mild fever, muscle or joint aches,
nausea, vomiting, loss of appetite, vague
abdominal pain, and, sometimes, diarrhea. Less common symptoms include
dark urine, light-colored stools, itching,
and jaundice (a yellowish color of the
skin and the whites of the eyes).
Whether or not they cause symptoms,
however, both HBV and HCV have the
potential to progress to chronic liver disease. Only HAV does not.
Hepatitis A
HAV is transmitted primarily via the
fecal-oral route; that is, it is contracted by
eating food or drinking water that has
been contaminated with human excrement. The Centers for Disease Control
and Prevention lists household or sexual
contact, recent international travel, and
day care attendance or employment as
risk factors for HAV. Infected food han-
dlers can also transmit the disease, and,
although injection-drug use is considered
a relatively rare route of transmission,
those who have used contaminated needles are at risk for this form of hepatitis.
Numerous outbreaks have also been
reported among homosexual men, and
oral/anal sexual practices have been postulated as the route of transmission in
these cases.
HAV is usually self-limiting, and patients
experience full recovery within approximately 6 months. A vaccine for HAV is
available and is recommended for people
at risk, including those who have household or sexual contact with an infected
person; those who live in areas where an
HAV outbreak is occurring; travelers
going to developing countries; men who
have sex with men; people who engage
in high-risk sexual behaviors; those who
use injection drugs; and those who have
preexisting, chronic liver disease.
The clinical course and severity of HAV
does not seem to be affected by the presence of HIV but does seem to be worsened by the presence of HCV. HAV
vaccination does not appear to negatively impact CD4 cell counts in patients
with HIV, although it may not be as effective in preventing the disease in these
patients. Immunization is recommended
for people with chronic liver disease.
Note that HAV may necessitate interruption of antiretroviral therapy, since HAVinduced liver inflammation may cause
intolerance to antiretrovirals.
Hepatitis B
An estimated 1.2 million Americans are
chronic carriers of HBV, which makes this
infection much more prevalent than
HIV infection. In up to 10% of those
infected, HBV may develop into a
chronic disease; if left untreated, this
chronic condition increases the risks of
cirrhosis and liver cancer.
HBV is known to be transmissible from
mother to child at birth or soon after,
through sexual contact, or through blood
transfusions or contaminated needles.
The source of one third of cases, however,
is unknown. Homosexual men, IDUs,
people who have sex with multiple
partners or with infected partners,
healthcare workers, emergency responders, and hemodialysis patients are
considered to be at risk. A vaccine is
available that provides protection for up
to 18 years; however, it is often ineffective or only partially effective in HIVpositive patients.
Antiviral agents have been used to treat
HBV, with varying degrees of success. The
principal treatment has been interferon
alfa. Recently, 3TC was approved by the
Food and Drug Administration as the
first oral treatment for HBV. The dosage
of 3TC used to treat HBV is lower than
that used to treat HIV. To avoid the
development of HIV drug resistance,
therefore, patients' HIV status must be
known before HBV treatment with 3TC
is initiated.
HIV infection impairs cell-mediated
immunity, which is essential to the
body's immune response to HBV; thus,
the presence of HIV can affect the clinical
picture and progression of HBV and
vice versa.
Hepatitis C
The most common form of hepatitis is
HCV, and approximately 3.5 million
Americans are chronically infected. The
disease progresses to a chronic state in up
to 85% of the 150,000 Americans who
are newly infected each year. Like HBV,
HCV can lead to cirrhosis, liver cancer, or
liver failure.
The modes of transmission of HCV are
similar to those of HBV, with the excep(continued on page 8)
-
HIVfrogtlioe
H·l·V
N·E·W·S
B·R·l·E·F·S
ii' HIV »aced to Subspecies of Chimpanzee
■
Researchers at the 6th Conference on Retroviruses and Opportunistic Infections, held in Chicago, IL, from January 31 to
February 4, announced that the roots of HIV-1 can be traced to Pan troglodytes troglodytes, a subspecies of chimpanzee found in
Africa. According to the international team of scientists, led by Dr Beatrice H. Hahn of The University of Alabama at
Birmingham, the subspecies has managed to survive with SIVcpz (simian immunodeficiency virus-chimpanzee, a form of virus
that is 98% similar to HIV-1) without becoming ill. This discovery could prompt research into why HIV-1 leads to death in
humans, although SIVcpz apparently does not cause illness in chimpanzees. The discovery also could h elp in detecting viruses
that might be capable of being transmitted from animals to human h osts.
■
Long In Used Syringes
A study cited in the fournal of Acquired Immune Deficiency Syndromes and Human Retrovirology found that viable HIV-1 can be
recovered from syringes up to 4 or more weeks after they are used. According to Dr Nadia Abdala and colleagues of Yale
University, who conducted the study, this finding highlights the need fo r needle-exchange programs and the removal of dangerous, used needles from circulation.
■
CetJarean Delivery Cited as Standard of Care for. HIV-Positive Mothers
Results of a recent study indicate that if clin icians treat HIV-positive pregnant women with ZDV, then deliver the babies via
cesarean section, the risk of perinatal HIV transmission would practically be eliminated. The risk would be reduced to just 2%.
In addition to setting a standard of care for HIV-positive pregn ant patients, this study, which will be published in the New
England fournal of Medicine in March, also highlights the importance of HIV testing for pregnant women. Dr Lynne Mofenson,
coauthor of the report, noted, "All infected women need to be told about this information."
mNumber of AIDS-Associated Deaths in New York City
■
New York City officials announced that, according to preliminary 1998 data, there was a 26% decline from 1997 in the number
of AIDS-associated deaths. The drop marks the fourth consecutive year of such decline in th e city and the first time the number
of AIDS-associated deaths has dropped below 2000 since 1985. The decrease in deaths was observed among both sexes and all
age and racial groups. The smallest decline was among female African Americans. The decline was attributed to improved drug
therapy and better access to care.
■
Gay Men May Contribute to Jump in Positive HIV Tests
The proportion of positive HIV tests increased by 50% in 1998. This increase has been blamed, at least in part, on recreational
drug use by gay men. Some reports indicate that more gay men, particularly young gay men , are practicing unprotected anal
sex. It has been suggested that recreational drug use, which reduces inhibition, may fuel such unsafe sex practices. Some advocates for the gay community say that there has been a reluctance to address this issue openly. Th ere is a fear that acknowledgment of the issue might convey an inaccurate image of all gay men as drug users. In light of the increased prevalence of positive test results, however, several advocacy groups have initiated educational programs design ed to focus on the connection
between drug use and unsafe sex.
HIV and Addiction (continued from page 5)
■
Resources
Harm Reduction Coalition
East Coast office
22 West 27th Street, 9th floor
New York, N Y 10001
(212) 213-6376
West Coast office
3223 Lakeshore Avenue
Oakland, CA 94610
(510) 444-6969
Website: http://www.harmreduction .org
Narcotics Anonymous
PO Box 9999
Van Nuys, CA 91409
Phone (8 18) 773-9999
Fax (818) 700-0700
Website: http://www.na.org
Alcoholics Anonymous
AA General Service Office
4 75 Riverside Drive
New York, NY 10015
Phone (212) 870-3400
Fax (212) 870-3003
Website: http://www.alcoh olics-anonymous.org
HIVfrogtl ioe
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HIVfcontline
HIV-Related Conditions Focus On: Hepatitis
tion that sexual transmission and
mother-to-child transmission are considered unlikely in the case of HCV.
Although no vaccine is available for
HCV at this time, it can be treated with
interferon, either alone or as part of
combination therapy with ribavirin.
Treatment is only effective for approximately one third of patients.
It is believed that the course of acute
HCV infection may be more aggressive
in patients with HIV, but the effect of
HIV on chronic HCV is less clear; similarly, the effect of HCV on HIV infection
is not well understood. Although HIVpositive patients appear to respond as
well to HCV treatment as do their HIVnegative counterparts, they appear to
have a much higher rate of relapse.
(continued from page 6J
COUNSELING CLIENTS ABOUT HEPATITIS
The best defense against hepatitis is prevention. Clients should be counseled
with regard to measures that can be taken to prevent its transmission.
ForHAV
• Wash hands with soap and water after using the toilet, after having sex, and
after handling condoms
• Use household bleach to clean surfaces contaminated with feces
• Wash fresh fruit and vegetables before eating them
• Practice safer sex
• Consider vaccination if you engage in high-risk behaviors
For HBV and HCV
• Practice safer sex
• Clean up infected blood with bleach and wear protective gloves
• Do not share needles (or other injection-drug paraphernalia), razors,
or toothbrushes
• When getting a manicure, a tattoo, or body piercing, make sure that only
sterile instruments are used
• Get vaccinated for HBV
Meeting Announcement
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in New York City on March 20, 1999. Frontline Forums for a more general audience of HIV counselors will be held
in the following cities in 1999: Tampa, Atlanta, New Orleans, and Houston. For more information,
contact Brendan Maney by phone at (212) 892-1711 or by E-mail at bmaney@41mad.com.
Conference Announcement
The 11th Annual National Conference on Social Work and HIV/AIDS will be held in
Chicago on May 26-29, 1999. For more information, contact Dr Vincent Lynch
by phone at (617) 552-4038 or by E-mail at lynchv@bc.edu.
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Property of the Center
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This newsletter is supported through an independent educational grant from
ISSUE NO. 36
6/axoWel/come
HIV and Addiction:
Providing Co111passionate Care
to a Complex Population
arious addictive behaviors, particularly addiction to injection drugs, have been associated with
HIV/AIDS since the early days of the epidemic. Today, however, injection-drug users (IDUs)
account for an increasingly large proportion of those diagnosed with the infection. Despite the
enormous body of literature that has been amassed on the subject of HIV, relatively little has
been published to guide the HIV counselor in working with this population. Therefore, this issue of
HIV Frontline focuses on the substance-using HIV-infected client.
1111 The Scope of the Substance-Use
Problem
Injection-drug use, the second most common risk factor
for HIV, is a source of viral transmission in an everincreasing number of patients with HIV. As of December
1996, 36% of all reported AIDS cases were attributable to
injection-drug use; half of all new infections occur in this
population. With HIV hitting disproportionately hard in
the Latino and African-American communities, it has
been estimated that an African-American IDU is at four
times greater risk of contracting HIV than of dying of a
drug overdose. Eight out of 10 women with AIDS
reported injection-drug use or sexual contact with an
IDU as their primary risk factors for contracting the virus.
1111 A Unique Set of Needs
For a variety of reasons, substance-using and -addicted
clients with HIV tend to present more significant care
complexities than their non-su bstance-using cou nter-
Inside ...
• HIV and Addiction
• Focus on Hepatitis
*
* New Features
Introduction to
• HIV News Briefs
•
parts. Often marginalized and stigmatized, they may
have little access to preventive care and may not seek
treatment until later in the disease process. When these
clients do seek treatment, they may lack the resources to
meet its demands and the demands placed on them by
the medical establishment.
"Medical systems are not created for some of the people
they serve," noted Edith Springer, ACSW, a trainer at New
York's Harm Reduction Institute, and formerly clinical
director of the New York Peer AIDS Education Coalition,
also in New York City. "They are created for high-functioning, highly organized, appointment-book-carrying,
middle-class-ideology kinds of people. But because substance users have been kept out of the societal mainstream, because they've been stigmatized by every
segment of society including their own families, they
don't have the cultural norms and skills that would allow
them to work within the traditional medical system. And
the system, in general, doesn't consider their needs."
Ms Springer offered an example of a hospital in New York
th at schedules each of its female patients with HIV for a
9:00 AM appointment. If she shows up on time, she's
expected to sit and wait to be seen-sometimes all day.
"So there are 80 women with their kids running around,
with no activities, nothing to keep them occupied, and
no food. The women who are addicted are, at some point
during this long day, going to go into withdrawal, but
there are no provisions for that either. And then we say
that drug users don't follow through."
(continued on page 2)
www.HIVLine.com
February 1999
HIYfcontline
Editorial
Advisory 1°@rd
Richard S. Ferri, PhD,
ANP, ACRN
HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts
-
Michele Fontaine, MA, CASAC
Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York
Susan M . Gallego, MSSW,
LMSW-ACP
Private Practitioner/Consultant
Austin, Texas
Vincent J. Lynch, DSW
Director,
National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts
John G. O'Brien, PharmD
Assistant Clinical Professor
University of California, San Francisco
HIV Pharmacist Specialist
Ira Greene Positive PACE Clinic
San Jose, California
-
George Perez, MD
Director of Virology
St Michael's Medical Center
Medical Director
North Jersey Community
Research Initiative
Newark, New Jersey
Michael E. Sheran, MD
Assistant Professor of Medicine
New York Medical College
Associate Attending Physician
Department of Medicine
St Vincent's Hospital
New York, New York
Angela Shiloh-Cryer, MSW
Director
Office of Health Policy and
AIDS Funding
New Orleans, Louisiana
-
Barry Zevin, MD
Medical Director
Tom Waddell Health Center
San Francisco, California
This newsletter is published by World Health CME, a division of World Health Communications Inc., and is supported tluough an independent educational grant from
Glaxo Welkome. The views and opinions expressed herein do not necessarily reflect those of Glaxo Wellcome,
World Health CME, or the Editorial Advisory Board.
Statements regarding drugs,, dosages, and procedures are
not meant to serve as guidelines in the treatment of
patients. Please see the full prescribing information before
using any agent mentioned in this publication.
© 1999, World Health CME. All rights reserved. Printed in
the USA. Permission granted tor noncommercial reproduction of this material.
HIV and Addiction (continued from page 1)
For substance users who are poor, as many are, the correlates of poverty-inadequate housing, lack of access to transportation, poor nutrition-further complicate the picture. There is substantial evidence that many substance-using clients
with HIV carry triple diagnoses of HIV, addiction, and psychiatric disorders. Four
common psychological factors have been observed in drug-using patients with
HIV who are enrolled in substance-abuse treatment programs: denial, anger
(sometimes accompanied by antisocial behavior), depression, and isolation.
Certain medical problems are considerably more common among IDUs
with HIV than among their nonusing counterparts (Table 1). Some of these
problems, such as skin abscesses and viral hepatitis, are related directly to
injection-drug use. Others, such as tuberculosis, are particularly common
among homeless drug users and shelter residents. These problems are associated with crowded living conditions, such as those found in correctional
facilities. According to Peter Selwyn, MD, MPH, professor and chairman,
Unified Department of Family Medicine, Montefiore Medical Center, Albert
Einstein College of Medicine, Bronx, NY, sexually transmitted diseases are
common among IDUs with HIV, because many HIV-infected drug users
may continue to practice unsafe sex even after they have adopted safer
drug-use practices.
Although there is some laboratory evidence to indicate that cocaine may
facilitate replication of HIV in the test tube, HIV does not appear to progress
more rapidly in drug users. It is therefore important, according to Dr Selwyn,
to avoid a two-class system of care in which vulnerable and disenfranchised
populations are not benefiting fully from the range of antiretroviral
(continued on page 3)
Introducing Two New Features
Do you have thoughts or questions about topics covered in HIV Frontline that you would
like to express? Do you have ideas or suggestions for future articles or features that you
would like to see in this publication?
We are pleased to introduce the "Reader's Column," a new feature that will appear
beginning with our next issue (April 1999). The Reader's Column will offer you a chance to
share your thoughts, ideas, and opinions with your fellow HN counselors. We will answer
your questions and air your concerns.
The column will only be as valuable as its content, however. We need your input to make
it work. Whether you like or disagree with something you read here, or learn something
useful from an article that appears here, we want to hear from you.
Another new feature we are introducing is "Tips for Counselors," which will also make
its debut in the April issue of HIV Frontline. If you have had any experiences working
with clients that you think would be instructive for your fellow HN counselors, "Tips for
Counselors" will provide you with an opportunity to share them. Any ideas or pointers for
dealing with a difficult counseling situation, any specialized knowledge you have regarding
a particular counseling issue, or techniques or approaches you've used that have proved
successful will be welcome.
Please fax your questions, comments, and tips to Frontline Editor at (212) 481-8532.
Thanks for your continued interest in HIV Frontline.
HIYfrontline
HIV and Addiction (continued from page 2)
treatments available. "Drug users are certainly among
the vulnerable and disenfranchised, and the challenge
is to ensure that we work diligently to extend treatment
benefits to these individuals,"
11111
Substances and Highly Active
Antiretroviral Therapy: Can They
Go Together?
One factor that can interfere with substance-addicted
patients' receiving full access to highly active antiretroviral therapy (HAART) is concern that these medications
may interact if taken concomitantly with "street" drugs.
Dr Selwyn acknowledged that the potential for drug
interactions is something to be aware of and considered.
This concern, however, should not deter healthcare
providers from prescribing HAART for their substanceusing clients. "For the most part, there seems to be not
much of an interaction effect. This issue has really been
overblown. In this country, the drugs that are most comTABLE 1
Common Medical Problems in
HIV-Infected IDUs
• Severe bacterial infections (including those of the
respiratory system, heart, and/or blood)
• Mycobacterium tuberculosis (including multidrug
resistant)
• Sexually transmitted diseases
-Herpes simplex virus (genital; chronic
mucocutaneous)
-Human papillomavirus (oral; genital; cervical
dysplasia/carcinoma in women)
-Syphilis (genital; neurosyphilis)
-Pelvic inflammatory disease
• Others
-Skin abscesses, cellulitis (from "skin popping")
- Viral hepatitis (B, C)
-Alcohol-induced hepatitis and cirrhosis
-Alcohol-induced gastritis
-Intoxication and withdrawal states
-Other central nervous system complications
-Hepatic (liver-related) encephalopathy
-Cocaine-induced ischemia (local anemia)
and seizures
Adapted with permission from Ferrando SJ, Batki SL. HIV infection: From
dual to triple diagnosis . In: Kranzler HR, Rounsaville BJ, eds. Dual
Diagnosis and Treatment. New York, NY: Marcel Dekker; 1998:515.
monly abused are, overwhelmingly, heroin and
cocaine-and neither one of those is likely to have a
major effect.
"Having said that," Dr Selwyn added, "there have been
some case reports of serious problems in individuals taking ritonavir with the recreational drug Ecstasy, because
some protease inhibitors can inhibit the metabolism of
Ecstasy, allowing it to build up to toxic levels."
Dr Selwyn stated that there is also concern that some of
the antiretroviral agents might reduce methadone levels
in some patients. As a result, these patients either will
need more methadone or will not take their antiretrovirals in an effort to avoid withdrawal. "So far, though," he
said, "it looks as if this is only an issue with nevirapine,
for which methadone doses may need to be increased,
and possibly also with efavirenz. But in general, the
nucleoside analogs, such as [ZDV], 3TC, ddI, and d4T,
have been used without problematic interactions with
methadone, as have some of the protease inhibitors,
such as indinavir, saquinavir, and possibly nelfinavir."
In the absence of complete information on this issue, Dr
Selwyn said, the best approach is to be honest with
clients. "We need to tell them that, number one, it's
harmful to use street drugs, and number two, we just
don't know for sure whether or not they can interfere
with your HIV therapy or vice versa. We don't think so,
but we can't be absolutely sure it won't happen."
Simplicity is another issue to be considered when antiretroviral regimens are designed for substance-using
clients, because clients' lifestyles may complicate adherence. One regimen recommended by Dr Selwyn that preserves the protease option, offers the effectiveness of
triple-drug therapy with the ease of only four pills daily,
and encourages adherence is lamivudine (3TC)/zidovudine (ZDV) and nevirapine, two nucleoside reverse transcriptase inhibitors (NRTis) and one nonnucleoside RTI
(NNRTI), respectively. Although nevirapine may necessitate an increase in methadone dosage, it is still a good
choice for this population because of its easy dosing and
minimal side effects. Another possible combination,
requiring further study, is 3TC/ZDV and abacavir, a tripleNRTI regimen that offers the advantage of preserving the
options of NNRTis and protease inhibitors for future use,
if necessary. Other regimens that preserve the protease
option and offer simplified dosing include 3TC/stavudine plus nevirapine (two NRTis and one NNRTI) and
3TC/ZDV plus efavirenz (two NRTis and one NNRTI).
(continued on page 4)
HIYfrogtlige
HIV and Addiction (continued from page 3)
Dr Selwyn noted that with substance-using clients, as with
any client, it is crucial to assess commitment to and readiness for treatment. "It doesn't really matter whether they're
using drugs or not. What matters is whether they are willing and able to deal with the demands [and possible side
effects] of taking antiretroviral medication effectively."
1111 Abstinence or Harm Reduction?
A somewhat controversial issue is whether commitment
to antiretroviral therapy also requires a commitment to
abstinence from substance use. The crux of this issue
(and this applies to the non-HIV-infected substance user
as well) is determining which of two major approaches to
treatment is more appropriate for the addicted client:
standard substance-abuse treatment (the "moral" or "disease" model) or treatment within the context of the
"harm reduction" model.
1111 The Standard Model
The moral model of standard treatment holds that substance users tend to be weak and/or lazy or that they lack
moral character. Interventions have traditionally
included incarceration and scapegoating of the user. The
disease model contends that drug use is an incurable,
progressive medical condition in which the first step in
■ Counseling Addicted
HIV-Infected Clients
Regardless of whether one subscribes to the harm-reduction model
in total, in part, or not at all, there are elements of its clientfocused approach that can be helpful when counselors work with
substance-using HIV-positive clients in any setting.
• Break down the barriers. One of the simplest things
healthcare providers can do to place themselves and their
clients on equal footing, Ms Springer said, is to ask that
clients call them by their first names. "I've had doctors
really object to this advice, insisting that they need to set
boundaries. My response is that boundaries are not the
same as barriers."
• See the client's drug use as what it is-a coping
mechanism-and respect it as such. According to Ms
Springer, people may start using drugs recreationally, but
once they become dependent, the drugs are used as coping mechanisms. "The first thing we learn in our training
as counselors is that you don't take away one coping
mechanism before there's another in its place."
treatment is admitting one's powerlessness over one's
addiction. Interventions include complete abstinence
supported by peer groups or other treatment programs
and controlled prescription of cross-tolerant drugs.
Recovery is regarded as a lifetime process.
For substance users with HIV, the standard model maintains that elimination of substance use itself is crucial. It
not only improves the quality of life but also decreases
the risk of HIV transmission. The initial phase of such
treatment focuses on detoxification, after which the goals
of treatment become maintenance of abstinence and
rapid recovery from relapses. Self-help programs, such as
Alcoholics Anonymous and Narcotics Anonymous, are
generally encouraged as part of this treatment.
An expectation of abstinence is pivotal to the treatment
of substance-using clients, asserted Michele Fontaine,
MA, CASAC, former director of Greenwich House's AIDS
Mental Health Project in New York, and a member of the
Frontline Editorial Advisory Board. To approach treatment otherwise is to feed into the denial that is central to
substance use and addiction. That denial becomes
extremely destructive to the lives of substance users.
They are "already societally stigmatized by virtue of having HIV," Fontaine said. "Their substance use stigmatizes
them further and makes their lives even more difficult.
• Be absolutely accepting and genuinely nonjudgmental. "These individuals are constantly hypervigilant,
because they live in 'survival mode' on a daily basis, and
they are so accustomed to feeling stigmatized that they'll
pick up anything in your behavior that even hints at disapproval of them or their drug use. So, you have to be
conscious of your eyes, your hands, your facial expressions
-everything. You can't just pretend; you have to mean it."
• Be understanding of your clients' needs. For clients
who are homeless, said Ms Springer, that means understanding that survival needs must be met first. "For drug
users, especially those who are homeless, the needs of the
moment are so overwhelming that they can only worry
about today, this minute. While you might be talking
about the importance of their doctor's appointment
tomorrow, they're thinking, 'How am I going to eat
today? Where am I going to sleep? How am I going to not
get murdered tonight?"' In that context, medical appointments might not be their first priority-unless, of course,
you can help them meet some of those survival needs.
"A warm shower, clean socks, and a good meal go
a long way."
(continued on page 5)
HIVFrontline
HIV and Addiction (continued from page 4)
"Saying that abstinence is an unrealistic goal minimizes
the power of the client and the idea that he or she can
achieve sobriety and live without substance use,"
continued Ms Fontaine. "The abstinence approach is
preferable, because in the long run, it allows clients to
obtain a better picture of who they really are and to
achieve more honesty in their lives."
"Harm reduction is value neutral on the issue of substance use," Edith Springer said. "It does not try to make
people change. It allows people to change if they want to.
In the harm-reduction client-worker relationship, the
client has the power, makes the choices, and chooses the
goals. The worker acts as a consultant to help the client
reach those goals."
The harm-reduction philosophy has several basic tenets:
Ill The Harm-Reduction Model
At the other end of the spectrum is a relatively newer
approach, referred to as the harm-reduction model. The
harm-reduction philosophy was developed in the 1980s,
when countries such as The Netherlands, Great Britain,
and Australia began to recognize the need for more realistic and effective ways of reducing the spread of HIV
infection among IDUs. Harm-reduction-based programs,
including decriminalization of drug use and needle- and
syringe-exchange programs, had the desired effect of dramatically reducing HIV transmission in those communities in which the programs were implemented.
■
r
l
• HIV prevention takes priority over drug-use prevention
because of the high cost of AIDS medications to the
patient, the community, and society
• Although eventual abstinence is desirable, it should not be
the only goal of services for drug users, because abstinence
excludes the large proportion of people who will continue
to use drugs in the long term
• Abstinence should be viewed as the final goal in a series of
objectives that seek to reduce the harm that drug use causes
• An important method for helping people minimize the
harmful effects of their drug use is to provide services
that are attractive, easily accessed, and empowering
Associated Addictions: Food and Sex
Although substance use is certainly the addiction of
greatest concern regarding HIV-positive clients, it is
important to note that these people may be dealing
with other addictions as well. Addictions to food and
sex are not uncommon among substance users and are
often at the root of all substance addictions.
when people go off drugs, they tend to eat more and
put on weight. In some cases-particularly those
involving women, gay men, transgendered men, and
sex workers-they may actually go back on the drugs
in order to lose the weight, which they believe has made
them less attractive."
According to Edith Springer, "The drug-use career of
many substance-addicted women starts with early
issues around food and weight. They have an addictive relationship with food, they overeat, they become
concerned about being 'too fat,' they're put on diet
pills at the age of 13, and by the age of 17 they're
shooting heroin or using cocaine." Although this pattern may be more prevalent among white, middleclass women, Springer noted that eating disorders can
affect homeless and substance-using AfricanAmerican women as well. Springer described another
troubling phenomenon she has observed: "Often,
Where sex is the source of the addiction, the dynamics
are similar. "In my experience working with gay and
transgendered street [drug] users, their sexual compulsivity, when it is present, frequently results from a sexually traumatic experience in childhood. The sexual
compulsivity becomes a coping mechanism, just as
drug use would be. So there is a direct relationship
between sexual trauma and risk for HIV infection. 11
Of course, drug use also increases the likelihood that
individuals will engage in unsafe sex, which
also increases risk of HIV. As Springer said, "It's all
connected."
(continued on page 7)
HIYfrontline
HIV-Related COndltlons Focus On: Hepatitis
Now that advances in treatment have significantly lengthened survival duration for patients with HIV infection, healthcare providers
will increasingly find themselves working with clients who are coinfected with HIV and another potentially life-threatening infection
that has become a growing cause for concern: hepatitis. This article focuses on the three most common forms of viral hepatitis.
Types of Hepatitis
Hepatitis is defined as inflammation of
the liver. Although hepatitis can also be
caused by nonviral substances such as
chemicals, drugs, and alcohol, viral
hepatitis is the most common form of
the disease. Approximately 70,000 cases
of viral hepatitis are reported to the
Centers for Disease Control and
Prevention each year; howev er, this
number probably represents only a
fraction of the actual incidence rate of
the disease.
At least five types of viral hepatitis are
known, each one caused by a different
virus. The most common by far, however,
are hepatitis A (HAV), B (HBV), and C
(HCV). Use of contaminated needles is a
risk factor for HBV and HCV; thu s, all
IDUs must be considered at risk.
All forms of hepatitis cause fairly similar
symptoms, when they cause any at all.
The most common symptoms are
fatigue, mild fever, muscle or joint aches,
nausea, vomiting, loss of appetite, vague
abdominal pain, and, sometimes, diarrhea. Less common symptoms include
dark urine, light-colored stools, itching,
and jaundice (a yellowish color of the
skin and the whites of the eyes).
Whether or not they cause symptoms,
however, both HBV and HCV have the
potential to progress to chronic liver disease. Only HAV does not.
Hepatitis A
HAV is transmitted primarily via the
fecal-oral route; that is, it is contracted by
eating food or drinking water that has
been contaminated with human excrement. The Centers for Disease Control
and Prevention lists household or sexual
contact, recent international travel, and
day care attendance or employment as
risk factors for HAV. Infected food han-
dlers can also transmit the disease, and,
although injection-drug use is considered
a relatively rare route of transmission,
those who have used contaminated needles are at risk for this form of hepatitis.
Numerous outbreaks have also been
reported among homosexual men, and
oral/anal sexual practices have been postulated as the route of transmission in
these cases.
HAV is usually self-limiting, and patients
experience full recovery within approximately 6 months. A vaccine for HAV is
available and is recommended for people
at risk, including those who have household or sexual contact with an infected
person; those who live in areas where an
HAV outbreak is occurring; travelers
going to developing countries; men who
have sex with men; people who engage
in high-risk sexual behaviors; those who
use injection drugs; and those who have
preexisting, chronic liver disease.
The clinical course and severity of HAV
does not seem to be affected by the presence of HIV but does seem to be worsened by the presence of HCV. HAV
vaccination does not appear to negatively impact CD4 cell counts in patients
with HIV, although it may not be as effective in preventing the disease in these
patients. Immunization is recommended
for people with chronic liver disease.
Note that HAV may necessitate interruption of antiretroviral therapy, since HAVinduced liver inflammation may cause
intolerance to antiretrovirals.
Hepatitis B
An estimated 1.2 million Americans are
chronic carriers of HBV, which makes this
infection much more prevalent than
HIV infection. In up to 10% of those
infected, HBV may develop into a
chronic disease; if left untreated, this
chronic condition increases the risks of
cirrhosis and liver cancer.
HBV is known to be transmissible from
mother to child at birth or soon after,
through sexual contact, or through blood
transfusions or contaminated needles.
The source of one third of cases, however,
is unknown. Homosexual men, IDUs,
people who have sex with multiple
partners or with infected partners,
healthcare workers, emergency responders, and hemodialysis patients are
considered to be at risk. A vaccine is
available that provides protection for up
to 18 years; however, it is often ineffective or only partially effective in HIVpositive patients.
Antiviral agents have been used to treat
HBV, with varying degrees of success. The
principal treatment has been interferon
alfa. Recently, 3TC was approved by the
Food and Drug Administration as the
first oral treatment for HBV. The dosage
of 3TC used to treat HBV is lower than
that used to treat HIV. To avoid the
development of HIV drug resistance,
therefore, patients' HIV status must be
known before HBV treatment with 3TC
is initiated.
HIV infection impairs cell-mediated
immunity, which is essential to the
body's immune response to HBV; thus,
the presence of HIV can affect the clinical
picture and progression of HBV and
vice versa.
Hepatitis C
The most common form of hepatitis is
HCV, and approximately 3.5 million
Americans are chronically infected. The
disease progresses to a chronic state in up
to 85% of the 150,000 Americans who
are newly infected each year. Like HBV,
HCV can lead to cirrhosis, liver cancer, or
liver failure.
The modes of transmission of HCV are
similar to those of HBV, with the excep(continued on page 8)
-
HIVfrogtlioe
H·l·V
N·E·W·S
B·R·l·E·F·S
ii' HIV »aced to Subspecies of Chimpanzee
■
Researchers at the 6th Conference on Retroviruses and Opportunistic Infections, held in Chicago, IL, from January 31 to
February 4, announced that the roots of HIV-1 can be traced to Pan troglodytes troglodytes, a subspecies of chimpanzee found in
Africa. According to the international team of scientists, led by Dr Beatrice H. Hahn of The University of Alabama at
Birmingham, the subspecies has managed to survive with SIVcpz (simian immunodeficiency virus-chimpanzee, a form of virus
that is 98% similar to HIV-1) without becoming ill. This discovery could prompt research into why HIV-1 leads to death in
humans, although SIVcpz apparently does not cause illness in chimpanzees. The discovery also could h elp in detecting viruses
that might be capable of being transmitted from animals to human h osts.
■
Long In Used Syringes
A study cited in the fournal of Acquired Immune Deficiency Syndromes and Human Retrovirology found that viable HIV-1 can be
recovered from syringes up to 4 or more weeks after they are used. According to Dr Nadia Abdala and colleagues of Yale
University, who conducted the study, this finding highlights the need fo r needle-exchange programs and the removal of dangerous, used needles from circulation.
■
CetJarean Delivery Cited as Standard of Care for. HIV-Positive Mothers
Results of a recent study indicate that if clin icians treat HIV-positive pregnant women with ZDV, then deliver the babies via
cesarean section, the risk of perinatal HIV transmission would practically be eliminated. The risk would be reduced to just 2%.
In addition to setting a standard of care for HIV-positive pregn ant patients, this study, which will be published in the New
England fournal of Medicine in March, also highlights the importance of HIV testing for pregnant women. Dr Lynne Mofenson,
coauthor of the report, noted, "All infected women need to be told about this information."
mNumber of AIDS-Associated Deaths in New York City
■
New York City officials announced that, according to preliminary 1998 data, there was a 26% decline from 1997 in the number
of AIDS-associated deaths. The drop marks the fourth consecutive year of such decline in th e city and the first time the number
of AIDS-associated deaths has dropped below 2000 since 1985. The decrease in deaths was observed among both sexes and all
age and racial groups. The smallest decline was among female African Americans. The decline was attributed to improved drug
therapy and better access to care.
■
Gay Men May Contribute to Jump in Positive HIV Tests
The proportion of positive HIV tests increased by 50% in 1998. This increase has been blamed, at least in part, on recreational
drug use by gay men. Some reports indicate that more gay men, particularly young gay men , are practicing unprotected anal
sex. It has been suggested that recreational drug use, which reduces inhibition, may fuel such unsafe sex practices. Some advocates for the gay community say that there has been a reluctance to address this issue openly. Th ere is a fear that acknowledgment of the issue might convey an inaccurate image of all gay men as drug users. In light of the increased prevalence of positive test results, however, several advocacy groups have initiated educational programs design ed to focus on the connection
between drug use and unsafe sex.
HIV and Addiction (continued from page 5)
■
Resources
Harm Reduction Coalition
East Coast office
22 West 27th Street, 9th floor
New York, N Y 10001
(212) 213-6376
West Coast office
3223 Lakeshore Avenue
Oakland, CA 94610
(510) 444-6969
Website: http://www.harmreduction .org
Narcotics Anonymous
PO Box 9999
Van Nuys, CA 91409
Phone (8 18) 773-9999
Fax (818) 700-0700
Website: http://www.na.org
Alcoholics Anonymous
AA General Service Office
4 75 Riverside Drive
New York, NY 10015
Phone (212) 870-3400
Fax (212) 870-3003
Website: http://www.alcoh olics-anonymous.org
HIVfrogtl ioe
READER
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Dear HIV Frontline Reader:
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HIVfcontline
HIV-Related Conditions Focus On: Hepatitis
tion that sexual transmission and
mother-to-child transmission are considered unlikely in the case of HCV.
Although no vaccine is available for
HCV at this time, it can be treated with
interferon, either alone or as part of
combination therapy with ribavirin.
Treatment is only effective for approximately one third of patients.
It is believed that the course of acute
HCV infection may be more aggressive
in patients with HIV, but the effect of
HIV on chronic HCV is less clear; similarly, the effect of HCV on HIV infection
is not well understood. Although HIVpositive patients appear to respond as
well to HCV treatment as do their HIVnegative counterparts, they appear to
have a much higher rate of relapse.
(continued from page 6J
COUNSELING CLIENTS ABOUT HEPATITIS
The best defense against hepatitis is prevention. Clients should be counseled
with regard to measures that can be taken to prevent its transmission.
ForHAV
• Wash hands with soap and water after using the toilet, after having sex, and
after handling condoms
• Use household bleach to clean surfaces contaminated with feces
• Wash fresh fruit and vegetables before eating them
• Practice safer sex
• Consider vaccination if you engage in high-risk behaviors
For HBV and HCV
• Practice safer sex
• Clean up infected blood with bleach and wear protective gloves
• Do not share needles (or other injection-drug paraphernalia), razors,
or toothbrushes
• When getting a manicure, a tattoo, or body piercing, make sure that only
sterile instruments are used
• Get vaccinated for HBV
Meeting Announcement
The Frontline Forum at Riker's Island, a day-long symposium for correctional healthcare professionals, will be held
in New York City on March 20, 1999. Frontline Forums for a more general audience of HIV counselors will be held
in the following cities in 1999: Tampa, Atlanta, New Orleans, and Houston. For more information,
contact Brendan Maney by phone at (212) 892-1711 or by E-mail at bmaney@41mad.com.
Conference Announcement
The 11th Annual National Conference on Social Work and HIV/AIDS will be held in
Chicago on May 26-29, 1999. For more information, contact Dr Vincent Lynch
by phone at (617) 552-4038 or by E-mail at lynchv@bc.edu.
To add your name to the mailing list for this publication, please send your request to HIV Frontline, World Health CME,
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Now there is also an HIV Frontline Fax Newsletter, bringing you timely reports from major national
and international medical conferences. To receive this publication by fax,
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