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Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services
This report originated in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Kevin Fenton, MD, PhD, Director.
Corresponding preparer: Salaam Semaan, DrPH, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, 1600 Clifton Road, MS E-07, Atlanta, GA 30333; Telephone: 404-639-8870; Fax: 404-639-3125; E-mail:SSemaan@cdc.gov.
Summary
This report summarizes current (as of 2011) guidelines or recommendations published by multiple agencies of the U.S. Department of Health and Human Services (DHHS) for prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) for persons who use drugs illicitly. It also summarizes existing evidence of effectiveness for practices to support delivery of integrated prevention services. Implementing integrated services for prevention of HIV infection, viral hepatitis, STDs, and TB is intended to provide persons who use drugs illicitly with increased access to services, to improve timeliness of service delivery, and to increase effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants. This guidance is intended for use by decision makers (e.g., local and federal agencies and leaders and managers of prevention and treatment services), health-care providers, social service providers, and prevention and treatment support groups. Consolidated guidance can strengthen efforts of health-care providers and public health providers to prevent and treat infectious diseases and substance use and mental disorders, use resources efficiently, and improve health-care services and outcomes in persons who use drugs illicitly.
An integrated approach to service delivery for persons who use drugs incorporates recommended science-based public health strategies, including 1) prevention and treatment of substance use and mental disorders; 2) outreach programs; 3) risk assessment for illicit use of drugs; 4) risk assessment for infectious diseases; 5) screening, diagnosis, and counseling for infectious diseases; 6) vaccination; 7) prevention of mother-to-child transmission of infectious diseases; 8) interventions for reduction of risk behaviors; 9) partner services and contact follow-up; 10) referrals and linkage to care; 11) medical treatment for infectious diseases; and 12) delivery of integrated prevention services. These strategies are science-based, public health strategies to prevent and treat infectious diseases, substance use disorders, and mental disorders. Treatment of infectious diseases and treatment of substance use and mental disorders contribute to prevention of transmission of infectious diseases. Integrating prevention services can increase access to and timeliness of prevention and treatment.
Introduction
This report summarizes current (as of 2011) public health recommendations and guidelines from multiple agencies of the U.S. Department of Health and Human Services (DHHS) for science-based public health strategies for the prevention of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) (referred to collectively as infectious diseases) among persons who use drugs illicitly and their contacts (sex and drug-using partners) in the United States. In addition, the report recommends integrated delivery of the public health strategies and includes a review of recent programmatic efforts to integrate prevention services for persons who use drugs illicitly. Integrated prevention services provide multiple prevention services at a single venue, coordinate referrals, and provide linkage to services delivered at multiple venues to improve access to high-quality and comprehensive prevention services. Such integration can offer providers and programs the opportunity to address multiple infectious diseases and related health conditions (e.g., substance use and mental disorders) at one time or at a single facility, thereby increasing the likelihood that clients will receive needed services (1). Without access to integrated prevention services, persons who use drugs illicitly would need to go to different facilities to access prevention and treatment services for HIV infection, viral hepatitis, STDs, or TB and for substance use or mental disorders. Implementing integrated services is intended to increase access to services, improve the timeliness of service delivery, and increase the effectiveness of efforts to prevent infectious diseases and disorders that share common risk factors, behaviors, and social determinants. The guidance does not review the topic of physical integration of all medical treatment services for such diseases, especially as different regulatory, accreditation, and licensing policies govern the delivery of treatment services for these diseases. However, the guidance emphasizes the importance of treatment for infectious diseases as a major strategy in preventing their further transmission. The guidance also emphasizes treatment of substance use and mental disorders, comorbidities that must be treated effectively to optimize prevention outcomes for infectious diseases.
This report is divided into seven sections: 1) an introduction to the scope and purpose of the guidance; 2) a summary of the methods, including steps and procedures followed in development of the guidance; 3) a brief outline of the epidemiology of illicit drug use and of HIV infection, viral hepatitis, STDs, TB, and their sequelae among persons who use drugs illicitly in the United States; 4) a description of science-based public health strategies for prevention of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly; 5) a brief summary of special considerations that affect the prevention and control of infectious diseases among persons who use drugs illicitly; 6) a section discussing practical aspects of delivery of integrated prevention services; and 7) a short conclusion stating the rationale and importance of integrated prevention services for infectious diseases among persons who use drugs illicitly.
Illicit Use of Drugs and Infectious Diseases
Rates of HIV infection, viral hepatitis, STDs, and TB are substantially higher among persons who use drugs illicitly than among persons who do not use drugs illicitly (2–5). The term "illicit use of drugs" encompasses all levels of use, abuse, and dependence because each level is associated with behaviors that increase the risk for contracting or transmitting infectious diseases. Persons who use drugs illicitly are defined as those who use, without prescription, prescription drugs (e.g., oxycodone), or as those who use illicit drugs such as opiates (e.g., heroin), stimulants (e.g., powder cocaine, crack cocaine, and methamphetamine), or other so-called "club drugs" (e.g., gamma hydroxybutyrate [GHB], ketamine, flunitrazepam, and ecstasy). Marijuana use and nonmedical use of prescription drugs also are associated with risk for contracting or transmitting infectious diseases. Although alcohol and tobacco use is considered illicit for certain age groups (i.e., age <21 years for alcohol in all states; age <18 years for tobacco in most states and <19 years in some states) (6), this report does not focus in great detail on tobacco use or alcohol use, even though excessive alcohol use and tobacco use are associated with infectious diseases (7–9). Illicit use of drugs includes multiple drug use (i.e., simultaneous use of illicit drugs and legal substances).
In general, the risk for acquiring and transmitting infectious disease in a population is a reflection of the prevalence of a given infection in the population, the efficiency of transmission of the organism, and the burden of infectious diseases and patterns of the risk behaviors in which that population engages. The high rates of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly reflect behavioral, social, cultural, environmental, and structural factors that facilitate disease transmission (10–12). Behavioral factors include the use and sharing of contaminated injection equipment (i.e., needles and syringes) and drug preparation equipment (e.g., water, cotton, and a cooker). Bloodborne infections such as HIV infection and viral hepatitis are transmitted efficiently through sharing of contaminated needles. The transmission also can occur through unprotected sex. Illicit use of alcohol by youth, alcohol intoxication, and illicit use of drugs are associated with unsafe sexual behaviors, which are risk factors for HIV infection, viral hepatitis, and STDs. Such social and cultural factors as marginalization, stigma, and lack of social support can contribute to disease transmission; these factors often affect persons who are members of a sexual minority (i.e., lesbian, gay, bisexual, and transgender), persons who use drugs illicitly, or persons who have a mental disorder (9,10). Environmental factors common among persons who use drugs illicitly include unstable living conditions, and limited availability of sterile injection and drug preparation equipment (13). Lack of access to and underenrollment in substance abuse treatment programs are other structural factors contributing to infectious disease transmission. In addition, fear of arrest by law enforcement officers and fear of discrimination by health-care providers can discourage persons who use drugs illicitly from using health-care services adequately (14). Persons who use drugs illicitly often have other complex health and social needs, including treatment for substance abuse and for preexisting or concurrent mental disorders (9,15–17). Throughout the guidance provided in this report, efforts to facilitate treatment of infectious diseases and treatment of substance use and mental disorders also are classified as preventive interventions.
Utility of the Guidance
This guidance is intended for public health officials at all levels, leaders and managers of programs, program providers, health-care providers (e.g., clinicians, providers of mental health services, outreach workers, and social workers), and prevention and treatment support groups for persons who use drugs illicitly (e.g., coalitions). Persons who use this guidance should adapt it to meet the specific prevention needs of their communities, while preserving the core missions of the organizations, programs, and venues that provide these services.
A coordinated approach to service delivery needs to incorporate multiple science-based public health strategies. Staff working in prevention programs for HIV infection, viral hepatitis, STDs, and TB and in programs to prevent and treat substance use and mental disorders need to consider program collaboration and service integration as an approach to improve access to multiple services (18–21). Preventing infectious diseases among persons who use drugs illicitly can also help prevent infections among their sex and drug-using partners and among other members of their communities.
Program Collaboration and Service Integration
Program collaboration and service integration are mechanisms that programs use to organize and combine interrelated health issues, activities, and prevention strategies so as to facilitate comprehensive delivery of services, to foster integrated care, and to increase operational efficiencies (18). Agencies and providers at the federal, state, local, tribal, and service delivery levels can provide leadership and resources to develop and implement programs that enhance program collaboration and service integration (19).
To the extent that programs can collaborate and integrate prevention services, they can save time, money, and effort. Providing multiple prevention services at a single venue or coordinating referrals and linkage to care for services delivered at multiple venues can improve access to quality and comprehensive prevention services. Such coordination can offer the opportunity to address multiple infectious diseases and related health conditions, such as substance use and mental disorders, at one time or at a single facility, thus increasing the likelihood that clients will receive needed services. Program collaboration and integration of prevention services can be expected to maximize opportunities for prevention, reduce delays between infection and diagnosis and between diagnosis and treatment, and improve adherence to risk reduction behaviors and to treatment regimens for infectious diseases, substance use disorders, and mental disorders.
Program collaboration is a mutually beneficial and well-defined relationship entered into by two or more programs, organizations, or organizational units to achieve common goals (18). The collaboration usually includes a commitment to relationships and mutual goals, a jointly developed structure, shared responsibility, mutual authority and accountability for success, and shared resources and benefits for programs that are not necessarily all delivered at the same physical location. Service integration is intended to provide persons with seamless services from multiple programs or areas within programs without repeated registration procedures, waiting periods, or other administrative barriers (18). By providing access to services at a single health-care entry point, service integration is different from system coordination, in which multiple agencies provide services but at multiple locations, possibly requiring persons to visit several locations and register separately for each program to obtain the services (1).
Comprehensive and integrated service delivery, either through provision of multiple services at a single venue or through coordination of referrals for services delivered at multiple venues, requires collaborative planning and a coordinated approach among service providers. Such collaboration and coordination are needed to ensure that provided services meet the needs of persons who use drugs illicitly and that the methods of service delivery are acceptable both to providers and to clients. However, an integrated approach to service delivery requires that local, state, and federal agencies work together, which is often a difficult process because of different regulatory constraints, including those caused by complying with the Health Insurance Portability and Accountability Act (HIPAA) regulations. Electronic and portable health records are inconsistently available, further complicating delivery of health-care services. In addition, patients frequently are lost to follow-up in transition from the detection and diagnosis to the treatment of disease. Despite these concerns, a coordinated approach to integrated service delivery can improve services offered to persons who use drugs illicitly and can improve their health seeking behaviors.
Guidance Development Methods
This guidance was developed and written by a CDC work group (members are listed alphabetically on page 1). The work group included health-care professionals, public health scientists, and public health analysts with experience and expertise in prevention of HIV infection, viral hepatitis, STDs, and TB in persons who use drugs illicitly. The work group developed and wrote the guidance to support the needs of stakeholders (e.g., policymakers, leaders, managers, providers, and recipients of prevention and treatment services) for one document that summarizes recommendations and guidelines of science-based public health strategies that can be integrated to enhance service delivery and public health outcomes for persons who use drugs illicitly.
The guidance is the result of the efforts of several DHHS agencies and offices to synchronize activities and achieve synergies in areas where their missions for persons who use drugs illicitly overlap. Starting in late 2007, the work group met biweekly to develop and write the guidance. The group used multiple search strategies in preparing the guidance, including searching medical and professional computerized databases (e.g., PubMed, Psychinfo, and National Guideline Clearinghouse) using relevant key terms and search strings, previously published guidelines or guidance, review papers, and reference lists of published papers and documents (Appendix A). During 2008–2010, the work group wrote a draft document for discussion. In late 2010 and throughout 2011, DHHS agencies, including DHHS offices, reviewed a draft of this report to ensure that the recommendations were science-based and consistent with the missions and recommendations of DHHS agencies and offices. They provided questions or comments that were addressed or incorporated in this report. DHHS operating divisions or institutes that approved this guidance included the Agency for Healthcare Research and Quality (AHRQ), CDC, the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the National Institute on Drug Abuse (NIDA), the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration (SAMHSA). The DHHS offices and staff divisions that approved this guidance included the Office of the Secretary, the Office of the Assistant Secretary for Health, the Office of the Assistant Secretary for Legislation, the Office of the Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Public Affairs, the Office of the Assistant Secretary for Financial Resources, the Office of the General Counsel, and the Office of Global Affairs. In addition, several experts who are not part of the federal or local government reviewed the draft guidance and provided questions or comments that were addressed in this report (see Acknowledgments). These persons have expertise in prevention and treatment of HIV infection, viral hepatitis, STDs, TB, substance use disorders, and mental disorders; they are affiliated with private organizations that support services provided to persons who use drugs illicitly, or else have experience working with this population. None of these reviewers reported financial or other conflicts of interest that would preclude their involvement in reviewing this guidance.
Prior to this guidance, recommendations and guidelines for public health strategies for preventing and treating HIV infection, viral hepatitis, STDs, TB, substance use disorders, and mental disorders among persons who use drugs illicitly have appeared in different publications (Appendix B). This guidance provides a summary of published scientific and programmatic literature, including current (as of 2011) recommendations and guidelines for 12 science-based public health strategies: 1) prevention and treatment of substance use and mental disorders; 2) outreach programs; 3) risk assessment for illicit use of drugs; 4) risk assessment for HIV infection, viral hepatitis, STDs, and TB; 5) screening, diagnosis, and counseling for HIV infection, viral hepatitis, STDs, and TB; 6) vaccination; 7) prevention of mother-to-child transmission of HIV infection, viral hepatitis, and STDs; 8) interventions for reduction of risk behaviors; 9) partner services and contact follow-up; 10) referrals and linkage to care; 11) medical treatment for HIV infection, viral hepatitis, STDs, and TB; and 12) delivery of integrated prevention services.
The recommendations and guidelines of CDC, NIDA, SAMHSA, AHRQ, and the U.S. Preventive Services Task Force (USPSTF) for these science-based public health strategies are consistent across the agencies for this high-risk population, i.e., persons who use drugs illicitly. CDC's recommendations address prevention and treatment of HIV infection, viral hepatitis, STDs, and TB. The guidelines of NIDA and SAMHSA are for prevention and treatment of substance use and mental disorders. The Advisory Committee on Immunization Practices and CDC issued the vaccination recommendations. The recommendations for screening or testing of persons who use drugs illicitly for HIV infection, viral hepatitis, STDs, and TB made by AHRQ and the U.S. Preventative Services Task Force are consistent with those of CDC.
The recommendations or guidelines from CDC, NIDA, and SAMHSA are based on reviews of the scientific evidence and programmatic literature, expert opinion, field experience, and lessons learned from and results of projects funded by these agencies. Recommendations of AHRQ and the U.S. Preventive Services Task Force are based on systematic reviews of the scientific literature. Evidence for the effectiveness of the delivery of integrated prevention services for persons who use drugs illicitly, like the evidence supporting the previously published recommendations and guidelines, is based on a combination of a literature review, expert opinion, field experience, and results of and lessons learned from delivery of integrated services in projects funded by DHHS agencies. The evidence supports delivery of integrated prevention services at venues that serve persons who use drugs illicitly. The report includes information on relevant practical steps (e.g., development of a coordinating body, analysis of local data, staff training, evaluation) to support service integration and to plan, deliver, monitor, and evaluate integrated services. Earlier versions of this report were presented at the National HIV Prevention Conference held in August 2009 and at the National STD Prevention Conferences held in March 2010 and in March 2012.
Epidemiology of Illicit Use of Drugs and of HIV Infection, Viral Hepatitis, STDs, TB, and Their Sequelae in the United States
Illicit Use of Drugs and Its Sequelae
In the 2009 National Survey on Drug Use and Health (NSDUH), an estimated 8.7% of the U.S. noninstitutionalized population aged ≥12 years reported illicit use of drugs (i.e., marijuana, cocaine, heroin, hallucinogens, inhalants, and prescription drugs used for nonmedical purposes) during the month before data collection (22). In the 2006–2008 NSDUH, an estimated 425,000 persons aged ≥12 years (0.17% of the age-group population) had injected heroin, cocaine, or stimulants during the year before data collection (23). Relatively recent publications provide relevant information. Approximately 1.2 million persons in the United States injected drugs in 2002 (24). The prevalence of a history of injection-drug use remained relatively stable at 1.5% (95% confidence interval [CI] = 1.4%–1.6%; weighted estimate: 3.4 million persons) during 1979–2002 (25). Data from the 2008 NSDUH indicate that an estimated 3.8 million persons in the United States have used heroin at least once in their lives and that an estimated 213,000 persons used heroin during the month before data collection (26). In 1998, the estimated number of persons who injected drugs ranged from 19 to 173 persons per 10,000 population (median: 60) across 96 large U.S. metropolitan areas (27). Monitoring changes in drug use among all age groups remains important for developing and implementing relevant prevention and treatment programs (28–30).
Persons who inject drugs illicitly are a heterogeneous group, and >50% of them use more than one drug illicitly through means other than injection (e.g., inhalation, sniffing, smoking, or ingesting). They tend to drink alcohol in excess and tend to smoke tobacco (31–36). Estimates of the number of users of illicit drugs through means other than injection range from 1 million to 1.5 million (26).
Illicit drug use is associated with a high risk for mortality and comorbidities. Of particular significance, overdosing with injected drugs poses a risk for death (37,38). Persons who inject drugs illicitly can overdose when they inject alone. They often are in settings where peers are not trained in overdose prevention or are reluctant to call for medical help because of fear of legal consequences, or they are in settings where medical help is not available or accessible in a timely manner (39–41). Drug overdose death rates increased nearly fivefold during 1990–2007 (from two deaths per 100,000 population in 1990 to nine per 100,000 in 2007) (42). In 2006, among unintentional injury- and accident-related causes of death, rates of drug overdose were second only to motor-vehicle crash deaths (42). Opioid pain medications account for the highest number of unintentional overdose deaths, followed by cocaine and heroin (43). Drug overdose is a leading cause of mortality among persons who inject drugs illicitly (44–49). Overdose can be prevented by overdose prevention training programs (37,38,50–52).
HIV Infection, Viral Hepatitis, STDs, and TB Among Persons Who Use Drugs Illicitly
Persons who use drugs illicitly are at increased risk for acquiring and transmitting infectious diseases via bloodborne exposure (for those who inject), and they are at increased risk for sexual exposure to HIV and STDs (4,53–55). Some persons who use drugs illicitly might share unsterile drug injection equipment as well as engage in unprotected vaginal or anal intercourse with partners who engage in high-risk behaviors or with partners who have infectious diseases (56). In the United States, approximately 9%–12% of new HIV cases (57,58), 50% of new hepatitis C cases (59), and 2% of hepatitis A cases (59,60) are associated with illicit injection of drugs. Among persons who are at risk for infectious diseases, men who have sex with men (MSM) are affected disproportionately by HIV. For example, CDC estimates that the rate of new HIV diagnoses among MSM is between 44 and 86 times that among other men, and between 40 and 77 times that among women (61). A 2008 survey of MSM from cities with high AIDS prevalence indicated that 5% of MSM had ever injected drugs (62), compared with 1.5% among the general population (25). The number of new HIV infections is highest among MSM, particularly young MSM, and next highest among persons infected through heterosexual contact, followed by persons who inject drugs (58).
The epidemiology of HIV infection differs by groups and is influenced by demographic factors affecting use of health-care services. For example, persistent racial and ethnic disparities in infectious diseases among persons who use illicit drugs remain a challenge (63–71). Data indicate racial and ethnic disparities in use of health-care services, including entry and retention in substance abuse treatment programs and other programs (72–84). Data also exist on the limited number of gender-sensitive interventions that meet the sex-specific needs of women who use drugs (e.g., negotiation and empowerment for adoption of safer behaviors and providing for needs of children) (85).
A large body of research has demonstrated that illicit drug use, regardless of the route of absorption of the drug, puts users at risk for acquiring HIV infection and STDs. For example, illicit injection of drugs can impair judgment, increasing the likelihood of engaging in risky sexual behaviors (86). Illicit noninjection drug use also puts users at risk for infectious diseases (72,87,88). Fortunately, prevention efforts aimed at reducing drug injection risk can be successful (57). For example, in recent years, a convergence in HIV prevalence and incidence among those who engage illicitly in injection or noninjection drug use suggests that a decrease has occurred in HIV transmission; the decrease is associated with safer use of syringes. There has also been a corresponding increase in HIV transmission associated with risky sexual behaviors (89). Illicit noninjection drug use, particularly use of stimulants, "club drugs," and, to some extent, poppers (e.g., amylnitrite or butylnitrite) and erectile enhancement drugs, plays a substantial role in transmission of infectious diseases although patterns of substance abuse and preferences vary by age group, race, and ethnicity (90). Many studies highlight the role of methamphetamine and other drugs in risky sexual behavior among MSM as well as the effect of crack cocaine use on exchange of sex for illicit drugs, all of which have implications for infection with HIV and STDs (88,91–98).
The prevalence of STDs among persons who use drugs illicitly varies (range: 1%–6% for syphilis, 1%–5% for chlamydia, 1%–3% for gonorrhea, and 38%–61% for herpes simplex virus-2 [HSV-2] infection) (70,99). The moderately high prevalence of bacterial STDs among persons who inject drugs illicitly is not much different from the prevalence among youth at high risk (100). The high prevalence of HSV-2 among persons who use drugs illicitly contrasts with the 17% prevalence reported for the general population of persons aged 14–49 years (101). In one study of young persons (median age: 24 years) who use drugs illicitly, the seroprevalence of infection with high-risk oncogenic types of human papillomavirus (HPV) was 7% among men and 38% among women for HPV-16 and 7% among men and 42% among women for HPV-18 (68). For comparison, according to 2003–2004 data from CDC's National Health and Nutrition Examination Survey, the prevalence of infection with these HPV-types among women aged 15–49 years in the general population was 16% and 7% for HPV-16 and HPV-18, respectively; for men in the same age group, the prevalence was 5% and 2%, respectively (102). In the United States, approximately one in five patients with active TB either uses a drug illicitly or drinks alcohol in excess, or both (103). Among U.S.-born TB patients, one in three patients with TB reports substance abuse (103). In 2008, illicit noninjection drug use was reported in 7.3% of U.S. TB patients, and illicit injection drug use was reported in 1.8% (104).
Comorbidities
Persons who use drugs illicitly have moderate-to-high co-infection rates. They often experience more than one infection, disease, or disorder (i.e., substance use or mental disorders) at the same time (17,86,104,105). Epidemiologic synergy, in which co-occurring infections increase the likelihood of infection transmission and progression of infectious diseases, highlights the importance of preventing and treating co-infections, diseases, and disorders.
Increasing awareness of infectious disease comorbidities and of overlapping risks for multiple infections is essential because of the overlapping risk behaviors associated with acquiring these conditions, the synergistic effects of disease progression and treatment needs, and the social determinants for prevention and treatment. Among HIV-infected persons who inject drugs illicitly, 80% also are infected with hepatitis C virus (HCV) (86). In studies of persons who use drugs illicitly in New York City, infection with HSV-2 is associated with HIV infection (106,107). For example, 80% of HIV-positive persons who inject drugs illicitly are HSV-2 positive (106). In a prospective study, newly detected HPV was more common among HIV-infected women than among women who were not infected with HIV (30% and 6%, respectively) (108). Increased awareness of infectious disease comorbidities is especially important for delivery of comprehensive and integrated services.
Science-Based Public Health Strategies for Prevention
Implementing science-based public health strategies in a manner that respects the rights of persons who use drugs illicitly and their partners is vital for preventing HIV infection, viral hepatitis, STDs, and TB in this population (106,109–113). Decision makers can make the most efficient use of public resources by choosing cost-effective, science-based prevention strategies.
Prevention and Treatment of Substance Use and Mental Disorders
In the field of prevention and treatment of substance use disorders, the terms "use," "abuse," and "dependence" are defined in ways that reflect their association with risk for infectious diseases, other health conditions, and adverse social consequences (114,115). From an epidemiologic perspective, frequency of use of a substance and total number of times a substance is used in a lifetime are the principal measures of substance use. Abuse refers to a level of use of a substance that has short-term acute personal or social consequences, including sporadic, nondependent patterns of use despite social problems or physical hazards. The clinical definition of dependence includes psychologic as well as physiologic components. Psychiatric diagnosis of dependence requires evidence of consequences during an extended period of time (114). Salient markers of dependence include loss of behavioral control over using drugs, withdrawal symptoms, and an obsessive-compulsive style of use. The criteria commonly used for dependence include 1) more use of a substance than intended, 2) inability to reduce use, 3) amount of time seeking the substance, 4) physical effects of use, 5) use replacing other activities, 6) continued use despite problems, 7) tolerance, 8) withdrawal symptoms, or 9) use to avoid withdrawal symptoms (114). The term "substance abuse" denotes substance abuse or dependence as defined in the diagnostic and statistical manual (DSM) (114), and the term "substance use disorder" sometimes is used in the literature as a synonym for the term "addiction."
Evidence demonstrates the effectiveness of science-based approaches to prevent and treat substance use and mental disorders (115–117). The evidence base indicates that scaling-up science-based approaches for treating substance use and mental disorders in publicly funded programs would improve health outcomes. Providing persons who use drugs illicitly with increased access to science-based treatment for substance use and mental disorders is one way to improve prevention and control of infectious diseases (116). The national strategy to reduce drug demand focuses on curtailing illicit drug consumption and on improving public health and public safety by reducing the consequences of drug abuse (118,119). The strategy provides a collaborative and balanced approach that emphasizes community-based prevention, integration of evidence-based treatment into the health-care system, innovations in prevention and treatment strategies in the criminal justice system, and international partnerships to disrupt drug-trafficking organizations (118,119). The priorities of the national strategy to reduce drug demand acknowledge that it is important to prevent drug use, reduce drug use, and treat substance abuse, and that behavioral, social, environmental, and structural factors contribute to illicit use of drugs (119,120).
Evidence points to the efficacy of "screening, brief intervention, referral, and treatment" (SBIRT) approaches in primary care settings to identify problematic use of drugs and to reduce substance abuse (121–123). SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders and for those at risk for developing them (121). SBIRT can be provided in a range of health facilities, including primary care centers (121). The goals of SBIRT are to 1) encourage health-care providers to screen and provide brief advice or counseling to their patients who misuse alcohol or abuse other drugs so as to reduce hazardous use of substances, 2) reduce vulnerability to the negative consequences of substance use, and 3) improve linkages between general community health care and specialized substance abuse providers to facilitate access to care when needed (121).
The spectrum of science-based treatment for substance use disorders is broad. Medication approaches (often referred to as medication-assisted therapy) are effective for treating nicotine, alcohol, and opioid addiction, as reflected in recommendations of national and international organizations (115). The use of effective medications in conjunction with science-based behavioral treatments remains valuable because combination interventions can be more effective than single interventions. Science-based behavioral treatments include cognitive behavioral therapy (including relapse prevention), motivational interviewing, and community reinforcement approaches (including contingency management as a stand-alone intervention) (124–126).
Outreach Programs
Community-based outreach, in which peer educators or other persons have established trust and rapport with persons who use drugs illicitly, can reduce risky behaviors (127,128). Outreach is particularly useful in reaching and assisting those who use drugs illicitly who are not ready to enter substance abuse treatment or to be involved in other interventions for risk reduction. Outreach has been demonstrated to increase the use of condoms, substance abuse treatment, and other prevention services (127,128). Outreach to persons who use drugs illicitly can occur at locations where they congregate, on the streets, or in mobile vans (129). It often involves informal leaders, peers (e.g., trained persons who are former drug users), and other volunteers from the community who have existing relationships and access to the target population (130–132). Providing drug- and sex-related risk-reduction information and materials via trusted peers, while not sufficient to reduce the prevalence of behaviors associated with increased risk for infections, can help establish safer peer norms of behavior and common expectations of safer behaviors (4,11,127).
Outreach workers can provide education on drug- and sex-related risks and risk-reduction information to persons who use drugs illicitly. They can provide persons who use drugs illicitly with risk-reduction supplies (e.g., condoms, sterile syringes and needles, and naloxone) and refer them to prevention programs (129). Outreach workers also can refer persons who use drugs illicitly to facilities that offer targeted testing for TB infection; those identified with active TB disease can be treated appropriately, and those identified with TB infection (3) can be given preventive therapy for TB (133,134). Outreach workers also can provide referrals or direct links to counseling, testing, and treatment for HIV infection; to facilities that offer vaccinations for hepatitis A and hepatitis B; to programs that offer screening and treatment for viral hepatitis and STDs; and to substance abuse treatment (135,136). In addition, outreach workers can help in building trust in prevention and treatment services and in health-care providers (106,127,137).
Risk Assessment for Illicit Use of Drugs
The high prevalence of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly should sensitize prevention and care providers to conduct risk assessment for illicit use of drugs for everyone seeking services for these infectious diseases (138,139). In addition, many users use multiple drugs, as well as alcohol or tobacco, and eliciting information on use of these substances could assist with prevention and treatment services. For multiple reasons, patients might not be forthcoming about illicit use of drugs; the reasons include fear of legal consequences and concerns about confidentiality. Thus, patients need to feel comfortable about their privacy and confidentiality of their data to share their behaviors with providers.
Risk assessment and risk reduction interventions are essential for adoption of safer behaviors and for referral of clients to relevant prevention and treatment programs (32,33,140–142). The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) can be used as a screening instrument for drug use (143,144).
The recommendation to assess persons who seek preventive and medical care for infectious diseases for illicit use of drugs is consistent with recommendations of the USPSTF (145), CDC's STD treatment guidelines (146), and the American Medical Association (AMA) guidelines for adolescents (147), which recommend that health-care providers screen adolescents for substance abuse during preventive-service visits.
Risk Assessment for Infectious Diseases
Persons who use drugs illicitly should receive appropriate screening for other risk factors for infectious diseases (e.g., risky sexual behaviors or being a known contact of a person with active TB). They also should receive relevant preventive services and risk-reduction counseling. CDC's 2010 STD treatment guidelines support this approach by recommending that health-care providers of STD services routinely obtain sexual histories from their patients (146). Risk assessments for infectious diseases can be performed by health-care providers at venues that serve persons who use drugs illicitly (5,148).
Screening, Diagnosis, and Counseling for Infectious Diseases
Screening services for infectious diseases are critical components of a comprehensive strategy to reduce and eliminate incident infections among persons who use drugs illicitly (149–159). Such services identify those who are unaware of their infections and provide them with counseling and education and refer and link to treatment those who are infected. Knowledge of one's infection status can help uninfected persons who use drugs illicitly make behavioral changes to reduce the risk for infection (160–164) and can help infected persons reduce the likelihood of medical sequelae and transmission of infection to others (149–164). Screening for illicit use of drugs, including offering brief interventions and providing referrals, and screening for misuse of prescription drugs, can be useful adjuncts to screening for infectious diseases (121). The screening and counseling recommendations for preventing HIV infection, viral hepatitis, STDs, and TB infection in persons who use drugs illicitly have been summarized (Box 1).
Vaccination
Hepatitis A vaccination is recommended for persons who use drugs illicitly. Hepatitis B vaccination is recommended for all adults in certain settings, including STD clinics, HIV testing and treatment facilities, facilities providing substance abuse treatment and prevention services, correctional facilities, and health-care settings serving persons who inject drugs illicitly (100,165).
Prevaccination testing for hepatitis B is recommended for household, sex, and needle-sharing contacts of hepatitis B surface antigen (HBsAg)–positive persons and for HIV-infected persons (152). In addition, testing might be cost-effective in adult populations with a prevalence of hepatitis B virus (HBV) infection of >20% (e.g., persons who inject drugs illicitly or incarcerated persons). If prevaccination testing for antibody to the hepatitis B surface antigen (anti-HBs) is used to identify immunity after previous HBV infection, HBsAg testing also must be performed to identify persons with chronic HBV infection. Serologic testing should not be a barrier to vaccination of susceptible persons, especially in hard-to-reach populations. The first vaccine dose typically should be administered immediately after collection of the blood sample for serologic testing (166).
Recommendations for the administration of HPV vaccinations are the same for persons who use drugs illicitly as for the general population (167). No vaccines are available for the prevention of infection with HIV, HCV, or any STD other than HPV and HBV. For TB prevention, use of Bacille Calmette-Guérin (BCG) vaccine generally is not recommended in the United States because of the low risk for infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine's potential interference with tuberculin skin test reactivity (155,168).
Prevention of Mother-to-Child Transmission of Infectious Diseases
Pregnant women who use drugs illicitly are at elevated risk for transmitting infections (e.g., HIV, HBV, HCV, syphilis, chlamydia, and gonorrhea) to their children during pregnancy or at delivery if they are infected with these pathogens. Women who use drugs illicitly are less likely to use family planning services than other women (169). Pregnant women who use drugs illicitly are more likely than other women to initiate prenatal care later or not at all (170,171). Pregnant women with HIV infection have cited illicit use of drugs as a barrier to prenatal care, because some fear incarceration for illicit use of drugs and possible placement of their newborns in foster care (171). Although the recommendations of the U.S. Public Health Service Task Force to reduce perinatal HIV transmission do not outline special considerations for pregnant women who use drugs illicitly, the recommendations note that discontinuing illicit use of drugs has been associated with a reduced risk for perinatal transmission of HIV (172). HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women (149). All pregnant women, including those who use drugs illicitly, should be screened for HBsAg, and immunoprophylaxis should be administered to infants born to HBsAg-positive women or to women with unknown HBsAg status (152). Previously unvaccinated women at risk for HBV infection, including persons who use or inject drugs illicitly, should be vaccinated against HBV infection.
Screening pregnant women for HSV-2 at their first prenatal visit is not recommended, but it is important to test pregnant women with symptoms of genital herpes, including those with symptoms at time of delivery, and to provide treatment for pregnant women with newly acquired HSV-2 (146). A summary of current recommendations and guidelines for prevention of mother-to-child transmission of infectious diseases has been provided (Box 2).
Interventions for Reduction of Risk Behaviors
Four broad strategies have been developed to reduce risk behaviors. They are 1) risk-reduction programs and messages, 2) treatment of substance use and mental disorders to prevent infectious diseases, 3) access to sterile injection and drug preparation equipment, and 4) interventions to increase condom availability (173,174).
Risk-Reduction Programs and Messages
Much of the research on HIV prevention programs for persons who inject drugs illicitly has focused on injection-related risk. In recent years, however, multiple studies have concluded that persons who use drugs illicitly, through injection or noninjection routes, are at increased risk for sexual transmission of HIV, HBV, and other STDs, regardless of the means of introducing the drug into the body (70,89,152,166,175,176). Most persons who use drugs illicitly, through injecting or other means (e.g., inhaling, sniffing, or snorting), are sexually active (87,99). Levels of sexual risk are influenced both by the drugs that are used illicitly and by their route of administration (86). Sexual transmission of HIV among persons who use drugs illicitly is associated with several factors, including a history of other STDs, recent initiation of illicit drug injection, and exchange of sex for money or for illicit drugs (87). Male-to-male sex as well as illicit use of drugs through noninjection means, including the use of such stimulants as crack cocaine and methamphetamine, is associated with increased risky sexual behaviors; these drugs increase the libido or reduce inhibitions (70,86).
Although persons who inject drugs illicitly have reduced their injection risk behaviors in response to behavior-change health interventions (177,178), reducing their risky sexual behaviors remains a challenge, similar to the challenge that faces persons who do not use drugs illicitly (179,180). Results of two meta-analyses of studies of HIV prevention interventions for persons who use drugs illicitly indicate that multisession psychosocial behavioral interventions that address sexual risk behaviors have a modest added effect compared with the effect of shorter educational interventions and a larger added effect compared with minimal interventions (e.g., waitlist or provision of a self-help booklet) (179,181). Those results indicate that such interventions should be implemented on a wider scale to reach all persons who use drugs illicitly with messages about safer sex behaviors (87,179,181). However, participants with modest reductions in sexual risk might return to pre-intervention sexual risk (e.g., no condom use or a higher number of sex partners) more rapidly than they would return to pre-intervention injection-risk (e.g., use of contaminated needles and sharing of needles) (182). Decision makers can consider strengthening risk-reduction programs because data from several cities indicate that a greater proportion of HIV infections are attributable to sexual risk than to injection risk among persons who use drugs illicitly (4,107,183). The brief counseling intervention in project RESPECT that reduced sexual risk among persons seeking care at STD clinics (184) was also effective in reducing sexual risk and bacterial STDs among those who had ever injected drugs illicitly (183). This result indicates the potential value of offering and evaluating brief counseling for reducing sexual risk (183).
Risk-reduction interventions for sexual risk are important because illicit noninjection use of drugs has been associated with participation in high-risk sexual activity and with acquisition of HIV, HBV, HCV, or other STDs (88,106,185–192). For example, methamphetamine use has been associated with unprotected sex and with higher numbers of sex partners, both among MSM and among persons who engage in heterosexual sex (188,193–195). Crack cocaine use has been associated with higher prevalence of HIV and HCV infection and with higher frequencies of unprotected sex, sex with multiple partners, and exchange of sex for money or for illicit drugs (189,196–202). Persons who use drugs illicitly should be provided with or referred to interventions that include some or all of the following prevention components (86,203):
- information on prevention and transmission of infectious diseases and on safer sex and injection practices,
- assessment of personal risk,
- training in how to use condoms correctly and the importance of using condoms consistently,
- counseling to address emotional or practical issues in practicing safe sex,
- training in safer sex negotiation,
- HIV testing,
- STD screening and treatment,
- referral to substance abuse treatment and social services (e.g., housing),
- psychosocial support,
- referrals to relevant mental health and family planning services, and
- training in overdose prevention and provision of naloxone.
CDC has identified several behavioral health interventions for persons who use drugs illicitly. These interventions have been demonstrated to reduce the frequency of high-risk behaviors and ultimately are intended to reduce the risk for acquiring HIV infection or other STDs (204). Other effective interventions can be adapted for use with persons who use drugs illicitly (205). The compendium of science-based HIV prevention interventions includes information on 70 effective interventions, including at least 15 for persons who use drugs illicitly, at least 12 for persons who inject drugs illicitly, and eight that were evaluated with racial and ethnic minority persons who use drugs illicitly (206). Safety Counts and Community Promise are two evidence-based HIV prevention interventions for persons who use drugs illicitly that were developed based on work with persons who were recruited from settings other than substance abuse treatment. These interventions, which use goal-oriented counseling and peer-support approaches while drawing on several behavior-change principles, have been associated with reductions in high-risk behaviors (207–210). Previously published recommended messages for use by health and social service professionals and by other persons who have clients or client partners who use drugs illicitly have been summarized (Boxes 3 and 4).
Treatment of Substance Use and Mental Disorders to Prevent Infectious Diseases
In general, a short detoxification program from opioids has limited success in leading persons who use drugs illicitly to abstain from such use (211,212). For persons who use drugs illicitly, a longer program for substance abuse treatment that includes medication-assisted therapy (e.g., methadone or buprenorphine) and behavioral interventions is helpful for treating illicit drug use as well as for preventing HIV infection, viral hepatitis, STDs, and TB (116,204–210,213–217). Reducing or eliminating illicit drug use through substance abuse treatment promotes an overall healthy lifestyle and reduces other negative consequences of illicit drug use, including overdose (218).
An estimated 15%–25% of persons addicted to opiates in the United States during 1998–2004 were in methadone maintenance programs (219). Estimates of the percentage of persons who inject drugs illicitly and who are in substance abuse treatment programs have varied greatly (range: 1%–39%) across large U.S. metropolitan areas (27). For persons who use drugs illicitly, both lack of motivation to enter substance abuse treatment and the moderately long waiting periods that face them can be barriers to enrollment (220). Other factors affecting access to substance abuse treatment programs include poverty, lack of health insurance, and fear of being stigmatized as persons who use drugs illicitly (138).
Substance abuse treatment can reduce such risk behaviors as needle-sharing and exchange of sex for money or for illicit drugs (221–227). In addition, substance abuse treatment can serve as an entry point to medical care, and it can improve adherence to medical treatment regimens for infectious diseases (116,228–230). Substance abuse treatment includes nonpharmacologic, psychosocial approaches as well as pharmacologic therapies (174). Often, a combination of the two approaches is employed (215). For example, cognitive and behavioral therapies are effective treatments for abuse of amphetamine-type stimulants; the use of such therapies has demonstrated reductions in illicit drug use and in high-risk behaviors (125,231). Nonpharmacologic psychotherapies (i.e., behavioral interventions) are valuable when medications are not available or allowable (117,125,126). Adherence interventions might greatly enhance the effects of nonpharmacologic psychotherapies and medications and reduce high-risk behaviors associated with acquisition or transmission of infectious diseases (232,233).
Medication-assisted therapy with methadone or buprenorphine is highly effective for opioid addiction; it can promote adherence to needed medical care (116,234). An extensive body of evidence demonstrates that therapy with methadone or buprenorphine reduces the frequency of heroin injection, increases rates of retention in substance abuse treatment programs (235,236), and markedly decreases criminal activity (11,14,109,112). For example, methadone maintenance therapy has been associated with reductions in the frequency of illicit injection and sharing of injection equipment (212). It also has been associated with reductions in the number of sex partners and in the exchange of sex for money or for illicit drugs (237,238).
Increased condom use (239,240) and increased safer sexual behaviors (132,241) have been reported by persons who have reduced their illicit use of drugs. Substance abuse treatment is also a key step toward successful therapy of infectious diseases (9,242). Substance abuse treatment improves HIV treatment adherence (230,243,244), resulting in lower viral loads and lower likelihood of HIV transmission (245–247). Substance abuse treatment also facilitates the prevention of TB among persons who use drugs illicitly. Treatment of TB infection and of TB disease among persons who use drugs illicitly is more successful when integrated with substance abuse treatment, incentives (e.g., food coupons), facilitators (e.g., tokens for transportation), and other services (3,98,248,249).
Access to Sterile Injection and Drug Preparation Equipment
Bloodborne pathogens can be transmitted easily through shared injection and drug-preparation equipment (203,250). Evidence suggests that access to sterile injection equipment can reduce transmission of these pathogens among persons who inject drugs illicitly (251). However, access to sterile needles and syringes generally is controlled by federal and state-specific laws and regulations that control their sale, distribution, and possession. In December 2011, the U.S. Congress reinstated a ban on the use of federal funds for carrying out any program that distributes sterile needles or syringes for hypodermic injection of illegal drugs.
Distribution policies for sterile injection equipment (e.g., secondary exchange or conditions and numbers of syringes provided) can allow syringe services programs to overcome operational barriers (e.g., limited locations or hours of operation) (252) and can increase access to sterile equipment for persons who inject drugs illicitly (253,254). The term "syringe services programs" was adopted by DHHS in 2010 (255,256). The term includes all services and interventions that provide sterile needles and syringes, including syringe exchange programs and nonprescription pharmacy sale of sterile needles and syringes, as well as syringe disposal. It also includes referral and linkage to programs for prevention and treatment of infectious diseases and substance use and mental disorders (255,256).
Although most states do not require a prescription to buy syringes, many states and pharmacies require customers to present personal identification or to sign for the purchase of sterile needles and syringes (83). Participation in no-cost syringe exchange programs leads to a decrease in the frequency of needle-sharing without causing an increase in the frequency of illicit use of drugs (177,257–264).
Existing evidence indicates that syringe exchange programs are effective in reducing the incidence of HIV infection (265). Syringe exchange programs reduce the risk for infection with HCV, which is the most common bloodborne pathogen among persons who inject drugs illicitly (153,266–269). Participation in a syringe exchange program was associated with reduced rates of hepatitis B and C in a case-control study in Tacoma, Washington (270). An indirect protective effect of syringe exchange programs on HCV infection through reduced injection risk behaviors was found in a study of young persons (aged 18–30 years) who inject drugs illicitly conducted in several cities (269). However, the prevalence and incidence of HCV infection remain higher among those persons than among the general population (64,271–273).
In addition to providing sterile syringes, most syringe exchange programs provide other health-related supplies and services to their clients (252,274). In 2008, more than 90% of syringe exchange programs provided male condoms, alcohol pads, and education on safer injection practices and on prevention of HIV infection, viral hepatitis, STDs, and abscesses; 87% provided HIV counseling and testing; 65% provided testing and counseling for HCV; 55% provided STD screening; 49% provided vaccination for hepatitis B; 47% provided vaccination for hepatitis A; 24% provided counseling and testing for hepatitis B; 31% provided TB screening; and 18% provided counseling and testing for hepatitis A (275).
Syringe exchange programs often provide referrals to substance abuse treatment and social services (275). Syringe exchange programs also can serve as sites for TB screening and for testing for TB infection (133,276), and they can serve as gateways to treatment for HIV or HCV infection (275,277,278). Innovative strategies and programs should be developed and tested, such as those that prevent the progression of noninjection drug use to injection drug use and those that promote safer and hygienic injection practices and facilities to prevent HIV and HCV transmission among persons who use drugs illicitly (4,37,107,153,272,273).
Interventions to Increase Condom Availability
Increasing the availability of condoms is associated with substantial reductions in HIV risk (274,279). Results of a Louisiana study on the effects of widespread condom distribution indicated that the rates of condom use increased, while the average number of sex partners over a 12-month period did not increase (274). Limited condom availability attributable to high cost, a low concentration of sale outlets in a given area, or limits on free distribution of condoms is often cited as a barrier to condom use (274). Distributing condoms free of charge at clinics, substance abuse treatment centers, jails and prisons, businesses, or other community locations (e.g., outreach and syringe services programs) can serve as a public health intervention or a supplement to existing campaigns and interventions, because prices as low as 25 cents per condom have been demonstrated to deter their use (280). Condom distribution has been demonstrated to reach a substantial segment of the population and to be cost-effective (280). In addition, condom use can reduce risk for oral and vaginal transmission of HIV, viral hepatitis, and bacterial and viral STDs among persons who use drugs illicitly (57,70,71,106,183,281–286). Because gonorrhea, chlamydia, syphilis, HSV-2, and HIV can be transmitted by oral sex, condom use also can reduce transmission of these infections through oral sex (283).
Partner Services and Contact Follow-up
Partner services begin when persons who have an infection are interviewed to obtain information about their partners in a voluntary and confidential manner. Following this step, partners are notified confidentially of their possible exposure to infection (287). Services that can be offered to infected persons and to their partners include risk-reduction counseling, testing (including partner or couple testing), hepatitis A and B vaccination, treatment or referral to medical care, and referral to other services (e.g., substance abuse treatment, social support, housing assistance, and mental health services) (287). Partner notification services for persons at risk for infections transmitted through illicit injection of drugs (e.g., HIV and HCV) are as effective in reducing transmission of these infections as are the partner notification services for infections transmitted through risky sexual behaviors (e.g., bacterial STDs) (288). Partners can be notified by their infected partners. Alternatively, they can be notified (through the use of information provided confidentially and on a voluntary basis by the infected persons) by trained health department personnel or by health-care providers. This can be done without identifying the names of the infected persons (287–289). State and local health departments provide partner notification services according to state and local regulations. Protocols for partner services include services for patients who inject drugs illicitly, engage in risky sexual behaviors, or have signs or symptoms of infections. All patients should receive treatment as well as risk-reduction counseling or be referred for counseling or other prevention interventions (287).
Venues where drugs are used illicitly (e.g., bars and crack houses) have been identified as sites of TB transmission because of factors such as close person-to-person proximity, repetitive exposure, and poor ventilation (98,290–293). Persons with TB disease who use drugs illicitly might be reluctant or unable to name other contacts who engage in illicit drug use or venues where drugs are used illicitly (291–293). The inability to generate a comprehensive list of contacts or venues can contribute to incomplete contact investigations, ongoing transmission of TB, and missed opportunities to prevent cases of TB disease. Therefore, if health-care staff members suspect that a patient with TB disease who uses drugs illicitly is not providing a complete contact list, the staff should expand the contact investigation by seeking alternative sources of information that can include the patient's social network and settings frequented by the patient (e.g., jail, homeless shelters, or venues where drugs are used illicitly).
Referrals and Linkage to Care
Persons who use drugs illicitly and who are identified to be infected with HIV, viral hepatitis, STDs, or TB should be referred and linked actively to medical care. Medical care includes treatment for these infections as well as treatment for other health conditions that affect the lives and well-being of persons who use drugs illicitly, including treatment for substance use and mental disorders (294). Substance abuse treatment serves as a preventive intervention for HIV infection, viral hepatitis, STDs, and TB (116,126,295). Referral to and linkage with mental health services provide a supportive role for persons receiving treatment for infectious diseases and substance use disorders, including persons who are receiving treatment for hepatitis C infection, because HCV treatment regimens are associated with increased levels of depression (294,296,297).
Three approaches to referrals and linkage to care are used commonly. First, persons who use drugs illicitly are referred, following a needs assessment process, for medical treatment, care, and supportive services. Assistance with follow-up can facilitate initial contact with and linkage to appropriate service providers (18). A second approach is the "strengths-based case management approach," which calls on clients to identify internal strengths and abilities and to develop a personal plan that includes meetings with case managers to acquire needed resources (298,299). A third approach is active linking, which can include health-care visits accompanied by a linkage coordinator or case manager to ensure that clients obtain appropriate medical care. Such accompaniment is especially important for the first appointment (300,301). TB programs have been using this approach to increase adherence to treatment (302). Active linking based on the principles of a "strengths-based, intensive case management approach" has been more successful than a mere referral in getting persons with newly diagnosed HIV infection to make at least one medical care visit (298,303). Linkage-to-care approaches are effective in improving health-care outcomes; on the other hand, referral alone has not been effective in enhancing linkage and adherence to care (304,305).
Supportive strategies or incentives can be helpful in increasing adherence and linkage to care, e.g., co-location of services, deployment of outreach workers, peer navigators, monetary incentives, and motivational enhancements (306). In a multisite study, onsite linkage to buprenorphine-naloxone treatment delivered in an infectious disease clinic was demonstrated to be more effective than offsite referrals (307). Persons interacting with the criminal justice system or leaving correctional facilities (jails or prisons) can benefit particularly from active linkage to HIV medical care, TB linkage interventions, HCV medical care, STD services, substance abuse treatment, and overdose prevention programs (308–311). HIV-related strategies carried out in different venues and facilities, such as the "seek, test, treat, and retain" strategy, target persons who use drugs illicitly and help to identify those who are HIV-positive and link them to care (312). Such strategies also can support those in the criminal justice system who need to be linked to care during and after incarceration (308,313–315).
Medical Treatment for Infectious Diseases
Persons who use drugs illicitly need to receive appropriate treatment for infectious diseases and relevant health education messages from trained personnel. An infected person who receives a diagnosis of HIV infection, viral hepatitis, STDs, or TB should be referred to care providers and receive primary medical care and evaluation for progression of infection to disease, as well as treatment. In addition, infected persons need to be provided with counseling and guidance on how to stay healthy and prevent disease progression. They also should be instructed about how to reduce the risk for transmitting their infections to others, receive encouragement to seek further medical evaluation, and, if necessary, be given information about the importance of adhering to medical treatment regimens. Most persons who use drugs illicitly are capable of adhering actively to complex medical regimens (148,316–319). Persons who use drugs illicitly and are HIV-positive are capable of adhering to HIV treatment (318,319). Antiretroviral therapy for HIV infection reduces HIV transmission (320). Therefore, past or current illicit use of drugs should not be considered a contraindication to successful treatment for infectious diseases. Treatment of infectious diseases reduces and potentially prevents transmission of infectious diseases in the communities where persons who use drugs illicitly reside (317). Sex partners and drug-using partners and contacts of infected persons should be identified and provided with prevention information, in addition to referral for medical evaluation and for treatment, if necessary.
Adherence to treatment of infectious diseases among persons who use drugs illicitly can be enhanced by addressing different comorbid conditions, including mental disorders and such other factors as poverty-related issues, including homelessness and limited access to transportation (321–323). HIV treatment is greatly improved by treatment of substance abuse (9). Among persons who use drugs illicitly and who have active TB, use of incentives and enablers to encourage clinic visits has been associated with improved treatment adherence (98,134,324,325), better doctor-patient relationships, and delivery of TB treatment in substance abuse treatment programs or methadone-maintenance programs (326). Directly observed therapy (DOT) for TB, in which the infected person receives treatment for TB infection or TB disease in the presence of a provider, and shorter treatment regimens have improved treatment adherence and completion among patients, including those who use drugs illicitly (3).
There is a potential for harmful medication interactions or toxic effects in the treatment of persons with multiple infections who inject drugs illicitly. Adverse effects of medications can include the effects of HIV antiretroviral medications on liver, kidney, and neurologic functions. Providers should consider how different antiretroviral medications or antibiotics might interact with methadone or with drugs used illicitly when selecting a medical treatment regimen for persons who inject drugs illicitly and have multiple infections (9,327,328). For example, rifampin, a first-line medication for treating TB, interacts both with methadone (for treating addiction to heroin) and with efavirenz and nevirapine (for treating HIV infection) (329,330).
Before 2002, the National Institutes of Health (NIH) considered illicit use of drugs a contraindication for HCV treatment, meaning that persons who used drugs illicitly were routinely denied medical treatment for HCV infection. In 2002, NIH issued a consensus statement that HCV treatment for persons who use drugs illicitly should be considered on a case-by-case basis (331). Since then, according to some studies, illicit use of drugs during HCV therapy has been associated with lower rates of adherence and with increased risk for reinfection (332,333) although this association has not been demonstrated consistently (334). Other studies have indicated that HCV treatment adherence among persons who use drugs illicitly was increased by use of integrated service models that included mental health and substance abuse treatment (335,336), peer-based support groups (335), and a specific version of DOT for HCV treatment (337). Persons who use drugs illicitly should be counseled to avoid alcohol and other drugs that are harmful to the liver and to seek treatment for substance use and, if necessary, for mental disorders (338).
Delivery of Integrated Prevention Services
Persons who use drugs illicitly can benefit from comprehensive (or at least combination) services that meet their individual clinical needs or community needs. They can be expected to benefit from synergy among services that are delivered jointly at the service delivery level as integrated services.
Comprehensive Interventions
The Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC), and the World Health Organization (WHO) have endorsed nine interventions for comprehensive HIV prevention for persons who inject drugs illicitly (5). This comprehensive package includes syringe exchange programs; substance abuse treatment, including medication-assisted therapy; voluntary HIV counseling and testing; antiretroviral therapy for those who are HIV-infected; STD prevention and treatment; condom distribution; information, education, and communication for persons who inject drugs illicitly and for their partners; hepatitis diagnosis and treatment or vaccination; and TB prevention, diagnosis, and treatment (5).
In endorsing comprehensive prevention using nine interventions for HIV prevention (also referred to as "combination prevention"), UNAIDS, UNODC, and WHO have noted that although each intervention is useful for HIV prevention and care for persons who inject drugs illicitly, the nine interventions form a package and have the greatest beneficial impact when delivered together to a person who needs them (5). Thus, comprehensive prevention can bring scientifically based behavioral, biomedical, and structural interventions to persons who use drugs illicitly (281,339) because it offers a multipronged approach for addressing complex social and public health needs (113,281,340). Decisions about the comprehensive interventions to be offered in a particular program or community need to be influenced by three factors: the local epidemiology of infectious diseases and substance use and mental disorders, the spectrum of already existing services, and the patterns of illicit drug use (5).
Integrated Services
At the service delivery level, service integration offers an opportunity to optimize the effect of comprehensive interventions. CDC defines service integration as a distinct method of service delivery that provides persons with seamless services from multiple programs or areas within programs without repeated registration procedures, waiting periods, or other administrative barriers (18). Service integration differs from system coordination, in which services from multiple agencies are provided but persons might have to visit different locations and register separately for each provider's programs to obtain these services (18). Service integration is intended to enhance the receipt of comprehensive or multiple interventions that persons who use drugs illicitly need and to target methods of service delivery, with an emphasis on co-locating services or having a single point of entry. Recently, European agencies and partners have called for targeted delivery of services to persons who inject drugs and have suggested that services should be combined, organized, and delivered according to user needs and local conditions (341).
Thus, comprehensive prevention refers to the range, content, type, and combination of interventions that persons need. Delivery and outcomes of comprehensive services for individual and public health benefits can be enhanced by following the principles of service integration at the service delivery level.
Programmatic Initiatives on Service Integration
Syringe exchange programs provide integrated preventive services for persons who use drugs illicitly (275,342). These services include screening for HBV and HCV infections, vaccination for HAV and HBV (343), and HIV and STD testing (252). Other integrated services include integration of HIV, TB, and substance abuse treatment services (83); integration of HCV and HIV prevention services (343,344); and integration of viral hepatitis, HIV, and STD services (345). In New York State several substance abuse treatment centers have implemented a comprehensive prevention program of outreach, HIV education, counseling, testing, referral, and partner notification (343). The Massachusetts Department of Public Health has integrated its HIV, hepatitis, and addiction services (346). San Diego offers an integrated program of hepatitis, STD, and HIV prevention services (347).
Programmatic evidence supports the need for providing comprehensive or integrated services for persons who use drugs illicitly (113,339,348–352). Other integrated guidelines emphasize the importance of integrated services for optimizing prevention of and treatment of HIV infection, viral hepatitis, STDs, and TB (18,148,353,354).
Evaluation and Research Initiatives on Integration
The scientific evidence is increasing for development, implementation, and evaluation of projects that focus on program collaboration and service integration (349,350,354–356). For example, description of the process of implementing integrated services provides rich information on the feasibility and benefits of this effort (132,214,335,336,342–345,347,357–365). Studies that examined outcomes of integrated services show a decrease in high-risk behaviors; an increase in testing for HIV infection, viral hepatitis, STDs, or TB; an increase in prevention and treatment services; and better adherence to prevention and treatment regimens (340,356,366–369). Economic analyses demonstrate the cost or cost-effectiveness of integrated services (346,347,370–372).
The scientific evidence is largely built on observational studies and demonstration projects. These studies and projects provide sufficient evidence for implementing and evaluating the effectiveness of integrated prevention services (132,214,335,336,340,342–345,347,356–372).
Future Research and Allocation Approaches
New research studies and demonstration projects, including quasi-experimental studies (373,374) and cost-effectiveness studies, would add to the evidence base for integrated services. Such new initiatives would provide a basis for estimating the specific effect of integrated services relative to other concurrent public health services (e.g., comprehensive but not integrated services, limited integrated services vs. expanded integrated services) and would control for possible confounders (e.g., changes in drug use, injection use, sexual risk behaviors, the drug market, reimbursement mechanisms, funding opportunities).
It is also relevant to identify whether there are certain subpopulations of persons who use drugs illicitly (e.g., younger persons, racial and ethnic minority persons) who need or who would benefit from integrated services more than other subpopulations. To strengthen the evidence-base for integrated services, conducting systematic reviews or a meta-analysis of the effects of integrated services and grading the evidence will be relevant (110,375–379). Meta-analyses of observational studies of public health programs can provide useful information, because although randomized controlled trials have their advantages, they might still have weaknesses in terms of their implementation and analysis or their application to public health programs (380,381).
Mathematical modeling, as well as spatiotemporal epidemiology methods, can inform public health decision making (382,383). The Bradford Hill criteria and other methods for assessing causality remain relevant for evaluation of integrated services (384– 387). Clinical and health outcomes can be enhanced by population-specific funding streams and allocation of resources for programs for persons who use drugs illicitly or for integrated services for this population. Tracking the monetary resources allocated for this population, as well as the resources devoted to integrated services for this population can enhance delivery of integrated programs and can be useful in evaluating the cost-effectiveness of integrated services.
Examples of Integrated Services in Particular Settings
Many settings, including primary care settings, are important venues for providing integrated services. Examples of integrated services that are based on recommendations and guidelines of science-based public health strategies for prevention and treatment of infectious diseases for persons who use drugs illicitly, as summarized in this guidance, have been provided (Table). By definition, services that are infection-specific or disorder-specific are nonintegrated services and are not represented in tabular form. Recommended science-based public health strategies that health-care providers and public health providers can implement to reduce the risk for HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly have been summarized (Box 5), and a list of recommendations and guidelines in which these strategies are outlined is provided (Appendix B).
Special Considerations for Prevention and Control of Infectious Diseases
Several factors are integral to the success of prevention of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly. These factors include understanding how contextual factors, mental health needs, and fear of criminalization or stigmatization, can affect prevention and treatment efforts, and how effective patient-provider relations and communication can help ensure that the needs of persons who use drugs illicitly are met.
Contextual Factors
The general environment, with its different influencing factors (e.g., laws, policies, social factors) and different levels of influence (e.g., macro and micro), affects risk behaviors and transmission of HIV infection, viral hepatitis, STD, and TB (10,388–390). Contextual factors influence differentially the exposure of majority and minority racial and ethnic groups to risky environments, risk-reduction interventions, and access to prevention and treatment services (335,391–394). As an example, the nature of a neighborhood influences risk behaviors (391,392). Black persons who use drugs illicitly have been more likely to be arrested and to receive longer sentences (10,27). Spatial or geographic access to pharmacies that sell syringes over the counter has been lower in areas that have lower proportions of non-Hispanic whites (84). Laws that inadvertently make pregnant drug-using women reluctant to seek prenatal care because of fear of incarceration or fear of losing the newborn child to foster care and prevention programs that do not offer training or services in drug overdose prevention can have a negative impact on the health and well-being of persons who use drugs illicitly (84,88,275,395).
Persons who use drugs illicitly often live in unstable housing or experience periods of homelessness. Their lives are complicated by other factors, such as poverty, unemployment, lack of social support, and discrimination because of prior incarceration. Their health status is often poor because of inconsistent health care, poor nutrition, lack of health insurance, and interruptions in care due to incarceration and loss to follow-up after incarceration (13,396). Long waiting periods during appointments for medical care and the need for repeat visits to receive HAV and HBV vaccinations, HIV and HCV treatment, and test results for infectious diseases are often barriers to receipt of prevention and treatment services (397–402). Providing prevention and treatment services in convenient locations and at convenient times reduces the need for repeat visits and can increase the likelihood of obtaining necessary services (403,404). Providing treatment for HIV infection, viral hepatitis, STDs, and TB is in itself a preventive intervention that reduces the risk for transmitting infection to others who live in the same high-risk environments or engage in similar risk behaviors. Coordination with public agencies (e.g., Medicaid services and state AIDS drug assistance programs) that provide or reimburse for health care can mitigate barriers associated with cost of care (405).
Mental Health Needs
Persons with substance use disorders are at elevated risk for depression, anxiety, and severe mental illness, compared with persons who do not have substance use disorders (15). At least in part, persons might use drugs illicitly and drink alcohol in excess to self-treat pre-existing or concurrent mental disorders (406,407). Persons with HIV infection who use drugs illicitly often live in socially and economically disadvantaged communities characterized by a high prevalence of psychosocial problems (408). Similarly, depressive symptoms are highly prevalent among HCV-infected persons who use drugs illicitly (409,410). Persons who use drugs illicitly and have depressive symptoms are less likely to be tested for HIV infection than are persons who use drugs illicitly and do not have such symptoms (399). Mental health disorders often hinder persons who use drugs illicitly from receiving health-care services, and such disorders can be a barrier to eligibility for treatment. For example, uncontrolled depression is a contraindication for starting HCV antiviral treatment; thus, screening for and treating depression are prerequisites for providing HCV treatment to HCV-infected persons who use drugs illicitly (338). Providers of mental health services have an important role in substance abuse treatment and clinical HCV treatment.
Fear of Criminalization or Stigmatization
The fear of being arrested because of illicit drug use can prevent persons who use drugs illicitly from seeking prevention services for HIV infection, viral hepatitis, STDs, or TB (248,411). They might fear that interacting with health authorities, prevention providers, or substance abuse treatment programs will lead to arrest or prosecution (253,412). Thus, while the intent of the laws is to reduce illicit drug use, the laws also might unintentionally reduce use of prevention and treatment services by persons who use drugs illicitly.
Perceptions held by peers of persons who use drugs illicitly might stigmatize the use of prevention and treatment services (413–415). For example, persons who inject drugs illicitly might be deterred from participating in syringe services programs for fear of stigmatization (416). Persons who use drugs illicitly cite fear of social discrimination as a reason for not getting tested for HIV infection (417). They often are marginalized socially and estranged from their families; consequently, they might fear being dually stigmatized as having HIV infection or another disease. Because of these fears, persons who use drugs illicitly might have concerns about confidentiality when visiting medical providers or using prevention or treatment services. Community-based organizations, health-care providers, and law enforcement staff should work together to ensure that persons who use prevention services are treated according to ethical principles and human rights considerations, that confidential and identifying information are protected, and that no unintended harm is done (109,418–420).
Patient-Provider Relations and Communication
How persons who use drugs illicitly and health-care providers perceive each other can be a barrier to a person's receipt of services. Persons who use drugs illicitly have reported avoiding screening or counseling and testing because they perceive health-care providers to be uncaring, indifferent, or unfamiliar with treating patients with substance use disorders (399,403,411). Tension in the client-provider relationship can result from the patient's perception that the provider cares more about the disease than about the person with the disease, often making persons who use drugs illicitly feel unacknowledged (421). They might also feel that providers have not given them sufficient information on the effectiveness, complexity, and side effects of medical treatment regimens (422).
Health-care providers might have negative perceptions of persons who use drugs illicitly (332,400,411). For example, HIV and HCV treatment providers might perceive persons who use drugs illicitly as not likely to adhere to treatment regimens or to keep appointments (393,396,423). Such perceptions have led to decreased initiation of medical care by persons who use drugs illicitly (402). In spite of such perceptions, however, health-care providers can be poor predictors of patients' treatment adherence (424); a number of studies have shown that persons who use drugs illicitly have adhered to medical treatment regimens, particulary when special considerations and incentives were provided (243,318,425–427). Researchers have formulated 13 principles for managing health-care relationships with users of heroin and cocaine (332,428). Although these principles were developed specifically for HCV treatment, they can be used for treating other medical conditions, including HIV infection (203,332,428; Box 6).
In addition to ensuring conditions for successful delivery of services for persons who use drugs illicitly, administrative directors and decision makers at local venues providing services to this population need to be cognizant of relevant programmatic considerations. These considerations have been summarized (Box 7).
Practical Aspects of Delivery of Integrated Prevention Services
Overview
Many public health systems have separate organizational structures and programs for the delivery of prevention and treatment services for HIV infection, viral hepatitis, STDs, and TB. These structures and programs often operate separately from substance abuse treatment centers or mental health services, with separate funding streams, management structures, and operating procedures. Integrated prevention implies service coordination to ensure delivery and receipt of prevention services (e.g., screening, testing, prevention counseling) for two or more infections or health conditions during a single visit at a venue (336,361). The need for holistic services is particularly great for persons who use drugs illicitly because of increased risk among these persons for having or acquiring multiple infections and health conditions. Delivery of integrated prevention services can help with this need (385) because it can improve the efficiency and the quality of services provided, maximize opportunities for comprehensive services, and reduce service duplication and procurement and distribution costs (148,346).
Referrals, based on the needs of persons who use drugs illicitly, can be made for treatment, care, and supportive services and can include necessary assistance to facilitate initial and follow-up contact with appropriate service providers. Referrals to other service providers through a coordinated referral system represent a useful approach that can improve service provision. Providing treatment for HIV infection, viral hepatitis, STDs, and TB should be facilitated as interventions for preventing transmission of these diseases. Where feasible, treatment for substance use and mental disorders needs to be integrated with prevention and treatment services for HIV infection, viral hepatitis, STDs, and TB, thereby reducing barriers to care associated with illicit use of drugs.
Factors influencing integration of prevention services include separate, often categorical programs (362); program differences in approaches to service delivery; a lack of staff training in implementing integrated services (132,351); program resistance to integration because of fear that it will lower the quality of core services (148,360,362); and providers' resistance to providing prevention services for additional infectious diseases or health conditions, because of concerns about demands on staff and staff burnout (344,351,362,368). Success in reducing these barriers can be rewarded by efficiencies gained through integration of prevention services and improvement in clinical and public health outcomes for persons who use drugs illicitly (367).
Although maximizing opportunities for providing comprehensive services might be ideal, service integration might not be achievable in every setting because it is dependent on local needs and because of funding, organizational, or policy constraints (214). Providing prevention services for HIV infection, viral hepatitis, STDs, and TB for persons who use drugs illicitly, including treatment for substance use and mental disorders, requires coordinated and collaborative planning approaches, an integrated service delivery plan, and a plan for monitoring and evaluating integrated service delivery (9,352,359,429). An overview of the key practical components necessary for implementing integrated services is provided (Figure 1).
Coordinated and Collaborative Planning Approaches
Health officials who aim to improve delivery of integrated prevention services for persons who use drugs illicitly need to use the best available evidence to understand the local needs regarding services for HIV infection, viral hepatitis, STDs, and TB for this population. They also need to consider the extent to which integrated services are offered and the collaborations that are in place to prevent and reduce infectious diseases, as well as substance use and mental disorders. Relevant settings for integrated services include those that interact with or serve persons who use drugs illicitly, such as outreach programs; syringe services programs; public health clinics; jails, prisons, and juvenile detention centers; and substance use and mental disorders treatment centers.
In general, collaborative planning for service integration requires a high-level coordinating body composed of key staff with expertise in designing, implementing, and managing service delivery for HIV infection, viral hepatitis, STDs, and TB. The composition and authority of the coordinating body are locally determined, and need to be endorsed officially at the highest level possible to enable it to leverage resources and identify or develop policies that support integrated prevention services. Because service integration requires commitment and communication among the agencies whose services are to be integrated, the coordinating body needs to include leaders from these agencies. The coordinating body needs to also include representation from community-based organizations that provide prevention services and representation from the community of persons who use drugs illicitly.
Although strategies for limited service integration might be implemented with existing resources, extensive integration might require additional investments. Cost-sharing among programs might be one way to facilitate collaboration and integration among programs that agree to integrate their services; another way to facilitate such collaboration and integration might include providing free test kits or vaccines through grants and other initiatives (21). The coordinating body also can work to reduce the stigmatization of persons who use drugs illicitly, a factor that often leads to reluctance to fund programs designed to help this population. Ensuring that participating programs are reimbursed adequately and ethically for their cooperation in any plan for integrated services is essential (1,343,430). Guidance from state and regional public health officials might be required for implementing integrated services at the local and agency levels; the particulars are best determined locally.
Integrated Service Delivery Plan
The coordinating body needs to develop a mutually beneficial plan across programs. The plan needs to clarify the specific opportunities for collaboration and integration, to use this information to reduce operational barriers, and to outline the specific steps for delivery of integrated services. When developing the plan, the coordinating body needs to evaluate the strengths and weaknesses of the various programs that might be involved in planning and delivering integrated prevention services.
The plan needs to describe how services are currently provided and whether an integrated approach would be an improvement over a single infection- or disease-specific approach. The plan also needs to describe needed changes in policies, procedures, and methods of service delivery; additional training required for staff; and strategies to monitor and evaluate integrated service delivery (70,148).
The coordinating body needs to ensure that the proposed plan does not adversely affect the delivery of services or the mission of the program, meets the public health needs of persons who use drugs illicitly, is acceptable to providers and clients, and is consistent with state and local laws and policies. The plan must ensure that core program activities are sustained and are based on a realistic assessment of each program's capacity for collaboration or integration. The service plan needs to include clear guidance for implementing public health strategies in a coordinated approach. On the basis of available resources, the plan needs to indicate whether specific prevention services are to be provided on-site by cross-trained staff or by providers at other sites to whom those in need of these services are referred through a clearly defined referral and linkage-to-care system. The plan also needs to define the roles and responsibilities of all service providers, ensure that they are trained appropriately, and clarify lines of communication among venues or programs participating in the proposed delivery of integrated prevention services. The plan needs to specify how confidentiality will be maintained and how client information (e.g., risk assessment, test results, vaccination histories) will be shared among service providers.
The plan also needs to specify the needs for staff training. Whether prevention services are provided in a single or in a coordinated fashion between multiple locations or services, providers might need training in the screening, diagnosis, treatment, and prevention of other related infectious diseases, along with training about issues related to co-infection. Studies have demonstrated that training is essential to integrating services in prevention and treatment settings for substance use and mental disorders (132,351,368). One example of successful cross-training programs for service providers is a hepatitis training program that SAMHSA developed and provided to more than 150 substance abuse treatment programs (21), including training modules on the delivery of hepatitis services to persons who use drugs illicitly in New York City (343). Training in the prevention of multiple conditions can be provided either by expanding an established training program for the treatment of a single infection or disease or by providing separate but coordinated training in the prevention or treatment of each infection or disease (362). Moreover, training in the provision of integrated service delivery should continue after services have been integrated (431).
In addition to cross-training, service providers might need training that is specific to working with persons who use drugs illicitly. Training sessions should address how illicit use of drugs affects persons' lives and how to be sensitive to the stigma and discrimination related to illicit use of drugs and infectious diseases. Improved sensitivity and understanding among service providers about prevention needs might help improve patient-provider relations and reduce barriers to service recipients when they discuss illicit use of drugs with service providers.
Monitoring and Evaluation of Integrated Service Delivery
Monitoring and evaluation have been defined as systematic and rigorous applications of scientific qualitative and quantitative methods to assess the design, implementation, and outcomes of programs (432,433). Monitoring and evaluation projects frequently require such resources as evaluator expertise, staff, time, and a sizeable budget (432). Relevant frameworks and publications can assist in developing and conducting monitoring and evaluation of integrated services (432,434–437). Three tiers of evaluation questions (Are the right things being done? Are they being done right? Are they being done on a large enough scale?) also can be used to determine what is being done, ensure that enough persons benefit from the program, and achieve the intended outcomes and impact (436). Thus, monitoring and evaluation projects of integrated services can focus on reductions in new infections resulting from service integration, as well as on other health outcomes, such as changes in mortality rates. Pertinent monitoring and evaluation questions of integrated service delivery programs can assess the extent to which these programs identify comorbid infections and diseases, provide relevant prevention and treatment services, and prevent and treat comorbid infections and diseases. An overview of integrated prevention services that can be delivered in multiple settings and in an integrated fashion has been provided (Table).
Other aspects of monitoring and evaluation include those that assess integration strategies (e.g., coordinating groups, co-location of services, pooled funding, cross-training of staff). An organizational index can measure operating costs and can provide an objective structured method to evaluate the organizational process associated with program collaboration and system integration (355).
Monitoring and evaluation activities can benefit from cost-effectiveness analysis that compares the relative costs and outcomes of two or more programs (438). Cost-effectiveness of a program typically is expressed as an incremental cost-effectiveness ratio, i.e., the ratio of change in costs to the change in the outcomes (e.g., years of life gained, number of infections averted, and quality-adjusted life years saved) (439,440). Cost-effectiveness analysis can be useful in comparing similar outcomes of different programs (e.g., integrated vs. nonintegrated programs, limited integrated programs vs. expanded integrated programs). Programs are considered cost-saving when the program implementation cost is less than the health care costs avoided by the program. For example, if an integrated program incurs $10,000 for screening and treatment costs and avoids $20,000 in future treatment cost, the program is cost-saving. The program can still be considered to be cost-effective even if it does not avert enough sequelae cost to be cost-saving. A program that has a net cost (program cost minus averted sequelae cost) that is lower than the threshold cost being used per case of infection averted might be considered cost-effective, compared to another program, even if it is more expensive, if it prevented more cases (441,442). When calculating the costs and benefits of integrated service programs, researchers and program planners need to define the perspective of interest (e.g., a specific program, a community-based organization, the entire health care system, or society as a whole). The perspective determines the costs and benefits to be included in the calculations. For example, a societal perspective cost-effectiveness analysis includes all costs and benefits associated with a program, whereas a health care-system perspective cost-effectiveness analysis includes direct medical costs but excludes costs borne solely by patients (e.g., transportation and lost productivity). Economic analysis can be considered with other factors (e.g., population prevalence and disease prevention goals) in implementing and evaluating integrated services.
From a practical perspective, a monitoring and evaluation plan that discusses and depicts the relationship between implementation and outcomes can guide monitoring and evaluation activities. The plan specifies the goals and objectives of the program and it can be used to develop a conceptual framework that links the input, activities, output, outcomes, and impact of integrated services. An example of how to lay out these components is provided (Figure 2). The plan also can establish realistic expectations for the monitoring and evaluation activities. In addition, monitoring and evaluation plans need to describe in sufficient detail how to evaluate the process, outcomes, and effectiveness, including cost-effectiveness of service integration. Local stakeholders need to be involved in developing monitoring and evaluation plans and in setting goals for improving the delivery and effectiveness of integrated prevention services (368). Monitoring and evaluation activities can be supported by data systems that track services and client data. Data collected for each activity before services are integrated can be used as baseline measures of prevention services, and changes in those measures can be used to assess the effectiveness of service integration. In addition, there is a need to define and to monitor routinely indicators for delivery of new services that are provided as a result of implementing integrated services (Table), including indicators of clients' perspectives and satisfaction. Surveys of persons who use drugs illicitly can assess during the planning phase their opinions about the feasibility of proposed integrated services, and, as part of process evaluations, the extent to which integrated prevention services are implemented as planned. Surveys of frontline service providers can assess during the planning phase their opinions about the feasibility of various proposed integrated services, and as part of process evaluations, the extent to which integration prevention activities are implemented as planned.
Surveillance data for HIV infection, viral hepatitis, STDs, or TB can be examined jointly so that health officials can analyze trends in disease prevalence and co-infection. Joint examination of surveillance data might include reviewing or publishing data on similar variables from the separate surveillance systems (443,444), collecting and analyzing data on a standardized set of variables, and integrating discrete surveillance systems into a single entity.
Sharing surveillance information across jurisdictions can be complicated by political, legislative, or regulatory issues. The sharing of combined data on multiple infectious diseases must be consistent with data confidentiality standards for each disease. For example, when HCV data are incorporated into an existing HIV data system (445), the data should be treated with the same strict security and confidentiality protections required for all U.S. HIV surveillance data (446,447).
Conclusion
This guidance is intended to support the efforts of agencies, programs, and providers to implement science-based public health strategies for integrated prevention services at venues that serve persons who use drugs illicitly. It summarizes multiple current (as of 2011) guidelines or recommendations for the prevention and control of HIV infection, viral hepatitis, STDs, and TB for persons who use drugs illicitly and provides a summary of published scientific and programmatic literature. An integrated approach to service delivery for persons who use drugs illicitly need to incorporate recommended science-based public health strategies. The 12 science-based public health strategies are as follows: 1) prevention and treatment of substance use and mental disorders; 2) outreach programs; 3) risk assessment for illicit use of drugs; 4) risk assessment for HIV infection, viral hepatitis, STDs, and TB; 5) screening, diagnosis, and counseling for HIV infection, viral hepatitis, STDs, and TB; 6) vaccination; 7) prevention of mother-to-child transmission of HIV infection, viral hepatitis, and STDs; 8) interventions for reduction of risk behaviors; 9) partner services and contact follow-up; 10) referrals and linkage to care; 11) medical treatment for HIV infection, viral hepatitis, STDs, and TB; and 12) delivery of integrated prevention services.
The integration of prevention services must make epidemiologic and programmatic sense, and it should be contextually appropriate and consistent with state and local laws and policies. All persons who use drugs illicitly are not at equal risk for HIV infection, viral hepatitis, STDs, or TB, and service integration is not feasible in all settings. However, opportunities exist to improve prevention services and eliminate duplication of health services. Program collaboration and service integration can provide persons who use drugs illicitly with increased access to services, improve the timeliness of service delivery, and increase the effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants. Collaborative planning at the local level with a coordinating body is needed to develop plans across programs to reduce operational barriers and to clarify delivery of integrated services. Feasibility studies and monitoring and evaluation studies can ensure the success of integrated services delivered to prevent and reduce HIV infection, viral hepatitis, STDs, and TB, as well as to prevent and treat substance use and mental disorders among persons who use drugs illicitly. Consolidated recommendations and guidelines of science-based public health strategies as summarized in this guidance can have synergistic effects in enhancing efforts of health-care providers and public health providers to optimize prevention and treatment, use resources efficiently, and improve health outcomes in persons who use drugs illicitly.
Acknowledgments
The following persons reviewed a draft of this report: Allan Clear, Harm Reduction Coalition, New York, New York; Don Des Jarlais, PhD, Beth Israel Medical Center, New York, New York; Holly Hagan, PhD, New York University; David Perlman, MD, Beth Israel Medical Center, New York, New York; T. Steve Jones, MD, T. Stephen Jones Public Health Consulting, Florence, Massachusetts; Hannah Cooper, PhD, Emory University, Atlanta, Georgia; Steven Shoptaw, PhD, University of California–Los Angeles, Los Angeles, California; Bruce G. Trigg, MD, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; Gustavo Aquino, MPH, Yarnell Martin, and Laurie C. Reid, MS, CDC.
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BOX 1. (Continued) Summary of recommended screening, counseling, and vaccination services for persons who use drugs illicitly |
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injected drugs illicitly or have partners who have exchanged sex or money for illicit drugs. Persons seeking treatment or screening for a particular STD should be evaluated for all common bacterial and parasitic STDs (e.g., chlamydia, gonorrhea, syphilis, and trichomoniasis) and informed if testing for any common STD has not been performed. Although no comprehensive national guidelines regarding STD care and management have been developed for correctional populations, the utility of expanded STD services in correctional settings has been reported. Universal screening of some populations (e.g., adolescent females) for chlamydia and gonorrhea is recommended at intake in juvenile detention and jail facilities. Universal screening for syphilis should be conducted based on local and institutional prevalence. Chlamydia§§ Annual chlamydia screening for all sexually active women aged <25 years and screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners) are recommended. Chlamydia-infected women and men should be retested approximately 3 months after treatment. Among persons in correctional facilities, universal screening of adolescent females for chlamydia should be conducted at intake. Universal screening of adult females should be conducted at intake among women up to age 35 years (or on the basis of local institutional prevalence data). Pregnant women should be screened routinely for chlamydia at the first prenatal visit. Pregnant women at increased risk for chlamydia and women found to have chlamydial infection during the first trimester should be retested during the third trimester to prevent postnatal complications and chlamydial infection in the infant. Sexually active men who have sex with men (MSM) who have had insertive or receptive anal intercourse or who have had oral sex in the past year should be screened for chlamydia. Testing should be performed on specimens obtained from the pharynx, urethra, or rectum depending on the site of exposure. Screening at 3-to 6-month intervals is recommended for MSM who have multiple or anonymous sex partners, have sex in conjunction with illicit use of drugs, use methamphetamine, or have partners who participate in these activities. Gonococcal infections¶¶ Screening all sexually active women for gonorrhea, including those who are pregnant, if they are at increased risk, is recommended. Women aged <25 years are at highest risk for gonorrhea. Other risk factors for gonorrhea include a previous gonococcal infection, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and illicit drug use. Infected women and men should be retested approximately 3 months after treatment. Among persons in correctional facilities, universal screening of adolescent females for gonorrhea should be conducted at intake in juvenile detention or jail facilities. Universal screening of adult females should be conducted at intake among females up to age 35 years (or on the basis of local institutional prevalence data). Pregnant women should be screened at the first prenatal visit. Pregnant women found to have gonococcal infection during the first trimester should be retested in 3–6 months, preferably in the third trimester. Sexually active MSM who have had insertive, receptive anal or oral intercourse during the previous year should be screened for urethral, rectal, and pharyngeal infection with Neisseria gonorrhoeae using specimens obtained from exposed sites. Screening at 3–6 month intervals is recommended for MSM who have multiple or anonymous sex partners, have sex in conjunction with illicit use of drugs, use methamphetamine, or have partners who participate in these activities. Syphilis*** Syphilis serology should be performed at least annually for sexually active MSM, including MSM with or without established HIV infection. More frequent screening (at 3–6 month intervals) is indicated for MSM who have multiple or anonymous sex partners, have sex in conjunction with illicit drug use, use methamphetamine, or have sex partners who participate in these activities. A serologic test for syphilis should be performed for all pregnant women at the first prenatal visit. Women who are at high risk for syphilis, live in areas of high syphilis morbidity, are previously untested, or have positive serology in the first trimester should be screened again early in the third trimester (28 weeks of gestation) and at delivery. Among persons in correctional facilities, universal |
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BOX 1. (Continued) Summary of recommended screening, counseling, and vaccination services for persons who use drugs illicitly |
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screening should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, and early latent) infectious syphilis. Herpes simplex virus-2††† HSV serologic testing should be considered for persons presenting for an STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Human papillomavirus (HPV)§§§ Routine pre-exposure vaccination of those aged 11 or 12 years is recommended to prevent cervical precancer and cancer caused by high-risk HPV types. Catch-up vaccination is recommended for those aged 13–26 years, as indicated and recommended. |
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* Sources: CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14); CDC. HIV/AIDS. Available at http://www.cdc.gov/hiv; US Preventative Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005;143:32–7. (USPSTF does not have a recommendation on frequency of screening.) † Sources: CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55(No. RR-7); CDC. Viral hepatitis. Available at http://www.cdc.gov/hepatitis. § Sources: CDC. Viral hepatitis. Available at http://www.cdc.gov/hepatitis; Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2010–2011, section 2, infectious diseases. Available at http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2b.htm; CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55(No. RR-16). ¶ Sources: Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2010–2011, section 2, Infectious Diseases. Available at http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2b.htm; CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55(No. RR-16); CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19). ** Sources: CDC. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(No. RR-6); CDC. Guidelines for the investigation of contacts of persons with infectious tuberculosis: recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 2005;54(No.RR-15); CDC. Tuberculosis. Available at http://www.cdc.gov/tb. †† Sources: CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12); CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std. §§ Sources: Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2010–2011, section 2, infectious diseases. Available at http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2b.htm; CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12); US Preventive Services Task Force. Screening for chlamydial infection. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm; CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std. ¶¶ Sources: Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2010–2011, section 2, infectious diseases. Available at http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2b.htm; CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std; US Preventive Services Task Force. Screening for gonorrhea. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsgono.htm. *** Sources: Agency for Healthcare Research and Quality. Guide to clinical preventive services, 2010–2011, section 2, infectious diseases. Available at http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2b.htm; CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12); CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std. ††† Sources: CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12); CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std. §§§ Sources: CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std; US Preventive Services Task Force. Screening for cervical cancer. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm; CDC. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60:1705–8. |
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BOX 2. Recommendations to improve prenatal care and prevent mother-to-child transmission of human immunodeficiency virus( HIV), sexually transmitted diseases (STDs), hepatitis B virus (HBV), and hepatitis C virus (HCV) |
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Sources: CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14); CDC. HIV/AIDS. Available at http://www.cdc.gov/hiv; CDC. Sexually transmitted diseases treatment guidelines 2010. MMWR 2010;59(No. RR-12); CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std; CDC. Hepatitis B vaccine: what you need to know. Available at http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-b.pdf; CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). Part I: immunization of infants, children, and adolescents. MMWR 2005;54(No. RR-16); CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. Part II: immunization of adults. MMWR 2006;55(No. RR-16). |
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BOX 3. Summary of recommended messages for persons who use drugs illicitly to reduce drug use and infectious disease–related risks |
Sources: CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14); CDC. HIV/AIDS. Available at http://www.cdc.gov/hiv; CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55(No. RR-7); CDC. Viral hepatitis. Available at http://www.cdc.gov/hepatitis; CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. Part II: immunization of adults. MMWR 2006;55(No. RR-16); National Institute on Drug Abuse. Drug facts: nationwide trends. Available at http://www.drugabuse.gov/publications/drugfacts/nationwide-trends; CDC. Persons who use drugs. Available at http://www.cdc.gov/pwud; National Institute on Drug Abuse. Principles of HIV prevention in drug-using populations: a research-based guide. Available at http://archives.drugabuse.gov/POHP; CDC. Questions and answers: HIV prevention. Available at http://www.cdc.gov/hiv/resources/qa/prevention.htm; CDC. How can HIV be prevented? Available at http://www.cdc.gov/hiv/topics/basic/index.htm#prevention; CDC. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19); CDC. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR 2012;61(No. RR-4). |
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BOX 4. Summary of recommended messages for persons with a history of high-risk sexual practices |
Sources: CDC. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydia infection. MMWR 2008;57(No. RR-9); National Institute on Drug Abuse. Drug facts: nationwide trends. Available at http://www.drugabuse.gov/publications/drugfacts/nationwide-trends; CDC. How can HIV be prevented? Available at http://www.cdc.gov/hiv/topics/basic/index.htm#prevention. CDC. Sexually transmitted diseases. Available at http://www.cdc.gov/std; CDC. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR 2011;60:1705–8. |
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BOX 5. Science-based public health strategies for persons who use drugs illicitly to reduce human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) |
Sources: See Appendix B for a list of recommendations and guidelines that outline these public health strategies. |
* This figure displays components of integrated services as recommended in this report.
Alternate Text: This figure shows the components of integrated services as recommended in this report. Both a coordinated approach and a collaborative planning approach lead to an integrated service delivery plan, which leads to monitoring and evaluation of service deliver, which feeds back into a collaborative planning approach.
FIGURE 2. Simplified logic model recommended to monitor and evaluate integrated services for persons who use drugs illicitly*
Abbreviations: HIV = human immunodeficiency virus; STDs = sexually transmitted diseases; TB = tuberculosis; CBOs = community-based organizations.
* This figure summarizes the process recommended in this report.
Alternate Text: This figure summarizes the process recommended in this report. At the policy, community, organization, and individual levels, activities result in increases in policies, funding, and systems that promote integrated services and to population and provider knowledge, attitudes, and interventions about integrated services. These outcomes lead to increased provider practices that promote integrated services and to an increase in norms that support integrated services. These outcomes lead to an increase in integrated preventive and treatment services and to an increased proportion of persons who use drugs illicitly seeking integrated services, resulting in improved health outcomes and a decrease in disparities in health outcomes as the end result.
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