Promoting Risk Assessment & Behavior Change to Prevent the Spread of Infectious Disease Among Substance Abusers
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Promoting Risk Assessment and Behavior Change for Prevention of Spread of Infectious Disease Among Substance Abusers
1. Promoting Risk Assessment &
Behavior Change to Prevent the
Spread of Infectious Disease
Among Substance Abusers
Glenda Clare
G. Portlynn Clare & Associates
g_portlynnclare@hotmail.com
2. Workshop Objectives
To discuss the epidemiology, symptoms,
and methods of transmission of STDs,
hepatitis, HIV and tuberculosis;
To discuss the connection between
substance abuse and infectious disease;
To identify and practice using effective
screening and assessment tools;
To identify, support and enhance self-
directed change behaviors in their clients
3. Workshop Objectives
To identify and utilize strategies and models
to work cooperatively with clients to set their
priorities and time lines for action
To develop effective drug and sexual
behavior change interventions that are
appropriate to their clients’ readiness for
change.
To discuss issues of confidentiality pertinent
to substance abuse and infectious disease.
4. Introductions
Who are you?
What kind of work do you do?
Why did you decide to attend this
workshop?
What is one behavior that you have
tried to change
8. Population Groups with
Especially High Risks
Certain racial and ethnic groups
Men who have sex with men (MSM)
Homeless individuals
Incarcerated individuals
Injection drug users (IDUs)
Female sex workers and IDUs
Adolescents
Immigrant Population
9. Population Groups with
Especially High Risks
Men and women involved in
international slave trafficking (i.e.
“indentured servants,” “mail-order
brides,” “garment workers”)
Trans-gendered male to female on
injection hormone therapy
Trans-gendered male to female sex
workers
11. Gonorrhea- Overview
Gonorrhea is caused by a bacterium that
grows and multiplies quickly in moist, warm
areas of the body such as the cervix,
urethra, mouth, throat , or rectum
Gonorrhea can be spread in the following
ways:
Penis to vagina sex
Penis to mouth “oral” sex
Penus to retum “anal”sex
Mouth to vagina “oral” sex
Passed from an infected mother to a baby
during birth
12. Gonorrhea – Possible
Symptoms
Men:
Yellow pus-like discharge from the urethra
Dysuria, frequent urination, and blood in
urine
Adenopathy of groin lymph glands
Pain during pelvic exam
Women:
Vaginal discharge
Irritation of the external vagina and dysuria
Abnormal menstrual bleeding
13. Gonorrhea – Possible
Complications
Pelvic inflammatory disease (PID), a major
cause of infertility
Gonorrhea during pregnancy may cause
spontaneous abortion, premature labor,
increased neonatal morbidity and spread
from mother to infant.
Infection may cause swollen or tender
testicles, urethral stricture, and
disseminated gonococcal infection (DGI)
Often used to determine sexual abuse in
children
14. Gonorrhea – Screening,
Prevention and Treatment
Screening is recommended for anyone
exposed to an infected individuals
All persons with gonorrhea should be
screened for chlamydia, syphilis, and
HIV
Clients & patients should be given
information about the source of spread,
mode of transmission, incubation period,
and treatment
Gonorrhea can be cured with antibiotics,
any damage to the body cannot be
repaired
15. Syphilis Overview
The organism that causes syphilis is
called Treponema pallidum.
The bacterium spreads from the sores of
an infected person to mucous
membranes of the genital area, the
mouth or the anus of a sexual partner. It
can also pass through broken skin on
other parts of the body
A pregnant woman with syphilis can
pass the bacterium to her unborn child
Syphilis can be controlled with antibiotic
therapy
16. Syphilis - Stages
Primary: A painless sore or lesion called
a “chancre” appears that lasts from 1- 5
weeks and heals without treatment
Secondary: Rashes may be on the
palms of the hands, bottoms of the feet,
or all over the body. Symptoms may
include fever, swollen lymph glands,
headaches, hair loss, weight loss and
muscle aches, and may last 2-6 weeks
17. Syphilis - Stages
Latent: Usually no visible symptoms are
present
Late: Develops in one-third of persons
with untreated syphilis. Symptoms may
include paralysis, insanity, blindness,
swollen joints, personality changes,
impotency, aneurysm, and tumors on the
skin, bones or liver
18. Syphilis – Risk Assessment
Screening and Testing
Risk assessment varies
Screening involves gathering subjective
data. It should be repeated every year if
at-risk behavior continues
Testing concerns performing medical
tests (e.g., blood tests, tests on the
discharge of open sores, or examination
of spinal fluid) on symptomatic patients
19. Syphilis - Treatment
If syphilis is detected early, it can be
completely cured with antibiotics, any
damage to the body cannot be
repaired
Treatment involves large doses of
penicillin given by injection into a
muscle
Repeated blood and bacteria tests are
needed to determine if treatment has
been successful or if re-infection has
occurred
20. The National Plan to
Eliminate Syphilis from the
United States
Epidemic re-emerged in the 1990s by
persons infected and affected by
HIV/AIDS
1998, over 50% of infectious cases
reported in 28 counties in the South
Syphilis elimination is defined as the
absence of sustained transmission in the
United States
Syphilis elimination is defined as the
absence of transmission of new cases
within the jurisdiction except within 90
days of report of an imported index case
21. Chlamydia - Overview
Chlamydia infection is the leading STD
in the nation
Chlamydial infection is caused by a
bacterium, Chlamydia trachomatis, and
is transmitted during vaginal or anal
sexual contact with an infected person
A pregnant woman may pass chlamydial
infection on to her newborn during
delivery, causing subsequent neonatal
eye infection or pneumonia
22. Chlamydia - Overview
Rate of infection is highest in young
adolescent women
Chlamydial infections are responsible for
about 20 to 30 percent of diagnosed
Pelvic Inflammatory Disease (PID) cases
23. Chlamydia -
Complications
Women
Pelvic Inflammatory
Disease (PID)
Infertility
Ectopic pregnancy
Premature labor
Early rupture of
fetal membranes
Increase neonatal
morbidity
Men
Nongonococcal
urethritis (NGU)
Epididymitis
Urethral stricture
Infertility
24. Chlamydia – Screening
and Treatment
Screening for chlamydia infection is strongly
encouraged for high-risk pregnant women,
adolescents, and clients with multiple
sexual partners
Routine testing of all pregnant women is
recommended
Clients should be provided with information
about their infection. Identify level of risk
and making a plan to prevent re-infection
Chlamydia can be cured with antibiotics, but
any damage to the body cannot be repaired
25. Genital Herpes - Overview
Genital herpes is a contagious viral
infection that affects an estimated 30
million people in the US. 500,000 new
cases every year
The virus remains in certain nerve cells
of the body for life, causing periodic
symptoms in some people
26. Genital Herpes - Overview
Genital herpes is a contagious viral
infection that affects an estimated 30
million people in the US. 500,000 new
cases every year
The virus remains in certain nerve cells
of the body for life, causing periodic
symptoms in some people
27. Genital Herpes -
Transmission
Sexual contact with someone who has an
outbreak of herpes sores in the genital area
Oral-genital sex with someone who has an
outbreak of oral herpes
Sexual contact with someone who is
infected but has no noticeable symptoms
Neonatal infection at the time of passage
through the birth canal (typically from
mothers with no history of clinically
apparent genital herpes)
28. Genital Herpes – Diagnosis,
Screening and Treatment
Testing is recommended for clients with
genital, rectal, or oral ulcers.
At the onset of labor, all women should be
examine for the presence of lesions. The
baby should be delivered by casesarean
section if symptoms or signs are present
Clients should be provided with information
about their infection. Identify level of risk
and making a plan to prevent re-infection
Herpes can be treated with medication but
cannot be cured
29. Human Papillomavirus
(HPV) - Overview
An estimated 20 million people in the US
are infected
More than 100 types of HPV have been
identified, over 30 of which are sexually
transmitted
Several types of HPV can lead to genital
warts, the most recognizable sign of genital
HPV infections
Other types have been closely associated
with the development of cervical cancer and
other genital cancers
30. HPV – Possible Symptoms
HPV infections often does not cause
visible symptoms
The virus can remain latent in the
skin, so infected persons may not be
aware of their infection and potential
risk of complications
Genital warts, when visible, occur in
or around the vulva, vagina, cervix,
phneum and canal, urethra, and glans
penis
31. HPV – Diagnosis,
Screening and Treatment
Diagnosis of genital warts is made by
recognizing lesions.
Regular pap smears can detect cellular
changes in the cervix that are due to HPV
infection. It may take years for the cellular
changes to occur
HPV can be treated by removing the warts,
but the virus cannot be eradicated.
Appropriate treatment can be given to
prevent the cellular changes from
progressing to cancer
32. Hepatitis - Overview
Hepatitis A (HAV) – once known as
infectious, or short-incubating; not
commonly sexually transmitted
Hepatitis B (HBV) – once known as serum,
or long incubating; can be sexually
transmitted; only vaccine preventable STD
Hepatitis C (HCV) – once known as
parenterally transmitted (or blood-borne),
non-A, non-B; has been known to be
transmitted sexually, but magnitude of risk
unknown; injection drug use is the leading
factor for contracting HCV
33. Hepatitis A - Overview
Hepatitis A:
Found in the stool (feces) of persons
with with hepatitis A
Usually spread from person to person
by putting something in the mouth that
has been contaminated with the stool
of a person with hepatitis A
Not commonly sexually transmitted
34. Hepatitis B - Overview
Hepatitis B:
Blood/body fluids from an infected
person enter the body of a person who is
not immune
Spread by having sex with an infected
person sharing or being stuck by
needles, or from an infected mother to
her baby during birth
A sexually transmitted disease
The only vaccine-preventable STD
35. Hepatitis B – Prevention
and Treatment
Persons at high-risk for sexual
transmission of hepatitis B include men
who have sex with men, heterosexual
men, women with multiple sex partners
and intravenous drug users
CDC recommends vaccination for those
listed above, as well as for residents of
correctional or long-term care facilities,
persons seeking treatment for STDs,
commercial sex workers, and health care
workers
36. Hepatitis B – Prevention
and Treatment
Vaccinations carry minimal but potential
risk and side effects and general
discomfort and reactions are possible
Most persons with hepatitis B infection
recover and return to normal, but 2 – 10
percent may develop chronic hepatitis
37. Hepatitis C - Overview
Hepatitis C:
Occurs when blood or body fluids from
an infected person enter the body of a
person who is not immune
Is spread by sharing needles or “works”
when “shooting” drugs, by
needlesticks or sharp exposures on
the job, or from an infected mother to
her baby during birth
38. Hepatitis C - Overview
Hepatitis C:
Has been known to be transmitted
heterosexually, but the magnitude of
this risk is unknown at this time
Causes approximately 75 to 85 percent
of patients with acute HCV infection to
remain chronically infected, with the
associated risk of cirrhosis
39. Hepatitis Testing
Substance abuse treatment programs
should routinely screen for hepatitis B and
vaccinate all susceptible individuals.
Additional testing needs to be done as
follows:
Serologic testing for hepatitis A should be
done only for persons with acute hepatitis
Serologic testing for hepatitis C should be
done for all persons with identified risk
factors; and
Routine hepatitis A and B immunization
should be done for injection drug users
40. Information Update on
Viral Hepatitis D (HDV)
Endemic in the Mediterranean, Balkan
Peninsula, former Soviet Union, parts of
African and Middle East and Amazon
basin of South America. Infection via
interfamilial & sexual contact
Uncommon in general population in non-
endemic regions - but does occur in
IDUs & persons with the frequent
exposure to blood products & their
sexual contacts
Prevention based on HDV vaccination in
susceptible individuals.
41. Information Update on
Viral Hepatitis E
Acute, self-limited form of viral hepatitis
spread by fecally contaminated water
Occurs endemically in developing
countries (Asia, African and Central
America) Rare cases have been
described in travelers returning from
endemic regions
Extremely high mortality rate when
infection occurs in pregnancy,
particularly in the third trimester. No
HEV vaccine available
42. Information Update on
Viral Hepatitis G
Some cases of presumed viral hepatitis are
not attributable to hepatitis A-E.
HGV infection is common (1-2% of US
blood donors have HGV RNA detectable in
their serum). Agent is transmitted by
transfusion
Chronic HGV infection does not appear to
commonly cause important liver disease
and does not alter the course of chronic
HCV infection. The vast majority of cases
of acute non A-E hepatitis have no evidence
of HGV infection
43. Human Immunodeficiency
Virus (HIV) - Transmission
Overwhelming majority of cases are
transmitted sexually (exposure to body
fluids, such as semen, blood and vaginal or
cervical secretions)
Other cases are spread by parenteral
transmission either by transfusion of
contaminated blood or blood products or
through injection with a blood-contaminated
needle or syringe
A third route of HIV transmission is perinatal
transmission, which may occur during
pregnancy, delivery, or breast-feeding
44. HIV Manifestations
Chills and fever
Night sweats
Unexplained weight
loss, loss of appetite
Lethargy
Cough, shortness of
breath
Visual changes,
including visual field
defects
Recurrent or persistent
sinusitis
Abdominal pain,
diarrhea
Persisten, recurrent
Candida vaginitis in
women
Cervical/vaginal
dysplasia
Neurological
conditions, headaches,
difficulty concentrating,
short-term memory
loss, pain in extremities
Easy bruising or
abnormal bleeding
associated with low
platelets
45. HIV Treatment
HIV-related mortality has declined
dramatically because of the use of highly
active antiretroviral therapies (HAART) and
prophylaxis against traditional opportunistic
diseases (e.g., Kaposi’s sarcoma, hepatitis
C, TB, pneumocystis carnii pneumonia)
As therapies prolong life expectancy of HIV-
infected persons, other chronic diseases
such as hepatitis C increasingly cause
mortality. HIV co-infection, HIV
immunosuppression, and substance abuse
all influence HCV liver-related disease
progression
46. Tuberculosis (TB) -
Overview
When an individual with no previous
exposure to TB inhales a sufficient number
of tubercle bacilli into the lungs, tuberculosis
infection occurs
While most other infections disappear when
overcome by the body’s defenses, TB does
not. Persons who have been infected by
TB harbor the organism for the remainder of
their lives unless they have received
prophylactic isoniazid
Only 1 out of 10 persons with a positive
tuberculin test will ever develop an active
case of TB
47. TB Conditions That Increase
the Risk of Developing TB
Disease
HIV infection
Diabetes
Substance abuse (especially drug injection)
Infection within the past 2 years with M.
tuberculosis
Chest X-ray findings suggestive of previous TB
( in a person who received inadequate or no
treatment)
Prolonged corticosteriod therapy
Other immunosuppressive therapies
Low body weight (10 percent or more below the
ideal)
48. TB – People at Risk
Populations with high
prevalence of TB
infection
Close contacts of
persons with infectious
TB
Foreign-born persons
from areas where TB is
common
Medically underserved,
low-income
populations, including
high-risk racial and
ethnic groups
The elderly
Residents of long-term
care facilities
Persons in correctional
facilities, homeless
shelters, and nursing
homes
Person who inject
drugs
Identified high-
prevalence groups
such as migrant farm
workers or homeless
persons
Persons who have
occupational exposure
to TB
49. TB- Screening and
Diagnosis
Screening is done to identify
Infected persons at high risk for TB
Persons with TB disease who need
treatment
TB skin testing is safe during
pregnancy, and if active TB is found,
treatment should not be delayed
The preferred method of screening for
TB infection is the Manoux tuberculin
skin test
50. TB - Symptoms
Symptoms of pulmonary TB
Productive, prolonged cough
Chest pain
Spitting or coughing up blood
Systemic symptoms of TB
Fever
Chills
Night sweats
Easy fatigability
Loss of appetite
Weight loss
51. TB – Medical Evaluation
Persons suspected of having TB should be
referred for a complete medical evaluation
including:
Medical history
Physical exam
Mantoux tuberculin skin test
Chest X-ray
Bacteriologic exam (when sputum or other
body fluid are examined by culture for
bacteria
A positive bacteriologic culture for tuberculosis
confirms the diagnosis of TB
52. HIV/AIDS Prevention
Primarily transmission occurs via
two routes
Sharing contaminated syringes,
needles, and other drug injecting
equipment
Unprotected sex with infected
individuals
53. Key Issues
Substance abuse increases the risk of
contracting HIV.
Substance abusers are at risk for HIV
infection through sexual behaviors.
Despite the fact that primary spread is
associated with same sex activities
amongst men and male injection drug
use, HIV is rapidly spreading among
women and adolescents
54. Key Issues
Substance abuse treatment serves as
HIV prevention.
HIV/AIDS, substance abuse disorders
and mental disorders interact in a
complex fashion
High-risk behaviors for HIV
transmission – sex, drug use, sharing
of injection materials and tattooing –
occur in correctional facilities.
57. Personalizing Risk
Content
Beliefs about the modes of disease infection
Substance use, including sharing drug-
injection equipment
Unsafe sexual activity
Other exposures to potentially contaminated
blood products, semen or equipment
Involvement in the above activities among
or with people from locations of high levels
of infectious disease
Physical symptoms that may be related to
substance abuse and infectious disease
59. Motivational Interviewing
Motivational interviewing is based on
motivational psychology. The model
was developed by Miller and Rollnick
Motivational interviewing can be used
with anyone at any time
In motivational interviewing the job of
the clinician is to find out what
motivates an individual to change a
behavior to a desired one
60. Components of a
Motivational Interview
The following components are key to
conducting an effective motivational
interview:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
61. Motivational Interviewing
Approach
The following elements are part of a motivational
approach in interviewing
Giving advice
Removing barriers
Providing choices
Decreasing
desirability
Practicing empathy
Providing feedback
Clarifying goals
Active helping
62. Reporting Requirements
Reporting Anonymously
Using Qualified Service Organization
Agreements (QSOAs)
Medical Emergency Exception
Criminal Activity
Court-Ordered Disclosure
63. Anonymous Disclosure
Under Anonymous or Non-Patient-
Identifying Disclosures, a program is
allowed, for example to disclose a
patient’s name and state of health and
even his or her whereabouts, as long
as in doing so it does not also
disclose that the client is in substance
abuse treatment
64. Medical Emergency
Exception
Under the Medical Emergency
Exception, a program may disclose
patient-identifying information to
medical personnel in a medical
emergency that requires immediate
medical intervention
65. Medical Emergency
Exception
A program can report a communicable
disease to public health officials only if
the following conditions are met
The presence of an infected or
allegedly infected individual in the
program could be said to constitute a
medical emergencyu
Public health officials are medical
personnel
Editor's Notes
List Evaluation Questions for Day I
Prevention planners tend to focus on one aspect or another of the problem. Substance abuse treatment providers focus on the quality of substance abuse treatment, encouraging HIV prevention efforts or helping IDUs who continue to inject to obtain sterile syringes
What has been your primary focus?