Implementing Cultural Competent Care to Substance Users Diagnosed with HIV Presented: August 26, 2011 Updated: July 29,

1. Presented by John W. Hogan, MD Unity Health Care, Inc., Regional Addiction Prevention Implementing Cultural Competent Care to Substance Users Diagnosed with HIVPresented:August 26, 2011Updated: July 29, 2013

2. Learning Objectives • At the end of the presentation participants will: • Discuss the difference between substance abuse and substance dependence/addiction. • State the relationship between substance use and HIV. • Discuss barriers that prevent minorities from accessing care for substance use. • Discuss various substance abuse interventions. • Discuss why drug treatment is also HIV prevention.

3. Definition of Substance Abuse • SUBSTANCE ABUSE: • Recurrent substance use resulting in failure to fulfill role obligations at work, school, or home. • Recurrent use in physically hazardous situations. • Recurrent substance-related legal problems. • Continued use despite social or interpersonal problems caused by the substance. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC; 2000.

4. Substance Abuse • SUBSTANCE DEPENDENCE (Addiction)-Need to satisfy three or more of the following in the same 12 month period: • Tolerance: need for use of increasing amounts of the substance in order to achieve intoxication. • Withdrawal symptoms typical for the substance. • Substance taken in larger amounts or over a longer period of time than intended. • Desire to cut down or control use. • Great deal of time spent on using, obtaining, or recovering from the substance. • Reduced social, occupational or recreational activities because of substance use. • Continued use despite adverse physical or psychological consequences.

5. Substance Dependence • DSM-IV criteria for substance dependence include several specifiers, one of which outlines whether substance dependence is: • with physiologic dependence (evidence of tolerance or withdrawal) or • without physiologic dependence (no evidence of tolerance or withdrawal). • In addition, remission categories are classified into four subtypes: • (1) full, • (2) early partial, • (3) sustained, and • (4) sustained partial. • This is based on whether any of the criteria for abuse or dependence have been met and over what time frame. • The remission category can also be used for patients receiving agonist therapy (such as methadone maintenance) or for those living in a controlled, drug-free environment.

6. Addiction • Addiction is a chronic medical disorder that includes: • multifactorialgenetic components, • biologic changes due to exposure to addictive substances, and • behavioral components. • Treatment for addictive disorders frequently must address both neurobiological and behavioral components.

7. Recovery • Recovery • This is the SAMHSA definition: • Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness and quality of life. • It is a voluntarily maintained lifestyle characterized by sobriety with a healthy and productive way of life.

8. Cognitive Effects Associated With Illicit Drug Use

9. Cognitive Effects Associated With Illicit Drug Use (cont’d)

10. The Connection between Substance Use and HIV

11. Epidemiology • Outside of sub-Saharan Africa, an estimated 10% of all new HIV infections are attributed to injection drug use (IDU) despite significant regional variations. • According to the Joint United Nations Program on HIV/AIDS, IDU is responsible for more than 80% of all HIV infections in eastern Europe and central Asia. • The epidemic in countries in the Middle East and North Africa have been largely attributed to IDU, and it is currently linked to the growing epidemic in Indonesia, Vietnam, and Malaysia. Joint United Nations Program on HIV/AIDS (UNAIDS). AIDS Epidemic Update '09. UNAIDS; November 2009. Geneva, Switzerland: UNAIDS, WHO; November 2009. UNAIDS/09.36E/JC1700E.

12. Epidemiology • In the U.S. Drug abuse is a significant risk factor for HIV/AIDS • An estimated 1 million people in the U.S. are living with HIV/AIDS; about one-third of these cases are linked directly or indirectly to injection drug use. • In 2003, more than one quarter (11,326) of the 43,171 AIDS cases reported in the U.S. involved injection drug use. • Linked Epidemics: Drug Abuse and HIV/AIDS • A Research Update from the National Institute on Drug Abuse — October 2005

13. Substance Abuse Statistics • National Survey on Drug Use and Health 2008 • In 2008, an estimated 20.1 million Americans aged 12 or older were current (past month) illicit drug users • This estimate represents 8.0 percent of the population aged 12 or older. • The overall rate of current illicit drug use among persons aged 12 or older in 2008 (8.0 percent) was the same as the rate in 2007 and has remained stable since 2002 (8.3percent).

14. Substance Abuse Statistics • Marijuana was the most commonly used illicit drug (15.2 million past month users). • In 2008, marijuana was used by 75.7 percent of current illicit drug users and was the only drug used by 57.3 percent of them. • Illicit drugs other than marijuana were used by 8.6 million persons or 42.7 percent of illicit drug users aged 12 or older. • Current use of other drugs but not marijuana was reported by 24.3 percent of illicit drug users, and 18.4 percent used both marijuana and other drugs. • Among persons aged 12 or older, the overall rate of past month marijuana use in 2008 (6.1 percent) was similar to the rate in 2007 and the rates in earlier years going back to 2002 (Figure 2.2).

15. Substance Abuse Statistics • An estimated 8.6 million people aged 12 or older (3.4 percent) were current users of illicit drugs other than marijuana in 2008. • The majority of these (6.2 million persons or 2.5 percent of the population) used psychotherapeutic drugs nonmedically. • An estimated 4.7 million persons used pain relievers nonmedically in the past month in 2008, 1.8 million used tranquilizers, 904,000 used stimulants, and 234,000 used sedatives.

16. PREGNANT WOMEN AND ILLICIT DRUG USE • Among pregnant women aged 15 to 44 years, 5.1 percent used illicit drugs in the past month based on data averaged for 2007 and 2008. • This rate was significantly lower than the rate among women in this age group who were not pregnant (9.8 percent). • The rate of current illicit drug use in the combined 2007-2008 data was lower for pregnant women than for nonpregnant women among those aged 18 to 25 (7.1 vs. 16.2 percent, respectively) and among those aged 26 to 44 (3.0 vs. 6.7 percent). • Among women aged 15 to 17, however, those who were pregnant had a higher rate of use than those who were not pregnant (21.6 vs. 12.9 percent).

17. ETHNICITY AND ILLICIT DRUG USE • Current illicit drug use among persons aged 12 or older varied by race/ethnicity in 2008, with the lowest rate among Asians (3.6 percent). • Rates were: • 14.7 percent for persons reporting two or more races, • 10.1 percent for blacks, • 9.5 percent for American Indians or Alaska Natives, • 8.2 percent for whites, • 7.3 percent of Native Hawaiians or Other Pacific Islanders, and • 6.2 percent for Hispanics. • There were no statistically significant changes between 2007 and 2008 in the rate of current illicit drug use for any racial/ethnic group among persons aged 12 or older.

18. ALCOHOL AND ILLICIT DRUG USE • The level of alcohol use was associated with illicit drug use in 2008. • Among the 17.3 million heavy drinkers aged 12 or older, 29.4 percent were current illicit drug users. • Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (3.3 percent) than those who reported: • (a) current use of alcohol but did not meet the criteria for binge or heavy use (6.1 percent), • (b) binge use but did not meet the criteria for heavy use (16.4 percent), or • (c) heavy use of alcohol (29.4 percent).

19. ALCOHOL, CIGARETTES AND ILLICIT DRUG USE • Use of illicit drugs and alcohol was more common among current cigarette smokers than among nonsmokers in 2008, as in prior years since 2002. • Among persons aged 12 or older, 20.4 percent of past month cigarette smokers reported current use of an illicit drug compared with 4.2 percent of persons who were not current cigarette smokers. • Past month alcohol use was reported by 67.4 percent of current cigarette smokers compared with 46.7 percent of those who did not use cigarettes in the past month. • The association also was found with binge drinking (44.6 percent of current cigarette smokers vs. 16.5 percent of current nonsmokers) and heavy drinking (16.8 vs. 3.8 percent, respectively).

20. MENTAL ILLNESS AND SUBSTANCE ABUSE • Past year illicit drug use in 2008 was higher among adults aged 18 or older with past year SMI (serious mental illness) (30.3 percent) than among adults without SMI (12.9 percent). • Similarly, the rate of past year cigarette use was higher among adults with SMI (50.5 percent) than among adults without SMI (28.5 percent). • Among adults aged 18 or older with past year SMI in 2008, the rate of binge alcohol use (drinking five or more drinks on the same occasion [i.e., at the same time or within a couple of hours of each other] on at least 1 day in the past 30 days) was 29.4 percent, which was higher than the 24.6 percent among adults who did not meet the criteria for SMI. • Similarly, the rate of heavy alcohol use (drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days) among adults with SMI in the past year (11.6 percent) was higher than the rate reported among adults without SMI in the past year (7.3 percent).

21. FIRST TIME DRUG USE • In 2008, of the 2.9 million persons aged 12 or older who used illicit drugs for the first time within the past 12 months, a majority reported that their first drug was marijuana (56.6 percent). • The average age at initiation among persons aged 12 to 49 was 18.8 years. • Nearly one third initiated with psychotherapeutics (29.6 percent, including 22.5 percent with pain relievers, 3.2 percent with tranquilizers, 3.0 percent with stimulants, and 0.8 percent with sedatives). • A sizable proportion reported inhalants (9.7 percent) as their first drug, and a small proportion used hallucinogens as their first illicit drug (3.2 percent). • Between 2007 and 2008, the percentage of past year illicit drug initiates whose first drug was tranquilizers decreased from 6.5 to 3.2 percent, while the percentage whose first drug was inhalants decreased between 2003 and 2008 from 12.9 to 9.7 percent.

22. Substance Abuse and HIV • Although IDU-related HIV transmission is most closely related to sharing injection equipment, a significant portion of transmission is related to sexual behaviors. • Even after controlling for other potential risk factors, HIV infection rates tend to be higher among individuals who abuse alcohol. • Individuals who abuse one drug or alcohol are more likely to use/abuse other substances as well. • Over half of cocaine-dependent and 17–50% of heroin-dependent individuals abuse alcohol and alcohol use is associated with needle sharing in both heroin- and cocaine-abusing persons (Petry, 1999).

23. Substance Abuse and HIV • Drug use and drug abuse play other, less recognized, roles in HIV transmission. • Drug and alcohol intoxication affects users' mental status and judgment, which, in turn, can increase the likelihood that they will engage in high-risk sexual behavior. • Addiction to drugs, as documented for crack cocaine, can further increase users' exposure to unprotected sex as a means to obtain drugs. • Physiological consequences of drug abuse may alter susceptibility to infection and interact with HIV treatment drugs. • Linked Epidemics: Drug Abuse and HIV/AIDS • A Research Update from the National Institute on Drug Abuse — October 2005

24. Substance Abuse and HIV • The role of non-injection substance use (non-IDU) to the HIV/AIDS epidemic is important. • Research has shown that among heterosexuals, alcohol and non-injection drug use are consistent predictors of HIV risks and new infections. • Among MSM, substance use is more prevalent compared with the general population and is a known risk factor for HIV infection. • In prospective studies, substance abuse is consistently found to be a powerful predictor of new HIV infections.

25. Substance Abuse and HIV • The use of crack cocaine has been associated with high-risk behaviors and has disproportionately affected African American women. • Studies have shown that smoking crack cocaine and exchanging sex for money are co-factors for the risk of HIV infection, especially for women. • Women who smoke crack are more likely than non-crack-using women to • 1) sell sex, • 2) have more sexual partners, • 3) have an STD. • Women who use crack are also more likely to be assaulted during a sex exchange.

26. Cultural Competency and Substance Abuse

27. Definitions Culture is a set of shared behaviors, ideas and values which are symbolic, systematic, cumulative and transmitted from generation to generation. “Culture is a particular set of values, norms, attitudes, and expectations about the world that shapes the personalities of those reared in that culture.” (Marin, 1991) Cultural Competency has been defined as a “set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups.” (L.A. County, Dept. of Health Services)

28. Dimension of Cultural Diversity Primary Dimensions 1. Age 2. Ethnicity 3. Gender 4. Race 5. Language 6. Physical Abilities and Qualities 7. Sexual /Affectional Orientation 8. Childhood Experiences and Family Factors (Family religion, place of birth and household location, family social class, parents occupations, etc.)

29. Dimension of Cultural Diversity Secondary Dimensions 1. Education 2. Geographic Location 3. Income 4. Marital Status 5. Military Experience 6. Parental Status 7. Religion 8. Work Experience 9. Current Social Class

30. Dimension of Cultural Diversity Tertiary Dimensions 1. Experiences with Immigration, Exile, etc. 2. Lifestyle 3. Degree of Assimilation

31. Cultural Values • “Cultural Competency in the Context of ALL RISE” • S. Wolfgram , H. Teuber

32. Cultural Values Dimensions – African Americans • *Kinship bonds and extended family • *Takes a “Village” mentality-Grandparents key • *Value balance between nurture-discipline • *Women social equals and interdependent relationships • *Importance of the Black Church and religiousity • *History oppression = mistrust of the dominant majority and system. • (Wolfgram, 2010)

33. Cultural Value Dimensions- Native American Indian • Familial/tribal communities as support- Collectivists • Sharing- Humble – “Place” (Role) in WORLD • Cooperation VS. Competition • Deep spirituality/ritual-Living in harmony with all creation • Communal sharing of childcare responsibilities • Respect for elderly • Mistrust of whites because of oppression history • Boarding school history has contributed to Native families displacement • (Wolfgram, 2010)

34. Cultural Values Dimensions- Asian-Pacific Islander • Patriarchy • Suffering/sacrificing self • Fatalism: things are meant to happen the way they happen • Shamanism • Conflict Avoidance • Collectivism: protecting family name at all costs-harmony • Saving Face/Avoiding Shame • Obligation of younger generation to care for older generation, “filial piety” • (Wolfgram, 2010)

35. Cultural Values Dimensions- Hispanic-Latino/Latina • Familism; extended family as sole support system • Machismo: head of household protector, provider, honor, pride, hyperaggressive sign of strength (Marianismo) • Respeto: respect owed to others who are older • Catholic Fatalism, “suffering expected on earth and reward in heaven” • Santeria: an Afro-Cuban belief system= cultural medicinal practice • (Wolfgram, 2010)

36. Racial Ethnic Differences • Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatments (Saunders et al, 2006) • Racial and ethnic minorities appear to have significantly higher rates of unmet needs for substance use disorders and are less likely to seek or complete treatment (Campbell et al, 2006) • Studying Black and Hispanic populations is particularly important given their anticipated growth and that they make up the majority of the nation's urban population (Kang et al, 2006) • Blacks utilized multiple service types that have strong community and network connections (Perron et al, 2009)

37. Barriers to Accessing Treatment and HIV Testing

38. Barriers to Treatment • Underestimation of the extent of the problem • Underutilization of treatment services (delaying or not seeking treatment) due to: • Shame • Stigma • Lack of knowledge • Health insurance • Lack of cultural & language appropriate treatment programs

39. Barriers Among Substance Users • Different historical background • Different family structure, inter-personal relationships • Different cultural values • Different substance abuse preferences • Different help-seeking patterns • Different languages & dialects

40. ALCOHOL AND SUBSTANCE ABUSE CAUSE A DELAYED PESENTATION TO CARE • This study investigated the time between HIV testing and presentation to primary care. • One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. • Socio-demographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV. • Samet JH, Freedberg KA, Stein MD, et al. Trillion virion delay: time from testing positive for HIV to presentation for primary care. • Arch Intern Med. 1998;158(7):734-740

41. ALCOHOL AND SUBSTANCE ABUSE CAUSE A DELAYED PESENTATION TO CARE • Delay After Positive HIV Test Results and Patient Characteristics on Initial Presentation to Primary Medical Care: • Not having a spouse or partner 8.6 mo • Not having a living mother 13.9 mo • Not aware of HIV risk at testing 18 mo • Not told positive status in person 30.4 mo • Injection drug use 19.2 mo • Interaction of sex and CAGE • Men, positive CAGE results 14.6 mo • Women, positive CAGE results -10 mo

42. Barriers from the Communities • Strong stigma for substance abuse problems • Communities hold moralistic attitude towards individuals with addiction problems • Insufficient outreach & prevention services • Substance abuse treatment & recovery not communities’ priority • Lack of recovery support services & organizations

43. Stigma • The stigma and discrimination associated with drug and alcohol abuse, as well as the disorganization often seen in the lifestyle of those with active substance abuse, can lead to denial, delay in diagnosis of HIV, and reluctance to seek care.

44. Stigma • Accurate information about HIV transmission, as well as the reduction of stigmas associated with infection, is a critical measure for prevention. • Research has shown that people who fear HIV related stigma and discrimination are less likely to seek information about prevention, may delay being tested for HIV and implementing treatment, and may be reluctant to discuss their HIV status.

45. Stigma • Women with drug and alcohol abuse are more likely to experience poor health and are less likely to access services, receive treatment, or seek health care, partially because of the stigma of substance abuse. • Suspicion, fear, and distrust of the health care system result in reluctance among drug users to disclose medically necessary information. • Negative sanctions, such as mandatory HIV testing during pregnancy and incarceration of drug-using pregnant women for child abuse, have intensified fears about contact with the health system.

46. Asian-Americans Attitude toward Alcohol & Substance Abuse • Often they do not consider alcohol as a harmful drug, using it with herbal medicine & cooking. • Moderate use of alcohol at social & ceremonial occasions. • Outward drunkenness and acting out behavior is not tolerated. • Some use of substance at some communities for special groups of people is acceptable. • Alcohol and drug problems, especially related to criminal activities considered extreme shame & disgrace to family.

47. Alcohol & Substance Abuse Patterns • There is insufficient credible research data & small sample sizes make meaningful analysis impossible. • Generally they drink less, ”Flush Syndrome” & high percentage of persons not drinking at all. • Less illicit drug use. • Drug treatment admissions among AAPI increased by 37% (SAMHSA 2000) between 1994 and 1999 • There is a different pattern of use for different ethnic groups, American or foreign born, age groups.

48. Coexisting Problems • Mental Health problems • Close relations to addiction problems • Strong stigma • Long waiting list for MH services • Gambling problems • Asian-Americans and American Indians have a long history of accepting gambling as a community and family recreation • High prevalence of problem gambling & pathological gambling

49. Strategies to Overcome Barriers & Underutilization • Understanding the cultural and practical barriers that exist are the first step in reducing them. • Increase & enhance language & culturally appropriate community education, outreach, screenings & interventions. • Increase language & cultural appropriate treatment services in all levels of care. • Improve linkages within the providers networks and with community based organizations. • Address the workforce issues for the communities. • Create alternative self-help/support group that is less confrontational and more supportive & educational. • Work with families separately, to reduce enabling and negative feelings.

50. DRUG USE AND INFECTIONS • HIV infected substance abusers have more: • Bacterial infections: • Cellulitis, abscesses, endocarditis, pneumonia, Tb • Viral hepatitis: • Chronic Hepatitis B and C • Renal disease: • HIVAN, chronic kidney disease • Neurologic disorders: • Toxoplasmosis, Cryptococcus, Tb