The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N5428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation—such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment—and should educate smokers regarding the HIV-specific health benefits of cessation.

Tobacco use and readiness to quit smoking in low-income HIV-infected persons.

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

/pdf/the-case-for-chronic-disease-management-for-addiction-5rovc16qjq.pdf

The Case for Chronic Disease Management for Addiction

Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes.

There is a growing body of research highlighting the potential benefits of integrated care as a way of addressing the needs of people with alcohol and other drug (AOD) problems, given the broad range of other issues clients often experience. However, there has been little academic attention on the strategies that treatment systems, agencies and clinicians could implement to facilitate integrated care. We synthesised the existing evidence on strategies to improve integrated care in an AOD treatment context by conducting a systematic review of the literature. We searched major academic databases for peer-reviewed articles that evaluated strategies that contribute to integrated care in an AOD context between 1990 and 2014. Over 2600 articles were identified, of which 14 met the study inclusion criteria of reporting on an empirical study to evaluate the implementation of integrated care strategies. The types of strategies utilised in included articles were then synthesised. We identified a number of interconnected strategies at the funding, organisational, service delivery and clinical levels. Ensuring that integrated care is included within service specifications of commissioning bodies and is adequately funded was found to be critical in effective integration. Cultivating positive inter-agency relationships underpinned and enabled the implementation of most strategies identified. Staff training in identifying and responding to needs beyond clinicians’ primary area of expertise was considered important at a service level. However, some studies highlight the need to move beyond discrete training events and towards longer term coaching-type activities focussed on implementation and capacity building. Sharing of client information (subject to informed consent) was critical for most integrated care strategies. Case-management was found to be a particularly good approach to responding to the needs of clients with multiple and complex needs. At the clinical level, screening in areas beyond a clinician's primary area of practice was a common strategy for facilitating referral and integrated care, as was joint care planning. Despite considerable limitations and gaps in the literature in terms of the evaluation of integrated care strategies, particularly between AOD services, our review highlights several strategies that could be useful at multiple levels. Given the interconnectedness of integrated care strategies identified, implementation of multi-level strategies rather than single strategies is likely to be preferable.

/pdf/strategies-to-facilitate-integrated-care-for-people-with-2z2qu2rntt.pdf

Strategies to facilitate integrated care for people with alcohol and other drug problems: a systematic review

Introduction: Substance use is an important risk factor for HIV, with both concentrated in certain vulnerable and marginalized populations. Although their management differs, there may be opportunities to integrate services for substance use and HIV. In this paper we systematically review evidence from studies that sought to integrate care for people living with HIV and substance use problems.

Methods: Studies were included if they evaluated service integration for substance use and HIV. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias.

Results and discussion: 11,057 records were identified, with 7616 after removal of duplicates. After screening titles and abstracts, 51 met the inclusion criteria. Integration models were categorized by location (HIV, substance use and other facilities), level of integration from mirco (integrated care delivered to individuals) to macro (system level integrations) and degree of integration from least (screening and counselling only) to most (care for HIV, substance use and/or other illnesses at the same facility). Most reported descriptive or cohort studies; in four randomized control trials integrated activities improved patient outcomes. There is potential for integrating services at all facility types, including mobile health services. While services offering screening only can achieve synergies, there are benefits from delivering integrated treatment for HIV and substance use, including ease of referral to other mental health and social services.

Conclusions: Our review used a wide range of databases and conference archives to increase representation of papers from low- and middle-income countries. Limitations include the overrepresentation of studies from the United States, and the descriptive nature of the majority of papers. The evidence reviewed shows that greater integration offers important benefits in both patient and service outcomes but further research and outcome reporting is needed to better understand innovative and holistic care models at the complex intersection of substance use and HIV services.

https://onlinelibrary.wiley.com/doi/pdf/10.7448/IAS.20.1.21585

Integrating HIV and substance use services: a systematic review.

Forty-five active substance abusers with HIV/AIDS voluntarily participated in a substance abuse treatment research study with interviews at intake, 6 months and 12 months. These participants were engaged in treatment for a minimum of 45 days and a maximum of 90 days. The study used a nursing model of care, The Personalized Nursing LIGHT model, to integrate treatment for HIV/AIDS with substance abuse treatment. The LIGHT model seeks to enhance patient well being directly and thereby to support interventions that decrease substance use and improve management of chronic disease. The substance abuse treatment team included a nurse who used the LIGHT model and coordinated an integrated care protocol. The nurse accompanied clients on visits to their physicians for HIV treatment and facilitated the integration of medical recommendations with the substance abuse treatment. Six-month posttest data were gathered on all 45 participants and 12-month posttest interviews were accomplished with 29 of them. At 6 months, 78% of the respondents (35/45) reported no drug use in the past 30 days, and, at 12 months, 79% (23/29) were drug free for the past month. Significant decreases from intake to 6 months were detected on Addiction Severity Index (ASI) composite scores for drug use (p < 0.01), alcohol use (p < 0.04), medical severity (p < 0.02), psychiatric severity (p < 0.01), legal problems (p < 0.04), and employment difficulty (p < 0.01). Improvement of 6-month drug use composite scores was related significantly to treatment duration (R = 0.42; p < 0.01). Significant decreases in ASI measures of drug use (p < 0.01), alcohol use (p < 0.01), employment difficulty (p < 0.01), and family/social problems (p < 0.01) also occurred at 12 months. Well being, as measured by a Global Well Being Index, was found to improve significantly at 6 months (p < 0.02) and 12 months (p < 0.07). Concurrently, significant improvement was observed on Medical Outcomes Study-36-Item Short-Form Health Survey (SF-36) measures of general health and health functioning. These changes were noted at 6 months in the general health (p < 0.02), mental health (p < 0.01), social functioning (p < 0.01), role/emotional status (p < 0.04), and vitality (p < 0.01) subscales. At 12 months, the social functioning (p < 0.01) subscale responses were further decreased.

Integrating medical and substance abuse treatment for addicts living with HIV/AIDS: evidence-based nursing practice model.

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Integrating medical and substance abuse treatment for addicts living with HIV/AIDS: evidence-based nursing practice model.