The answer is complex, but critical. The reality is that HIV-positive substance abusers who are in counseling, be it individual or group, have greater contact with their substance abuse clinician than they do with their physician. This regularity provides an important window of opportunity for counselors to reinforce the importance of adherence to HIV therapies. These regimens are complicated, individualized, and have a direct effect on a client's daily routine. Change, for any recovering person, is often difficult to manage and a frequent trigger for relapse. Change that requires adjustments to a person's eating, sleeping, and health behaviors is particularly difficult. If "Hungry, Angry, Lonely, and Tired" (HALT) is one of the slogans that we emphasize with clients to make them aware of potential relapse triggers, then medication that necessitates planning and change around eating habits, sleeping patterns, and the management of side effects, presents a challenge for people who are HIV-positive and in recovery.
This challenge can be overcome with the help of all auxiliary health care workers who are in contact with the client. In fact, when an HIV-positive client is considering combination therapy, the counselor has an opportunity to examine the lifestyle changes that can impact his or her client, anticipate these changes, and mitigate some of the hardships involved with undertaking combination therapy. These hardships can lead, directly or indirectly, to relapse, and need to be incorporated into relapse prevention curriculum and training.
Moreover, certain protease inhibitors affect methadone patients in a dramatic way, either lessening or increasing the methadone in the blood stream. Both protease inhibitors and methadone are processed by the liver. Although preliminary studies have been conducted in vitro, as opposed to live studies, indinavir, ritonavir and saquinavir all inhibited methadone metabolism to varying degrees.1 Moreover, "one can expect to find a two-fold increase in Area Under the Curve (AUC) when coadministered with ritonavir, a 30% increase in AUC with indinavir, and no interaction of significance with saquinavir."2 Anecdotally, people taking AZT and methadone report that they feel withdrawal symptoms. If methadone patients experience this symptomology, the danger is that they may supplement their methadone with street drugs and be at risk of an overdose. Substance abuse counselors working in methadone clinics or in a harm reduction model need to be aware of these potential chemical interactions between protease inhibitors and methadone. (Editor's note: For more information about how methadone interacts with protease inhibitors see the article "Recreational Drugs, Methadone, and Protease Inhibitors") Many studies have looked at the issue of treatment adherence and the HIV-positive patient, but few, if any, have addressed this issue as an obstacle to recovery. Substance abuse counselors are required to perform twelve competencies in their daily work with clients. Counseling clients regarding their HIV regimen falls under several of these twelve competencies, including but not limited to: screening, assessment, evaluation, referral, treatment planning, patient education, case management, and consultation with other professionals.
Many AIDS service organizations, including Body Positive, have treatment education services and make their staff available to drug and alcohol facilities to train substance abuse counselors and case managers on the basics of HIV treatment. Additional services for the HIV-positive client contemplating combination therapy are in place at several agencies throughout New York City. It is an excellent linkage in the continuum of care to have substance abuse facilities working with AIDS service organizations to ensure that clients are supported throughout three critical stages: contemplating combination therapy, maintenance, and switching therapies when a particular combination fails.
Continuity of care, rather than any other factor, has been identified as one of the predictors of patient adherence. A patient's knowledge and expectations also influence treatment adherence. Patients with chronic illnesses often have non-compliance rates of almost 50%. While no single intervention can work, bringing substance abuse counselors, patients, and treatment educators together to prepare the client for combination therapy provides a continuum of care that is urgently needed.
1 "Drug Interactions With HIV Protease Inhibitors," ICAAC '97. Available on the Medscape server (registration required).