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Integrated Addiction and HIV Care: Why It’s Important

I could bore you with data but I won’t. I’m not that kind of social worker. HIV is still an epidemic, addiction rates are still higher than in the general population, and it’s everyone’s problem. (I’m that kind of social worker). There is a lot of talk currently about integrating behavioral health into primary care settings, and research has shown its effectiveness in HIV and other specialty clinic settings. Full disclosure: I work in one of those clinics and have participated in the research. So take my naturally and admittedly biased view for what it’s worth.

    • What it is: To put things in context, a brief explanation of levels of integration. In coordinated care, medical and behavioral health providers (BHPs) work in their own respective practices, refer when appropriate and collaborate only on request. Co-located care system BHPs are located within the same practice (physical location) but don’t necessarily share documentation or collaborate on patient care.

      In fully integrated care, there is organizational integration (data collection, funding, billing etc.) as well as a shared documentation system and collaborative treatment planning. BHPs, medical providers, pharmacists and case managers communicate regularly. Every patient that needs it gets a “team” of providers.


  • Why it’s important: We have come to learn that viral suppression (less than 20 copies per milliliter) is paramount in preventing transmission of HIV; adherence to anti-retroviral medications is the best predictor of suppressed viral load. It’s a pretty simple concept – less virus, less chance of spreading it. What this graph, commonly known as the “treatment cascade,” shows us is obvious: we need to work harder to get and keep HIV+ patients in treatment to keep their disease under control and prevent widespread effects. (Sound familiar, addiction pros?)So what we have in an integrated system is the opportunity to increase adherence on both sides of the coin. A veritable public health two-fer!
  • Why it works: Now down to the good stuff – why this works. And not just the way I see it, but what I’ve been told by providers and patients alike.Many HIV patients suffering with addiction lead chaotic lives. Their HIV provider becomes their primary care physician. As compassionate and empathetic HIV providers are, they have neither the tools nor the time to treat addiction. One doctor told me that while he had known this patient for over 10 years, after learning more about his traumatic history and repeated attempts at sobriety he was able to better understand the patient and it changed the way in which he treated him, medically.

    Patients have expressed gratitude for us sharing with their providers what they could not, but wanted them to know. With complicated pain management, doctors like the coordination and patients appreciate the advocacy. They appreciate that BHPs understand all of what living with HIV entails. They feel less shame when their providers show more understanding of addiction. When we describe the “team” concept, we reinforce that they are in charge, and nothing will be shared without their being consulted. “Don’t tell my doctor” becomes “can you” then “should we” becomes “I told…” Patients feel empowered when they are consulted by “their team” about medical decisions. Trust is gained, communication improves, outcomes improve.

    Doctors appreciate that they can knock on our doors and bring us into an exam room when they have concerns. BHPs appreciate getting a call when one of our patients is admitted to the hospital. Patients appreciate when you pop in to see them, even if they didn’t follow through after that first meeting. Or after they relapsed. If a patient drops out of treatment, we can follow up when they present for their next medical appointment. We are always there, just checking in. And whether they’re ready to change or not, they generally appreciate it. Not that many people are there for them on a consistent basis.

    Many who attempt recovery have negative experiences in 12-step… HIV is a significant issue in their lives, but even if they choose to disclose they are told it’s an “outside issue.”-Keith McAdam

    Addiction and HIV can be alienating, lonely paths to walk. For many, “family” can be more a source of trauma than support. Due to their sexuality, HIV status, addiction and/or mental illness, many are rejected not only by their blood families but their church communities and all other social supports. Sometimes their HIV providers are the only ones who know their HIV status. The term “medical home” takes on a whole new meaning. The clinic may be the only place they feel safe, physically and emotionally. Many who attempt recovery have negative experiences in 12-step meetings; HIV is a significant issue in their lives, but even if they choose to disclose they are told it’s an “outside issue.” Conversely, a homogenous HIV+ substance abuse group allows them to share things that they cannot share anywhere else. Many patients refer to the group as “our family” as they learn to forgive the blood family that turned them away. When medical providers come to group for educational sessions, patients not only beam with pride – “that’s MY doctor” – they welcome them into “the family.”

Challenges in the face of changing demographics: The face of HIV/AIDS continues to change. Currently, one population where the incidence has not gone down is young MSM of color. They are the hardest to reach. There are subcultures within subcultures, “ball scenes” and “houses” virtually invisible to the uninitiated. Methamphetamine is the drug of the day. I’ve been told “that’s just part of being young and gay.” Years of focus groups, analyses and meta-analyses later, something is still missing. When dealing with HIV and addiction, it’s imperative that we find a way to give everyone the opportunity to be well.

So integration works, for all the obvious reasons. It’s up to us to make it happen, wherever possible. Addiction care IS health care. Addiction, and those suffering with it, don’t deserve to be “referred out” or simply told “go to a meeting.” It’s dismissive. And being dismissed is the last thing an HIV+ addict – any addict – needs.

Photo Source: istock

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