|
Volume No.
XI Issue
No.3 March,
2003
HIV/AIDS Volunteer Enrichment Network
|
|
Volume No.
XI Issue
No.3 March,
2003
HIV/AIDS Volunteer Enrichment Network
|
By Michelangelo
Signorile
Michelangelo Signorile is a former editor at The
Advocate, a national gay magazine, and author of "Queer in America"
and "Life Outside."
January 13, 2003
Much
of the American press seemed to lurch back toward the early '80s two weeks ago,
while reporting on the death of the famed celebrity and fashion photographer
Herb Ritts.
It
was downright creepy to see a Reagan-era euphemism for AIDS pop up as the cause
of Ritts' death in obituary after obituary: "complications from
pneumonia." The New York Times, CNN, the Los Angeles Times, the Associated
Press (in a story that ran in Newsday and many other papers) and other media
organizations quoted Ritts' publicist, also identified as a friend, who used
that term to describe what brought the openly gay photographer's life to an end
at the age of 50.
Soon
enough it was revealed in the gay press (and since has only appeared in a few
gossip columns) that Ritts had in fact been HIV-positive for years. His immune
system had been sufficiently weakened; HIV infection had left him unable to
fight off the pneumonia.
In
other words, Herb Ritts' death was an AIDS fatality. And the ignorance of the
truth surrounding it signals that, once again, this is a disease that dare not
speak its name. And that silence has consequences.
The
New York Times' policy regarding obituaries - formulated in 1986, precisely
because of the problems encountered in reporting on public figures who died of
complications from AIDS - states that "the obituary of a newsworthy public
personality, of any age, should reflect energetic reporting on the cause."
The
Associated Press doesn't have an official policy, but advises reporters to
exhaust every means available - including interviews with the deceased's
friends and family, public records and statements by doctors - to determine the
cause of a public figure's death.
But
it doesn't appear that there was any kind of "energetic reporting" in
this instance. Most mainstream press reporters seemed to have spoken to only
one individual - the publicist - and even then seemed to have followed a sort
of "don't ask, don't tell" policy.
The
Advocate, the national gay and lesbian newsmagazine, however, did ask. And, lo
and behold, the very same publicist offered a fuller explanation: "Herb
was HIV[-positive], but this particular pneumonia was not PCP [pneumocystis
pneumonia, a common opportunistic infection of AIDS]. But at the end of the
day, his immune system was compromised." That statement perhaps prompted
the Washington Blade, the gay weekly in the nation's capital, to rightly run
with the headline, "Gay photographer Herb Ritts succumbs to AIDS."
It's
nice to know that small pockets of the gay community might now have the full
story. But the fact remains: Millions of Americans, gay and straight, still
haven't a clue about what took the life of the celebrity photographer who was
himself a big supporter of AIDS causes.
This
isn't just another example of incomplete or deceptive reporting. It's also a
tragic omission at a time when study after study shows unsafe sex and new
infections continuing to rise steeply among younger generations of gay men,
often because the realities of AIDS are abstract to them - enough to allow them
to take foolish risks.
They
are often too young to remember the AIDS deaths of celebrities, like Rock
Hudson in 1985, which jolted America and the world. Most young gay men also
have not watched their own friends die, as was the case for gay men of previous
generations. This is true even as many of these young men become infected with
HIV themselves and stay quiet about their illness, going on the drug
"cocktail," chained for the rest of their lives to powerful
pharmaceuticals that often have horrific side effects.
Those
drugs have thankfully saved many lives. Ironically, they've also driven AIDS
back into the closet. The decline of AIDS awareness in the newsroom mirrors
what has happened in society in general. No longer are many people with HIV
walking around rail-thin and gaunt. Many even use testosterone as part of their
therapy, building up their bodies and developing bulging biceps, often
appearing more fit than their uninfected friends. AIDS becomes increasingly
invisible, on the streets as well as in the media, even as HIV infection is an
ever-present danger. And clearly, though American fatalities have decreased a
great deal, HIV still kills.
That's
why the story behind the death of Herb Ritts, a man who photographed Hollywood
icons and shot music videos for youth idols such as Jennifier Lopez and 'NSync,
would go a long way.
That is, if anybody
actually heard about it.
Copyright © 2003, Newsday,
Inc.
Substance
Abuse and HIV
By Jeffrey
H. Hsu, M.D.
Since 1989, approximately one-third of
all AIDS cases in the United States have been among active or former injection
drug users (IDUs) [MMWR 2001; 50(21): 430]. Although the major risk
factor for HIV infection in the United States among men is same-sex contact,
the major risk factor among women with AIDS is either IDU or heterosexual
contact with an injection drug user [CDC, HIV/AIDS Surveillance Report
2002;13]. Once HIV enters any IDU population, the virus can spread very
quickly. For example, in the Northeast of the United States, where injection
drug use is prominent, the prevalence of HIV among IDUs entering drug treatment
centers from the period of 1998-1997 was 28% compared to only 3% in the West
[CDC National Serosurveillance, 1993-1997]. It has been estimated that at least
55% of the patients seen in the Johns Hopkins AIDS Service (JHAS) in Baltimore
are injection drug users.
Injection drug users
engage in two behaviors that put them at risk for HIV infection: needle sharing
and having multiple injection partners. However, substance abuse can play a
major role in HIV transmission even among non-injection drug users. Addiction
and high-risk sexual behavior have been linked across a wide range of settings.
For example, women who use crack cocaine are more likely to engage in
unprotected sex in exchange for money or drugs [Edlin BR, et al. N Eng J Med
1994; 331(21):1422-7; Astemborski J, et al., Am J Public Health
1994;84:382-87]. Men who use crack cocaine are more likely to engage in
unprotected anal sex with casual male contacts [deSouza CT, et al. J Acquir
Immune Defic Syndr 2002;29(1):95-100]. Alcohol intoxication has been
associated with high-risk sexual behavior as well as more needle sharing among
drug users [Stein MD, J Subst Abuse Treat 2000;18:359-63, Rees V, J
Subst Abuse Treat 2001;21:129-34].
Even though it is evident
that a high proportion of IDUs are infected with HIV, there has been little
research on how to improve treatment accessibility and outcome in this
population. It is estimated the approximately 80% of IDUs in the United States
are not in drug treatment [National Association of State Alcohol and Drug Abuse
Directors, unpublished data]. Adherence to treatment in this population is
difficult because of the high prevalence of psychiatric, cognitive and social
problems. This article will examine the nature of drug addiction, its
interaction with HIV and psychiatric co- morbidities, assessment and screening
of the drug user, and the types of treatments that may be useful for these
patients.
A Model for
Understanding Addiction The Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) divides substance use disorders into two main categories: substance
dependence and substance abuse. In order to satisfy the criteria for substance
dependence, an individual must have at least three of the following criteria:
1.
Tolerance:
need for use of increasing amounts of the substance in order to achieve
intoxication.
2.
Withdrawal
symptoms typical for the substance.
3.
Substance
taken in larger amounts or over a longer period of time than intended.
4.
Desire
to cut down or control use.
5.
Great
deal of time spent on using, obtaining, or recovering from the substance.
6.
Reduced
social, occupational or recreational activities because of substance use.
7.
Continued
use despite adverse physical or psychological consequences.
According to the DSM-IV
criteria, tolerance and withdrawal are not sufficient or even necessary to make
a diagnosis
of substance dependence. Compulsive cannabis use, for example, can occur in the
absence of significant tolerance or withdrawal symptoms. Likewise, surgical patients
can experience tolerance and withdrawal from opioid pain medications without
showing signs of compulsive use.
To better understand
the nature of habitual substance use, various models of addiction have been
developed. Currently, the most popular model for understanding substance
addiction is to view it as a chronic disease, akin to diabetes or asthma, in
which behavioral interventions and treatment compliance play a part in
controlling a lifelong illness [Leshner AI, Hosp Practice 1997:6-8;
McLellan AT, et al. JAMA 2000; 284(13):1689-95]. Although the medical
paradigm has done much to lessen the stigma and has resulted in improved
treatment services, it is inadequate in that it fails to address the importance
of psychosocial and cognitive learning variables in addiction. On the JHAS
Psychiatry Service, we have used a “motivated behavior” model for understanding
addiction [McHugh PR, The Perspectives of Psychiatry]. This model takes
into account the individual’s free will, biological drive, and conditioned
learning, which interact to produce addictive behavior.
Ongoing substance
abuse has grave medical implications for HIV-infected individuals. Many
physical symptoms of HIV infection overlap with those of laboratory testing
[Arici substance abuse and withdrawal, including malaise, fatigue, weight loss,
fever, diarrhea and night sweats. The accumulation of medical sequelae from
chronic substance use may accelerate HIV infection itself. HIV-seropositive
IDUs, for example, are at higher risk for developing bacterial infections such
as pneumonia, sepsis, soft tissue infections and endocarditis than seronegative
drug users [Selwyn PA, et al. N Eng J Med 1992;24:1697-703].
Tuberculosis and hepatitis C infection are found more commonly in this
population as well [O’Connor PG, et al. N Eng J Med 1994;331:450-59].
Because high-risk sexual behavior and drug use are often linked, these patients
are also at risk for contracting and spreading a variety of STDs.
Neurological
symptoms due to HIV infection and substances of abuse can overlap. For
instance, both AIDS dementia and drug intoxication can present with apathy,
disorientation, aggression, and an altered level of consciousness. Drug
withdrawal can present with seizures and neurovegetative symptoms, as can
opportunistic infections of the CNS.
With respect to medical treatment, HIV-infected active IDUs tend to be less
compliant with medical appointments, medications, and in obtaining regular C,
et al. HIV Clin Trials 2002;3(1):52-7]. Substance use is associated with
poor antiretroviral medication adherence, resulting in higher viral loads and
lower CD4 cell counts [Lucas GM, et al. AIDS 2002;16(5):767-74].
Because the
HIV-infected patient is likely to be on a variety of antiretroviral medications
and prophylactic agents for opportunistic infections, the clinician must be especially mindful of interactions between these
medications and methadone treatment. Decreased plasma levels of methadone can occur with concurrent administration
of ritonavir, nelfinavir, efavirenz, and
nevirapine,
necessitating
adjustments in methadone dosage if withdrawal symptoms occur [Gourevitch MN, The
Mt Sinai J Med 2000;67:429]. Medications used to treat opportunistic
infections and seizures such as rifampin, phenytoin, phenobarbital, and
carbam-azepine can also cause decreased methadone levels.
Concurrent
Psychiatric Disorders
The term “dual
diagnosis” refers to a patient who has both a drug use disorder and another
psychiatric disorder; “triple diagnosis” refers to a dual diagnosis patient who
also has HIV. Such patients are over-represented in treatment settings because
of their symptom severity and chronicity. In a study of 50 new entrants to the
JHAS, 44% of the patients had a diagnosis of current or previous substance use
disorder, and 24% of those patients had both a comorbid primary psychiatric
diagnosis and substance use disorder [Lyketsos CG, et al. Int J Psych Med
1994; 24(2):103-113].
Personality disorders, especially antisocial personality disorder, are commonly
found in the substance abusing population. Although the DSM-IV uses a
categorical approach to diagnosing personality disorders in which patients need
to meet a certain set of criteria to qualify for a diagnosis, it is often more
helpful to view personality traits as existing along a continuum. Thus, more or
less of a particular personality trait can predict habitual adaptive or
maladaptive responses to life circumstances.
One model that we
use on the JHAS Psychiatry Service depicts personality as existing around the
axes of stability-instability and introversion-extroversion [see Hutton, HHR
2001,13(6):5]. The combination of the personality traits of instability and
extroversion are often seen in patients being treated in the HIV clinic.
Persons with extreme traits of instability have very strong and reactive
emotional responses that tend to be overpowering, easily taking control of the
person’s judgment and behavior. Persons with extreme traits of extroversion
have emotional responses that are quick and changeable, focused in the present,
and tend to be predominantly reward-seeking rather than harm-avoiding. These
traits are generally found in the so-called cluster B personality disorders in
the DSM-IV (antisocial, borderline, narcissistic, and histrionic), which can be
found in as many as 49% of all substance abusers [Kokkevi A, et al. Addictive
Behaviors 1998; 23(6):841-53].
Unstable
extroversion has important implications for the HIV-infected addict. Not only
do these traits result in a vulnerability to addiction and other risky
behaviors that predispose to HIV infection, but they also pose significant
barriers to treatment. These patients tend to act on strong, impulsive feelings
rather than on carefully considered treatment instructions. Their behavior will
tend to be driven by the transient, immediate rewards of drugs rather than by
their lasting future consequences. Such patients tend to become bored easily.
They tend to “want what they want when they want it” rather than when it may be
good for them. Studies have shown that drug users with a diagnosis of
antisocial personality disorder are more likely to engage in HIV risk behaviors
such as needle sharing and injection drug use [Brooner RK, et al. Am J
Psychiatry 1993:140:309] and to have a greater number of sexual partners
[Kelley JL, J Subst Abuse Treat 2000;19:59-66]. They are also less
likely to stop high-risk sexual behaviors after being educated about HIV
prevention [Comptom WM, et al. Drug and Alcohol Dependence
2000;58(3):247-57]. It is critical to identify such personality vulnerabilities
in this patient population, because they can have a profound effect on
treatment engagement and prognosis.
Mood disorders,
especially major depressive disorder, are also found in these patients, with
studies estimating a prevalence of 15% to 30% [Ahmad B, et al. J Pak Med
Assoc 2001;51(5):183-6; Brooner BK, et al. Arch Gen Psychiatry
1997;54(1):
71-80]. Diagnosing affective disorders in drug users can be difficult and even
controversial. This controversy stems from the problem of determining the
causal or even chronological relationship between drug disorders and affective
disorders.
In making the diagnosis of a primary mood disorder, it often becomes necessary
to observe the patient over a period
of abstinence, ideally in a confined environment. Careful consideration should
be given to whether the symptoms are isolated or whether they meet the full
criteria for a major depressive syndrome. The temporal relationship of symptoms
to substance use should also be considered. Patients with a family history of
psychiatric disorders are more likely to have a
comorbid psychiatric diagnosis than those who do not. Finally, collateral
informants such as family members and friends who have knowledge of a patient’s
premorbid functioning can be invaluable in determining the longitudinal course
of a patient’s symptoms.
The importance of
identifying affective disorders early on lies not only in their own well-known
sequelae, including suicide, but also in their complex interactions with
addiction. Depression is associated with worsening of addiction and resistance
to treatment. Depressed patients are also more difficult to engage in and
maintain in treatment given their anergy, hopelessness, and negativism. Given
the high prevalence of overlapping addictive and affective disorders in
clinical settings, as well as the poor prognosis associated with untreated
affective disorders, a treatment
approach should necessarily emphasize simultaneous and equal treatment of both
entities.
Because of societal
stigma attached to both substance abuse and HIV, a patient may be reluctant to
disclose information in an initial evaluation. Forming a close therapeutic
alliance is the first step to effective history taking. If necessary, it can be
spread out over several sessions. The clinician should take a nonjudgmental and
empathetic approach to interviewing the patient and move from more comfortable
topics of discussion (employment, family, friends, hobbies) before introducing
questions about drug use and sexual behavior. Confidentiality should be
assured, as in other types of medical settings. In many cases collateral
sources of information can be helpful in eliciting accurate histories. These
may include old medical records, family members, friends, and health care
providers (both previous and current).
A careful substance
abuse history should contain specific information not only about the type of
substances used but also about routes of administration, duration, frequency of
use, date of first use, most recent use, and the highest/usual amount used of
each drug. The patient should also be asked about periods of abstinence and
relapse and the respective conditions surrounding each one.
A drug treatment
history should also be obtained, including the types and period of
detoxification, outpatient drug treatment, methadone maintenance, attendance at
AA/NA meetings, and residential drug treatment. This information is helpful in
ascertaining which methods of treatment may have been helpful in the past and
which treatment modalities have failed.
A complete physical
examination should include a careful search for physical evidence of drug
abuse, including injection marks, scars, burns, nasal septum erosion or
perforation, skin abscesses, cellulitis, and soft-tissue infection. Stigmata of
alcohol abuse include hepatosplenomegaly, ascites, and physical trauma. A
careful neurological assessment, including a complete mental status examination
is essential in order to assess for the presence of both substance intoxication and the neuropsychiatric manifestations
of AIDS. The initial and often most daunting
task of treating the addict is engagement and induction of the patient role.
The general rule is that addicts and treatment providers begin with differing
agendas—addicts tend to come to treatment settings seeking comfort and immediate crisis
relief, whereas physicians and other health
providers look at long term goals of improvement in a patient’s health and
overall functioning. One of the clinician’s initial goals should be to
gradually bring the patient’s attitudes in line with the treatment plan.
Working with the
HIV-infected substance abuser is a challenging and often frustrating task. An
integrated treatment team approach consisting of medical providers,
psychiatrists, substance abuse counselors, therapists and social workers is
essential in unraveling and addressing the variety of problems these patients
face which make them vulnerable to nonadherence. Early identification and rapid
accessibility to treatment is essential in improving both their mental and
physical well-being and in halting further spread of HIV.
Jeffrey H. Hsu, M.D. is an Instructor in the Department of Psychiatry, Johns Hopkins University, School of Medicine.
Copyright © 1997-2003 The
Johns Hopkins University on behalf of its Division of Infectious Diseases and
AIDS Service. Permission to use and reproduce portions of this newsletter is
hereby granted, provided that author and publication are fully credited and both
the copyright and permission notice appear. All other rights reserved.
Need Help With Your SSI Application?
Need
help with your SSI application, please call the Health Department at (410)
244-7108.
Buddy Services
If you are a Buddy and need to chat, always feel free to call Vance
Larson at (410) 672-7571, or page him at (410) 863-8500.
Anne Arundel County Community Warmline
410 768-5522
Clip this out and carry it with
you in your wallet or purse. Share it
with those who need it. If you have a
friend who says he fears hurting himself or others give him the number. When
it seems like you are at the
end
of your rope, don't
be afraid to ask for help and call the number yourself.
Quality of Life Retreat
Dates
May 16th –18th, 2003
Camp
Manidokan, Knoxville, MD.
h.A.v.e.n.
Telephone Numbers
H.A.V.E.N.
P.O. BOX 514
Arnold, Maryland 21012
Office: (410) 224-AIDS [2437]
Fax: (410) 571-9328
Interim President Board of Directors
Steve Migdal
(410) 263-8855
Executive Director
Diane Goforth
(410) 544-2244
Director of Volunteer & Client Services
Tony Teano
(410) 224-2437
Buddy Program Director
Vance Larson
(410) 672-7571
Anne Arundel County
Health Department
(410) 222-7108
HERO Legal Service
(410) 685-1180
Legal Aid
(410) 263-8330
CDC National AIDS Hotline:
1-800-342-AIDS (342-2437)
Spanish: 1-800-342-SIDA
1-800-342-7432
Deaf TTD: 1-800-AIDS-TTY
1-800-243-7889
National STD (Sexually Transmitted Diseases)
Hotline
1-800-227-8922
National Lesbian & Gay Crisis Line:
1-800-SOS-GAYS
1-800-767-4497
National Runaway Switchboard:
1-800-344-7432
Teens & AIDS Hotline:
1-800-234-TEEN
1-800-8336
Questions About Treatment for HIV Disease?
Call the
HIV/AIDS Treatment Information Service for
federally approved treatment information.
Call:
1-800-HIV-0440
1-800-448-0440
TDD/Deaf Access:
1-800-243-7012
Monday - Friday
9:00 a.m. to 7:00 p.m. EST
All calls are completely
confidential.
Write:
P.O. Box 6063
Rockville, MD 20849-6303
Fax: 1-301-738-6616
Sponsored by the U.S. Public
Health Service
Free Testing
For free, anonymous HIV/AIDS
testing and counseling, call the Anne Arundel County Health Department at:
222-7493
- Annapolis (Riva Road)
222-6633 -
Glen Burnie Health Center
Become
A branch
On our
family tree!
Advertise your business in this newsletter! It’s a WIN-WIN situation for all of us. You will reach 600 readers of similar interests,
and help us with the mailing costs.
Send
us your card
(PO Box 514, Arnold 21012) and a
