Introduction

These guidelines provide a framework for the implementation of sound HIV/AIDS policies in all substance abuse treatment programs funded by Massachusetts Department of Public Health, Bureau of Substance Abuse Services. The guidelines were developed early in the epidemic and revised in response to changes in the face and landscape of the AIDS epidemic. Revisions have been made in response to advances in the diagnosis and treatment of HIV disease, shifting socio-political environments and the increasing demand for access to comprehensive substance abuse treatment services in the Commonwealth.

The relationship between HIV and substance abuse is well documented. In 1996, injection drug use was the primary risk factor in 50% of report AIDS cases in Massachusetts and the proportion of AIDS cases attributable to injection drug use has been increasing steadily. In addition, numerous behavioral research studies indicate that the use of alcohol and other drugs is a significant factor in the sexual transmission of HIV.

Substance abuse providers are in an optimal position to educate clients about HIV transmission and risk reduction as well as to provide them with the tools of prevention. New developments in the treatment of HIV disease make case finding and early medical intervention increasingly important for maintaining the health and well being of HIV positive clients and reducing the perinatal transmission of HIV. The highly effective and complex treatment protocols necessitated by newer combination drug therapies require participating clients to adhere to a highly structured treatment regimen; a treatment regimen which can be most effectively achieved through a clean and sober lifestyle.

Effective substance abuse treatment provides an opportunity for each clients to participate in a client-centered continuum of HIV prevention, education and treatment. Components of this continuum include: prevention and education; HIV antibody counseling and testing; and medical intervention for HIV disease. Effective HIV programming is enhanced through the establishment of sensitive admission and discharge policies, client-centered HIV/AIDS risk reduction education and by safeguarding confidential client information, as long been the tradition of substance abuse treatment in Massachusetts. The Bureau is committed to ensuring that each client has an opportunity to access all of these services.

Each substance abuse treatment program is required to designate an AIDS Coordinator whose responsibility it is to ensure the implementation of the Bureau's HIV/AIDS policy Guidelines.

Compliance with the federal OSHA Standards for the Prevention of Transmission of Bloodborne Pathogens is required of all programs. OSHA Standards are available through the Massachusetts Department of Public Health State Laboratory (Telephone: (617) 522-3700).

Prevention and Education

HIV/AIDS education is critical for both clients and staff in substance abuse treatment settings, because such education facilitates programmatic accommodation of clients living with HIV disease; promotes discussion of risk behavior and risk reduction; supports direct care staff; and provides a forum for discussing HIV-related issues as they impact on relapse and recovery.

The theory of harm reduction recognizes that abstinence from drugs and alcohol may be especially challenging for some clients and that for these clients, the goal of public health interventions may begin with reducing the adverse health outcomes associated with substance abuse and high risk sexual behaviors. The promotion and distribution of risk reduction materials, including condoms and bleach kits (for clients who are actively engaged in substance abuse), are harm reduction activities that are encouraged by the Bureau.

The behaviors which place substance abusers at risk for exposure to HIV are emotionally charged, usually conducted in secrecy and linked to denial and the feeling of shame and guilt that are associated with addiction. Effective prevention messages must therefore be delivered with sensitivity to the dynamics to influence attitudinal and behavioral norms, they must also be internalized by the program staff who interact daily with clients. Program-based HIV education must include opportunities for staff to work through complex feelings and attitudes about high risk sexual and needle sharing behaviors, harm reduction and the culture of recovery.

Finally, the Bureau recommends that all programs create linkages with support services for both male and female victims of domestic violence. For many clients, substance abuse (of clients or their partners) may exacerbate domestic violence, thereby increasing the risk exposure to HIV through nonconsensual sex or other involuntary activities. Disclosure of HIV status between sexual or domestic partners, in combination with substance abuse, may increase the incidence of domestic violence episodes between partners.

The Bureau contracts with an HIV/AIDS Targeted Capacity Building Services Vendor to support substance abuse treatment programs to develop and implement effective HIV education programming that is sensitive to these and other issues. The HIV Targeted Capacity Building Services Vendor works with programs to ensure that HIV-related services are delivered with competence in content, language, culture, gender, sexual orientation and age. Contact information for the HIV/AIDS Targeted Capacity Building Services Vendor is available through the Bureau.

Informational materials about HIV and AIDS, as well as risk reduction materials, including condoms, bleach kits are available through The Massachusetts Department of Public Health AIDS Bureau, Telephone (617) 624 5300.

HIV Antibody Counseling and Testing

HIV antibody testing of substance abusers in early recovery has been a controversial issue since the test was first introduced in the early years of the epidemic. The anxiety that the testing process evokes in substance abuse treatment clients has been thought to have a negative impact on the process of recovery. The development of increasingly supportive, behavioral models of HIV antibody counseling, coupled with advances in early medical intervention for HIV disease, gives rise t new opportunities for substance abuse treatment providers to collaborate with HIV antibody counseling/testing staff to support clients who choose to address concerns about HIV status in a clinically supportive setting.

General guidelines for HIV antibody counseling and testing are found in the Massachusetts Department of Public Health publication, Guidelines for Physician and Health Care Providers on HIV Counseling, Testing and Early Treatment, available through the Massachusetts Department of Public Health HIV/AIDS Bureau (Tel: 617-624-5300).

The following components of the Guidelines are mandated by law, very clear, and must be followed without exception:

1. Testing is always voluntary. Programs cannot require HIV antibody testing of clients either before admission or during treatment.

2. Specific written informed consent is required before an individual is tested for the presence of antibodies to HIV.

3. Pre-and post-test counseling is always provided for the client.

4. Confidentiality of test results is strictly protected.

HIV Antibody Counseling, Testing During Substance Abuse Treatment

The following questions and answers address the most frequently raised concerns of substance abuse treatment staff about HIV antibody counseling and testing of clients in early recovery.

What is the HIV antibody test?
The HIV antibody test is a measure of HIV antibody production as a result of exposure to HIV. Antibody production usually occurs 4-6 weeks after exposure. The test measures the individual's HIV antibody status up to the point at which the blood sample was drawn.

What do test results mean?
A positive HIV means that the client has been infected with HIV and is capable of transmitting the virus to others. A negative test result means that the client did not have antibodies to HIV at the time the blood sample was drawn. It is possible for newly infected (within the past 4-6 weeks) individuals to have insufficient antibody production for the test to register as "positive". This is an infrequent occurrence, but individuals who may have had multiple recent exposures to HIV should re-test 3-6 months after a negative test. An "indeterminate" test means that the test was inconclusive and the client should be advised to repeat the test in one to three months.

What is the difference between anonymous and confidential testing?
In an anonymous testing situation, the client's name is usually not known to the test site. Client information obtained in an anonymous counseling session may not be shared. The blood sample is labeled with code number, which is known only to the client and the test site. The results are linked to the client by the code number without any other identifier.

In a confidential testing situation, the client's name is known to the test site (but often not to the laboratory, since a code number may still be used to label the blood sample). In substance abuse treatment settings, confidential testing provides the advantage of allowing collaboration between HIV counselors and substance abuse treatment staff, so that the client may benefit from clinical support during the counseling and testing process.

HIV Counseling, Testing and Support Services sites funded by the Massachusetts Department of Public Health AIDS bureau, usually offer clients a choice of anonymous or confidential testing. Whether a client chooses to test anonymously or confidentially, Massachusetts general law requires the test site to obtain the client's written informed consent prior to disclosure of information.

Who should be tested?
In light of positive developments in early intervention for HIV disease, it is important for persons at risk for HIV infection to known their HIV status and to access medical services early in the course of HIV disease. This is especially important for HIV positive pregnant women, who have an opportunity to reduce the risk of perinatal transmission through early medical intervention.

When should substance abuse treatment clients be tested?
For most individuals, the HIV antibody testing process is stressful. For individuals in early recovery, the counseling and testing process may be especially stressful. Providers who assist clients in making HIV antibody counseling and testing decisions should consider the following:

  • The decision about when to begin the HIV antibody counseling and testing process is a clinical decision which is part of the client's individualized service plan;
  • Pretest counseling provides the client with an opportunity to explore risk behavior confidentially, with an unbiased counselor;
  • HIV antibody counseling has the capacity to reinforce harm reduction messages when conducted in a confidential setting, and
  • Early diagnosis is the course of HIV disease is enables clients to access early medical intervention services.

What is the impact of testing in early recovery?
The HIV counseling and testing experience is stressful and has the capacity to either trigger relapse or reinforce recovery. For this reason, it is important for psycho-social support services to be built into the counseling and testing process for clients who choose to initiate the process while in treatment. Pre-test counseling that addresses psychological, behavioral and social issues, is provided by qualified HIV antibody counseling and testing staff. More than one pre-test session is encouraged, to ensure client readiness for testing. It is crucial for supportive counseling to be available on-site, between the time that the blood is drawn and the time that the test results are received.

A component of HIV antibody counseling involves client assessment of a personal support network. Client support networks often include trusted substance abuse treatment staff. It is therefore important for all staff to be educated about the HIV antibody counseling and testing process and to know how to access additional support resources for clients, within the treatment program and in the community.

The Bureau requires all of its contracted programs to collaborate with an HIV counseling and testing site to provide HIV antibody counseling within the program and/or referral to these services. HIV antibody counseling, testing and support services are provided with competencies in culture, language, gender, sexual orientation and age. A list of HIV counseling and testing sites may be obtained through the AIDS Bureau (Telephone: 1-800-750-2016).

Early Medical Intervention

Early medical intervention in HIV disease can prolong life. An individual who is HIV positive must have access to medical care if the benefits of early intervention are to be realized. Clients living with HIV disease may improve treatment outcomes for both substance abuse and HIV, through retention in substance abuse treatment and compliance with medical care during in the course of HIV disease.

HIV positive clients are provided with assistance in notifying sex or needle sharing contacts.

The Voluntary Partner Notification Program is available to assist to notify sex or needle sharing contacts of a possible exposure, without revealing the identity of the client. These services are available through DPH, Division of STD Prevention. Information is available through the STD Program: Telephone: (617) 983-6954.

The following safeguard may minimize the risk of relapse for clients newly diagnosed with HIV disease:

1. The establishment of clinical collaborations between substance abuse treatment programs and HIV test sites is essential. Such collaborations have the capacity to minimize client anxiety and encourage client retention in substance abuse treatment, regardless of the test result.
2. The establishment of collaborations with primary care sites to which newly diagnosed HIV positive individuals are referred for medical evaluation is also essential. Through these referrals, clients may be linked to the appropriate social service, including HIV drug reimbursement programs

HIV Disease in Women

Historically, HIV disease has been studied and observed in men. Complications that arise in women may not be recognized by medical practitioners as markers for HIV infection. Vaginal candidiasis (yeast infections), pelvic inflammatory disease (PID), abnormal Pap smears, and other gynecological care for HIV positive clients is important and should be made to practitioners who are experienced in the treatment of women with HIV disease and sensitive to their specific needs and concerns.

Family Planning Issues for HIV Positive Clients

The following family planning-related services are provided for HIV positive clients:

  • Education about safer sex practices and family planning;
  • Education about the prevention of perinatal transmission of HIV; and
  • Referral to prenatal care for HIV positive pregnant women.

HIV-Related Health Issues

Substance abuse treatment programs maintain awareness of health issues that relate to HIV transmission and immune function. Examples of these health issues are tuberculosis (TB) and sexually transmitted diseases (STDs). In addition, the interface of HIV with the complex medical and psychosocial dynamics of

pregnancy, family planning, and related women's health issues, challenge substance abuse providers to develop program policies that address these health issues and support women to access health care and make responsible reproduction choices. It is critical that agencies establish operational linkages with community-based health services that are sensitive to the dynamics of HIV, women's health care, substance abuse and recovery.

Tuberculosis (TB)

TB case rates increased in the United States in the late 1980s. This increase was due to many factors, including compromised immune function secondary to HIV infection and the emergence of multi-drug resistant strains of TB. Because TB is readily transmitted through the air and because clients living with HIV disease may be especially vulnerable to infection from any pathogen, it is critical that all programs screen both clients and staff for TB at regular intervals.

TB screening of clients and staff is mandatory for all substance abuse treatment programs. The Massachusetts Department of Public Health, Bureau of Communicable Disease recommends Mantoux (PPD) testing of all clients and staff. The use of control antigens with PPD testing is not necessary. Severely immunosuppressed clients should be evaluated for TB within the context of primary care.

Additional information about TB may be obtained from the Massachusetts Department of Public Health, Division of TB Prevention and Control at (617) 983-6954.

Sexual Transmitted Disease (STDs)

The incident of STDs, including syphilis, gonorrhea, and chlamydia, among others, has been increased at an alarming rate in the early 1990s. The presence of an STD in an individual increases the likelihood of HIV infection through sexual contact. Because STD's are reportable illnesses, epidemiologists use STD rates as predictors of future trends in HIV infection (the presence of an STD is an indicator of unprotected sexual activity). Education about STD transmission and prevention is an integral component of a comprehensive HIV education program. Such education includes sensitivity to issues related to same-gender sexual relationships.

For information about STDs and available services, call DPH-Division of Sexually Transmitted Disease Prevention at (617) 983-6954.

Admission and Discharge Guidelines for HIV Positive Clients

Admission Guidelines for HIV positive Clients

Admission to all substance abuse treatment program is based on the program's ability to provide quality care for each client. This includes HIV risk assessment, HIV/AIDS education, and support and referral for clients living with HIV disease.

1. Clients who are at high risk for HIV exposure or who are living with HIV disease receive priority status for admission. Clients who are at highest risk for exposure to HIV include injection drug users (IDUs) and their sex partners, men who have sex with men (MSMs) and others whose behavior puts them at risk.

2. A sensitive and thorough intake process includes a safe and confidential opportunity for clients to disclose HIV status or concerns about HIV status. The Bureau recommends that HIV/AIDS-related questions be raised by qualified staff, with sensitivity to client sexual identity and confidentiality concerns.

3. The program's HIV policy statement is communicated in an effective manner to each client upon admission and is posted conspicuously.

4. It is illegal to deny admission to an individual on the basis of HIV status. For example:

  • An individual who is HIV positive, asymptomatic and meets all other requirements of the program, cannot be excluded.
  • An individual who is HIV positive, occasionally ill and unable to work, cannot be excluded. (The Bureau of Substance Abuse Services policies and procedures for residential programs prohibits exclusion of an individual due to the individual's inability to work.)
  • An individual who is HIV positive, or who has an AIDS diagnosis, and is in need of specialized medical service, may not be excluded, if the program can provide a reasonable accommodation within the context of applicable state and federal laws.
  • Programs having legal questions about eligibility for admission of specific clients, should consult with their agency's legal counsel.

Discharge Guidelines for HIV Positive Clients

Programs develop and maintain linkages to HIV-related primary medical, mental health and social support services. Clients living with HIV disease who complete treatment, or who leave treatment prematurely, are referred to appropriate medical and social services.

In the event that a client is unable to continue to participate in treatment due to the progression of HIV disease, discharge may be considered. The following process is followed:

  • A discharge treatment plan which addresses both HIV disease and addiction is developed with the client;
  • A long-term plan for care that involves the client, family members and significant others (when appropriate) is developed with informed consent); and
  • Referral is made to a residential setting (e.g. medical setting, home, transitional unit, sober housing, shelter).

Legal Protection From Discrimination

The Federal Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 prohibit federally funded programs, including alcohol and other drug abuse treatment programs, from discriminating against persons on the basis of physical or mental impairment, who are otherwise eligible to receive the services offered by the program. Additionally, Massachusetts state legislation prohibits discrimination on the basis of the disability, including denial of access to any public or private program or activity. The definition of "disability" is:

  • a person who has a physical or mental impairment which substantially limits one or more major life activities;
  • a person who has a record of such an impairment; and
  • a person who is regarded as having an impairment.

Under all applicable Federal and State Laws, including the Americans with Disabilities Act (U>S>C> sec 12001, et seq., and Article 1154 of the Massachusetts Constitution), it is unlawful to discriminate on the basis of disability. The state civil rights status allows a person who has been denied a constitutional right by threats, intimidation or coercion to file a lawsuit to seek redress. In addition, the Massachusetts Commission Against Discrimination (MCAD) has extended the protection offered to people with disabilities to individuals who are perceived to be at risk or who have HIV/AIDS. MCAD's applicable statutes and regulations prohibit discrimination in employment, public accommodation, and public housing.

The Massachusetts statute on confidentiality and disclosure of HIV/AIDS information also prohibits HIV antibody or antigen testing as a condition of employment.

The above laws are applicable to discrimination issues related to HIV/AIDS raised by employees or clients. Both employees and clients may seek legal redress under the ADA, if they believe that they have been discriminated against. Agencies having legal questions about specific discrimination issues, should consult with legal counsel.

Legal resource: Legal Action Center of New York

Each substance abuse treatment program should obtain and become familiar with the contents of "AIDS: A guide to legal and Policy Issues". This document is available through the Legal Action Center of New York. It provides a national perspective on confidentiality, client's rights, legal obligations, and HIV antibody testing. Legal Action Center, 153 Waverly Place, New York, NY 10014, (212) 243-1313.

Confidentiality

Federal Confidentiality Laws

Federal law strictly protects the confidentiality of all information about persons receiving alcohol or drug abuse treatment services, under 42 U.S.C. (United States Code) Section 290dd-2 and 42 C.F.R. (Code of Federal Regulations) Part II. Disclosure of such information without express statutory or judicial authorization is subject to criminal and /or civil penalties.

In Massachusetts, the legal protection specifically covers the disclosure of HIV antibody test results.

Confidentiality of HIV Antibody test Results in Massachusetts

Chapter 111, section 70F, of Massachusetts General Laws makes the following statement.
No health care facility, physician or health care provider shall:

  • test any person for presence of HIV antibody or antigen without first obtaining written informed consent;
  • disclose the result of such test to any person other than the subject thereof without first obtaining the subject's written informed consent; and identify the subject of such tests to any person without first obtaining the subject's written informed consent.

Many individuals who are infected with HIV choose not disclose HIV status due to fear of discrimination. For some HIV positive clients, fear of HIV disclosure may be a barrier to treatment access. Substance abuse treatment providers have an opportunity to overcome this barrier by supporting HIV disclosure while remaining sensitive to client confidentiality concerns.

Bureau Confidentiality and Record Keeping Guidelines

To ensure compliance with federal and state regulations, the Bureau has developed the following guidelines:

Confidentiality

1. Each program develops a statement of confidentiality as it applies to HIV infection, communicates it verbally and in written to all clients and posts the statement in a highly visible common area.

2. When disclosure of HIV-related information is necessary, the client's consent is obtained in writing. The consent must include the following information:

  • name (or general description) of the program making the disclosure;
  • name of the client;
  • name or title of the individual or organization that will receive the disclosed information;
  • purpose or need for the disclosure;
  • how much and what kind of information will be disclosed;
  • statement that the client may revoke the consent at any time, except to the extentthat the program has already acted in reliance on previous consent;
  • date, event, or condition upon which the consent expires;
  • signature of the client; and
  • date that the consent is signed.

3. General disclosure of HIV information that occurs in a group setting is not documented in the client's record or in other program records (i.e. group "notes").

4. Self-disclosure by an individual client does not give program staff or other clients the right to disclose the information to others.

5. Clients are informed of the confidentiality policies of the program, and that any disclosures of personal information in a group or to a counselor are protected by the program policies.

6. The Bureau's HIV confidentiality policies are intended to ensure each client's right to privacy with respect to HIV status. The ability to control the sharing of sensitive information is especially important for clients in recovery who are also living with HIV disease. Supporting the client's right to privacy with respect to HIV status has a positive impact on the process of recovery.

Confidentiality of Records

In order to comply with confidentiality requirements, the following guidelines have been developed.

  • Client records are kept in locked files at all times.
  • Medical records for HI-infected individuals include basic information such as: medical history and results of physical examination, name of primary care provider, results of TB testing, current medical treatment or prophylaxis, pregnancy and reproduction concerns, and current health status.
  • Access to HIV-related information in records is restricted to program staff who have clear and direct need for access to such information. Each program should identify Key staff (by position) who have a direct need for access to information relating to HIV status of specific clients. For most programs these staff include only the client's individual counselor and nurse.
  • A written record keeping policy is developed and made available to clients on request.


This information is provided by the Bureau of Substance Abuse Services within the Department of Public Health.