1. Optimizing Care for PWIDs
Frederick L. Altice, M.D.
Director of Clinical and Community Research
Professor of Medicine
Yale University

2. The Doctor-Patient Relationship

3. Hippocratic Oath First do no harm.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.

4. The Future HIV Healthcare Providers: Professional Students in Malaysia
P=NS

5. Percent Who Would Defer Antiretroviral Therapy

6. Definition: Syndemic
A set of linked health problems involving two or more conditions, interacting synergistically, and contributing to excess burden of disease in a population.
Syndemics occur when health-related problems cluster by person, place, or time.

7. Triple Layers of Stigma
HIV
Arrest
Incarceration
Substance Use Disorder

8. Substance Use Disorder
Infectious Diseases (HIV, HCV, TB)
Mental Illness (Mood or Thought Disorders)

9. ADDICTION IS A DISEASE OF THE BRAIN
as other diseases it affects the tissue function
Decreased Brain Metabolism in Addiction Patient
High
Low
Healthy Control Cocaine Abuse
Decreased Heart Metabolism in Heart Disease Patient
Healthy Heart
Diseased Heart
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

10. ADDICTION INVOLVES MULTIPLE FACTORS
Biology/Genes
John Smith
James Smith
Ann Jones
John Jones
Mary Hill
Walter Jones
James Hill
Susan Adams
Alice Price
Thomas Jones
William Price
Richard Hill
Steven Adams
Allison Fields
Mary Walters
Alice Benson
Rebecca Wilson
ThomasSmith
EdwardSmith
AnneCook
JaneWalker
John Walker
JaneJones
Susan Edwards
JamesCook
Beth Bryson
JonathanCook
Edward Bryson
Amy Mason
Beth Carter
Environment
Addiction
DRUG
Brain Mechanisms

11. Reward (Pleasure) Pathway
Ventral Tegmental Area
Alcohol
Stimulants
Heroin
Nicotine

12. HIV
OST
Mental Illness
Medical Care
The Problem!

13. Integrating Care for PLWHA
Secondary HIV Prevention and Adherence Counseling
Pharmacologist
Addiction Treatment Specialist

14. Guidelines for Integrating Collaborative Services
Common comorbidities in people who use drugs
TB, HIV, HCV, STIs
Mental illness
Studies where services are NOT integrated have poorer treatment outcomes – patients don’t travel to new sites for treatment (convenience, mistrust, etc)

15. Integration is Internationally Recommended

16. Steps in Organizational Change Toward Healthcare Integration
OAT
Communication
Coordination
OAT
HIV
Co-Located Services
OAT
HIV
Partial Integration
Complete Integration
HIV/OAT
HIV
Separate Sites

17. Specific Recommendations for PLH and SUDs
Prescribing opioid agonist therapy with either methadone or buprenorphine for individuals with opioid use disorders
Integration of HIV and addiction services
Directly administered antiretroviral therapy (DAART), including into methadone treatment

18. Portugal Experience (Decentralization)
Outreach Teams
Prisons
Addiction Centers
TB Centers
Hospitals: Integrated Services
Primary Care Centers
Pharmacies
Testing Center
ART
OAT
TB treatment
HCV treatment
HIV testing
NSP
TB screening

19. Addiction Integration into Primary Care
Correlates of retention on buprenorphine:
Having a primary care rather than an addiction specialist prescribing treatment
Not using cocaine
Being prescribed anti-depressant medications
Receipt of addiction counseling

20. Retention on Buprenorphine

21. Addiction Integration into Primary Care
Correlates of higher quality health indicators:
Having a primary care rather than an addiction traetment doctor prescribing treatment
Being retained on buprenorphine ≥3 months
Being HIV-infected
Male gender

22. Quality Health Indicators

24. Integration of Buprenorphine into HIV Clinical Care Settings
Prospective, cohort (N=295) study of HIV+ patients at 10 diverse HIV clinical care settings
Each site was organized differently
Hospital-based HIV clinic (N=6)
Community health centers (N=4)
Research HIV Clinic (N=1)
Resulted in increased number of patients initiating ART
Best outcomes when both buprenorphine and ART prescribed by the same provider
Succeeded best if there was a coordinator (“the glue”)
Nurse (N=5)
Substance abuse counselor (N=3)
Health educator (N=2)
Pharmacist (N=1)
Altice, JAIDS, 2011; Weiss, JAIDS, 2011

25. Altice, JAIDS, 2011

26. Required multiple prescribers within a “practice”
Needed a “glue” person to anchor the program (counselor, nurse, etc)
Challenges of “culture” between HIV and addiction and new practices (urine screens)
Polysubstance use and mental illness comorbidities created additional challenges

27. Integration in Ukraine: Improvements in Health

29. Overview
Cross-sectional study of 296 HIV+ opioid dependent patients in Kiev and Dnipropetrovsk regions in Fall 2010
Randomly recruited from three settings
Integrated & Co-Located Clinics (ICL)
Non-Co-Located Narcology Clinics (NCL)
Harm Reduction & Outreach Sites (HRO)
Primary Outcomes
Performance on Quality Health Indicators (QHI)
Health-related Quality of Life (HRQoL)

30. Quality Health Indicators
An index that is created to measure health outcomes across a number of diseases
HIV Index (N=3)
CD4 monitoring in previous 6 months; receipt of ART; receipt of ART if CD4<200
OST Index (N=3)
Methadone dose ≥80mg; any IDU in previous 30 days; daily IDU in previous 30 days
TB Index (N=2)
TB screening in past 12 months; isoniazid preventive therapy

31. HIV Quality Indicators

32. OAT Quality Indicators

33. TB Quality Indicators

34. Mean Quality Health Indicator Score
P<.001
P<.001

35. Health-Related Quality of Life
P<0.001
P<0.001

36. Health Services Integration OAT and TB Treatment OAT and HCV Treatment

37. OAT and TB Treatment Hospitalized Patients in Ukraine
Morozova et al, IJDP, 2013

38. South Central Rehabilitation Center

39. SCRC Services Provided
Treatment for alcohol and substance use disorders, including 7 day inpatient detoxification
Methadone and buprenorphine maintenance
Routine screening of ALL patients for HIV, TB, HBV, HCV and mental illness
Onsite treatment for HIV, HCV and uncomplicated mental illness
DOT for HIV, HCV and TB prophylaxis treatment

40. OAT and HCV Treatment Onsite vs Referral for HCV Treatment

41. The Solution!
HIV
OST
Medical Care
Mental Illness