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The majority of the training day was spent attending workshops led by staff from across the three schools involved, designed to share good practice and give plenty of opportunities for staff to network and share expertise and experience. Speaking at the end of the day, Ollie Lee, Assistant Headteacher and organiser of the event said, ‘This was a great example of collaboration and was only possible due to the many staff that shared their own great practice with colleagues. Richard Arundell, Acting Head of School at Landulph, said, ‘Thank you so much for making us feel part of such a fabulous day. Landulph school may account for only 3% of the total student population of the MAT but you have made us all feel so much more than that today. Lisa Tamblyn, Headteacher at Burraton, said, ‘Today we have seen three schools come together – new bonds have been formed and already good relationships have been strengthened.
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This report summarizes current (as of 2011) guidelines or recommendations published by multiple agencies of the U.S. This report summarizes current (as of 2011) public health recommendations and guidelines from multiple agencies of the U.S.
Rates of HIV infection, viral hepatitis, STDs, and TB are substantially higher among persons who use drugs illicitly than among persons who do not use drugs illicitly (2–5). In general, the risk for acquiring and transmitting infectious disease in a population is a reflection of the prevalence of a given infection in the population, the efficiency of transmission of the organism, and the burden of infectious diseases and patterns of the risk behaviors in which that population engages. A coordinated approach to service delivery needs to incorporate multiple science-based public health strategies. Program collaboration and service integration are mechanisms that programs use to organize and combine interrelated health issues, activities, and prevention strategies so as to facilitate comprehensive delivery of services, to foster integrated care, and to increase operational efficiencies (18). To the extent that programs can collaborate and integrate prevention services, they can save time, money, and effort.
Program collaboration is a mutually beneficial and well-defined relationship entered into by two or more programs, organizations, or organizational units to achieve common goals (18). Comprehensive and integrated service delivery, either through provision of multiple services at a single venue or through coordination of referrals for services delivered at multiple venues, requires collaborative planning and a coordinated approach among service providers. This guidance was developed and written by a CDC work group (members are listed alphabetically on page 1). The guidance is the result of the efforts of several DHHS agencies and offices to synchronize activities and achieve synergies in areas where their missions for persons who use drugs illicitly overlap.
Prior to this guidance, recommendations and guidelines for public health strategies for preventing and treating HIV infection, viral hepatitis, STDs, TB, substance use disorders, and mental disorders among persons who use drugs illicitly have appeared in different publications (Appendix B). The recommendations or guidelines from CDC, NIDA, and SAMHSA are based on reviews of the scientific evidence and programmatic literature, expert opinion, field experience, and lessons learned from and results of projects funded by these agencies.
Persons who use drugs illicitly are at increased risk for acquiring and transmitting infectious diseases via bloodborne exposure (for those who inject), and they are at increased risk for sexual exposure to HIV and STDs (4,53–55). The epidemiology of HIV infection differs by groups and is influenced by demographic factors affecting use of health-care services. A large body of research has demonstrated that illicit drug use, regardless of the route of absorption of the drug, puts users at risk for acquiring HIV infection and STDs. Increasing awareness of infectious disease comorbidities and of overlapping risks for multiple infections is essential because of the overlapping risk behaviors associated with acquiring these conditions, the synergistic effects of disease progression and treatment needs, and the social determinants for prevention and treatment. Implementing science-based public health strategies in a manner that respects the rights of persons who use drugs illicitly and their partners is vital for preventing HIV infection, viral hepatitis, STDs, and TB in this population (106,109–113). In the field of prevention and treatment of substance use disorders, the terms "use," "abuse," and "dependence" are defined in ways that reflect their association with risk for infectious diseases, other health conditions, and adverse social consequences (114,115).
Evidence demonstrates the effectiveness of science-based approaches to prevent and treat substance use and mental disorders (115–117). Evidence points to the efficacy of "screening, brief intervention, referral, and treatment" (SBIRT) approaches in primary care settings to identify problematic use of drugs and to reduce substance abuse (121–123). Community-based outreach, in which peer educators or other persons have established trust and rapport with persons who use drugs illicitly, can reduce risky behaviors (127,128). Outreach workers can provide education on drug- and sex-related risks and risk-reduction information to persons who use drugs illicitly.
The high prevalence of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly should sensitize prevention and care providers to conduct risk assessment for illicit use of drugs for everyone seeking services for these infectious diseases (138,139).
Risk assessment and risk reduction interventions are essential for adoption of safer behaviors and for referral of clients to relevant prevention and treatment programs (32,33,140–142). The recommendation to assess persons who seek preventive and medical care for infectious diseases for illicit use of drugs is consistent with recommendations of the USPSTF (145), CDC's STD treatment guidelines (146), and the American Medical Association (AMA) guidelines for adolescents (147), which recommend that health-care providers screen adolescents for substance abuse during preventive-service visits. Screening services for infectious diseases are critical components of a comprehensive strategy to reduce and eliminate incident infections among persons who use drugs illicitly (149–159).
Prevaccination testing for hepatitis B is recommended for household, sex, and needle-sharing contacts of hepatitis B surface antigen (HBsAg)–positive persons and for HIV-infected persons (152). Recommendations for the administration of HPV vaccinations are the same for persons who use drugs illicitly as for the general population (167). Screening pregnant women for HSV-2 at their first prenatal visit is not recommended, but it is important to test pregnant women with symptoms of genital herpes, including those with symptoms at time of delivery, and to provide treatment for pregnant women with newly acquired HSV-2 (146). Much of the research on HIV prevention programs for persons who inject drugs illicitly has focused on injection-related risk.
Although persons who inject drugs illicitly have reduced their injection risk behaviors in response to behavior-change health interventions (177,178), reducing their risky sexual behaviors remains a challenge, similar to the challenge that faces persons who do not use drugs illicitly (179,180). Risk-reduction interventions for sexual risk are important because illicit noninjection use of drugs has been associated with participation in high-risk sexual activity and with acquisition of HIV, HBV, HCV, or other STDs (88,106,185–192). CDC has identified several behavioral health interventions for persons who use drugs illicitly.
In general, a short detoxification program from opioids has limited success in leading persons who use drugs illicitly to abstain from such use (211,212).
Substance abuse treatment can reduce such risk behaviors as needle-sharing and exchange of sex for money or for illicit drugs (221–227). Medication-assisted therapy with methadone or buprenorphine is highly effective for opioid addiction; it can promote adherence to needed medical care (116,234). Increased condom use (239,240) and increased safer sexual behaviors (132,241) have been reported by persons who have reduced their illicit use of drugs.
Bloodborne pathogens can be transmitted easily through shared injection and drug-preparation equipment (203,250). Although most states do not require a prescription to buy syringes, many states and pharmacies require customers to present personal identification or to sign for the purchase of sterile needles and syringes (83). Existing evidence indicates that syringe exchange programs are effective in reducing the incidence of HIV infection (265). In addition to providing sterile syringes, most syringe exchange programs provide other health-related supplies and services to their clients (252,274).
Syringe exchange programs often provide referrals to substance abuse treatment and social services (275).
Increasing the availability of condoms is associated with substantial reductions in HIV risk (274,279).
Partner services begin when persons who have an infection are interviewed to obtain information about their partners in a voluntary and confidential manner. Persons who use drugs illicitly and who are identified to be infected with HIV, viral hepatitis, STDs, or TB should be referred and linked actively to medical care. Persons who use drugs illicitly need to receive appropriate treatment for infectious diseases and relevant health education messages from trained personnel.
Adherence to treatment of infectious diseases among persons who use drugs illicitly can be enhanced by addressing different comorbid conditions, including mental disorders and such other factors as poverty-related issues, including homelessness and limited access to transportation (321–323). There is a potential for harmful medication interactions or toxic effects in the treatment of persons with multiple infections who inject drugs illicitly. Before 2002, the National Institutes of Health (NIH) considered illicit use of drugs a contraindication for HCV treatment, meaning that persons who used drugs illicitly were routinely denied medical treatment for HCV infection. Persons who use drugs illicitly can benefit from comprehensive (or at least combination) services that meet their individual clinical needs or community needs. In endorsing comprehensive prevention using nine interventions for HIV prevention (also referred to as "combination prevention"), UNAIDS, UNODC, and WHO have noted that although each intervention is useful for HIV prevention and care for persons who inject drugs illicitly, the nine interventions form a package and have the greatest beneficial impact when delivered together to a person who needs them (5). At the service delivery level, service integration offers an opportunity to optimize the effect of comprehensive interventions. Thus, comprehensive prevention refers to the range, content, type, and combination of interventions that persons need. Syringe exchange programs provide integrated preventive services for persons who use drugs illicitly (275,342).
Programmatic evidence supports the need for providing comprehensive or integrated services for persons who use drugs illicitly (113,339,348–352).
The scientific evidence is increasing for development, implementation, and evaluation of projects that focus on program collaboration and service integration (349,350,354–356). The scientific evidence is largely built on observational studies and demonstration projects.
New research studies and demonstration projects, including quasi-experimental studies (373,374) and cost-effectiveness studies, would add to the evidence base for integrated services.
If the form somehow hasn’t made its way home you can download the Christmas Production Letter. Please return your completed form no later than Wednesday 18th December to allow for enough time to get your DVD to you. DVD’s will be available to collect from Monday if you return your form before the weekend!
This entry was posted in Admin, Everyone, Letters and tagged Christmas, DVD, Form, Letter, Productions on December 12, 2013 by Mr Heward. In this activity participants have to locate and match pairs of cards as they think out about the inequalities of educational provision world-wide and how to achieve "Education for All". The intention in using this technique is to bring an ingredient of fun to the process of gaining information which will be needed for the discussion.
You can tell people that the game is called "Memory" because people have to memorise where the different cards lie in order to be able to pick up matching pairs.
In part 2, you may like to organise it so that two different groups discuss the same issue. When you photocopy the cards it is a good idea to enlarge them to make them easier to read.
Note that one-third of the cards contain statements relating to the goals of education for all as stated by the World Education Forum (WEF), Dakar, Senegal in April 2000.
If there is not enough time to do part 2, you could use the technique described in the activity "Just a minute" instead. In part 2, you can save some time by preparing in advance a set of very enlarged picture cards on which you have written the related headings.
We also had indispensable help from six year 7 students that helped organise staff on the day, the smooth running of the event would not have happened without them. What has shone out for me today has been the collaboration and networking that has gone on. Department of Health and Human Services (DHHS) for prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) for persons who use drugs illicitly. These strategies are science-based, public health strategies to prevent and treat infectious diseases, substance use disorders, and mental disorders. Department of Health and Human Services (DHHS) for science-based public health strategies for the prevention of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) (referred to collectively as infectious diseases) among persons who use drugs illicitly and their contacts (sex and drug-using partners) in the United States.
The term "illicit use of drugs" encompasses all levels of use, abuse, and dependence because each level is associated with behaviors that increase the risk for contracting or transmitting infectious diseases.
The high rates of HIV infection, viral hepatitis, STDs, and TB among persons who use drugs illicitly reflect behavioral, social, cultural, environmental, and structural factors that facilitate disease transmission (10–12). Persons who use this guidance should adapt it to meet the specific prevention needs of their communities, while preserving the core missions of the organizations, programs, and venues that provide these services.
Staff working in prevention programs for HIV infection, viral hepatitis, STDs, and TB and in programs to prevent and treat substance use and mental disorders need to consider program collaboration and service integration as an approach to improve access to multiple services (18–21). Agencies and providers at the federal, state, local, tribal, and service delivery levels can provide leadership and resources to develop and implement programs that enhance program collaboration and service integration (19).
Providing multiple prevention services at a single venue or coordinating referrals and linkage to care for services delivered at multiple venues can improve access to quality and comprehensive prevention services.
The collaboration usually includes a commitment to relationships and mutual goals, a jointly developed structure, shared responsibility, mutual authority and accountability for success, and shared resources and benefits for programs that are not necessarily all delivered at the same physical location. Such collaboration and coordination are needed to ensure that provided services meet the needs of persons who use drugs illicitly and that the methods of service delivery are acceptable both to providers and to clients.
The work group included health-care professionals, public health scientists, and public health analysts with experience and expertise in prevention of HIV infection, viral hepatitis, STDs, and TB in persons who use drugs illicitly. Some persons who use drugs illicitly might share unsterile drug injection equipment as well as engage in unprotected vaginal or anal intercourse with partners who engage in high-risk behaviors or with partners who have infectious diseases (56). For example, persistent racial and ethnic disparities in infectious diseases among persons who use illicit drugs remain a challenge (63–71).
For example, illicit injection of drugs can impair judgment, increasing the likelihood of engaging in risky sexual behaviors (86).
The moderately high prevalence of bacterial STDs among persons who inject drugs illicitly is not much different from the prevalence among youth at high risk (100). Among HIV-infected persons who inject drugs illicitly, 80% also are infected with hepatitis C virus (HCV) (86). Decision makers can make the most efficient use of public resources by choosing cost-effective, science-based prevention strategies. From an epidemiologic perspective, frequency of use of a substance and total number of times a substance is used in a lifetime are the principal measures of substance use. The evidence base indicates that scaling-up science-based approaches for treating substance use and mental disorders in publicly funded programs would improve health outcomes. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders and for those at risk for developing them (121). Medication approaches (often referred to as medication-assisted therapy) are effective for treating nicotine, alcohol, and opioid addiction, as reflected in recommendations of national and international organizations (115).
Outreach is particularly useful in reaching and assisting those who use drugs illicitly who are not ready to enter substance abuse treatment or to be involved in other interventions for risk reduction. In addition, many users use multiple drugs, as well as alcohol or tobacco, and eliciting information on use of these substances could assist with prevention and treatment services. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) can be used as a screening instrument for drug use (143,144).
Such services identify those who are unaware of their infections and provide them with counseling and education and refer and link to treatment those who are infected. Hepatitis B vaccination is recommended for all adults in certain settings, including STD clinics, HIV testing and treatment facilities, facilities providing substance abuse treatment and prevention services, correctional facilities, and health-care settings serving persons who inject drugs illicitly (100,165).
No vaccines are available for the prevention of infection with HIV, HCV, or any STD other than HPV and HBV. Women who use drugs illicitly are less likely to use family planning services than other women (169). A summary of current recommendations and guidelines for prevention of mother-to-child transmission of infectious diseases has been provided (Box 2).



They are 1) risk-reduction programs and messages, 2) treatment of substance use and mental disorders to prevent infectious diseases, 3) access to sterile injection and drug preparation equipment, and 4) interventions to increase condom availability (173,174). In recent years, however, multiple studies have concluded that persons who use drugs illicitly, through injection or noninjection routes, are at increased risk for sexual transmission of HIV, HBV, and other STDs, regardless of the means of introducing the drug into the body (70,89,152,166,175,176). For example, methamphetamine use has been associated with unprotected sex and with higher numbers of sex partners, both among MSM and among persons who engage in heterosexual sex (188,193–195). These interventions have been demonstrated to reduce the frequency of high-risk behaviors and ultimately are intended to reduce the risk for acquiring HIV infection or other STDs (204). In addition, substance abuse treatment can serve as an entry point to medical care, and it can improve adherence to medical treatment regimens for infectious diseases (116,228–230). An extensive body of evidence demonstrates that therapy with methadone or buprenorphine reduces the frequency of heroin injection, increases rates of retention in substance abuse treatment programs (235,236), and markedly decreases criminal activity (11,14,109,112). Substance abuse treatment is also a key step toward successful therapy of infectious diseases (9,242).
Evidence suggests that access to sterile injection equipment can reduce transmission of these pathogens among persons who inject drugs illicitly (251). Participation in no-cost syringe exchange programs leads to a decrease in the frequency of needle-sharing without causing an increase in the frequency of illicit use of drugs (177,257–264).
Syringe exchange programs reduce the risk for infection with HCV, which is the most common bloodborne pathogen among persons who inject drugs illicitly (153,266–269).
Syringe exchange programs also can serve as sites for TB screening and for testing for TB infection (133,276), and they can serve as gateways to treatment for HIV or HCV infection (275,277,278). Results of a Louisiana study on the effects of widespread condom distribution indicated that the rates of condom use increased, while the average number of sex partners over a 12-month period did not increase (274). Following this step, partners are notified confidentially of their possible exposure to infection (287).
Persons with TB disease who use drugs illicitly might be reluctant or unable to name other contacts who engage in illicit drug use or venues where drugs are used illicitly (291–293). Medical care includes treatment for these infections as well as treatment for other health conditions that affect the lives and well-being of persons who use drugs illicitly, including treatment for substance use and mental disorders (294). First, persons who use drugs illicitly are referred, following a needs assessment process, for medical treatment, care, and supportive services.
In a multisite study, onsite linkage to buprenorphine-naloxone treatment delivered in an infectious disease clinic was demonstrated to be more effective than offsite referrals (307). An infected person who receives a diagnosis of HIV infection, viral hepatitis, STDs, or TB should be referred to care providers and receive primary medical care and evaluation for progression of infection to disease, as well as treatment.
Adverse effects of medications can include the effects of HIV antiretroviral medications on liver, kidney, and neurologic functions. In 2002, NIH issued a consensus statement that HCV treatment for persons who use drugs illicitly should be considered on a case-by-case basis (331). They can be expected to benefit from synergy among services that are delivered jointly at the service delivery level as integrated services. Thus, comprehensive prevention can bring scientifically based behavioral, biomedical, and structural interventions to persons who use drugs illicitly (281,339) because it offers a multipronged approach for addressing complex social and public health needs (113,281,340). CDC defines service integration as a distinct method of service delivery that provides persons with seamless services from multiple programs or areas within programs without repeated registration procedures, waiting periods, or other administrative barriers (18).
Delivery and outcomes of comprehensive services for individual and public health benefits can be enhanced by following the principles of service integration at the service delivery level.
These services include screening for HBV and HCV infections, vaccination for HAV and HBV (343), and HIV and STD testing (252).
Other integrated guidelines emphasize the importance of integrated services for optimizing prevention of and treatment of HIV infection, viral hepatitis, STDs, and TB (18,148,353,354). Ask participants what they know about the World Education Forum (WEF) and "Education for All" (EFA).
Explain that the activity is divided into two parts: part 1, the memory game and part 2, reporting on the issues.
Ask if participants know a game called Concentration, Memory, Pelmanism or Pairs because this is what they are going to play in small groups of four. When the issues have been agreed and allocated, give the groups 20 minutes to discuss their two chosen issues.
If you then stick the sheets onto stiff paper it will make the finished cards more durable and easier to handle.
Make sure that when you introduce the game you explain what these letters stand for (see under "Further information" below). The rest of the cards are on human rights and education issues, or on issues that have to be addressed in order to achieve good quality education for all. Ask each participant to choose one of the issues on the cards they picked up, and to speak about it for one minute without hesitation or repetition.
For instance, if you want to explore the issue of budgets for education and other social needs with the budget spent on militarisation, you can do the activity "How much do we need". It also summarizes existing evidence of effectiveness for practices to support delivery of integrated prevention services.
Treatment of infectious diseases and treatment of substance use and mental disorders contribute to prevention of transmission of infectious diseases. In addition, the report recommends integrated delivery of the public health strategies and includes a review of recent programmatic efforts to integrate prevention services for persons who use drugs illicitly.
Preventing infectious diseases among persons who use drugs illicitly can also help prevent infections among their sex and drug-using partners and among other members of their communities. Such coordination can offer the opportunity to address multiple infectious diseases and related health conditions, such as substance use and mental disorders, at one time or at a single facility, thus increasing the likelihood that clients will receive needed services. Service integration is intended to provide persons with seamless services from multiple programs or areas within programs without repeated registration procedures, waiting periods, or other administrative barriers (18).
However, an integrated approach to service delivery requires that local, state, and federal agencies work together, which is often a difficult process because of different regulatory constraints, including those caused by complying with the Health Insurance Portability and Accountability Act (HIPAA) regulations. CDC's recommendations address prevention and treatment of HIV infection, viral hepatitis, STDs, and TB. Preventive Services Task Force are based on systematic reviews of the scientific literature. Estimates of the number of users of illicit drugs through means other than injection range from 1 million to 1.5 million (26). Data indicate racial and ethnic disparities in use of health-care services, including entry and retention in substance abuse treatment programs and other programs (72–84). Epidemiologic synergy, in which co-occurring infections increase the likelihood of infection transmission and progression of infectious diseases, highlights the importance of preventing and treating co-infections, diseases, and disorders.
In studies of persons who use drugs illicitly in New York City, infection with HSV-2 is associated with HIV infection (106,107).
Abuse refers to a level of use of a substance that has short-term acute personal or social consequences, including sporadic, nondependent patterns of use despite social problems or physical hazards.
Providing persons who use drugs illicitly with increased access to science-based treatment for substance use and mental disorders is one way to improve prevention and control of infectious diseases (116). SBIRT can be provided in a range of health facilities, including primary care centers (121). The use of effective medications in conjunction with science-based behavioral treatments remains valuable because combination interventions can be more effective than single interventions.
Outreach has been demonstrated to increase the use of condoms, substance abuse treatment, and other prevention services (127,128). Outreach workers also can refer persons who use drugs illicitly to facilities that offer targeted testing for TB infection; those identified with active TB disease can be treated appropriately, and those identified with TB infection (3) can be given preventive therapy for TB (133,134).
For multiple reasons, patients might not be forthcoming about illicit use of drugs; the reasons include fear of legal consequences and concerns about confidentiality. CDC's 2010 STD treatment guidelines support this approach by recommending that health-care providers of STD services routinely obtain sexual histories from their patients (146). If prevaccination testing for antibody to the hepatitis B surface antigen (anti-HBs) is used to identify immunity after previous HBV infection, HBsAg testing also must be performed to identify persons with chronic HBV infection.
For TB prevention, use of Bacille Calmette-Guerin (BCG) vaccine generally is not recommended in the United States because of the low risk for infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine's potential interference with tuberculin skin test reactivity (155,168). Pregnant women who use drugs illicitly are more likely than other women to initiate prenatal care later or not at all (170,171). Those results indicate that such interventions should be implemented on a wider scale to reach all persons who use drugs illicitly with messages about safer sex behaviors (87,179,181). Crack cocaine use has been associated with higher prevalence of HIV and HCV infection and with higher frequencies of unprotected sex, sex with multiple partners, and exchange of sex for money or for illicit drugs (189,196–202).
Other effective interventions can be adapted for use with persons who use drugs illicitly (205).
Reducing or eliminating illicit drug use through substance abuse treatment promotes an overall healthy lifestyle and reduces other negative consequences of illicit drug use, including overdose (218). Substance abuse treatment includes nonpharmacologic, psychosocial approaches as well as pharmacologic therapies (174). For example, methadone maintenance therapy has been associated with reductions in the frequency of illicit injection and sharing of injection equipment (212). Substance abuse treatment improves HIV treatment adherence (230,243,244), resulting in lower viral loads and lower likelihood of HIV transmission (245–247). However, access to sterile needles and syringes generally is controlled by federal and state-specific laws and regulations that control their sale, distribution, and possession.
The term includes all services and interventions that provide sterile needles and syringes, including syringe exchange programs and nonprescription pharmacy sale of sterile needles and syringes, as well as syringe disposal.
Participation in a syringe exchange program was associated with reduced rates of hepatitis B and C in a case-control study in Tacoma, Washington (270). Innovative strategies and programs should be developed and tested, such as those that prevent the progression of noninjection drug use to injection drug use and those that promote safer and hygienic injection practices and facilities to prevent HIV and HCV transmission among persons who use drugs illicitly (4,37,107,153,272,273). Limited condom availability attributable to high cost, a low concentration of sale outlets in a given area, or limits on free distribution of condoms is often cited as a barrier to condom use (274).
The inability to generate a comprehensive list of contacts or venues can contribute to incomplete contact investigations, ongoing transmission of TB, and missed opportunities to prevent cases of TB disease.
Substance abuse treatment serves as a preventive intervention for HIV infection, viral hepatitis, STDs, and TB (116,126,295). Assistance with follow-up can facilitate initial contact with and linkage to appropriate service providers (18).
Persons interacting with the criminal justice system or leaving correctional facilities (jails or prisons) can benefit particularly from active linkage to HIV medical care, TB linkage interventions, HCV medical care, STD services, substance abuse treatment, and overdose prevention programs (308–311). In addition, infected persons need to be provided with counseling and guidance on how to stay healthy and prevent disease progression. Among persons who use drugs illicitly and who have active TB, use of incentives and enablers to encourage clinic visits has been associated with improved treatment adherence (98,134,324,325), better doctor-patient relationships, and delivery of TB treatment in substance abuse treatment programs or methadone-maintenance programs (326). Providers should consider how different antiretroviral medications or antibiotics might interact with methadone or with drugs used illicitly when selecting a medical treatment regimen for persons who inject drugs illicitly and have multiple infections (9,327,328). Since then, according to some studies, illicit use of drugs during HCV therapy has been associated with lower rates of adherence and with increased risk for reinfection (332,333) although this association has not been demonstrated consistently (334).
Decisions about the comprehensive interventions to be offered in a particular program or community need to be influenced by three factors: the local epidemiology of infectious diseases and substance use and mental disorders, the spectrum of already existing services, and the patterns of illicit drug use (5).
Service integration differs from system coordination, in which services from multiple agencies are provided but persons might have to visit different locations and register separately for each provider's programs to obtain these services (18).
If necessary, explain briefly about the EFA goals and that achieving primary schooling for everyone is one of the Millennium Development Goals (MDGs). The starting point for the discussions should be the question printed in italics in the cards.
Be sure that you know which card matches with which so that during the game you can offer guidance and verify that pairs are correct. It will mean that the sub-groups will have to do some negotiating about which issues to discuss. This is also a good option if you feel that the participants need to improve their oral presentation skills. Issues relating to child labour and lack of access to education can be explored in the activity "Ashique's story".
Implementing integrated services for prevention of HIV infection, viral hepatitis, STDs, and TB is intended to provide persons who use drugs illicitly with increased access to services, to improve timeliness of service delivery, and to increase effectiveness of efforts to prevent infectious diseases that share common risk factors, behaviors, and social determinants. Integrating prevention services can increase access to and timeliness of prevention and treatment. Integrated prevention services provide multiple prevention services at a single venue, coordinate referrals, and provide linkage to services delivered at multiple venues to improve access to high-quality and comprehensive prevention services.
Marijuana use and nonmedical use of prescription drugs also are associated with risk for contracting or transmitting infectious diseases. Bloodborne infections such as HIV infection and viral hepatitis are transmitted efficiently through sharing of contaminated needles.
Program collaboration and integration of prevention services can be expected to maximize opportunities for prevention, reduce delays between infection and diagnosis and between diagnosis and treatment, and improve adherence to risk reduction behaviors and to treatment regimens for infectious diseases, substance use disorders, and mental disorders.
By providing access to services at a single health-care entry point, service integration is different from system coordination, in which multiple agencies provide services but at multiple locations, possibly requiring persons to visit several locations and register separately for each program to obtain the services (1).
Electronic and portable health records are inconsistently available, further complicating delivery of health-care services. The guidelines of NIDA and SAMHSA are for prevention and treatment of substance use and mental disorders. Evidence for the effectiveness of the delivery of integrated prevention services for persons who use drugs illicitly, like the evidence supporting the previously published recommendations and guidelines, is based on a combination of a literature review, expert opinion, field experience, and results of and lessons learned from delivery of integrated services in projects funded by DHHS agencies.
They often are in settings where peers are not trained in overdose prevention or are reluctant to call for medical help because of fear of legal consequences, or they are in settings where medical help is not available or accessible in a timely manner (39–41). Among persons who are at risk for infectious diseases, men who have sex with men (MSM) are affected disproportionately by HIV. Fortunately, prevention efforts aimed at reducing drug injection risk can be successful (57). For example, 80% of HIV-positive persons who inject drugs illicitly are HSV-2 positive (106). The clinical definition of dependence includes psychologic as well as physiologic components.
The national strategy to reduce drug demand focuses on curtailing illicit drug consumption and on improving public health and public safety by reducing the consequences of drug abuse (118,119).
The goals of SBIRT are to 1) encourage health-care providers to screen and provide brief advice or counseling to their patients who misuse alcohol or abuse other drugs so as to reduce hazardous use of substances, 2) reduce vulnerability to the negative consequences of substance use, and 3) improve linkages between general community health care and specialized substance abuse providers to facilitate access to care when needed (121). Science-based behavioral treatments include cognitive behavioral therapy (including relapse prevention), motivational interviewing, and community reinforcement approaches (including contingency management as a stand-alone intervention) (124–126). Outreach to persons who use drugs illicitly can occur at locations where they congregate, on the streets, or in mobile vans (129).
Thus, patients need to feel comfortable about their privacy and confidentiality of their data to share their behaviors with providers.
Risk assessments for infectious diseases can be performed by health-care providers at venues that serve persons who use drugs illicitly (5,148).


Screening for illicit use of drugs, including offering brief interventions and providing referrals, and screening for misuse of prescription drugs, can be useful adjuncts to screening for infectious diseases (121).
Serologic testing should not be a barrier to vaccination of susceptible persons, especially in hard-to-reach populations. Pregnant women with HIV infection have cited illicit use of drugs as a barrier to prenatal care, because some fear incarceration for illicit use of drugs and possible placement of their newborns in foster care (171). Levels of sexual risk are influenced both by the drugs that are used illicitly and by their route of administration (86). The compendium of science-based HIV prevention interventions includes information on 70 effective interventions, including at least 15 for persons who use drugs illicitly, at least 12 for persons who inject drugs illicitly, and eight that were evaluated with racial and ethnic minority persons who use drugs illicitly (206). For persons who use drugs illicitly, both lack of motivation to enter substance abuse treatment and the moderately long waiting periods that face them can be barriers to enrollment (220).
It also has been associated with reductions in the number of sex partners and in the exchange of sex for money or for illicit drugs (237,238). Substance abuse treatment also facilitates the prevention of TB among persons who use drugs illicitly. It also includes referral and linkage to programs for prevention and treatment of infectious diseases and substance use and mental disorders (255,256). An indirect protective effect of syringe exchange programs on HCV infection through reduced injection risk behaviors was found in a study of young persons (aged 18–30 years) who inject drugs illicitly conducted in several cities (269).
Referral to and linkage with mental health services provide a supportive role for persons receiving treatment for infectious diseases and substance use disorders, including persons who are receiving treatment for hepatitis C infection, because HCV treatment regimens are associated with increased levels of depression (294,296,297).
A second approach is the "strengths-based case management approach," which calls on clients to identify internal strengths and abilities and to develop a personal plan that includes meetings with case managers to acquire needed resources (298,299). HIV-related strategies carried out in different venues and facilities, such as the "seek, test, treat, and retain" strategy, target persons who use drugs illicitly and help to identify those who are HIV-positive and link them to care (312). They also should be instructed about how to reduce the risk for transmitting their infections to others, receive encouragement to seek further medical evaluation, and, if necessary, be given information about the importance of adhering to medical treatment regimens. Directly observed therapy (DOT) for TB, in which the infected person receives treatment for TB infection or TB disease in the presence of a provider, and shorter treatment regimens have improved treatment adherence and completion among patients, including those who use drugs illicitly (3). For example, rifampin, a first-line medication for treating TB, interacts both with methadone (for treating addiction to heroin) and with efavirenz and nevirapine (for treating HIV infection) (329,330). Other studies have indicated that HCV treatment adherence among persons who use drugs illicitly was increased by use of integrated service models that included mental health and substance abuse treatment (335,336), peer-based support groups (335), and a specific version of DOT for HCV treatment (337). Service integration is intended to enhance the receipt of comprehensive or multiple interventions that persons who use drugs illicitly need and to target methods of service delivery, with an emphasis on co-locating services or having a single point of entry. In New York State several substance abuse treatment centers have implemented a comprehensive prevention program of outreach, HIV education, counseling, testing, referral, and partner notification (343). Economic analyses demonstrate the cost or cost-effectiveness of integrated services (346,347,370–372). The statements on the cards all relate to issues concerning Education for All and human rights and education. Give each group just 5 minutes to feed back and allow no more than an extra 5 minutes for questions from the floor. When explaining how to play the game, you may like to illustrate the instructions by showing what one of the pairs looks like. In addition, patients frequently are lost to follow-up in transition from the detection and diagnosis to the treatment of disease.
In late 2010 and throughout 2011, DHHS agencies, including DHHS offices, reviewed a draft of this report to ensure that the recommendations were science-based and consistent with the missions and recommendations of DHHS agencies and offices. The Advisory Committee on Immunization Practices and CDC issued the vaccination recommendations. The evidence supports delivery of integrated prevention services at venues that serve persons who use drugs illicitly.
Drug overdose death rates increased nearly fivefold during 1990–2007 (from two deaths per 100,000 population in 1990 to nine per 100,000 in 2007) (42). For example, CDC estimates that the rate of new HIV diagnoses among MSM is between 44 and 86 times that among other men, and between 40 and 77 times that among women (61).
For example, in recent years, a convergence in HIV prevalence and incidence among those who engage illicitly in injection or noninjection drug use suggests that a decrease has occurred in HIV transmission; the decrease is associated with safer use of syringes. Psychiatric diagnosis of dependence requires evidence of consequences during an extended period of time (114). The strategy provides a collaborative and balanced approach that emphasizes community-based prevention, integration of evidence-based treatment into the health-care system, innovations in prevention and treatment strategies in the criminal justice system, and international partnerships to disrupt drug-trafficking organizations (118,119). In addition, outreach workers can help in building trust in prevention and treatment services and in health-care providers (106,127,137). The screening and counseling recommendations for preventing HIV infection, viral hepatitis, STDs, and TB infection in persons who use drugs illicitly have been summarized (Box 1). The first vaccine dose typically should be administered immediately after collection of the blood sample for serologic testing (166). Sexual transmission of HIV among persons who use drugs illicitly is associated with several factors, including a history of other STDs, recent initiation of illicit drug injection, and exchange of sex for money or for illicit drugs (87).
Decision makers can consider strengthening risk-reduction programs because data from several cities indicate that a greater proportion of HIV infections are attributable to sexual risk than to injection risk among persons who use drugs illicitly (4,107,183). Safety Counts and Community Promise are two evidence-based HIV prevention interventions for persons who use drugs illicitly that were developed based on work with persons who were recruited from settings other than substance abuse treatment. Other factors affecting access to substance abuse treatment programs include poverty, lack of health insurance, and fear of being stigmatized as persons who use drugs illicitly (138). For example, cognitive and behavioral therapies are effective treatments for abuse of amphetamine-type stimulants; the use of such therapies has demonstrated reductions in illicit drug use and in high-risk behaviors (125,231).
Congress reinstated a ban on the use of federal funds for carrying out any program that distributes sterile needles or syringes for hypodermic injection of illegal drugs.
However, the prevalence and incidence of HCV infection remain higher among those persons than among the general population (64,271–273).
Condom distribution has been demonstrated to reach a substantial segment of the population and to be cost-effective (280). A third approach is active linking, which can include health-care visits accompanied by a linkage coordinator or case manager to ensure that clients obtain appropriate medical care.
Such strategies also can support those in the criminal justice system who need to be linked to care during and after incarceration (308,313–315).
Most persons who use drugs illicitly are capable of adhering actively to complex medical regimens (148,316–319). Persons who use drugs illicitly should be counseled to avoid alcohol and other drugs that are harmful to the liver and to seek treatment for substance use and, if necessary, for mental disorders (338). Recently, European agencies and partners have called for targeted delivery of services to persons who inject drugs and have suggested that services should be combined, organized, and delivered according to user needs and local conditions (341).
The Massachusetts Department of Public Health has integrated its HIV, hepatitis, and addiction services (346). If one (or both) of the cards is a statement card, then the player reads aloud the title and the statement (not the question in italics a€“ that is for part 2!). Consolidated guidance can strengthen efforts of health-care providers and public health providers to prevent and treat infectious diseases and substance use and mental disorders, use resources efficiently, and improve health-care services and outcomes in persons who use drugs illicitly. Without access to integrated prevention services, persons who use drugs illicitly would need to go to different facilities to access prevention and treatment services for HIV infection, viral hepatitis, STDs, or TB and for substance use or mental disorders. Illicit use of alcohol by youth, alcohol intoxication, and illicit use of drugs are associated with unsafe sexual behaviors, which are risk factors for HIV infection, viral hepatitis, and STDs. Despite these concerns, a coordinated approach to integrated service delivery can improve services offered to persons who use drugs illicitly and can improve their health seeking behaviors. The recommendations for screening or testing of persons who use drugs illicitly for HIV infection, viral hepatitis, STDs, and TB made by AHRQ and the U.S. In 2006, among unintentional injury- and accident-related causes of death, rates of drug overdose were second only to motor-vehicle crash deaths (42). There has also been a corresponding increase in HIV transmission associated with risky sexual behaviors (89).
In the United States, approximately one in five patients with active TB either uses a drug illicitly or drinks alcohol in excess, or both (103). Increased awareness of infectious disease comorbidities is especially important for delivery of comprehensive and integrated services. Salient markers of dependence include loss of behavioral control over using drugs, withdrawal symptoms, and an obsessive-compulsive style of use. The priorities of the national strategy to reduce drug demand acknowledge that it is important to prevent drug use, reduce drug use, and treat substance abuse, and that behavioral, social, environmental, and structural factors contribute to illicit use of drugs (119,120).
Providing drug- and sex-related risk-reduction information and materials via trusted peers, while not sufficient to reduce the prevalence of behaviors associated with increased risk for infections, can help establish safer peer norms of behavior and common expectations of safer behaviors (4,11,127). Public Health Service Task Force to reduce perinatal HIV transmission do not outline special considerations for pregnant women who use drugs illicitly, the recommendations note that discontinuing illicit use of drugs has been associated with a reduced risk for perinatal transmission of HIV (172).
Male-to-male sex as well as illicit use of drugs through noninjection means, including the use of such stimulants as crack cocaine and methamphetamine, is associated with increased risky sexual behaviors; these drugs increase the libido or reduce inhibitions (70,86).
The brief counseling intervention in project RESPECT that reduced sexual risk among persons seeking care at STD clinics (184) was also effective in reducing sexual risk and bacterial STDs among those who had ever injected drugs illicitly (183). These interventions, which use goal-oriented counseling and peer-support approaches while drawing on several behavior-change principles, have been associated with reductions in high-risk behaviors (207–210). In addition, condom use can reduce risk for oral and vaginal transmission of HIV, viral hepatitis, and bacterial and viral STDs among persons who use drugs illicitly (57,70,71,106,183,281–286). Alternatively, they can be notified (through the use of information provided confidentially and on a voluntary basis by the infected persons) by trained health department personnel or by health-care providers.
Persons who use drugs illicitly and are HIV-positive are capable of adhering to HIV treatment (318,319).
San Diego offers an integrated program of hepatitis, STD, and HIV prevention services (347). Implementing integrated services is intended to increase access to services, improve the timeliness of service delivery, and increase the effectiveness of efforts to prevent infectious diseases and disorders that share common risk factors, behaviors, and social determinants. DHHS operating divisions or institutes that approved this guidance included the Agency for Healthcare Research and Quality (AHRQ), CDC, the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the National Institute on Drug Abuse (NIDA), the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration (SAMHSA). Earlier versions of this report were presented at the National HIV Prevention Conference held in August 2009 and at the National STD Prevention Conferences held in March 2010 and in March 2012.
Data from the 2008 NSDUH indicate that an estimated 3.8 million persons in the United States have used heroin at least once in their lives and that an estimated 213,000 persons used heroin during the month before data collection (26). Opioid pain medications account for the highest number of unintentional overdose deaths, followed by cocaine and heroin (43). The number of new HIV infections is highest among MSM, particularly young MSM, and next highest among persons infected through heterosexual contact, followed by persons who inject drugs (58).
The criteria commonly used for dependence include 1) more use of a substance than intended, 2) inability to reduce use, 3) amount of time seeking the substance, 4) physical effects of use, 5) use replacing other activities, 6) continued use despite problems, 7) tolerance, 8) withdrawal symptoms, or 9) use to avoid withdrawal symptoms (114). HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women (149). This result indicates the potential value of offering and evaluating brief counseling for reducing sexual risk (183).
Adherence interventions might greatly enhance the effects of nonpharmacologic psychotherapies and medications and reduce high-risk behaviors associated with acquisition or transmission of infectious diseases (232,233). Because gonorrhea, chlamydia, syphilis, HSV-2, and HIV can be transmitted by oral sex, condom use also can reduce transmission of these infections through oral sex (283).
The guidance does not review the topic of physical integration of all medical treatment services for such diseases, especially as different regulatory, accreditation, and licensing policies govern the delivery of treatment services for these diseases. Environmental factors common among persons who use drugs illicitly include unstable living conditions, and limited availability of sterile injection and drug preparation equipment (13). The DHHS offices and staff divisions that approved this guidance included the Office of the Secretary, the Office of the Assistant Secretary for Health, the Office of the Assistant Secretary for Legislation, the Office of the Assistant Secretary for Planning and Evaluation, the Office of the Assistant Secretary for Public Affairs, the Office of the Assistant Secretary for Financial Resources, the Office of the General Counsel, and the Office of Global Affairs. Drug overdose is a leading cause of mortality among persons who inject drugs illicitly (44–49). Many studies highlight the role of methamphetamine and other drugs in risky sexual behavior among MSM as well as the effect of crack cocaine use on exchange of sex for illicit drugs, all of which have implications for infection with HIV and STDs (88,91–98). State and local health departments provide partner notification services according to state and local regulations. Active linking based on the principles of a "strengths-based, intensive case management approach" has been more successful than a mere referral in getting persons with newly diagnosed HIV infection to make at least one medical care visit (298,303). Therefore, past or current illicit use of drugs should not be considered a contraindication to successful treatment for infectious diseases. However, the guidance emphasizes the importance of treatment for infectious diseases as a major strategy in preventing their further transmission. Lack of access to and underenrollment in substance abuse treatment programs are other structural factors contributing to infectious disease transmission. In addition, several experts who are not part of the federal or local government reviewed the draft guidance and provided questions or comments that were addressed in this report (see Acknowledgments).
Previously unvaccinated women at risk for HBV infection, including persons who use or inject drugs illicitly, should be vaccinated against HBV infection. Protocols for partner services include services for patients who inject drugs illicitly, engage in risky sexual behaviors, or have signs or symptoms of infections.
Linkage-to-care approaches are effective in improving health-care outcomes; on the other hand, referral alone has not been effective in enhancing linkage and adherence to care (304,305). Treatment of infectious diseases reduces and potentially prevents transmission of infectious diseases in the communities where persons who use drugs illicitly reside (317). The guidance also emphasizes treatment of substance use and mental disorders, comorbidities that must be treated effectively to optimize prevention outcomes for infectious diseases. In addition, fear of arrest by law enforcement officers and fear of discrimination by health-care providers can discourage persons who use drugs illicitly from using health-care services adequately (14).
These persons have expertise in prevention and treatment of HIV infection, viral hepatitis, STDs, TB, substance use disorders, and mental disorders; they are affiliated with private organizations that support services provided to persons who use drugs illicitly, or else have experience working with this population.
Monitoring changes in drug use among all age groups remains important for developing and implementing relevant prevention and treatment programs (28–30). All patients should receive treatment as well as risk-reduction counseling or be referred for counseling or other prevention interventions (287).
Sex partners and drug-using partners and contacts of infected persons should be identified and provided with prevention information, in addition to referral for medical evaluation and for treatment, if necessary. Persons who use drugs illicitly often have other complex health and social needs, including treatment for substance abuse and for preexisting or concurrent mental disorders (9,15–17). None of these reviewers reported financial or other conflicts of interest that would preclude their involvement in reviewing this guidance.
Throughout the guidance provided in this report, efforts to facilitate treatment of infectious diseases and treatment of substance use and mental disorders also are classified as preventive interventions.



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