The purpose of this article is to identify an alcohol and other drug (AOD) treatment protocol for HIV-infected individuals seeking those services, a protocol that is both effectual and acceptable for medical health care and AOD treatment providers. The article first presents the scope of the problem and current treatment methods, based on a review of the literature; then it describes motivational interviewing and advocates for its use as a best practice model for this doubly vulnerable and at-risk population — HIV-infected individuals who use AODs.

Abstinence is the foundation of many AOD treatment facilities around the United States, but surprisingly, the majority of AOD money earmarked for HIV-infected addicts supports a harm reduction approach (U.S. Department of Health and Human Services, n.d.). In addition to methadone programs, there are other harm reduction efforts being funded by the U.S. Department of Health and Human Services, specifically through the Ryan White CARE Act. Within the Title III, IV and Special Projects of National Significance (SPNS) grantees, funded through Ryan White, 90 percent of the programs providing substance abuse treatment services took a harm reduction approach to treatment (n.d.).

Though research and clinical protocol support the use of the abstinence-based approach, medical health follows one of harm reduction. Because most hospital-based physicians cannot easily identify patients who need AOD assistance, Blondell and colleagues (2001) note, such clinicians lack either the skills and/or the time necessary to deal with these issues. The result is that physicians may focus primarily on treating physical complaints and HIV-related disease progression, while remaining hopeful that the client can reduce the harm caused by their AOD problem.

Harm reduction, also referred to as damage limitation, risk reduction, and/or harm minimization, does not ascribe to a specific formula, but rather reflects specific individual and community needs (Reid, 2002). Researchers (Brettle, 1991; Des Jarlais, 1995; Des Jarlais & Friedman, 1993; Inciardi & Harrison, 2002) contend that harm reduction intervention and policies have emerged as viable strategies to ameliorate the adverse health, social, and economic consequences associated with AOD use behaviors. Proponents of harm reduction acknowledge the prevalence of illicit drug use in our communities, and recognize that drugs may not always be used in a safe manner; they also believe that the prevalence of addiction can be remedied by teaching addicts safer or reduced drug-use practices (Reid, 2002).

Although HIV health care providers and AOD treatment professionals may approach treatment differently, recent data suggest that continued AOD use: (a) impairs cognitive functioning resulting in poor decision-making (e.g., lowering of inhibitions, medication non-compliance, and treatment retention) (Masliah, Ge, & Mucke, 1996); (b) accelerates the progression of the HIV infection, depleting overall health (Meyerhoff, 2001; Petry, 1999); and (c) influences risk behaviors thereby continuing the spread of HIV (Avins, Woods, Lindan, Hudes, Clark, & Hulley, 1994; Metzger, Navaline, & Woody, 1998; Stein, Hanna, Natarajan, Clarke, Marisi, Sobota, & Rich, 2000). In light of these discoveries, a coinciding increase has been noted in HIV transmission, which is challenging HIV health care providers and alcohol and drug counselors to re-examine approaches to care. AOD counselors who believe in abstinence-based treatment should provide the means necessary to accommodate referrals from medical facilities along with altering the image that AOD treatment is generally uncompromising with HIV-infected addicts.

AOD use and HIV transmission
Research suggests that AOD abuse plays a dominant role in HIV transmission. For example, HIV historically has been most prevalent among men who have sex with men (Catania, Osmond, Stall, Pollack, Paul, Blower, Binson, Canchola, Mills, Fisher, Choi , Porco, Turner, Blair, Henne, Bye, & Coates, 2001) and most new HIV infections are reported between this population and among injection drug users (Karon, Fleming, Steketee, & De Cock, 2001).

Current findings indicate that AIDS is highly prevalent and being transmitted in ways and in populations that are historically undocumented (i.e., heterosexual females and minority groups). With an estimated total infection rate approaching 900,000 in the United States and 40,000 new cases of active AIDS diagnosed annually (Karon et al., 2001), the proportion of HIV cases acquired through heterosexual contact has increased and is now equal to the proportion of cases attributed to intravenous drug use (Center for Disease Control and Prevention, 2001; Karon et al., 2001). Additionally, reports of women being infected with HIV have tripled since the mid-1980s mainly resulting from heterosexual exposure and secondarily from intravenous drug use (Center for Disease Control and Prevention, 2001). Finally, minority groups are the most affected by HIV associated with drug injection and blacks and Hispanics now account for approximately 70 percent of all new AIDS cases (Center for Disease Control and Prevention; Karon et al., 2001).

It is ironic that the medical field would remain tolerant of advocating reduced and controlled drinking given a large body of medical literature that has suggested AOD abuse (above 1 or 2 drinks per day) negatively effects most body systems. Many HIV-positive individuals seeking AOD treatment report a decade or more of abuse that has gone untreated, and AOD abuse seems to be high among this population. For example, among cross-sectional studies comparing HIV-infected subjects and non-infected ones, Rosenberger and colleagues (1993) discovered that approximately 75 percent had a lifetime diagnosis of AOD abuse. As reported earlier, a heavy drinking history places people in the higher risk category for contracting HIV/AIDS. Additionally, HIV-infected individuals who abuse AOD are apt to have higher rates of cognitive impairment than those who do not (Egan, Crawford, Brettle, & Goodwin, 1990).

For the AOD addict entering treatment for HIV/AIDS, it is important to fully address both illnesses. This can require a more intensive level of substance abuse treatment. One of the strongest indicators of AOD treatment success has been the amount of time in treatment and completion rate (e.g. Miller & Rollnick, 2002). It takes time to heal from any disease, and AOD addiction is no exception, especially considering those who are also HIV-infected. A goal of successful AOD treatment is to address psychosocial needs. Complete abstinence is the only way to assure the likelihood of unaltered cognitive function, health promotion, and minimize the spread of HIV. Treatment counselors who come into contact with an AOD-addicted HIV-infected client are confronted with a dual disease requiring a dual treatment. Given the mounting evidence of how AOD use interferes with both brain functions and HIV medications, treatment goals should include abstinence from all mind- and mood-altering substances, along with simple cognitive exercises that begin to heal malfunctions of the brain, thereby altering behaviors and lowering HIV exposure risk(s).

Current treatment methods
Current AOD treatment approaches for HIV patients are described in this section. We also suggest an approach that is amenable to both psychosocial counselors who are largely accustomed to delivering an abstinence-based approach and medical practitioners who may favor a harm reduction approach that is accepting reduced and limited abuse of AOD. This article does not debate the validity of abstinence-based versus harm reduction approaches, but does acknowledge widely differing views between medical practitioners and addiction counselors that could create a barrier to treatment and coordination of services. This discussion emphasizes a treatment approach that has been demonstrated to be effective in a variety of settings, including health care settings. We also review some research literature that might guide us in recommending a method that is amenable to both HIV health care providers and AOD counselors.

Based on interactions with several HIV medical providers, we have observed that physicians in AIDS clinics are sometimes not accepting of abstinence-based treatment approaches. There are many reasons for this, such as their focus on physiological issues related to HIV progression; their lack of funding and reimbursement to engage in abstinence-based treatment; their lack of education on the treatment of substance abuse; and their education, which emphasizes proven and research-based practice. Regarding the latter point, addiction counselors may be surprised to know that while research generally has supported the effectiveness of treatment for addiction, results have not been impressive. In this regard, Miller and colleagues (1992) summarize several well-designed research studies noting that only 24 percent of those treated in abstinence-based treatment (including cognitive-behavioral skills training and 12-step facilitative methods) remain completely abstinent in the year following treatment. In addition, while there is considerable correlational evidence to support 12-step effectiveness, there is no evidence of its effectiveness derived from well-designed randomly controlled trials. This lack of respected research evidence may further limit physician referrals to treatment programs, which are largely based on 12-step facilitative strategies. Although Project MATCH and the Veterans Administration study provided random assignment to one of three conditions, motivational enhancement therapy (MET), cognitive behavioral therapy (CBT), and 12-step facilitation (TSF),1 neither study provided a no-intervention group and the results indicated that TSF approaches improved post-treatment drinking outcomes as good or better than MET or CBT (Humphreys, 1999). CBT and brief interventions designed and tested for physicians (CSAT, 1999) are equally unlikely to be implemented by medical practitioners given that they are psychology based, time consuming, and intensive — requiring more than one session and not fitting with physiological and fast-paced culture of the medical world (Blondell, Looney, Northington, Lasch, Rhodes, & McDaniels, 2001).

Motivational interviewing (MI) (Miller & Rollnick, 2002) is a proven practice method that has been shown to be as effective as CBT and TSF methods, yet much briefer and time limited. For example, Project MATCH researchers (Project MATCH Research Group 1993, 1997a, 1997b), in a large (n = 1,726) and highly respected randomly controlled trial concluded that an adaptation of motivational interviewing, MET, delivered in four 1-hour weekly sessions (Miller et al., 1992) was as effective as CBT (Kadden, Carroll, Donovan, Cooney, Monti, Abrams, Litt, & Hester, 1992) or TSF methods (Nowinski et. al., 1992) delivered across 12 weekly one hour sessions. Although the adaptation of MI had one-third the number of sessions as CBT or 12-Step clients, the number of days using alcohol in the year following treatment was substantially the same across all three methods (Gordis & Fuller, 1999).

MI provides an approach to explore and resolve ambivalence about recovery. As such, MI may offer a common ground on which both AOD treatment field and health-care providers may be able to unite and collaborate to ensure appropriate care of HIV-infected individuals who are abusing substances. The logic behind using MI with this clientele is that replicated clinical trials have demonstrated it is a brief intervention (one to four sessions) effective at improving substance use outcomes as well as treatment retention and compliance (Zweban & Zuckoff, 2002; Miller & Rollnick, 2002). Miller and Rollnick (2002) define MI as a way of being with people and a set of clinical methods that can be taught and learned. MI involves the application of four basic principles; (a) expressing empathy; (b) developing discrepancy; (c) rolling with resistance; (d) supporting self-efficacy, thus enhancing intrinsic motivation related to initiating some change to a healthier behavior. MI matches specific treatment strategies to where the client is in the “stage of change” (Prochaska & DiClemente, 1982). Stages of change are:

Precontemplative – The client is unaware or unwilling to look at behavioral change. Interventions include learning why clients may be resistant to change and using strategies that diffuse that resistance in a positive way. Many or most HIV clients with substance abuse problems seem to fall into this category, either in early stages of addiction or simply unconcerned about changing their use of substances because of the high value placed on substance abuse as a method to cope with HIV/AIDS. The counselor or HIV professional can use a decisional balance exercise or value-based inquiry to create ambivalence and raise discrepancy (Miller & Rollnick, 2002). These exercises provide an opportunity for the client to consider the pros of using (e.g., relief of negative side effects from medications, such as nausea, stress reduction) compared to the many cons of alcohol and drug abuse.

Contemplative – In this stage, one recognizes behavior as a problem but is ambivalent about change. Skills to addressing contemplative clients consist of thinking through the risks of the identified problem behavior and potential benefits of change instilling hope that change is possible. The decisional balance exercise described above may be useful in this stage also; however, some type of goal or value based dialogue designed to raise discrepancy may be equally effective (Miller & Rollnick, 2002). The counselor should refer to the Miller and Rollnick’s Motivational Interviewing (2002) on strategies to increase discrepancy. In general, identify important goals and values and then facilitate discussion and raise awareness on how continued use fits with these goals and values. For instance, if the goal is to sustain health and to stay out of the hospital, the counselor can help the client see how the use of alcohol or drugs may interfere with this goal.

Preparation – In this period, there is a commitment to change in the near future, usually one month. A task for clinicians working with clients in the preparation stage is to assess the strength(s) of the client’s commitment to change and think creatively about how to develop the most effective plan of action. As with any motivational intervention, we would want to collaborate with the client on a plan of action.

Action – This is the stage in which change or modification of behavior takes place. Strategies involve careful listening and affirming for clients that they are doing the right thing while checking with the client to see if any revisions are needed. Once the client initiates changes in use of alcohol or drugs, the counselor would visit how these changes are progressing, checking any unanticipated negative effects (e.g., are symptoms of HIV more difficult to cope with, is the client practicing alternative coping strategies) of stopping the use of alcohol or drugs and are there any unanticipated positive effects (e.g., do medications actually work better, are they aware of how sobriety is helping them to achieve important goals and live congruently with cherished values).

Maintenance – This stage focuses on lifestyle modification in order to avoid relapse and stabilize behavioral change. A key to facilitating this stage is practicing an active and intelligent maintenance of the change clients have made (Cassidy, 1997; DiClemente & Prochaska, 1998). Interested readers are referred to the Miller and Rollnick (2002) book Motivational Interviewing or the Web site www.motivationalinterviewing.org for more information and training resources.

Once a patient overcomes ambivalence, the counselor’s clinical skills assist the client’s progression and movement along the stages of change continuum. MI facilitates this movement and builds on the foundation of understanding that the role of service providers is to advance patients toward a state of action that leads to improved health status outcomes. The idea is to challenge patients without eliciting defensiveness. In this regard, MI is presented as analogous with a dance between two individuals who are deferring judgment and averting confrontation. The overall goal of MI is to resolve ambivalence related to change and to vocalize the client’s ability (self efficacy) and reasons for engaging in a change. The professional’s role is to elicit this material, thereby building motivation in a constructive way.

Although the AOD treatment field has advanced over the years, addiction counselors continue to rely on the Minnesota Model or some form of 12-step facilitation treatment method (Humphreys, 1997). According to this model, which is not client-centered, the AOD counselor acts as an authority — the client is educated that they suffer from a progressive disease and must work through the “denial” and become completely abstinent from all AODs in a markedly confrontational counseling style (Cloud, McKiernan, & Cooper, in press; Miller & Rollnick, 1991, 2002). Miller & Rollnick (1991, 2002) present research evidence and generally argue against overt confrontation, education, and use of a one up authoritative therapy style, as well as provide support that such styles minimize client beliefs, reduce client self-determination, avert client collaboration in treatment planning, and generally raise resistance to treatment and treatment completion (Cloud et al., in press; Miller & Rollnick, 1991, 2002).

Because of differences previously summarized, we have observed that medically based personnel favor harm-reduction programs and are reluctant to refer to traditional abstinence-only treatment centers. We suspect that this is in part due to perception that addiction treatment tends to be heavy-handed — and even coercive. Furthermore, we contend that the spirit of MI is a better fit within the values and beliefs of the medical community. MI is a brief and research-based practice method that is proven to be successful at raising intrinsic motivation and self efficacy to volitionally engage clients in a collaborative recovery program while avoiding an authoritative role, reliance on education, use of overt confrontation, and mandated abstinence. MI is a highly directive and skilled method that, when practiced correctly, allows the client to reach the conclusion that abstinence is in his or her best interest and leads to collaboration on a treatment plan that can include more traditional forms of addiction treatment (e.g. TSF, CBT, involvement in 12-Step programs). In brief, MI’s directive approach increases levels of client motivation and commitment to change thereby facilitating a more naturally occurring change process.

Considerable research has demonstrated that MI is well-suited for improving treatment retention, abstinence, and reduced-risk behaviors. Although MI was developed as a treatment for alcohol problems, its application has spread in other areas including general medical care, health promotions, social work, and corrections. Because HIV-infected AOD-disordered individuals are often more available within health-care facilities, a brief and limited amount of MI sessions could be provided. As stated, given that MI is a proven practice method that does not presuppose abstinence, it is likely to make it more acceptable to the medical community compared to confrontational methods normally used by addiction professionals. Use of MI could eliminate the philosophical disparity between health care providers and AOD treatment providers. It is the belief of Miller and Rollnick (2002) that “it is the client who should be voicing the arguments for change” (p.22). This approach removes the addiction professional from the argument and focuses on the client’s motivation for change.

Summary
Research suggests that the rate of HIV infection within the AOD abusing population is ever increasing. This would seem to place medical health care and AOD providers on the same team. These two important players must work toward an agreeable, evidenced-based, treatment philosophy. Following are five strategies that we have learned that can be recommended as methods to enhance the effectiveness of services to addicted persons with HIV:

1. Recognize the importance of substance abuse as a coping strategy among this highly distressed population, and carefully formulate and aid the client in implementing alternative strategies to deal with their HIV status.

2. Implement MI (Miller & Rollnick, 2002) strategies, which fit better with the harm reduction mentality present in the medical world than the confrontative, educational approaches commonly observed in addiction treatment agencies.

3. Put into practice regular weekly MI supervision to insure greater MI protocol compliance and fidelity.

4. Focus motivational strategies on ambivalence related to both engaging the client in recovery as well as HIV treatment compliance.

5. Use MI strategies to advance and improve relations with the HIV medical treatment community.

Regarding the latter, it is likely that a certain amount of misunderstanding and ambivalence exists among the medical community related to our abstinence-based approaches to treatment; MI offers a complete package to help resolve ambivalence and to strengthen coordination of services. Because MI could bridge the gap between health-care providers and AOD treatment, it seems to be a promising alternative for those clients who continue to suffer from HIV and AOD addiction, and may be more readily accepted by the medical community.

David A. Patterson, MSSW, CADC, is in the PhD program at the University of Louisville Kent School of Social Work. He manages a CSAT TCE/HIV grant focusing on AOD treatment for HIV-infected and/or high-risk persons.

Richard N. Cloud, PhD, is an Assistant Professor at the University of Louisville Kent School of Social Work and is an active member of the Research Society on Alcoholism.

Patrick M. McKiernan, PhD, holds state and national certifications as an alcohol and drug counselor. For the past 14 years, he has worked for the Volunteers of America as head of the alcohol and drug treatment programs.

Footnote
1Project MATCH was a large (N=1726) and well controlled NIAAA experiment conducted over nine geographically dispersed sites wherein alcohol disordered subjects were randomly assigned to three treatment conditions, one of which was a TSFT method (N=553; Nowinski et al., 1992). Follow-up was conducted at 3, 6, 9, and 12 months intervals following treatment.

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This article is published in Counselor,The Magazine for Addiction Professionals, June 2004, v.5, n.3, pp. .

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