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The Elephant in the Room: Talking to Patients About HIV in Addiction Medicine Settings

Jenna Butner, MD

Affiliate Medical Assistant Professor
Department of Clinical Medicine
CUNY School of Medicine
New York, New York
Attending Physician
Addiction Medicine and Infectious Disease
Bronx, New York


Jenna Butner, MD, has no relevant conflicts of interest to report.


View ClinicalThoughts from this Author

Released: August 24, 2020

Given the incidence of HIV among people who inject drugs, it is prudent to counsel patients in substance use disorder treatment settings about their risk of HIV infection and how to prevent HIV transmission. In practice, of course, there are many barriers that get in the way of this happening, but in my experience, until these discussions are had, HIV infection is the elephant in the room. As addiction care providers, we need to ask ourselves, if not now, when? We are already talking to our patients about their substance use, which has its own challenges, so we may as well discuss HIV, hepatitis C, and other sexually transmitted infections.

Many patients with substance use disorders are terrified of going to other providers. Unfortunately, there exists stigma of addiction in medical settings, which then translates into fear of discussing infections like HIV or hepatitis C. Often the fear of judgment involved in asking a provider to be screened for these infections translates into discouraging openness. As an addiction medicine provider, I am providing my patients with primary care, infectious disease management, and mental healthcare. By believing in those patients and showing them the respect and dignity they deserve, we may become very symbolic for them because, in general, they are less likely to experience that kind of treatment from other providers.

Using Pre-Exposure Prophylaxis (PrEP) as an Entry Point for Ongoing Intervention
PrEP is an underused resource for HIV prevention in a range of at-risk populations, but particularly among people who inject drugs. For addiction providers, talking to our patients about PrEP should be considered essential, and ideally all patients who meet criteria should be receiving the medication. PrEP delivery is straightforward and does not need to be prescribed by a specialist; however, consultation with an experienced colleague is always an option.

Having a patient on PrEP opens the door to talk about prevention of sexually transmitted infections and safer drug use. It also ensures a patient is secured into a system of regular screening, because once they start PrEP, they will need to return for follow-up monitoring every 3 months, at the bare minimum. As addiction care providers, we should keep in mind that our patients may be engaging not only in high-risk practices relating to their drug use but also in high-risk sexual behaviors. I think of that initial discussion that we may have with a patient about PrEP as ripping off the Band-aid. Once HIV risk has been put on the table, it makes it easier to talk about sexual practices that may put them at increased risk. We have established that safe space for our patients, which is critical to establishing and maintaining their trust. For women of childbearing age, we need to use that space not only for talking about PrEP, but also about contraception. I always try to incorporate discussion about family planning for all patients.

PrEP prescribing may also act as a gateway for addiction medicine providers to gain confidence in prescribing ART to treat HIV infection. This is an important provision both in more remote settings, as well as within centers more closely linked to infectious disease services, bearing in mind that our patients may be most comfortable accessing HIV care with their addiction care provider. Over the years, HIV treatment has been greatly simplified. Patients who are virologically suppressed are seen for follow-up only a few times per year. In my view, addiction medicine is far more complex than treating HIV, prescribing PrEP, or providing HCV treatment. And it is rewarding. When you treat a patient’s substance use disorder, you become a trustworthy person for that patient. When you treat HIV, it is the same­—you are trusted with information that is not readily shared by your patients. It is another layer of trust to build with your patients.

Resources and Your Thoughts
So, if you are an addiction medicine provider, including all practitioners such as pharmacists, who wants to learn more about HIV medicine, where do you start? There are many excellent sources of HIV education available, including Clinical Care Options’ live and online programs and the American Academy of HIV Medicine, which provides certification as an HIV medicine provider, as well as linking providers to a mentoring program. What other resources have you found helpful? Share your thoughts in the comment box.

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