• New York State Department of Health. Medical care of HIV-infected substance-using women. New York (NY): New York State Department of Health; 2005. 6 p. [17 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Substance-use and substance-use disorders

Counseling
Management
Screening

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Preventive Medicine

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments
Substance Use Disorders Treatment Providers

To address gender differences in the causes, progression, and effective methods of treatment for substance use disorders among women

Human immunodeficiency virus (HIV)-infected substance-using women

1. Obtaining a patient's substance use history
2. Screening all substance-using women for trauma and physical and/or sexual abuse
3. Counseling patients about practicing risk-reduction activities including safer sexual activities and using latex or polyurethane condoms
4. Counseling all human immunodeficiency virus (HIV)-infected pregnant women and women of childbearing age about the specific effects of alcohol and illicit drugs on the fetus
5. Referring substance-using women to drug-treatment programs that are best able to meet the needs of individual patients
6. Co-management of HIV-infected substance users by an HIV specialist and obstetrical care provider
7. Inpatient or outpatient treatment for alcohol- and cocaine-dependent HIV-infected women
8. Methadone maintenance for an HIV-infected women dependent on opioids
9. Considering buprenorphine for opioid dependency in pregnant women on a case-by-case basis
10. Consultation between a pediatric HIV specialist and the pregnant opioid user
11. Reporting cases of suspected abuse or neglect of other children in the household to the New York State Central Registry

• Prevalence of substance use and substance use disorders among women
• Efficacy of management strategies for substance use in women

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3 to 4 times per year, and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Gender Differences in Substance Use

Prevalence of Substance Use and Substance Use Disorders Among Women

Key Point

Women are more likely to misuse prescription drugs than men.

Patterns and Impact of Use

The clinician should inquire about the addiction patterns of the patient's partner(s) when obtaining a patient's substance use history.

Key Point

Women injection drug users (IDUs) are more likely than male IDUs to adopt the drug use patterns of their partners and to share needles with their partners.

Barriers to Treatment

When referring substance-using women to drug-treatment programs, clinicians should choose programs that are best able to meet the particular needs of the individual patient.

Contraception for the Substance-using Woman

Clinicians should counsel all human immunodeficiency virus (HIV)-infected women to use latex or polyurethane condoms, regardless of current contraceptive method of choice.

Key Point

Combined oral contraceptives may be contraindicated in women with abnormal liver function.

Pregnant HIV-Infected Substance-Using Women

Clinicians should counsel both HIV-infected pregnant women and HIV-infected women of childbearing age about the specific effects of alcohol and illicit drugs on the developing fetus.

Pregnant HIV-infected substance users should be co-managed by an HIV Specialist and an obstetrical care provider experienced in the care of HIV-infected women.

Although there is no mandate in New York State to report substance use during pregnancy to child protective services, New York State law requires clinicians to report cases of suspected abuse or neglect involving other children in the household to the New York State Central Registry at 1-800-635-1522.

Opioid Use

If a woman who is dependent on opioids becomes pregnant, the clinician should discuss treatment options with her, informing her that methadone maintenance is preferred to detoxification. If she is already enrolled in a methadone maintenance program, the clinician should advise her to continue it.

Clinicians should arrange a consultation between a pediatric HIV Specialist and the pregnant opioid user to discuss the possibility of neonatal withdrawal syndrome and the care of the neonate.

Alcohol Use

Clinicians should recommend inpatient or outpatient treatment for alcohol-dependent pregnant women.

Pregnant women who are physically dependent on alcohol should undergo medically supervised detoxification prior to initiating longer-term abstinence-based treatment.

Key Point

Infants whose mothers consume excessive amounts of alcohol during pregnancy are at high risk for adverse effects, such as fetal alcohol syndrome, regardless of the HIV infection status of the mother.

Cocaine Use

Clinicians should recommend inpatient or outpatient treatment for cocaine-dependent pregnant women.

Substance Use and Trauma in HIV-Infected Women

Clinicians should screen all substance-using women for trauma and physical and/or sexual abuse, which may trigger or exacerbate substance use in female patients. Initial assessments of new female patients should include questions that document whether a woman has a history of past or current physical or sexual abuse.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• This guideline may help the clinician with appropriate counseling and management of human immunodeficiency virus (HIV)-infected substance-using women
• Methadone maintenance treatment is an effective therapy for opioid-dependency during pregnancy, and does not adversely affect fetal or post-natal development.

Not stated

Combined oral contraceptives may be contraindicated in women with abnormal liver function.

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening, or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience.
• Define target audience (providers, consumers, support service providers).
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)?
• Define implementation methods.
  • What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)?
• Determine appropriate implementation processes.
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)?
  • What necessary processes are external to the organization (e.g., meetings with external groups, conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress.
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate.
  • Did the processes and strategies work? Were the guidelines implemented?
  • What could be improved in future endeavors?

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• New York State Department of Health. Medical care of HIV-infected substance-using women. New York (NY): New York State Department of Health; 2005. 6 p. [17 references]

Not applicable: The guideline was not adapted from another source.

2005 Mar

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Substance Use Committee

Committee Members: Marc N. Gourevitch, MD, MPH, Director, Division of General Internal Medicine, New York University School of Medicine (Chair); Bruce Agins, MD, MPH, Medical Director, AIDS Institute, New York State Department of Health; Julia H. Arnsten, MD, MPH, Associate Professor, Medicine, Epidemiology and Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center; Steven L. Batki, MD, Director, Addiction Psychiatry Clinic, Crouse Chemical Dependency Treatment Services, Interim Associate Chief of Staff for Research, Syracuse VA Medical Center, Professor and Director of Research, Department of Psychiatry, SUNY Upstate Medical University; Lawrence S. Brown, Jr., MD, MPH, Clinical Associate Professor of Public Health, Weill Medical College, Cornell University, President, American Society of Addiction Medicine, Senior Vice President, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Brenda Chabon, PhD, Assistant Professor, Dept. of Psychiatry and Behavioral Sciences, Montefiore Medical Center/Albert Einstein College of Medicine; Barbara Chaffee, MD, MPH, Clinical Associate Professor of Medicine, Upstate Medical Center Clinical Campus at Binghamton, Binghamton, New York, Medical Director, Internal Medicine, Binghamton Family Care Center, United Health Services Hospitals; Steven Kipnis, MD, FACP, FASAM, Medical Director, New York State Office of Alcoholism & Substance Abuse Services; Nancy Murphy, NP, HIV Primary Care Provider, Center for Comprehensive Care, Room 14A36, St Luke's Roosevelt Hospital Center; David C. Perlman, MD, Chief, Infectious Diseases, Beth Israel Medical Center - Singer Division, Professor of Medicine, Albert Einstein College of Medicine, Director, AIDS Inpatient Unit, Beth Israel Medical Center; Benny Primm, MD, Executive Director, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Sharon Stancliff, MD, Medical Director, Harlem East Life Plan, Medical Consultant, NYSDOH, AIDS Institute; Robert Whitney, MD, Erie County Medical Center

AIDS Institute: Diane Rudnick, Director, Substance Abuse Section, New York State Department of Health

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on May 5, 2005.