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Guideline Summary
Guideline Title
Medical care of HIV-infected substance-using women.
Bibliographic Source(s)
New York State Department of Health. Medical care of HIV-infected substance-using women. New York (NY): New York State Department of Health; 2009 Feb. 6 p. [15 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: 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]

Scope

Disease/Condition(s)

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

Guideline Category
Counseling
Management
Screening
Clinical Specialty
Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments
Substance Use Disorders Treatment Providers
Guideline Objective(s)

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

Target Population

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

Interventions and Practices Considered

  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. Avoidance of combined oral contraceptive use in women with abnormal liver function
  5. 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
  6. Referring substance-using women to drug-treatment programs that are best able to meet the needs of individual patients
  7. Co-management of HIV-infected substance users by an HIV specialist and obstetrical care provider
  8. Inpatient or outpatient treatment for alcohol- and cocaine-dependent HIV-infected women
  9. Methadone maintenance for an HIV-infected women dependent on opioids
  10. Considering buprenorphine for opioid dependency in pregnant women on a case-by-case basis
  11. Consultation between a pediatric HIV specialist and the pregnant opioid user
  12. Reporting cases of suspected abuse or neglect of other children in the household to the New York State Central Registry

Major Outcomes Considered

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

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with human immunodeficiency virus (HIV) infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

* Current committees include:

  • Medical Care Criteria Committee
  • Committee for the Care of Children and Adolescents with HIV Infection
  • Dental Standards of Care Committee
  • Mental Health Committee
  • Women's Health Committee
  • Substance Use Committee
  • Physician's Prevention Advisory Committee 
  • Pharmacy Committee
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

Recommendations

Major Recommendations

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

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

Key Point:

Female 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.

Clinicians should avoid the use of combined oral contraceptives 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 potential about the specific effects of alcohol and illicit drugs on the developing fetus.

Pregnant HIV-infected substance users should be co-managed by an experienced HIV provider 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.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Overall Benefits

Appropriate counseling and management of human immunodeficiency virus (HIV)-infected substance-using women

Specific Benefits

Methadone maintenance treatment is an effective therapy for opioid-dependency during pregnancy, and it does not adversely affect fetal or post-natal development.

Potential Harms

Not stated

Contraindications

Contraindications

  • The US Food and Drug Administration (FDA) considers pregnancy a contraindication for buprenorphine use; however, many clinicians feel that buprenorphine is a safer alternative to methadone or heroin use.
  • Combined oral contraceptives should be avoided in women with abnormal liver function.

Implementation of the Guideline

Description of Implementation Strategy

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with human immunodeficiency virus (HIV) infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
New York State Department of Health. Medical care of HIV-infected substance-using women. New York (NY): New York State Department of Health; 2009 Feb. 6 p. [15 references]
Adaptation

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

Date Released
2005 Mar (revised 2009 Feb)
Guideline Developer(s)
New York State Department of Health - State/Local Government Agency [U.S.]
Source(s) of Funding

New York State Department of Health

Guideline Committee

Substance Use Committee

Composition of Group That Authored the Guideline

Committee Chair: Marc N. Gourevitch, MD, MPH, New York University School of Medicine, New York, New York

Vice-Chair: Chinazo O Cunningham, MD, MS, Montefiore Medical Center, Bronx, New York

Committee Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Julia H. Arnsten, MD, MPH, Montefiore Medical Center, Bronx, New York; Lawrence S. Brown, Jr., MD, MPH, FASAM, Addiction Research and Treatment Corporation, Brooklyn, New York, Weill Medical College, Cornell University, New York, New York; Brenda Chabon, PhD, Montefiore Medical Center, Bronx, New York; Barbara Chaffee, MD, MPH, United Health Services, Binghamton, New York; Michael Christie, MD, Anthony L Jordan Health Center, Rochester, New York; Nereida Ferran-Hansard, MD, Jacobi Medical Center, Bronx, New York; Steven S Kipnis, MD, FACP, FASAM, New York State Office of Alcoholism & Substance Abuse Services, Orangeburg, New York, Albany Medical College, Albany, New York; Joseph P Merlino, MD, MPA, Kings County Hospital, Brooklyn, New York; Nancy Murphy, NP, St Luke's Roosevelt Hospital Center, CUNY Graduate Center, New York, New York; Edward V Nunes, MD, Columbia University College of Physicians and Surgeons, New York, New York; David C Perlman, MD, Beth Israel Medical Center, New York, New York, National Development and Research Institutes, New York, New York, Albert Einstein College of Medicine, Bronx, New York; Sharon Stancliff, MD, Harm Reduction Coalition, New York, New York; Robert B Whitney, MD, Erie County Medical Center, Buffalo, New York

Liaisons: Daliah Heller, MPH, Liaison to the New York City Department of Health and Mental Hygiene, New York, New York; Diane M Rudnick, MEd, Liaison to the New York State Department of Health AIDS Institute, New York, New York

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: 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]

Guideline Availability

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site External Web Site Policy.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on May 5, 2005. This NGC summary was updated by ECRI Institute on January 4, 2009.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site External Web Site Policy for terms of use.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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