Risk behaviours and health care needs of drug-using female prostitutes (part II)

This paper is the second of two parts and focuses on the results of the study by Faugier (1996) in her investigation of the working practices, levels of HIV risk behaviour and use of health care services of 100 drug-using and 50 non-drug-using prostitutes in Manchester. It provides a full discussion on the implications of these findings and the challenges this poses for providers. Part I was published in Journal of Substance Misuse Vol. 2 No. 3, pp. 144–149.     

Intervening to identify and reduce drug use and sexual HIV risk patterns among men who have sex with men in three provinces in South Africa

Formative work to inform interventions aimed at addressing drug and sexual risk behaviours among men who have sex with men (MSM) in South Africa highlighted the need to target drug-using MSM with prevention interventions addressing both sexual and drug-related HIV risk. From 2007, in collaboration with two local NGOs, intervention activities were rolled out to vulnerable drug-using MSM. Over the first two years, 3475 drug-using MSM were reached through community outreach that promotes HIV/AIDS prevention and addresses drug risk behaviours and 745 among them were tested for HIV and received their results and 239 of them were referred from HCT to other services. Additionally, 66 individuals were trained to promote HIV/AIDS prevention services and 15 were trained in HCT. Twelve new targeted condom and lubrication services and 7 new HCT outlets were established. MSM reported a variety of high-risk activities including not using condoms for anal sex, having sex while under the influence of alcohol or drugs and sharing needles (among injection drug users). However, MSM were willing to develop risk reduction strategies. Year one and two of the intervention has demonstrated the willingness of the NGOs to broaden their service delivery, improved integration of drug treatment, HIV intervention and other services, and has shown positive results across a number of risk behaviours among MSM.     

HIV in women in the sex industry and/or injection drug users

Women working in the sex industry are at risk for HIV infection acquired through intravenous drug use or sexual practices with steady sex partners, but there is no evidence that they are transmitting the virus to their customers. Most HIV infection in women in the United States is related to injection drug use (personal or that of a partner). Scapegoating and prejudice toward prostitutes and IVDUs is widespread. Services must be provided with attention to unique social and psychological concerns. Both educational and medical interventions must be sensitive and accessible, and, at times, must be provided outside traditional health care settings.     

Street Level Prostitution: A Systematic Literature Review

The aim of this study was to synthesize research on female street level prostitutes for application in mental health practice and identification of future research needs. The data were from reports conducted in Westernized countries on female street level prostitutes between the years 2000 and 2014. Street level prostitutes are at high risk for HIV/STIs, chronic and acute physical/mental health problems, and violence, but there is a paucity of research on resilience and coping skills. We conclude that street level prostitutes suffer severe health disparities, yet they do not seek health care on a consistent basis. It is important for mental healthcare providers to offer women a safe, non-judgmental environment while providing assessment and referral. Future research on mental health consequences as well as resilience and coping skills would support effective interventions that address the women holistically.     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

Correcting deficiencies in HIV/AIDS care for transgendered individuals.

Studies suggest that transgendered individuals are at high risk for acquiring HIV through injection drug use and sexual risk behaviors. Beginning efforts are being directed to identify the unique needs and concerns of these individuals and to develop culturally sensitive programs that will be successful in recruiting and retaining these individuals in drug abuse and HIV treatment services. These efforts include examining the available and needed services from the perspectives of both the transgendered community and health care professionals. This article reviews the phenomenon of transgenderism and the social context that places these individuals at risk for HIV. Additionally, this article proposes some guidelines for those who are in positions responsible for designing, evaluating, and implementing existing health care services to transgendered populations.     

HIV prevention for people with serious mental illness: a survey of mental health workers’ attitudes,knowledge and practice

Aim. The aim of this survey was to investigate the attitudes, knowledge and reported practice (capabilities) of mental health workers concerning humanimmunodeficiency virus (HIV) and other sexually transmitted diseases in people with serious mental illness. Background. People with serious mental illness are at increased risk of HIV and other sexually transmitted infections. Mental health workers have a key role to play in promoting sexual health in this population, but it is unclear how they perceive their role in this work and whether they have the capabilities to deliver sexual health promotion. Design. Cross sectional survey. Methods. A questionnaire was devised and distributed to 650 mental health workers working in a London (UK) NHS mental health service. Results. A response rate of 44% was achieved. Overall, workers reported positive attitudes to sexual health promotion and were knowledgeable about risk behaviours and risk factors for HIV infection. Adherence to glove wearing was good. However, participants’ knowledge about HIV/AIDS in people with schizophrenia was poor and most reported they were not engaged in sexual health promotion activities with people with serious mental illness. Glove wearing was predicted by those who had drug and alcohol training and clinical experience and knowledge of risk factors was predicted by previous health promotion training. No other demographic factors predicted any of the other subscales. Conclusion. Mental health workers require training to provide skills for health promotion regarding sexual health and HIV in people with serious mental health problems. In addition, there needs to be more research on risk behaviours. Relevance to clinical practice. The development of effective interventions to reduce this behaviour.     

A review of the literature on HIV infection and schizophrenia: implications for research,policy and clinical practice

AIDS represents one of the major public health problems of the 21st century. Men having sex with men, injecting drug use and having multiple sexual partners are well-established risk behaviours for transmitting the HIV virus. People with schizophrenia are more likely to engage in these behaviours than the general population and as a result there is an increased prevalence of HIV infection in this group. However, many contemporary mental health policy reports fail to discuss the risk of HIV/AIDS in people with schizophrenia, and there are few specific references to sexual health promotion in these documents. People with schizophrenia should be considered an at-risk population for HIV infection and other sexually transmitted diseases. Psychiatric research, policy and clinical practice need to develop rapidly to address this important aspect of a major public health problem.     

Primary and preferred sources for HIV/AIDS and sexual risk behavior information among adolescents in Swaziland, Southern Africa

The HIV/AIDS epidemic in Sub-Saharan Africa poses a massive diffusion and persuasion challenge for health professionals. Individuals working with adolescents to prevent the spread of HIV/AIDS must gain an understanding of adolescent's preference in obtaining information about HIV/AIDS and sexual behaviors. This study describes the primary and preferred sources of information regarding HIV/AIDS and sexual risk behavior in relation to several socio-demographic variables (n=941) in Swaziland, Southern Africa. Although print/broadcast media was the primary source for HIV/AIDS and sexual risk behavior information for the students, most participants preferred information from the healthcare workers. This study suggests a greater role for healthcare providers in providing HIV/AIDS and sexual risk information.     

Ethical issues.

The HIV virus and the associated worldwide pandemic pose enormous biomedical, clinical, and social dilemmas for health care providers, biomedical researchers, policy analysts, and the public at large 10 years after its discovery. Many of these dilemmas and challenges are captured in the difficult ethical issues the HIV epidemic has highlighted for primary care physicians. Given the vanishingly small risk to primary care providers of acquiring HIV infection in office practice and the rapidly increasing prevalence of the virus, a clear ethical obligation to care for HIV-infected patients exists for primary care physicians. Primary care providers should be sensitive to the potentially sensitive nature of patient risk status and HIV testing results and balance confidentiality in the medical record with the "need to know" the patient's clinical status by other health care professionals. Every attempt should be made by the primary care provider to encourage HIV-infected patients to act responsibly toward their intimate sexual partners and inform them of their HIV status to take appropriate precautions against acquiring the virus. Primary care providers should also model responsible shared decision making and goal setting with HIV-infected patients early in the course of the disease, laying the foundation for subsequent decision making later in the course of the illness. Finally, considerable controversy exists about the responsibilities of HIV-infected providers to inform patients of their status; professional and public policy in this area is in rapid flux. Undoubtedly, the HIV epidemic will continue to challenge us and force careful examination of many of the critical dilemmas in modern biomedical ethics.     

Addressing HIV infection in office practice. Assessing risk, counseling, and testing.

HIV risk assessment, counseling, and testing performed by primary care physicians can be valuable in the early identification of persons infected with HIV, can contribute to their appropriate medical treatment, and may help to prevent the further spread of the disease. HIV risk assessment comprises a detailed sexual and drug use history, awareness of the mechanisms of HIV transmission, and knowledge of which patients should be encouraged to undergo counseling and testing. During pretest counseling, the physician asks for informed consent for the HIV test, explains the meaning of positive and negative test results, reviews risk behaviors, and offers an appropriate prevention message. During posttest counseling, the physician informs the patient of the results, reviews the meaning of the test results, and reinforces the appropriate prevention messages. Follow-up care for seropositive patients should be arranged, including appropriate medical care, referral to social and support services, and, if indicated, mental health care.     

Diagnosis and treatment of substance users with HIV infection.

Drug users with HIV infection pose an important clinical challenge for primary care practitioners, the provider group that is particularly well situated to supply comprehensive care both for HIV-related conditions and substance-abuse problems. It is important for primary care clinicians to be familiar with the full spectrum of HIV-related disease in drug users, especially concerning bacterial infections, tuberculosis, and sexually transmitted diseases, and with the medical complications of drug use, which may mimic, mask, be obscured by, or simply coexist with HIV-specific conditions. Primary care providers must also be familiar with screening, diagnosis, and treatment of substance-use disorders, and can play a critical role in the identification of drug-use problems and the initiation of drug treatment. An understanding of the special issues of drug interactions, self-medication, and pain management is also important for the care of drug-using patients with HIV infection. Most importantly, providers' awareness of certain common behavioral patterns, problems, and shared concerns among drug users will also help to promote favorable patient outcomes and to minimize frustration and dissatisfaction among clinical staff.     

A forensic nursing protocol for initiating human immunodeficiency virus post-exposure prophylaxis following sexual assault

The use of human immunodeficiency virus post-exposure prophylaxis (HIV PEP) should be considered in the care of sexual assault patient populations. In order to effectively implement HIV PEP following sexual assault, healthcare providers need to have a working knowledge of HIV transmission risk factors following a sexual exposure and protocols for initiating HIV PEP. Being able to implement evidence-based practices that address each of these factors is paramount to successful prevention of HIV transmission following a sexual assault exposure. Most healthcare practitioners, however, lack the specialized knowledge needed to address these issues in the expeditious manner necessitated by a potential HIV exposure. Implications: This paper is designed to provide healthcare providers with a basic understanding of HIV transmission risk factors and the knowledge and skills needed to effectively implement HIV PEP following a sexual assault exposure.     

Cardiometabolic health nursing to improve health and primary care access in community mental health consumers: Protocol for a randomised controlled trial

Background

People with a serious mental illness are at significantly greater risk of poor cardiometabolic health with recent studies showing a greater than two-fold increase in the risk of obesity, infectious diseases, diabetes and cardiovascular disease. Contributing factors to this disparity include poorer health behaviours such as suboptimal physical activity, poor diet, smoking, alcohol and illicit drug misuse. In particular, the limited access to primary health care experienced by people with a serious mental illness has been highlighted. Persons with a serious mental illness are around 30% less likely than those without serious mental illness to receive health assessments, hospital admissions or procedures for cardiovascular disease and diabetes, and are less likely to undergo cancer screening or receive vaccinations. Studies show that mental health consumers may be more likely to use mental health services rather than primary care for contact with the health care system. However mental health nurses report several barriers to their capacity to provide cardiometabolic health care crucial for the treatment of people with a serious mental illness.

Objectives

To assess the impact of a specialist Cardiometabolic Health Nurse on the physical health care of community based mental health consumers.

Setting

Community mental health facility in a large regional centre in Central Queensland, Australia.

Design/methods

Community based mental health consumers will be randomised to receive either usual care, or consultations with a Cardiometabolic Health Nurse. The Cardiometabolic Health Nurse will be responsible for assessing the client and coordinating cardiometabolic health care as required. Post intervention review of health records will be performed with the primary outcome measure being self-reported physical health. Secondary outcomes include the utilisation of primary care services and changes in health behaviours. We hypothesise that the Cardiometabolic Health Nurse will increase the utilisation of health care services for mental health consumers.

Results

Data collection commenced in March 2013 and will conclude September 2013. Preliminary finding are expected in December 2013.     

Professional Education in Co-occurring Disorders: Some Considerations towards Practice Development

The aims of this paper are to provide a brief overview of the types of education and training as well as a framework for co-occurring disorders courses at foundation and advanced levels. Mental health nurses encounter substance abuse problems as part of their workload and should be prepared adequately to work with individuals with the co-existence of mental health and substance abuse. However, co-occurring disorders are not often picked up by substance abuse or mental health services, indicating a need for improvement in ongoing professional development. The targeted audience for education and training in core competencies should be staff working in community mental health teams, inpatient services, assertive outreach teams, early intervention teams, crisis resolution teams, primary care, mental health services for older people, independent mental health projects, accommodation services, day care services, statutory drug and alcohol services, independent drug and alcohol service providers, and those working in hostel accommodations, housing, prison health care probation, and others in the criminal justice system. The theoretical and skills-based training will need to adopt a two-tiered approach as individuals working within mental health services will by definition need a higher emphasis on training around substance misuse and vice versa for individuals working in substance misuse services. One of the agenda items for interagency training is to challenge negative attitudes and prejudices around both mental health problems and substance misuse.     

How and why do GPs use specialist palliative care services?

This study presents findings on the interaction of generalists and specialists within palliative care. General practitioners (GPs) are central to community palliative care as most of the last year of a patient's life is spent at home under the care of the primary health care team. GPs see few palliative care patients each year, however, and access to specialist palliative care services for support, advice and referral can be important particularly to support patients who wish to die at home. The aim of this study was to explore GP use of and attitudes towards specialist palliative care services through semi-structured interviews in inner city, urban and rural areas. It was part of a longitudinal evaluation of an educational intervention, and the quantitative components are reported elsewhere. Sixty-three GPs were interviewed, having been sampled randomly from inner city, urban and rural health authority district lists. While most interviewees reported using specialist palliative care services as a resource, other models of use included working together as an extended team, seldom using such services and handing over care or responsibility entirely. Availability of services clearly shaped use, but previous experience and expectations of easy access were also important. Patterns of use were not necessarily fixed, but dependent also on the differing needs of and wishes of patients and carers. Specialist palliative care services need to be aware of such variations in ways of working and to consider the implications for the capacity and flexibility of both primary care and specialist service provision.     

The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study

Guidelines portray low back pain (LBP) as a benign self‐limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease‐related and socio‐demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.     

HIV/AIDS awareness in those diagnosed with mental illness

The spread of human immunodeficiency virus (HIV) continues to increase among the general population. Previous studies in this field focused mainly on the 'at-risk' groups such as homosexuals, prostitutes, intravenous drug users, bisexual men and women. Mentally ill men and women remain one of the subgroups understudied and yet continue to show disproportionately high levels of seroprevalence. The purpose of this study was to elucidate awareness of the risk factors associated with HIV transmission and development of AIDS in those diagnosed with mental illness. Using questionnaires, information regarding HIV method of transmission, knowledge on HIV/AIDS and at-risk behaviour awareness was obtained from 30 subjects in an acute psychiatric mental health unit (13 women and 17 men). Significant association between different variables was determined at 95.5% confidence level (P=0.05). Assessment of HIV/AIDS awareness and at-risk behaviour awareness revealed significant knowledge deficit among this subject group. The outcome of this study underscores the need to introduce intervention programmes tailored to individual needs of the mentally ill. Measures such as 'at-risk sexual' behaviours should be incorporated into the current assessment process or profile so that accurate information and informed judgement can be reached regarding client or patient sexual behaviour.     

Specialist or generic community nursing care for HIV/AIDS patients?

Improved management of HIV-related illness means that patients spend over 80% of their time in non-institutional settings Most community-based health care in the United Kingdom is provided by primary health care teams general practitioners and community nurses, with support from social workers However, in many areas specialist HIV services have assumed responsibility for the care of HIV/AIDS patients, and primary health care teams have only played a marginal role Our study examined patterns of community nursing for HIV/AIDS patients in one regional health authority, North-East Thames (NETRHA) Interviews with 77 people in seven health districts included community nurse managers, clinical nurse specialists (CNS) HIV/AIDS and palliative care nurses The appropriateness of different nursing models was assessed, taking into account the changing epidemiological and demographic profile of the disease, the influence of dedicated HIV funding, and the effect of recent British National Health Service reforms Three models of care have developed in NETRHA specialist HIV teams, individual CNS HIV/AIDS acting as a resource to generic staff, and care given by generic community nurses Our work suggests that both generic community nurses and patients benefit from specialist input, and that this should be provided using CNSs HIV/AIDS in an advisory and facilitative capacity