HIV and Substance Abuse on the Border Workshop



Case Outline: Dewayne

Dewayne is a 29-year-old returning to your agency. He last came to your clinic a year ago. After several appointments he was started on HIV medications, an antidepressant and a sleep aid. At the time his CD4 cells were 220 and his viral load test showed 80,000 copies. The clinic case manager was then unable to contact Dewayne after repeated attempts to tell him a bed was finally available at a substance abuse treatment facility. His last appointment at your agency was with the social worker who noted he was smoking crack again and was homeless.

At today’s visit Dewayne indicates he is ready to restart HIV and substance abuse treatment again. He said he is depressed about losing a friend last year and does not want to be next. He also shares that he met a woman through a church group who he thinks will help him get his life together. When asked about his current living situation he admits he still needs to ‘do what I need to do.’ He says the man he lives with gives him a place to stay in exchange for sexual favors. He confirms he always uses condoms with his girlfriend, but not with male partners, as he only engages in oral sex with men. He says he has not used crack for the two weeks since making the appointment with you and is desperate to get back into treatment as he feels like he is “going crazy.”

What other information would you like to have about Dewayne? Why?

Given the limited information presented here, what are your primary concerns?

Why?

What can you or your agency do to help Dewayne? What agencies could you refer Dewayne to for additional help? What challenges do you see?

Other information about Dewayne (to be solicited in role play exercise):

• He identifies as heterosexual and calls men who identify as gay ‘punks.’

• He attends church regularly, and once went to an HIV support group they set up for straight men, but will answer he never went again as “it wasn’t for me.”

• He receives SSI and occasionally receives money from his roommate for small crack deals he does in his neighborhood.

• He used to believe HIV meds are worse than HIV but has seen more friends get better with meds over the past 2 years than those who chose not to take them.

Case Outline: Maria

Maria is a 24-year-old mother of two. She is looking for work and has not had a job since last year, when she first told you some weight loss was from ‘partying too much.’ Her viral load has been stable and her CD4 cell count has been over 400 for the past several years, but her last two CD4 cell counts showed a significant decrease. She then missed her previous two appointments with you.

Maria was introduced to methamphetamine about one year ago while working in a bar. She liked the way methamphetamine lessoned her inhibitions and allowed her to lose weight. At first she snorted a little on weekends only, but now finds herself wanting to buy some during the week. She was previously given it for free by one of the bar’s customers. At her last appointments she states that she is increasingly concerned she will not be able to stop using.

Maria is afraid that she will not be able to provide for her children, whom she says are “the best part of my life.” She says she knows her use of drugs and alcohol has become a “problem” for her and she worries that her life has become “out of control.” She is also worried that if she goes into treatment, authorities may be notified.

What other information would you like to have about Maria? Why?

Given the limited information presented here, what are your primary concerns?

Why?

What can you or your agency do to help Maria? What agencies could you refer Maria to for additional help? What challenges do you see?

Other information about Maria (to be solicited in role play exercise):

• Maria is undocumented.

• She is high during visit and will remember very little what she is told.

• Maria is separated from the father of her children and is living with her Aunt. She is afraid her Aunt may kick them out if she finds out she is using drugs. She is considering telling her Aunt about her HIV status.

• Maria has heard about the side effects of HIV medications and is afraid of starting them.

Case Outline: Mary

Mary is a 42-year-old mother of two. She has not held a job since last year, when she experienced substantial weight loss from “too much partying.” She is currently looking for work and living with relatives. Her viral load has been stable and her CD4 cell count has been over 300 for the past several years, but her last CD4 cell count showed a significant decrease. Mary was subsequently very anxious and has been prescribed Halcion (triazolam) by a psychiatrist at a community clinic. She then missed her next two appointments with you.

Mary was introduced to crack cocaine about one year ago. She liked the way the drug lessoned her inhibitions and allowed her to lose weight. At first she smoked a little on weekends, but now finds herself wanting to buy some during the week (gets it free from her boyfriend). During her last appointment she stated that she is increasingly concerned she will not be able to stop using.

Mary is afraid that she will not be able to provide for her children, whom she says are “the best part of my life.” She says she knows her use of crack has become a problem for her and she worries that her life has become “out of control.” She is also apprehensive that if she goes into treatment, authorities may be notified. She asks for your advice as she says you are one of the few people she has left that she can trust.

What other information would you like to have about Mary? Why?

Given the limited information presented here, what are your primary concerns?

Why?

What can you or your agency do to help Mary? What agencies could you refer Mary to for additional help? What challenges do you see?

Other information about Mary (to be solicited in role play exercise):

• Mary has previously attended a 12-step program after getting a DUI, but stopped going to meetings years ago. She does not believe they work.

• Mary has a boyfriend and they do not use condoms. He is also HIV positive and she does not see the point as they are both using and they only have sex with each other.

• Mary is afraid her 15 year-old son is also using as she found a crack pipe in his room. She is also afraid the sister she lives with may find out she is using crack and ask her to leave. Her sister knows of her HIV status.

Case Outline: Pedro

Pedro is 21 years old and new to your agency He is asking to be prescribed ‘something for uncontrollable depression and anxiety.’ He was diagnosed with HIV several years ago and was monitored at another clinic in another town. At his first visit he stated he never started HIV meds as “I’m not sure they’re for me.” He doesn’t remember his last CD4 or viral load test results, but does remember the viral load was “somewhere in the thousands.” He states he has not been to a medical appointment for over a year, and recites a long list of problems moving into town and finding housing. He currently receives unemployment and is living on a friend’s couch.

Pedro initially denies using drugs during routine screening/intake questions. Before the end of the first appointment, when discussing sex partners, he shares that he does occasionally use “Tina” as he says it helps him deal with “all the stresses in his life.” He also says it helps him “focus” and adds “she’s improved my social life here.” He emphasizes that he has never purchased drugs, and never missed a day of work, when he was working. He demands that you not write any of this information in his chart.

You ask permission to contact Pedro’s case manager. She leaves you a note that he has a history of “psychological problems” and was recently admitted to an emergency room where he tested positive for methamphetamine. He missed their last appointment. She also notes that another case manager at another clinic called her this week and said that Pedro had also gone to their clinic for services and asked about housing services.

You’re meeting with Pedro today. His latest CD4 cell count is now 170 and his viral load is over 150,000 copies. You want to discuss his options for his continued care.

What other information would you like to have about Pedro? Why?

Given the limited information presented here, what are your primary concerns? Why?

What can you or your agency do to help Pedro? What challenges do you see?

Please explain.

Case Outline: Tomas

Tomas is a 34-year-old male who comes to clinic because he saw a poster for free STD screening. Tomas’ wife and three children are still at home in the small rural village in Mexico he came from eight years ago. At least once a year, Tomas tries to make the trek home, but he spends the rest of the year working the farm fields and following the harvests in Arizona and California. He has also worked as a day laborer in construction, when the work is available.

When asked about drug use, Tomas reluctantly admits (through an interpreter) to occasional use of “La Tina.” He says he first starting using methamphetamine about three years ago while working the strawberry fields. At first, he would just snort it, but one day one he tried injecting it and has shot up and snorted since then. He asks about HIV testing, and what would happen if he were to test positive. Tomas is concerned about the amount of weight that he has lost in the last three months (15 lbs) and his ‘crazy new life.’

Tomas knows that his continued use of meth is not good, but reports that it is everywhere and that he is afraid that he can not keep up without continued use. He is scheduled to make his annual trek home in the next couple of months and is very anxious about the trip, and what he will tell his wife. He said this worrying has affected his sleep.

What other information would you like to have about Tomas? Why?

Given the limited information presented here, what are your primary concerns. Why?

What can you or your agency do to help Tomas? What agencies could you refer Tomas to for additional help? What challenges do you see?

Other information about Tomas (to be solicited in role play exercise):

• He has only slept 5-6 hours in last 4 days and remembers little he is told.

• He has been seeing and hearing things that are not there.

• He wants to delay HIV medications as long as possible as he is afraid they will make him “look like he has AIDS.” He wants to know if he can get a Viagra prescription from the clinic.

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