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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 16: Infectious Diseases

INTRODUCTION
Hepatitis B, hepatitis C, and the Human Immunodeficiency (HIV) viruses are germs that cause illnesses and that can easily be spread from one person to another. This chapter describes three common but dangerous infectious diseases that are caused by viruses: the hepatitis B virus, the hepatitis C virus, and the Human Immunodeficiency virus (HIV). These diseases are spread by contact with contaminated blood or other body fluids. Each of these diseases is serious, and can harm a person's health and well-being and result in life-threatening illness. This chapter can be used to educate yourself and your clients. It explains:

• how these viruses infect people
• whether a person should be tested for the diseases
• the treatment options for the diseases
• how to protect oneself from these viruses
• if someone has a disease, how to avoid spreading it to others

HOW COMMON ARE INFECTIOUS DISEASES?
Infectious diseases are more common in some places than others, and in some years compared to others. As of the year 2001 in the United States, about 1 person in 20 (5%) is infected with hepatitis B virus, and about 1 person in 50 (2%) has hepatitis C virus. HIV is less common, about 1 person in 200 (.5%) is infected with the virus.

People with dual disorders are considerably more likely to have an infectious disease than people who have no disorder or one disorder. Among people who have both disorders, almost 1 in 4 (25 %) has hepatitis B virus, about 1 in 5 (20%) has hepatitis C virus, and about 1 in 25 (4%) has HIV.

WHAT IS HEPATITIS?
Hepatitis is a disease of the liver, which is part of the digestive tract. The liver helps filter out toxic materials, builds proteins for the body, and stores vitamins, minerals, and carbohydrates. A person needs a functioning liver to stay alive.

When a person has hepatitis, the liver becomes sick or inflamed because it has been infected with a virus. Though it can take many years to happen, this sickness can cause more serious liver problems and death. The problems can include:

• cirrhosis (permanent scarring of the liver that reduces blood flow),
• liver failure (the liver is unable to function)
• liver cancer (cancer cells attack the liver)

There are many kinds of hepatitis viruses, but the most serious ones are hepatitis B and hepatitis C. Preventing infection with hepatitis B and hepatitis C, or taking care of oneself if one has the infection, is important to prevent liver damage and death.

WHAT ARE HIV AND AIDS?
HIVis a virus that attacks and destroys special white blood cells in the body called T-helper or CD4 cells. These T-helper cells are a part of the immune system, which helps the body fight infection and stay healthy. When HIV destroys these cells, the immune system breaks down and is unable to fight infections. Infections that are normally mild can then become serious, causing the person to get very sick and even to die. Acquired Immunodeficiency Syndrome (AIDS) is the disease someone gets after the HIV virus has destroyed the immune system and the body cannot fight infections.

HOW DO HEPATITIS VIRUSES AND HIV SPREAD?
These viruses pass from one person to another through exposure to infected blood and body fluids. A person gets infected when the blood of an infected person enters the blood stream of an uninfected person. The HIV and hepatitis B viruses can also be passed by the sex fluids (such as semen or vaginal secretions) of an infected person to an uninfected person when they have unprotected sex. Hepatitis C is much less likely to be passed to another person by sex fluids, but it can be in some cases.

Some of the ways people get exposed to the contaminated blood of other people and get infectious diseases are listed in Table 1. You can review this list with your clients and have them check off the ones that apply to them.

Hepatitis B, hepatitis C, and HIV cannot be spread through insect bites, kissing, hugging, or using public toilet seats, unless there is direct contact with other people's body fluids.

TESTS FOR HEPATITIS B, HEPATITIS C AND HIV
Most people who have these viruses do not have symptoms until long after they get the virus, and they might not have any symptoms at all. Therefore, people need to get blood tests to tell if they are infected with hepatitis B, hepatitis C, or HIV. A person should get tested if he or she has had any of the risk factors listed in Table 1. Since people with dual disorders are at such high risk to be exposed to these viruses, they should all be offered a blood test to see if they are infected. If your client was tested in the past and the results were negative, but they have since been involved in risk behaviors, they should be re-tested every six months.

TREATMENT
Treatments are helpful for hepatitis B and C and HIV, but a vaccine can prevent only one of the viruses, hepatitis B virus, if the person gets the vaccine before he or she is exposed to the virus. This vaccine is safe and available. To get protection against hepatitis B, a person needs 3 vaccine shots over a period of months. Since persons with dual disorders are at such high risk for being exposed to hepatitis B, they should all be offered the vaccine.

Most people who get hepatitis B virus recover on their own. However, about 1 in 10 people get a chronic illness after years of having the virus. People who have chronic hepatitis B virus may improve from treatment with medicines that boost the body's ability to fight the infection. These medicines are given in a series of injections into the muscle over a 16-week period and in pills that are taken daily.s

People who have chronic hepatitis B illness who get infected with a different virus, hepatitis A, can then get sick with fulminant hepatitis. Fulminant hepatitis is a very serious disease that can cause death. To prevent this, people with hepatitis B virus need to get hepatitis A vaccine shots. All children are currently vaccinated against hepatitis A and B.

Unlike hepatitis B, there is no vaccine that protects a person from getting hepatitis C virus. Also unlike hepatitis B virus, most people (85%) with hepatitis C virus carry the virus for life unless they are treated. This is called chronic hepatitis C infection, and can cause very serious illness over a period of years.

Several medications help people with hepatitis C. They are given by weekly injections into the muscle and daily by mouth for up to a year. These treatments completely get rid of hepatitis C virus from the body for many people who complete the treatment. Because treatments for hepatitis C virus can cause serious side effects, such as experiencing flu-like symptoms or depression, doctors decide to treat people with hepatitis C depending on how sick a person's liver is.

Similar to hepatitis B virus, people with hepatitis C virus who are then infected with the hepatitis A virus can develop fulminant hepatitis, a deadly disease. This can be prevented by taking a vaccine for hepatitis A. People who have chronic hepatitis C should get the hepatitis A vaccine.

No vaccine or cure exists for HIV or AIDS. However, medications can slow down the illness. In addition, new medications are being developed and tested for HIV and AIDS that may help more in the future.

TAKING CARE OF ONESELF
When your client has one of these viruses, it's important to encourage him to take care of himself. Since hepatitis harms the liver, and alcohol is toxic to the liver, people infected with hepatitis B virus and hepatitis C virus need to avoid drinking alcohol. There are other steps people with hepatitis B, hepatitis C, and HIV can take to help themselves. First, clients need to get a medical provider (such as a nurse or doctor) who can monitor health and discuss treatment options. They need to take medication as prescribed, get enough rest, and eat healthy foods.

HOW TO AVOID GETTING OR SPREADING INFECTIOUS DISEASES
To avoid getting or spreading these infectious diseases, people need to avoid contact with infected body fluids. Table 2 presents a list of ways people can avoid contact with body fluids.

Because most of the behaviors associated with spreading infectious disease occur in the context of substance use, effective dual disorder treatment will help reduce the spread of these deadly diseases. Offering your clients testing, immunization, and risk reduction counseling is important to include in dual disorder treatment.

Recommended reading
There are many books about coping with HIV and Hepatitis that you and your clients and their families may find helpful. Here are two to start with: Guide to Living with HIV Infection by John Bartlett and others (Johns Hopkins U. Press, 1998) and Living with Hepatitis C by Gregory Eversen and Hedy Weinberg (Hatherleigh, 1999).

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