From: MShernoff@aol.com Date: Thu, 14 Sep 1995 16:52:54 -0400 Subject: Counseling Chemcially Dependent People With HIV I am attaching an article that I'd like to post on the QRD AIDS resources. Thanks MShernoff@aol.com Counseling Chemically Dependent People With HIV Illness Lesson Plan for Directions in Substance Abuse Counseling V.2 = 1994 Published by = Hatherleigh Press, NYC; NY Michael Shernoff, MSW, ACSW Private Practice, NYC Adjunct Faculty Hunter College Graduate School of Social Work C1994 Hatherleigh Press =0C Counseling Chemically Dependent People With HIV Illness Michael Shernoff, MSW, ACSW Introduction By October, 1993, more than 80,000 heterosexual intravenous drug use= rs had been diagnosed with AIDS in the United States. This group represen= ts 24% of the nation's AIDS caseload. Six percent of the gay and bisexual= men reported a history of injecting drugs, making a full 31% of all AIDS= cases related to intravenous drug use. = Newmeyer notes that substance use increases an individual's vulnerab= ility to HIV in three ways. First, a person who shares hypodermic needles= or other drug using paraphernalia such as "cookers,"(the container in wh= ich the drug is dissolved in water) or the "cotton," (the material used t= o strain the drug solution as it is drawn up into the syringe) with someo= ne infected with HIV is at risk. Secondly, someone who becomes intoxicate= d may lose inhibitions against risky practices-for example, neglecting th= e use of a condom during a drunken or stoned sexual encounter. Thirdly, = a number of substances, such as alcohol, cannabis, "speed," inhaled nitra= tes and cocaine, may have direct immunosuppressive properties. If one is= already HIV infected, heavy use of an immunosuppressive substance might = accelerate the collapse of the helper T-Cell activity. All workers in the field of substance abuse, both professional and p= ara-professional need to be educated about the spectrum of HIV illness, A= IDS and HIV transmission. Similarly, all people working in AIDS must be k= nowledgeable about issues of substance abuse and chemical dependency. Sh= ernoff and Springer describe many of the difficulties of working with ind= ividuals who have a dual diagnosis of chemical dependency and AIDS, inclu= ding: locating scarce resources and quality medical care; drug treatment = and psychosocial services; stigma and discrimination. In addition to the= above mentioned professional challenges, the nature of HIV illness and c= hemical dependency brings up many emotional reactions in the worker which= can interfere with optimal delivery of services to these very needy clie= nts. = Chemically dependent clients with HIV are best served by an interdis= ciplinary team who, in consultation, can together develop appropriate and= flexible treatment plans that prepare for and encompass expected fluctua= tions in the client's bio-psychosocial condition. In addition, workers mu= st be trained to treat the inevitable deterioration in the clients' physi= cal and mental conditions as the illness progresses, including relapse in= to active use of chemicals. This lesson will outline salient issues and = treatment approaches in a variety of modalities which serve chemically de= pendent people who are infected with HIV or who have full blown AIDS. = Definitions During the course of this lesson, the term "chemically dependent" wi= ll be used to include all individuals who have a current or past history = of abusing alcohol or drugs, even if they have not had a history of actua= l addiction to substances. Since the majority of people with AIDS who con= tracted the disease through shared drug injection paraphernalia reside in= inner cities and are members of racial minorities, it is often erroneous= ly assumed that categories of people with AIDS are very discrete. This c= omes from racist and classist assumptions which must be discarded if one = is going to be able to work effectively with this population. = Many individuals who work primarily with gay men infected with HIV or = who have AIDS assume that their clients contracted the disease through se= xual transmission. While this is often correct, many people have engaged= in multiple at risk behaviors for contracting AIDS. Six percent of all = reported cases of AIDS involved gay or bisexual men who are also IV drug = users. Shernoff reported patterns of injected drug use by middle class g= ay white men. Stall and Wiley found that gay men not only used drugs mor= e often, but used a greater variety of drugs than did heterosexual men. = Every client presenting for AIDS related services should have an alc= ohol and drug use history taken. Similarly, every client in treatment fo= r substance abuse should be questioned about his or her sexual orientatio= n since the stage of lesbian or gay identity formation can have a signifi= cant impact on how to approach treatment issues regarding recovery from u= se of chemicals. Simply asking an individual "Are you gay?" is not suffic= ient since many men who have sex with other men do not label themselves a= s homosexual, and do not identify as part of the gay community. It is mo= re useful to ask "have you ever had sex with another man (or woman)?" If = the answer is "yes," then asking "When was the last time?" can provide us= eful and pertinent information helpful in developing an appropriate treat= ment plan. Drug Use and AIDS Prevention Most AIDS service organizations will not accept an individual who is= currently using drugs as a client, unless he or she demonstrates that th= ey are in drug treatment. In the age of AIDS, this approach to working w= ith chemically dependent people, reflecting the current trend that only a= bstinence from use of chemicals is the goal of drug treatment, needs to b= e evaluated. The abstinence only focus must be challenged as counterprod= uctive, since the very individuals most in need of bio-psychosocial suppo= rts will not receive these supports if they are unable to stop using drug= s. These same people are most likely to be transmitting HIV to drug usin= g or sexual partners or their children, and are most likely to be deprive= d of education or support to change these high risk behaviors. Eight out = of ten substance abusers in the United States are not in treatment for th= eir chemical dependency. A majority of these express no desire to seek tr= eatment. However, they do express a desire to avoid AIDS. Placing abstinence from drugs as the highest treatment priority with = this population, unless the client is truly committed to achieving abstin= ence will only alienate the client or cause the client to begin a dishone= st game with the worker. The goal of AIDS prevention work with drug user= s is simply to prevent HIV transmission from one drug user to another, fr= om drug users to their sexual partners, and from drug users to their unbo= rn children. Springer notes that "the goals of drug treatment and the goa= ls of AIDS prevention must be seen separately. Abstinence from drugs is = not the goal of AIDS prevention. While abstinence from drugs may be a st= rategy for some people in avoiding HIV infection, it is not necessary or = desirable for all drug users to embrace this strategy as an AIDS preventi= on strategy." = Apart from methadone maintenance, abstinence is the goal of the vast = majority of drug treatment agencies; the concept that active drug users r= equire and deserve services is controversial. Workers need to embrace the= concept that individuals who are not committed to a drug free life also = deserve services. Advocating this position with agencies is necessary if = the large population of chemically dependent people with HIV who are not = committed to giving up drugs or alcohol are ever going to receive life s= aving AIDS education. Taking this approach does not condone drug use, but= merely accepts the reality that people who still actively use drugs are = in desperate need of AIDS education services. = Many drug treatment agencies and workers have taken an approach to A= IDS risk reduction that encompasses the following: IF YOU DON'T WANT TO GET AIDS... 1. THE BEST WAY IS TO QUIT SHOOTING UP DRUGS: You can get help to stop. 2. IF YOU MUST SHOOT UP: Don't share needles, or cookers. Remember that people can look healthy and still carry the AIDS virus. 3. IF YOU MUST SHARE WORKS: Flush needle, syringe and cooker with Chlorox bleach. Rinse well = with water. Or boil for 15 minutes. 4. REDUCE THE RISK OF GETTING AIDS SEXUALLY: Use Condoms Avoid contact with semen (cum) or blood. Learn safe sex guidelines. = During initial assessment sessions counselors should specifically dis= cuss the issues in the above list, creating a climate for talking honestl= y about preventing the spread of AIDS, in addition to other issues import= ant for their recovery. One controversial approach to reducing the spread of AIDS in drug use= rs is needle exchange programs. These programs offer individuals new syri= nges free in exchange for used ones. Researchers in New Haven, Ct. and L= iverpool, England showed that the spread of HIV declined sharply when add= icts were given clean needles; they reported no increase in heroin use. = Making needles and syringes available has increased the demand for drug t= reatment, probably because of the contact the exchange allows between act= ive drug users and service providers Another radical intervention to fight the spread of AIDS is to have s= treet workers (who are themselves in recovery), do peer education to acti= ve drug users on the streets about safe needle use and safe sex. These w= orkers can also distribute condoms, do needle exchange and provide inform= ation about where treatment for drug addiction or AIDS can be obtained. = Condoms, and clear instructions about their correct use, should be ma= de available to all clients at drug treatment facilities. Sexually explic= it AIDS prevention messages are especially important with this population= since many women and men sell sex in order to raise money for the purcha= se of drugs. Thus workers need to address their own discomfort in talkin= g with clients about sex and should receive training in how to discuss sa= fer sex and safer drug using techniques. Stall et al has documented that = a majority of gay men who fail to practice safer sex are under the influe= nce of alcohol and/or drugs. Clearly, workers need training in gay sexual= ity and how to discuss safer sex with gay male clients as well. Until fairly recently AIDS prevention programs ignored the needs of = lesbians. Since lesbians are exposed to HIV through contaminated needles = or sexual partners, workers must also become comfortable with initiating = safer sex discussions with women that includes relevant information about= woman to woman transmission. Chemically Dependent Adolescents Hein notes that "the risk-related behaviors of adolescents put some = teenagers directly in the path of the AIDS epidemic." She goes on to say= that recent statistics have demonstrated that HIV infection is already p= resent in the United States adolescent population. Thus it is imperative = that "adolescent specialists from various disciplines begin to prepare pr= ograms and strategies that serve the special population of chemically dep= endent adolescents who are infected with HIV." Adolescents who are at hi= ghest risk for HIV infection fall into four groupings: those who inject d= rugs; gay and bisexual males; those who work in the sex industry (prostit= ution) or who barter sex for survival; and those whose sex partners are o= r have engaged in the above named risk behaviors . Many of the adolescents who work in the sex industry or who barter s= ex for drugs, have either run away or have been thrown out of their homes= , and are therefore likely to be homeless. Many of these adolescents enga= ge in sex for pay to buy food, drugs, shelter or clothing. One strategy = for engaging these hard to reach adolescents is to entice them into the a= gency with concrete services like medical care, food, clothing, a shower = or a referral to a safe place to sleep. The tangible and immediate benefi= ts of these inducements create the opportunity to develop a helping relat= ionship with these high risk youths; this can eventually encompass HIV te= sting, medical follow up for AIDS related conditions, safer sex and safe = drug use information, counseling, referrals for detox and help in stoppin= g use of alcohol or drugs. Reulbach notes that when adolescents continued to use crack or other = drugs they were difficult to treat in a hospital based adolescent AIDS pr= ogram in a large urban center. He reports that active drug using adolesc= ents were less likely to keep clinic appointments, follow through on heal= th promoting behaviors e.g. taking medication or improving diet and pract= icing safer sex than those adolescents who were not using drugs. = Reulbach also found that when counseling chemically dependent HIV pos= itive adolescents the worker needed to help the client negotiate the expe= cted psychosocial tasks that include dealing with the ambiguity of HIV po= sitive diagnosis; integrate knowledge of HIV as a progressive, but gradua= l decline of the immune system; develop disclosure strategies for family = and friends; make decisions regarding continuing sexual relationships and= safer sex practices; and in general cope with the emotional roller coast= er associated with HIV. If the adolescent has ongoing relationships with family members it is o= ften useful to engage them in treatment as well. In addition friends and = other significant others can often help confront the adolescent's denial = about both the negative impact of drug use and their own HIV condition. = For some homeless or run away youth agency staff or fellow members of twe= lve step programs may serve many of the functions of family members, and = the appropriateness of enlisting them as allies in the treatment process = needs to be evaluated. Outpatient Treatment Chemically dependent individuals who learn that they are infected wi= th HIV or have AIDS are immediately faced with new life stressors. When = someone who is chemically dependent learns that he or she is HIV positive= , they often cope by behaving in the way they know best: by using drugs. = Fontaine states that outpatient psychotherapy, by itself, cannot provide = enough support and treatment for a person who is both chemically dependen= t and HIV infected, especially if the individual is actively using drugs.= However, outpatient psychosocial services can add an important componen= t of care within a whole array of treatment by providing a supplemental s= upport system for a client who is already engaged in various other suppor= t systems or by becoming the sole support system for an isolated individu= al. Fischer et al state that "like any reaction to severe stress, adjust= ment to a diagnosis of HIV disease is governed by habitual coping mechani= sms and psychosocial resources. In the case of active substance abusers,= such mechanisms and resources are typically absent, severely strained, u= ndeveloped or maladaptive." If the individual is actively in recovery fro= m substance abuse then he or she is likely to possess more intrapsychic a= nd interpersonal tools and resources for meeting this crisis. Dr. Stuart Nichols developed the "AIDS Situational Distress Model" = which is useful for understanding the process of adjusting to a diagnosis= of HIV disease. This model describes four possible stages of adjustment = to a diagnosis of HIV disease: crisis, transition, acceptance, and eventu= ally, preparation for death. The following is how Fischer et al summarize= the supportive interventions appropriate to each stage. The initial crisis of an HIV diagnosis is commonly met with denial as= a defense against extreme anxiety. Denial has been the prime psychologic= al defense used by chemically dependent people, enabling them to continue= using substances that created chaotic life situations. Thus many users r= emain in denial throughout the entire course of their HIV illness. This = defense allows them to continue to engage in self-destructive behaviors t= hat place themselves as well as others at risk for infection. Sometimes H= IV status is disclosed to persons who have no need to know out of a desir= e to gain sympathy or manipulate a situation to their advantage. HIV infe= ction may also cause disclosure of previously disguised drug use to frien= ds or family in an effort to gain much needed emotional support. This ma= y precipitate a crisis if the double stigma and ignorance about AIDS and = drug use drives key people away. Workers need to challenge maladaptive d= enial which leads to increased use of chemicals. It is appropriate and natural for a person with a life threatening i= llness to initially deny the threat to his or her existence. Workers must= support this kind of denial until "a person can begin to absorb the impa= ct of the implications of diagnosis. If the denial about both HIV and sub= stance abuse is not confronted it can impede progress in other areas vita= l to a person living with HIV. For example, financial assistance may be u= sed to purchase drugs; physical, emotional and legal problems may be exac= erbated. Fischer et al describe a transitional stage, in which alternating wa= ves of anxiety, anger, guilt, self pity, and depression are typical. Che= mically dependent individuals generally experience these feelings as into= lerable and historically mismanage these feelings. For people in recover= y a diagnosis of HIV or AIDS can be a thoroughly faith shattering and reg= ressive time where self-medication with alcohol and drugs and thoughts of= suicide are common. Workers need to prepare themselves for possibly bec= oming the brunt of the intense acting out or manipulations that are attem= pts to maintain some semblance of control. = A client who has accepted the realities of being both chemically dep= endent and having HIV will demonstrate this acceptance by his or her beha= viors as well as a willingness to honestly discuss both issues. When clie= nts report seeking appropriate medical consultation for HIV as well as at= tending Narcotics Anonymous and/or Alcoholics Anonymous meetings that hav= e adapted their agendas to include AIDS, counselors can begin to gently p= robe for the feelings that accompany a growing acceptance. Additional support may be gained by helping the client enroll in buddy pr= ograms or support groups which have a proven sensitivity to chemical depe= ndency issues. Fischer et al note that gaining support from a substance = abuser's family members or a significant other often requires task-orient= ed family therapy that addresses obstacles present from long standing dys= functions that preceded HIV. American society is notorious for being death denying. Working in A= IDS causes all people to confront their own mortality, through the deaths= of clients and colleagues. Thus when the time for preparation for death = nears, it is crucial that workers recognize that chemically dependent ind= ividuals and their families are historically ill prepared to manage the f= eelings and tasks attendant to any loss, much less dying. The result can = be an extremely difficult time for families and practitioners who must of= ten be the patient's advocate, in addition to helping arrange wakes, fune= rals and memorials. = Residential Treatment Facilities It is estimated that in large cities in the U.S. up to one half of a= ll heterosexual intravenous drug users are infected with HIV. Not surpri= singly, many of the clients of residential treatment facilities or therap= eutic communities are HIV positive or symptomatic with AIDS. Similarly si= nce many of the staff of these facilities are former drug users, many of = them are also either HIV positive or have AIDS. One of the therapeutic as= pects of these programs occurs through the role modeling provided by reco= vering staff who are able to empathize with the difficulties of clients s= truggling to become and remain drug free. Residential programs need to have special support groups and specia= l twelve step meetings for clients who have HIV. Staff who are living wi= th HIV can provide meaningful role models to clients who are questioning = why should they remain drug free if they now have only a short period of = time to live. Residential facilities must be affiliated with clinics or hospitals t= hat offer state of the art medical care for AIDS related conditions, incl= uding the ever increasing number of options for prophlaxing against vario= us opportunistic infections. All residents need information about health = promotion that discusses healthy eating, exercise and safe sexual practic= es. Staff of these facilities must be trained to recognize symptoms of HI= V related medical conditions, since early medical intervention is often l= ife saving or prevents major physical disabilities like blindness. Since= many HIV medical conditions are now routinely treated at home or as outp= atients, residential facilities will have residents with catheters, ports= or other medically implanted intravenous access through which they recei= ve medication. Some physicians are reluctant to prescribe these devices = for patients who have a history of intravenous drug use since they provid= e the temptation of an easy way to use illicit drugs. Workers at drug tr= eatment agencies need to raise this issue with clients, and develop strat= egies that deal with this high risk situation for relapse into drug use. Staff need to initiate discussions in treatment groups and community m= eetings which elicit feelings about residents who have become acutely ill= and required hospitalization. When a resident, staff person or recent g= raduate dies from AIDS there need to be provisions made to mourn his or h= er death within the community, and to discuss all of the resulting feelin= gs and fears that emerge. Handling these situations directly and honestl= y within the facility is an opportunity to teach invaluable coping skills= to all the clients. = Methadone Maintenence Programs Most of the issues discussed above also pertain to clients in methad= one maintenance treatment programs, (MMTPs). All drug treatment programs= need to offer special support groups for clients who are living with HIV= and AIDS. Providing groups for significant others of clients with HIV c= an increase the systemic support the client receives. Another useful tre= atment option is multiple family groups where all involved can share copi= ng strategies and support. = With clients who are living with HIV or AIDS, the counselor should agg= ressively pursue a case manager role as liaison between the various profe= ssionals on the client's treatment team. Since clients on methadone are = often stigmatized and not offered dignified and sensitive treatment at cl= inics and agencies, once other professionals on the treatment team learn = that there is a caring colleague coordinating and monitoring the client's= treatment, the patient is more likely to receive quality and humane trea= tment. = Thus when a client in a MMTP is hospitalized, a visit from the worke= r can serve a number of useful purposes. The first is to support the cli= ent during the stressful period of acute illness and hospitalization. Th= e second is to act as an intermediary and advocate for the client with th= e nursing staff. It is important for workers at methadone programs to develop flexibl= e pick up schedules for clients with HIV or AIDS, because long waits at t= he frequent medical appointments often mean that clients will not be able= to come to the clinic with the frequency and at the times assigned by th= e clinic. As the illness progresses, provisions for delivering methadone= to a client's home need to be arranged. When a client dies from AIDS a notice announcing his or her death an= d specifics regarding the wake, funeral or memorial is usually posted. W= orkers should be prepared to elicit reactions and feelings from all clien= ts, especially those who are themselves, or whose spouses are living with= HIV. A death can be a potent stressor that has the ability to trigger dr= ug taking as a means of avoiding the feelings. Thus a drug treatment age= ncy is a perfect place to anticipate these reactions, prepare for them an= d help clients seek out healthy alternatives for dealing with their feeli= ngs. = Chemically Dependent People With HIV as Inpatients in Hospitals Weiss writes that "working with chemically dependent HIV infected p= atients on an inpatient medical unit poses special problems for the medic= al staff. These patients are perceived as irresponsible, manipulative, d= emanding, drug-seeking trouble makers who rarely follow the rules of the = ward. Medical, nursing and social work staff working with these patients = need support and education to help them with this population". She goes = on to say that unless the medical unit is equipped to search patients' po= ssessions and rooms regularly and restrict visitors, illicit drug use on = wards is unavoidable. Once staff understands this, their efforts can be d= irected towards minimizing this phenomenon and its consequences. Chemcially dependent individuals are used to getting their drugs whe= n they want it, and thus usually have difficulty waiting for medication o= r declining drugs offered by visitors. This impatience on the client's pa= rt is usually expressed as irritability, anger or demanding medication fr= om staff, resulting in staff labelling these patients as "management prob= lems." Weiss states that chemcially dependent patients usually require g= enerous amounts of medication while in the hospital. Staff often withho= ld from these patients the very medication they need, making these patien= ts even more irritable and difficult to manage. Making the patient comfo= rtable with adequate opiates or sedatives will help the patient feel hear= d, enhance the patient's trust and improve the working relationship betwe= en the chemcially dependent patient and staff. Social workers or psychiatric nurses are in a perfect position to or= ganize groups that provide clients the opportunity to vent their feelings= appropriately and offer one another mutual support. These groups can al= so be psycho-educational and attempt to teach patients how to better advo= cate for themselves in ways that the medical staff can respond to. = Attempts should be made to interest hospitalized clients in educationa= l seminars about their health condition, drug treatment and available ser= vices once they are discharged. Where hospitals serve large populations = of chemically dependent individuals staff shoudl reach out to local inter= group offices to arrange daily meetings of AA or NA in the hospital. Psychotropic Medication Anxiety disorders are probably the most frequent psychiatric complic= ations of HIV disease in both those who themselves are uninfected but at = high risk as well as those who have symptomatic HIV disease. Depression = is the next most common psychiatric symptom. Both of these conditions re= spond well to supportive individual and group psychotherapy. Yet chemica= lly dependent people have historically demonstrated an inability to toler= ate these feelings, resorting to self-medication. When the symptoms are = severe, it is important to make a referral to a psychopharmacologist who = is skilled in both substance abuse and AIDS. Workers should expect that = chemically dependent clients are likely to abuse or over medicate themsel= ves with prescription drugs. Close interdisciplinary team work is invalua= ble in preventing manipulation of one professional against the other. Co= ncrete, cognitive interventions need to point out that taking more than t= he prescribed dosage will result in a period of time when the patient wil= l have to do without prescribed medication. Many individuals in recovery and some professionals are reluctant to= prescribe anti-anxiety mediciation, anti-depressants or other psychotrop= ic drugs to chemically dependent clients. While twelve step programs and= psychotherapy can go far in helping relieve some psychiatric symptoms if= left untreated by appropriate medication these clients will generally re= sort to self-medication and relapse. Since the anxiety or depression oft= en has an organic origin, these clients often respond well to medication.= Once they experience relief from psychiatric symptoms they often have th= e psychic availability to cope with other demanding tasks in the manageme= nt of their health. Workers must be alert to any indications of the onset of AIDS related = dementia, which often takes the form of short term memory loss or erratic= behavior. Drug treatment workers often interpret missed appointments or= other bizarre behavior as an acting out or response to being under the i= nfluence. An evaluation by a neurologist and psychiatrist skilled in dia= gnosing AIDS related dementia is essential at the first indications of a = change in a client's mental status. These symptoms sometimes resolve aft= er treatment with either antiretroviral drugs or psychotropic medication.= Since people with AIDS take a variety of prescribed drugs, many of w= hich can be mood altering, it is sometimes necessary to develop an approp= riate treatment strategy that addresses this reality. Faltz offers the s= uggestion of drawing up the following agreement during counseling session= s with chemcially dependent people with HIV. = Medication Agreement I,__________________________, REALIZE THE FOLLOWING PROBLEMS WITH MY= CURRENT USE OF MEDICATION: (Check if applicable) 1. Feeling tired or having a clouded mental state. 2. Feeling "hyperactive" or nervous. 3. Anticipating my next dose ahead of time. 4. Wishing for a higher dose or stronger medication. 5. Supplementing medication with alcohol or drugs. 6. Thinking of asking more than one doctor for medication. 7. Other_______________________________________ = I AGREE THAT THESE PROBLEMS INTERFERE WITH MY TREATMENT, AND I COMMIT= TO THE FOLLOWING AGREEMENTS: 1. Not to exceed the daily dose of medication prescribed. 2. To discuss any medication problems with my primary Health Care Wo= rker. 3. Not to obtain medication from other sources. 4. Not to self-medicate with alcohol or drugs. = 5. Other_______________________________________ = Medication Name Dose Frequency ___________________ ________________ ________________ ___________________ ________________ ________________ ___________________ ________________ ________________ ___________________ ________________ ________________ ___________________ ________________ ________________ _______________________ ______________________ ________ Patient Signature MD/Health Care Worker Date Summary Working with chemically dependent people with HIV is intensely diffi= cult work for a number of reasons. Both people with HIV and people who h= ave injected illicit drugs are stigmatized in contemporary American socie= ty. It can be very draining for workers to try setting limits with a pop= ulation who has as one characteristic a history of chronic impulse contro= l disorder. In order to be effective with this population workers need to= readjust their expectations about what constitutes success. Often, it i= s not appropriate to try and do traditional intrapsychic psychotherapy. P= ractical problem solving counseling is generally a more realistic mode of= intervening. In short much of this lesson has focused on practical sugge= stions for simply engaging members of this population in needed services = that will help improve the quality of their lives as chemically dependent= people living with HIV. = =0C = --PART.BOUNDARY.0.581.emout05.mail.aol.com.811111972--