Introduction

In Mexico, epidemiological monitoring systems estimate that there are approximately 200,000 people living with HIV/AIDS (PLHIV), equivalent to .24% of the general population. Estimated prevalence of the Hepatitis C virus (HCV) is 1.4% with an annual incidence of approximately 19,300 cases; whereas for the hepatitis B virus (HBV) it has been estimated at between .16% and .33%; while a prevalence of 1.53% has been found for syphilis (Nattional Center for the Prevention and Control of HIV and AIDS [CENSIDA, by its acronym in Spanish], 2019; Fundación Mexicana para la Salud Hepática, 2011).

It is also known that in Mexico, as in many parts of the world, the HIV epidemic focuses on key populations (CENSIDA, 2019): men who have sex with other men (MSM), persons deprived of their liberty (PDL) or incarcerated, sex workers (SW), transgender people (TP), and people who use drugs of abuse (particularly people who inject drugs [PWIDs]), the latter being one of the major public health concerns, since it is associated with clinical and psychosocial complications that hamper the detection, diagnosis and treatment of any STI or blood-borne viruses (BBV) (Marín-Navarrete, Magis-Rodríguez, & Strathdee, 2017).

SUDs and their relationship

with HIV and other STIs

International reports estimate that over 50% of PLHIV have had a substance use disorder (SUD) (Rabkin, McElhiney, & Ferrando, 2004).

Although it is true that it is necessary to differentiate between a SUD and non-problematic use of alcohol, tobacco and/or other substances of abuse, it has been found that substance use in PLHIV is generally associated with health risk behaviors, immunosuppression, poor adherence to antiretroviral treatment, an increase in the disease burden, greater morbidity and mortality and higher medical care costs (Chander, Himelhoch, & Moore, 2006). It should also be borne in mind that the use of substances of abuse constitutes an indirect and direct transmission vector. The former is characterized by increasing the likelihood of participating in risky sexual behaviors (unprotected sex, multiple sexual partners, group sex, among others) since it inhibits judgment, heightens sexual arousal and increases impulsivity. The latter is associated with the use of injectable drugs, since PWIDs frequently exchange syringes and other drug paraphernalia, thereby significantly increasing the risk of transmission (Klinkenberg & Sacks, 2004; Strathdee et al., 2008).

In addition to HIV, the most prevalent BBV in people with SUD is HCV, since a prevalence of over 90% has been estimated in PWIDs, in addition to the fact that it is associated with a higher risk of co-infection. In this regard, there is evidence that HCV/HIV coinfection accelerates the course of HCV infection with fatal outcomes of terminal liver disease (Altice, Kamarulzaman, Soriano, Schechter, & Friedland, 2010).

Studies have reported that the prevalence of co-infection between HIV and HBV in the general population ranges from 5% to 20%, but that in PWIDs it is just under 30% (Singh et al., 2017; Thio et al., 2002). As with other diseases, HBV/HIV coinfection is common, causing a greater risk of developing liver cirrhosis and hepatocellular carcinoma, with up to sixfold progressions of liver disease (Sulkowski, Thomas, Chaisson, & Moore, 2000). HIV infection affects the immune system in many ways, which directly or increase: a) HBV liver fibrosis, (depleting CD4 cells, which in turn cause liver damage), b) hepatotoxicity caused by medication, and c) the presence of opportunistic infections (Benhamou et al., 1999; Sulkowski et al., 2000).

Another important STI in drug users is syphilis, for which a prevalence of 3% is estimated, rising to between 8% and 20% for PWIDs (Rhodes et al., 2006; Centers for Disease Control and Prevention, 2019). Since primary syphilis acts as a facilitator of both HIV transmission and acquisition, it is a matter of concern in the expansion of the HIV epidemic in key populations. It has therefore been hypothesized that the increase in the syphilis rate is associated with the increase in recreational use of psychostimulant drugs (such as cocaine, amphetamines, methamphetamines and synthetic cathinones) and alcohol, which can be mitigated by safe sex practices (condom use), whether oral, anal and/or vaginal (Wong, Chaw, Kent, & Klausner, 2005; Marcus et al., 2006).

Like other infectious conditions, syphilis shows transient increases in viral load and reduces the CD4 cell count. These increases contribute to the risk of HIV transmission, facilitating concordance between the two viruses. (Quinn et al., 2000).

From this perspective, the use of alcohol and other drugs is a transversal axis of utmost importance since virtually all groups in a situation of vulnerability (adolescents, orphans, children in street situations, people with disabilities, migrants, women and indigenous people) and key populations (MSM, PDL, SW, TP and PWIDs) are susceptible to use substances and develop SUDs (Scheinmann et al., 2007).

Barriers to access to STIs treatment services

in substance users

Among substance users, there are barriers that limit help seeking, which impacts detection, diagnosis and treatment. In this regard, the specialized literature identifies the following as barriers: a) lack of knowledge of medical comorbidities and their impact on health, b) misperceptions about STIs and their treatment, c) lack of symptoms, d) employment status (self-employment/unemployment), e) unstable housing (people in street situations, etc.), f) social stigma and g) difficulties accessing specialized health services (Grebely & Tyndall, 2011; Treloar, Newland, Rance, & Hopwood, 2010). In relation to access, HIV is known to disproportionately affect people with limited economic resources, who generally lack social security or insurance policies for medical expenses.

Fortunately, in Mexico, HIV treatment is free, which is not the case for other viruses such as HCV, since access to public services for detection, diagnosis and treatment is limited, a situation associated with the increase in morbimortality due to HCV (Centro de Investigación en Enfermedades Infecciosas [CIENI], 2011).

Another common structural barrier in health systems is the disconnection between programs for the care of SUDs and other mental disorders in programs for the care of HIV/AIDS and other STIs. The absence of effective reference and counter-reference algorithms makes it difficult and complex for patients to navigate health services (Szerman et al., 2017).

As in other countries, the ability of the Mexican state to respond to major public health problems is limited (Marín-Navarrete, Medina-Mora, Pérez-López, & Horigian, 2018), as is the case with chronic-degenerative and infecto-contagious diseases, and mental and addictive disorders.

However, Mexico has a growing health system for the care of SUDs, HIV and other STIs. For SUDs, the supply of treatment consists of private care (very expensive for most of the people affected), public care (more than 400 outpatient centers and just under 30 residential units) and mutual assistance (over 20,000 groups based on the 12 AA steps and approximately 2,000 residential community care and peer assistance centers) (Marín-Navarrete, Medina-Mora, & Tena-Suck, 2014). For HIV/AIDS and other STIs, the supply of public treatment comprises 78 outpatient units (CAPASIT by its acronym in Spanish) and 63 hospital units (SAIH by its acronym in Spanish), which currently lack easily accessible programs for the treatment of HCV (CENSIDA, 2019).

Despite the progress achieved to date, there is a marked gap between both public care systems, due to the absence of reference and counter-reference algorithms to facilitate patients’ navigation. This situation highlights the need for inter-institutional models and programs based on scientific evidence that will contribute to the integration of public health systems and facilitate interaction between centers for the treatment of SUDs and centers for the care of HIV and other STIs, with the goal of strengthening the care cascade.

The purpose of this article is to present the narrative of the process for the development of a standardized model based on scientific evidence for the detection, orientation and reference of people with HIV, HBV, HCV and syphilis at addiction treatment centers in the public health system in Mexico.

Method

Study design and sites

As part of a strategic plan for the development of the model, two collaborative work teams were formed, one consisting of medical science researchers at the Clinical Trials Unit on Addictions and Mental Health of the Ramón de la Fuente Muñiz National Institute of Psychiatry (UEC-INPRFM by its acronym in Spanish), which served as the leading team for the implementation of the study and a team of experts on HIV and other STIs from the National Center for the Prevention and Control of HIV/AIDS (CENSIDA by its acronym in Spanish), who served as specialized advisors. Under a collaborative work scheme, a development methodology of the model was established: a) review of the scientific literature, b) feasibility study, c) integration of the final version of the model.

Procedure

Section 1: Review of the scientific literature

A systematic review of the scientific literature was undertaken to identify: a) basic concepts of HIV and other STIs, b) their relationship with the use of alcohol and other drugs of abuse, c) evaluation of risky sexual behaviors, d) application of rapid testing to detect HIV, HCV and other STIs, and e) specialized psychological counseling. The review of the scientific literature was conducted through a systematized search of information from the past five years, using the PubMed, Scielo, and Google Scholar search engines. To this end, a search algorithm was generated that included keywords on the study topics. Articles, guides and scientific manuals were selected through a process of consensus between members of both collaborative work teams, on the basis of their quality and scientific relevance, to ensure that the guides and manuals were written using scientific methods and bases, in addition to being products agreed on by experts and endorsed by prestigious scientific organizations in this field of health knowledge. Following the selection and review of the literature, a group of key recommendations for the development of the model was drawn up: a) general principles of psychological counseling and the application of rapid testing (Table 1), b) considerations for the psychological counseling process and the application of rapid testing (Table 2), c) considerations regarding users of substances of abuse (Table 3), and d) considerations for giving back results and referral to health services (Table 4).

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Lastly, the systematic review of the scientific literature made it possible to use scientific evidence to construct a model of Brief psychological counseling for the application of rapid testing (OPB-APR by its acronym in Spanish) comprising three key components: a) brief psychological counseling, b) application of rapid testing for the detection of HIV and other STIs, and c) the exploration of risky behaviors (sexual practices and injected drug use), which will be described later.

Section 2: Feasibility Study

Cognitive laboratories

In order to systematically capture the procedures of the OPB-APR model, a standardized manual/guide was developed, which underwent a cognitive laboratory process to ensure that the theoretical content, support materials and graphic resources were cognitively ergonomic (clear, understandable and intuitive), for the health professionals who would be trained in the model.

Each cognitive laboratory was made up of at least ten people, including health professionals (doctors, nurses and psychologists). The cognitive laboratories were carried out in three stages: content presentation, information gathering and consensus groups. In the first stage, each participant read the information corresponding to the components of the model, with the aim of identifying words, ideas or fragments that were difficult to understand. In the second stage, participants received semi-structured questionnaires (which included open-ended and multiple-choice questions) to express their comments, which included recommendations to improve the understanding of the fragments identified.

In the third stage, a member of the collaborative work team presented the problematic words, ideas or fragments, as well as the recommendations made. Subsequently, a discussion between the participants was coordinated with the aim of agreeing on the recommendations that would be used to increase understanding of the documents presented. Lastly, the collaborative work team incorporated the suggested modifications for each component, which resulted in the final design of the OPB-APR model manual/guide.

Field team formation and training

Three field teams were formed, each comprising six non-specialized health professionals (psychologists, nurses and general practitioners), with the aim of conducting feasibility tests on the OPB-APR model.

Likewise, specific training was developed for the field teams in order for their members to develop the skills (knowledge, attitudes and skills) required for the implementation of the procedures and components of the OPB-APR model.

The training lasted 42 hours, divided into seven six-hour sessions. The first session consisted of the presentation of basic aspects of HIV and other STIs, as well as their relationship with SUDs. The second session focused on the basic characteristics of psychological counseling. The third session addressed the exploration of risky sexual behaviors in people who use alcohol and other substances of abuse. The fourth session dealt with the brief, specific psychological counseling for the application of rapid HIV, HBV, HCV and syphilis tests. Sessions five and six focused on the management and application of rapid testing. Session seven provided a detailed explanation of the study and model procedures and implemented skills development strategies such as modeling and role play. At the end of the training, participants’ understanding of OPB-APR model procedures was tested.

Field tests

For the field tests, the collaborative work teams of UEC-INPRFM and CENSIDA formed three field work teams, each consisting of five psychologists and a supervisor (a doctor or a psychologist). All members of the field work team were certified in the OPB-APR model procedures. Field tests were carried out in residential (n = 31) and outpatient (n = 10) treatment centers in four states in Mexico (Mexico City, Puebla, Mexico State, and Hidalgo), achieving a total of 600 applications of OPB-APR model procedures. For more information on the research protocol and results, see the associated articles (Sánchez-Domínguez, Villalobos-Gallegos, Félix-Romero, Morales-Chainé, & Marín-Navarrete, 2017; Villalobos-Gallegos et al, 2019; Marín-Navarrete, Magis-Rodríguez, Medina-Mora, & Uribe-Zúñiga, 2019; Marín-Navarrete, Villalobos-Gallegos, Medina-Mora, & Magis-Rodríguez, 2019).

Section 3: Integration of the final version
of the OPB-APR model

Throughout the process, meetings were periodically held between the collaborative work and field teams to identify procedures that might experience complications when implemented in real treatment scenarios for SUDs. During the meetings, the procedures were evaluated and field staff were given feedback to increase adherence to the OPB-APR model components. Lastly, comments and recommendations that had arisen during the meetings were used to draft the final version of the OPB-APR model manual/guide.

Ethical considerations

This study was implemented with the approval of the INPRFM Research Ethics Committee (CEI/C071/2016). Likewise, all procedures were performed in accordance with good research practices in human subjects, and both participating patients and health professionals gave their written consent for inclusion in the study (Marín-Navarrete, Villalobos-Gallegos et al., 2019).

Results

After the multi-stage process, the final version of the OPB-APR model was obtained, whose main objective is the detection of new cases of HIV infection and other STIs to refer them to antiretroviral treatment. It also seeks to increase the perception of risk of situations and behaviors associated with contracting or transmitting a STI or BBV, in addition to promoting the development of personalized strategies to prevent and reduce the risk of infection.

The OPB-APR model consists of two parts: the first part explores and provides feedback on risk behaviors and situations (risky sexual behavior and substance use) for contracting STIs or BBVs. The second part focuses on providing feedback on the rapid testing results, as well as offering specific recommendations for risk prevention and reduction. The whole procedure lasts approximately 30 minutes.

Specifically, the OPB-APR model consists of five focused steps (Figure 1):

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• Step 1. Presentation and description of the procedure: In this step, the counselor provides general information on the procedure, requests written informed consent and provides answers on the information provided.

• Step 2. Application of rapid tests: This involves aseptic procedures, blood sampling through finger pricks, using a reagent kit and disposing of materials.

• Step 3. Exploration of and feedback on risk behaviors: This consists of applying the questionnaire on risky sexual behaviors and the use of alcohol and other substances of abuse.

• Step 4. Reporting results: This step involves reviewing and analyzing the results of the rapid testing, considering the information obtained in the forms. In addition, feedback is provided on the results and a risk reduction plan is drawn up.

• Step 5. Reference to services and delivery of information brochures: This final step is designed to provide patients with brochures with general information on STIs and safe sex practices. Cases with reactive results are informed about public care services where they can have confirmatory tests and receive comprehensive treatment that includes ART.

Discussion and conclusions

Using substances by any route of administration increases the risk of contracting a STI, co-infections, medical complications, poor adherence to antiretroviral treatments and therefore increases morbidity and mortality rates. In this respect, SUDs form a transverse axis that significantly impacts vulnerable groups and key populations (Marín-Navarrete, et al., 2017; Marín-Navarrete, Magis-Rodríguez, et al., 2019).

The purpose of this article was to present the narrative of the process for the development of a standardized model based on scientific evidence for the detection, orientation and referral of people with HIV, HBV, HCV and syphilis at addiction treatment centers in the Mexican public health system. This aim is based on the theoretical assumption that the detection of probable cases increases access to antiretroviral therapy (ART), which is associated with a reduction in the transmission, progression and death of people due to advanced immunological disease. It also seeks to adhere to the recommendations of the US Preventive Services Task Force on the application of rapid testing to all those at increased risk of contracting HIV, HCV and other STIs (Moyer, 2013), and of WHO for the implementation of harm reduction strategies (The Joint United Nations Program on HIV/AIDS [UNAIDS], 2016).

As a result of the process, the OPB-APR model was obtained, which was developed with the goal of constructing a standardized model based on scientific evidence that will contribute to strengthening the public health system in Mexico as a fundamental element in achieving the goal established by UNAIDS known as 90-90-90, which sets three specific goals in the HIV/AIDS care cascade for 2020: (1) 90% of all PLHIV will know their serological status; (2) 90% of all people diagnosed with HIV will receive sustained ART; and 90% of all people receiving ART will achieve viral suppression (The Joint United Nations Program on HIV/AIDS [UNAIDS], 2014), and HIV will have been eradicated worldwide by 2030 (UNAIDS, 2014).

Likewise, having a detection, orientation and referral model, based on scientific evidence, contributes to the reduction of barriers that exist in health services (Schneider et al., 2006; Rawat, Uebel, Moore, Cingl, & Yassi 2018), and the personal barriers that influence the initiation of ART (Posse, Meheus, Van Asten, H., Van Der Ven, & Baltussen, 2008; Johnson et al., 2015). Barriers reported by various studies include lack of training in the application of rapid tests. This can be offset by basic training to offer psychological guidance, provide feedback on safe sexual behaviors to reduce the likelihood of transmission of HIV and other STIs, and liaise with health services for the application of supplementary (confirmatory) tests and/or initiating ART (Posse et al., 2008; Rawat et al., 2018; Johnson et al., 2015) to prevent late diagnoses and ensure that PLHIV improve their quality of life through early detection (Magis-Rodríguez, Villafuerte-García, Cruz-Flores, & Uribe-Zuniga, 2015).

In Mexico, implementing a permanent program for monitoring risk behaviors and detecting HIV, HCV and other STIs in the population of people receiving treatment for SUDs can be a major task for a single system (CAPASIT and SAIH), since the universe of people with SUDs is larger than that of people with HIV, HCV and other STIs. Thus, incorporating professionals from addiction treatment centers in the public system into a permanent program for detection, orientation and referral could significantly strengthen the actions for achieving the eradication of HIV by 2030, in addition to significantly impacting the detection and care of HCV and other STIs.

In this respect, the OPB-APR model can serve as a key element in the implementation of risk and harm reduction strategies in people who use substances of abuse by any route of administration.

Another advantage of this proposal is that the OPB-APR model would enable the homologation of procedures between health professionals who are specialized in HIV and other STIs and those who are not (general practitioners, nurses, psychologists, etc.) for their performance in clinical and community settings. Since it is a standardized procedure, it would be feasible to transfer the implementation of the model to community agents who have direct contact with members of key populations, including PWIDs and thus strategically contribute to the country’s efforts to prevent HIV and other STIs.