Alcohol abusers suffer significant health consequences as a result of their substance use, including increased risk for HIV infection, yet they are particularly difficult to engage in primary medical care. Because of this, they often miss opportunities to receive preventive healthcare, including HIV risk reduction interventions, addictions behavioral counseling, prevention of the complications of HIV, and ongoing treatment for illnesses. Substance abuse treatment presents an opportunity to link alcohol abusers to primary medical care. Engaging alcohol abusers with or at-risk of HIV infection in health issues during detoxification may promote their subsequent linkage to primary medical care. This linkage, the addition of primary medical care to their addiction care, may result in more appropriate utilization of HIV and other health services, reduced alcoholism severity, decreased HIV risk behaviors, and improved health status. To test these hypotheses, a cohort of 240 individuals undergoing detoxification from alcohol, including 40 who are HIV-infected (the remaining individuals categorized as at high or low risk for HIV), will be identified and followed for two years. The cohort will be randomized into two groups. One group will receive standard care, including information about available primary care. The other group will attend the Health Evaluation and Linkage to Primary care (HELP) Clinic based at the detoxification unit, which will include a comprehensive medical, substance abuse, and social service assessment, referral to a primary care physician at a site where patients are seen regardless of ability to pay; and nurse contacts to remind them of primary care appointments. To study secondary prevention issues, the study will also enroll and follow a longitudinal cohort of 100 HIV-infected alcohol abusers presenting for initiation of ongoing medical care to the HIV Diagnostic Evaluation Unit at Boston City Hospital. All patients will be assessed at baseline regarding alcohol abuse severity using the alcohol factor score from the Addiction Severity index and the Alcohol Dependence Scale; health status using the EuroQol and the SF-36 Health Survey; and history of high-risk HIV behavior. The subjects will participate in interviews at 6, 12, 18, and 24 months after enrollment. The linkage outcome measure will be connecting to primary care follow-up after enrollment. It is expected that subjects randomized to the HELP Clinic will be more likely to attend visits with a primary care physician. Barriers to primary care and measures of primary care continuity, comprehensiveness and coordination will be documented. We hypothesize that the resultant linkage with primary care will result in improved addiction, health status, and HIV risk behavior outcomes, and more appropriate utilization of medical and addiction treatment services over two years. By establishing the HELP Clinic and rigorously assessing patient outcomes, we plan to determine the efficacy of a specific innovative strategy for linking substance abuse treatment and primary medical care for an alcohol abusing population at risk of HIV or living with HIV infection.
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