Title : QGcover tip6 9-05-01ph.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 6 Screening for Infectious Diseases Among Substance Abusers ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 The Initial Patient Contact . . . . . . . . . . . . . . .5 The Role of the Counselor . . . . . . . . . . . . . . 9 Legal and Ethical Issues . . . . . . . . . . . . . . 21 Resources . . . . . . . . . . . . . . . . . . . . . . . . . 30 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 6, published in 1993 and based on information updated through approximately 1991. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 6 Screening for Infectious Diseases Among Substance Abusers ----------------------------------------------- 2 Screening for Infectious Diseases Among Substance Abusers WHY A QUICK GUIDE? This Quick Guide was developed to accompany Screening for Infectious Diseases Among Substance Abusers, Number 6 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 6 and is designed to meet the needs of the busy clinician for concise, easily accessed how-to information. The Guide is divided into six sections (see Contents) to help readers quickly locate relevant material. Terms related to infectious diseases among substance abusers are listed on page 32 in the Glossary. Clinicians can use the Resources beginning on page 30 to keep updated with cur rent information in screening for infectious dis eases. For more information on the topics in this Quick Guide, readers are referred to TIP 6. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest. TIP 6 • Addresses concerns of a broad range of read ers, including clinicians, social workers, medical personnel, mental health workers, program administrators, and policymakers • Includes extensive research • Lists numerous resources for further informa tion • Provides a comprehensive reference on screen ing for infectious diseases among substance abusers See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 Screening for Infectious Diseases Among Substance Abusers INTRODUCTION There is a vital need for the integration of sub stance abuse treatment and infectious disease screening, testing and counseling. Drug use is an important risk factor for infectious diseases, since it is commonly associated with such risk behav iors as the sharing of contaminated needles and other drug paraphernalia, and with unsafe sexual practices that contribute to transmission. This Quick Guide is designed to provide helpful information about transmission, symptoms, and indications for screening of a number of these conditions. It also contains basic guidelines for effective counseling, along with information about reporting infectious diseases where mandated by Federal, State and/or local regulations. Please remember: Many drug users are reluctant to become involved with traditional medical providers because of previous poor treatment, and/or may have had minimal or no medical care before enrolling in a treatment program. Substance abuse treatment providers must be sensitive to and knowledgeable about the experi ences, concerns and needs of these individuals. For more detailed information, see TIP 6, pp. 1–3. ----------------------------------------------- The Initial Patient Contact 5 THE INITIAL PATIENT CONTACT Goals The goals of the initial patient contact are to • Lay the foundation for a positive relationship between treatment staff and the patient • Obtain a thorough and complete medical, sexu al, psychosocial, and drug use history • Prepare for initial physical examination and infectious disease screening • Begin treatment planning Studies show that an open, trusting relationship with treatment staff helps the patient remain in and benefit from treatment services. The inter viewer can begin creating this supportive relation ship during the first contact by • Being accepting and nonjudgmental • Providing complete information about assess ment and diagnostic procedures • Answering the patient's questions • Being open to and understanding of the needs and concerns of the patient A comfortable rapport encourages the patient to trust the interviewer with sensitive and personal ----------------------------------------------- 6 Screening for Infectious Diseases Among Substance Abusers information. To further facilitate patient respon siveness, the interviewer can • Begin the process of taking a history with the least stressful areas of questioning (e.g., gather ing general demographic information first, then addressing drug use, sexual practices, and infectious disease testing) • Introduce the objectives of the interview and explain to the patient that the questions asked are intended to help both treatment staff and the patient develop appropriate care • Explain to the patient how Federal, State and local regulations affect the confidentiality of drug treatment information, infectious disease test results, contact tracing and partner notifica tion procedures, and medical records • Inform the patient that testing for infectious dis eases, including HIV, is voluntary Patient History Medical History • History of and treatment for infectious diseases • Vaccination status • Current medical treatments • Obstetrical/gynecological status ----------------------------------------------- The Initial Patient Contact 7 History of Drug Abuse • History of injection drug use • History of sharing needles and other drug para phernalia Psychosocial History • Family history of infectious disease(s) • Psychiatric disorders • Socioeconomic and housing status Sexual History • Number and background of sexual partners • High-risk sexual practices • Sexual activity while under the influence of alcohol or illicit drugs It may be helpful during this process to assure the patient that a sexual history provides the treat ment team with information that can be critical for the prevention and treatment of infectious dis eases and that this is the only purpose for gather ing such information. The Medical Examination Every patient entering substance abuse treatment should have a thorough physical examination to • Assist medical staff to diagnose infectious dis eases in patients ----------------------------------------------- 8 Screening for Infectious Diseases Among Substance Abusers • Provide a basis for infectious disease testing • Assist medical staff to plan for and provide medical care for patients with infectious dis eases • Provide a basis for planning preventive interven tions • Provide a basis for planning follow-up medical care • Develop a comprehensive drug treatment plan (with the patient's input) For more detailed information, see TIP 6, pp. 31–33. ----------------------------------------------- The Role of the Counselor 9 THE ROLE OF THE COUNSELOR Screening for infectious diseases in the treatment setting requires not only medical management but supportive counseling. Pre-Test Counseling The counselor should • Create an environment that conveys trust and acceptance, encourages communication, and validates feelings • Stress the benefits of testing • Discuss the process of testing, possible out comes and treatment resources • Explain confidentiality procedures and reporting requirements • Discuss infection containment and risk reduc tion strategies • Discuss retesting and the circumstances under which it may be indicated • Discuss contact tracing and partner notification • Help the patient make the best decisions in obtaining medical care Patients may be particularly anxious about how and when test results will be provided, and they may experience some distress while waiting. The ----------------------------------------------- 10 Screening for Infectious Diseases Among Substance Abusers counselor should assure the patient that, if the results are positive, medical treatment is available and can be effective. Post-Test Counseling Because of the severe distress some patients experience while waiting for test results, coun selors are advised that they only have 10 to 60 seconds to communicate information that will be comprehended by the patient after the test result is reported. A second post-test session may be needed after the patient gets over the initial ela tion or depression. Patients With Positive Test Results Patients infected with TB, viral hepatitis, syphilis or other sexually transmitted diseases (STDs) need emotional support and counseling. The counselor can assist these patients in the follow ing ways: • Discuss the importance of following all proce dures, keeping appointments for checkups, and taking medications. • Make sure the patient is familiar with the right to confidentiality, while being aware of the need to inform health department infectious disease practitioners of all contacts and partners who may be at risk for infection. ----------------------------------------------- The Role of the Counselor 11 • Inform the patient about the signs and symp toms of disease, routes of transmission, and short- and long-term effects. • Discuss safer sexual practices and abstinence from drugs as important risk-reduction behav iors. Patients With Negative Test Results Patients need a careful explanation of the mean ing of negative test results. In some cases, repeat tests may be needed on a regular basis. With many patients, a negative test result provides a non-threatening window of opportunity for impor tant education and counseling about protection from infectious disease. This may be particularly important for adolescent drug users, who might otherwise continue high-risk behaviors without being concerned about infection risks. Patients With Negative HIV Test Results In such cases, the counselor should discuss the possible need for retesting. Although HIV-antibody tests are extremely accurate when properly done, (re)testing may be advisable for • Persons who strongly deny any risk factors and are unwilling to accept an initial positive result • A patient who may have been infected with HIV in the recent past (8 to 12 weeks), since the HIV ----------------------------------------------- 12 Screening for Infectious Diseases Among Substance Abusers tests may be falsely negative because of the incubation period before seroconversion • A person with known HIV risk factors (the HIV test should be repeated in 3 months and again in 6 to 12 months) • As long as a patient engages in behavior associ ated with risk of exposure to HIV (retested every 3 to 6 months) • The children of HIV-infected women HIV-Positive Patients HIV is dealt with separately because the severity of the illness and the stigma surrounding it make this condition an especially difficult one for patients to accept and deal with. Begin with the facts: Patients with a positive HIV test result have HIV infection and must deal with questions about AIDS. The progression of illness in individual patients is unpredictable, but proper medical care may significantly slow this process. The counselor should advise the patient that he or she is infectious and must follow precautions to prevent the transmission of the virus to others, especially via sexual contact or injection drug use. Patient responses to this information can vary greatly, from intense anxiety, guilt and feelings of ----------------------------------------------- The Role of the Counselor 13 physical and social isolation to anger, fear and concerns about loss of relationships and support systems. The counselor should reassure patients that these feelings are understandable and nor mal. Employ additional methods as necessary to help the patient maintain a positive approach to coping with HIV: Discuss withdrawal and self-imposed isolation. Being HIV positive is associated with being viewed as someone who engages in high-risk sexual behavior and/or drug abuse. Patients are often faced with extreme isolation because of misunder standings about modes of transmission. They may need assistance to maintain an existing network of friends and family or to develop a support net work. Assess suicide potential and provide referral to mental health care. Patients who are HIV positive may contemplate suicide at some point following their diagnosis. It is imperative that substance abuse treatment programs have a well-defined protocol to respond to all suicidal thoughts or ges tures. Emphasize risk-reduction behaviors. Of particular concern is the risk of infection with a different and potentially more virulent and resistant strain of ----------------------------------------------- 14 Screening for Infectious Diseases Among Substance Abusers HIV, which can hasten the progression of HIV to AIDS. In addition, drug use may further impair the immune system. Support the patient in joining an HIV support group. The patient who is HIV positive may benefit from the help and understanding provided by a community-based HIV support group. The coun selor can encourage and facilitate attendance by patients and family members during treatment and after its completion. Support the patient and family members in anticipatory mourning and other feelings. Feelings of impending loss and grief can be fright ening and may lead to the further debilitation and isolation of the patient. Patients need assurance that these feelings are a part of a healthy coping process. Patients and their family members may also confront employment, physical, and financial concerns. Counseling and referrals to community- based resources can provide the assistance need ed to maintain a positive lifestyle. Contact Tracing and Partner Notification Once positive test results are received, patients should be encouraged to provide the names and locations of sexual partners, injection drug-sharing partners, or contacts at risk for infection. For reportable diseases, contact tracing and partner ----------------------------------------------- The Role of the Counselor 15 notification are conducted by health department personnel regardless of the wishes of the infected person. It is helpful for patients to have opportunities to discuss their fears about contact and partner noti fication. Patients may fear the loss of a relation ship, physical violence, the loss of housing or other physical or emotional support, and the loss of confidentiality and misuse of the information. When patients do choose notification, they may need assistance to develop effective ways to com municate with these individuals. Using techniques such as role-playing, patients can be prepared for potentially uncomfortable situations: • Adolescents may be particularly embarrassed about their infection and may continue risky behaviors. The counselor can discuss referral options to community-based services to address needs such as housing and financial assis tance, peer support groups, and mental health care. • Some may fear abandonment, or physical or emotional abuse from a partner, if their test results are revealed. The counselor can discuss referral options to community-based services to address needs such as legal intervention, hous- ----------------------------------------------- 16 Screening for Infectious Diseases Among Substance Abusers ing assistance, child care services, and financial assistance. • Patients may fear that contacts will be able to discern their identity and that confidential and sensitive information will be misused, and thus may be unwilling to provide information, or may provide information that is incorrect or incom plete. The counselor can acknowledge the patient's concerns and be reassuring about the confidentiality of treatment records. Risk Reduction Every patient should receive risk reduction educa tion and counseling to help prevent future infec tion in patients who test negative and reduce the risk to others from patients who test positive. The experiences of drug treatment programs suggest that the following broad principles can effectively guide counselor-based risk reduction activities: • Establish a warm and trusting relationship with the patient, based on mutual respect and regard. • In the overall treatment program, incorporate risk-reduction approaches that emphasize the benefits of preventive health behaviors. • Provide risk reduction education and counseling that is sensitive to the cultural values, religious beliefs and traditions of the individuals being ----------------------------------------------- The Role of the Counselor 17 served, as well as their socioeconomic and day to-day realities. • Understand that it is fairly easy to change knowledge, more difficult to change attitudes, and extremely difficult to change behavior. • Forego scare tactics: They are usually ineffec tive, especially when dealing with adolescents and young adults. • Expect modest levels of change. • Encourage participation in an HIV/AIDS self-help group for HIV-positive patients. Safer Sexual Practices The initiation of safer sexual practices is a primary risk reduction strategy. Factors associated with a return to high-risk sexual practices include • Higher levels of unsafe sexual activity prior to behavioral change • Perceptions that behavioral change does not offer protection from infection • Failure to use condoms with a steady and "safe" sexual partner • Negative attitudes concerning condom use • Use of alcohol or illicit drugs • A lack of enjoyment of sexual activity using safer sex methods ----------------------------------------------- 18 Screening for Infectious Diseases Among Substance Abusers • A preference for high-risk sexual activities, such as unprotected anal intercourse • Social support for high-risk behavior Beyond sexual abstinence, the consistent and proper use of condoms is currently the most effec tive way to prevent HIV and other STDs. For more information, refer to Table 1, Recommendations for the use of condoms, p. 16 of TIP 6. The following examples of counselor-based activi ties can also promote safer sexual behavior by patients: • Educate patients about the risk of infection through unprotected sex, particularly with injec tion drug users and multiple partners. • Incorporate ethnic and cultural perspectives to circumvent barriers to the use of condoms. • Provide materials that offer sex-positive mes sages that make safer sex appealing to patients. • Educate both women and men about the poten tial impact of infection on a developing fetus or newborn infant (infection may occur at concep tion, but there is continued risk throughout the pregnancy). ----------------------------------------------- The Role of the Counselor 19 • Assist women to assess and avoid possible domestic violence should they initiate unwel come changes in sexual practices. • Offer coping skills and assertiveness training that assist patients in resisting pressures from partners to engage in unsafe sexual practices. • Stress that maintaining safer sexual practices and not returning to high-risk behaviors is an ongoing, lifelong challenge. Retention in Treatment Studies and clinical experience show that the longer patients stay in treatment, the better the outcome and the less likely relapse becomes. For patients not in long-term therapy, it is vitally important to make sure they know who the local health care provider is and how to get there. The patient should be in the habit of accessing care and making return visits, and should know how and where to reenter the drug treatment sys tem. During treatment, information should be pro vided about community-based programs that deal with ongoing recovery needs. A counselor should work out insurance benefits with the patient. If the patient is not eligible for insurance, that patient should know how to get care for medical emergencies. In addition, the counselor can ----------------------------------------------- 20 Screening for Infectious Diseases Among Substance Abusers • Encourage and support the patient to make a commitment not to use non-prescribed drugs while in treatment. • Encourage the patient's participation in self- help groups. • Provide skills training that is oriented to chronic and complex life problems, such as job-seeking. • Provide aggressive diagnosis and treatment for comorbid psychiatric disorders, particularly depression and anxiety. • Provide comprehensive counseling that includes drug avoidance skills. • Help the patient develop coping strategies, such as anger management and social skills develop ment. • Teach patients self-management and social skills that assist them to create steady and self- affirming social supports and drug-free con tacts, resist coercion, and improve decision making. • Teach patients relaxation and meditation tech niques to combat the stress and tension that can lead to drug use. • Understand that it is never appropriate to dis charge a patient solely on the basis of drug use while in treatment. For more detailed information, see TIP 6, pp. 11–17. ----------------------------------------------- Legal and Ethical Issues 21 LEGAL AND ETHICAL ISSUES Treatment Access The following practices can discourage drug users from seeking treatment and are likely to violate Federal and State nondiscrimination laws (not to mention being unethical): • Requiring individuals to be tested for infectious diseases as a condition of admission to treat ment • Providing differential treatment to such patients • Refusing to admit otherwise eligible individuals However, to protect the safety and health of other patients and staff, an individual seeking treat ment who is thought to have infectious TB or any other highly contagious disease (such as chicken pox) may be denied admission until it has been medically determined if the patient needs treat ment. Some accommodations by treatment providers may be needed to enable individuals to partici pate in and benefit from treatment services. Providers are required by Federal nondiscrimina tion laws to make reasonable accommodations for clients with disabilities, but not to change the basic nature of the services offered or incur undue financial hardship. ----------------------------------------------- 22 Screening for Infectious Diseases Among Substance Abusers Segregating persons with HIV or AIDS, or providing differential treatment to such patients under the guise of protecting others from infection, must generally be avoided. Other, nondiscriminatory means are usually available to protect patients and staff. Appropriate infection control and prevention measures include education and training for staff about transmission modes for HIV and other com municable diseases and about preventive prac tices such as those detailed by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). Confidentiality, Disclosure and Informed Consent The benefits of the therapeutic relationship depend, in part, on maintaining strict confidential ity for all patient information. Patients in treat ment rely on this and they trust that their medical and personal records will be protected from unwarranted and unwanted disclosure. Federal laws and regulations now protect drug treatment patient records, and some State statutes may equal or exceed these Federal requirements. Treatment staff members need to be familiar with these laws, and a discussion of ----------------------------------------------- 24 Screening for Infectious Diseases Among Substance Abusers out patient consent, each of which have their own requirements and limitations. In general, permit ted disclosures are those made as follows: • With the written informed consent of the patient • Pursuant to internal program communications • Pursuant to a medical emergency • In response to a special court order following a court hearing in which disclosure is authorized • For the purpose of reporting a crime at the treatment program or against program person nel • For research or audit purposes • In the course of reporting child abuse or neglect • Pursuant to a qualified service organization agreement (QSOA) • In response to a request for non-patient-identify ing information State confidentiality laws may also limit the ability of persons to testify in court based on information obtained when providing professional services (testimonial privilege). Informed Consent Informed consent consists of communicating to the patient the risks involved and benefits to be ----------------------------------------------- Legal and Ethical Issues 25 derived from a test in a way that allows the patient to make a decision about whether or not he or she will have the test done. The practitioner involved in securing the patient's informed con sent will generally include a note in the patient's record. Written informed consent requires the patient's signature on a document that specifies the above elements in a language that the patient is com fortable with. If there is any question about the process, legal counsel should be sought. State laws generally govern whether and what form of informed consent is required for medical testing (including infectious disease testing). Informed consent is required for HIV testing in many jurisdictions. In some States, minors can give informed consent without parental agree ment. Drug treatment providers should make sure their consent forms for HIV or other infectious dis eases testing comply with applicable State laws. Some patients may choose not to undergo testing. Treatment providers need to be respectful of these choices. Patients generally have this right, and they cannot be denied access to or continua tion of treatment services based solely on that refusal. ----------------------------------------------- 26 Screening for Infectious Diseases Among Substance Abusers HIV Issues The unfortunate discrimination that persists for many HIV-positive individuals makes it imperative that treatment providers act with great care to inform patients of their legal rights concerning testing. Patients need to receive professional counseling before reaching a decision about HIV testing. In some States, HIV laws mandate pre and post-test counseling. Under current Federal law, mandatory HIV testing is required • Upon entrance to the military • For donors of blood, organs, and tissue • For Federal prisoners • For persons seeking immigration to the U.S. States may also require mandatory HIV testing of individuals under certain circumstances, such as marriage applicants, mentally ill or mentally retarded patients, injection drug users, and sex offenders. Anonymous Testing For patients who agree to HIV-antibody testing, confidential as well as anonymous procedures are available in many communities and should be dis cussed as alternatives. Anonymous testing assigns a unique identifier to each patient, and results are not traceable to an individual. ----------------------------------------------- Legal and Ethical Issues 27 Confidential testing, on the other hand, links the individual by name to test results, and confiden tiality safeguards protect the test results. In States that require the reporting of HIV-positive individu als by name to health authorities, patients may choose to use anonymous testing sites. Contact Tracing and Partner Notification Public health statutes in States usually authorize or require contact tracing for STDs. Most States currently do not classify HIV infection as an STD, although some States have specifically authorized or required such tracing. The informed consent of the patient must be sought for contact tracing and partner notifications in circumstances where statutes are silent. All notifications that are accomplished by persons other than the patient, regardless of the reporting requirement, are performed without revealing the identity of the patient (although it may be inferred by the partner in some situations). These notifications may place patients in treat ment at risk for negative consequences, such as physical abuse or abandonment. Treatment providers should exercise care to protect patient confidentiality when counseling about, assisting with, or performing partner notifications and con tact tracing. ----------------------------------------------- 28 Screening for Infectious Diseases Among Substance Abusers "Duty to Warn" In spite of strict ethical codes and legal require ments for the confidentiality of patient informa tion, some treatment providers may find them selves subject to a "duty to warn" that requires a breach of confidentiality. "Duty to warn" refers to the legal duty of a physi cian, health care worker, or other professional to protect another individual from harm. The legal basis for warning an individual in order to protect that person from severe or deadly harm may be provided by State law. If so, it is likely that the State statute will allow, but not require, that a warning be made. The moral duty to warn conflicts with the legal and professional sanctions against unauthorized dis closure of confidential patient information. Drug treatment providers must keep in mind that, even if State law permits or requires disclosures of patient-identifying information in "duty to warn" sit uations, they may make such warnings only in ways that are permitted by the Federal drug confi dentiality laws and regulations. Treatment providers should be aware of applica ble State laws, have procedures in place that sup port legally required actions, and understand that a breach of confidentiality is punishable by law. ----------------------------------------------- Legal and Ethical Issues 29 Record Keeping Treatment programs have a duty to maintain adequate patient records. These are useful in monitoring patient progress, case management, seeking funding and reimbursement, and evaluat ing program effectiveness. In States in which there are laws covering disclosure of HIV in health records, drug treatment programs need to comply with restrictions about mentioning HIV diagnosis and treatment in such records. A number of approaches are possible, and treat ment providers should ensure that the approach selected meets all Federal and State confidentiali ty requirements. Options include • Maintaining a single, comprehensive record with integrated test results and limiting access to medical staff and others authorized by consent of the patient • Maintaining infectious disease and/or HIV test results separately from the main part of the patient's record and limiting access to medical staff and others authorized to have access to medical information • Maintaining all medical information separately from the main part of the patient's record and limiting access to medical personnel and others authorized to have access to medical informa tion For more detailed information, see TIP 6, pp. 19–24. ----------------------------------------------- 30 Screening for Infectious Diseases Among Substance Abusers RESOURCES Listed below are a number of related resources for infectious disease screening, counseling and treatment. The National Institute on Drug Abuse (NIDA) (301) 443-1124; NIDA Clearinghouse: 1-800-729- 6686 The Federal alcohol and drug clearinghouses list ed below can all be reached through one tele phone number: 1-800-788-2800. Individual num bers are also listed. CDC National Prevention Information Network (formerly known as the CDC National AIDS Clearinghouse) 1-800-458-5231; TTY: 1-800-243- 7012; Information on AIDS clinical trials: 1-800- 874-2572; online at www.cdcnac.org Centers for Disease Control and Prevention (CDC) online at www.cdc.gov Drug Information and Strategy Clearinghouse 1-800-578-3472 or (301) 251-5154 ----------------------------------------------- Resources 31 The National Drug and Alcohol Treatment Referral and Routing Service (formerly known as the Drug Abuse Information and Treatment Referral Line) 1-800-662-4357; Spanish: 1-800-662-9832 Drug-Free Workplace Helpline 1-800-843-4971 SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) 1-800-729-6686 National Institutes of Health (NIH) online at www.nih.gov For more detailed information, see TIP 6, pp. 137–138. ----------------------------------------------- 32 Screening for Infectious Diseases Among Substance Abusers GLOSSARY Anonymous Testing: Testing which assigns a unique identifier to each patient, with the results not being traceable to an individual. Disclosure: A communication that identifies an individual as having participated in, participating in, or seeking to participate in drug or alcohol abuse treatment. “Duty to Warn”: The legal duty of a physician, health care worker or other professional to protect another individual from harm. EIA: Abbreviation for enzyme immunoassay, a type of screening test for certain infectious diseases. Informed Consent: Communicating to the patient the risks involved and benefits to be derived from a test in a way that allows the patient to make a decision about whether or not he or she will have the test done. Qualified Service Organization Agreement (QSOA): A contract that, under certain conditions, permits a substance abuse treatment provider to share patient-identifying information with an out side service provider. ----------------------------------------------- Ordering Information TIP 6 Screening for Infectious Diseases Among Substance Abusers TIP 6-Related Products KAP Keys for Clinicians based on TIP 6 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT's Website at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3553 Printed 2001 TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (1994) BKD143 TIP 16, Alcohol and Other Drug Screening of Hospitalized Trauma Patients (1995) BKD164 TIP 18, The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers (1995) BKD173 TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (2000) BKD359