Provision of onsite HIV Services in Substance Use Disorder Treatment Programs: A Longitudinal Analysis

Past-Year HIV Testing, Current Antiretroviral Therapy Use, and Participation in Services for People Who Inject Drugs

Evaluating routine HIV testing and treatment and use of services for people who inject drugs (PWID) is critical to curb the ongoing HIV epidemic. We analyzed data from the 2018 National HIV Behavioral Surveillance of PWID aged 18 years or older, recruited using respondent-driven sampling and offered anonymous HIV testing after survey. We performed bivariate and multivariable analyses with log-linked Poisson regression of the generalized linear models to examine the associations between demographics and PWID service use, past-year HIV testing, and current antiretroviral therapy (ART) use. Among 10,311 HIV-negative PWID, 56% reported past-year HIV testing, and of the 553 HIV-positive PWID, 69% reported current ART use. Of the HIV-negative PWID, 64% (2874/4482) in drug treatment and 62% (3386/5440) who used syringe service programs (SSPs) reported past-year HIV testing. Among HIV-positive PWID, 75% (187/248) in drug treatment and 67% (200/298) SSP participants were on ART. In the adjusted multivariable model, past-year HIV testing was associated with drug use treatment (aPR 1.26, 95% CI 1.23-1.31) and SSP participation (aPR 1.19, 95% CI 1.13-1.26) among HIV-negative PWID. Current ART use was associated with drug use treatment (aPR 1.13, 95% CI 1.00-1.28) but the link was not significant probably due to small sample size. Findings support the expansion and improvement of PWID-targeted services, into comprehensive programs, including drug use treatment, SSP, and HIV testing and treatment.

HIV Prevention Services in Residential Substance Use Disorder Treatment Facilities in the United States

Residential substance use disorder treatment is designed to treat more severe substance use disorders. Considering the strong association between substance use and HIV, providing HIV prevention services during residential substance use disorder treatment is imperative. However, not all treatment facilities offer the same services, and differences in residential substance use disorder treatment facilities providing HIV prevention services might stem from facility-level characteristics. Using 3 years (2018-2020) of cross-sectional data from the National Survey of Substance Abuse Treatment Services, we examined which treatment facility characteristics were associated with having HIV prevention services. Using a logistic regression model with HIV prevention services as the outcome, we found that facilities that were accredited, engaged in community outreach, and offered assistance with housing and transportation were more likely to provide HIV prevention services. Furthermore, facilities in the Midwest and West were less likely to provide HIV prevention services than those in the South.

Co-occurring opioid use disorder and serious mental illness: A selective literature review

OBJECTIVE

The overarching goal of this review is to provide a clinical overview of epidemiology, diagnosis, and treatment, and to discuss the public health impact, social determinants including access to care, and implications for health care delivery and research. It is estimated that approximately 1 in 4 individuals suffering from a serious mental illness (SMI) may have a co-occurring opioid use disorder (OUD). In these individuals, the overall disease burden is higher and clinical outcomes are worse compared to those without a co-occurring illness, making an integrated approach to diagnosis and treatment an urgent priority.

METHODS

We conducted a selective review of the literature to investigate prevalence, etiology for co-occurring OUD and SMI, and diagnostic and clinical guidelines in the United States, and consideration special populations.

FINDINGS

Our findings suggest that, despite the high prevalence of co-occurring OUD and SMI, contemporary diagnostics and treatment approaches are underutilized in this patient population. The literature also suggests that both pharmacological and psychosocial treatment approaches need to be tailored to optimize clinical management, and that integrated treatment is pivotal for improving overall outcomes, yet comprehensive clinical guidelines for co-occurring OUD and SMI are lacking at this time.

A Call to Action: Integration of Buprenorphine Prescribing into the Care of Persons with HIV and Opioid Use Disorder

During the coronavirus disease 2019 (COVID-19) pandemic, we also experienced a worsening opioid overdose epidemic. Untreated opioid use disorder (OUD) in persons with human immunodeficiency virus (HIV) is associated with worse HIV-related outcomes. Buprenorphine is a safe, evidence-based medication for OUD and is effective in reducing opioid craving and overdose and improving outcomes along the HIV care continuum. Despite the longstanding evidence supporting the benefits of buprenorphine, there remains an implementation gap in the uptake of buprenorphine prescribing in HIV care settings. To improve integration of OUD care and HIV primary care, we recommend (1) all HIV clinicians obtain a buprenorphine waiver, (2) teaching on OUD should be integrated into infectious diseases and HIV continuing medical education, and (3) previously validated models of integrated care should be leveraged to urgently expand access to buprenorphine for persons with HIV and OUD.

Addressing Barriers to On-site HIV and HCV Testing Services in Methadone Maintenance Treatment Programs in the United States: Findings From a National Multisite Qualitative Study

CONTEXT

Few substance use disorder (SUD) treatment programs provide on-site human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) testing, despite evidence that these tests are cost-effective.

OBJECTIVE

To understand how methadone maintenance treatment (MMT) programs that offer on-site HIV/HCV testing have integrated testing services, and the challenges related to offering on-site HIV/HCV testing.

DESIGN

We used the 2014 National Drug Abuse Treatment System Survey to identify outpatient SUD treatment programs that reported offering on-site HIV/HCV testing to 75% or more of their clients. We stratified the sample to identify programs based on combinations of funding source, type of drug treatment offered, and Medicaid-managed care arrangements. We conducted semi-structured qualitative interviews with leadership and staff in 2017-2018 using a directed content analysis approach to identify dominant themes.

SETTING

Seven MMT programs located in 6 states in the United States.

PARTICIPANTS

Fifteen leadership and staff from 7 MMT programs with on-site HIV/HCV testing.

MAIN OUTCOME MEASURE

Themes related to integration of on-site HIV/HCV testing.

RESULTS

Methadone maintenance treatment programs identified 3 domains related to the integration of HIV/HCV testing on-site at MMT programs: (1) payment and billing, (2) internal and external stakeholders, and (3) medical and SUD treatment coordination. Programs identified the absence of state policies that facilitate medical billing and inconsistent grant funding as major barriers. Testing availability was limited by the frequency at which external organizations could provide services on-site, the reliability of those external relationships, and MMT staffing. Poor electronic health record systems and privacy policies that prevent medical information sharing between medical and SUD treatment providers also limited effective care coordination.

CONCLUSION

Effective and sustainable integration of on-site HIV/HCV testing by MMT programs in the United States will require more consistent funding, improved billing options, technical assistance, electronic health record system enhancement and coordination, and policy changes related to privacy.

Effect of Medicaid Expansions on HIV Diagnoses and Pre-Exposure Prophylaxis Use

INTRODUCTION

Increased insurance coverage and access to health care can increase identification of undiagnosed HIV infection and use of HIV prevention services such as pre-exposure prophylaxis. This study investigates whether the Medicaid expansions facilitated by the Affordable Care Act had these effects.

METHODS

A difference-in-differences design was used to estimate the effects of the Medicaid expansions using data on HIV diagnoses per 100,000 population, awareness of HIV status, and pre-exposure prophylaxis use. The analyses involved first calculating differences in new diagnoses and pre-exposure prophylaxis use before and after the expansions and then comparing these differences between treatment counties (i.e., all counties in states that expanded Medicaid) and control counties (i.e., all counties in states that did not expand Medicaid). Further analyses to investigate mechanisms addressed associations with HIV incidence, rates of sexually transmitted infections, and substance use. Analyses were conducted between August 2019 and July 2020.

RESULTS

Medicaid expansions were associated with an increase in HIV diagnoses of 0.508 per 100,000 population, or 13.9% (p=0.037), particularly for infections contracted via injection drug use and among low-income, rural counties with a high share of pre-Affordable Care Act uninsured rates that were most likely to be affected by the expansions. In addition, Medicaid expansions were associated with improvements in the knowledge of HIV status and pre-exposure prophylaxis use. There was no impact of the expansions on incident HIV, substance use, or sexually transmitted infection rates with the exception of gonorrhea, which decreased after the expansions. Altogether, these results suggest that the changes in new HIV diagnoses, awareness of HIV status, and pre-exposure prophylaxis were not simply because of a higher incidence or an increase in infection risk.

CONCLUSIONS

Medicaid expansions were associated with increases in the percentage of people living with HIV who are aware of their status and pre-exposure prophylaxis use. Expanding public health insurance may be an avenue for curbing the HIV epidemic.

Prevalence and Correlates of Sex Selling and Sex Purchasing among Adults Seeking Treatment for Cocaine Use Disorder

Exchange sex places individuals with cocaine use disorder (CUD) at particularly high risk for deleterious safety and health outcomes. A substance use treatment provider who is aware of a patient's exchange sex behavior is better able to provide appropriate screening, care, and/or referral to risk reduction services. However, little is known about exchange sex, especially purchasing, among treatment-seeking adults with CUD. The current study examined the prevalence and correlates of sex selling and sex purchasing among treatment-seeking men and women with CUD (n = 109; ClinicalTrials.gov #NCT02896712). Separate binary logistic regressions via backward elimination were used to identify best fitting models for sex selling and sex purchasing. Over 41% of participants endorsed exchange sex within the last 30 days; 20.2% reported selling sex and 30.3% reported purchasing sex. Sex selling and sex purchasing rates differed by gender and race. Number of sexual partners (OR = 5.83, 95% CI = 2.07-16.43), concern about contracting HIV/AIDS (OR = 2.01, 95% CI = 1.31-3.44), cumulative interpersonal trauma exposure (OR = 1.82, 95% CI = 1.20-2.77), years using cocaine (OR = 1.11, 95% CI = 1.03-1.20), drug-related problem days (OR = 1.07, 95% CI = 1.00-1.14), and sexual preference (OR = 9.50, 95% CI = .69-130.35) were retained in the final model estimating sex selling (Nagelkerke R² = .56). In the final sex purchasing model (Nagelkerke R² = .46), gender (OR = 36.17, 95% CI = 2.96-441.75), number of sexual partners (OR = 6.28, 95% CI = 2.69-14.66), number of convictions (OR = 1.13, 95% CI = 1.02-1.25), and drug-related problem days (OR = 0.96, 95% CI = .92-1.01) were retained. Predictive models in this study identified distinct sets of variables related to sex selling and purchasing. Findings may be used to improve identification of exchange sex in the substance use treatment setting and referral to targeted interventions to reduce associated risk.

The use of off-label medications in substance abuse treatment programs

Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US (N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.

Translation of basic research in cognitive science to HIV-risk: a randomized controlled trial

Many people enrolled in drug diversion programs are not receiving evidence-based prevention for HIV or hepatitis. This study translated basic research from cognitive science to increase screening for infection and condom use in this population. A parallel three-condition randomized trial was conducted in a drug diversion sample (N = 358), comparing a memory practice condition with two active control conditions. Outcomes were condom use frequency and testing for infection (hepatitis B/C, HIV). At 3-month follow-up, participants in the memory practice condition were at least twice as likely (OR = 2.10 or greater, p < .01) to self-report testing compared to those in the control conditions and also reported more frequent condom use compared to a health education condition [B = .37, t(1) = 2.02, p = .02]. Basic research on memory can be effectively translated to brief interventions on infection screening and risk prevention in existing drug diversion programs.

Patterns of Substance Use and Arrest Histories Among Hospitalized HIV Drug Users: A Latent Class Analysis

Using baseline data from the NIDA Clinical Trials Network 0049 study (Project HOPE), we performed latent class analyses (LCA) to identify discrete classes, or clusters, of people living with HIV (PLWH) based on their past year substance use behaviors and lifetime arrest history. We also performed multinomial logistic regressions to identify key characteristics associated with class membership. We identified 5 classes of substance users (minimal drug users, cocaine users, substantial cocaine/hazardous alcohol users, problem polysubstance users, substantial cocaine/heroin users) and 3 classes of arrest history (minimal arrests, non-drug arrests, drug-related arrests). While several demographic variables such as age and being Black or Hispanic were associated with class membership for some of the latent classes, participation in substance use treatment was the only covariate that was significantly associated with membership in all classes in both substance use and arrest history LCA models. Our analyses reveal complex patterns of behaviors among substance using PLWH and suggest that HIV intervention strategies may need to take into consideration such nuanced differences to better inform future studies and program implementation.

Informing Targeted Interventions to Optimize the Cascade of HIV Care Using Cluster Analyses of Health Resource Use Among People Living with HIV/AIDS

Increased awareness of the secondary preventive benefits of antiretroviral treatment (ART) has strengthened the desire to optimize health care systems' response to HIV/AIDS. We identified clusters of health resource utilization (HRU) among people living with HIV (PLHIV) to inform targeted interventions aimed to optimize the cascade of HIV care. Using linked population-level health databases in British Columbia, Canada, we selected two analytic samples of PLHIV with 3 years of follow-up between 2006-2011 that were classified as intermittently retained in care or intermittently engaged in ART, and executed a probabilistic model-based clustering analysis for each sample with 5 and 9 quarterly HRU variables, respectively. We found clear HRU profile differences among both samples with similar HIV-related care: one featured active involvement in non-HIV care, the other little or no health care interaction following linkage to care. Differential reengagement intervention strategies capitalizing on missed opportunities in non-HIV care and further engaging physicians delivering HIV care are needed to optimize the response to the HIV epidemic.

Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers

BACKGROUND

Contemporary studies about HIV care continuum (HCC) outcomes within substance using populations primarily focus on individual risk factors rather than provider- or systems-level influences. Over 25% of people living with HIV (PLWH) have substance use disorders that can alter their path through the HCC. As part of a study of HCC outcomes in nine small cities in Southern New England (population 100,000-200,000 and relatively high HIV prevalence particularly among substance users), this qualitative analysis sought to understand public health staff and HIV service providers' perspectives on how substance use may influence HCC outcomes.

METHODS

Interviews with 49 participants, collected between November 2015 and June 2016, were analyzed thematically using a modified social ecological model as the conceptual framework and codes for substance use, HCC barriers and facilitators, successes and failures of initiatives targeting the HCC, and criminal justice issues.

RESULTS

Eight themes were identified concerning the impact of substance use on HCC outcomes. At the individual level, these included coping and satisfying basic needs and could influence all HCC steps (i.e., testing, treatment linkage, adherence, and retention, and viral load suppression). The interpersonal level themes included stigma issues and providers' cultural competence and treatment attitudes and primarily influenced treatment linkage, retention, and viral load suppression. These same HCC steps were influenced at the health care systems level by organizations' physical environment and resources as well as intra-/inter-agency communication. Testing and retention were the most likely steps to affect at the policy/society level, and the themes included opposition within an organization or community, and activities with unintended consequences.

CONCLUSIONS

The most substantial HCC challenges for PLWH with substance use problems included linking and retaining in treatment those with multiple co-morbidities and meeting their basic living needs. Recommendations to improve HCC outcomes for PLWH with substance use problems include increasing easy access to effective drug and mental health treatment, expanding case management and peer navigation services, training staff about harm reduction, de-stigmatizing, and culturally competent approaches to interacting with patients, and increasing information-sharing and service coordination among service providers and the social service and criminal justice systems.

Substance Use Disorder Treatment Services for Women in the Veterans Health Administration

PURPOSE

The present study used national Veterans Health Administration (VHA) facility-level data to examine the extent of women's specialty substance use disorder (SUD) treatment programming in the VHA. In addition, the study compared facilities with women's specialty SUD programming with facilities without to determine whether having this programming was associated with serving other special patient populations, treatment staffing, and breadth of service provision.

METHODS

The study used data from the VHA Program Evaluation and Resource Center's Drug and Alcohol Program Survey, conducted in 2015 (100% response rate among VHA specialty SUD treatment programs). Program responses were calculated at the facility level (n = 140 VHA facilities).

MAIN FINDINGS

The majority of VHA facilities (85%) provided women veterans with SUD-specific individual psychotherapy. However, only 30% of facilities provided SUD-specific groups for women only, and only 14% provided SUD-posttraumatic stress disorder groups for women only in specialty SUD treatment. VHA facilities with greater numbers of specialty SUD treatment staff members, a greater breadth of staff roles, and a broader scope of treatment services, activities, and practices were more likely to provide women-only groups.

CONCLUSIONS

Because the number of women veterans in specialty SUD treatment is likely to continue to grow, these data serve as a benchmark against which future administrations of the Drug and Alcohol Program Survey will document the extent to which VHA services are responsive to their needs.

The Relationship Between Client Characteristics and Wraparound Services in Substance Use Disorder Treatment Centers

OBJECTIVE

The National Institute on Drug Abuse (NIDA) recommends a comprehensive treatment program for individuals with substance use disorder (SUD) in order to treat needs they often have in addition to their SUD. Specifically, NIDA suggests providing services related to the following issues: medical care, mental health care, HIV/AIDS, child care, educational, vocational, family counseling, housing, transportation, financial, and legal. By providing a comprehensive model that combines core and wraparound services, treatment centers can deliver a higher quality of treatment. In this article, we assessed the relationship between client characteristics and the availability of wraparound services in SUD treatment centers.

METHOD

We combined two nationally representative samples of treatment centers and used a negative binomial regression and a series of logistic regressions to analyze the relationship between client characteristics and wraparound services.

RESULTS

On average, centers offered fewer than half of the wraparound services endorsed by NIDA. Our results indicated that client characteristics were significantly related to the provision of wraparound services. Most notably, the proportion of adolescent clients was positively related to educational services, the proportion of female clients was positively related to child care, but the proportion of clients referred from the criminal justice system was negatively associated with the provision of multiple wraparound services.

CONCLUSIONS

Our findings have important implications for SUD clients and suggest that, although centers are somewhat responsive to their clients' ancillary needs, most centers do not offer the majority of wraparound services.

Low Rates of Adoption and Implementation of Rapid HIV Testing in Substance Use Disorder Treatment Programs

INTRODUCTION

Rapid HIV testing (RHT) greatly increases the proportion of clients who learn their test results. However, existing studies have not examined the adoption and implementation of RHT in programs treating persons with substance use disorders, one of the population groups at higher risk for HIV infection.

METHODS

We examined 196 opioid treatment programs (OTPs) using data from the 2011 National Drug Abuse Treatment System Survey (NDATSS). We used logistic regressions to identify client and organizational characteristics of OTPs associated with availability of on-site RHT. We then used zero-inflated negative binomial regressions to measure the association between the availability of RHT on-site and the number of clients tested for HIV.

RESULTS

Only 31.6% of OTPs offered on-site rapid HIV testing to their clients. Rapid HIV testing was more commonly available on-site in larger, publicly owned and better-staffed OTPs. On the other hand, on-site rapid HIV testing was less common in OTPs that prescribed only buprenorphine as a method of opioid dependence treatment. The availability of rapid HIV testing on-site reduced the likelihood that an OTP did not test any of its clients during the prior year. But on-site availability rapid HIV testing was not otherwise associated with an increased number of clients tested for HIV at an OTP.

CONCLUSIONS

New strategies are needed to a) promote the adoption of rapid HIV testing on-site in substance use disorder treatment programs and b) encourage substance use disorder treatment providers to offer rapid HIV testing to their clients when it is available.