Availability of HIV-related health services in adolescent substance abuse treatment programs

Factors associated with the adoption of evidence-based innovations by substance use disorder treatment organizations: A study of HIV testing

INTRODUCTION

Though prior research shows that a range of important regulatory, market, community, and organizational factors influence the adoption of evidence-based practices (EBPs) among health care organizations, we have little understanding of how these factors relate to each other. To address this gap, we test a conceptual model that emphasizes indirect, mediated effects among key factors related to HIV testing in substance use disorder treatment organizations (SUTs), a critical EBP during the US opioid epidemic.

METHODS

We draw on nationally representative data from the 2014 (n = 697) and 2017 (n = 657) National Drug Abuse Treatment System Survey (NDATSS) to measure the adoption of HIV testing among the nation's SUTs and their key organizational characteristics; we also draw on data from the US Census Bureau; Centers for Disease Control; and legislative sources to measure regulatory and community environments. We estimate cross-sectional and longitudinal structural equation models (SEM) to test the proposed model.

RESULTS

Our longitudinal model of the adoption of HIV testing by SUTs in the United States identifies a pathway by which community and market characteristics (rurality and the number of other SUTs in the area) are related to key sociotechnical characteristics of these organizations (alignment of clients, staff, and harm-reduction culture) that, in turn, are related to the adoption of this EBP.

CONCLUSIONS

Results also show the importance of developing conceptual models that include indirect effects to account for organizational adoption of EBPs.

A mixed methods study of HIV-related services in buprenorphine treatment

BACKGROUND

Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers' medical specialty and across practice settings.

METHODS

Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers' medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states.

RESULTS

Qualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings.

CONCLUSIONS

Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.

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

The provision of HIV education and testing in substance use disorder (SUD) treatment programs is an important public health strategy for reducing HIV incidence. For many at-risk individuals, SUD treatment represents the primary point of access for testing and receiving HIV-related services. This study uses two waves of nationally representative data of 265 privately-funded SUD treatment programs in the U.S. to examine organizational and patient characteristics associated with offering a dedicated HIV/AIDS treatment track, onsite HIV/AIDS support groups, and onsite HIV testing. Our longitudinal analysis indicated that the majority of treatment programs reported providing education and prevention services, but there was a small, yet significant, decline in the number of programs providing these services. Programs placed more of an emphasis on providing information on the transmission of HIV rather than on acquiring risk-reduction skills. There was a notable and significant increase (from 26.0% to 31.7%) in programs that offered onsite HIV testing, including rapid HIV testing, and an increase in the percentage of patients who received testing in the programs. Larger programs were more likely to offer a dedicated HIV/AIDS treatment track and to offer onsite HIV/AIDS support groups, while accredited programs and programs with a medical infrastructure were more likely to provide HIV testing. The percentage of injection drug users was positively linked to the availability of specialized HIV/AIDS tracks and HIV/AIDS support groups, and the percentage of female clients was associated with the availability of onsite support groups. The odds of offering HIV/AIDS support groups were also greater in programs that had a dedicated LGBT track. The findings suggest that access to hospitals and medical care services is an effective way to facilitate adoption of HIV services and that programs are providing a needed service among a group of patients who have a heightened risk of HIV transmission. Nonetheless, the fact that fewer than one third of programs offered onsite testing, and, of the ones that did, fewer than one third of their patients received testing, raises concern in light of federal guidelines.

Prevalence and correlates of HIV risk among adolescents and young adults reporting drug use: Data from an urban Emergency Department in the U.S

Adolescents and young adults who use substances are at particularly high risk for contracting Human Immunodeficiency Virus (HIV). The Emergency Department (ED) is a critical location for HIV prevention for at-risk youth. To inform future interventions in the ED, this study identifies correlates of HIV risk behaviors among substance using youth seeking ED care. Among 600 14-24-year-olds with past 6-month drug use, bivariate correlates of HIV risk included: older age, female gender, depressive symptoms, alcohol use, marijuana use, other drug use, and dating, peer, and community violence. Regression analyses indicated that older age, marijuana use, and dating violence were positively related to HIV risk. Results suggest HIV prevention efforts for youth in the urban ED should address marijuana use and dating violence as well as sexual risk behaviors.

Nonmedical prescription drug users in private vs. public substance abuse treatment: a cross sectional comparison of demographic and HIV risk behavior profiles

Background

Little is known regarding the demographic and behavioral characteristics of nonmedical prescription drug users (NMPDUs) entering substance abuse treatment settings, and information on the HIV-related risk profiles of NMPDUs is especially lacking. Participation in substance abuse treatment provides a critical opportunity for HIV prevention and intervention, but successful initiatives will require services appropriately tailored for the needs of NMPDUs.

Methods

This paper compares the HIV risk profiles of NMPDUs in public (n = 246) and private (n = 249) treatment facilities. Participants included in the analysis reported five or more recent episodes of nonmedical prescription drug use, a prior HIV negative test result, and current enrollment in a substance abuse treatment facility. A standardized questionnaire was administered by trained interviewers with questions about demographics, HIV risk, and substance use.

Results

Private treatment clients were more likely to be non-Hispanic White, younger, and opioid and heroin users. Injection drug use was higher among private treatment clients, whereas public clients reported higher likelihood of trading or selling sex. Public treatment clients reported higher rates of HIV testing and availability at their treatment facilities compared to private clients.

Conclusions

Findings suggest differing demographics, substance use patterns, profiles of HIV risk and access to HIV testing between the two treatment samples. Population tailored HIV interventions, and increased access to HIV testing in both public and private substance treatment centers, appear to be warranted.

Integrating adolescent substance abuse treatment with HIV services: evidence-based models and baseline descriptions

Adolescents with substance use disorders are at high risk for contracting Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and other sexually transmitted infections (STIs). Adolescence is the period of sexual maturation that compounds the issues associated with infection transmission for this risk-taking group. Integrated treatment models for implementing HIV education, counseling, and testing is a promising approach. This study describes four substance abuse treatment programs of varying levels of care that integrated HIV services for adolescents. Additionally, the evidence-based substance abuse treatment and HIV models are discussed and the baseline characteristics presented. The authors provide a discussion and offer recommendations for service implementation and additional research.

Prevalence and predictors of injection drug use and risky sexual behaviors among adolescents in substance treatment

BACKGROUND AND OBJECTIVES

The longitudinal risk for human immunodeficiency virus (HIV) infection following adolescent substance treatment is not known. Therefore, it is not known if adolescent substance treatment should include HIV prevention interventions. To address this important research gap, this study evaluates the longitudinal prevalence and predictors of injection drug use (IDU) and sex risk behaviors among adolescents in substance treatment.

METHODS

Participants were 260 adolescents (13-18 years) in substance treatment and 201 community control adolescents (11-19 years). Participants were assessed at baseline and follow-up (mean time between assessments = 6.9 years for the clinical sample and 5.6 years for the community control sample). Outcomes included self-report lifetime history of IDU, number of lifetime sex partners and frequency of unprotected sexual intercourse.

RESULTS

At baseline, 7.5% of the clinical sample, compared to 1.0% of the community control sample had a lifetime history of IDU (χ12=10.53, p = .001). At follow-up, 17.4% of the clinical sample compared to 0% of the community control sample had a lifetime history of IDU (χ12=26.61, p = .0005). The number of baseline substance use disorders and onset age of marijuana use significantly predicted the presence of lifetime IDU at follow-up, after adjusting for baseline age, race, and sex. The clinical sample reported more lifetime sex partners and more frequent unprotected sex than the community control sample at baseline and follow-up.

CONCLUSIONS

Many adolescents in substance treatment develop IDU and report persistent risky sex. Effective risk reduction interventions for adolescents in substance treatment are needed that address both IDU and risky sex.

HIV rapid testing in drug treatment: comparison across treatment modalities

Despite high rates of risky behavior among patients, many drug abuse treatment programs do not provide on-site HIV testing. This secondary analysis examined differences in outcome by program modality from a multi-site trial in which 1281 HIV-negative patients in three methadone programs, seven non-methadone outpatient programs, and three residential programs were randomly assigned to: (1) off-site referral for HIV risk reduction counseling and testing; or on-site rapid testing (2) with or (3) without risk reduction counseling. The parent study using generalized estimating equations with site as a cluster variable found significantly higher rates of HIV testing and feedback of results by 1 month post-enrollment for the combined on-site conditions compared to the offsite condition [RR=4.52, 97.5% CI (3.57, 5.72)]. Utilizing the same statistical approach, we found neither significant treatment modality nor significant treatment modality by testing condition interaction effects either for receipt of HIV test results at 1 month or for sexual or drug use HIV-risk behaviors at 6-month follow-up. On-site HIV testing is effective across treatment modalities for achieving high rates of testing and results feedback. All programs should be encouraged to adopt or expand this service.

Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs

Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008-2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse's Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users

OBJECTIVE

To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).

DESIGN

Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).

METHODS

We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.

DISCUSSION

Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

HIV testing in recent college students: prevalence and correlates

Prevalence and correlates of HIV testing were examined in a sample of 957 unmarried recent college students in the United States. Participants were asked about HIV testing, past-six-months sexual activities, lifetime treatment for sexually transmitted infections (STI), past-year health service utilization, and DSM-IV criteria for alcohol and other drug (AOD) dependence during the 2008-2009 academic year. Two in five (41.9%(wt)) were ever tested for HIV. Holding constant demographics, HIV testing was positively related to AOD dependence, frequency of unprotected sex, number of sex partners, having a physical exam by a medical professional, number of visits to a health provider for physical health problems, and lifetime STI treatment. Women were more likely than men to be tested for HIV despite similar levels of risky sex. Results demonstrate the feasibility of achieving high HIV testing rates in a college population.

Reproductive health characteristics of marijuana and cocaine users: results from the 2002 National Survey of Family Growth

CONTEXT

Illicit drug use is associated with risky sexual behaviors in adolescents and young adults. However, few studies have examined these associations among drug users of all reproductive ages, using a control group of nonusers.

METHODS

Associations between marijuana and cocaine use, and outcomes related to sexual behaviors and reproductive health, were assessed using data from the 2002 National Survey of Family Growth. Overall, 4,928 men and 7,643 women aged 15-44 were interviewed. Chi-square tests, t tests and multivariable logistic regression analyses were used; in supplementary analyses, men and women were stratified by age-group (25 or younger, and older than 25), to capture the understudied older adults who use drugs.

RESULTS

Twenty-seven percent of men and 16% of women reported use of marijuana or cocaine in the last year. Drug users were younger than nonusers at first vaginal sex (mean, 15.2-16.1 vs. 17.3-17.5 years) and were more likely to have engaged in risky sexual behaviors in the last year, including having had sex with a nonmonogamous partner (odds ratios, 3.3-5.2 for men and 2.9-6.5 for women), while high on alcohol or drugs (10.1-18.0 and 8.1-24.2), or in exchange for money or drugs (2.7-2.8 and 2.3-9.2). They also were more likely to have undergone STD testing or treatment. Drug use was associated with risky sexual behaviors in both age-groups.

CONCLUSION

Programs aimed at reducing sexual risks among drug users should address the behaviors of men and women of all reproductive ages.

HIV/AIDS services in private substance abuse treatment programs

BACKGROUND

HIV infection among substance abusers is a growing concern in the United States. Little research, however, has examined the provision of HIV/AIDS services in substance abuse treatment programs.

METHODS

This study examines the provision of onsite HIV/AIDS services in a nationally representative sample of 345 privately funded substance abuse treatment programs. Data were collected via face-to-face interviews with administrators and/or clinical directors of treatment programs in 2007-2008.

RESULTS

Results show that larger programs and programs with a higher percentage of both African American and injection drug using (IDU) patients were more likely to offer onsite HIV/AIDS support groups and a dedicated HIV/AIDS treatment track. Multinomial logistic regression reveals that the odds of offering onsite HIV testing services were higher for hospital based programs, programs providing medical services onsite, and programs with higher percentages of African American patients, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services. The odds of providing onsite testing were lower for outpatient-only treatment programs, relative to the odds of offering no HIV testing or referring patients to an external provider for HIV testing services.

CONCLUSIONS

Our findings highlight critical barriers to the adoption of onsite HIV/AIDS services and suggest treatment programs are missing the opportunity to significantly impact HIV-related health outcomes.

A comparison of sexual and reproductive health services provided by genitourinary and family planning clinics for adolescents

The purpose of the study was to assess the use of sexual and reproductive health services by adolescents aged 15 years and younger. A case-note review was conducted at both a genitourinary medicine clinic and a family planning clinic in Edinburgh, UK. The demographics of the attendees, reasons for attending, risk factors, diagnostic tests undertaken and contraceptive advice given differed between the two clinics. Approximately 73% of attendees with documented responses used alcohol and 21% used recreational drugs, 5% reported self-harm, 25% reported being victims of sexual assault, 13% had a current sexually transmitted infection and 6% of girls had already been pregnant. While this group of young people understand the differences in emphasis between the clinics, adolescents may be intimidated and discouraged from attending or may fail to return, and the combination of overlap, together with omissions in cross-clinic function, suggests that for this age group the services of these clinics should be combined.

Drug treatment as HIV prevention: a research update

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.