Integrating substance abuse treatment into HIV care: missed opportunities in the AIDS Drug Assistance Program

The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

Access to Medications for Opioid Use Disorder for Persons With Human Immunodeficiency Virus in the United States: Gaps in Coverage by State AIDS Drug Assistance Programs

Life-saving medications for opioid use disorder are inaccessible for people with human immunodeficiency virus relying on the AIDS Drug Assistance Programs (ADAP) in 40% of jurisdictions. Funding/policies should address this through increasing access through ADAP and the Ryan White HIV/AIDS Program (RWHAP), partnerships between RWHAP and substance use programs, and other state/federal initiatives.

Association of Substance Use Disorders with Engagement in Care and Mortality among a Clinical Cohort of People with HIV in Washington, DC

Substance use disorders (SUDs) are common among people with HIV and can prevent achievement of optimal health outcomes. Using data from a longitudinal HIV cohort study in the District of Columbia (2011-2018), we calculated the prevalence and correlates of SUD (alcohol, stimulant, and/or opioid use disorders) and determined the association of SUD with engagement in HIV care, ART prescription, viral suppression, and mortality. Of 8420 adults, 3168 (37.6%) had a history of any SUD, most commonly history of alcohol use disorder (29.6%). SUDs disproportionately affected Black individuals (aOR 1.33) and heterosexuals (aOR 1.18), and women had a lower risk of SUD (aOR 0.65). SUD was not associated with engagement in care, ART prescription, or viral suppression. SUD was associated with mortality (aHR 1.31). Addressing alcohol use disorder and preventable causes of death among people with HIV and substance use disorders should be priorities for clinical care and public health.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location

BACKGROUND

While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers.

OBJECTIVE

To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources.

METHODS

Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators.

RESULTS

We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services.

CONCLUSION

Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Perceived benefits and negative consequences of alcohol consumption in women living with HIV: a qualitative study

Background

Women living with HIV have increased prevalence of medical and psychological comorbidities that could be adversely affected by alcohol consumption. Little is known about their unique motivations for drinking or perceptions of HIV-related consequences. In preparation for an alcohol intervention study, we sought to better understand reasons for drinking and perceived consequences of alcohol consumption among a sample of women living with HIV.

Methods

Four focus groups, with a total of 24 adult women (96 % African-American, 88 % HIV-positive), were conducted in Jacksonville, FL, Washington, DC and Chicago, IL. Focus group discussions were tape-recorded and transcribed verbatim; a conventional content analysis approach was used to identify themes, that were then grouped according to a biopsychosocial model.

Results

Regarding reasons for drinking, women described themes that included biological (addiction, to manage pain), psychological (coping, to escape bad experiences, to feel in control), and social (peer pressure, family). Themes related to consequences from alcohol included biological (damage to body, poor adherence to medications), psychological (risky or regrettable behavior, memory loss), and social (jail, loss of respect, poor choices). When discussing how their drinking impacted their health, women focused on broader issues, rather than HIV-specific issues.

Conclusion

Many women living with HIV are drinking alcohol in order to self-manage pain or emotions, and their perceived consequences from drinking extend beyond HIV-specific medical issues. Most participants described themes related to psychological issues and situations that are common in women living with HIV. Interventions to address drinking should inquire more specifically about drinking to manage pain or emotion, and help women to recognize the potential adverse impact of alcohol on comorbid health issues, including their own HIV infection.

The Impact of State AIDS Drug Assistance Policies on Clinical and Economic Outcomes of People With HIV

We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.

The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes

OBJECTIVES

We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history.

METHODS

We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values.

RESULTS

Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level.

CONCLUSIONS

Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.

Service delivery and pharmacotherapy for alcohol use disorder in the era of health reform: Data from a national sample of treatment organizations

BACKGROUND

Although there is a growing literature examining organizational characteristics and medication adoption, little is known about service delivery differences between specialty treatment organizations that have and have not adopted pharmacotherapy for alcohol use disorder (AUD). This study compares adopters and nonadopters across a range of treatment services, including levels of care, availability of tailored services for specific populations, treatment philosophy and counseling orientations, and adoption of comprehensive wraparound services.

METHODS

In-person interviews were conducted with program leaders from a national sample of 372 organizations that deliver AUD treatment services in the United States.

RESULTS

About 23.6% of organizations had adopted at least 1 AUD medication. Organizations offering pharmacotherapy were similar to nonadopters across many measures of levels of care, tailored services, treatment philosophy, and social services. The primary area of difference between the 2 groups was for services related to health problems other than AUD. Pharmacotherapy adopters were more likely to offer primary medical care, medications for smoking cessation, and services to address co-occurring psychiatric conditions.

CONCLUSIONS

Service delivery differences were modest between adopters and nonadopters of AUD pharmacotherapy, with the exception of health-related services. However, the greater adoption of health-related services by organizations offering AUD pharmacotherapy represents greater medicalization of treatment, which may mean these programs are more strongly positioned to respond to opportunities for integration under health reform.

Attitudes and Training Needs of New England HIV Care and Addiction Treatment Providers: Opportunities for Better Integration of HIV and Alcohol Treatment Services

OBJECTIVES

Unhealthy alcohol use is common among HIV-infected patients and contributes to co-morbidities, cognitive decline, unprotected sex, and poor medication adherence. Studies consistently show missed opportunities to address unhealthy alcohol use as part of care. Although treatment of other drug use has been integrated into HIV care in some settings, more information is needed regarding provider attitudes regarding the need for integration of alcohol treatment and HIV care.

METHODS

We surveyed 119 HIV and 159 addiction providers regarding the following domains: existing knowledge, desire for new knowledge (with subdomains relative advantage, compatibility, and complexity of integrating knowledge), and individual and program development needs. Scale scores for each domain were correlated with demographics to identify factors associated with training need.

RESULTS

Both HIV and addiction providers reported agreement with statements of existing knowledge and the need for additional skills. The priority attributed to training, however, was low for both groups. Knowledge and perceived prevalence of HIV and unhealthy alcohol use increased with years of experience. Perceived prevalence correlated with compatibility but not the relative advantage of training.

CONCLUSIONS

Though addressing alcohol use and HIV was acknowledged to be important, the priority of this was low, particularly early career providers. These providers may be important targets for training focusing on motivating coordination of care and skills related to assessment and counseling.

Active injection drug-abuse offsets healthcare engagement in HIV-infected patients

Active injection drug use (IDU) is a behavior with the potential to offset healthcare engagement for those with HIV. At the Washington DC Veterans Affairs Medical Center, we identified 316 patients with a history of addiction during an 11-year period while actively engaged in routine visits to our HIV-primary care clinic. Among all IDU, active-abuse was determined in 141/316 (45 %). There were 120 clinically relevant blood stream infection (BSI) episodes. HIV/HCV co-infection (95 %) and use of antiretroviral therapy (76 %) were common at the time of BSI. The majority of BSIs occurred among those with active-IDU (72/120, 60 %). Active-IDU behavior was associated with more thrombotic disease (12 vs. 2 %, P = 0.001) and more frequent hospitalization (1.1/year ± 1.2 vs. 0.8/year ± 1.1, P = 0.03). When compared to drug-users with no active injection practices or those with remote IDU, active-IDU was associated with an increase in all-cause mortality (43 vs. 27 %, P = 0.003) and a decrease in age-adjusted survival (HR 1.7, CI 1.16-2.51, P = 0.007). Addressing addiction has the potential to impact avoidable medical complications and contribute to the continued, overall health of patients linked to HIV-care.

Optimizing care for HIV-infected people who use drugs: evidence-based approaches to overcoming healthcare disparities

Substance use disorders (SUDs) and human immunodeficiency virus (HIV) are pervasive epidemics that synergize, resulting in negative outcomes for HIV-infected people who use drugs (PWUDs). The expanding epidemiology of substance use demands a parallel evolution of the HIV specialist-beyond HIV to diagnosis and management of comorbid SUDs. The purpose of this paper is to describe healthcare disparities for HIV-infected PWUDs along each point of a continuum of care, and to suggest evidence-based strategies for overcoming these healthcare disparities. Despite extensive dedicated resources and availability of antiretroviral therapy (ART) in the United States, PWUDs continue to experience delayed HIV diagnosis, reduced entry into and retention in HIV care, delayed initiation of ART, and inferior HIV treatment outcomes. Overcoming these healthcare disparities requires integrated packages of clinical, pharmacological, behavioral, and social services, delivered in ways that are cost-effective and convenient and include, at a minimum, screening for and treatment of underlying SUDs.