HIV/AIDS-Related Services HIV/AIDS-Related Services in Substance Abuse in Substance Abuse Treatment Settings: Treatment Settings: Preliminary ResultsPreliminary Results

The NIDA Clinical Trials The NIDA Clinical Trials NetworkNetwork

Lawrence S. Brown, Jr., MD, MPH, FASAMLawrence S. Brown, Jr., MD, MPH, FASAM

Addiction Research and Treatment CorporationAddiction Research and Treatment Corporation

Clinical Associate Professor of Public HealthClinical Associate Professor of Public Health

Weill Medical College, Cornell UniversityWeill Medical College, Cornell University

Oral Presentation at the College on Problems of Drug DependenceScottsdale, Arizona - June 18, 2006

ACKNOWLEDGEMENTSACKNOWLEDGEMENTSPATIENTS AND PATIENTS AND

STAFF OF THE STAFF OF THE ADDICTION ADDICTION RESEARCH AND RESEARCH AND TREATMENT TREATMENT CORPORATION, A CORPORATION, A COMMUNITY-COMMUNITY-BASED SUBSTANCE BASED SUBSTANCE ABUSE SERVICE ABUSE SERVICE AGENCYAGENCY

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

• Research Supported by National Institute Research Supported by National Institute on Drug Abuse (NIDA) as part of a on Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046)Cooperative Agreement (1U10DA013046) with the NIDA CTN and Protocol Team with the NIDA CTN and Protocol Team members consisting of:members consisting of:– Steven Kritz, MD; John Rotrosen, MD; Jim Steven Kritz, MD; John Rotrosen, MD; Jim

Robinson, MEd; Edmund Bini, MD, MPH; Jeff Robinson, MEd; Edmund Bini, MD, MPH; Jeff Goldsmith, MD; Dennis McCarty, PhD; Donald Goldsmith, MD; Dennis McCarty, PhD; Donald Calsyn, PhD; Patrick McAuliffe, MBA, LADC; Calsyn, PhD; Patrick McAuliffe, MBA, LADC; Karen Reese, CAC-ADKaren Reese, CAC-AD

– Shirley Irons; Sherryl Baker, PhD; Shirley Irons; Sherryl Baker, PhD; Kathlene Kathlene Tracy, PhD Tracy, PhD

GAME PLANGAME PLAN

•Rationale Rationale

•Main Study Main Study DescriptionDescription

•Results & Next Results & Next Steps Steps

Drug Abuse Treatment Clinical Trials Network

Philadelphia

Portland

Los Angeles

Charleston

Miami

Cincinnati

Denver

CTN Sites

Seattle

Raleigh/Durham

Long Island

Boston

San Francisco (CA/AZ Node)

New York City

Detroit

Albuquerque

Baltimore/Richmond

New Haven

17 Nodes with 116 Community Treatment 17 Nodes with 116 Community Treatment Agencies Reaching into 26 States!Agencies Reaching into 26 States!

STUDY SITESSTUDY SITES• New York Node:New York Node: New York University, New York, NYNew York University, New York, NY• South Carolina Node:South Carolina Node: Medical University of South Carolina, Medical University of South Carolina,

Charleston, SCCharleston, SC• Florida Node:Florida Node: University of Miami, Coral Gables, FLUniversity of Miami, Coral Gables, FL• Great Lakes Node:Great Lakes Node: Wayne State University, Detroit, MIWayne State University, Detroit, MI• Ohio Valley Node:Ohio Valley Node: University of Cincinnati, Cincinnati, OHUniversity of Cincinnati, Cincinnati, OH• Rocky Mountain Node:Rocky Mountain Node: University of CO Health Sciences Center, University of CO Health Sciences Center,

Denver, CODenver, CO• New England Node:New England Node: Yale University, New Haven, CTYale University, New Haven, CT• Delaware Valley Node:Delaware Valley Node: University of Pennsylvania, Philadelphia, PAUniversity of Pennsylvania, Philadelphia, PA• Mid-Atlantic Node:Mid-Atlantic Node: Johns Hopkins Univ., Baltimore, MD; Medical Johns Hopkins Univ., Baltimore, MD; Medical

College College of Virginia, Richmondof Virginia, Richmond• Pacific Region Node:Pacific Region Node: University of California at Los Angeles, CAUniversity of California at Los Angeles, CA• Oregon Node:Oregon Node: Oregon Health Sciences University, Portland, OROregon Health Sciences University, Portland, OR• Washington Node:Washington Node: University of Washington, Seattle, WAUniversity of Washington, Seattle, WA• Long Island Node:Long Island Node: NY State Psychiatric Institute, New York, NYNY State Psychiatric Institute, New York, NY• North Carolina Node:North Carolina Node: Duke University, Raleigh/Durham, NCDuke University, Raleigh/Durham, NC• Southwest Node:Southwest Node: University of New Mexico, Albuquerque, NMUniversity of New Mexico, Albuquerque, NM• Northern New England Node:Northern New England Node: McLean Hospital, Belmont, MAMcLean Hospital, Belmont, MA• California-Arizona Node:California-Arizona Node: University of California at San Francisco, CAUniversity of California at San Francisco, CA

MAIN STUDY RATIONALEMAIN STUDY RATIONALE

• HIV/HIV/HCV/STIHCV/STI: major causes of excess : major causes of excess morbidity and mortality in the USmorbidity and mortality in the US

• Substance abuse: a major vehicle for the Substance abuse: a major vehicle for the transmission of infectiontransmission of infection

• Substance abuse treatment= HIV preventionSubstance abuse treatment= HIV prevention

• Scope of, and challenges to identifying, Scope of, and challenges to identifying, counseling, and treating persons with these counseling, and treating persons with these infections in substance abuse treatment will infections in substance abuse treatment will assist in developing effective interventionsassist in developing effective interventions

MAIN STUDY: PRIMARY MAIN STUDY: PRIMARY OBJECTIVESOBJECTIVES

• TO DESCRIBE:TO DESCRIBE: – Range of Infection-Related Services AvailableRange of Infection-Related Services Available– CTP Characteristics (funding, staffing)CTP Characteristics (funding, staffing)– Clinician Characteristics (training, knowledge, Clinician Characteristics (training, knowledge,

behavior)behavior)– OpinionsOpinions– Perceived Barriers to Providing Infection-Related Perceived Barriers to Providing Infection-Related

ServicesServices– State Regulatory GuidelinesState Regulatory Guidelines

• TO EXAMINE ASSOCIATIONS BETWEEN: TO EXAMINE ASSOCIATIONS BETWEEN: – CTPs’ Availability of Selected Infection ServicesCTPs’ Availability of Selected Infection Services– Other Constructs Listed AboveOther Constructs Listed Above

IMPORTANT TERMSIMPORTANT TERMS• Treatment Program vs. NIDA CTN CTPTreatment Program vs. NIDA CTN CTP

• Services AssessedServices Assessed– Provider EducationProvider Education

– Patient EducationPatient Education

– Patient Risk AssessmentPatient Risk Assessment

– Patient CounselingPatient Counseling

– Patient Medical History & Physical ExamPatient Medical History & Physical Exam

– Patient Biological TestingPatient Biological Testing

– Patient TreatmentPatient Treatment

– Patient MonitoringPatient Monitoring

• Medical vs. Non-Medical Clinical StaffMedical vs. Non-Medical Clinical Staff

• ‘‘Expert’ Clinical StaffExpert’ Clinical Staff

MAIN STUDY: DESIGN AND MAIN STUDY: DESIGN AND POPULATIONPOPULATION

• STUDY DESIGNSTUDY DESIGN– 3 3 Cross-sectional Surveys Cross-sectional Surveys – Descriptive & ExploratoryDescriptive & Exploratory

• STUDY POPULATIONSTUDY POPULATION– CTP AdministratorsCTP Administrators– CTP CliniciansCTP Clinicians– Administrators of State Health Administrators of State Health

Departments and State Substance Abuse Departments and State Substance Abuse AgenciesAgencies

ETHICAL, REGULATORY ETHICAL, REGULATORY & ADMINISTRATIVE & ADMINISTRATIVE

CONSIDERATIONSCONSIDERATIONS

• Expedited IRB Approval Expedited IRB Approval

• Waiver of Informed ConsentWaiver of Informed Consent

• Training for Node Protocol Training for Node Protocol ManagersManagers

STUDY PROCEDURESSTUDY PROCEDURES

• Node Protocol Managers Node Protocol Managers

• Information Sheet In Lieu of Informed Information Sheet In Lieu of Informed ConsentConsent

• Survey AdministrationSurvey Administration– Paper or ElectronicPaper or Electronic– Central data acquisitionCentral data acquisition

RESULTSRESULTS

• 269 administrators responded 269 administrators responded (84%)(84%) out out of 319 substance abuse program of 319 substance abuse program administrators surveyed, from 95 CTPs in administrators surveyed, from 95 CTPs in the NIDA CTN, covering 26 states & DCthe NIDA CTN, covering 26 states & DC

• 1723 clinicians of 2210 targeted 1723 clinicians of 2210 targeted (78%)(78%)

• At least one substance abuse or health At least one substance abuse or health department administrator from 48 states department administrator from 48 states and the District of Columbia and the District of Columbia (96%)(96%)

Characteristics of Treatment Programs Characteristic Number of Surveys with

Valid ResponsesNumber (%) of

Treatment Programs*

Corporate structure Private not-for-profit Private for profit Government Other

268212 (78.5)15 (5.6)

36 (13.4)6 (2.2)

Largest source of revenueCounty/local grants State funds Medicaid Federal grants VA Benefits Medicare Private contracts/insurance Self-pay Other Unknown

26945 (16.7)103 (38.1)46 (17.0)33 (12.2)

5 (1.9)4 (1.5)9 (3.3)

15 (5.6)3 (1.1)7 (2.6)

**Percentages do not total 100% due to rounding and non-respondentsPercentages do not total 100% due to rounding and non-respondents

Characteristics of Treatment Programs

Patient census ≤500 500 – 1000 >1000

250145 (53.9)52 (19.3)53 (19.7)

Addiction Services Offered #

Inpatient or residential services Outpatient pharmacotherapy Other outpatient services Outreach & support services

256242257259

148 (55.0)89 (33.1)

206 (76.6)227 (84.4)

Medical Staff 01

2-34-78+

55 (20.4)31 (11.5)64 (23.8)54 (20.1)57 (21.2)

Non-Medical Staff 0-78-11

12-1718+

79 (29.4)59 (21.9)59 (21.9)64 (23.8)

Characteristic Number of Surveys with Valid Responses

Number (%) of Treatment Programs*

**Percentages do not total 100% due to rounding and non-respondentsPercentages do not total 100% due to rounding and non-respondents## Responses were not mutually exclusive for this item Responses were not mutually exclusive for this item

PRELIMINARY RESULTSPRELIMINARY RESULTS: TREATMENT : TREATMENT PROGRAM CHARACTERISTICS BY PROGRAM CHARACTERISTICS BY AVAILABILITY OF HIV/AIDS PROVIDER AVAILABILITY OF HIV/AIDS PROVIDER EDUCATION: NIDA CTNEDUCATION: NIDA CTN

TREATMENT PROGRAM TREATMENT PROGRAM CHARACTERISTICSCHARACTERISTICS

For-For-ProfitProfit

Non-Non-ProfitProfit

ResidentiResidentialal

Drug Drug FreeFree

OpiateOpiate

Agonist Agonist RxRx

Offer Offer Provider Provider EducationEducation

n (%)n (%)

15 (93)15 (93) 146 (75)146 (75) 59 (82) 59 (82) 105 105 (74)(74)

61 (82)61 (82)

PRELIMINARY RESULTS:PRELIMINARY RESULTS: Relationship Between State Relationship Between State Policy & Treatment Program (TP) Policy & Treatment Program (TP) Provision of HIV Provider Provision of HIV Provider EducationEducation• State Administrator RespondentsState Administrator Respondents

– 67%67% Reported Guidelines/Regulations/Policies Reported Guidelines/Regulations/Policies

• TP Administrator RespondentsTP Administrator Respondents– In States With Guidelines/Regulations/Policies: In States With Guidelines/Regulations/Policies:

77%77% Provide the Service Provide the Service– In States Without In States Without

Guidelines/Regulations/Policies: Guidelines/Regulations/Policies: 65%65% Provide Provide the Servicethe Service

HIV/AIDS-RELATED SERVICES IN HIV/AIDS-RELATED SERVICES IN SUBSTANCE ABUSE TREATMENT SUBSTANCE ABUSE TREATMENT PROGRAMS: NIDA CTN ADMINISTRATOR PROGRAMS: NIDA CTN ADMINISTRATOR RESPONSES (N=269)RESPONSES (N=269)

Service OfferedService Offered

Service TypeService Type n (%)n (%)Risk AssessmentRisk Assessment 224 (89)224 (89)

Patient EducationPatient Education 226 (84)226 (84)

Patient CounselingPatient Counseling 178 (66)178 (66)

History & Physical ExaminationHistory & Physical Examination 150 (56)150 (56)

Biological AssessmentsBiological Assessments 131 (49)131 (49)

Pharmacotherapies Pharmacotherapies Administered/ PrescribedAdministered/ Prescribed

103 (38)103 (38)

Clinical MonitoringClinical Monitoring 117 (43)117 (43)

RELATIONSHIP BETWEEN STATE POLICIES, RELATIONSHIP BETWEEN STATE POLICIES, GUIDELINES, & REGULATIONS AND GUIDELINES, & REGULATIONS AND

HIV/AIDS-RELATED SERVICES IN SUBSTANCE HIV/AIDS-RELATED SERVICES IN SUBSTANCE ABUSE TREATMENT PROGRAMS ABUSE TREATMENT PROGRAMS

State Policies/Guidelines/RegsState Policies/Guidelines/Regs

ServicesServices YESYES NONOPatient EducationPatient Education 218 (90)218 (90) 7 (88)7 (88)

Risk AssessmentRisk Assessment 180 (91)180 (91) 42 (79)42 (79)

CounselingCounseling 137 (72)137 (72) 39 (71)39 (71)

History & Physical History & Physical ExaminationExamination

67 (59)67 (59) 60 (59)60 (59)

Biological TestingBiological Testing 65 (52)65 (52) 66 (54)66 (54)

TreatmentTreatment 66 (59)66 (59) 37 (27)37 (27)

MonitoringMonitoring 44 (72)44 (72) 72 (39)72 (39)

SUBSTANCE ABUSE TREATMENT SUBSTANCE ABUSE TREATMENT PROGRAMS OFFERING SERVICES PROGRAMS OFFERING SERVICES SPECIFICALLY FOR WOMEN AND SPECIFICALLY FOR WOMEN AND

MINORITIES:MINORITIES:WomenWomen ChildrenChildren TeensTeens MinoritieMinoritie

s (all)s (all)

n (%)n (%) n (%)n (%) n (%)n (%) n (%)n (%)

191 191 (71)(71)

62 (23)62 (23) 89 (33)89 (33) 127 (47)127 (47)

BlacksBlacks Indian/ Indian/ EskimoEskimo

HispaniHispanicc

AsianAsian Hawaiian/ Hawaiian/ Pacific Pacific

IsleIsle

n (%)n (%) n (%)n (%) n (%)n (%) n (%)n (%) n (%)n (%)

91 (34)91 (34) 46 (17)46 (17) 106 106 (39)(39)

44 (16)44 (16) 37 (14)37 (14)

HIV/AIDS-RELATED SERVICES IN HIV/AIDS-RELATED SERVICES IN PROGRAMS WITH SERVICES TARGETED PROGRAMS WITH SERVICES TARGETED

FOR SUBPOPULATIONS: NIDA CTNFOR SUBPOPULATIONS: NIDA CTN

WomenWomen

BlacksBlacks

HispanicHispanicss

ServiceService n (%) n (%) n (%)

Provider EducationProvider Education 130(73) 130(73) 74(86)74(86) 86(85)86(85)

Patient EducationPatient Education 164(92) 164(92) 82(95)82(95) 95(94)95(94)

Risk AssessmentRisk Assessment 161(90)161(90) 79(92)79(92) 92(91)92(91)

CounselingCounseling 132(75)132(75) 74(86)74(86) 80(82)80(82)

History & Physical History & Physical ExaminationExamination

110(62)110(62) 61(72)61(72) 65(66)65(66)

Biological TestingBiological Testing 95(54)95(54) 50(60)50(60) 55(57)55(57)

TreatmentTreatment 79(45)79(45) 54(64)54(64) 57(58)57(58)

MonitoringMonitoring 92(53)92(53) 56(67)56(67) 61(63)61(63)

SERVICES TARGETED FOR SUBPOPULATIONS SERVICES TARGETED FOR SUBPOPULATIONS IN TREATMENT PROGRAMS WITH HIV/AIDS-IN TREATMENT PROGRAMS WITH HIV/AIDS-

RELATED SERVICES: NIDA CTNRELATED SERVICES: NIDA CTN

WomenWomen

BlacksBlacks

HispanicHispanicss

ServiceService n (%) n (%) n (%)

Provider EducationProvider Education 130(73) 130(73) 74(44)74(44) 86(50)86(50)

Patient EducationPatient Education 164(75) 164(75) 82(39)82(39) 95(45)95(45)

Risk AssessmentRisk Assessment 161(74)161(74) 79(38)79(38) 92(44)92(44)

CounselingCounseling 132(76)132(76) 74(45)74(45) 80(48)80(48)

History & Physical History & Physical ExaminationExamination

110(75)110(75) 61(44)61(44) 65(46)65(46)

Biological TestingBiological Testing 95(74)95(74) 50(42)50(42) 55(45)55(45)

TreatmentTreatment 79(79)79(79) 54(56)54(56) 57(58)57(58)

MonitoringMonitoring 92(80)92(80) 56(51)56(51) 61(54)61(54)

STUDY STUDY LIMITATIONSLIMITATIONS

• Generalizability of ResultsGeneralizability of Results

– Consistent with 2 previous publicationsConsistent with 2 previous publications

• Lack of detailed description of services Lack of detailed description of services tailored for women and minoritiestailored for women and minorities

• Does not include utilization, cost, Does not include utilization, cost, efficiency, or effectiveness of HCV-efficiency, or effectiveness of HCV-related servicesrelated services

– Hypothesis generatingHypothesis generating

SUMMARYSUMMARY• Most HIV/AIDS-related services are Most HIV/AIDS-related services are

offered by:offered by:– a substantial proportion of private not-a substantial proportion of private not-

for-profit, for-profit, and public agenciesfor-profit, for-profit, and public agencies– a substantial proportion of substance a substantial proportion of substance

abuse treatment programs of all sizesabuse treatment programs of all sizes

• A significant number of programs A significant number of programs offer no HIV-related services.offer no HIV-related services.

SUMMARYSUMMARY• Availability of HIV/AIDS-related services Availability of HIV/AIDS-related services

appears to be related to:appears to be related to:– State Guidelines, Policies, or RegulationState Guidelines, Policies, or Regulation– Availability of substance abuse treatment Availability of substance abuse treatment

services for women & minoritiesservices for women & minorities

• A number of hypotheses & opportunities A number of hypotheses & opportunities remain to be proposed, pursued, and remain to be proposed, pursued, and answeredanswered

• These are These are preliminarypreliminary results of a larger results of a larger studystudy

NEXT STEPSNEXT STEPS

•Tests for significanceTests for significance

•Generate additional hypotheses Generate additional hypotheses for testingfor testing

FOR MORE FOR MORE INFORMATION ABOUT THIS INFORMATION ABOUT THIS

STUDYSTUDY• AT THIS MEETINGAT THIS MEETING

– Symposium III-Symposium III- Disparities in Substance Disparities in Substance Abuse Treatment- Salon HI- 6/19 -1-3 PMAbuse Treatment- Salon HI- 6/19 -1-3 PM

• PEER-REVIEWED PUBLICATIONSPEER-REVIEWED PUBLICATIONS– Brown LS. et. al., Journal of Substance Abuse Brown LS. et. al., Journal of Substance Abuse

Treatment, 2006;30: 315-321Treatment, 2006;30: 315-321

• CONTACTING STUDY PERSONNELCONTACTING STUDY PERSONNEL– Dr. Brown, the Lead Investigator: Dr. Brown, the Lead Investigator:

lbrown@artcny.orglbrown@artcny.org– Steven Kritz, MD – the Project Director: Steven Kritz, MD – the Project Director:

skritz@artcny.orgskritz@artcny.org