HIV/AIDS-Related Services in Substance Abuse Treatment Settings: Preliminary Results The NIDA Clinical Trials Network Lawrence S. Brown, Jr., MD, MPH, FASAM Addiction Research and Treatment Corporation Clinical Associate Professor of Public Health Weill Medical College, Cornell University Oral Presentation at the College on Problems of Drug Dependence Scottsdale, Arizona - June 18, 2006

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

ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS Research Supported by National Institute on Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046) with the NIDA CTN and Protocol Team members consisting of: Research Supported by National Institute on Drug Abuse (NIDA) as part of a Cooperative Agreement (1U10DA013046) with the NIDA CTN and Protocol Team members consisting of: –Steven Kritz, MD; John Rotrosen, MD; Jim Robinson, MEd; Edmund Bini, MD, MPH; Jeff Goldsmith, MD; Dennis McCarty, PhD; Donald Calsyn, PhD; Patrick McAuliffe, MBA, LADC; Karen Reese, CAC-AD –Shirley Irons; Sherryl Baker, PhD; Kathlene Tracy, PhD

GAME PLAN Rationale Rationale Main Study Description Main Study Description Results & Next Steps Results & Next 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 Agencies Reaching into 26 States!

STUDY SITES STUDY SITES New York Node: New York University, New York, NY New York Node: New York University, New York, NY South Carolina Node: Medical University of South Carolina, Charleston, SC South Carolina Node: Medical University of South Carolina, Charleston, SC Florida Node: University of Miami, Coral Gables, FL Florida Node: University of Miami, Coral Gables, FL Great Lakes Node: Wayne State University, Detroit, MI Great Lakes Node: Wayne State University, Detroit, MI Ohio Valley Node: University of Cincinnati, Cincinnati, OH Ohio Valley Node: University of Cincinnati, Cincinnati, OH Rocky Mountain Node: University of CO Health Sciences Center, Denver, CO Rocky Mountain Node: University of CO Health Sciences Center, Denver, CO New England Node: Yale University, New Haven, CT New England Node: Yale University, New Haven, CT Delaware Valley Node: University of Pennsylvania, Philadelphia, PA Delaware Valley Node: University of Pennsylvania, Philadelphia, PA Mid-Atlantic Node: Johns Hopkins Univ., Baltimore, MD; Medical College Mid-Atlantic Node: Johns Hopkins Univ., Baltimore, MD; Medical College of Virginia, Richmond of Virginia, Richmond Pacific Region Node: University of California at Los Angeles, CA Pacific Region Node: University of California at Los Angeles, CA Oregon Node: Oregon Health Sciences University, Portland, OR Oregon Node: Oregon Health Sciences University, Portland, OR Washington Node: University of Washington, Seattle, WA Washington Node: University of Washington, Seattle, WA Long Island Node: NY State Psychiatric Institute, New York, NY Long Island Node: NY State Psychiatric Institute, New York, NY North Carolina Node: Duke University, Raleigh/Durham, NC North Carolina Node: Duke University, Raleigh/Durham, NC Southwest Node: University of New Mexico, Albuquerque, NM Southwest Node: University of New Mexico, Albuquerque, NM Northern New England Node: McLean Hospital, Belmont, MA Northern New England Node: McLean Hospital, Belmont, MA California-Arizona Node: University of California at San Francisco, CA California-Arizona Node: University of California at San Francisco, CA

MAIN STUDY RATIONALE MAIN STUDY RATIONALE HIV/HCV/STI: major causes of excess morbidity and mortality in the US HIV/HCV/STI: major causes of excess morbidity and mortality in the US Substance abuse: a major vehicle for the transmission of infection Substance abuse: a major vehicle for the transmission of infection Substance abuse treatment= HIV prevention Substance abuse treatment= HIV prevention Scope of, and challenges to identifying, counseling, and treating persons with these infections in substance abuse treatment will assist in developing effective interventions Scope of, and challenges to identifying, counseling, and treating persons with these infections in substance abuse treatment will assist in developing effective interventions

MAIN STUDY: PRIMARY OBJECTIVES TO DESCRIBE: TO DESCRIBE: –Range of Infection-Related Services Available –CTP Characteristics (funding, staffing) –Clinician Characteristics (training, knowledge, behavior) –Opinions –Perceived Barriers to Providing Infection-Related Services –State Regulatory Guidelines TO EXAMINE ASSOCIATIONS BETWEEN: TO EXAMINE ASSOCIATIONS BETWEEN: –CTPs ’ Availability of Selected Infection Services –Other Constructs Listed Above

IMPORTANT TERMS Treatment Program vs. NIDA CTN CTP Treatment Program vs. NIDA CTN CTP Services Assessed Services Assessed –Provider Education –Patient Education –Patient Risk Assessment –Patient Counseling –Patient Medical History & Physical Exam –Patient Biological Testing –Patient Treatment –Patient Monitoring Medical vs. Non-Medical Clinical Staff Medical vs. Non-Medical Clinical Staff ‘Expert’ Clinical Staff ‘Expert’ Clinical Staff

MAIN STUDY: DESIGN AND POPULATION STUDY DESIGN STUDY DESIGN –3 Cross-sectional Surveys –Descriptive & Exploratory STUDY POPULATION STUDY POPULATION –CTP Administrators –CTP Clinicians –Administrators of State Health Departments and State Substance Abuse Agencies

ETHICAL, REGULATORY & ADMINISTRATIVE CONSIDERATIONS Expedited IRB Approval Expedited IRB Approval Waiver of Informed Consent Waiver of Informed Consent Training for Node Protocol Managers Training for Node Protocol Managers

STUDY PROCEDURES Node Protocol Managers Node Protocol Managers Information Sheet In Lieu of Informed Consent Information Sheet In Lieu of Informed Consent Survey Administration Survey Administration – Paper or Electronic – Central data acquisition

RESULTS RESULTS 269 administrators responded (84%) out of 319 substance abuse program administrators surveyed, from 95 CTPs in the NIDA CTN, covering 26 states & DC 269 administrators responded (84%) out of 319 substance abuse program administrators surveyed, from 95 CTPs in the NIDA CTN, covering 26 states & DC 1723 clinicians of 2210 targeted (78%) 1723 clinicians of 2210 targeted (78%) At least one substance abuse or health department administrator from 48 states and the District of Columbia (96%) At least one substance abuse or health department administrator from 48 states and the District of Columbia (96%)

Characteristics of Treatment Programs CharacteristicNumber of Surveys with Valid Responses Number (%) of Treatment Programs* Corporate structure Private not-for-profit Private for profit Government Other (78.5) 15 (5.6) 36 (13.4) 6 (2.2) Largest source of revenue County/local grants State funds Medicaid Federal grants VA Benefits Medicare Private contracts/insurance Self-pay Other Unknown (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-respondents

Characteristics of Treatment Programs Patient census ≤ – 1000 > (53.9) 52 (19.3) 53 (19.7) Addiction Services Offered # Inpatient or residential services Outpatient pharmacotherapy Other outpatient services Outreach & support services (55.0) 89 (33.1) 206 (76.6) 227 (84.4) Medical Staff (20.4) 31 (11.5) 64 (23.8) 54 (20.1) 57 (21.2) Non-Medical Staff (29.4) 59 (21.9) 64 (23.8) CharacteristicNumber of Surveys with Valid Responses Number (%) of Treatment Programs* *Percentages do not total 100% due to rounding and non-respondents # Responses were not mutually exclusive for this item

PRELIMINARY RESULTS: TREATMENT PROGRAM CHARACTERISTICS BY AVAILABILITY OF HIV/AIDS PROVIDER EDUCATION: NIDA CTN TREATMENT PROGRAM CHARACTERISTICS For- Profit Non- Profit Residential Drug Free Opiate Agonist Rx Offer Provider Education n (%) 15 (93) 146 (75) 59 (82) 105 (74) 61 (82)

PRELIMINARY RESULTS: Relationship Between State Policy & Treatment Program (TP) Provision of HIV Provider Education State Administrator Respondents State Administrator Respondents –67% Reported Guidelines/Regulations/Policies TP Administrator Respondents TP Administrator Respondents –In States With Guidelines/Regulations/Policies: 77% Provide the Service –In States Without Guidelines/Regulations/Policies: 65% Provide the Service

HIV/AIDS-RELATED SERVICES IN SUBSTANCE ABUSE TREATMENT PROGRAMS: NIDA CTN ADMINISTRATOR RESPONSES (N=269) Service Offered Service Type n (%) Risk Assessment 224 (89) Patient Education 226 (84) Patient Counseling 178 (66) History & Physical Examination 150 (56) Biological Assessments 131 (49) Pharmacotherapies Administered/ Prescribed 103 (38) Clinical Monitoring 117 (43)

RELATIONSHIP BETWEEN STATE POLICIES, GUIDELINES, & REGULATIONS AND HIV/AIDS- RELATED SERVICES IN SUBSTANCE ABUSE TREATMENT PROGRAMS State Policies/Guidelines/Regs ServicesYESNO Patient Education 218 (90) 7 (88) Risk Assessment 180 (91) 42 (79) Counseling 137 (72) 39 (71) History & Physical Examination 67 (59) 60 (59) Biological Testing 65 (52) 66 (54) Treatment 66 (59) 37 (27) Monitoring 44 (72) 72 (39)

SUBSTANCE ABUSE TREATMENT PROGRAMS OFFERING SERVICES SPECIFICALLY FOR WOMEN AND MINORITIES: WomenChildrenTeens Minorities (all) n (%) 191 (71) 62 (23) 89 (33) 127 (47) Blacks Indian/ Eskimo HispanicAsian Hawaiian/ Pacific Isle n (%) 91 (34) 46 (17) 106 (39) 44 (16) 37 (14)

HIV/AIDS-RELATED SERVICES IN PROGRAMS WITH SERVICES TARGETED FOR SUBPOPULATIONS: NIDA CTN Women Blacks Hispanics Service n (%) Provider Education 130(73)74(86)86(85) Patient Education 164(92)82(95)95(94) Risk Assessment 161(90)79(92)92(91) Counseling132(75)74(86)80(82) History & Physical Examination 110(62)61(72)65(66) Biological Testing 95(54)50(60)55(57) Treatment79(45)54(64)57(58) Monitoring92(53)56(67)61(63)

SERVICES TARGETED FOR SUBPOPULATIONS IN TREATMENT PROGRAMS WITH HIV/AIDS- RELATED SERVICES: NIDA CTN Women Blacks Hispanics Service n (%) Provider Education 130(73)74(44)86(50) Patient Education 164(75)82(39)95(45) Risk Assessment 161(74)79(38)92(44) Counseling132(76)74(45)80(48) History & Physical Examination 110(75)61(44)65(46) Biological Testing 95(74)50(42)55(45) Treatment79(79)54(56)57(58) Monitoring92(80)56(51)61(54)

STUDY LIMITATIONS Generalizability of Results Generalizability of Results –Consistent with 2 previous publications Lack of detailed description of services tailored for women and minorities Lack of detailed description of services tailored for women and minorities Does not include utilization, cost, efficiency, or effectiveness of HCV-related services Does not include utilization, cost, efficiency, or effectiveness of HCV-related services –Hypothesis generating

SUMMARY Most HIV/AIDS-related services are offered by: Most HIV/AIDS-related services are offered by: –a substantial proportion of private not-for- profit, for-profit, and public agencies –a substantial proportion of substance abuse treatment programs of all sizes A significant number of programs offer no HIV-related services. A significant number of programs offer no HIV-related services.

SUMMARY SUMMARY Availability of HIV/AIDS-related services appears to be related to: Availability of HIV/AIDS-related services appears to be related to: –State Guidelines, Policies, or Regulation –Availability of substance abuse treatment services for women & minorities A number of hypotheses & opportunities remain to be proposed, pursued, and answered A number of hypotheses & opportunities remain to be proposed, pursued, and answered These are preliminary results of a larger study These are preliminary results of a larger study

NEXT STEPS Tests for significance Tests for significance Generate additional hypotheses for testing Generate additional hypotheses for testing

FOR MORE INFORMATION ABOUT THIS STUDY FOR MORE INFORMATION ABOUT THIS STUDY AT THIS MEETING AT THIS MEETING –Symposium III- Disparities in Substance Abuse Treatment- Salon HI- 6/ PM PEER-REVIEWED PUBLICATIONS PEER-REVIEWED PUBLICATIONS –Brown LS. et. al., Journal of Substance Abuse Treatment, 2006;30: CONTACTING STUDY PERSONNEL CONTACTING STUDY PERSONNEL –Dr. Brown, the Lead Investigator: –Steven Kritz, MD – the Project Director: