Barriers to Providing Health Services for HIV/AIDS, Hepatitis C Virus Infection, and Sexually Transmitted Infections in Substance Abuse Treatment Programs in the United States Edmund J. Bini, MD, MPH1, Steven Kritz, MD2, Lawrence S. Brown, Jr, MD,

1
Barriers to Providing Health Services for
HIV/AIDS, Hepatitis C Virus Infection, and
Sexually Transmitted Infections in Substance
Abuse Treatment Programs in the United
StatesEdmund J. Bini, MD, MPH1, Steven Kritz,
MD2, Lawrence S. Brown, Jr, MD, MPH2,3, Jim
Robinson, MEd4, Don Alderson, MS5, John Rotrosen,
MD61Division of Gastroenterology, VA New York
Harbor Healthcare System and New York University
School of Medicine, New York, NY 2Addiction
Research and Treatment Corporation, Brooklyn, NY
3Department of Public Health, Weill Medical
College, Cornell University, New York, NY
4Nathan Kline Institute, Orangeburg, NY 5New
York State Psychiatric Institute, New York, NY
6Department of Psychiatry, VA New York Harbor
Healthcare System and New York University School
of Medicine, New York, NY
Methods
Results
Results
Background Aim

• To assess barriers to delivering health services
  for the 3 targeted infections, program
  administrators were provided with a list of 7
  barriers and were asked to choose yes or no for
  each of the 7 barriers to delivering each of the
  4 medical and 4 non-medical services
• The treatment program clinician surveys were sent
  by mail to 2,210 randomly selected clinicians at
  each of the programs
• The questions that assessed clinician barriers
  were identical to the questions in the program
  administrator survey

• Human immunodeficiency virus (HIV), hepatitis C
  virus (HCV), and sexually transmitted infections
  (STI) are major public health problems worldwide
• The use and abuse of illicit substances is also a
  major public health problem, and substance abuse
  is largely responsible for sustaining the
  epidemics of HIV, HCV, and STI in the United
  States
• To date, however, the limited multicenter data
  that are available demonstrate that HIV/AIDS,
  HCV, and STI health services are not universally
  available in all drug treatment programs
• The reasons why these services are not offered
  are unknown
• The primary aim of this study was to determine
  barriers to offering health services for
  HIV/AIDS, HCV, and STI within substance abuse
  treatment programs in the United States

HIV/AIDS, HCV, and STI Services Offered by the
269 Substance Abuse Programs
Barriers to Providing HIV/AIDS, HCV, and STI
Services Reported by Program Administrators
HIV/AIDS Services Offered HCV Services Offered STI Services Offered P-Value
Patient medical history and physical exam 59.8 52.9 51.6 0.14
Patient biological testing 52.4 36.8 42.2 lt0.01
Patient treatment 41.5 30.8 35.8 0.04
Patient monitoring 47.4 37.5 41.2 0.08
Provider education 73.2 67.3 60.8 0.01
Patient education 89.3 78.4 80.1 lt0.01
Patient risk assessment 88.5 75.8 76.5 lt0.01
Patient counseling 71.8 62.4 63.7 0.06
Medical Services Medical Services Medical Services Medical Services Non-Medical Services Non-Medical Services Non-Medical Services Non-Medical Services
Barriers to Providing Services Patient Medical History and Physical Exam Patient Biological Testing Patient Treatment Patient Monitoring Provider Education Patient Education Patient Risk Assessment Patient Counseling
HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS HIV/AIDS
Government regulations 11.8 16.0 17.9 14.3 9.4 9.1 5.8 10.5
Treatment program policies 14.2 18.3 19.2 18.4 8.2 7.4 7.1 11.3
Staff training 27.0 29.2 34.9 34.0 41.5 39.4 32.8 39.5
Funding 56.7 63.8 70.4 64.9 64.2 58.4 47.9 62.0
Patient/client health insurance benefits 48.3 52.1 58.6 53.8 34.6 42.3 35.8 51.9
Patient/client acceptance 32.8 37.3 41.4 39.3 17.0 38.6 33.8 43.3
Staff acceptance 11.0 16.5 14.3 16.0 13.3 13.0 11.3 15.9
Other barriers 4.8 3.4 8.2 6.5 3.4 5.4 2.1 6.7
HCV HCV HCV HCV HCV HCV HCV HCV HCV
Government regulations 13.2 14.2 15.7 16.3 7.4 7.0 5.7 8.7
Treatment program policies 11.8 20.7 22.9 20.6 8.3 7.0 8.3 12.3
Staff training 27.6 31.7 39.6 36.8 41.3 44.7 36.2 43.9
Funding 55.3 65.1 71.7 63.4 65.2 61.5 48.5 60.3
Patient/client health insurance benefits 49.1 57.1 59.4 53.9 34.3 42.1 35.6 48.7
Patient/client acceptance 33.8 39.8 47.8 43.7 13.0 33.8 31.0 39.7
Staff acceptance 11.8 16.4 17.0 17.5 12.2 12.4 12.7 14.2
Other barriers 8.3 10.3 8.8 8.6 6.9 7.6 4.1 8.2
STI STI STI STI STI STI STI STI STI
Government regulations 11.7 14.7 14.2 12.3 8.1 10.3 8.2 10.8
Treatment program policies 13.7 20.3 16.4 17.8 10.2 13.2 9.4 12.0
Staff training 31.8 31.9 36.1 31.9 42.2 45.1 33.8 41.3
Funding 53.4 59.2 63.8 57.8 62.3 59.7 50.8 59.0
Patient/client health insurance benefits 47.4 53.0 55.2 50.4 32.3 41.6 36.4 49.8
Patient/client acceptance 33.8 36.2 37.4 39.5 14.8 34.8 35.5 40.9
Staff acceptance 11.7 16.5 16.0 15.8 13.3 14.2 10.3 15.5
Other barriers 6.6 6.6 6.6 6.5 6.7 4.8 5.2 7.9
Results
Median Number of the 8 Health Services Offered
for HIV/AIDS, HCV, and STI

• Completed surveys were received from
• 269 of the 319 program administrators (84.3)
• 1,723 of the 2,210 clinicians (78.0)

P lt0.01
Methods
Characteristics of the 269 Substance Abuse
Programs
Characteristic Percent
Corporate structure Private not-for-profit Private for-profit Government Other 78.7 5.6 13.4 2.2
Nature of the program Hospital/Medical School/University Mental Health/Family/Child Services Center Free-Standing Other 13.9 12.7 60.7 12.7
Largest source of revenue County/local grants State funds Medicaid Federal grants Other 17.2 39.3 17.6 12.6 13.4
Addiction services offered Inpatient or residential services Outpatient pharmacotherapy Other outpatient services Outreach support services 55.0 36.8 80.2 87.6
Medical staff (MD, PA, NP, RN, LPN, etc.) 0 1 3 4 or more 21.1 36.4 42.5
Non-medical staff 0 7 8 17 18 or more 30.3 45.2 24.5
Current patient census 0 1 500 501 1,000 1,000 or more 2.0 56.9 20.4 20.8
Percent of patients infected with HIV 0 1 10 11 20 21 or more 12.4 65.7 12.4 9.6
Percent of patients infected with HCV 0 1 10 11 20 21 or more 9.2 30.1 12.1 48.6
Percent of patients infected with STI 0 1 10 11 20 21 or more 8.3 57.5 15.0 19.2

• The target population for this study included
  treatment program administrators (program
  directors or managers) and treatment program
  clinicians in all substance abuse treatment
  programs within the National Drug Abuse Treatment
  Clinical Trials Network (CTN) in the United
  States
• The CTN includes a large number of treatment
  programs whose mission is to improve the quality
  of drug abuse treatment throughout the country
  using evidence-based medicine and science as the
  vehicle
• The treatment program administrator surveys were
  sent by mail to each of the administrators of the
  319 treatment programs within the CTN
• This comprehensive survey assessed the structure
  of the treatment program, staffing, funding,
  characteristics of the patients enrolled in the
  program, services offered for HIV/AIDS, HCV, and
  STI, and barriers to offering services for these
  infections
• For each of the 3 infections, we assessed the
  availability of 8 health services (offered either
  on-site or by contractual agreement with another
  provider), including
• 4 medical services (medical history/physical
  examination, biological testing, medical
  treatment, medical monitoring)
• 4 non-medical services (provider education,
  patient education, patient risk assessment,
  patient counseling)

Proportion of Programs That Did Not Offer Any of
the 4 Medical or 4 Non-Medical Services for
HIV/AIDS, HCV, and STI
No Medical Services
No Non-Medical Services
P lt0.01
P lt0.01
References
Conclusions

• Health service delivery for HIV/AIDS, HCV, and
  STI is less than optimal in drug treatment
  programs in the United States
• There are numerous barriers to providing these
  services
• Public health interventions to overcome barriers
  to care afford an opportunity to enhance
  treatment and prevention of these infections

• The frequency and types of barriers reported by
  program administrators and clinicians were
  similar
• Only the barriers reported by the program
  administrators are presented