Relationships between State Policies and the Availability of Services for HIV/AIDS, Hepatitis C Viral Infection, and Sexually Transmitted Infections in Substance Abuse Treatment Programs

1
Relationships between State Policies and the
Availability of Services for HIV/AIDS, Hepatitis
C Viral Infection, and Sexually Transmitted
Infections in Substance Abuse Treatment Programs

• L.S. Brown, MD, MPH S. Kritz, MD J. Rotrosen,
  MD R.J. Goldsmith, MD E. Bini, MD,
  MPH J. Robinson, MEd and the NIDA Clinical
  Trials Network Infections Study (CTN-0012) Team
• Addiction Research Treatment Corp, Brooklyn,
  NY NYU School of Medicine and VA Hospital, NY,
  NY University of Cincinnati Medical Center,
  Cincinnati, OH and Nathan Kline Institute,
  Orangeburg, NY

2
ABSTRACT
Purpose This report examines the associations
between HIV/AIDS, hepatitis C (HCV), and sexually
transmitted infection (STI)-related services
provided by substance abuse treatment programs in
the National Institute on Drug Abuse Clinical
Trials Network (NIDA CTN), and the states within
which they are located. Methods Substance abuse
treatment programs from nearly 100 different
agencies within the NIDA CTN participated in this
study. Administrators of state substance abuse
and/or health departments from 48 states and the
District of Columbia also participated. Data for
this report was derived from two surveys one for
substance abuse treatment program administrators,
and one for state health and substance abuse
department administrators. The surveys included
a cross-sectional, descriptive survey of eight
infection-related services provider education,
patient education, risk assessment, history and
physical exam, biological testing, counseling,
treatment and monitoring in the context of
treatment program structure, setting, and
staffing. The analysis included descriptive
statistics for survey variables principal
component, cluster or factor analysis to group
and reduce the number of variables, and
structural equation models to test for
associations. Results 265 of 313 (86) substance
abuse treatment program administrators responded
from 95 agencies in the NIDA CTN, covering 26
states DC. Six of eight services were provided
by a similar percentage of substance abuse
programs regardless of state mandates, whereas
two services (treatment and monitoring) were
provided by a substantially higher percentage of
sites where it was state mandated. Summary There
was variation in the of programs offering the
various services for a particular infection
group, whether state mandated or not, however
there was consistency in the of programs
offering a particular service for all three
infection groups, whether state mandated or not.
This information can be used to inform public
policy to encourage best practices in treating
these epidemic infections.
3
ACKNOWLEDGEMENTS

• Research Supported by National Institute on Drug
  Abuse (NIDA) as part of a Cooperative Agreement
  (1U10DA013046) with the NIDA CTN and other
  Protocol Team members consisting of
• Randy Seewald, MD Cheryl Smith, MD Frank
  McCorry, PhD Dennis McCarty, PhD Donald Calsyn,
  PhD Leonard Handelsman, MD Steve Kipnis, MD
• Patrick McAuliffe, MBA, LADC Al Hassen, MSW
  Karen Reese, CAC-AD Sherryl Baker, PhD
• Shirley Irons Kathlene Tracy, PhD

4
17 Nodes with 116 Community Treatment Agencies
Reaching into 26 States!
Drug Abuse Treatment Clinical Trials Network
Seattle
Portland
New York City
Detroit
Boston
New Haven
Denver
Long Island
Philadelphia
Cincinnati
San Francisco (CA/AZ Node)
Baltimore/Richmond
Raleigh/ Durham
Albuquerque
Los Angeles
Charleston
Miami
CTN Sites
5
STUDY SITES

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

6
STUDY RATIONALE

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

7
IMPORTANT ABREVIATIONS

• HIV Human Immunodeficiency Virus
• AIDS Acquired Immunodeficiency Syndrome
• HCV Hepatitis C Virus
• STI Sexually Transmitted Infections
• CTP Community Treatment Program
• CTN Clinical Trials Network
• SOP Standard Operating Procedures
• IRB Institutional (Human Subject) Review Board

8
IMPORTANT TERMS

• Treatment Program vs. NIDA CTN CTP
• Services Assessed
• Provider Education
• Patient Education
• Patient Risk Assessment
• Patient Medical History Physical Exam
• Patient Biological Testing
• Patient Counseling
• Patient Treatment
• Patient Monitoring

9
PRIMARY OBJECTIVES

• TO DESCRIBE
• Range of Infection-Related Services Available
• CTP Characteristics (funding, staffing)
• Perceived Barriers to Providing Infection-Related
  Services
• State Regulatory Guidelines
• TO EXAMINE ASSOCIATIONS BETWEEN
• CTPs Availability of Selected Infection Services
• Other Constructs Listed Above

10
DESIGN AND POPULATION

• STUDY DESIGN
• 2 Cross-sectional Surveys
• Descriptive Exploratory
• STUDY POPULATION
• CTP Administrators
• Administrators of State Health Departments and
  Substance Abuse Agencies

11
ETHICAL, REGULATORY ADMINISTRATIVE
CONSIDERATIONS

• Expedited IRB Approval
• Waiver of Informed Consent
• Training for Node Protocol Managers

12
STUDY PROCEDURES

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

13
Administrator Surveys
Contact CTP Directors for Treatment Program and
Administrator contact information
Administrator completes survey online or mails to
Data Center Administrator enters contact
information for Clinicians
Ensure IRB approval
Survey materials mailed to Administrators
Data Center contacts Administrators that have not
completed the survey or Clinician contact
information within 30 days

Node Protocol Manager contacts Administrators
that have not responded within two weeks
Data Center contacts Administrators to resolve
any data queries
After four weekly attempts, Administrators
flagged as non-responders by the Data Center

Node Protocol Managers contact non-responder Admin
istrators weekly
For Administrators that refuse to participate or
still have not responded after two additional
weeks, the Node Protocol Manager alerts the Node
Principal Investigator

14
State Surveys
Project Manager enters State Administrator
contact information into the Data Center system
Data Center mails survey material to State
Administrators
State Administrator completes the survey online
or mails to Data Center
Project Manager contacts State Administrators that
have not completed survey within 30 days
After four weekly attempts to contact State
Administrators, the Project Manager flags them as
non-responders
Data Center reviews data and communicates any
issues to Project Manager
Project Manager contacts State Administrators to
resolve data queries
15
STATISTICAL ELEMENTS

• Sample Size and Precision of the Estimated Mean
• Analytic Plan
• Descriptive stats for survey variables
• Principal Component or Cluster or Factor Analysis
  to group and reduce the number of variables
• Structural Equation Models to test for
  associations

16
RESULTS

• 269 administrators responded (84) out of 319
  substance abuse program administrators surveyed,
  from 95 CTPs in the NIDA CTN, covering 26 states
  DC
• At least one health department or substance abuse
  agency administrator from 48 states and the
  District of Columbia (96) responded

17
Characteristics of Treatment Programs
Characteristic Number of Surveys with Valid Responses Number () of Treatment Programs
Corporate structure Private not-for-profit Private for profit Government Other 268 212 (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 269 45 (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
18
Characteristics of Treatment Programs
Characteristic Number of Surveys with Valid Responses Number () of Treatment Programs
Patient census 500 500 1000 gt1000 250 145 (53.9) 52 (19.3) 53 (19.7)
Addiction Services Offered Inpatient or residential services Outpatient pharmacotherapy Other outpatient services Outreach support services
Addiction Services Offered Inpatient or residential services Outpatient pharmacotherapy Other outpatient services Outreach support services 256 242 257 259 148 (55.0) 89 (33.1) 206 (76.6) 227 (84.4)
Medical Staff 0 1 2-3 4-7 8 55 (20.4) 31 (11.5) 64 (23.8) 54 (20.1) 57 (21.2)
Non-Medical Staff 0-7 8-11 12-17 18 79 (29.4) 59 (21.9) 59 (21.9) 64 (23.8)
Percentages do not total 100 due to rounding
and non-respondents Responses were not mutually
exclusive for this item
19
HIV/AIDS, HCV STI-RELATED SERVICES PROVIDED IN
SUBSTANCE ABUSE TREATMENT PROGRAMS WHEN STATE
MANDATED
HIV/AIDS HCV STIs
n () n () n ()
Provider Education 137 (77) 113 (69) 113 (64)
Patient Education 218 (90) 140 (80) 154 (84)
Risk Assessment 180 (91) 147 (79) 140 (82)
History Physical Examination 67 (59) 62 (57) 58 (54)
Biological Testing 65 (52) 48 (43) 53 (47)
Counseling 137 (72) 93 (73) 75 (70)
Treatment 66 (59) 38 (56) 42 (51)
Monitoring 44 (72) 38 (69) 43 (70)
20
HIV/AIDS, HCV STI-RELATED SERVICES PROVIDED IN
SUBSTANCE ABUSE TREATMENT PROGRAMS WHEN NOT STATE
MANDATED
HIV/AIDS HCV STIs
n () n () n ()
Provider Education 48 (65) 57 (65) 41 (54)
Patient Education 7 (88) 58 (75) 49 (70)
Risk Assessment 42 (79) 45 (65) 53 (65)
History Physical Examination 60 (59) 54 (50) 57 (51)
Biological Testing 66 (54) 45 (32) 56 (39)
Counseling 39 (71) 65 (52) 87 (59)
Treatment 37 (27) 40 (25) 50 (29)
Monitoring 72 (39) 57 (29) 62 (32)
21
SUMMARY

• Most HIV/AIDS, HCV STI-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
• Staffing patterns (medical and non-medical) are
  quite varied

22
SUMMARY

• Six of eight targeted services were provided by a
  similar of programs, regardless of state
  mandates
• Two services (treatment and monitoring) were
  provided by a substantially higher percentage of
  sites where it was state mandated

23
SUMMARY

• There is substantial variation in the of
  programs offering the various services for a
  particular infection group
• There is consistency in the of programs
  offering a particular service for all three
  infection groups

24
...And THERE IS MORE DATA