Relationships between State Relationships between State Policies Policies

and the Availability of Services for and the Availability of Services for HIV/AIDS, Hepatitis C Viral Infection, HIV/AIDS, Hepatitis C Viral Infection, and Sexually Transmitted Infections and Sexually Transmitted Infections

in Substance Abuse Treatment in Substance Abuse Treatment

ProgramsPrograms

L.S. Brown, MD, MPH; S. Kritz, MD; J. Rotrosen, L.S. Brown, MD, MPH; S. Kritz, MD; J. Rotrosen, MD; R.J. Goldsmith, MD; E. Bini, MD, MPH; J. MD; R.J. Goldsmith, MD; E. Bini, MD, MPH; J. Robinson, MEd and the NIDA Clinical Trials Robinson, MEd and the NIDA Clinical Trials Network Infections Study (CTN-0012) TeamNetwork Infections Study (CTN-0012) Team

Addiction Research & Treatment Corp, Brooklyn, Addiction Research & Treatment Corp, Brooklyn, NY; NYU School of Medicine and VA Hospital, NY, NY; NYU School of Medicine and VA Hospital, NY, NY; University of Cincinnati Medical Center, NY; University of Cincinnati Medical Center, Cincinnati, OH; and Nathan Kline Institute, Cincinnati, OH; and Nathan Kline Institute, Orangeburg, NYOrangeburg, NY

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

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 other Protocol Team with the NIDA CTN and other Protocol Team members consisting of:members consisting of:– Randy Seewald, MD; Cheryl Smith, MD; Frank Randy Seewald, MD; Cheryl Smith, MD; Frank

McCorry, PhD; Dennis McCarty, PhD; Donald McCorry, PhD; Dennis McCarty, PhD; Donald Calsyn, PhD; Leonard Handelsman, MD; Steve Calsyn, PhD; Leonard Handelsman, MD; Steve Kipnis, MD Kipnis, MD

– Patrick McAuliffe, MBA, LADC; Al Hassen, MSW; Patrick McAuliffe, MBA, LADC; Al Hassen, MSW; Karen Reese, CAC-AD; Sherryl Baker, PhDKaren Reese, CAC-AD; Sherryl Baker, PhD

– Shirley Irons; Shirley Irons; Kathlene Tracy, PhDKathlene Tracy, PhD

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

STUDY RATIONALESTUDY RATIONALE

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

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

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

IMPORTANT IMPORTANT ABREVIATIONSABREVIATIONS• HIV = Human Immunodeficiency VirusHIV = Human Immunodeficiency Virus

• AIDS = Acquired Immunodeficiency SyndromeAIDS = Acquired Immunodeficiency Syndrome

• HCV = Hepatitis C VirusHCV = Hepatitis C Virus

• STI = Sexually Transmitted InfectionsSTI = Sexually Transmitted Infections

• CTP = Community Treatment ProgramCTP = Community Treatment Program

• CTN = Clinical Trials NetworkCTN = Clinical Trials Network

• SOP = Standard Operating ProceduresSOP = Standard Operating Procedures

• IRB = Institutional (Human Subject) Review IRB = Institutional (Human Subject) Review BoardBoard

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 Medical History & Physical ExamPatient Medical History & Physical Exam

– Patient Biological TestingPatient Biological Testing

– Patient CounselingPatient Counseling

– Patient TreatmentPatient Treatment

– Patient MonitoringPatient Monitoring

PRIMARY OBJECTIVESPRIMARY OBJECTIVES

• TO DESCRIBE:TO DESCRIBE: – Range of Infection-Related Services AvailableRange of Infection-Related Services Available– CTP Characteristics (funding, staffing)CTP Characteristics (funding, staffing)– Perceived Barriers to Providing Infection-Perceived Barriers to Providing Infection-

Related ServicesRelated Services– State Regulatory GuidelinesState Regulatory Guidelines

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

DESIGN AND POPULATIONDESIGN AND POPULATION

• STUDY DESIGNSTUDY DESIGN– 2 2 Cross-sectional Surveys Cross-sectional Surveys – Descriptive & ExploratoryDescriptive & Exploratory

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

Departments and Substance Abuse Departments and 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 STUDY PROCEDURESPROCEDURES

• 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

Administrator SurveysContact CTP Directors for Treatment Program and Administrator contact information

Survey materials mailed to Administrators

Ensure IRBapproval

Administrator completes survey online or mails to Data Center; Administrator enters contact information for Clinicians

Node Protocol Manager contacts Administrators that have not responded within two weeks

Data Center contacts Administratorsthat have not completed the survey or Clinician contact information within 30 days

Data Center contactsAdministratorsto resolve any data queries

After four weekly attempts, Administrators flagged as non-responders by the Data Center

Node Protocol Managers contact non-responderAdministrators 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

State Surveys

Data Center mails survey material to State Administrators

Project Manager enters State Administrator contact information into the Data Center system

State Administrator completes the survey online or mails to Data Center

Project Manager contacts State Administratorsthat have not completed surveywithin 30 days

After four weekly attempts to contact State Administrators, the Project Manager flags them as non-responders

Project Manager contacts State Administrators to resolve data queries

Data Center reviews data and communicates any issues to Project Manager

STATISTICAL STATISTICAL ELEMENTSELEMENTS

• Sample Size and Precision of the Sample Size and Precision of the Estimated MeanEstimated Mean

• Analytic PlanAnalytic Plan– Descriptive stats for survey variablesDescriptive stats for survey variables– Principal Component or Cluster or Factor Principal Component or Cluster or Factor

Analysis to group and reduce the Analysis to group and reduce the number of variablesnumber of variables

– Structural Equation Models to test for Structural Equation Models to test for associationsassociations

RESULTSRESULTS

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

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

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

HIV/AIDS, HCV & STI-RELATED SERVICES HIV/AIDS, HCV & STI-RELATED SERVICES PROVIDED IN SUBSTANCE ABUSE PROVIDED IN SUBSTANCE ABUSE

TREATMENT PROGRAMS WHEN STATE TREATMENT PROGRAMS WHEN STATE MANDATEDMANDATED

HIV/AIDSHIV/AIDS HCVHCV STIsSTIs

n (%)n (%) n (%)n (%) n (%)n (%)Provider EducationProvider Education 137 (77)137 (77) 113 (69)113 (69) 113 (64)113 (64)

Patient EducationPatient Education 218 (90)218 (90) 140 (80)140 (80) 154 (84)154 (84)

Risk AssessmentRisk Assessment 180 (91)180 (91) 147 (79)147 (79) 140 (82)140 (82)

History & Physical History & Physical ExaminationExamination

67 (59)67 (59) 62 (57)62 (57) 58 (54)58 (54)

Biological TestingBiological Testing 65 (52)65 (52) 48 (43)48 (43) 53 (47)53 (47)

CounselingCounseling 137 (72)137 (72) 93 (73)93 (73) 75 (70)75 (70)

TreatmentTreatment 66 (59)66 (59) 38 (56)38 (56) 42 (51)42 (51)

MonitoringMonitoring 44 (72)44 (72) 38 (69)38 (69) 43 (70)43 (70)

HIV/AIDS, HCV & STI-RELATED SERVICES HIV/AIDS, HCV & STI-RELATED SERVICES PROVIDED IN SUBSTANCE ABUSE PROVIDED IN SUBSTANCE ABUSE

TREATMENT PROGRAMS WHEN NOT STATE TREATMENT PROGRAMS WHEN NOT STATE MANDATED MANDATED

HIV/AIDSHIV/AIDS HCVHCV STIsSTIs

n (%)n (%) n (%)n (%) n (%)n (%)Provider EducationProvider Education 48 (65)48 (65) 57 (65)57 (65) 41 (54)41 (54)

Patient EducationPatient Education 7 (88)7 (88) 58 (75)58 (75) 49 (70)49 (70)

Risk AssessmentRisk Assessment 42 (79)42 (79) 45 (65)45 (65) 53 (65)53 (65)

History & Physical History & Physical ExaminationExamination

60 (59)60 (59) 54 (50)54 (50) 57 (51)57 (51)

Biological TestingBiological Testing 66 (54)66 (54) 45 (32)45 (32) 56 (39)56 (39)

CounselingCounseling 39 (71)39 (71) 65 (52)65 (52) 87 (59)87 (59)

TreatmentTreatment 37 (27)37 (27) 40 (25)40 (25) 50 (29)50 (29)

MonitoringMonitoring 72 (39)72 (39) 57 (29)57 (29) 62 (32)62 (32)

SUMMARYSUMMARY• Most HIV/AIDS, HCV & STI-related Most HIV/AIDS, HCV & STI-related

services are offered by:services are 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

• Staffing patterns (medical and non-Staffing patterns (medical and non-medical) are quite variedmedical) are quite varied

SUMMARYSUMMARY• Six of eight targeted services were Six of eight targeted services were

provided by a similar % of programs, provided by a similar % of programs, regardless of state mandatesregardless of state mandates

• Two services (treatment and Two services (treatment and monitoring) were provided by a monitoring) were provided by a substantially higher percentage of substantially higher percentage of sites where it was state mandatedsites where it was state mandated

SUMMARYSUMMARY• There is substantial variation in the There is substantial variation in the

% of programs offering the various % of programs offering the various services for a particular infection services for a particular infection groupgroup

• There is consistency in the % of There is consistency in the % of programs offering a particular programs offering a particular service for all three infection groupsservice for all three infection groups

...And… THERE IS MORE DATA