Article

HIV Testing and Counseling in the Nation's Outpatient Substance Abuse Treatment System, 1995–2005

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Abstract

This article examines the extent to which U.S. outpatient substance abuse treatment (OSAT) facilities provide HIV counseling and testing (C&T) to clients between 1995 and 2005. We also examine organizational and client characteristics associated with OSAT facilities' provision of HIV C&T. Data were collected from a nationally representative sample of outpatient treatment facilities in 1995 (n = 618), 2000 (n = 571), and 2005 (n = 566). Results show that in 1995, 26.8% of OSAT clients received HIV C & T; by 2005, this proportion had increased, but only to 28.8%. Further, results from random-effects interval regression analysis show that C&T is especially widespread in public and nonprofit facilities, in methadone facilities, and in units that serve injection drug users and commercial sex workers. HIV C&T was also more widespread in units that employed formal intake protocols. Despite widespread efforts to increase HIV C&T services in OSAT care, only a small and stable minority of clients receive these services. Adoption of formal intake procedures may provide one vehicle to increase provision of C&T services.

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... In this sample, HIV prevalence was 6%, higher than the 1% recommended by the CDC for the provision of routine, opt-out HIV testing (Branson et al. 2006). Encouraging routine HIV testing is crucial in substance abuse treatment patients because these individuals often have limited access to routine medical care (Branson et al. 2006;Guerrero & Cederbaum 2011;Metsch et al. 2012;Pollack & D'Aunno 2010;SAMHSA 2011). These substance abuse treatment clinics differed dramatically in terms of the proportion of patients who had been tested previously. ...
... Rates of testing may have differed had a wider variety of settings been included. Numerous structural, cultural, and cognitive factors can reduce the likelihood of undergoing HIV testing (Bond et al. 2005;Guerrero & Cederbaum 2011;Inungu 2002;Kalichman & Simbavi 2003;Pollack & D'Aunno 2010;Rountree et al. 2009). Although such issues were not addressed in the present study, these data are derived from a large sample of patients with substance use disorders from six clinical sites in New England. ...
... HIV testing remains the critical first step in accessing HIV care for the individual, and current technologies that include rapid HIV testing can be done by non-licensed staff quickly, efficiently, and at low cost. If the infected are retained in care and on antiretroviral therapy, the risk of HIV transmission is markedly reduced at the community level (Anderson et al. 2005;Montaner 2011;Montaner et al. 2010;Paltiel et al. 2005;Pollack & D'Aunno 2010). Public health authorities have called for expanded routine HIV testing in all settings with high HIV prevalence rates (Branson et al. 2006), and NIDA recommends routine HIV testing in individuals with substance use disorders (Volkow & Montaner 2011). ...
Article
Abstract Routine testing is the cornerstone to identifying HIV, but not all substance abuse treatment patients have been tested. This study is a real-world evaluation of predictors of having never been HIV tested among patients initiating substance abuse treatment. Participants (N = 614) from six New England clinics were asked whether they had ever been HIV tested. Eighty-five patients (13.8%) reported having never been tested and were compared to those who had undergone testing. Clinic, male gender (adjusted odds ratio (AOR) = 1.91, 95% confidence interval (CI) = 1.07-3.41), and having fewer employment (AOR = 0.31; 95% CI = 0.11-0.88) and medical problems (AOR = 0.40, 95% CI = 0.17-0.99) were independently correlated with having never been HIV tested. Thus, there is still considerable room for improved testing strategies as a clinically significant minority of substance abuse patients have never undergone HIV testing when they initiate treatment.
... Research on programs affiliated with the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) also excluded patient characteristics from analyses of the availability of services for infectious diseases (Bini et al., 2011; Brown et al., 2006). Other studies that include patient characteristics have not differentiated programs providing onsite HIV testing from programs that refer patients to external providers (D'Aunno, Vaughn & McElroy, 1999; Guerrero & Cedarbaum, 2011; Pollack, D'Aunno & Lamar, 2006; Pollack & D'Aunno, 2010). Consideration of caseload characteristics is significant because certain groups of SUD patients, such as racial and ethnic minorities and intravenous drug users (IDUs), are at increased risk of contracting and transmitting HIV/AIDS. ...
... However, adoption of rapid HIV testing may decrease the spread of HIV among IDU patients by increasing early detection and entry into HIV treatment. Consistent with prior research (Abraham et al., 2011; D'Aunno et al., 1999; Guerrero & Cedarbaum, 2011; Knudsen & Oser, 2009; Pollack & D'Aunno, 2010; Pollack et al., 2006; Strauss et al., 2003), certain organizational characteristics were associated with availability of rapid and non-rapid HIV testing. Hospital-based programs were more likely than freestanding programs to offer traditional non-rapid HIV testing, relative to the odds of offering no onsite testing. ...
... Together, these OTPs are estimated to treat approximately one quarter of all patients receiving substance abuse treatment in specialty settings nationally on any given day. The current study uses data from the nationally representative sample of 170 OTPs that participated in the 2005 wave of NDATSS, which yielded a response rate of 88% (Friedmann et al., 2010; Pollack & D'Aunno, 2010)., we compared OTPs that participated in the study with these nonresponding OTPs, by size (as measured by staff, clients, and budget), location , specialization in buprenorphine or methadone, organizational age, and ownership (public, private for-profit, private nonprofit). The analysis yielded no significant differences across any of these variables. ...
... Reliability checks include comparisons of reported totals (e.g., total revenue) with the sum of reported detail (e.g., revenues by source); comparison of responses to related questions; comparison of responses between director and supervisor; and, for panel programs, comparison of responses over time. Results from several analyses provide support for NDATSS data reliability and validity (Pollack & D'Aunno, 2010). ...
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This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.
... multiple factors that researchers have found influence the behavior and service output patterns of SUD treatment clinics(Blum and Roman 1985;Friedmann, Alexander, and D'Aunno 1999;D'Aunno 2006;Pollack and D'Aunno 2010;Friedman et al. 2016;Park et al. 2020). ...
Article
Health, social, and human service providers seek diverse ways to engage service users in the service production process. This approach to engagement with users is known as “coproduction.” In addition to conventional user-provider coproduction (i.e., patient-centered care), providers attending to stigmatized and marginalized groups may hire staff who share life experiences with user groups. These providers are known as “user representatives,” and their service provision is known as “peer coproduction.” Using nationally representative data from substance use disorder treatment clinics in the United States, I investigate how clinics’ use of patient-centered care and peer coproduction mechanisms is associated with organizational service availability and utilization patterns. Results demonstrate the potential and limitations of the two coproduction mechanisms in substance use disorder treatment. This study is a critical examination of working conditions and the impact of user-engagement mechanisms and calls for a more empowered work environment in human service organizations.
... In the US, while approaximely 90% of opioid treatment programs provide some form of federally mandated HIV/AIDS education, only 74% of opiod treatment progams offered HIV testing (Kresina et al 2005). These services appear underutilized in that approximately one-in-three persons receiveving subtance abuse treatment also received HIV testing and counselling (Pollack & D'Aunno, 2010). Globally, although subtantial efforts are being made to increase the availability of HIV testing, most-at-risk populations remain underserved with regard to HIV prevention service utilization. ...
... Globally, availability of health services such as HIV counselling and testing and ART has been as a significant enabler to HIV/AIDS-related service accessibility [16]. Moreover, HIV/AIDS education and knowledge about HIV/AIDS have also been reported as facilitators of HIV/AIDS-related health service accessibility among different populations, such as students, men who have sex with men, sex workers, and transgender persons [17][18][19][20]. ...
Article
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The study aimed to explore facilitators or enabling factors that enhance accessibility (defined as the opportunity to be able to use) to HIV/AIDS-related health services among HIV positive transgender women, also known as Waria in Yogyakarta, Indonesia. A qualitative study employing one-on-one in-depth interviews was conducted from December 2017 to February 2018. Participants were HIV positive Waria recruited using purposive and snowball sampling techniques. Data were analysed using the framework analysis for qualitative research. The findings showed that participants’ knowledge of HIV/AIDS and the availability of HIV/AIDS-related health services were enablers to the services accessibility. Emotional support from fellow Waria displayed in various ways, such as kind and caring attention, attentive listening, and encouraging words, was an important social support that played a role in supporting Waria’s accessibility to the services. HIV/AIDS-related health service information shared personally or jointly by fellow Waria and instrumental support including helping each other to collect antiretroviral (ARV) from hospitals or community health centres, contacting ambulance in emergency situations, accompanying each other to health service facilities, and helping those without the health insurance to receive free health services were also the social support enabling accessibility to the services among the study participants. Appraisal support such as providing constructive feedback and affirmation was another enabling factor to Waria ’s accessibility to the services. The findings indicate the needs to broadly disseminate information and educate Waria populations and their significant others about HIV/AIDS and related health services to raise their awareness of HIV/AIDS and acceptance of HIV/AIDS positive individuals. Educating and broadly disseminating this information in other settings in the country will also increase accessibility to the HIV/AIDS services among Waria , their families, and communities addressing the currently existing inequities in health. The findings also reinforce the importance of the establishment of Waria peer-support groups within Waria communities and the involvement of Waria in HIV/AIDS activities and programs, which may increase their awareness of HIV/AIDS, and accessibility to HIV/AIDS-related health services.
... In 2009, 45% of HIV-infected injection drug users were undiagnosed, and only 49% of injection drug users at risk for HIV report having been previously tested (Centers for Disease Control and Prevention, 2012). Previous studies have shown that fewer than half of US community-based substance abuse treatment programs make HIV testing available either onsite or through referral agreements with other agencies (Brown et al., 2006;Pollack and D'Aunno, 2010;Strauss et al., 2003). Onsite HIV testing requires more resources from substance abuse treatment programs than off-site referral. ...
Article
Background: The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral. Methods: We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. Results: Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit. Conclusions: A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.
... In the USA, while approximately 90% of opioid treatment programs provide some form of federally mandated HIV/AIDS education, only 74% of opioid treatment programs offered HIV testing [39]. These services appear underutilized in that approximately one-in-three persons receiving substance abuse treatment also received HIV testing and counselling [40]. Globally, although substantial efforts are being made to increase the availability of HIV testing, key populations remain underserved with regard to HIV prevention services. ...
Article
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The continuum of response (CoR) to HIV/AIDS is a framework for implementation of HIV prevention, care, and treatment programs based on a national strategic plan for HIV/AIDS services. The CoR for people who inject drugs (PWID) is an important extension of the developed CoR to HIV/AIDS. The CoR-PWID employs stakeholders who together plan, develop, pilot, and provide a full range of services that address the various prevention, care/support, and treatment needs of people, families, and communities infected or affected by HIV/AIDS and injection drug use. The CoR-PWID comprises a broad range of services that include but are not limited to the World Health Organization priority interventions for HIV/AIDS prevention, treatment, and care in the health sector and the package of essential interventions for the prevention, treatment, and care of HIV for people who inject drugs. Implementation of these well-defined, essential prevention, care/support, and treatment services, in addition to locally defined needed services, in a coordinated fashion is important to clients, their families, and communities. The CoR-PWID is, therefore, a necessary framework essential for service development for countries that address HIV/AIDS in populations of PWID.
... Testing substance abuse treatment program clients for HCV represents an important opportunity to identify and cure chronically infected individuals [6] in order to fully realize the potential of new, highly effective and welltolerated HCV therapies [7]. However, in a survey of community-based substance abuse treatment programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) only 28% of programs offered HCV antibody testing on-site or through referral to other testing sites, and in a survey of out-patient substance abuse treatment programs only 29% of clients had received HIV testing on-or off-site [8,9]. A more recent survey found a significant reduction in the proportion of opioid treatment programs conducting HIV testing between 2005 and 2011 and a significantly higher likelihood of testing in publicly owned programs [10], suggesting that lack of reimbursement may be playing an increasing role in decisions about whether to offer testing in private for-profit and non-profit programs. ...
Article
AimsTo evaluate the cost-effectiveness of rapid hepatitis C virus (HCV) and simultaneous HCV/HIV antibody testing in substance abuse treatment programs.DesignWe used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer, off-site HCV testing referral, on-site rapid HCV testing offer, and on-site rapid HCV and HIV testing offer. Base case inputs included 11% undetected chronic HCV, 0.4% undetected HIV, 35% HCV co-infection among HIV-infected, 53% linked to HCV care after testing antibody positive, and 67% linked to HIV care. Disease outcomes were estimated from established computer simulation models of HCV (HEP-CE) and HIV (CEPAC).Setting and ParticipantsData on test acceptance and costs were from a national randomized trial of HIV testing strategies conducted at 12 substance abuse treatment programs in the USA.MeasurementsLifetime costs (2011 US dollars) and quality-adjusted life years (QALYs) discounted at 3% annually; incremental cost-effectiveness ratios (ICERs)FindingsOn-site rapid HCV testing had an ICER of $18,300/QALY compared with no testing, and was more efficient than (dominated) off-site HCV testing referral. On-site rapid HCV and HIV testing had an ICER of $64,500/QALY compared with on-site rapid HCV testing alone. In one and two-way sensitivity analyses, the ICER of on-site rapid HCV and HIV testing remained <$100,000/QALY, except when undetected HIV prevalence was <0.1% or when we assumed frequent HIV testing elsewhere. The ICER remained <$100,000/QALY in approximately 90% of probabilistic sensitivity analyses.Conclusions On-site rapid hepatitis C virus and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/ quality-adjusted life years threshold.
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Objective: The objective of this study was to determine the availability and national distribution of HIV testing and counseling at substance use treatment facilities in the United States. Methods: Analyses of data from the 2018 National Survey of Substance Abuse Treatment Services assessed HIV testing and counseling availability in U.S. substance use treatment facilities (excluding those in U.S. territories). Facilities were subcategorized by availability of mental health services and medication for opioid use disorders and compared by using logistic models. Descriptive statistics were calculated to characterize the availability of HIV testing and counseling by state, state HIV incidence, and facility characteristics. Results: Among U.S. substance use treatment facilities (N=14,691), 29% offered HIV testing, 53% offered HIV counseling, 23% offered both, and 41% offered neither. Across states, the proportions of facilities offering HIV testing ranged from 9.0% to 62.8%, and the proportion offering counseling ranged from 19.2% to 83.3%. In only three states was HIV testing offered by at least 50% of facilities. HIV testing was significantly more likely to be offered in facilities that offered medication for opioid use disorder (48.0% versus 16.0% in those not offering such medication) or mental health services (31.2% versus 24.1% in those not offering such services). Higher state-level HIV incidence was related to an increased proportion of facilities offering HIV testing. Conclusions: Only three in 10 substance use treatment facilities offered HIV testing in 2018. This finding represents a missed opportunity for early identification of HIV among people receiving treatment for substance use disorders.
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Substance use disorders (SUDs) and human immunodeficiency virus (HIV) are pervasive epidemics that synergize, resulting in negative outcomes for HIV-infected people who use drugs (PWUDs). The expanding epidemiology of substance use demands a parallel evolution of the HIV specialist - beyond HIV to diagnosis and management of comorbid SUDs. The purpose of this paper is to describe healthcare disparities for HIV-infected PWUDs along each point of a continuum of care, and to suggest evidence-based strategies for overcoming these healthcare disparities. Despite extensive dedicated resources and availability of antiretroviral therapy (ART) in the United States, PWUDs continue to experience delayed HIV diagnosis, reduced entry into and retention in HIV care, delayed initiation of ART, and inferior HIV treatment outcomes. Overcoming these healthcare disparities requires integrated packages of clinical, pharmacological, behavioral, and social services, delivered in ways that are cost-effective and convenient and include, at a minimum, screening for and treatment of underlying SUDs. © 2013 The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected] /* */
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Objectives: We examined trends and organizational-level correlates of the availability of HCV testing in opioid treatment programs. Methods: We used generalized ordered logit models to examine associations between organizational characteristics of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey and HCV testing availability. Results: Between 2005 and 2011, the proportion of opioid treatment programs offering HCV testing increased but largely because of increases in off-site referrals rather than on-site testing. HCV testing availability was higher in opioid treatment programs affiliated with a hospital and those receiving federal funds. Opioid treatment programs providing both methadone and buprenorphine were more likely to offer any HCV testing, whereas opioid treatment programs providing only buprenorphine treatment were less likely to offer on-site testing. HCV testing availability was associated with more favorable staff-to-client ratios. Conclusions: The increasing use of off-site referrals for HCV testing in opioid treatment programs likely limits opportunities for case finding, prevention, and treatment. Declines in federal funding for opioid treatment programs may be a key determinant of the availability of HCV testing in opioid treatment programs.
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To the Editor Opioid dependence is a risk factor for human immunodeficiency virus (HIV), sexually transmitted infections (STIs), and hepatitis C virus (HCV) infection.1 Opioid treatment programs, which provide medication-assisted treatment to over 300 000 opioid-dependent Americans,2 are well-positioned to offer testing for these infectious diseases to a high-risk population. They were among the first venues to offer HIV testing and are more likely to offer HIV, STI, and HCV testing than other drug treatment programs.1 Private for-profit opioid treatment programs are increasingly widespread and such programs offer on-site HIV testing less often than nonprofit and public programs.3 However, with the 2006 national recommendations for routine opt-out HIV testing,4 we hypothesized that the percent of programs offering on-site testing for HIV, STIs, and HCV would increase.
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To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients. Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200). Random-effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs. Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing. The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients. The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt-out approach to informed consent for testing.
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Despite high rates of risky behavior among patients, many drug abuse treatment programs do not provide on-site HIV testing. This secondary analysis examined differences in outcome by program modality from a multi-site trial in which 1281 HIV-negative patients in three methadone programs, seven non-methadone outpatient programs, and three residential programs were randomly assigned to: (1) off-site referral for HIV risk reduction counseling and testing; or on-site rapid testing (2) with or (3) without risk reduction counseling. The parent study using generalized estimating equations with site as a cluster variable found significantly higher rates of HIV testing and feedback of results by 1month post-enrollment for the combined on-site conditions compared to the offsite condition [RR=4.52, 97.5% CI (3.57, 5.72)]. Utilizing the same statistical approach, we found neither significant treatment modality nor significant treatment modality by testing condition interaction effects either for receipt of HIV test results at 1month or for sexual or drug use HIV-risk behaviors at 6-month follow-up. On-site HIV testing is effective across treatment modalities for achieving high rates of testing and results feedback. All programs should be encouraged to adopt or expand this service.
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Prevalence and correlates of HIV testing were examined in a sample of 957 unmarried recent college students in the United States. Participants were asked about HIV testing, past-six-months sexual activities, lifetime treatment for sexually transmitted infections (STI), past-year health service utilization, and DSM-IV criteria for alcohol and other drug (AOD) dependence during the 2008-2009 academic year. Two in five (41.9%(wt)) were ever tested for HIV. Holding constant demographics, HIV testing was positively related to AOD dependence, frequency of unprotected sex, number of sex partners, having a physical exam by a medical professional, number of visits to a health provider for physical health problems, and lifetime STI treatment. Women were more likely than men to be tested for HIV despite similar levels of risky sex. Results demonstrate the feasibility of achieving high HIV testing rates in a college population.
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Increasing rates of HIV testing within substance use disorder (SUD) treatment clients is an important public health strategy for reducing HIV transmission rates. The present study examined uptake of HIV testing among 1,224 clients in five SUD treatment units that offered on-site testing in Florida, New York, and California. Nearly one-third (30 %) of the participants, who had not previously tested positive, reported not having been tested for HIV within the past 12 months. Women, African Americans, and injection drug users had a higher likelihood of having been tested within the past 12 months. The SUD treatment program was the most frequently identified location of participants' last HIV test. Despite the availability of free, on-site testing, a substantial proportion of clients were not tested, suggesting that strategies to increase uptake of testing should include addressing barriers not limited to location and cost.
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The provision of HIV education and testing in substance use disorder (SUD) treatment programs is an important public health strategy for reducing HIV incidence. For many at-risk individuals, SUD treatment represents the primary point of access for testing and receiving HIV-related services. This study uses two waves of nationally representative data of 265 privately-funded SUD treatment programs in the U.S. to examine organizational and patient characteristics associated with offering a dedicated HIV/AIDS treatment track, onsite HIV/AIDS support groups, and onsite HIV testing. Our longitudinal analysis indicated that the majority of treatment programs reported providing education and prevention services, but there was a small, yet significant, decline in the number of programs providing these services. Programs placed more of an emphasis on providing information on the transmission of HIV rather than on acquiring risk-reduction skills. There was a notable and significant increase (from 26.0% to 31.7%) in programs that offered onsite HIV testing, including rapid HIV testing, and an increase in the percentage of patients who received testing in the programs. Larger programs were more likely to offer a dedicated HIV/AIDS treatment track and to offer onsite HIV/AIDS support groups, while accredited programs and programs with a medical infrastructure were more likely to provide HIV testing. The percentage of injection drug users was positively linked to the availability of specialized HIV/AIDS tracks and HIV/AIDS support groups, and the percentage of female clients was associated with the availability of onsite support groups. The odds of offering HIV/AIDS support groups were also greater in programs that had a dedicated LGBT track. The findings suggest that access to hospitals and medical care services is an effective way to facilitate adoption of HIV services and that programs are providing a needed service among a group of patients who have a heightened risk of HIV transmission. Nonetheless, the fact that fewer than one third of programs offered onsite testing, and, of the ones that did, fewer than one third of their patients received testing, raises concern in light of federal guidelines. Copyright © 2015. Published by Elsevier Inc.
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Due to the scarcity of resources for implementing rapid onsite HIV testing, many substance abuse treatment programs do not offer these services. This study sought to determine whether addressing previously identified implementation barriers to integrating on-site rapid HIV testing into the treatment admissions process would increase offer and acceptance rates. Results indicate that it is feasible to integrate rapid HIV testing into existing treatment programs for substance abusers when resources are provided. Addressing barriers such as providing start-up costs for HIV testing, staff training, addressing staffing needs to reduce competing job responsibilities, and helping treatment staff members overcome their concerns about clients’ reactions to positive test results is paramount for the integration and maintenance of such programs.
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Background The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV—a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP). Methods and findings We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities. Conclusions We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.
Article
Background: Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services. Methods: Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics. Results: In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services. Conclusions: A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.
Article
This study extends the representative bureaucracy literature by theorizing and empirically testing how staff sharing lived experience with service users can serve as user representatives in service provision processes (i.e., the peer coproduction mechanism). Using survey data from a representative sample of substance use disorder treatment clinics in the United States, we explore factors associated with descriptive representation (the presence of staff with firsthand experience of a substance use disorder in both frontline treatment and senior positions) and directors’ perceptions of recovering staff’s potential to serve as user representatives in individual care and organizational decision-making processes. Recovering staff accounted for a third of the field’s workforce, but the majority of the clinics did not employ them in senior staff positions. Regression results suggest that organizational leaders’ recognition of recovering staff’s unique representation capacities may facilitate greater descriptive representation and grant meaningful organizational decision-making authority to recovering staff. Multiple research and practice implications are discussed.
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Background: Given the close connection between human immunodeficiency virus (HIV) infection and substance use disorder (SUD), access to integrated HIV and SUD services is critical for individuals experiencing both challenges and their biopsychosocial conditions. Method: Adopting an integrative method, this systematic review included 23 empirical studies published between 2000 and 2018. Articles investigated providers' and clients' perspectives on barriers to accessing integrated HIV and SUD services in various service settings (e.g., HIV primary care, SUD treatment, pharmacy). Results: Using a client-centered relational framework, we identified barriers in three relational domains with "the client" as the focus of each: client-provider, client-organization, and client-system. The review shows that (1) barriers to HIV and SUD services do not exist in isolation, but in the dynamics within and across three relational domains; (2) service providers and clients often have different perceptions about what constitutes a barrier and the origin of such barriers; and (3) interprofessional and interorganizational collaborations are crucial for integrating HIV and SUD services. Conclusion: This review points out the limitations of the conventional paradigm grouping barriers to service integration into isolated domains (client, provider, organization, or system). Reforms in service arrangements and provider training are recommended to address barriers to integrated services.
Article
Objective: Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment. Methods: Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices. Results: Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care. Conclusions: A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.
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Access to HIV/AIDS-related health services among transgender women living with HIV is still a major public health issue in many developing countries, and Indonesia is not an exception. However, reportedly compared to other settings in the country, transgender women in Yogyakarta have a good access to the HIV-related health services. This study aimed to explore perceptions among transgender women living with HIV, locally known as waria, of factors supportive of their access to the services in Yogyakarta, Indonesia. A qualitative inquiry using in-depth interview method was conducted from December 2017 to February 2018 to collect the data from a selection of waria living with HIV (n = 29) recruited using both purposive and snowball sampling techniques. Data analysis employed a thematic approach which was guided by the framework analysis for qualitative data. The findings indicated several health service system-related determinants supportive of waria's access to HIV/AIDS-related health services. These included the availability of the services, the simplicity and convenience of accessibility to the services and the comfort felt by the participants while accessing the services. Health professionals' positive attitudes during healthcare provision, social relationships between waria and health professionals, proximity to healthcare facilities, free access to the services, and information sessions on HIV infection and prevention were also reported to enable participants' access to the services. These findings call to efforts and strengthening of HIV health service system to support and provide equal access to HIV/AIDS-related services including to all Indonesians living with HIV, but more so for transgender women and other high-risk groups such as sex workers and their clients and men who have sex with men.
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Antiretroviral therapy for treatment of HIV infection has become increasingly effective. Persistent poor HIV outcomes in racial and ethnic minority populations in the US call for a closer examination into why Latinos are at significant risk for acquiring and dying from HIV. To improve clinical outcomes and achieve an AIDS-free generation, HIV research must address disparities in HIV outcomes in Latinos, the largest ethnic/racial minority population in the US. Immigrant status as well as cultural factors influence HIV care utilization and are essential to highlight for effective intervention development in Latinos. A better understanding of these individual and contextual factors is critical to developing tailored approaches to engaging Latinos in HIV care. Based on a comprehensive literature review, we offer a framework for understanding what is needed from clinical practice and research to improve engagement in HIV care for US-based Latinos. These findings may have implications for other minority populations.
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Background Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers’ medical specialty and across practice settings. Methods Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers’ medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states. ResultsQualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings. Conclusions Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.
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In the European Union, it is estimated that there are 5.5 million individuals with chronic infection of hepatitis C. Intravenous drug abuse is undoubtedly the key source of the hepatitis C epidemic in Europe and the most efficient mode of transmission of HCV infections (primarily due to short incubation time, but also because the virus is introduced directly into the blood stream with the infected needle). Potentially high-risk and vulnerable populations in Europe (and the world) include immigrants, prisoners, sex workers, men having sex with men, individuals infected with HIV, psychoactive substance users etc. Since there is a lack of direct evidence of clinical benefits of HCV testing, decisions related to testing are made based on indirect evidence. Clinical practice has shown that HCV antibody tests are mostly adequate for identification of HCV infection, but the problem is that this testing strategy does not hit the target. As a result of this health care system strategy, a large number of infected patients remain undetected or they are diagnosed late. There is only a vague link between screening and treatment outcomes since there is a lack of evidence on transmission risks, multiple causes, risk behavior, ways of reaching screening decisions, treatment efficiency, etc. According to results of limited number of studies it can be concluded that there is a need to develop targeted programmes for detection of HCV and other infections, but there also a need to decrease potential harms.
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Context: Few substance use disorder (SUD) treatment programs provide on-site human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) testing, despite evidence that these tests are cost-effective. Objective: To understand how methadone maintenance treatment (MMT) programs that offer on-site HIV/HCV testing have integrated testing services, and the challenges related to offering on-site HIV/HCV testing. Design: We used the 2014 National Drug Abuse Treatment System Survey to identify outpatient SUD treatment programs that reported offering on-site HIV/HCV testing to 75% or more of their clients. We stratified the sample to identify programs based on combinations of funding source, type of drug treatment offered, and Medicaid-managed care arrangements. We conducted semi-structured qualitative interviews with leadership and staff in 2017-2018 using a directed content analysis approach to identify dominant themes. Setting: Seven MMT programs located in 6 states in the United States. Participants: Fifteen leadership and staff from 7 MMT programs with on-site HIV/HCV testing. Main outcome measure: Themes related to integration of on-site HIV/HCV testing. Results: Methadone maintenance treatment programs identified 3 domains related to the integration of HIV/HCV testing on-site at MMT programs: (1) payment and billing, (2) internal and external stakeholders, and (3) medical and SUD treatment coordination. Programs identified the absence of state policies that facilitate medical billing and inconsistent grant funding as major barriers. Testing availability was limited by the frequency at which external organizations could provide services on-site, the reliability of those external relationships, and MMT staffing. Poor electronic health record systems and privacy policies that prevent medical information sharing between medical and SUD treatment providers also limited effective care coordination. Conclusion: Effective and sustainable integration of on-site HIV/HCV testing by MMT programs in the United States will require more consistent funding, improved billing options, technical assistance, electronic health record system enhancement and coordination, and policy changes related to privacy.
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Background: To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement. Methods: We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services. Results: The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type. Conclusions: Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation.
Article
We sought to determine the linkage to and retention in HIV care after HIV diagnosis in foreign-born compared with US-born individuals. From a clinical data registry, we identified 619 patients aged ≥18 years with a new HIV diagnosis between 2000 and 2012. Timely linkage to care was the proportion of patients with an ICD-9 code for HIV infection (V08 or 042) associated with a primary care or infectious disease physician within 90 days of the index positive HIV test. Retention in HIV care was the presence of an HIV primary care visit in each 6-month period of the 24-month measurement period from the index HIV test. We used Cox regression analysis with adjustment for hypothesized confounders (age, gender, race/ethnicity, substance abuse, year, and location of HIV diagnosis). Foreign-born individuals comprised 36% (225/619) of the cohort. Index CD4 count was 225/µl (IQR 67-439/µl) in foreign-born compared with 328/µl (IQR 121-527/µl) in US-born individuals (p < .001). The proportion linked to care was 87% (196/225) in foreign-born compared with 77% (302/394) in US-born individuals (p = .002). The adjusted hazard ratio of linkage to HIV care in foreign-born compared with US-born individuals was 1.28 (95% confidence interval [CI], 1.05-1.56). Once linked, there was no difference in retention in care or virologic suppression at 24 months. These results show that despite late presentation to HIV care, foreign-born persons can subsequently engage in HIV care as well as US-born persons. Interventions that promote HIV screening in foreign-born persons are a promising way to improve outcomes in these populations.
Article
Background: The total population health benefits and costs of HIV preexposure prophylaxis (PrEP) for people who inject drugs (PWID) in the United States are unclear. Objective: To evaluate the cost-effectiveness and optimal delivery conditions of PrEP for PWID. Design: Empirically calibrated dynamic compartmental model. Data sources: Published literature and expert opinion. Target population: Adult U.S. PWID. Time horizon: 20 years and lifetime. Intervention: PrEP alone, PrEP with frequent screening (PrEP+screen), and PrEP+screen with enhanced provision of antiretroviral therapy (ART) for individuals who become infected (PrEP+screen+ART). All scenarios are considered at 25% coverage. Outcome measures: Infections averted, deaths averted, change in HIV prevalence, discounted costs (in 2015 U.S. dollars), discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of base-case analysis: PrEP+screen+ART dominates other strategies, averting 26 700 infections and reducing HIV prevalence among PWID by 14% compared with the status quo. Achieving these benefits costs $253 000/QALY gained. At current drug prices, total expenditures for PrEP+screen+ART could be as high as $44 billion over 20 years. Results of sensitivity analysis: Cost-effectiveness of the intervention is linear in the annual cost of PrEP and is dependent on PrEP drug adherence, individual transmission risks, and community HIV prevalence. Limitations: Data on risk stratification and achievable PrEP efficacy levels for U.S. PWID are limited. Conclusion: PrEP with frequent screening and prompt treatment for those who become infected can reduce HIV burden among PWID and provide health benefits for the entire U.S. population, but, at current drug prices, it remains an expensive intervention both in absolute terms and in cost per QALY gained. Primary funding source: Grant R01-DA15612 from the National Institute on Drug Abuse.
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Health care organizations do not adopt best practices as often or quickly as they merit. This gap in the integration of best practices into routine practice remains a significant public health concern. The role of program managers in the adoption of best practices has seldom been investigated. We investigated the association between characteristics of program managers and the adoption of hepatitis C virus (HCV) testing services in opioid treatment programs (OTPs). Data came from the 2005 (n = 187) and 2011 (n = 196) National Drug Abuse Treatment System Survey (NDATSS). We used multivariate regression models to examine correlates of the adoption of HCV testing. We included covariates describing program manager characteristics, such as their race/ethnicity, education, and their sources of information about developments in the field of substance use disorder treatment. We also controlled for characteristics of OTPs and the client populations they serve. Program managers were predominantly white and female. A large proportion of program managers had post-graduate education. Program managers expressed strong support for preventive services, but they reported making limited use of available sources of information about developments in the field of substance use disorder (SUD) treatment. The provision of any HCV testing (either on-site or off-site) in OTPs was positively associated with the extent to which a program manager was supportive of preventive services. Among OTPs offering any HCV testing to their clients, on-site HCV testing was more common among programs with an African American manager. It was also more common when program managers relied on a variety of information sources about developments in SUD treatment. Various characteristics of program managers are associated with the adoption of HCV testing in OTPs. Promoting diversity among program managers, and increasing managers’ access to information about developments in SUD treatment, may help foster the adoption of best practices.
Article
Background: Trading sex for drugs or money is common in substance abuse treatment patients, and this study evaluated prevalence and correlates of this behavior in women with cocaine use disorders initiating outpatient care. In addition, we examined the relation of sex trading status to treatment response in relation to usual care versus contingency management (CM), as well as predictors of continued involvement in sex trading over a 9-month period. Methods: Women (N=493) recruited from outpatient substance abuse treatment clinics were categorized according to histories of sex trading (n=215, 43.6%) or not (n=278). Results: Women with a history of trading sex were more likely to be African American, older and less educated, and they had more severe employment problems and were more likely to be HIV positive than those without this history. Controlling for baseline differences, both groups responded equally to substance abuse treatment in terms of retention and abstinence outcomes. Fifty-four women (11.3%) reported trading sex within the next nine months. Predictors of continued involvement in trading sex included a prior history of such behaviors and achieving less abstinence during treatment. Each additional week of abstinence during treatment was associated with a 16% reduction in the likelihood of trading sex over the follow-up. Conclusions: Because over 40% of women receiving community-based treatment for cocaine use disorders have traded sex for drugs or money and more than 10% persist in the behavior, more intensive and directed approaches toward addressing this HIV risk behavior are recommended.
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Introduction: Rapid HIV testing (RHT) greatly increases the proportion of clients who learn their test results. However, existing studies have not examined the adoption and implementation of RHT in programs treating persons with substance use disorders, one of the population groups at higher risk for HIV infection. Methods: We examined 196 opioid treatment programs (OTPs) using data from the 2011 National Drug Abuse Treatment System Survey (NDATSS). We used logistic regressions to identify client and organizational characteristics of OTPs associated with availability of on-site RHT. We then used zero-inflated negative binomial regressions to measure the association between the availability of RHT on-site and the number of clients tested for HIV. Results: Only 31.6% of OTPs offered on-site rapid HIV testing to their clients. Rapid HIV testing was more commonly available on-site in larger, publicly owned and better-staffed OTPs. On the other hand, on-site rapid HIV testing was less common in OTPs that prescribed only buprenorphine as a method of opioid dependence treatment. The availability of rapid HIV testing on-site reduced the likelihood that an OTP did not test any of its clients during the prior year. But on-site availability rapid HIV testing was not otherwise associated with an increased number of clients tested for HIV at an OTP. Conclusions: New strategies are needed to a) promote the adoption of rapid HIV testing on-site in substance use disorder treatment programs and b) encourage substance use disorder treatment providers to offer rapid HIV testing to their clients when it is available.
Article
People who use drugs are at increased risk for HIV acquisition, poor engagement in health care, and late screening for HIV with advanced HIV at diagnosis and increased HIV-related morbidity, mortality, and health care costs. This systematic review evaluates current evidence about the effectiveness and feasibility of implementing HIV testing in U.S. substance use treatment programs. The literature search identified 535 articles. Full text review was limited to articles that explicitly addressed strategies to implement HIV testing in substance use programs: 17 met criteria and were included in the review; 9 used quantitative, qualitative or mixed-method designs to describe or quantify HIV testing rates, acceptance by clients and staff, and cost-effectiveness; 8 organization surveys described barriers and facilitators to testing implementation. The evidence supported the effectiveness and feasibility of rapid, routine, and streamlined HIV testing in substance use treatment programs. Primary challenges included organizational support and sustainable funding.
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HIV testing and receipt of HIV test results among individuals with substance use disorders is less than optimal. We examined rates and correlates of HIV testing and receipt of test results in one of the largest public addiction health services systems in the United States. The study included 139,516 adult clients in treatment between 2006 and 2011. We used logistic regression models to examine associations between predisposing, enabling, and need factors and two dependent variables, HIV testing rates and receipt of test results. Associations were considered statistically significance at p < .01. We found that 64 % of clients reported being tested for HIV, of whom 85 % reported receiving their test results. Likelihood of being tested was positively associated with being female, a minority, homeless, employed, having prior treatment episodes, comorbidities, injection drug use, or a history of mental illness. It was negatively associated with alcohol or marijuana as primary drug. Receipt of test results was more likely among clients on medication (methadone or buprenorphine) or whose method of drug use was smoking, inhalation, or injecting; it was less likely among older clients and those with more outpatient psychiatric visits. Findings from this study may inform strategies and targeting of population groups to improve HIV testing practices and ultimately increase awareness of infection status among clients of addiction health services.
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Substance users are at increased risk for HIV and HCV infection. Still, many substance use treatment programs (SUTP) fail to offer HIV/HCV testing. The present secondary analysis of screening data from a multi-site randomized trial of rapid HIV testing examines self-reported HIV/HCV testing patterns and serostatus of 2473 SUTP patients in 12 community-based sites that had not previously offered on-site testing. Results indicate that most respondents screened for the randomized trial tested more than a year prior to intake for HIV (52 %) and HCV (38 %). Prevalence rates were 3.6 and 30 % for HIV and HCV, respectively. The majority of participants that were HIV (52.2 %) and HCV-positive (40.5 %) reported having been diagnosed within the last 1–5 years. Multivariable logistic regression showed that members of high-risk groups were more likely to have tested. Bundled HIV/HCV testing and linkage to care issues are recommended for expanding testing in community-based SUTP settings. Resumen Usuarios de drogas están en mayor riesgo de infección de VIH y VHC. Aún así, muchos programas de tratamiento de sustancias no ofrecen pruebas de VIH/VHC. El presente análisis secundario relacionado con un estudio de pruebas rápidas de VIH examina los datos reportados por 2473 pacientes en 12 programas de tratamiento de sustancias basados en la comunidad que no ofrecian pruebas de VIH/VHC. Los resultados indican que la mayoría de participantes tomaron una prueba de VIH (52 %) y VHC (38 %) mas de un año antes. Las tasas de prevalencia fueron de 3,6 % (VIH) y 30 % (VHC). Los participantes que reportaron ser VIH (52,2 %) y VHC-positivo (40,5 %) fueron diagnosticados recientemente. Regresión logística multivariante mostró que miembros de grupos de mas alto riesgo eran más propensos a hacerce las pruebas. Recomendamos amplear las pruebas de VIH/VHC con la vinculación a atención medica entre programas de tratamiento de sustancias basado en la comunidad.
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The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment-the state governmental organizations charged with overseeing addiction treatment programs-are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment. Project HOPE—The People-to-People Health Foundation, Inc.
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: Despite the Centers for Disease Control and Prevention recommendations for annual HIV testing of at-risk populations, including those with substance use disorders, there are no data on the human immunodeficiency virus (HIV) testing practices of buprenorphine-prescribing physicians. : To describe HIV testing practices among buprenorphine-prescribing physicians. : We conducted a cross-sectional survey of physicians enrolled in a national system to support buprenorphine prescribing between July and August 2008. The electronic survey included questions on demographics; clinical training and experience; clinical practice; patient characteristics; and physician screening practices, including HIV testing. : Only 46% of 382 respondent physicians conducted HIV testing. On univariate analysis, physicians who conducted HIV testing were more likely to report addiction specialty training (33% vs 19%, P = 0.001), practicing in addiction settings (28% vs 16%, P = 0.006), and having treated more than 50 patients with buprenorphine (50% vs 31%, P < 0.0001) than those who did not. Compared with physicians who did not conduct HIV testing, physicians who conducted HIV testing had a lower proportion of buprenorphine patients who were white (75% vs 82%, P = 0.01) or dependent upon prescription opioids (57% vs 70%, P < 0.0001). In multivariate analysis, physicians who conducted HIV testing were more likely to have treated more than 50 patients with buprenorphine (odds ratio = 1.777, 95% CI 1.011-3.124) and had fewer patients dependent upon prescription opioids (odds ratio = 0.986 95% CI 0.975-0.998) than physicians who did not. : Interventions to increase HIV testing among physicians prescribing buprenorphine are needed.
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Describes a conceptual framework for research on mental health organizations (MHOs) that rests on a set of assumptions concerning the environment of MHOs, organizational response or adaptation to the environment, and client–organization relationships. Methodology and a few preliminary findings of a national study of drug abuse treatment in the community mental health system are described. (28 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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As the acquired immunodeficiency syndrome (AIDS) epidemic among drug users enters its third decade in the United States, it is important to consider the role playing by substance abuse treatment in the prevention of human immunodeficiency virus (HIV) infection. The authors review the research literature, examining findings from studies with behavioral and serologic measures on the association among treatment participation, HIV risk reduction, and HIV infection. Numerous studies have now documented that significantly lower rates of drug use and related risk behaviors are practiced by injecting drug users (IDUs) who are in treatment. Importantly, these behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users. The underlying mechanism of action suggested by the collective findings of the available literature is rather simple-- individuals who enter and remain in treatment reduce their drug use, when leads to fewer instances of drug-related risk behavior. This lower rate of exposure results in fewer infections with HIV. The protective effects of treatment, however, can only be achieved when programs are accessible and responsive to the changing needs of drug users. Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.
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Opportunistic infections (OIs) were first recognized among injection drug users (IDUs) in New York City in 1981. By the mid-1980s, OIs had become associated with HIV infection, and attention began to focus on efforts to prevent HIV transmission among IDUs. Since then, a range of prevention strategies has been implemented and evaluated in an attempt to reduce the spread of HIV infection among drug users. These prevention strategies include (1) HIV testing and counseling and educational and behavioral interventions delivered through community outreach; (2) condom, bleach, and needle distribution and syringe access and exchange programs; (3) substance abuse treatment; and, more recently, (4) prevention interventions targeting HIV-positive IDUs. Data from evaluations of these strategies over the past 20 years have provided substantial evidence of effectiveness and have helped to inform network-based and structural interventions. Despite the cumulative empirical evidence, however, research findings have yet to be widely disseminated, adopted, and implemented in a sustained and integrated fashion. The reasons for this are unclear, but point to a need for improved communications with program developers and community planners to facilitate the implementation and evaluation of integrated intervention strategies, and for collaborative research to help understand policy, legal, economic, and local barriers to implementation.
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The majority of opiate-dependent clients entering substance abuse treatment are referred to "drug-free" (non-methadone) modalities. Given the known challenges of treating these clients in drug-free settings relative to the documented effectiveness of methadone maintenance, these analyses investigate the availability of various clinical and wraparound services for this population among a US sample of addiction treatment programs with and without methadone maintenance services (N = 763). Face-to-face interviews conducted in 2002-2003 gathered data on the number of opiate-dependent clients treated; organizational characteristics, including size, ownership, accreditation, and staffing; treatment practices, including methadone availability, use of other pharmacotherapies, and levels of care; and services offered, including vouchers, transportation, and other wraparound services. Facilities treating proportionately more opiate-dependent clients were significantly more likely to offer a variety of evidence-based services, regardless of methadone availability. Implications for referral linkages and quality of care are discussed.
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Objective. As the acquired immunodeficiency syndrome (AIDS) epidemic among drug users enters its third decade in the United States, it is important to consider the role played by substance abuse treatment in the prevention of human immunodeficiency virus (HIV) infection. Methods. The authors review the research literature, examining findings from studies with behavioral and serologic measures on the association among treatment participation, HIV risk reduction, and HIV infection. Results. Numerous studies have now documented that significantly lower rates of drug use and related risk behaviors are practiced by injecting drug users (IDUs) who are in treatment. Importantly, these behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users, Conclusion. The underlying mechanism of action suggested by the collective findings of the available literature is rather simple-individuals who enter and remain in treatment reduce their drug use, which leads to fewer instances of drug-related risk behavior. This lower rate of exposure results in fewer infections with HIV, The protective effects of treatment, however, can only be achieved when programs are accessible and responsive to the changing needs of drug users. Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.
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Ethynylmagnesium bromide reacted with 2,3,5-tri-O-benzyl-D-ribofuranose (1) in tetrahydrofuran to give, in quantitative yield, a mixture of 4,5,7-tri-O-benzyl-1,2-dideoxy-D-altro- and D-allo-hept-1-ynitol [(2) and (7)] in the ratio 7:3. Treatment of the mixture with toluene-p-sulphonyl chloride in pyridine afforded (2,3,5-tri-O-benzyl-β-D-ribofuranosyl)ethyne (13)(52%) and its α-anomer (16)(13%), together with 4,5,7-tri-O-benzyl-1,2-dideoxy-3,6-bis-O-p-tolylsulphonyl-D-altro-hept-1-ynitol (4)(16%). 2,3,5-Tri-O-benzyl-D-ribofuranosyl chloride (12) and ethynylmagnesium bromide gave the ethynes (13) and (16) in 8 and 63% yield, respectively.
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The effectiveness of drug abuse treatment depends in part on meeting clients' medical and social needs related to drug abuse. Yet, we know little about the type and amount of medical and social services that clients receive in outpatient drug abuse treatment units. This article addresses this issue, drawing from conceptual perspectives in organizational theory and using data from a national random sample of 481 outpatient treatment units that participated in a phone survey in both 1988 and 1990. We examine the extent to which clients in these units receive: physical (medical) and mental health care; special treatment for multiple drug abuse; and employment, financial, and legal counseling. Results from a multivariate analysis of variance (MANOVA) indicate that there was a significant decrease from 1988 to 1990 in all of the services we examined. Regression analyses were conducted to identify organizational and client characteristics related to these decrease. Results show that changes in both client characteristics and key organizational factors (e.g., resources, staffing) are significantly related to decreases in the services clients receive. Implications for meeting the medical and social service needs of drug abuse clients are discussed.
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To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988-2005. Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146). Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses. Data regarding the proportion of patients who received maintenance dosages of <40, 60, and 80 mg/day were collected from unit directors and clinical supervisors. Forty-four percent of patients receive doses of at least 80 mg/day--the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care. One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders.
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Brief treatment of 2,3,4,6-tetra-O-benzyl-N,N-dimethyl-5-O-(methylsulfonyl)-D-gluconamide (3) in N,N-dimethylformamide solution with potassium acetate at 130° causes loss of the methylsulfonyl group, a benzyloxy group, and the dimethylamino function to give a crystalline enolic lactone. Catalytic debenzylation and reduction of this lactone affords a deoxyhexonolactone which was converted through the Ruff degradation into 2-deoxy-L-threo-pentose (10), isolated as its 2-benzyl-2-phenylhydrazone. On the basis of this evidence, the enolic lactone may be designated as 2,4,6-tri-O-benzyl-3-deoxy-L-threo-hex-2-enono-1,5-lactone (6); the mechanistic features of its formation from 3 are discussed. With dimethylamine, 6 gives 2,4,6-tri-O-benzyl-3-deoxy-N,N-dimethyl-L-threo-hex-2-enonamide (7); reduced with a limited proportion of lithium aluminum hydride, 7 affords the enolic hexose derivative 2,4,6-tri-O-benzyl-3-deoxy-L-threo-hex-2-enopyranose (8) which may be oxidized back to 6 through the action of dimethyl sulfoxide-acetic anhydride.
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The amorphous 2,3,5-tri-O-benzyl-D-ribofuranosyl chloride (3) which is readily preparable from 2,3,5-tri-O-benzyl-1-O-p-nitrobenzoyl- (or p-phenylazobenzoyl-) β-D-ribofuranose, is a mixture of anomers in which the β form predominates. On condensation with an excess of 5,6-dimethylbenzimidazole, this halide (3) gives the cis-glycoside derivative 1-(2,3,5-tri-O-benzyl-α-D-ribofuranosyl)-5,6-dimethylbenzimidazole (7) in 66% yield; catalytic debenzylation of 7 affords 5,6-dimethyl-1-α-D-ribofuranosylbenzimidazole (5, α-ribazole). As usually obtained, syrupy 2,3,5-tri-O-benzoyl-D-ribofuranosyl bromide (9) is a mixture of anomers with the α form in slight excess. On condensation with an excess of 5,6-dimethylbenzimidazole, 9 gives 1-(2,3,5-tri-O-benzoyl-β-D-ribofuranosyl)-5,6-dimethylbenzimidazole (6, isolated as its picrate) in 51% yield and the corresponding α anomer (8, also isolated as its picrate) in 28% yield. The substantial quantity of 8 formed from 9 emphasizes the fact that the presence of a participating acyl group at C-2 in a glycosyl halide cannot be relied upon to ensure, even under mild conditions, the exclusive formation of glycosides which are trans at C-1-C-2.
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Drawing from an institutional-theory perspective on innovations in organizations, this paper examines the use of human immunodeficiency virus (HIV) prevention practices by the nation's outpatient substance abuse treatment units during a critical period from 1988 to 1995. An institutional perspective argues that organizations adopt new practices not only for technical reasons, but also because external actors actively promote or model the use of particular practices. We examine the extent to which treatment units use several practices to prevent HIV infection among their clients and among drug-users not in treatment. Results from random-effects regression analyses of national survey data show that treatment units significantly increased their use of HIV prevention practices from 1988 to 1995. Further, the results show that treatment units' use of prevention practices was related to clients' risk for HIV infection, unit resources available to support these practices, and organizational support for the practices. Implications are discussed for an institutional view of organizational innovation as well as for research on HIV prevention.
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As investor-owned organizations increase their presence in the mental health care sector, questions emerge regarding the effects of ownership type on service delivery. One important question is whether ownership is related to patient access to care for persons requiring treatment for substance abuse problems. Using data from a 1995 national survey of outpatient substance abuse treatment units, the authors investigate whether there are differences in measures of patient access to care among investor-owned, not-for-profit, and public provider organizations. Results indicate investor-owned units cater to and serve a clientele that differs from that of not-for-profit and public units, suggesting the presence of a two-tiered system of substance abuse treatment.
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This study examines the extent to which managed care behavioral controls are associated with treatment intensity in outpatient substance abuse treatment facilities. Data are from the 1995 National Drug Abuse Treatment System Survey, a nationally representative survey that includes over 600 provider organizations with a response rate of 86%. Treatment intensity is measured in three ways: (1) the number of months clients spend in outpatient drug treatment, (2) the number of individual treatment sessions clients receive over the course of treatment, and (3) the number of group treatment sessions clients receive over the course of treatment. After accounting for selection bias and controlling for market, organization, and client characteristics, there is no significant relationship between the scope of managed care oversight and treatment intensity. However, the stringency of managed care oversight activities is negatively associated with the number of individual and group treatment sessions received over the course of treatment.
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Residential drug treatment units are uniquely situated to provide HIV testing and counseling to their patients. This article examines the extent to which residential drug treatment units in the United States provide HIV testing on-site, and identifies organizational and institutional characteristics that differentiate units in which on-site HIV testing is available from those in which it is not. The analyses use data collected in telephone interviews with unit managers from a random nationwide sample (N = 138) of residential drug treatment units in 2001. About half (48.6%) of the residential drug treatment units made HIV testing available to their patients on-site. Residential units were significantly more likely to make on-site testing available if they were larger (i.e., had a greater number of patients treated each month or had a greater number of staff that provided direct patient services) and if they were publicly rather than privately owned. Provision of on-site HIV testing was significantly correlated with having a medical orientation, i.e., with being operated by a hospital, with the unit viewing itself as patients' primary medical provider, or with providing medical care to the patients either on-site or at another part of the same treatment agency. In view of the critical importance of HIV testing for individuals who use illicit drugs and the existence of a simplified testing protocol involving saliva samples (eliminating the need for phlebotomy), units that do not have a medical orientation should be encouraged to make HIV testing available on-site.
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Since first recognition of the scope of the acquired immunodeficiency syndrome epidemic among the drug-using community, substance abuse treatment has been viewed as playing an important role in preventing new infections. In the past 20 years, many studies have documented significantly lower rates of drug use, drug-related risk behaviors, and human immunodeficiency virus (HIV) infections among drug users who remain in treatment programs. There is also growing evidence that drug detoxification alone is insufficient to provide protection from HIV infection. These findings have important implications for users of cocaine and noninjection drugs, as well as heroin injectors. Despite strong evidence of effectiveness and widespread support for the important public health role of drug treatment, its impact has been compromised by limited availability and acceptability. The available data clearly establish drug abuse treatment as HIV prevention, yet without expansion of existing treatment programs and the continued development of treatments for addiction to cocaine and other widely used stimulants, its public health potential cannot be realized.
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Testing and counseling, along with community outreach, have been identified as valuable in the prevention of human immunodeficiency virus (HIV) and other blood-borne diseases. This article assesses the extent to which outpatient substance abuse treatment (OSAT) programs provide such services. Longitudinal data for 1988-2000 were analyzed from the National Drug Abuse Treatment System Survey (NDATSS). Random-effects regression was used to examine factors associated with the provision of prevention services. HIV testing, which had became more common between 1990 and 1995, continued to proliferate between 1995 and 2000. The proportion of units that provide HIV testing and counseling increased from 66% to 86%. The proportion of units that provide HIV community outreach increased significantly before 1995 but then slightly decreased from 77% to 73% between 1995 and 2000. In conclusion, HIV testing and counseling widely proliferated in OSAT care. However, OSAT units remain less likely to offer HIV community outreach services.
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Illicit drug users sustain the epidemics of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hepatitis C (HCV), and sexually transmitted infections (STIs). Substance abuse treatment programs present a major intervention point in stemming these epidemics. As a part of the "Infections and Substance Abuse" study, established by the National Drug Abuse Treatment Clinical Trials Network, sponsored by National Institute on Drug Abuse, three surveys were developed; for treatment program administrators, for clinicians, and for state and District of Columbia health and substance abuse department administrators, capturing service availability, government mandates, funding, and other key elements related to the three infection groups. Treatment programs varied in corporate structure, source of revenue, patient census, and medical and non-medical staffing; medical services, counseling services, and staff education targeted HIV/AIDS more often than HCV or STIs. The results from this study have the potential to generate hypotheses for further health services research to inform public policy.
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To develop an understanding as to why there exists a seemingly wide gap between research and practice in the field of substance abuse treatment and, more important, to understand how this gap can be closed, researchers have focused their attention on the role of organizational and management factors in the delivery of treatment services. This article's overarching goal is to stimulate research and interventions that focus on these factors so as to improve the standards and outcomes of care in substance abuse treatment. Part 1 introduces the key assumptions and perspectives that guide organization and management research. Part 2 selectively reviews empirical studies that examine relationships between treatment programs' use of research-based treatment practices and organization and management factors. The article concludes with a discussion of the next important steps for research and policy.
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To compare HIV prevalence among injecting and non-injecting heroin and cocaine users in New York City. As HIV is efficiently transmitted through the sharing of drug-injecting equipment, HIV infection has historically been higher among injecting drug users. Two separate cross-sectional surveys, both with HIV counseling and testing and drug use and HIV risk behavior questionnaires. Injecting and non-injecting heroin and cocaine users recruited at detoxification and methadone maintenance treatment from 2001-2004 (n = 2121) and recruited through respondent-driven sampling from a research storefront in 2004 (n = 448). In both studies, HIV prevalence was nearly identical among current injectors (injected in the last 6 months) and heroin and cocaine users who had never injected: 13% [95% confidence interval (CI), 12-15%] among current injectors and 12% (95% CI, 9-16%) among never-injectors in the drug treatment program study, and 15% (95% CI, 11-19%) among current injectors and 17% (95% CI, 12-21%) among never injectors in the respondent driven sampling storefront study. The 95% CIs overlapped in all gender and race/ethnicity subgroup comparisons of HIV prevalence in both studies. The very large HIV epidemic among drug users in New York City appears to be entering a new phase, in which sexual transmission is of increasing importance. Additional prevention programs are needed to address this transition.
Article
This study compares the provision of HIV testing in a nationally representative sample of correctional agencies and community-based substance abuse treatment programs and identifies the internal organizational-level correlates of HIV testing in both organizations. Data are derived from the Criminal Justice Drug Abuse Treatment Studies' National Criminal Justice Treatment Practices Survey. Using an organizational diffusion theoretical framework [Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press], the impact of Centralization of Power, Complexity, Formalization, Interconnectedness, Organizational Resources, and Organizational Size on HIV testing was examined in correctional agencies and treatment programs. Although there were no significant differences in the provision of HIV testing among correctional agencies (49%) and treatment programs (50%), the internal organizational-level correlates were more predictive of HIV testing in correctional agencies. Specifically, all dimensions, with the exception of Formalization, were related to the provision of HIV testing in correctional agencies. Implications for correctional agencies and community treatment to adopt HIV testing are discussed.
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Interest in improving the quality of addiction treatment has led to the development of clinical paradigms that emphasize the principle of tailored care-matching treatments to the specific needs of each client or client subgroup. This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs.
Organizational adaptation to changing environments
  • D'Aunno
Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings
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The role of organization and management in substance abuse treatment: Review and roadmap
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Cases of HIV Infection and AIDS in the United States and Dependent Areas
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