HIV Testing in Substance Use Disorder Treatment Settings

1. HIV Testing in Substance Use Disorder Treatment Settings Beth Rutkowski, MPH UCLA Integrated Substance Abuse Programs (www.uclaisap.org) Pacific Southwest Addiction Technology Transfer Center (www.psattc.org) June 2014

2. Disclosure I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter of HIV rapid testing in substance use disorder treatment programs.

3. Special Acknowledgements Tim Matheson, PhD, San Francisco Department of Public Health NIDA/SAMHSA Blending Initiative HIV Rapid Testing Blending Team

4. What percentage of your patients/clients are HIV positive? • Less than 10% • 10-25% • 26-50% • More than 50% • I have no idea

5. Does your agency offer routine HIV testing? • Yes • No

6. Do you ask questions about HIV status on your standard intake forms? • Yes • No

7. What percentage of new HIV/AIDS cases are associated with a primary transmission mode of injection drug use? • 5% • 9% • 15% • 25% • More than 50%

8. An Urgent Need • Despite substantial increases in effective HIV management over the past 15 years, new HIV cases have appeared in the United States at a steady rate • In 2009, there were approximately 50,000 new cases of HIV in 2009. • Nearly 21% of persons who are HIV infected are unaware of their infection • The majority of new HIV infections are transmitted by these individuals

9. Substance Abuse as a Major Factor in the Transmission of HIV In 2009, 9% of the new cases of HIV/AIDS were attributed to transmission through injection drug use. Methamphetamine and amphetamine abuse is widespread and their use is associated with high risk sexual behaviors. Studies show that there is a high HIV prevalence among persons who are in SUD treatment programs (3% in non-injection drug users to 27% in IDUs)

10. And Yet… Despite this high prevalence and the known, well-established link among substance use, sex risk behaviors, and HIV, fewer than half of U.S. drug treatment programs offer HIV testing on-site

11. Advances in HIV Testing Technology HIV testing is more readily accessible with faster results, minimizing loss to follow-up and ensuring that those who are tested receive their results. Test results can now be obtained within community settings in as little as 1-20 minutes. This provides persons who test positive with preliminary information about their HIV status, allowing them to get the care they need to slow the progression of their disease and to take precautionary measures and medications that help prevent the spread of the HIV virus.

12. What does the research say?

13. Project RESPECT Results*: HIV Prevention Counseling Effectiveness (*p<0.05) Kamb, M.L., et al., JAMA, 1998

14. Results of Project RESPECT The results of RESPECT demonstrated that client-centered, RRC is effective in reducing STD incidence and risk behaviors and can be conducted in busy public health clinics.

15. “The benefit of providing prevention counseling in conjunction with HIV testing is less clear.” Branson BM, Handsfield HH, Lampe MA, et al; CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Recomm Rep 2006; 55(RR-14):1-17. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

16. CTN 0032: HIV Rapid Testing and Counseling Study • Multisite study to examine the efficacy of on-site rapid testing and risk-reduction counseling in increasing the receipt of results and reducing HIV risk behaviors of substance abuse treatment program patients. • Conducted in substance abuse treatment programs representing all different levels of care • Outpatient psychosocial, intensive outpatient, outpatient narcotic replacement, and residential programs Metsch, L.R., et al., AJPH, 2012.

17. Three Study Conditions • Adults who were HIV-negative or whose status was unknown and who reported no HIV testing in the last 12 months were assigned randomly to three study conditions: • Referral for off-site HIV testing; • On-site rapid HIV testing with brief, risk-reduction counseling (based on RESPECT-211); or • On-site rapid testing with verbal information about testing only Metsch, L.R., et al., AJPH, 2012.

18. Results More than 80% of those tested on-site received their test resultsas compared with only 18% who followed through when referred to an external resource for testing. On-site rapid HIV testing increased testing rates and receipt of test results, and identified HIV-infected persons. Providing brief, client-centered counseling to high risk drug users did not have an effect on the sexual risk behaviors of persons who tested negative. Metsch, L.R., et al., AJPH, 2012.

19. “There is no additional benefit from HIV sexual risk reduction counseling.”

20. NIDA’s Cost Study Cost of onsite rapid HIV testing with info only was approximately $36/test offered Set-up costs cost each program, on average, $2,000 Offering on-site testing with info only was cost effective compared to referral off-site ($60,300 quality-adjusted life year [QALY]) Metsch, L.R., et al., AJPH, 2012.

21. HIV Testing and Counseling in STD Clinics in the U.S.: An Adaptation of CTN0032 • Primary outcome: • Composite STI incidence at 6-month follow-up in which a person was considered positive for STIs if they were positive on any tested STI • Secondary outcomes: • Reduction of sexual risk behaviors • Reduction of substance use during sex • Cost and cost-effectiveness of counseling Metsch, L.R., et al., JAMA, 2013.

22. Two Testing Strategies Evaluated in AWARE RCT Arm 1: On-site HIV rapid testing (via fingerstick) with brief participant-tailored prevention counseling vs. Arm 2: On-site HIV rapid testing (via fingerstick) with information only Metsch, L.R., et al., JAMA, 2013.

23. STD Clinics and University Counterparts Metsch, L.R., et al., JAMA, 2013.

24. Recruitment & Screening First sites launched April, 2010 Recruitment took place over 8 months 6,237 screened 5,012 randomized 80.4% of those screened were randomized Six-month follow-up window September 21, 2010 – July 15, 2011 Metsch, L.R., et al., JAMA, 2013.

25. Overview of Methods • Recruitment - Minimal eligibility criteria • Rapid HIV testing • STI testing • Behavioral risk assessment • Counseling or information only • Intervention Fidelity and Quality Control • Cost and Cost-Effectiveness Analysis Metsch, L.R., et al., JAMA, 2013.

26. AWARE Counseling Intervention • Intervention was based on CDC’s RESPECT 2* counseling model • RESPECT 2: an individually tailored but focused (counselor directed) HIV prevention counseling format used in conjunction with rapid HIV testing which aims to: • Increase the individual’s awareness of personal risk for HIV • Assist the individual in creating an HIV risk reduction plan *Metcalf, Douglas, Malotte et al; 2005

27. Demographics of Persons Randomized (n=5012) • 28% MSM • Age Range • 53.4% 18-29 • 22.4% 30-39 • 14.8% 40-49 • 7.8% 50-59 • 1.4% 60-69 • 0.2% >69 • Gender • 65.6% Male • 33.8% Female • 0.5% Transgender • Race/Ethnicity • 31.7% Non-Hispanic White • 45.0% Non-Hispanic Black • 15.3% Hispanic • 8.0% Other Metsch, L.R., et al., JAMA, 2013.

28. Baseline Substance Use Metsch, L.R., et al., JAMA, 2013.

29. Baseline Substance Use Metsch, L.R., et al., JAMA, 2013.

30. Baseline STI Prevalence by Gender Metsch, L.R., et al., JAMA, 2013.

31. Baseline STI Prevalence by Treatment Metsch, L.R., et al., JAMA, 2013.

32. Primary Outcome Analysis – STI Incidence ***No significant differences across treatment arms*** Metsch, L.R., et al., JAMA, 2013.

33. Follow-up STI rates by Gender 1 CI is 98.3% (corrected for 3 tests) adjusted for site, race/ethnicity and baseline STI Metsch, L.R., et al., JAMA, 2013.

34. Substance Use and STIs • Substance use at baseline was associated with higher rates of STI at follow-up • Non-MSM • Marijuana Use: RR=1.34 95% CI(1.09, 1.66) • MSM • Stimulant Use: RR=1.88 95% CI(1.41, 2.49) • Club Drugs: RR=1.84 95% CI(1.35, 2.49) Metsch, L.R., et al., JAMA, 2013.

35. Self-Reported Sexual Risk Behavior Results Summary • No difference in rate of overall unprotected sex by treatment arm • Counseling was associated with about 25% lower rates of unprotected sex with non-primary partners. • IRR=.76 95% CI(.61, .94) • Counseling was associated with about 12% lower rates of total partners. • IRR=.88 95% CI(.82, .94) Metsch, L.R., et al., JAMA, 2013.

36. Summary & Conclusion No effect of counseling in primary analysis In planned subgroup analysis, significant MSM interaction: MSM in counseling arm have increased STIs at follow-up The intervention decreased reported risk behavior The trial provided no evidence in support of brief risk reduction counseling during HIV rapid testing Metsch, L.R., et al., JAMA, 2013.

37. Other Notes High rates of substance use in STD settings suggest that STD clinics are a potential setting for SBIRT type interventions Further work is needed to understand potential harmful effect of counseling for men having sex with men Findings are consistent and build on what was found in CTN 0032 Metsch, L.R., et al., JAMA, 2013.

38. HIV Rapid Testing: Comparisons across Treatment Modalities • Secondary analysis examined differences in outcome by program modality • Methadone maintenance programs (3) • Non-methadone outpatient programs (7) • Residential programs (3) • Random assignment to: • Off-site referral for HIV risk reduction counseling (RRC) and testing • On-site rapid testing with RRC • On-site rapid testing without RRC Schwartz et al., JSAT, 2013.

39. HIV Rapid Testing: Comparisons across Treatment Modalities Significantly higher rates of HIV testing and feedback of results by 1 month post-enrollment were seen for the combined on-site conditions compared to the offsite condition. No significant treatment modality or tx modality x testing condition interaction effects seen 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. Schwartz et al., JSAT, 2013.

40. Patient Characteristics and Availability of Onsite HIV Testing Data collected in 2008-2009 from 198 program administrators of agencies participating in the NIDA CTN Positive associations between the % of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapidHIV testing were more complicated. Abraham, A.J., et al., JSAT, 2013

41. Patient Characteristics and Availability of Onsite HIV Testing These findings suggest that many programs are responding to the needs of at-risk populations. Programs and their patients may benefit from greater adoption of rapid testing, which is less costly and better ensures that patients receive their results Abraham, A.J., et al., JSAT, 2013

42. HIV Rapid Testing in Substance Abuse Treatment Programs: A NIDA/SAMHSA Blending Initiative Product

43. NIDA/SAMHSA Blending Initiative The goal is to move important scientific findings into mainstream addiction treatment NIDA and SAMHSA’s Center for Substance Abuse Treatment began the Blending Initiative in 2001 to work on a common vision: To improve substance use disorder treatment and accelerate the dissemination of research-based findings into practice.

44. HIV Rapid Testing Blending Team Members Louise Haynes, MSW – LRADAC Christine Higgins, MA – Johns Hopkins University Tim Matheson, PhD – San Francisco DPH Lisa Metsch, PhD – University of Miami Nancy Roget, MS – Mountain West ATTC Bruce Schackman, PhD – Cornell Medical College Richard Spence, PhD – Gulf Coast ATTC Pamela Waters, MEd – Southern Coast ATTC Mike Wilhelm – Mountain West ATTC ATTC representative NIDA/CTN representative

45. The Headline Offering on-site rapid HIV testing in substance abuse treatment centers substantially increased receipt of HIV test results and identified persons who were unaware of their HIV infection

46. What Comprises the HIV Rapid Testing BT Product? Video Fact Sheet Resource Guide Marketing Materials Implementation Resources

47. Fact Sheet

48. Resource Guide

49. Marketing Materials

50. Implementation Resources SSA Directory CDC Guidelines State-Specific Testing Laws AETC Training and TA AETC Directory – HIV Outreach Programs Agency Budget Worksheet for HIV Rapid Testing Delivering HIV Rapid Test Results: FTCC Video and Discussion Guide